Golden Belt Hospice

“Based on review of the Emergency Preparedness Program (EPP) and interview, the hospice failed to do the following: (i) Provide initial training on the emergency preparedness plan, policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of the emergency preparedness plan, policies and procedures. (iii) Provide emergency preparedness plan training at least every 2 years, and (iv) Maintain documentation of all emergency preparedness plan training. This deficient practice has the potential to result in staff being unprepared for a proper response consistent with their roles to an emergency and could potentially place patients at risk for harm or injury during an emergency situation. Findings Include: During the review of the emergency preparedness program folder, staff orientation documentation, and the integrated online training program on 06/13/24 between 10:15 AM and 1:15 PM, it was revealed that the facility did not have documented training for staff specific to their emergency preparedness plan, policies and procedures. The Emergency Preparedness Program included the instruction to provide initial and continuing education to staff on EPP. This training was thought to be achieved via the integrated online training program. However, the integrated online training program is not specific to the facility’s risk analysis, emergency preparedness plan, policies and procedures consistent with their staff’s roles in the event of an emergency. Review of staff orientation documentation with the Manager, failed to include specific line item for training staff on the Emergency Preparedness Plan, and policies and procedures consistent with their roles. During an interview on 06/13/24 between 12:30 PM and 1:15 PM, it was revealed the integrated online staff training program did not consist of all necessary emergency topics. The Administrator presumed that the integrated online staff emergency training program consisted of the necessary topics. Staff was present and acknowledged findings.”

“Based on document review, policy review, and interview in Hospice failed to ensure the clinical record contain updated assessments and clinical notes for 5 of 10 patients reviewed (Patients 1, 2, 3, 4 and 8) who received hospice services. Failure of the hospice to ensure the clinical record contained updated assessments and notes has the potential to affect the plan of care and provision of hospice services for patients. Findings Include: Review of a hospice policy titled, “;Clinical Records, Rev 06/24”, showed medical records included, “;Signed and dated admission and clinical notes that are written the day the service is rendered and incorporated at least weekly. This document may include signs and symptoms; the treatment and/or invasive procedures, medication(s) provided/administered; client response to treatment and medication(s); and client progress and outcomes of care based on changes in the client condition.” Patient 1 Review of Patient 1s hospice medical record showed documentation of nursing visit titled, “;RN-Skilled Nursing Visit” for the 05/31/24 and 06/07/24 skilled nursing visits completed, were “;Not Started” status, indicating the notes did not contain assessment content from the visit as required. Review of the note content confirmed the assessments were not documented by the nurse and out of policy timelines. Patient 2 Review of Patient 2s hospice medical record showed the documentation of nursing visit titled, “;RN-Skilled Nursing Visit” for the 06/01/24, 06/02/24 and 06/08/24 skilled nursing visits completed, were “;Not Started” status, indicating the notes did not contain assessment content from the visit as required. Review of the note content confirmed the assessments were not documented by the nurse. and out of policy timelines. Patient 3 Review of Patient 3s hospice medical record showed the documentation of nursing visit titled, “;RN-Skilled Nursing Visit” for the Recertification assessment on 05/24/24 was “;Not Started” status, indicating the note did not contain assessment content from the visit as required. Review of the note content confirmed the assessment was not documented by the nurse and out of policy timelines. Patient 4 Review of Patient 4s hospice medical record showed the documentation of nursing visits titled, “;RN-Skilled Nursing Visit” for the 05/31/24, 06/03/24 and 06/06/24 skilled nursing visits completed were “;Not Started” status, indicating the notes did not contain assessment content from each visit as required. Review of the notes content confirmed the assessments were not documented by the nurse and out of policy timelines. Patient 8 Review of Patient 8s hospice medical record showed the documentation of nursing visit titled, “;RN-Skilled Nursing Visit” for the 06/04/24 skilled nursing visits completed were “;Not Started” status, indicating the notes did not contain assessment content from the visit as required. Review of the notes content confirmed the assessment was not documented by the nurse and out of policy timelines. During an interview on 06/12/24 at 11:37 AM, Staff A, Hospice Administrator, confirmed the visits had been completed with patients as assigned. The surveyor inquired regarding absent nursing assessment documentation and the “;Not Started” status. The administrator confirmed “;Unfortunately, youll find that, our nurses have been very busy and are behind.””

“Based on document review, policy review and interview, the hospice failed to ensure criminal background checks were obtained on all staff members employed by the agency for 2 of 5 personnel records reviewed (Staff B and D). Failure of the hospice to ensure completed criminal background checks on all staff has the potential to affect the safe provision of care and hospice services for patients. Findings Include: Review of a policy, titled “;1.03 Persons Seeking Employment Revised 04/2024, showed upon the decision to make a conditional offer and post-acceptance, a background check be completed. This includes a criminal background search.” Review of the employee file for Staff B, Registered Nurse, confirmed a hire date, 11/14/16. The file did not contain a criminal background check. Review of the employee file for Staff D, Chaplain, confirmed a hire date, 02/14/19. The file did not contain a criminal background check. During an interview on 06/13/24 at 3:30 PM, Staff A, Administrator and Staff G, Human Resources confirmed that the identified employee files did not contain criminal background checks as required.”