Ucm Home Care

“Based on a review of the Hospice Emergency Preparedness Plan and Staff interview it was determined that the Hospice failed to maintain a communication plan with the names and contact information for current Staff. Findings include: 1. The Hospice Emergency Preparedness Plan was reviewed on 01/22/25 at 11:00 AM. The communication plan did not include contact information of current Hospice Staff. 2. During an interview with the Administrator on 01/23/25 at 10:30 AM, the finding of the Hospice not having a communication plan that includes a contact list of current Staff, was confirmed.”

“Based on the clinical record review and Staff interview, it was determined in 2 of 19 (Pts. #15 and 19) clinical records reviewed, the IDG failed to ensure a completed comprehensive assessment within 5 days after the election. 2. Pt. #19 was admitted to the hospice services on 11/03/23 with diagnosis of Malignant Neoplasm of Right female Breast Unspecified Estrogen Receptor Status. The clinical record was reviewed on 01/22/25. The MSW and Chaplain did not assess the patient until 11/09/24 (more than 5 days of the election). 3. During the interviews conducted on 01/22/25 between 2- 3:00 PM, with the Executive Administrator and RN Coordinator, the above findings were confirmed. Findings include: 1. Pt. #15 was admitted to the hospice services on 01/11/24 with a diagnosis of Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection. The clinical record was reviewed on 01/22/25. The MSW and Chaplain did not assess the patient until 01/17/24, which was more than 5 days after the election.”

“Based on the review of the Governing Board minutes and Staff interview, it was determined the Hospice failed to ensure the frequency and details of the quality assessment and performance improvement program were approved. Findings include: 1. The 2024 Governing Board minutes and Hospice quality assessment and performance improvement program was reviewed on 01/22/25 at 11:00 AM. The 2024 Governing Board minutes lacked documentation that the Governing Board met to approve the data collection frequency and details of the quality assessment and performance improvement program. 2. The findings were confirmed during the interview on 01/22/25 at 1:30 PM, with the Executive Administrator.”

“Based on document review, policy review and staff interview it was determined the Hospice failed to provide documentation of cost savings achieved by utilizing volunteers for the years 2023 and 2024. This has the potential to affect all Pts. receiving Hospice services. Findings include: 1. On 01/22/25, documentation of cost savings achieved by using volunteers for the years 2023 and 2024 was requested but could not be provided by the Agency. 2. The Policy titled, “;Volunteer Services” was reviewed on 01/23/25 and required, “;A. Cost savings achieved through the use of volunteers will be documented.” 3. On 01/22/25, an interview was conducted with the Interim Volunteer Coordinators, (Executive Administrator and the Bereavement Coordinator/LCSW.) The Executive Administrator stated that since there were no volunteers for the years 2023 and 2024, there was no documentation of any cost savings for those years.”

“Based on document review, staff interview and policy reviews, it was determined the Hospice failed to ensure that the minimum of 5% cost saving requirement of total Pt. care hours of all Hospice paid employees achieved by using volunteers were met for the years 2023 and 2024. This has the potential to affect all Pts. receiving Hospice services. Findings include: 1. The documentation of the use of volunteers and types of services that they provided was requested but was not provided. The Executive Administrator stated that there were no volunteers for the years 2023 and 2024. The Hospice lacked documentation that the 5% cost savings requirement for the years 2023 and 2024 were met. 2. On 01/22/25, an interview was conducted with the Interim Volunteer Coordinators, (Executive Administrator and the Bereavement Coordinator/LCSW). The Executive Administrator stated there had been no volunteers since the year 2020 and currently there is 1 volunteer who signed up, but training will be set up for February 2025. 3. The policy titled, “;Volunteer Services” was reviewed on 01/23/25 and required, “;(Agency) maintains a volunteer staff sufficient to provide administrative support or direct care that amounts to a minimum of 5% of total patient care hours for paid hospice employees of contract staff...” 4. During the same interview on 01/22/25, the Executive Administrator confirmed that since there were no volunteers for the years 2023 and 2024, the Hospice did not meet the required cost savings requirement.”

“Based on the clinical records review and Staff interviews, it was determined that in 2 of 5 (Pts. # 18 and 19) discharge clinical records review, the Hospice lacked documentation of discharge summary. 2. Pt. #19 was admitted to the hospice services on 11/03/23 with diagnosis of Malignant Neoplasm of Right Female Breast Unspecified Estrogen Receptor Status. The clinical record was reviewed on 01/22/25. The clinical record lacked a discharge summary. 3. The findings were confirmed during the interviews on 01/22/25 at 1:30 PM and 01/23/25 at 10:30 AM with the Executive Administrator. Findings include: 1. Pt. #18 was admitted to the hospice services on 02/14/24 with diagnosis of Malignant Neoplasm of Right Ovary. The clinical record was reviewed on 01/22/25. The clinical record lacked a discharge summary.”