Guiding Light Hospice

“Based on a review of the agency’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), and staff interview, the Hospice failed to establish a Comprehensive Emergency Preparedness Program that complies with all applicable Federal Emergency Preparedness requirements that were based off the agency’s all hazard risk assessment and patient population it serves. This deficient practice has the potential to put the current 47 patients receiving care from the agency and agency staff from the agency at risk in the event of an emergent event. Findings include: Review of the agency’s emergency preparedness plan with the Owner and Governing Board member on 02/19/25 at 2:40 PM revealed that the binder contained an EPP that was last reviewed on 12/01/24; however, the plan did not contain a Comprehensive Emergency Preparedness Plan including the Emergency Preparedness Conditions of Participation, based on the agency’s all hazard risk assessment, community risk assessment, and patient population. (See findings in Tags E0007, E0013, E0016, E0024, E0026, E0030, E0031, E0033, and E0039.) Review of the agency EPP revealed an “Emergency Disaster Policy Update List” showed the EPP had been reviewed on 10/01/19, 12/03/20, 11/06/21, 2022, 12/23/23 and 12/01/24 without any changes or updates.”

“Based on interview and review of the agency’s Emergency Preparedness Plan (EPP), the agency failed to ensure policies identified the services the agency could provide or how the agency would continue operations during an emergency. This failure had the potential to affect the current 47 patients receiving care from the agency and planning for care provision in the event of an emergency event. Findings include: Review of the agency’s EPP, last reviewed by the Governing Body on 12/01/24, with the Owner/Governing Body member revealed that the EPP did not identify the services the agency would be able to provide during an emergency, or how the agency planned to continue operations during an emergency. During an interview on 02/19/25 at 5:38 PM, the Owner confirmed that only the patients at risk were identified, the other parts were not in the agency EPP.”

“Based on interview and review of the agency’s Emergency Preparedness Plan (EPP), the agency failed to ensure the EPP policies addressed procedures to follow up with on duty staff and patients to determine services that are needed in an emergent event. This failure had the potential to affect the current 47 patients receiving, or staff providing, hospice care. Findings include: Review of the agency’s EPP, last reviewed by the Governing Body on 12/01/24, with the Owner / Governing Body member revealed there was no procedure regarding how the agency will follow up with on duty staff and current patients to determine the services that may be required during an emergency event. During an interview on 02/19/25 at 3:10 PM, the Owner stated, “I don’t know that I’ve got one [procedure] for that.””

“Based on interview and review of the agency’s Emergency Operations Plan (EPP), the agency failed to ensure the EPP policies addressed the use of federal and/or state healthcare volunteers to meet staffing requirements during an emergency event. This failure had the potential to affect the current 47 patients receiving care from the agency. Findings include: Review of the agency’s EPP, last reviewed by the Governing Body on 12/01/24, with the Owner / Governing Body member revealed no policy regarding the use of State and/or Federal healthcare professional volunteers in an emergency as a staffing strategy. During an interview on 02/19/25 at 3:33 PM, the Owner confirmed the agency EPP “addresses just regular volunteers.” Review of policy titled, “Use of Volunteers During Emergency Events,” effective 04/2022, revealed: “Policy:Our Agency may choose to utilize volunteers or other emergency staffing strategies to address surge needs during an emergency event.Procedure:1. Volunteers utilized during emergency events may be utilized for multiple tasks, including but not limited to:a. Manning the Agency telephonesb. Office tasksc. Coordination of suppliesd. Phone calling2. Emergency staffing strategies - Our Agency will ongoing keep a list of potential individuals who are willing to volunteer during an emergency event.Our agency may also choose to collaborate with other local hospice agencies during emergency events.4. All individuals utilized as emergency staff during an emergency event will be provided training on the Agency Emergency Preparedness Plan.5. [sic]6. Volunteers will be trained for roles that they may assume during an emergency event.””

“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 current 47 patients receiving care and services from the organization and hindered the organization’s ability to provide care and services and keep patients safe during an emergency. Findings include: Review of the agency’s EPP Communication Plan, last reviewed by the Governing Body on 12/01/24, with Owner and Governing Body member did not reveal any policy or procedure regarding the role of the agency if the Health and Human Services Secretary should declare a section 1135 waiver. During an interview on 02/19/25 at 3:42 PM the Owner confirmed the agency role under an 1135 waiver was “Not addressed in the emergency plan right now.””

“Based on interview and review of the agency’s Emergency Preparedness Plan (EPP), the Hospice failed to maintain a current list of names and contact information in the “Emergency Preparedness Communication Plan” that included all patients’ physicians, entities providing services under arrangement, and other hospices. This failure had the potential to affect any of the current 47 patients receiving care from the organization and could delay the agency’s ability to respond to an emergency. Findings include: Review of the agency’s EPP Communication Plan, last reviewed by the Governing Body on 12/01/24, with the Owner / Governing Body member revealed no inclusion of a list of patient physicians, other hospices, and entities providing services under arrangement and their respective contact information. In an interview on 02/19/25 at 3:53 PM, the Owner confirmed the hospice employees were included, stating, “but none of the others are currently in emergency plan.””

“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 Federal, State, Regional, Tribal, and Local emergency preparedness staff and/or agencies in their Emergency Preparedness Communication Plan. This failure had the potential affect any of the 47 current patients receiving care from the agency and would 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 12/01/24, with the Owner / Governing Body member did not show the contact information for the Federal, State, Regional, Tribal, and Local emergency preparedness agencies. The Communication Plan listed numerous fire departments, sheriff departments, power companies, and water departments. During the review on 02/19/25 at 3:59 PM, the Owner confirmed the EP Communications plan was missing the federal, state, regional, tribal, and local emergency agencies and stated, “I will have to definitely do an update.””

“Based on interview and review of the agency’s Emergency Preparedness Plan (EPP), the agency failed to ensure the EPP Communication Plan included written a written policy or procedure that addressed the sharing of information and medical documentation for patients under the agency care. This failure had the potential to affect the current 47 patients receiving care from the agency and may potentially affect the patient’s care in an emergent event. Findings include: Review of the agency’s EPP Communication Plan, last reviewed by the Governing Body on 12/01/24, with the Owner / Governing Body member did not show a written policy or procedure regarding how the agency would share patient information and medical documentation with another provider in an emergent event. In an interview on 02/19/25 at 4:23 PM the Owner stated, “The how of the information to be shared is not in there [EP Communication Plan].””

“Based on interview and review of the agency’s documentation, the agency failed to ensure the Emergency Preparedness Plan (EPP) documented participation in disaster exercises as required. This failure had the potential to affect the current 47 patients, staff, volunteers, or visitors in the agency in an emergent event. Findings include: Review of the agency EPP, last reviewed by the Governing Body on 12/01/24, with the Owner / Governing Body member revealed no documentation of participation in a community-based full scale exercises to test the EPP; or the documentation of agency efforts to identify a full-scale community-based exercise; or an individual agency based functional exercise; or a mock disaster drill, or tabletop exercise every two years. During the review on 02/19/25 at 4:27 PM, the Owner showed documentation that on 01/15/25 and 01/10/24 the EPP’s call tree and fire drill were reviewed, and on 12/11/24 a fire drill was done; and stated, “They are not true table top drills; I don’t feel we met the exercises regulation.We have not tried to identify a community-based exercise.””

“Based on interview and record review, the agency failed to ensure plans of care reviewed for two of 14 patients (Patient (P) 5 and P8) contained measurable goals. This failure had the potential to keep patients from reaching their highest attainable level or ensuring hospice staff was providing required cares to ensure the patient reaches their desired outcomes. Findings include: 1. Review of P5’s agency printed “Face Sheet” showed a hospice admission date of 10/22/24 with medical diagnoses that included malignant carcinoid tumors of the lung and bronchus. Review of P5’s paper “Comprehensive Interdisciplinary Plan of Care,” dated 01/17/25, showed “Identified Problem” checked boxes of “Dyspnea” and “Orthopnea,” however, the column of “Goal/Outcomes” with the possibilities of:”-Comprehend change in resp. [respiratory] status-Tx [Treatment] effective in controlling resp. discomfort, per disease progression-Utilize O2 [oxygen], breathing Tx safely and as ordered-Other [with a line for clarification]” without any checked as a goal or outcome.Another “Identified Problem” with checked boxes for “Decreased mobility” and “Other” with handwritten “fall risk” and “weakness” showed a Goal/Outcome checked for “Maintain present MS [musculoskeletal] status, as possible” however, no present status was defined/described to ensure a baseline was identified to be measured for goal achievement. Another area (under “Cardiovascular”) also identified “Dyspnea” as an identified problem, with a goal/outcome checked as “Compliant with regime” but no regime was identified. 2. Review of P8’s agency printed “Face Sheet” showed a hospice admission date of 12/20/24 with medical diagnoses that included chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. Review of P8’s “Comprehensive Interdisciplinary Plan of Care,” dated 12/20/24, showed an identified problem of “Other” with clarification handwritten of “Bowel Regimen,” with a goal/outcome checked of “Compliance with bowel regime,” however, in the “Comments” section was handwritten “Not currently on bowel regime.” “Dyspnea” was an identified problem under “Cardiovascular” with a goal/outcome checked as “Compliant with regime” but no regime was identified. Under the category of “Elimination/Urinary” was an identified problem of “Incontinence” but none of the possible goals of “-Compliance with bladder regime-Effective control of bladder discomfort-Free from UTI [urinary tract infection]-Other [with blank lines for clarification]” were checked as goals. During an interview on 02/19/25 at 5:07 PM, the Nursing Director confirmed that the goals were identified or contained a baseline for measurement. Review of the agency policy titled “Plan of Care,” dated 2017, revealed:”PolicyThe interdisciplinary written plan of care is based on initial and updated patient-specificcomprehensive assessments by members of the IDG and is developed with measurablegoals and outcomes for planned interventions. The plan of care must include allservices necessary for the palliation and management of the terminal illness and relatedconditions. . . 11. Measureable [sic] outcomes are anticipated from implementing and coordinating the plan of care for each patient by using data elements identified by the hospice, and are used as part of the hospice’s QAPI [Quality Assurance Performance Improvement] program.” Review of the agency policy titled “Plan of Care – Content,” dated 2017, revealed:”...Procedure2. The hospice must develop an individualized written plan of care for each patient.The plan of care must reflect patient and family goals and interventions based on theproblems identified in the initial, comprehensive, and updated comprehensiveassessments. The plan of care must include all services necessary for the palliationand management of the terminal illness and related conditions, including thefollowing:...g. Measurable outcomes anticipated from implementing and coordinating the plan of care;””

“Based on interview and record review, the agency failed to ensure plans of care were updated for three of 14 patients (Patient (P) 6, P9, and P11) reviewed. This failure had the potential to cause the agency to provide care and services to ensure a patient’s highest level of function and/or comfort were attained. Findings include: 1. Review of P6’s agency printed “Face Sheet” showed a hospice admission date of 12/27/24 with medical diagnoses that included congestive heart failure (CHF). Review of P6’s agency printed “Initial Plan of Care,” signed by the Nursing Director on 01/04/25, and reviewed on 02/19/25 showed:”Problem: Patient is a new admission to hospice and requires a coordinated transition to hospice care” with a “Goal(s): Patient will have comprehensive assessment completed by end of 5th day after admission. Complete by: Ongoing.” 2. Review of P9’s agency printed “Face Sheet” showed a hospice admission date of 06/22/24 with medical diagnoses that included Alzheimer’s disease. Review of P9’s agency printed “Recertification Plan of Care” signed by a Registered Nurse on 01/17/25, showed “Problem: Patient is a new admission to hospice and requires a coordinated transition to hospice care” with a “Goal(s): Patient will have comprehensive assessment completed by end of 5th day after admission. Complete By: 5 Days” 3. Review of P11’s agency printed “Face Sheet” showed a hospice admission date of 10/21/24 with medical diagnoses that included cerebral infarct, type II diabetes, and chronic kidney disease. Review of P11’s agency printed “Recertification Plan of Care” signed by a Registered Nurse on 01/16/25 revealed “Problem: Patient is a new admission to hospice and requires a coordinated transition to hospice care” with a “Goal(s): Patient will have comprehensive assessment completed by end of 5th day after admission. Complete By: 5 Days” While reviewing patient records on 02/19/25 at 1:00 PM, the Alternate Administrator confirmed there were issues with the plan of care updates and stated an expectation that updates would be completed every two weeks or as needed. Review of the agency policy titled “Plan of Care,” dated 2017, revealed:”Policy . . . A plan of care must:. . . (d) Be reviewed and updated at intervals that are specified in the plan by the person who established the plan. The review must be documented in writing . . . Procedure . . . 4. The plan of care is reviewed and updated at specified intervals by the attendingphysician, the medical director or physician designee and the IDG:a. The written plan is reviewed every 15 days or more frequently as dictated by thepatient’s condition;b. The plan of care is revised as needed;c. Or as specified in the plan of care; andd. Review of the patient plan of care is documented . . . 10. A revised plan of care must include information from the patient’s updated comprehensive assessment and must note the patient’s progress toward outcomes and goals specified in the plan of care.””

“Based on interview and review of the agency documentation, the agency failed to ensure volunteers provided day-to-day administrative and/or direct patient care services equaling a minimum of 5 percent of the total patient care hours of all paid hospice employees and contract staff. Findings include: Review of the agency provided “Volunteer Activity” report for the time period of 01/01/24 – 12/31/24 showed:”Total Volunteer Hours: 0 hoursTotal Patient Care Hours: 7604.02 hoursPercentage of Volunteer Hours: 0%Hours Over/Under Required Threshold: -380.2 hoursTotal Cost Savings: $0” In an interview on 02/19/25 at 4:53 PM, the Owner confirmed there were no volunteer hours; and stated an expectation that the agency would follow regulations but that it’s hard to meet this regulation. Review of the agency policy titled “Volunteers – Services,” dated 2017, revealed:”Policy: The Volunteer Program is designed to meet Federal regulations for the provision of volunteer services to hospice patients and their caregivers . . .Procedure:9. The hospice documents and maintains a volunteer staff sufficient to provide administrative or direct patient care in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff.10. The hospice must document cost savings achieved through the use of volunteers . . .””