Vitalcaring Group

“Based on staff interview, review of the facilitys worker roster, review of the facilitys contract services, review of the facilitys contracted employee list, review of the facilitys governing body meeting minutes, review of facility complaint log, and review of the facility policy and procedure, the facility failed to provide all nursing core services directly by hospice employees for one (1) of three (3) Registered Nurses (RN); RN #5. Findings Include: Interview with Regional Administrator on 03/12/2024 at 3:15 p.m., confirms the facility has no documented evidence of a waiver for contract nursing and the facility currently has one (1) contract nurse on staff providing patient care as a nurse coordinator. Review of the facilitys, “;Worker Roster,” reveals a list of three (3) RN coordinators who are responsible for the coordination of care and implementation of the interdisciplinary plan of care and further reveals Registered Nurse #5 is listed on the roster as a contract nurse. Review of the facilitys contract titled, “;HOME HEALTH MASTER STAFFING SERVICES AGREEMENT,” reveals a current staffing agreement for the provision of nursing services effective 07/07/2023. Review of the facilitys list of contracted employees for the past 12 months revealed six (6) contracted Registered Nurses utilized to provide direct patient care from 09/05/2023 to 03/12/2024. Review of the facilitys, “;Governing Body Meeting Minutes,” dated 08/10/2023 for second quarter, 11/09/2023 for third quarter, and 02/05/2024 for the fourth quarter revealed no documentation of staffing shortages, temporary need of supplemental staffing, recruitment and retention efforts, or any indicators for use of contracted nursing services for over a year. Review of the facilitys policy and procedure titled, “;Interdisciplinary Group (IDG/IDT)/Core Services,” numbered LD.35, last review date 10/01/21, revealed, “;... II. The Hospice will routinely provide substantially all core services directly by hospice employees ... III. The Hospice may use contracted staff, if necessary, to supplement employees in order to meet the needs of patients only under extraordinary or other non-routine circumstances, as defined in the Federal Conditions of Participation, 418.64, Procedure I. The Hospice will establish and maintain a group of professional individuals, the core group, who are employees of the hospice and will provide substantially all core services...”. During Exit conference on 03/14/2024 at 3:30 p.m. with Clinical Care Manager, Quality and Education Manager, Branch Director, Vice President of Operations, and Regional Administrator, survey findings were discussed, and no further documentation was submitted for review.”

“Based on staff interviews, bereavement record reviews, and review of the facilitys bereavement policy/procedures, the facility failed to have an organized bereavement program under the supervision of a qualified professional and failed to ensure bereavement services were available to the patients family for up to one (1) year following the death of the patient on four (4) of four (4) days of survey, three (3) of three (3) bereavement records reviewed; Patients #1, #2, #3. Findings include: Interview with Registered Nurse (RN) #4 on 03/13/2024 at 2:50 p.m. confirms no documented bereavement follow up since 01/2024 for Patient #1, #2, and #13. RN #4 further confirms that the Volunteer Coordinator was assigned responsibility for sending out the bereavement letters and the Branch Director was responsible for supervisory oversight of the bereavement program since the facility had no social worker at the time to provide oversight. Interview with Branch Director on 03/13/2024 at 3:30 p.m. confirmed the Branch Director does not have grief counseling certification or training required to coordinator the facilitys Bereavement Program. Review of the facilitys Bereavement Records titled, “;Bereavement Activity Report” and “;Bereavement Plan of Care,” for Patient #1, #2 and #13 revealed no documented evidence of follow up bereavement activity since 01/03/2024, and there is no documented evidence of 11 and 13 month bereavement letters as ordered per the Bereavement Plan of Care. Review of the facility policy titled, “;Bereavement”, numbered PC.130, last review date 10/01/21 revealed, “;... I. The Hospice will have an organized program for the provision of bereavement services furnished under the supervision of a qualified professional with experience or education in grief and/or loss counseling... III. The Hospice will make bereavement services available to the family and other individuals in the Bereavement Plan of Care (POC) before, and for up to one year following the death of the patient...”. Review of personnel file for the facilitys chaplain revealed no job description for bereavement coordinator. Review of personnel file for Volunteer Coordinator revealed no job description for bereavement coordinator. Review of personnel file for Branch Director, revealed no job description for bereavement coordinator nor training or certification for grief counseling. During Exit conference on 03/14/2024 at 3:30 p.m. with Clinical Care Manager, Quality and Education Manager, Branch Director, Vice President of Operations, and Regional Administrator survey findings were discussed, and no further documentation was submitted for review.”