Amara Hospice, LLC

“Based on record review and interview, the agency failed to maintain an emergency preparedness plan centered on both agency-based and community-based risk assessments, resulting in a lack of direction and duties for agency personnel in the event of an actual disaster. This deficient practice has the potential to negatively affect the health and safety of all patients serviced by this agency. Findings include: On 4/25/24, the agencys Emergency Preparedness binder was reviewed. There were no dates listed on the emergency plan or evidence the plan had been reviewed or updated every 2 years. This finding was reviewed and acknowledged by the administrator (Staff A) during an interview on 4/29/24 at 12:45 p.m.”

“Based on record review and interview, the agency failed to maintain, review, and update the written emergency preparedness communication plan, resulting in the agency’s inability to implement appropriate emergency actions. This deficient practice has the potential to negatively affect the health and safety of all patients serviced by this agency. Findings include: On 4/25/24, the agencys Emergency Preparedness binder was reviewed. The binder contained an outdated staff list and failed to include multiple new staff including the administrator, clinical director, associate medical director, nurse case managers, hospice aides, and patient relations manager. This finding was reviewed and acknowledged by the administrator (Staff A) during an interview on 4/29/24 at 12:45 p.m.”

“Based on record review and interview, the agency failed to conduct exercises to test the emergency plan, resulting in the agency’s inability to implement appropriate emergency actions. This deficient practice has the potential to negatively affect the health and safety of all patients serviced by this agency. Findings include: On 4/25/24, the agencys Emergency Preparedness binder was reviewed. There was no documentation to indicate the agency had conducted a community-based, facility-based, or table-top exercise to test the emergency plan. This finding was reviewed and acknowledged by the administrator (Staff A) during an interview on 4/29/24 at 12:45 p.m.”

“Based on record review and interview, the agency failed to ensure all members of the interdisciplinary group completed the comprehensive assessment within 5 days in 3 (P-4, 6, 9) of 16 records reviewed, resulting in the potential for unidentified and unmet care needs. Findings include: P-6: This 54-year-old patient was admitted to this hospice agency on 2/20/24 with the terminal diagnoses of cirrhosis of the liver and chronic obstructive pulmonary disease (COPD). During record review on 4/24/24, it was noted the social worker started the evaluation for this patient on 2/21/24. Upon further review of the record, it was noted the evaluation was labeled as a late entry and was not completed until 2/28/24 – 8 days after the start of care. The Administrator (Staff A) was asked when the comprehensive assessment should have been completed during an interview on 4/29/24 at 1:00 PM. Staff A reported the comprehensive assessment should be completed within 5 days of the start of care. Staff A also reported staff is supposed to have documentation completed by 9:00 AM the day after the visit. As a result of the late documentation, the comprehensive assessment was not completed on time. P-9: This 79-year-old patient was admitted to this hospice agency on 2/3/24 with the terminal diagnosis of congestive heart failure (CHF) and hypertension (high blood pressure). During record review on 4/29/24, it was noted there was no evaluation done by the social worker. During an interview on 4/29/24 at 1:00 PM, Staff A was queried whether there was documentation regarding why the social work evaluation was not completed. Staff A reported she was unable to locate documentation of an attempted appointment or any missed visits/refusals by the patient. Staff A was unsure why it was not completed and acknowledged the findings. P-4: This 69-year-old patient was admitted to hospice on 3/11/24 with a terminal diagnosis of breast cancer. During record review on 4/24/24, it was noted that the plan of care dated 3/11/24, ordered a medical social worker (MSW) evaluation. The initial MSW visit note is dated 4/5/24, 26 days after the election of hospice care. There was no evidence the physician was notified or the reason for delay. This finding was reviewed and acknowledged by the administrator (Staff A) and patient relations manager (Staff B) during an interview on 4/29/24 at 12:30 p.m.”

“Based on record review and interview, the agency failed to ensure the comprehensive assessment included the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed to promote the well-being, comfort, and dignity of the patient in 1 (P-8) of 16 records reviewed, resulting in the potential for unmet care needs. Findings include: P-8: This 39-year-old patient was admitted to this hospice agency on 4/10/23 with the terminal diagnosis of congestive heart failure (CHF). During record review on 4/24/24, it was noted the registered nurse identified several concerns on the start of care assessment completed on 4/10/23. These included a number of safety concerns in the home (including unsafe cooking facilities, pest/rodent/insect infestation, inadequate disposal of trash); disheveled dress, body odor, and unclean hair or body; anxiety and depression; financial stress and stressed family relationships; and difficulty with activities of daily living. The narrative assessment section written by the registered nurse also reported: “;Pt could utilize a air mattress and bed related to him sleeping on floor but theres no room in house to fit the equipment. Pt very disholved on admission and ashamed. Very hard to shower related to house layout. Needs 6 out of 6 assistance. Pt very depressed with situations he is dealing with. Pts father is passing. Wife on hospice. He feels like a failure.” [sic] Upon review of the social work evaluation dated 4/11/23, it was noted that although some areas were briefly addressed as present, the narrative assessment section summarizing the patient after the evaluation stated: “;SW visited patient at home. Wife was present for visit. Patient was alert and oriented to person, place, and time. Patient stated some pain. Patient stated no concerns at this time,” and “;SW and nurse have discussed unsanitary living conditions.” The Administrator (Staff A) was interviewed on 4/29/24 at 1:00 PM regarding the information in the social work evaluation after reading the concerns identified by the registered nurse. Staff A acknowledged the social work evaluation did not include adequate information to assess the patients current needs. Staff A reported she remembered this case and agreed the social work evaluation should have included more information about his situation and psychosocial needs in order to better serve him. She acknowledged the findings at the time of interview.”

“Based on observation, interview and record review, the agency failed to ensure the initial bereavement assessment identified the social, spiritual and cultural needs of all family members and other individuals that may be affected by the patient’s death in 15 (P-2, 4, 5, 6, 7, 8, 9, 11, 13, 14, 15, 16, 17, 18, 19) records, from a total of 19 records reviewed, which included 3 bereavement records, resulting in the potential for unmet needs for bereavement support and grieving during the end of life. Findings include: P-11: The start of care (SOC) date was 3/12/24, with diagnoses of hypertension, chronic obstructive pulmonary disease and respiratory failure. During record review on 4/25/24, it was discovered that the agency failed to document a bereavement assessment in the patient’s record. During an interview on 4/29/24 at 1:30 p.m., the administrator (Staff A) and the Patient Relations Manager (Staff B) acknowledged the above findings. P-6: This 54-year-old patient was admitted to this hospice agency on 2/20/24 with the terminal diagnoses of cirrhosis of the liver and chronic obstructive pulmonary disease (COPD). During record review on 4/24/24, it was noted there was no initial bereavement assessment located in the record. The Administrator (Staff A) was asked to locate the initial bereavement assessment during an interview on 4/29/24 at 1:00 PM. Staff A reviewed the record and reported that no initial bereavement assessment had been completed for this patient. P-7: This 83-year-old patient was admitted to this hospice agency on 2/1/24 with the terminal diagnosis of Parkinsons Disease. During record review on 4/24/24, it was noted there was no initial bereavement assessment located in the record. Staff A was asked to locate the initial bereavement assessment during an interview on 4/29/24 at 1:00 PM. Staff A reviewed the record and reported that no initial bereavement assessment had been completed for this patient. P-8: This 39-year-old patient was admitted to this hospice agency on 4/10/23 with the terminal diagnosis of congestive heart failure (CHF). During record review on 4/24/24, it was noted there was no initial bereavement assessment located in the record. Staff A was asked to locate the initial bereavement assessment during an interview on 4/29/24 at 1:00 PM. Staff A reviewed the record and reported that no initial bereavement assessment had been completed for this patient. P-9: This 79-year-old patient was admitted to this hospice agency on 2/3/24 with the terminal diagnosis of congestive heart failure (CHF) and hypertension (high blood pressure). During record review on 4/29/24, it was noted there was no initial bereavement assessment located in the record. Staff A was asked to locate the initial bereavement assessment during an interview on 4/29/24 at 1:00 PM. Staff A reviewed the record and reported that no initial bereavement assessment had been completed for this patient. Staff A acknowledged the findings at the time of interview. P-2: This 95-year-old patient was admitted to hospice on 10/16/23 with a terminal diagnosis of chronic obstructive pulmonary disease. During record review on 4/24/24, it was noted that the record failed to include an initial bereavement assessment. P-4: This 69-year-old patient was admitted to hospice on 3/11/24 with a terminal diagnosis of breast cancer. During record review on 4/24/24, it was noted that the record failed to include an initial bereavement assessment. P-5: This 85-year-old patient was admitted to hospice on 3/8/24 with a terminal diagnosis of hydrocephalus. During record review on 4/25/24, it was noted that the record failed to include an initial bereavement assessment. These findings were reviewed and acknowledged by the administrator (Staff A) and patient relations manager (Staff B) during an interview on 4/29/24 at 12:30 p.m. Policy: “Bereavement Care Planning”, (Effective 07/20) stated, “Procedure: 1. During the initial bereavement assessment, the IDG (Interdisciplinary Group) identifies family members, caregivers, or significant others who may be significantly impacted by the patients death. The initial bereavement assessment is updated during IDG meetings throughout the course of the patients care.” P-13: The Start of Care (SOC) was dated 2/16/24. The Plan of Care (POC) identified a terminal diagnosis of Alzheimers. During record review on 4/25/24, it was noted that a bereavement risk assessment was not completed. The agency failed to assess potential bereaved per policy. P-14: The Start of Care (SOC) was dated 1/25/24. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 4/24/24, it was noted that the bereavement risk assessment was completed by the MSW on 3/4/24 for the patients nephew/DPOA (Durable Power of Attorney). On 2/16/24, Staff F documented a narrative note stating, “;...Nephew reports he and wife are out of state...” The bereavement risk assessment failed to include the patients nephews wife. P-15: The Start of Care (SOC) was dated 1/29/24. The Plan of Care (POC) identified a terminal diagnosis of Parkinsons. During record review on 4/24/24, it was noted that the bereavement risk assessment was completed by the MSW on 3/13/24 for the patients Husband. On 3/7/24, Staff G documented a narrative note stating, “;...Patients husband and daughter at bedside and grieving appropriately...” The bereavement risk assessment failed to include the patients daughter. P-16: The Start of Care (SOC) was dated 10/5/23. The Plan of Care (POC) identified a terminal diagnosis of Chronic Obstructive Pulmonary Disease. During record review on 4/23/24, it was noted that a bereavement risk assessment was not completed. The agency failed to assess potential bereaved per policy., P-17: During a bereavement record review on 4/24/24, it was noted that the bereavement risk assessment was completed by the MSW on 3/6/24 for the patients son. On 3/14/24, Staff H documented a narrative note stating, “;...Patients husband at bedside and very tearful...” The bereavement risk assessment failed to include the patients husband. P-18: During a bereavement record review on 4/24/24, it was noted that the bereavement risk assessment was completed by the MSW on 3/26/24 for the patients son. On 3/26/24, Staff I documented a narrative note stating, “;...Patient and husband both participated in the music therapy assessment...” The bereavement risk assessment failed to include the patients husband. P-19: During a bereavement record review on 4/24/24, it was noted that the bereavement risk assessment was completed by the MSW on 7/18/23 for the patients daughter. On 7/31/23, On-call documented a narrative note stating, “;Received a call from the cremation of Bay City that they can not get a hold of husband. They need to get a hold of the DPOA.” The bereavement risk assessment failed to include the patients husband. These findings were reviewed with and acknowledged by the Staff A (Administrator) and Staff B (Patient Relations Manager) during an interview on 4/29/24 at 12:15 pm.”

“Based on record review and interview, it was determined the hospice failed to include safety precautions on the plan of care (POC) for 4 records (P-6, 9, 10, 11), out of a total sample of 16 records reviewed, resulting in the potential for negative patient outcomes. Findings include: P-10: The start of care (SOC) date was 4/21/24 with diagnoses of weakness, hypertension and congestive heart failure. During record review on 4/24/24, it was discovered that the POC ordered oxygen therapy. The POC failed to include oxygen safety precautions. P-11: The SOC date was 3/12/24 with diagnoses of hypertension, chronic obstructive pulmonary disease and respiratory failure. During record review on 4/25/24, it was discovered that the POC ordered oxygen therapy. The POC failed to include oxygen safety precautions. During an interview on 4/29/24 at 1:30 p.m., the administrator (Staff A) and the Patient Relations Manager (Staff B) acknowledged the above findings. P-6: This 54-year-old patient was admitted to this hospice agency on 2/20/24 with the terminal diagnoses of cirrhosis of the liver and chronic obstructive pulmonary disease (COPD). During record review on 4/24/24, it was noted the plan of care (POC) ordered oxygen therapy under medications. The POC failed to include oxygen safety precautions. P-9: This 79-year-old patient was admitted to this hospice agency on 2/3/24 with the terminal diagnosis of congestive heart failure (CHF) and hypertension (high blood pressure). During record review on 4/29/24, it was noted the POC ordered oxygen therapy under medications. The POC failed to included oxygen safety precautions. The Administrator (Staff A) acknowledged the findings during an interview on 4/29/24 at 1:00 PM.”

“Based on record review and interview, the hospice failed to ensure services were provided at the frequency ordered in the plan of care for 2 of 12 (P-13, 14) from a total sample of 16 records reviewed, resulting in the patient not receiving care as ordered. Findings include: **Agency Policy: Plan of Care (Effective 7/20) states, “Procedure: The patients plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments of the patient.” P-13: The Start of Care (SOC) was dated 2/16/24. The Plan of Care (POC) identified a terminal diagnosis of Alzheimers. During record review on 4/25/24, it was noted that the POC ordered Massage and Music therapy to eval and treat. The record failed to contain any documentation of completed visits or refused visits for Massage and Music therapy. Staff A (Administrator) stated during an interview on 4/29/24 at 12:15 pm, “;The Music and Massage therapy visits were never plotted, its a clinical side of things for visits to be scheduled.” The agency failed to provide services as ordered. P-14: The Start of Care (SOC) was dated 1/25/24. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 4/24/24, it was noted that the Hospice Aide (HA) was ordered at a frequency of 4w1 (4 times a week for 1 week), 5w12. The HA failed to complete 5 of 5 visits during week 4 (2/11/24-2/17/24). The agency failed to provide services as ordered. These findings were reviewed with and acknowledged by the Staff A (Administrator) and Staff B (Patient Relations Manager) during an interview on 4/29/24 at 12:35 pm.”

“Based on record review and interview, it was determined the hospice failed to ensure the plan of care (POC) included patient specific measurable goals in 11 of 16 records reviewed (P- 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16) from a total sample of 16 records reviewed, which resulted in the potential for unmet patient care needs. Findings include: P-10: The start of care (SOC) date was 4/21/24, with diagnoses of weakness, hypertension and congestive heart failure. During record review on 4/24/24, it was discovered that the POC failed to include measurable goals. One goal stated, “Patient/Caregiver verbalizes understanding of pain scale.” Another stated, “Patient/Caregiver verbalizes proper fall precautions.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-11: The SOC date was 3/12/24 with diagnoses of hypertension, chronic obstructive pulmonary disease and respiratory failure. During record review on 4/25/24, it was discovered that the POC failed to include measurable goals. One goal stated, “Patient/Caregiver dietary and fluid required to promote healing process and healthy skin.” Another stated, “Patient verbalizes tolerance to wound care.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-12: The SOC date was 1/6/24, with diagnoses of muscle weakness, malignant neoplasm of endometrium, and senile degeneration. During record review on 4/29/24, it was discovered that the POC failed to include measurable goals. One goal stated, “Patient/Caregiver has decreased fear/anxiety regarding death and dying process.” Another stated, “Patient/Caregiver verbalize positive interaction/memories.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. During an interview on 4/29/24 at 1:30 p.m., the administrator (Staff A) and the Patient Relations Manager (Staff B) acknowledged the above findings. P-13: The Start of Care (SOC) was dated 2/16/24. The Plan of Care (POC) identified a terminal diagnosis of Alzheimers. Upon review of the POC, it was noted the goals were not measurable. Examples of goals on this patient’s POC included: “A nursing plan of care will be established that meets the patients needs, Patient will experience symptom reduction, Patients personal care needs will be met.” The goals in this plan of care were not specific to the patient’s hospice needs, nor were the goals objectively measurable to determine if the patient was progressing toward meeting each goal. P-14: The Start of Care (SOC) was dated 1/25/24. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. Upon review of the POC, it was noted the goals were not measurable. Examples of goals on this patient’s POC included: “A nursing plan of care will be established that meets the patients needs, Patient will experience symptom reduction, Patient will maintain optimal cardiac function within constraints of disease, Caregiver(s) are knowledgeable of care and need to report changes of LOC (Level of Consciousness).” The goals in this plan of care were not specific to the patient’s hospice needs, nor were the goals objectively measurable to determine if the patient was progressing toward meeting each goal. P-15: The Start of Care (SOC) was dated 1/29/24. The Plan of Care (POC) identified a terminal diagnosis of Parkinsons. Upon review of the POC, it was noted the goals were not measurable. Examples of goals on this patient’s POC included: “A nursing plan of care will be established that meets the patients needs, Patient will experience symptom reduction, Patient will receive personal care and hygiene, including other activities of daily living.” The goals in this plan of care were not specific to the patient’s hospice needs, nor were the goals objectively measurable to determine if the patient was progressing toward meeting each goal. P-16: The Start of Care (SOC) was dated 10/5/23. The Plan of Care (POC) identified a terminal diagnosis of Chronic Obstructive Pulmonary Disease. Upon review of the POC, it was noted the goals were not measurable. Examples of goals on this patient’s POC included: “A nursing plan of care will be established that meets the patients needs, Patient will experience symptom reduction, Patient/Caregiver will demonstrate independence in administration of ordered inhalation therapy and care for equipment as a result of skilled instruction.” The goals in this plan of care were not specific to the patient’s hospice needs, nor were the goals objectively measurable to determine if the patient was progressing toward meeting each goal. These findings were reviewed with and acknowledged by the Staff A (Administrator) and Staff B (Patient Relations Manager) during an interview on 4/29/24 at 12:25 pm. P-6: This 54-year-old patient was admitted to this hospice agency on 2/20/24 with the terminal diagnoses of cirrhosis of the liver and chronic obstructive pulmonary disease (COPD). During record review on 4/24/24, it was determined the goals were not measurable. Examples on this patients plan of care (POC) included: “;Patient tolerates administration of pain medications, understands the pain scale, medication regimen, including administration and potential side effects” and “;Patients stress/anxiety is reduced to level of comfort.” These goals are not specific to the patient, nor did they include objectively measurable data to determine the patients progress towards meeting each goal. P-7: This 83-year-old patient was admitted to this hospice agency on 2/1/24 with the terminal diagnosis of Parkinsons Disease. During record review on 4/24/24, it was determined the goals were not measurable. Examples on this patients POC included: “;Patient verbalize tolerance to catheter insertion” and “Patient tolerates assessment of sensory/neurological status.” These goals are not specific to the patient, nor did they include objectively measurable data to determine the patients progress towards meeting each goal. P-8: This 39-year-old patient was admitted to this hospice agency on 4/10/23 with the terminal diagnosis of congestive heart failure (CHF). During record review on 4/24/24, it was determined the goals were not measurable. Examples on this patients POC included: “;Patient tolerates administration of pain medications, understands the pain scale, medication regimen, including administration and potential side effects” and “;Patient discusses lifes experiences.” These goals are not specific to the patient, nor did they include objectively measurable data to determine the patients progress towards meeting each goal. P-9: This 79-year-old patient was admitted to this hospice agency on 2/3/24 with the terminal diagnosis of congestive heart failure (CHF) and hypertension (high blood pressure). During record review on 4/29/24, it was determined the goals were not measurable. Examples on this patients POC included: “Patient/caregiver(s) verbalized understanding of proper safety measures related to fall awareness” and “;Patients respirator status is stabilized to comfort within realms of disease.” These goals are not specific to the patient, nor did they include objectively measurable data to determine the patients progress towards meeting each goal. Findings were reviewed with and acknowledged by the Administrator (Staff A) during an interview on 4/29/24 at 1:00 PM.”

“Based on record review and interview, the agency failed to ensure care services were provided in accordance with the plan of care in 1 (P-8) of 16 records reviewed, resulting in the potential for unmet care needs. Findings include: P-8: This 39-year-old patient was admitted to this hospice agency on 4/10/23 with the terminal diagnosis of congestive heart failure (CHF). During record review on 4/24/24, the certification period from 7/9/23 to 9/26/23 was reviewed. It was noted the plan of care dated 7/9/23 ordered skilled nursing services 1 time per week. Upon further review of the record and visit notes, it was determined there was no skilled nursing visits the week of 7/9/23, 7/16/23, and 8/6/23. There was a missed visit note written for 7/9/23 and 7/16/23 that stated: “;Must document if rescheduling visit and/or that MD has been called for notification of alteration in the ordered visit pattern (document name/title of who you speak with at MD office). Duplicate.” There was no indication of attempts to reschedule the patient or of the doctor being notified. There was no missed visit note recorded for the week of 8/6/23. The Administrator (Staff A) was interviewed on 4/29/24 at 1:00 regarding her expectation on missed visits. Staff A stated the staff is to document a note, attempt to reschedule the patient, and contact the doctor regarding the change in frequency if the visit cannot be made up. Staff A acknowledged the findings at the time of interview.”

“Based on record review and interview, it was determined that the hospice failed to ensure the Quality Assessment Performance Improvement program demonstrated measurable improvement in patient outcomes and hospice services affecting all 228 patients admitted in the past 12 months, resulting in the potential for poor patient outcomes. Findings include: **Agency policy: AD.Q20 Quality Assessment and Performance Improvement – Program (QAPI), undated, states, “1. The performance improvement program: c. Focuses on indicators related to improved palliative outcomes and is capable of showing measurable improvements in indicators. It was revealed during review of the QAPI folder on 4/25/24 that there was no data collected for quarter 3 and quarter 4 of 2023, thus the agency failed to show measurable improvements for the QAPI program. This finding was reviewed with and acknowledged by the Staff A (Administrator) during an interview on 4/29/24 at 12:25 pm.”

“Based on record review and interview, the hospice failed to ensure the registered nurse prepared written patient care instructions for the aide that included safety precautions pertinent to the needs of the patient for 10 (P-1, 2, 3, 5, 10, 11, 13, 14, 15, 16) of 15 records reviewed with aide services, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-10: The start of care (SOC) date was 4/21/24, with diagnoses of weakness, hypertension and congestive heart failure. During record review on 4/24/24, it was discovered that the plan of care (POC) ordered oxygen therapy and home health aide services. The aide care plan dated 4/21/24 failed to include oxygen precautions. P-11: The SOC date was 3/12/24 with diagnoses of hypertension, chronic obstructive pulmonary disease and respiratory failure. During record review on 4/25/24, it was discovered that the POC ordered oxygen therapy and home health aide services. The aide care plan dated 3/12/24 failed to include oxygen precautions. During an interview on 4/29/24 at 1:30 p.m., the administrator (Staff A) and the Patient Relations Manager (Staff B) acknowledged the above findings. P-13: The Start of Care (SOC) was dated 2/16/24. The Plan of Care (POC) identified a terminal diagnosis of Alzheimers. During record review on 4/25/24, it was noted that the “Aide Care Plan” dated 2/16/24 completed by the Registered Nurse (RN) contained no safety precautions. The Aide Care Plan failed to include the necessary safety measure and precautions to alert the aide of the patient’s health concerns. P-14: The Start of Care (SOC) was dated 1/25/24. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 4/24/24, it was noted that the “Aide Care Plan” dated 1/25/24 completed by the RN contained no safety precautions. The Aide Care Plan failed to include the necessary safety measure and precautions to alert the aide of the patient’s health concerns. P-15: The Start of Care (SOC) was dated 1/29/24. The Plan of Care (POC) identified a terminal diagnosis of Parkinsons. During record review on 4/24/24, it was noted that the “Aide Care Plan” dated 1/29/24 completed by the RN contained no safety precautions. The Aide Care Plan failed to include the necessary safety measure and precautions to alert the aide of the patient’s health concerns. P-16: The Start of Care (SOC) was dated 10/5/23. The Plan of Care (POC) identified a terminal diagnosis of Chronic Obstructive Pulmonary Disease. During record review on 4/23/24, it was noted that the “Aide Care Plan” dated 10/5/23 completed by the RN contained no safety precautions. The Aide Care Plan failed to include the necessary safety measure and precautions to alert the aide of the patient’s health concerns. These findings were reviewed with and acknowledged by the Staff A (Administrator) and Staff B (Patient Relations Manager) during an interview on 4/29/24 at 12:35 pm. P-1: This 85-year-old patient was admitted to hospice on 6/24/33 with a terminal diagnosis of endometrial cancer. The 6/24/23 aide care plan created by the registered nurse instructed the aide to perform personal care every visit. During record review on 4/23/24, it was noted that the patient was on Eliquis, a blood thinner, and oxygen as needed. The aide plan of care failed to include safety precautions. P-2: This 95-year-old patient was admitted to hospice on 10/16/23 with a terminal diagnosis of chronic obstructive pulmonary disease. The 1/16/24 aide care plan created by the registered nurse instructed the aide to perform personal care every visit. During record review on 4/24/24, it was noted that the plan of care indicated patient “;needs max assist with standing” and had a history of multiple falls. The aide plan of care failed to include safety precautions. P-3: This 41-year-old patient was admitted to hospice on 3/4/24 with a terminal diagnosis of frontotemporal dementia. The 3/5/24 aide care plan created by the registered nurse instructed the aide to perform personal care every visit. During record review on 4/24/24, it was noted that the patient had a history of seizures and was ordered oxygen as needed. The aide plan of care failed to include safety precautions. P-5: This 85-year-old patient was admitted to hospice on 3/8/24 with a terminal diagnosis of hydrocephalus. The 4/4/24 aide care plan created by the registered nurse instructed the aide to perform personal care every visit. During record review on 4/25/24, it was noted the patient has a history of confusion and combative behavior. The aide plan of care failed to include safety precautions. These findings were reviewed and acknowledged by the administrator (Staff A) and patient relations manager (Staff B) during an interview on 4/29/24 at 12:30 p.m.”

“Based on record review and interview, the agency failed to ensure on-site visits were made no less than every 14 days to assess the quality of care provide by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient needs in 3 (P-3, 8, 9) of 16 records reviewed, resulting in unsupervised hospice aide care and the potential for unmet care needs. Findings include: **Policy titled “;Hospice Aide Supervision” (dated 7/20) stated, “;1. A registered nurse makes and on-site visit to the patients home no less frequently than every 14 days to ensure that the services ordered by the IDG and provided by the hospice aide are meeting the patients need.” P-8: This 39-year-old patient was admitted to this hospice agency on 4/10/23 with the terminal diagnosis of congestive heart failure (CHF). During record review on 4/24/24, it was noted a supervisory visit was performed by the registered nurse on 6/20/23. The next time a supervisory visit was conducted by the registered nurse was 8/21/23 – 62 days after the last supervisory visit. During this time, the aide completed 23 visits without supervision. The registered nurse did complete visits on 8/1/23 and 8/16/23, however, the section that asked, “;Were supervisory functions performed?” was marked “;No” and the reason was reported as “;Not applicable to todays visit.” P-9: This 79-year-old patient was admitted to this hospice agency on 2/3/24 with the terminal diagnosis of congestive heart failure (CHF) and hypertension (high blood pressure). During record review on 4/29/24, it was noted a supervisory visit was performed by the registered nurse on 2/9/24. The next time a supervisory visit was conducted by the registered nurse was 3/1/24 – 21 days after the last supervisory visit. The registered nurse did complete visits on 2/16/24 and 2/23/24, however, the section that asked, “;Were supervisory functions performed?” was marked “;No” and the reason was reported as “;Not applicable to todays visit.” The Administrator (Staff A) acknowledged the findings during an interview on 4/29/24 at 1:00 PM. P-3: This 41-year-old patient was admitted to hospice on 3/4/24 with a terminal diagnosis of frontotemporal dementia. During record review on 4/24/24, it was noted that the plan of care ordered skilled nursing twice a week for one week, then once a week and hospice aide services five times a week. The registered nurse (RN) had visited the patient ten times over 8 weeks and failed to conduct a supervisory visit for the aide, charting supervisory functions were “;not appropriate at time of evaluation.” This finding was reviewed and acknowledged by the administrator (Staff A) and patient relations manager (Staff B) during an interview on 4/29/24 at 12:30 p.m.”

“Based on record review and interview, the agency failed to provide evidence of volunteer orientation and training for 4 of 4 volunteers whose personnel files were reviewed, resulting in the potential for unsafe practices and unmet care needs. Findings include: **Policy titled “;Volunteers – Services” (dated 7/20) stated, “;5. Volunteers are required to complete an orientation and training program prior to assignment to patients and caregivers” and “;6. A personnel file is maintained for each volunteer that contains prescribed contents.” The Volunteer Coordinator (Staff E) was interviewed over the phone on 4/29/24 at 12:00 PM regarding the agencys volunteer program. During the interview, Staff E was asked where volunteer personnel files were kept to review documentation of training received prior to starting with the agency. Staff E stated she thought personnel files were kept at the extension location, but she was unsure. The Administrator (Staff A) was asked to locate the files on 4/29/24 at 12:30 PM. Staff A stated she would contact the other location to see if the information could be sent via e-mail. During a second interview on 4/29/24 at 2:30 PM prior to the exit interview, Staff A reported she had not received information regarding volunteer orientation and training. She acknowledged the findings.”

“Based on record review and interview, the agency failed to demonstrate viable and ongoing efforts to recruit and retain volunteers, resulting in the potential for unfulfilled patient volunteer requests. Findings include: **Policy titled “;Volunteers – Services” (dated 7/20) stated, “;Recruitment efforts are sufficient to ensure that the hospice has enough volunteers to meet the needs of patients and families and the requirements of Federal regulations.” The Volunteer Coordinator (Staff E) was interviewed over the phone on 4/29/24 at 12:00 PM regarding the agencys volunteer program. During the interview, Staff E was asked to provide documented evidence of her efforts to recruit and retain volunteers. Staff E stated she tells her boss what she is doing, however, she does not keep a record of her activities. The Administrator (Staff A) was asked if she kept a record of the recruitment activities reported to her during an interview on 4/29/24 at 1:00 PM. Staff A was unable to provide documented evidence of recruitment efforts. Staff A acknowledged the findings.”

“Based on record review and interview, the agency failed to document the cost savings achieved through the use of volunteers, resulting in a lack of accurate information on how volunteer usage can result in cost savings for the agency. Findings include: **Policy titled “;Volunteers – Services” (dated 7/20) stated, “;10. The Volunteer Coordinator maintains records of volunteer activity and records levels of volunteer participation and cost-savings on a monthly and annual basis.” The Volunteer Coordinator (Staff E) was interviewed over the phone on 4/29/24 at 12:00 PM regarding the agencys volunteer program, including identification of each position held by a volunteer, work time spent by volunteers and an estimated dollar amount the agency would have incurred if paid employees occupied these positions. During the interview, Staff E was asked to provide documentation regarding cost-savings the agency achieved by the usage of volunteers. Staff E stated she does not have this information and acknowledged the findings. The Administrator also acknowledged the findings during an interview on 4/29/24 at 1:00 PM.”

“Based on record review and interview, the agency failed to ensure volunteers provided administrative and/or direct patient care services in the amount that equals at least 5% of the total patient care hours of all paid hospice and contract staff, resulting in the lack of cost-savings for the agency. Findings include: **Policy titled “;Volunteers – Services” (dated 7/20) stated, “;10. The Volunteer Coordinator maintains records of volunteer activity and records levels of volunteer participation and cost-savings on a monthly and annual basis.” The Volunteer Coordinator (Staff E) was interviewed over the phone on 4/29/24 at 12:00 PM regarding the agencys volunteer program. During the interview, Staff E was asked if she had documentation to show the percentage of hours the volunteers provided for 2024. Staff E stated she had been on medical leave and did not have any data collected to show the use of volunteers. The Administrator (Staff A) was asked if she had data collected regarding the use of volunteers during Staff Es absence. Staff A reported she did not have any data collected and acknowledged the findings.”

“Based on record review and interview, the agency failed to ensure the clinical records included appropriate clinical notes to document the care provided in 1 (P-8) of 16 records reviewed, resulting in the potential for unmet care needs. Findings include: P-8: This 39-year-old patient was admitted to this hospice agency on 4/10/23 with the terminal diagnosis of congestive heart failure (CHF). During record review on 4/24/24, it was noted the narrative section of the social work note dated 8/3/23 stated, “;SW visited patient at assisted living facility. Patient was alert and oriented to person, place, and time. Patient stated no pain or concerns today.” Upon further review of the record, it was noted the narrative section of the social work notes dated 8/11/23, 8/25/23, 9/8/23, 9/14/23, and 9/21/23 had the same sentences written each time (with 1-2 words changed at most). It was also determined that each of these notes included the same 9 items listed under “;Interventions” and the same 6 items listed under “;Goals Met”, making it unclear as to what treatment was being provided by the social worker. The Administrator (Staff A) was interviewed on 4/29/24 at 1:00 PM regarding the information above. Staff A agreed it was unclear what treatment the social worked had provided for this patient and acknowledged the findings.”

“Based on record review and interview, it was noted that all visit notes completed within the Electronic Medical Record by all disciplines (Registered Nurses, Hospice Aides, Medical Social Workers, and Spiritual Counselors), were not authenticated in 16 of 16 patient chart reviews (P-1-16), resulting in not having knowledge of the authors credentials of each visit note who provided care to the patient. Findings included: **Agency Policy “;Documentation Requirements” (Effective 7/20). The policy states, “Policy: Members of the interdisciplinary group document the interventions provided to the patient/caregiver, their response to care, services provided and the goals or outcomes achieved. Procedure: 10. All documentation is signed using complete first and last name, credentials and title.” Example #1: P-13: The Start of Care (SOC) was dated 2/16/24. The Plan of Care (POC) identified a terminal diagnosis of Alzheimers. During record review on 4/25/24, upon review of the 61 visit notes for this patient which included visit notes from Registered Nurses (RN), Hospice Aides (HA), Medical Social Workers (MSW), and Spiritual Counselors (SC), the agency failed to document per policy the credentials and title of the staff member who completed the visit note to authenticate the clinical record. Example #2: P-15: The Start of Care (SOC) was dated 1/29/24. The Plan of Care (POC) identified a terminal diagnosis of Parkinsons. During record review on 4/24/24, upon review of the 50 visit notes for this patient which included visit notes from RN, HA, MSW, and SC, the agency failed to document per policy the credentials and title of the staff member who completed the visit note to authenticate the clinical record. These findings were reviewed with and acknowledged by the Staff A (Administrator) and Staff B (Patient Relations Manager) during an interview on 4/29/24 at 12:05 pm.”

“Based on document review and interview, the agency failed to ensure the clinical record contained a discharge summary concerning a patient’s revocation of hospice services in 1 (P-16) of 2 records reviewed, in which hospice services were revoked, from a total sample of 16 records reviewed, resulting in an incomplete clinical record for this patient. Findings include: Agency Policy: “Discharge from Hospice Services” (Effective 7/20) states, “;6. When a patient is discharged from hospice, the hospice provides a copy of the clinical record (if requested) and the hospice discharge summary to the patients attending physician. This discharge summary is filed in the clinical record and includes: ...B. a summary of the patients stay including treatments, and symptom and pain management.” P-16: The Start of Care (SOC) was dated 10/5/23. The Plan of Care (POC) identified a terminal diagnosis of Chronic Obstructive Pulmonary Disease. During record review on 4/23/24, it was noted that Staff J documented under Patient Disposition on 11/2/23, “;Discharge Reason: Discharged/transferred to a skilled nursing facility (SNF) with Medicare certification in anticipation of skilled care.” The EMR (Electronic Medical Record) did not contain a discharge summary. The clinical record failed to contain documentation of discharge summary per agency policy. These findings were reviewed with and acknowledged by the Staff A (Administrator) and Staff B (Patient Relations Manager) during an interview on 4/29/24 at 12:05 pm.”