Enhabit Hospice

“Based on record review and interview, the agency failed to ensure the Emergency Preparedness Communication Plans call tree included updated required information related to the administrative staff for the agency for all patients, staff and volunteers. Findings: A review of the Emergency Preparedness Communication Plans call tree did not include current administrative staff for the agency. On 07/16/24 at 1:45 p.m., Staff A stated the Emergency Preparedness Communication Plans call tree did not show contact information of current administrative staff for the agency and should have been updated as staff changed.”

“Based on record review and interview, the agency failed to ensure emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events were conducted for 05/12/2023 to 07/15/24 for all patients and employees. Findings: A review of emergency preparedness records showed no documentation of emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events for 05/12/2023 to 07/15/24. On 07/16/24 at 1:50 p.m., Staff A stated: The agency had no emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events for 05/12/2023 to 07/15/24.”

“Based on record review and interview, the hospice failed to ensure completion of an initial assessments/plan of care no later than 5 calendar days after the election of hospice benefits for two (Patients #11 and 12) of 14 patients. Findings: Patient #11 A review of the clinical record showed an election of the hospice benefit on 09/11/23 with POC from 09/11/23 to 12/09/23. Documentation showed a spiritual assessment by the chaplain was completed by telephone on 09/18/22 (7 days after the hospice election date). Documentation showed no patient or caregiver refusal of assessments and showed no communications or notifications to the physician. On 07/17/24 at 11:57 a.m., Staff B stated the spiritual component of the initial POC was not completed within the first five days after the election of the hospice benefit for patient #11. Patient #12 A review of the clinical record showed an election of the hospice benefit on 12/16/22 with POC from 12/16/22 to 03/15/23. Documentation showed a psychosocial assessment by the MSW was completed by telephone on 12/21/22 (6 days after the hospice election date). Documentation showed no patient or caregiver refusal of assessments and showed no communications or notifications to the physician. On 07/17/24 at 12:07 p.m., Staff B stated the psychosocial component of the initial POC was not completed in person within the first five days after the election of the hospice benefit for patient #12.”

“Based on record review and interview, the hospice failed to ensure a bereavement care plan was initiated and/or was included as a part of the overall POC after the initial and ongoing spiritual/bereavement assessments for three (Patients #2, 3, and #4) of 14 patients. Findings: Patient #2 A review of the clinical record showed an election of the hospice benefit on 12/05/23 with no completion of the initial bereavement assessment by 12/11/23 when the patient declined MSW visit (6 days from the election of benefits). A review of a POC dated 06/03/24 to 08/01/24 and IDG updates to the POC on 05/23/24, 06/05/24, 06/19/24 and on 07/03/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. On 07/17/24 at 11:20 a.m., Staff B stated documentation showed no bereavement POC for patient #2. Patient #3 A review of the clinical record showed an election of the hospice benefit on 05/20/24 with no completion of a bereavement POC. A review of a POC dated 05/20/24 to 08/17/24 and IDG updates to the POC on 05/30/24, 06/18/24, 06/26/24 and on 07/11/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. On 07/17/24 at 11:30 a.m., Staff B stated documentation showed no bereavement POC for patient #3. Patient #4 A review of the clinical record showed an election of the hospice benefit on 03/12/24 with no completion of a bereavement POC. A review of a POC dated 06/10/24 to 09/10/24 and IDG updates to the POC on 05/30/24, 06/13/24, 06/26/24 and on 07/11/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. On 07/17/24 at 11:30 a.m., Staff B stated documentation showed no bereavement POC for patient #4.”

“Based on record review and interview, the hospice failed to ensure: 1. Aide visits were provided in accordance with the plan of care for seven (Patients #1, 4, 5, 7, 10, 11 and 14) of 14 patients; 2. Social work services were provided in accordance with the plan of care for five (Patients #3, 4, 9, 10 and 11) of 14 patients; 3. SN visits were provided in accordance with the plan of care for five (Patients #1, 4, 5, 7 and 11) of 14 patients; 4. ST services were provided in accordance with the plan of care for one (Patient #7) of 14 patients and; 5. Chaplain services were provided in accordance with the plan of care for one (Patient #14) of 14 patients. Findings: Patient #1 A review of a POC dated 06/01/24 to 07/30/24 with IDG updates on 05/22/24, 06/05/24, 06/19/24 and 07/03/24 showed orders for the aide visit frequency of three times a week for eight weeks, then one week one; and a SN visit frequency of one time a week for eight weeks. Documentation showed during the week of 06/30/24 to 07/06/24 aide visits were conducted and/or missed on 07/02/24 and on 07/05/24 (three visits ordered, two visits scheduled and/or conducted); and during the weeks of 06/16/24 06/22/24 SN visits were conducted on 06/18/24 and 06/20/24 (one visit ordered and two non-PRN visits conducted). Documentation showed no communications between the IDG and showed no changes in the ordered aide or SN visit frequencies. On 07/17/24 at 11:15 a.m., Staff B stated aide and SN visits were not provided in accordance with the POC for patient #1. Patient #3 A review of a POC dated 05/20/24 to 08/17/24 with IDG updates on 05/22/24, 06/05/24, 06/19/24 and 07/03/24 showed MSW visit frequency orders for one-time a month for four months. A POC update dated 06/18/24 documented PRN MSW visit. Documentation showed no MSW visit on 06/18/24 during the week of 06/18/24 to 06/22/24 (one visit ordered, no visit conducted). Documentation showed no communications between the IDG and showed no changes in the ordered MSW visit frequency. On 07/17/24 at 11:30 a.m., Staff B stated MSW visit was not provided in accordance with the POC for patient #3. Patient #4 A review of a POC dated 06/10/24 to 09/07/24 with IDG updates on 05/30/24, 06/13/24, 06/26/24 and 07/11/24 showed orders for an aide visit frequency of three times a week for 13 weeks, with an update in the POC on 07/01/24 to one time a week; and a MSW visit frequency of one time a month for three months, with an update to the POC on 06/18/24 to change all MSW visits to telephone visits and an additional update to the POC on 06/25/24 changing all MSW visits to PRN. Documentation showed during the week of 07/07/24 to 07/13/24 aide visits were conducted on 07/09/24 and on 07/11/24 (one visit ordered, two visits conducted); and showed no MSW visits or telephone contact from 06/10/24 to 07/13/24 (one time per month ordered, no visits conducted). Documentation showed no communications between the IDG and showed no changes in the ordered aide or MSW visit frequencies. On 07/17/24 at 11:15 a.m., Staff B stated aide and MSW visits were not provided in accordance with the POC for patient #4. Staff A stated LCSW visits were being covered for OKC by the Tulsa hospice agency (affiliated agency [name withheld], licensed separately) as available. Patient #5 A review of a POC dated 06/26/24 to 08/24/24 with IDG updates on 05/22/24, 06/05/24, 06/19/24 and 07/03/24 showed orders for an aide visit frequency of one time a week, then two times a week for eight weeks; and a SN visit frequency of one time a week for nine weeks, with an update to the POC on 06/27/24 to change SN visit to telephone visits and an additional update to the POC on 07/12/24 for SN visit to PRN. Documentation showed during the week of 06/30/24 to 07/06/24 aide visits were conducted on 07/03/24 and missed on 07/05/24 (two visits ordered, one visit conducted; [documentation showed no attempts to make up missed aide visit due to the holiday]); and showed a SN telephone visit on 06/27/24 (one visit ordered, telephone visit conducted [documentation showed no attempt to conduct the SN visit in person]) Documentation showed no communications between the IDG and showed no changes in the ordered aide or SN visit frequencies. On 07/17/24 at 11:42 a.m., Staff B stated aide and SN visits were not provided in accordance with the POC for patient #5. At 11:45 a.m., Staff A stated telephone contact visits are in addition to ordered visits. Patient #7 A review of a POC dated 06/21/24 to 09/18/24 with IDG updates on 05/22/24, 06/05/24, 06/19/24 and 07/03/24 showed orders for an aide visit frequency of one time a week, three times a week for 12 weeks, then two times a week for one week; and an ST visit frequency of one time a week for one weeks to evaluate and a PT evaluation. Documentation showed during the week of 06/30/24 to 07/06/24 aide visits were missed on 07/01/24, conducted on 07/02/24 and on 07/06/24 (three visits ordered, two visit conducted; [documentation showed no attempts to make up missed aide visit due to the holiday]); and showed no ST evaluation visit during the week of 06/23/24 to 06/29/24 (one visit ordered, no visit conducted) and no PT evaluation from 06/21/24 to 06/30/24 [documentation showed a physicians order to discontinue PT and OT (discipline not ordered) effective 07/01/24. Documentation showed no communications between the IDG and showed no changes in the ordered aide or PT or ST visit frequencies. On 07/17/24 at 11:45 a.m., Staff B stated aide and PT and ST visits were not provided in accordance with the POC for patient #7. Patient #9 A review of a POC dated 05/23/24 to 08/20/24 with IDG updates on 05/22/24, 06/05/24, 06/19/24 and 07/03/24 showed orders for a MSW visit frequency of one time a month for one months, two times a month for one month, then one time per month for one month. Documentation showed a MSW visit from 05/28/24 to 07/13/24 on 05/28/24 (four visits ordered, one visit conducted). Documentation showed no communications between the IDG and showed no changes in the ordered MSW visit frequencies. On 07/17/24 at 11:15 a.m., Staff B stated MSW visits were not provided in accordance with the POC for patient #9. Staff A stated LCSW visits were being covered for OKC by the Tulsa hospice agency (affiliated agency [name withheld], licensed separately) as available. Patient #10 A review of a POC dated 06/06/24 to 08/04/24 with IDG updates on 05/30/24, 06/13/24, 06/26/24 and 07/11/24 showed orders for an aide visit frequency of three times a week for one weeks, then three times a week for eight weeks; and MSW of one time a month for one month, then one time every two months times two months. Documentation showed during the week of 06/16/24 to 06/22/24 aide visits were conducted on 06/18/24 and on 06/21/24 (three visits ordered, two visits conducted); and during the weeks of 06/23/24 to 06/29/24 visits were conducted on 06/25/24 and on 06/28/24 (three visits ordered, two visits conducted). Documentation showed no MSW visits from 06/06/24 to 06/17/24. A POC update on 06/18/24 changed ordered MSW visits to telephone visits due to no availability of LCSW and a POC update dated 06/25/24 ordered a PRN MSW visit. Documentation showed no PRN or telephone contact visit by the LCSW from 06/18/24 to 07/13/24. Documentation showed no communications between the IDG and showed no changes in the ordered aide or MSW visit frequencies. On 07/17/24 at 11:15 a.m., Staff B stated aide and MSW visits were not provided in accordance with the POC for patient #10. Staff A stated LCSW visits were being covered for OKC by the Tulsa hospice agency (affiliated agency [name withheld], licensed separately) as available. Patient #11 A review of a POC dated 12/10/23 to 03/08/24 with IDG updates on 01/11/24, 01/25/24, 02/08/24 and 02/22/24 showed documentation of an aide visit frequency of two times a week for 13 weeks; SN visit frequency of one time a week for 13 weeks and MSW of one time a month for two months. Documentation showed during the week of 12/10/23 to 12/16/23 aide visit was conducted on 12/13/23 (two visits ordered, one visits conducted), 12/24/23 to 12/30/23 aide visit was conducted on 12/29/23 (two visits ordered, one visits conducted), and during the weeks of 12/31/24 to 01/06/24 visits were conducted on 01/03/24 two visits ordered, one visits conducted). During the week of 01/28/24 to 02/03/24 a POC update on 02/02/24 documented to change the SN visit to telephone visit on 02/02/24 (one visit ordered, no visit conducted) and during the week of 02/11/24 to 02/17/24 showed no SN visit (one visit ordered, no SN visit conducted). Documentation showed no MSW visits from 12/10/23 to 02/20/24 (two visits ordered, no visits conducted). A POC update on 06/18/24 changed ordered MSW visits to telephone visits due to no availability of LCSW and a POC update dated 06/25/24 ordered a PRN MSW visit. Documentation showed no PRN or telephone contact visit by the LCSW from 06/18/24 to 07/13/24. Documentation showed no communications between the IDG and showed no changes in the ordered aide or MSW visit frequencies. On 07/17/24 at 11:15 a.m., Staff B stated aide, SN and MSW visits were not provided in accordance with the POC for patient #11. Staff A stated LCSW visits were being covered for OKC by the Tulsa hospice agency (affiliated agency [name withheld], licensed separately) as available. Patient #14 A review of a POC dated 12/27/23 to 03/25/24 with IDG updates on 01/11/24, 01/25/24, 02/08/24 and 02/22/24 showed documentation of an aide visit frequency of one time a week for one week then, two times a week for 12 weeks; and chaplain visits of two times a month for three months. Documentation showed during the week of 01/07/24 to 01/13/24 no aide visits were conducted (two visits ordered, no visits conducted), 01/28/24 to 02/03/24 aide visit was conducted on 02/02/24 (two visits ordered, one visits conducted), and during the weeks of 12/31/24 to 01/06/24 visits were conducted on 01/03/24 two visits ordered, one visits conducted). Documentation showed no MSW visits from 12/27/24 to 02/10/24 (two visits ordered, no visits conducted). Documentation showed no communications between the IDG and showed no changes in the ordered aide or MSW visit frequencies. On 07/17/24 at 11:15 a.m., Staff B stated aide and MSW visits were not provided in accordance with the POC for patient #14. Staff A stated LCSW visits were being covered for OKC by the Tulsa hospice agency (affiliated agency [name withheld], licensed separately) as available.”

“Based on record review and interview, the hospice failed to ensure: 1. The plans of care were fully developed to include service disciplines interventions and goals to meet individualized patient care for ten (Patients #1, 2, 4, 5, 9, 10, 11, 12, 13 and 14) of 14 patients; 2. POCs included identified wound sites for three (Patients #2, 12 and #14) of 14 patients and; 3. POC included urinary catheter management intervention and goals for one (Patient #1) of 14 patients. Findings: Patient #1 A review of a POC dated 06/01/24 to 07/30/24 with IDG updates on 05/22/24, 06/05/24, 06/19/24 and on 07/03/24 showed no documentation of SN interventions and no interventions and goals for aide and chaplain service disciplines. A POC update dated 06/08/24 documented SN to insert an indwelling urinary foley catheter 16 French/30 cc to be changed times 3 days or PRN. Documentation showed no urinary catheter management interventions and/or goals related to urinary catheter care and management. Documentation showed no communications between the IDG related to service discipline interventions and goals. On 07/17/24 at 11:15 a.m., Staff B stated the POC for patient #1 did not show service discipline interventions and/or goals for SN, aide of chaplain services. Patient #2 A review of a POC dated 06/03/24 to 08/01/24 with IDG updates on 05/22/24, 06/05/24, 06/19/24 and on 07/03/24 showed no documentation of SN interventions and no interventions and goals for aide service disciplines. POC updates dated 06/07/24, 06/08/24, 06/25/24, 06/27/24, 07/01/24 and on 07/08/24 documented wound care interventions to be performed by the SN but did not document identified wound sites to receive wound care interventions or goals. Documentation showed no communications between the IDG related to service discipline interventions and goals. On 07/17/24 at 11:20 a.m., Staff B stated the POC for patient #2 did not show service discipline interventions and/or goals for SN and aide services and wound care orders did not identify wound care sites. Patient #4 A review of a POC dated 06/10/24 to 09/07/24 with IDG updates on 05/30/24, 06/13/24, 06/26/24 and on 07/11/24 showed no documentation of SN interventions and no interventions and goals for aide service disciplines. Documentation showed no communications between the IDG related to service discipline interventions and goals. On 07/17/24 at 11:37 a.m., Staff B stated the POC for patient #4 did not show interventions and/or goals for SN and aide services. Patient #5 A review of a POC dated 06/26/24 to 08/24/24 with IDG updates on 05/22/24, 06/05/24, 06/19/24 and on 07/03/24 showed no documentation of SN interventions and no interventions and goals for aide service disciplines. Documentation showed no communications between the IDG related to service discipline interventions and goals. On 07/17/24 at 11:42 a.m., Staff B stated the POC for patient #5 did not show service discipline interventions and/or goals for SN and aide services. Patient #9 A review of a POC dated 05/23/24 to 08/20/24 with IDG updates on 05/22/24, 06/05/24, 06/19/24 and on 07/03/24 showed no documentation of SN interventions and no interventions and goals for aide services. Documentation showed no communications between the IDG related to interventions and goals. On 07/17/24 at 11:50 a.m., Staff B stated the POC for patient #9 did not show interventions and/or goals for SN and aide services. Patient #10 A review of a POC dated 06/06/24 to 08/04/24 with IDG updates on 05/30/24, 06/13/24, 06/26/24 and on 07/11/24 showed no documentation of interventions and goals for SN and aide services , and no goals for chaplain and MSW. Documentation showed no communications between the IDG related to interventions and goals. On 07/17/24 at 11:55 a.m., Staff B stated the POC for patient #10 did not show interventions and/or goals for SN, chaplain, MSW and aide services. Patient #11 A review of a POC dated 12/10/23 to 03/08/24 with IDG updates on 01/11/24, 01/25/24, 02/08/24 and on 02/22/24 showed no documentation of interventions and goals for SN and aide services, and no goals for chaplain and MSW services. Documentation showed no communications between the IDG related to interventions and goals. On 07/17/24 at 11:57 a.m., Staff B stated the POC for patient #11 did not show interventions and/or goals for SN and aide services. Patient #12 A review of a POC dated 01/10/24 to 03/09/24 with IDG updates on 01/04/24, 01/18/24, 01/31/24, 02/14/24, 02/28/24 and on 03/07/24 showed no documentation of interventions and goals for SN and aide services. Documentation showed no communications between the IDG related to interventions and goals. On 07/17/24 at 12:07 p.m., Staff B stated the POC for patient #12 did not show interventions and/or goals for SN and aide services. Patient #13 A review of a POC dated 04/14/24 to 06/12/24 with IDG updates on 05/22/24, 06/05/24, 06/19/24 and on 07/03/24 showed no documentation of SN interventions and no interventions and goals for aide and MSW services. Documentation showed no communications between the IDG related to interventions and goals. On 07/17/24 at 12:12 p.m., Staff B stated the POC for patient #13 did not show service discipline interventions and/or goals for SN, aide and MSW services. Patient #14 A review of a POC dated 12/27/23 to 03/25/24 with IDG updates on 01/11/24, 01/25/24, 02/08/24 and on 02/14/24 showed no documentation of interventions for SN, aide, MSW or chaplain services and no goals for aide, MSW or chaplain services. Documentation showed no communications between the IDG related to interventions and goals. On 07/17/24 at 12:15 p.m., Staff B stated the POC for patient #14 did not show interventions and/or goals for SN, aide, MSW or chaplain services.”

“Based on record review and interview, the hospice failed to ensure patient refusal of hospice aide services was communicated and addressed by the IDG for one (Patient #11) of 14 patients. Findings: Patient #11 A review of a POC dated 09/23/23 to 12/09/23 showed aide service discipline missed visits of 09/15/23, 09/19/23, 09/22/23, 10/05/23, 10/16/23, 10/30/23, 11/16/23, 11/28/23. The POC dated 12/10/23 to 03/08/24 with IDG updates on 01/11/24, 01/25/24, 02/08/24 and on 02/22/24 showed an aide visit frequency of two times a week for 13 weeks. Documentation showed aide missed visits of 12/18/23, 12/22/23, 12/27/23, 12/29/23, 01/03/24, 01/05/24, 01/08/24 and on 01/12/24. Documentation showed no communications between the IDG and showed no changes in the ordered aide visit frequencies and showed no coordination of care with the patient/caregiver to resolve issues with missed aide visits over two certification periods prior to patient discharge from hospice services for non-compliance on 02/20/24. On 07/17/24 at 11:57 a.m., Staff A stated the IDG and/or the SN should have shown documentation of attempts to resolve the aide missed visits and the IDG should have decreased the aide visit frequency and/or discontinued the aide service discipline based on the patients/caregivers requests for patient #11.”

“Based on record review and interview, the hospice failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. Findings: A review of QAPI records calendar years 2022, 2023, and 01/01/24 to 07/15/24 showed no QAPI program data collection sources or analysis/reporting of collected data or reporting activities for time periods of 2nd and 3rd quarters 2022; and 3rd quarter 2023. Additional requests for administrative records yielded no results. On 07/16/24 at 1:45p.m., Staff A stated the hospice had no administrative records which showed data collection sources, analysis/reporting of collected data or activities that showed improved quality of patient care for time periods of 2nd and 3rd quarters 2022; and 3rd quarter 2023.”

“Based on record review and interview, the hospice failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all patients and employees. Findings: A review of administrative records showed no governing body oversite of the ongoing QAPI program which identified the hospice that included data collection, analysis and reporting activities for the hospice for calendar years 2022, 2023 and 01/01/24 to 07/15/24. Additional requests for administrative records yielded no results. On 07/16/24 at 1:45p.m., Staff A stated the hospice had no documentation which showed governing body oversite of QAPI program activities that showed review and approval of data collection, analysis, implementation and follow up of QAPI activities and the QAPI program annual evaluation that identified the hospice for calendar years 2022, 2023 and 01/01/24 to 07/15/24.”

“Based on record review and interview, the hospice failed to ensure medical social services were available for all patients. Findings: On 07/15/24 at 11:00 a.m., OSDH arrived on site at the agency to conduct an unannounced survey. During the entrance conference Staff A identified self as the administrator of the hospice. Staff A stated MSW services for the hospice were being provided by an LCSW (name withheld, identified as Staff I) on staff for an affiliated hospice (located in Tulsa, Oklahoma; CCN provider number and State license number withheld). A review of clinical records showed multiple missed or unscheduled MSW service discipline visits for six (Patients #3, 4, 9, 10, 11 and #12) of 14 patients selected for the survey sample. See 2567, related Tags L523 and L543. A personnel record for Staff I was requested. On 07/17/24 at 10:45 a.m., Staff C stated the OKC hospice agency did not have a personnel record for Staff I, the affiliated hospice agency (located in Tulsa, Oklahoma; CCN provider number and State license number withheld) had her personnel records as she is their employee. On 07/17/24 at 3:00 p.m., Staff A stated Staff I has been covering the hospices needs as an LCSW when available.”

“Based on record review and interview, the hospice failed to review and update a hospice aide care plan prior to the provision of aide services for six (Patients #1, 2, 10, 12, 13 and #14) of 14 patients. Findings: Patient #1 A review of a POC dated 06/01/24 to 07/30/24 with IDG updates on 05/22/24, 06/05/24, 06/19/24 and on 07/03/24 showed an aide visit frequency of three times a week for eight weeks, then once a week. Documentation showed a hospice aide care plan dated effective 04/22/24 with an aide frequency of two week twelve, one week one. Documentation showed no aide care plan (aide assignment) review and update since 04/22/24 by the IDG. On 07/17/24 at 11:15 a.m., Staff A stated the clinical record showed no review and update of the aide care plan (aide assignment) for patient #1. Patient #2 A review of a POC dated 06/03/24 to 08/01/24 with IDG updates on 06/05/24, 06/19/24 and on 07/03/24 showed an aide visit frequency of one time a week for nine weeks. Documentation showed a hospice aide care plan dated effective 12/13/23 with an aide frequency of one week 13. Documentation showed no aide care plan (aide assignment) review and update since 12/13/23 by the IDG. On 07/17/24 at 11:20 a.m., Staff A stated the clinical record showed no review and update of the aide care plan (aide assignment) for patient #2. Patient #10 A review of a POC dated 06/06/24 to 08/04/24 showed an aide visit frequency of one time a week for one week, then three times a week for eight weeks. Documentation showed a hospice aide care plan dated effective 12/26/23 with an aide frequency of one week one, three week eight. Documentation showed no aide care plan (aide assignment) review and update since 12/26/23 by the IDG. On 07/17/24 at 11:55 a.m., Staff A stated the clinical record showed no review and update of the aide care plan (aide assignment) for patient #10. Patient #12 A review of a POC dated 01/10/24 to 03/09/24 with IDG updates on 01/04/24, 01/18/24, 01/31/24, 02/14/24, 02/28/24 and on 03/07/24 an aide visit frequency of two time a week for one week then, three times a week for eight weeks. Documentation showed a hospice aide care plan dated effective 12/15/23 with an aide frequency of one week one, two week twelve, then one week one. Documentation showed no aide care plan (aide assignment) review and update since 12/15/23 by the IDG. On 07/17/24 at 12:07 p.m., Staff A stated the clinical record showed no review and update of the aide care plan (aide assignment) for patient #12. Patient #13 A review of a POC dated 04/14/24 to 06/12/24 with IDG updates on 05/22/24, 06/05/24, 06/19/24 and on 07/03/24 showed an aide visit frequency of one time a week for nine weeks. Documentation showed a hospice aide care plan dated effective 01/29/24 with an aide frequency of two weeks twelve. Documentation showed no aide care plan (aide assignment) review and update since 01/29/24 by the IDG. On 07/17/24 at 12:12 p.m., Staff A stated the clinical record showed no review and update of the aide care plan (aide assignment) for patient #13. Patient #14 A review of a POC dated 12/27/23 to 03/25/24 with IDG updates on 01/11/24, 01/25/24, 02/08/24 and on 02/14/24 showed an aide visit frequency of one time a week for one week then, two times a week for 12 weeks. Documentation showed a hospice aide care plan dated effective 12/11/23 with an aide frequency of one week one, two week twelve, then one week one. Documentation showed no aide care plan (aide assignment) review and update since 12/11/23 by the IDG. On 07/17/24 at 12:15 p.m., Staff A stated the clinical record showed no review and update of the aide care plan (aide assignment) for patient #14.”

“Based on record review and interview, the hospice failed to ensure volunteer orientation and training related to hospice care and philosophy for one (Staff G; and two [Volunteer #1 and #2]) of five employees and three volunteers reviewed. Findings: Staff G A review of volunteer personnel records showed an orientation document related to hospice care and philosophy that was blank and signed by the employee at the time of hire on 05/22/18. Volunteer #1 A review of volunteer personnel records showed an orientation document related to hospice care and philosophy that was blank and signed by the volunteer at the time of hire on 01/24/23. Volunteer #2 A review of volunteer personnel records showed no orientation or training related to hospice care and philosophy since the hire date of 09/18/23. On 07/17/24 at 10:15 a.m., Staff C stated the hospice had no personnel record documentation that showed Staff G, Volunteers #1 and #3 were provided orientation and training related to hospice care and philosophy.”

“Based on record review and interview, the hospice failed to ensure provision of a completed summary of care to the receiving service provider at the time of transfer/discharge from the hospice for three (Patient #2, 8 and #14) of 14 patients. Findings: Patient #2 A review of the clinical record showed the patient was transferred from the hospice on 07/11/24 to in-patient hospital care services. Documentation showed no transfer/discharge summary was provided to the in-patient hospital service provider. On 07/17/24 at 11:15 a.m., Staff B stated the hospice failed to provide a completed summary of care to the receiving service provider at the time of transfer/discharge for patient #2. Patient #8 A review of the clinical record showed the patient was transferred from the hospice on 07/02/24 to in-patient respite care services. Documentation showed no transfer/discharge summary was provided to the in-patient respite service provider. On 07/17/24 at 11:47 a.m., Staff B stated the hospice failed to provide a completed summary of care to the receiving service provider at the time of transfer for patient #8. Patient #14 A review of the clinical record showed the patient was transferred from the hospice on 01/10/24 to in-patient hospital care services. Documentation showed no transfer/discharge summary was provided to the in-patient hospital service provider. On 07/17/24 at 12:15 a.m., Staff B stated the hospice failed to provide a completed summary of care to the receiving service provider at the time of transfer/discharge for patient #14.”