Hospice Services Inc.

“Based on review of agency documents, and interview it was determined the Home Health Agency (HHA) failed to maintain an up-to-date comprehensive emergency preparedness program plan (EPP). The cumulative effect of this deficient practice has the potential to place patients and staff at risk for harm during an emergency or disaster. Findings Include: 1. The Hospice failed to develop and maintain an emergency preparedness plan (EPP) that must be reviewed and updated at least every 2 years. (Refer to E0004) 2. The Hospice failed to develop and maintain an emergency preparedness program plan (EPP) based on a facility and community-based all hazards risk assessment (Refer to tag E0006) 3. The Hospice failed to develop and maintain an emergency preparedness plan (EPP) that addressed patient population. (Refer to E0007) 4. The Hospice failed to develop and maintain an emergency preparedness plan (EPP) that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. (Refer to E0009) 5. The Hospice failed to develop and implement policies and procedures, based on the emergency plan. (Refer to E0013) 6. The Hospice failed to develop and implement emergency preparedness (EPP) policies and procedures to follow up with on duty staff and patients to determine services that are needed and failed include a policy to inform State and local officials of any on-duty staff or patients that they are unable to contact. (Refer to E0016) 7. The Hospice failed to develop and implement policies and procedures to track the location of on-duty staff and sheltered patients in the agencys care during an emergency. (Refer to E0018) 8. The Hospice failed to develop and implement emergency preparedness program (EPP) policies and procedures to inform State and local emergency preparedness officials about homebound home health patients in need of evacuation. (Refer to tag E0019) 9. The Hospice failed to develop and implement policies and procedures for a means to shelter in place for patients, staff, and volunteers. (Refer to E0022) 10. The Hospice failed to develop and implement policies and procedures for a system of medical documentation. (Refer to E0023) 11. The Hospice failed to develop and implement policies and procedures for the use of volunteers in an emergency or other emergency staffing strategy. (Refer to E0024) 12. The Hospice failed to develop and implement policies and procedures for the development of arrangements with other providers to receive patients in the event of limitations or cessation of operations. (Refer to E0025) 13. The Hospice failed to develop and implement policies and procedures to describe its role in providing care at alternate care sites during an emergency. (Refer to E0026) 14. The Hospice failed to have a communication plan that included all of the names and contact information for hospice employees, entities providing services under arrangement, patients’ physicians, and other hospices. (refer to E0030) 15. The Hospice failed to develop an emergency officials contact list. (Refer to E0031) 16. The Hospice failed to develop and implement emergency preparedness program (EPP) policies and procedures for a communication plan that included methods of sharing information and medical documentation. (Refer to E0033) 17. The Hospice failed to develop and maintain an emergency preparedness program (EPP) training and testing program that is based on the emergency plan, its risk assessment and the communication plan. (Refer to E0036) 18. The Hospice failed to provide initial and annual training of the emergency preparedness policies and procedures to new and existing staff and individuals providing services under arrangement. (Refer to E0037) 19. The Hospice failed to participate in a full-scale community-based emergency preparedness program (EPP) exercise or conduct an annual facility-based functional exercise in the past 2 years. (Refer to E0039)”

“Based on interview and document review the Hospice failed to develop and maintain an emergency preparedness plan (EPP) that must be reviewed and updated at least every 2 years. Failure to develop, maintain, review and update at least every 2 years places patients at risk for harm or injury during an emergency situation. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM, the Administrator was interviewed about the EPP. The Administrator stated that there was no documented review or update for the EPP. Review of the EPP failed to show a review or update to the plan.”

“Based on interview and document review the Hospice failed to develop and maintain an emergency preparedness plan (EPP) that is based on and includes a documented, facility and community-based risk assessment, utilizing an all-hazards approach and include strategies for addressing emergency events identified by the risk assessment. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM. the Administrator was interviewed about the EPP. The Administrator stated that there was no Risk Assessment for the EPP. Review of agency documents failed to show a Risk Assessment for the Emergency Preparedness Program.”

“Based on interview and document review the Hospice failed to develop and maintain an emergency preparedness plan (EPP) that addressed patient population, the services the facility has the ability to provide in an emergency; and continuity of operations including the delegation of authority and succession plan. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM, the Administrator was interviewed about the EPP. The Administrator stated that the Patient Population was not addressed within the EPP. Review of facility documents failed to show Patient Population was addressed the Emergency Preparedness Program.”

“Based on interview and document review the Hospice failed to develop and maintain an emergency preparedness plan (EPP) that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM, the Administrator was interviewed about the EPP. The Administrator stated that there was no process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster for the EPP. Review of agency documents failed to show a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster for the EPP.”

“Based on interview and policy review the Hospice failed to develop and implement policies and procedures, based on the emergency preparedness plan (EPP) set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section, that must be reviewed at least every 2 years. The hospice’s failure to develop policies and procedures based on the emergency plan leaves them unprepared for emergency situations. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM, the Administrator was interviewed about the EPP. The Administrator stated that there were no policies and procedures based on the EPP. Review of agency documents failed to include policies and procedures based on the EPP.”

“Based on interview and policy review the Hospice failed to develop and implement emergency preparedness (EPP) policies and procedures to follow up with on duty staff and patients to determine services that are needed and failed include a policy to inform State and local officials of any on-duty staff or patients that they are unable to contact in the event that there is an interruption in services during or due to an emergency. This deficient practice has the potential to place patients at risk for harm during an emergency situation. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM, the Administrator was interviewed about the EPP. The Administrator stated that there were no procedures to follow up with on duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency for the EPP. Review of agency documents failed to show procedures to follow up with on duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency for the Emergency Preparedness Program.”

“Based on interview and policy review the Hospice failed to develop and implement policies and procedures to track the location of on-duty staff and sheltered patients in the agencys care during an emergency. This deficient practice has the potential to place staff and patients at risk for harm during an emergency situation. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM, the Administrator was interviewed about the Emergency Preparedness Program (EPP). The Administrator stated that there were no policies and procedures to track the location of on-duty staff and sheltered patients in the agencys care during an emergency. Review of agency documents failed to show policies and procedures to track the location of on-duty staff and sheltered patients in the facilitys care during an emergency.”

“Based on interview and policy review the Hospice failed to develop and implement emergency preparedness program (EPP) policies and procedures to inform State and local emergency preparedness officials about homebound hospice patients in need of evacuation. This deficient practice place patients at risk for harm during an emergency situation. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM, the Administrator was interviewed about the EPP. The Administrator stated that there was no policy which addressed the procedures to inform State and local emergency preparedness officials about homebound Hospice patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment for the EPP. Review of agency documents failed to show a policy or plan which addressed the procedures to inform State and local emergency preparedness officials about homebound Hospice patients in need of evacuation from their residences.”

“Based on interview and policy review the Hospice failed to develop and implement policies and procedures for a means to shelter in place for patients, staff, and volunteers. This deficient practice has the potential to place staff and patients at risk for harm during an emergency situation. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM, the Administrator was interviewed about the Emergency Preparedness Program (EPP). The Administrator stated that there were no policies and procedures for a means to shelter in place for patients, staff, and volunteers. Review of agency documents failed to show policies and procedures for a means to shelter in place for patients, staff, and volunteers.”

“Based on interview and policy review the Hospice failed to develop and implement policies and procedures for a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. This deficient practice has the potential to result in disruption in the continuity of care and patient protected health information being mishandled. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM, the Administrator was interviewed about the EPP. The Administrator stated that there were no policies and procedures for a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. Review of agency documents failed to show policies and procedures for a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.”

“Based on interview and policy review the Hospice failed to develop and implement policies and procedures for the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. Failure to address the use of volunteers in an emergency could adversely impact patient care during an emergency. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM, the Administrator was interviewed about the Emergency Preparedness Program (EPP). The Administrator stated that there were no policies and procedures for the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. Review of agency documents failed to show policies and procedures for the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency for the Emergency Preparedness Program.”

“Based on interview and policy review the Hospice failed to develop and implement policies and procedures for the development of arrangements with other providers to receive patients in the event of limitations or cessation of operations to maintain continuity of services for the patients. This deficient practice places patients at risk for the loss of care and services during an emergency situation. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM, the Administrator was interviewed about the Emergency Preparedness Program (EPP). The Administrator stated that there were no policies and procedures for agreements with other agencies and facilities for the transfer of patients in the event of an emergency. Review of agency documents failed to show policies and procedures for agreements with other agencies and facilities for the transfer of patients in the event of an emergency.”

“Based on interview and policy review the Hospice failed to develop and implement policies and procedures to describe its role, under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in providing care at alternate care sites during an emergency. This deficient practices places patients at risk for the loss of care and services during an emergency situation. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM, the Administrator was interviewed about the Emergency Preparedness Program (EPP). The Administrator stated that there were no policies and procedures to describe its role in providing care at alternate care sites during an emergency. Review of agency documents failed to show policies and procedures to describe its role in providing care at alternate care sites during an emergency for the Emergency Preparedness Program.”

“Based on interview and policy review the Hospice failed to develop and implement a communication plan which included all of the names and contact information for hospice employees, entities providing services under arrangement, patients’ physicians, and other hospices. This deficient practice has the potential to place patients, staff and others at risk for the loss of communication and contact during an emergency situation. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM, the Administrator was interviewed about the Emergency Preparedness Program (EPP). The Administrator stated that there was not a communication plan which included all of the names and contact information for the hospice employees, entities providing services under arrangement, patients’ physicians and other hospices. Review of agency documents failed to show a communication plan which includes all of the names and contact information for the hospice employees, entities providing services under arrangement, patients’ physicians and other hospices.”

“Based on interview and policy review the Hospice failed to develop an emergency officials contact list. Failure to have an emergency officials contact list during an emergency could lead to harm to both patients and staff if specific Federal, State, tribal, regional, and local emergency preparedness staff or other sources of assistance are not known if the need to contact them should arise. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM, the Administrator was interviewed about the Emergency Preparedness Program (EPP). The Administrator stated that there was no emergency official contact list for the EPP. Review of agency documents failed to show an emergency officials contact list.”

“Based on interview and policy review the Hospice failed to develop and implement emergency preparedness policies and procedures to develop a communication plan that included method of sharing information and medical documentation. This deficient practice places patients at risk for the loss of continuity of care and services. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM, the Administrator was interviewed about the Emergency Preparedness Program (EPP). The Administrator stated that there were no policies or procedures for sharing information and medical documentation for the EPP. Review of agency documents failed to show policies or procedures for sharing information and medical documentation.”

“Based on documentation review and interview, the facility failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, its risk assessment and the communication plan. Failure to develop and maintain an EPP training and testing program has to potential to place staff and patients at risk harm during an emergency situation. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM, the Administrator was interviewed about the Emergency Preparedness Program (EPP). The Administrator stated that there was no training and testing program based on the emergency plan, its risk assessment or the communication plan. Review of agency documents failed to show a training and testing program that is based on the emergency plan, its risk assessment and the communication plan.”

“Based on document review and staff interview, the Hospice failed to provide initial and annual training of the emergency preparedness policies and procedures that are consistent with their roles in an emergency to all new staff, existing staff and individuals providing services under arrangement. This includes any other individuals who provide services on an intermittent basis and would be expected to assist during an emergency. This deficient practice has the potential to place patients at risk for harm during an emergency situation. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM, the Administrator was interviewed about the Emergency Preparedness Program (EPP). The Administrator stated that there was no training and testing program for the Emergency Preparedness Program. Review of agency documents failed to show a training and testing program for the Emergency Preparedness Program.”

“Based on interview and document review the Hospice failed to participate in a full-scale community-based emergency preparedness program (EPP) exercise or conduct an annual facility-based functional exercise in the past 2 years. Failure to participate in or conduct an EPP exercise has the potential to place staff and patients at risk for harm during an emergency situation. Findings Include: On 11/09/23 between at 12:00 PM and 1:00 PM, the Administrator was interviewed about the Emergency Preparedness Program (EPP). The Administrator stated that there was no full-scale community-based emergency preparedness exercise conducted in the past 2 years for the Emergency Preparedness Program. Review of agency documents failed to show full-scale community-based emergency preparedness exercise which was conducted in the past 2 years.”

“Based on interview, record review, and agency policy review, the agency failed to ensure licensed practical nurse (LPN) staff were supervised at least every 30 days by a registered nurse (RN) for 1 (Patient 3) of 3 patients reviewed. Findings Include:Review of an agency policy titled, “;Supervision: Clinical Staff,” with an effective date of 09/2019, revealed, “;2. LPN staff shall be supervised: At least every patient every 30 days by a RN.”Review of Patient 3s record revealed LPN visits occurred on 09/08/23, 09/12/23, 09/15/23, 09/22/23, 09/26/23, 09/29/23, 10/07/23, 10/10/23, 10/13/23, 10/19/23, and 10/24/23 with no supervisory visits made within the 46 days that elapsed between the first and last identified visits. During an interview on 11/09/23 at 3:00 PM, the Administrator stated, “;I know we had trouble getting the supervisory visits coded correctly in the chart so some of the LPN supervisory visits were missed.””