Circle of Life Hospice

“Based on interview and review of the agency’s Emergency Preparedness Plan (EPP), the agency failed to ensure the Emergency Preparedness Plan (EPP) addressed a procedure to inform the State and Local Emergency Preparedness Officials of homebound patients in need of evacuation. This failure had the potential to affect any of the 63 patients currently receiving care from the agency. Findings include: Review of the agency’s EPP, last reviewed by the facility Governing Board on 10/17/23, with the Human Resources Director (HRD) revealed no policy or procedure that identified the procedure the agency would use to notify the local or state emergency officials of homebound patients that required evacuation in an emergency event. During the review on 02/13/25 at 3:54 PM, the HRD stated, “I dont think I have something that specifically says that. It [the EPP] addresses evacuation from facilities only.””

“Based on interview and review of the agency’s Emergency Preparedness Plan (EPP), the agency failed to ensure the EPP included a policy regarding the integration of State and Federally designated healthcare professional volunteers in the case of emergency to care for the agency’s residents. This has the potential to affect the continuity of care for the 63 patients receiving care from the agency in the event of an emergency. Findings include: A review of the agency’s EPP, last reviewed by the Governing Body on 10/17/23 with the Human Resources Director (HRD) revealed no evidence of inclusion of policies/procedures regarding the use of State and/or Federal healthcare professional volunteers in the event of an emergency. The agency’s EPP, page 50, recorded,”. . . Staff ShortagesIf the staff shortage is related to illness, Circle of Life Hospice will attempt to make scheduled home visits according to triage level and the necessity of the visit Staff [sic] may be asked to work outside their normal role and/or schedule. All nurses, including office nurses and the Clinical Managers will be utilized . . .” In an interview on 02/13/25 at 4:02 PM the HRD stated, “The emergency plan doesn’t specifically address the healthcare volunteers.””

“Based on interview and the review of the agency’s Emergency Preparedness Plan (EPP), the agency failed to ensure the EPP included arrangements with other agencies or providers to receive patients in the event the agency is not able to provide care in the event of an emergency This had the potential to affect the continuity of care for all patients 63 receiving care from the agency. Findings Include: A review of the agency’s EPP, last reviewed by the Governing Body on 10/17/23 with the Human Resources Director (HRD) revealed no evidence of arrangements or agreements with other healthcare providers to provide care if the agency should be unable to do so in the event of an emergency. In an interview on 02/13/25 at 4:04 PM the HRD stated agencies are in the contract book but not in the Emergency Plan. Two hospitals with phone numbers were listed in the Communications Plan, but no arrangements or what patients would be accepted were identified.”

“Based on interview and a review of the agency’s Emergency Preparedness Plan (EPP), the agency failed to include the role of the agency if a waiver was declared in accordance with section 1135 of the Social Security Act. This failure had the potential to affect the 63 patients receiving care and services from the agency during an emergency. Findings include: A review of the agency’s EPP, last reviewed by the Governing Body on 10/17/23 with the Human Resources Director (HRD) revealed no evidence regarding the role of the agency if the Health and Human Services Secretary should declare a section 1135 waiver. In an interview on 02/13/24 at 4:08 PM the HRD confirmed there was nothing regarding an 1135 waiver in the emergency policies.”

“Based on interview and review of the agency’s Emergency Preparedness Plan (EPP), the agency failed to maintain a current list of contact information that included the State, Tribal, Regional, and Local emergency preparedness staff, and/or agencies in their Emergency Preparedness Communication Plan. This failure had the potential to affect any of the 63 patients receiving care from the agency and could delay the agency’s ability to respond to an emergency and the potential to prevent first responders and other sources of assistance from providing care and services to the agency and its patients or staff during an emergency event. Findings include: Review of the agency’s EPP Communication Plan, last reviewed by the Governing Body on 10/17/23, with the Human Resources Director (HRD) revealed no inclusion of emergency contact information for the State, Tribal, Regional, or Local emergency staff/agencies. . During the review on 02/13/25 at 4:14 PM, the HRD confirmed the EPP only contained contact information for the Federal emergency agency.”

“Based on record review, interview, and policy review, the agency failed to ensure one of 19 patients reviewed (Patient (P) 14) had a plan of care updated to reflect the current care needs. This failure had the potential to delay medically needed social services and service provision to any of the current 64 patients. Findings include: Review of P14’s untitled patient demographic sheet, provided by the agency, showed a hospice admission date of 05/14/24 with medical diagnoses of senile degeneration of the brain, cerebral infarction sequalae, and cerebral vascular disease. Review of P14’s “Primary Plan of Care,” provided by the facility and created on 05/20/24 and updated on 11/20/24, showed a goal of “Caregiver(s), Family will verbalize/demonstrate knowledge of medication administration/record keeping within 48hr [hours],” and under the problem of altered elimination (created 05/20/24 with the last update on 12/06/24) the goal of “Caregiver(s), Family will verbalize understanding and importance of bowel regime within 48 hours.” During an interview on 02/14/25 at 4:45 PM, the Patient Care Manager (PCM) confirmed 48 hours had been exceeded. The PCM stated he/she started 12/27/24 and “found there has been a disconnect with the RNs [Registered Nurses] and the previous PCM regarding plan of care updates and I’ll be doing training.” Review of the agency’s policy titled “The Plan of Care,” revised November 2018, revealed, “. . . The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group . . . Revision dates will be noted on the plan of care . . .””

“Based on interview, record review, and agency agreement review, the agency failed to ensure the Skilled Nursing Facility (SNF) received the original certification of terminal illness for one of one patient (Patient (P) 3) reviewed who lived at a SNF out of a total sample of 19. This had the potential to affect the care and services were provided to the patient. Findings include: During a home visit, a review of the Hospice notebook for P3 did not reveal an original certification of terminal illness (CTI). During an interview on 02/14/25 at 12:10 PM, the SNF Director of Nursing (SDON) and MDS Coordinator (MDSC - Minimum Data Set is the federally mandated patient assessment required for SNF residents) reviewed the SNF electronic medical record (EMR) “Documents” tab for the original CTI which is required for accurate coding of the significant change of status MDS assessment required for hospice admission. A recertification CTI, noted as “Certification #6” for “Benefit Start Date 02/02/25” was in the EMR “Documents” tab, after both the DON and MDSC searching the EMR, no original CTI was found. Review of P3’s undated and untitled patient information sheet, provided by the agency, revealed P3 was admitted to hospice services on 02/08/24 with medical diagnoses that included Parkinson’s Disease and senile degeneration of the brain. Review of the agency’s EMR did not reveal evidence of provision of the original CTI. During an interview on 02/14/25 at 3:30 PM, the Administrator provided a successful facsimile from 02/16/24 at 12:14 PM with a “Subject” line of “Care Plan for [P3’s Name]” and stated the CTI was included, but was unable to prove it was included as it was not noted in the subject line.The Administrator stated there was no policy, but the generic contract titled “Patient and Respite Care Services Agreement” that addressed the requirement. Review of the “Patient and Respite Care Services Agreement,” revised 11/17/15, revealed, “. . . Services and Responsibilities of Hospice . . . Coordinator of Services . . .Hospice shall provide the following information to Nursing Facility for each Hospice Patient: ... (iii) Physician certification and recertification of the terminal illness specific to each Hospice Patient . . .””