Takara Hospice LLC

“It is required that the hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. 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. 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 second full-scale exercise that is community-based or a facility-based functional exercise, or a mock disaster drill, or 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. Review of the agency’s Emergency Plan revealed the agency did not ensure documentation that the Emergency Plan was tested annually. A review of the Emergency Preparedness Binders on 03/13/2025 revealed no documented evidence that the agency had tested the Emergency Preparedness Plan annually from 01/01/2023 through the date of review on 03/13/2025. During a joint review of the Emergency Preparedness Binder and interview on 03/13/2025, the Executive Director confirmed the agency had not tested the emergency preparedness plan annually in 2023, 2024, and through 03/13/2025. The Executive Director stated, “I was new to the position and was unaware that we needed to test it annually.” A review of the Emergency Preparedness Binders on 03/13/2025 revealed the agency did not ensure to test the emergency preparedness plan annually between 01/01/2023-03/13/2025.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. Review of the hospice volunteer program revealed, the agency did not ensure that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours. Review of the Volunteer Cost Savings Report for the period from 01/01/2024 through 12/31/2024 revealed a cost savings of 0.78%. The hospice did not ensure that that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. During a joint review of the Volunteer Cost Savings Report and interview on 03/12/2025, the Volunteer Coordinator agreed that the agency did not meet the minimum five percent cost savings requirement for 2024 and stated, “I am working on getting more volunteers.””

“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 2 of 10 (20%) personnel records reviewed, the hospice did not ensure the skills and competencies of individuals that provided care was evaluated and assessed as required by agency policy. Agency policy No. 3-001 Competency Program, required in part, “Personnel will demonstrate knowledge and proficiency of skills appropriate to their assigned responsibilities, including an ability to perform specific duties. The organization will establish and annually evaluate a group of specific skills related to patient care/service responsibilities. Competencies must be successfully demonstrated before organization personnel complete orientation. Organization personnel will not provide the care or service independently until satisfactory completion of required skills competency.” Agency policy No. 3-002 Competency Based Orientation, required in part, “Hospice ensures that the competency of all personnel is assessed on hire, prior to providing care to hospice patients.” Personnel Record 1: Registered Nurse Case Manager date of hire 10/17/2023. The nurse took on a new role as Executive Director at the end of May 2024. The personnel record contained no documented evidence of a competency assessment completed upon hire. Personnel Record 5: Licensed Vocational Nurse date of hire 01/02/2024. The personnel record contained no documented evidence of a competency assessment completed upon hire. During a joint record review and interview on 03/13/2025, the Executive Director stated, “I didn’t know these were missing until now. My orientation was minimal.” The Executive Director agreed there was no documented evidence that the agency assessed the skills and competencies of the nurses identified and confirmed both nurses were providing nursing visits to patients.”