Your Family Hospice, LLC

“Based on record review, review of facility policy, and staff interviews, it was determined that the hospice failed to develop an emergency preparedness plan based on a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach. Findings include: Review of the policy titled, “;Emergency Preparedness Program- Plan”, Policy #: AD.E11, dated January 2019 revealed the following: Procedures: “;The hospices emergency preparedness plan is based on and includes a documented community-based risk assessments, utilizing an all-hazards approach.” A review of the agencys Emergency Preparedness Plan revealed the plan lacked an all-hazards risk assessment. On 12/5/2023 at 11:00 a.m., an interview with the Chief Executive Officer (CEO) confirmed the governing body was not overseeing the agencys emergency plan; “;we can do better.” On 12/5/2023 at 11:30 a.m., an interview with the Administrator confirmed that the agencys emergency plan did not include an all-hazards risk assessment.”

“Based on record review, and staff interviews, it was determined that the hospice agency failed to meet the requirement of 5% percent of the hospices cost analysis report for volunteer activity in the provision of day-to-day administrative and or direct patient care services for six consecutive months. The findings include: The cost analysis report for volunteer activity for the period of June 2023 to November 2023 was unavailable to the State surveyor(s). Review of the November cost analysis completed by the Administrator revealed the percentage was 2.27%. There was no further documentation provided for the volunteer activities for June, July, August, September and October of 2023. On 12/5/2023 at 10:00 a.m., an interview was conducted with Volunteer Coordinator who confirmed the cost analysis report of volunteer activity for the period of June 2023 to November was not done, “;I didnt know how to calculate the percentage. This is why it was not done.” On 12/5/2023 at 10:25 a.m., an interview was conducted with the Administrator who confirmed the cost analysis report of volunteer activity for the period of June 2023 to November was not done, “;I didnt know how to calculate the percentage. The accountant used to do it, but he left the company last year 2022. Since then, no one did the volunteer calculation percentage.””

“Based on record review, policy review, and staff interviews, it was determined the hospices governing body failed to manage volunteer activities, Emergency Preparedness Plan, and Human resource files. Findings include: 1. The cost analysis report for volunteer activity for the period of June 2023 to November 2023 was unavailable to the State surveyor(s). Review of the November cost analysis completed by the Administrator revealed the percentage was 2.27%. On 12/5/2023 at 10:00 a.m., an interview was conducted with volunteer coordinator revealed, “;I didnt know how to calculate the percentage. This is why it was not done.” On 12/5/2023 at 10:25 a.m., an interview was conducted with the Administrator revealed, “;I didnt know how to calculate the percentage. The accountant used to do it, but he left the company last year 2022. Since then, no one did the volunteer calculation percentage.” 2. Review of the policy titled, “;Emergency Preparedness Program- Plan”, Policy #: AD.E11, dated January 2019 revealed the following: Procedures: “;The hospices emergency preparedness plan is based on and includes a documented community-based risk assessments, utilizing an all-hazards approach.” A review of the agencys Emergency Preparedness Plan revealed the plan lacked an all-hazards risk assessment. On 12/5/2023 at 11:00 a.m., an interview with the Chief Executive Officer (CEO) confirmed the governing body was not overseeing the agencys emergency plan; “;we can do better.” On 12/5/2023 at 11:30 a.m., an interview with the Administrator confirmed that the agencys emergency plan did not include an all-hazards risk assessment. 3. Record reviews revealed four HR files (DD, FF, HH, JJ) of seven failed to include an updated annual health screening determining if the staff can meet the demands of the assigned job. On 12/5/2023 at 12:30 p.m., the Administrator and the Chief Executive Officer (CEO) confirmed the missing updated annual health screening for four of seven employees HR files reviewed.”