My Choice Hospice Inc.

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The hospice EP training program includes for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by document review, interview, and personnel record review. In 9 of 10 (90%) personnel records reviewed revealed the hospice did not ensure that an initial emergency preparedness training was completed upon hire. Personnel Record 2: The Registered Nurse (RN) was hired on 07/31/2023. A review of the personnel record revealed no documented evidence of initial emergency preparedness training. Personnel Record 3: The Hospice Aide (HA) was hired on 12/11/2023. A review of the personnel record revealed no documented evidence of initial emergency preparedness training. Personnel Record 4: The Spiritual Counselor was hired on 04/21/2023. A review of the personnel record revealed no documented evidence of initial emergency preparedness training. Personnel Record 5: The Bereavement Coordinator (BC) was hired on 11/21/2023. A review of the personnel record revealed no documented evidence of initial emergency preparedness training. Personnel Record 6: The Licensed Vocational Nurse (LVN) was hired on 07/05/2022. A review of the personnel record revealed no documented evidence of initial emergency preparedness training. Personnel Record 7: The Medical Social Worker (MSW) was hired on 04/13/2022. A review of the personnel record revealed no documented evidence of initial emergency preparedness training. Personnel Record 8: The Medical Director was hired on 04/12/2022. A review of the personnel record revealed no documented evidence of initial emergency preparedness training. Personnel Record 9: The HA was hired on 05/26/2022. A review of the personnel record revealed no documented evidence of initial emergency preparedness training. Personnel Record 10: The Volunteer was hired on 10/11/2023. A review of the personnel record revealed no documented evidence of initial emergency preparedness training. The Director of Patient Care Services (DPCS) was interviewed on 02/29/2024 and stated that they have been educating the staff on emergency preparedness but have not been tracking it. The DPCS stated that they now have DocuSign to facilitate attendance tracking. In 9 of 10 (90%) personnel records reviewed revealed the hospice did not ensure that an initial emergency preparedness training was completed upon hire.”

“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 standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the hospice did not ensure that the interdisciplinary group completed the initial comprehensive assessment within five (5) calendar days after the election of hospice care. Clinical Record 1: The patient elected hospice care on 09/07/2023. The need for a spiritual care (SC) evaluation was documented in the initial comprehensive assessment. On 09/13/2023, the Chaplain documented “Unable to reach family,” with six (6) days outstanding. There was no documentation as to why the assessment was not completed within five (5) calendar days after the election of hospice care. During an interview on 02/27/2024, the Director of Patient Care Services (DPCS) stated they did not know why the chaplain did not contact the patient within the five (5) days. In 1 of 14 (7%) clinical records reviewed in which a comprehensive assessment was performed, revealed the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care.”

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the hospice did not ensure that the interdisciplinary group completed the initial bereavement risk assessment. Clinical Record 1: The patient elected hospice care on 09/27/2023. There was no documentation that a bereavement risk assessment was completed as of the date of the clinical record review on 02/27/2024. Clinical Record 7: The patient elected hospice care on 11/03/2023. There was no documentation that a bereavement risk assessment was completed as of the date of the clinical record review on 02/27/2024. During an interview on 02/27/2024, the Director of Patient Care Services (DPCS) stated that they did not know why the initial bereavement assessment was not completed as part of the comprehensive assessment. In 2 of 14 (14%) clinical records reviewed it was revealed that the hospice did not ensure that the interdisciplinary group completed the initial bereavement risk assessment.”

“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 standard was not met as evidenced by interview and personnel record review. In 6 of 10 (60%) personnel records reviewed, the hospice did not ensure that employees and contracted providers received infection control education. Personnel Record 3: The Hospice Aide (HA) was hired on 12/11/2023. A review of the personnel record revealed no documented evidence of infection control education provided by the hospice. Personnel Record 5: The Bereavement Coordinator (BC) was hired on 11/21/2023. A review of the personnel record revealed no documented evidence of infection control education provided by the hospice. Personnel Record 7: The Medical Social Worker (MSW) was hired on 04/13/2022. A review of the personnel record revealed no documented evidence of infection control education provided by the hospice. Personnel Record 8: The Medical Director was hired on 04/12/2022. A review of the personnel record revealed no documented evidence of infection control education provided by the hospice. Personnel Record 9: The HA was hired on 05/26/2022. A review of the personnel record revealed no documented evidence of infection control education provided by the hospice. Personnel Record 10: The Volunteer was hired on 10/11/2023. A review of the personnel record revealed no documented evidence of infection control education provided by the hospice. The Director of Patient Care Services (DPCS) was interviewed on 02/29/2024 and confirmed there was no evidence of infection control education in the specific employee records. In 6 of 10 (60%) personnel records reviewed revealed the hospice did not ensure that employees and contracted providers received education in infection control.”

“It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below AND the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below and the hospice maintains documentation that each hospice aide has met the requirements. Option 2: Hospice Aide Training and Competency Evaluation: A qualified hospice aide has successfully completed a competency evaluation program that: evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or pseudo-patient: communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; reading and recording temperature, pulse, and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; normal range of motion and positioning. Evaluates the aide’s competency in the following subject areas by written exam, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation: observation, reporting, and documentation of patient status and the care or service provided; basic infection control procedures; basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor; maintenance of a clean, safe, and healthy environment; recognizing emergencies and the knowledge of emergency procedures and their application; the physical, emotional, and developmental needs of—and ways to work with—the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property; adequate nutrition and fluid intake; [and] any remaining task(s) that the hospice chooses to have an aide perform. This standard was not met as evidenced by interview and personnel record review. In 1 of 2 (50%) personnel records reviewed of Hospice Aides (HA), the hospice did not ensure that a competency evaluation was completed prior to the aide performing care independently. Personnel Record 3: The Hospice Aide (HA) was hired on 12/11/2023. There was no evidence that a Registered Nurse (RN) documented a skills competency evaluation at the time of hire, and prior to the HA providing patient care. There was no documented evidence that a HA skills competency was completed. The Director of Patient Care Services (DPCS) was interviewed on 02/29/2024 and confirmed the finding. In 5 of 10 (50%) personnel records reviewed revealed the hospice did not ensure that skills and competency assessments were completed upon hire.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed of patients that received Hospice Aide services (HA), the hospice did not ensure that a Registered Nurse (RN) performed HA supervisory visits no less frequently than every 14 days. Clinical Record 3: The patient elected hospice care on 01/24/2024. The HA plan of care dated 01/24/2024 ordered HA services two (2) times a week. A clinical record review revealed documented evidence of HA visits dated 01/31/2024, 02/05/2024, 02/07/2024, 02/12/2024, 02/16/2024, 02/19/2024, and 02/21/2024. The clinical record included documented evidence of RN supervisory visits dated 02/07/2024 and 02/23/2024, with 16 days outstanding. Clinical Record 4: The patient elected hospice care on 09/07/2023. For benefit period #2, dated 12/06/2023 through 03/04/2024, HA services were ordered two (2) times a week). A clinical record review revealed documented evidence of HA visits dated 12/18/2023, 12/22/2023, 12/25/2023, 12/29/2023, 01/01/2024, and 01/05/2024. The clinical record included documented evidence of RN supervisory visits on 12/19/2023 and 01/05/2024, with 17 days outstanding. Clinical Record 6: The patient elected hospice care on 10/04/2023. The HA plan of care ordered HA services two (2) times a week. A clinical record review revealed documented evidence of HA visits dated 01/04/2024, 01/07/2024, 01/11/2024, 01/14/2024, 01/18/2024, 01/21/2024, and 01/25/2024. The clinical record included documented evidence of RN supervisory visits on 12/27/2023 and 01/11/2024, with 15 days outstanding, and 01/26/2024, with 15 days outstanding. During an interview on 02/27/2024, the Director of Patient Care Services (DPCS) confirmed the finding. The DPCS stated they will be re-educating the nurses on timely HA supervision. In 3 of 13 (23%) clinical records reviewed in which a hospice aide (HA) provided services, revealed that a registered nurse (RN) did not perform HA supervisory visits no less frequently than every 14 days.”

“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 standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel record review of a Volunteer, the hospice did not ensure that the Volunteer received Volunteer training. Personnel Record 10: The Volunteer was hired on 10/11/2023. A review of the personnel record revealed no documented evidence that Volunteer training was completed. The CEO/Volunteer Coordinator was interviewed on 02/29/2024. He stated he believes the volunteer participated in the on-line volunteer training program but agreed there was no evidence of his participation in the personnel record. In 1 of 1 (100%) personnel record reviewed in which the employee is employed as a volunteer, the hospice did not ensure that the volunteer received volunteer training.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care and documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 14 of 14 (100%) clinical records reviewed, the hospice did not ensure that volunteer services were offered. Clinical Record 1: The patient elected hospice care on 09/07/2023. A clinical record review revealed no documented evidence that volunteer services were offered or declined. Clinical Record 2: The patient elected hospice care on 06/20/2023. There was no documentation that a volunteer was offered/declined. Clinical Record 3: The patient elected hospice care on 01/24/2024. A clinical record review revealed no documented evidence that volunteer services were offered or declined. Clinical Record 4: The patient elected hospice care on 09/07/2023. A clinical record review revealed no documented evidence that volunteer services were offered or declined. Clinical Record 5: The patient elected hospice care on 06/07/2023. A clinical record review revealed no documented evidence that volunteer services were offered or declined. Clinical Record 6: The patient elected hospice care on 01/04/2023. A clinical record review revealed no documented evidence that volunteer services were offered or declined. Clinical Record 7: The patient elected hospice care on 11/03/2023. A clinical record review revealed no documented evidence that volunteer services were offered or declined. Clinical Record 8: The patient elected hospice care on 02/20/2023. There was no documentation that a volunteer was offered or declined. Clinical Record 9: The patient’s benefit election was dated 03/14/2023. A clinical record review revealed no documented evidence that volunteer services were offered or declined. Clinical Record 10: The patient elected hospice care on 10/25/2023. There was no documentation that a volunteer was offered or declined. Clinical Record 11: The patient elected hospice care on 01/17/2023. A clinical record review revealed no documented evidence that volunteer services were offered or declined. Clinical Record 12: The patient elected hospice care on 12/27/2022. A clinical record review revealed no documented evidence that volunteer services were offered or declined. Clinical Record 13: The patient elected hospice care on 07/25/2022. A clinical record review revealed no documented evidence that volunteer services were offered or declined. Clinical Record 14: The patient elected hospice care on 01/16/2023. A clinical record review revealed no documented evidence that volunteer services were offered or declined. During an interview on 02/27/2024, the Director of Patient Care Services (DPCS) confirmed that they have not been documenting the offering and declination of volunteer services. In 14 of 14 (100%) clinical records reviewed, there was no evidence that a volunteer was offered and/or the patient declined volunteer services.”

“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 interview and personnel record review. In 9 of 10 (90%) personnel records reviewed, the hospice did not ensure that each employee received an initial orientation that addressed specific job duties. Personnel Record 1: The Director of Patient Care Services (DPCS)/ Registered Nurse (RN) was hired on 04/13/2022. A review of the personnel record revealed no documented evidence that the RN received an initial orientation that addressed specific job duties. Personnel Record 3: The Hospice Aide (HA) was hired on 12/11/2023. A review of the personnel record revealed no documented evidence that the HA received an initial orientation that addressed specific job duties. Personnel Record 4: The Spiritual Counselor (SC) was hired on 04/21/2023. A review of the personnel record revealed no documented evidence that the SC received an initial orientation that addressed specific job duties. Personnel Record 5: The Bereavement Coordinator (BC)/SC was hired on 11/21/2023. A review of the personnel record revealed no documented evidence that the BC/SC received an initial orientation that addressed specific job duties. Personnel Record 6: The Licensed Vocational Nurse (LVN) was hired on 07/05/2022. A review of the personnel record revealed no documented evidence that the LVN received an initial orientation that addressed specific job duties. Personnel Record 7: The Medical Social Worker (MSW) was hired on 04/13/2022. A review of the personnel record revealed no documented evidence that the MSW received an initial orientation that addressed specific job duties. Personnel Record 8: The Medical Director was hired on 04/12/2022. A review of the personnel record revealed no documented evidence that the Medical Director received an initial orientation that addressed specific job duties. Personnel Record 9: The HA was hired on 05/26/2022. A review of the personnel record revealed no documented evidence that the HA received an initial orientation that addressed specific job duties. Personnel Record 10: The Volunteer was hired on 10/11/2023. A review of the personnel record revealed no documented evidence that the Volunteer received an initial orientation that addressed specific job duties. The Director of Patient Care Services (DPCS) was interviewed on 02/29/2024 and confirmed that the records did not contain evidence of orientations. In 9 of 10 (90%) personnel records reviewed revealed the hospice did not ensure that an initial orientation that addresses specific job duties was completed.”