Aa Care Hospice

“It is required that the hospice EP (Emergency Preparedness) 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; a) 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 IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by personnel record review and interview. In 2 of 2 (100%) personnel records reviewed, the hospice did not ensure that new employees received emergency preparedness training upon hire. Personnel Record 1: Social Worker (SW) date of hire 10/16/2023. The personnel record contained no documented evidence that the SW had completed emergency preparedness training. Personnel Record 2: Volunteer Coordinator (VC) date of hire 10/12/2023. The personnel record contained no documented evidence that the VC had completed emergency preparedness training. During joint record review and interview on 11/21/2023, the Director of Patient Care Services (DPCS) agreed there was no documented evidence of emergency preparedness training in the personnel records. The DPCS stated they haven’t been assigned the training yet but should have been.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. 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 record reviewed of patients admitted on or after 10/13/2023, the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care. Clinical Record 1: The patient elected the hospice benefit on 10/13/2023. The clinical record contained no documented evidence of an initial spiritual or psychosocial assessment. During joint review of the record and interview on 11/20/2023, the Director of Patient Care Services (DPCS) agreed there was no documented evidence that the initial spiritual and psychosocial assessments were completed. The DPCS stated “The patient declined the chaplain and social worker, but the nurse should have done the initial spiritual and psychosocial assessments, I am not sure why the nurse did not.””

“It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG (interdisciplinary group) in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 4 of 5 (80%) clinical records reviewed, the agency did not ensure hospice care and services were provided to patients as ordered on the individualized plan of care. Clinical Record 1: The patient elected the hospice benefit on 10/13/2023. The plan of care (POC) dated 10/13/2023 ordered SN (Skilled Nurse) visits once a week. The clinical record contained no documented evidence that a nursing visit was provided to the patient the week of 10/15/2023 to 10/21/2023. The clinical record contained no documentation of a missed visit. Clinical Record 2: The patient elected the hospice benefit on 08/26/2022. The POC dated 10/20/2023 included an order for SN visits twice a week. For the week of 10/29/2023 to 11/04/2023 the SN provided a nursing visit on 11/02/2023, but there was no documented evidence of the second nursing visit for the week. The clinical record contained no documentation of the missed visit. During the week of 11/12/2023 to 11/18/2023, the SN provided a visit on 11/16/2023, but there was no documented evidence of a second nursing visit or reason for a missed visit. Clinical Record 3: The patient elected the hospice benefit on 06/23/2023. The POC dated 10/21/2023 included an order for SN visits once a week. For the week of 11/5/2023 to 11/11/2023, the clinical record contained no documented evidence of a nursing visit or reason for the missed visit. Clinical Record 5: The patient elected the hospice benefit on 10/16/2022. The POC dated 10/11/2023 included an order for SN visits once a week. For the week of 11/05/2023 to 11/11/2023, the clinical record contained no documented evidence of a nursing visit or reason for the missed visit. During a joint review of records and interview on 11/21/2023, the Director of Patient Care Services (DPCS) agreed there was no documented evidence that nursing visits were completed as ordered. The DPCS stated, “The visits were assigned but we discovered the nurses did not complete them.””

“It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. THIS IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by personnel record review and interview. In 2 of 2 (100%) personnel records reviewed, the hospice did not ensure new employees received infection control education upon hire. Personnel Record 1: Social Worker (SW) date of hire on 10/16/2023. The personnel record contained no documented evidence that the SW had completed infection control education. Personnel Record 2: Volunteer Coordinator (VC) date of hire 10/12/2023. The personnel record contained no documented evidence that the VC had completed infection control education. During joint personnel record review and interview on 11/21/2023, the Director of Patient Care Services (DPCS) agreed there was no documented evidence of infection control education in the personnel records. The DPCS stated they haven’t been assigned the training yet but should have been.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. THIS IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed with hospice aide (HA) services provided, the agency did not ensure hospice aide services were provided as ordered on the plan of care. Clinical Record 2: The patient elected the hospice benefit on 08/26/2022. The HA plan of care assignment dated 10/22/2023 included aide frequency of visits three times a week. The clinical record contained no documented evidence the hospice aide provided visits from 10/22/2023 through 11/20/2023. Clinical Record 3: The patient elected the hospice benefit on 06/23/2023. The HA plan of care assignment dated 10/23/2023 included aide frequency of visits four times a week. The HA plan of care assignment dated 10/30/2023 assigned aide frequency of visits five times a week, the HA assignment dated 11/06/2023 assigned aide visits four times a week, and the HA plan of care dated 11/13/2023 assigned aide visits three times a week. The clinical record contained no documented evidence hospice aide visits were provided from 10/23/2023 through 11/20/2023. Clinical Record 4: The patient elected the hospice benefit on 08/07/2023. The HA plan of care assignment dated 10/24/2023 included aide frequency of visits twice a week. There was no documented evidence hospice aide services were provided between 10/24/2023 through the patient’s death on 11/07/2023. Clinical Record 5: The patient elected the hospice benefit on 10/16/2022. The HA plan of care assignment dated 10/23/2023 included aide frequency of visits three times a week. The HA plan of care dated 10/30/2023 assigned aide frequency of visits five times a week, the HA plan of care dated 11/6/2023 assigned aide frequency of visits four times a week, and the HA plan of care dated 11/13/2023 assigned aide frequency of visits three times a week. The clinical record contained no documented evidence hospice aide services were provided from 10/23/2023 through 11/20/2023. During joint review of records and interview on 11/20/2023, the Director of Patient Care Services (DPCS) agreed, there was no documented evidence that hospice aide services were provided as ordered. The DPCS stated, “I know she has been visiting the patients, but she has not been documenting her visits.””

“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. Volunteers are supervised by a designated hospice employee. THIS IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by document review and interview. The Volunteer manual was reviewed. There was no documented evidence of hospice volunteer orientation and training that was consistent with hospice industry standards, including 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. During an interview on 11/21/2023, an active patient volunteer stated, there wasn’t any training provided. We were just told during the interview upon hire what we can and cannot say. During joint review and interview on 11/21/2023, the Director of Patient Care Services (DPCS) stated, “I am still developing the volunteer training module, then we will train our volunteers.” The DPCS agreed, there was no documented evidence the active volunteers have completed volunteer training with the required elements. The Volunteer manual was reviewed. There was no documented evidence of hospice volunteer orientation and training that was consistent with hospice industry standards, including 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.”

“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 2 of 5 (40%) clinical records reviewed, the agency did not ensure recertification was completed no later than two calendar days after the first day of each benefit period. Clinical Record 2: The patient elected the hospice benefit on 08/26/2022. The clinical record contained no documented evidence that the hospice medical director or physician-designee provided written recertification for benefit period 7 dated 10/20/2023 through 12/18/2023, as of the date of record review on 11/20/2023, 31 days after the start of the benefit period. Clinical Record 3: The patient elected the hospice benefit on 06/23/2023. The clinical record contained no documented evidence that the hospice medical director or physician-designee provided written recertification for benefit period 9 dated 10/21/2023 through 12/19/2023, as of the date of record review on 11/20/2023, 30 days after the start of the benefit period. During joint record review and interview on 11/20/2023, the Director of Patient Care Services (DPCS) agreed there was no documented evidence that the recertifications were completed. The DPCS stated, “We are working on this with him, I am not sure if he realizes when they are due.””