Family Pillars Hospice Inc.

“Based on a review of agency policy/procedure, a review of the agency emergency preparedness plan, and an interview with the agency alternate Administrator, the agency failed to conduct exercises to test the emergency plan annually, for one (1) of one (1) emergency preparedness plan documentation (EPP) reviewed (EPP#1). Agency policy/procedure reviewed on May 22, 2025 at approximately 10:00 a.m. ‘Emergency Operations Plan’ ‘Procedure’ section (18) :The plan will be tested and evaluated annually at each site, either in response to an actual emergency or in a planned exercise. ...”The EPP was reviewed on May 21, 2025 at approximately 10:00 a.m.EPP#1: No documentation provided of the agency conducting exercises to test the emergency plan annually for 2023. Documentation provided of a table top exercise conducted on September 25, 2024.An interview conducted with the agency alternate Administrator on May 22, 2025 at approximately 11:30 a.m. confirmed the above findings.”

“Based on a review of agency policy/procedure, a review of hospice services contracts, and an interview with the agency alternate administrator, agency failed to follow the patients written plan of care for four (4) of nineteen (19) patient clinical records (CR) reviewed (CR#5, CR#10, CR#13, CR#15). Agency policy/procedure was reviewed on May 22, 2025 at approximately 10:00 a.m. IDG Care Planning Process’ ‘Procedure’ section (6) “All care and services furnished to the patients and their families follows an individualized written plan of care established by the IDG.....”A review of patient CRs was completed on May 22, 2025 at approximately 10:30 a.m. The patients start of care (SOC) is included below. CR#5, SOC 11/06/24: ‘Assignment Details’ dated 04/09/25 include but not limited to ‘Hospice Aide’ “5 visits weekly”, ‘Skilled Nurse’ “2 visits weekly.”Weeks of 04/13/25-05/17/25: 1/5 hospice aide visits.Week of 04/20/25-04/26/25: 0/2 skilled nurse visits.CR#10, SOC 04/02/25: ‘Assignment Details’ dated 04/09/25 include but not limited to ‘Skilled Nurse’ “2 visits weekly.”Week of 04/13/25-04/19/25: 1/2 skilled nurse visits.Week of 04/22/25-05/03/25: 0/2 skilled nurse visits.Week of 05/04/25-05/10/25: 1/2 skilled nurse visits.CR#13, SOC 03/24/25: ‘Assignment Details’ dated 04/09/25 include but not limited to ‘Skilled Nurse’ “2 visits weekly.”Week of 04/27/25-05/03/25: 0/2 skilled nurse visits.CR#15, SOC 04/11/24: ‘Assignment Details’ dated 04/09/25 include but not limited to ‘Hospice Aide’ “5 visits weekly.”Week of 05/12/24-05/18/24: 4/5 hospice aide visits.An interview conducted with the agency alternate Administrator on May 22, 2025 at approximately 11:30 a.m. confirmed the above findings.”

“Based on a review of agency policy/procedure, employee files, and an interview with the agency alternate Administrator, it was determined that the agency failed to ensure employees were tested and screened for tuberculosis (TB) upon hire and/or annually, per policy, for eight (8) of nine (9) employee files (EF) reviewed (EF#1, EF#2, EF#4 - EF#9). Agency policy/procedure reviewed on May 22, 2025 at approximately 10:00 a.m. ‘Occupational Exposure to Tuberculosis/Prevention of Transmission of TB Plan’ ‘Policy’ “Hospice will comply with .... as well as the Centers for Disease Control (CDC) guidelines.” ‘Procedure’ section (11) “All employees and patient care volunteers will receive education regarding TB ...., before initial assignment and annually.” A review of EFs conducted on May 19, 2025 at approximately 9:45 a.m. revealed the following:EF#1, date of hire 10/30/23: No documentation provided of 2024 annual TB education being provided.EF#2, date of hire 06/12/23: No documentation provided of 2024 annual TB education being provided.EF#4, date of hire 07/01/19: No documentation provided of 2023 nor 2024 annual TB education being provided.EF#5, date of hire 03/28/23: No documentation provided of 2024 annual TB education being provided.EF#6, date of hire 07/31/23: No documentation provided of 2024 annual TB education being provided.EF#7, date of hire 05/22/23: No documentation provided of a TB test being conducted upon hire. Documentation provided of a two-step TB test being administered late on 08/03/23 and on 08/24/23. No documentation provided of 2024 annual TB education being provided.EF#8, date of hire 06/24/19: No documentation provided of 2023 nor 2024 annual TB education being provided.EF#9, date of hire 06/24/19: No documentation provided of 2023 nor 2024 annual TB education being provided.An interview conducted with the agency alternate Administrator on May 22, 2025 at approximately 11:30 a.m. confirmed the above findings.”

“Based on a review of agency policy/procedure, a review of the agency volunteer utilization records, and an interview with the agency alternate Administrator, the agency failed to ensure volunteers provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours, for one (1) of one (1) volunteer cost savings documentation (VD) reviewed (VD#1). Agency policy/procedure reviewed on May 22, 2025 at approximately 10:00 a.m. ‘Volunteer Services’ ‘Procedure’ section (2) “Hospice will document the cost savings achieved through the use of volunteers and will include: .... Hospice will document and maintain a volunteer staff sufficient to provide administrative and/or direct patient care in an amount that, at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff.” Total patient care hours and volunteer percentage time was reviewed from June 2024 - April 2025.VD#1:June 2024: ‘Percent Volunteer Time’ .36%.July 2024: ‘Percent Volunteer Time’ 0%.October 2024: ‘Percent Volunteer Time’ 0%.November 2024: ‘Percent Volunteer Time’ 0%.December 2024: ‘Percent Volunteer Time’ 0%.January 2025: ‘Percent Volunteer Time’ 0%.February 2025: ‘Percent Volunteer Time’ 0%.March 2025: ‘Percent Volunteer Time’ 0%.The total cost savings equated to less than five (5) percent of the total patient care hours.An interview conducted with the agency alternate Administrator on May 22, 2025 at approximately 11:30 a.m. confirmed the above findings.”

“Based on a request of agency policy/procedure, inpatient facility contracts, and an interview with the agency alternate Administrator, it was determined that the agency failed to ensure the training of personnel who will be providing the patient’s care in an inpatient facility for two (2) of two (2) agency inpatient contract reviews (Inpatient Facility #1, Inpatient Facility #2). Agency policy/procedure related to short-term inpatient care facility employee training requested on May 22, 2025 at approximately 10:00 a.m. No specific policy provided.A review of inpatient facility contracts was conducted on May 21, 2025 at approximately 1:00 p.m. Inpatient Facility #1: A ‘One Time Hospice Services Agreement’ was signed by the hospice agency on 07/22/24 and signed by the inpatient facility on 07/25/24. The agreement specified the arrangement for care for patient #20 for the time period of 09/06/24 - 09/11/24. Documentation provided of patient #20 admitted to the facility for respite care 09/06/24 - 09/11/24. No documentation provided of the hospice agency ensuring training of the personnel who would be providing the patient’s care in the inpatient facility.Inpatient Facility #2: A ‘Nursing Facility Agreement (Single Patients)’ dated 07/07/2020 was signed by the Hospice and the Facility. Documentation provided of patient #15 admitted to the facility for respite care 05/20/24 - 05/23/24. No documentation provided of the hospice agency ensuring training of the personnel who would be providing the patient’s care in the inpatient facility.An interview conducted with the agency alternate Administrator on May 22, 2025 at approximately 11:30 a.m. confirmed the above findings.”

“Based on a review of agency policy, a review of patient clinical records, and an interview with the agency alternate Administrator, the hospice agency failed to provide the skilled nursing facility the patient hospice benefit of election form for two (2) of two (2) skilled nursing facilities (SNF) visited (SNF#1, SNF#2). Agency policy/procedure reviewed on May 22, 2025 at approximately 10:00 a.m. ‘Care to Patients of a SNF/NF or ICF/MR’ ‘Procedure’ section (7) “Hospice will provide to the SNF/NF or ICF/MR the following information: ..... Hospice election form ....”Patient home visits were conducted on May 20, 2025 between approximately 9:00 a.m. - 1:30 p.m. SNF#1: Review of the agency/facility written agreement was conducted on May 21, 2025 at approximately 11:00 a.m. Documentation provided of a ’’Purchase of Service Contract’ dated 10/09/24, signed by the Hospice agency and the facility.During a home visit for (patient #2) conducted at the facility on 05/20/25, the hospice benefit of election form was not in another hospice patients (patient #21, who also resided at the facility) hospice chart nor in the patients facility chart. This was confirmed onsite by the hospice agency nurse (employee #3) who was present during the patient home visit. SNF#2: Review of the agency/facility written agreement was conducted on May 21, 2025 at approximately 11:00 a.m. Documentation provided of a ’’Business Associate Agreement’ dated 05/15/19, unsigned by the Hospice agency and the facility.During a home visit for (patient #3) conducted at the facility on 05/20/25, the hospice benefit of election form was not in (patient #3) hospice chart nor the facility chart. Two (2) other hospice patients (patient #22, patient #23) residing at the facility also did not have the hospice benefit of election form in the hospice chart nor the facility chart. This was confirmed onsite by the hospice agency chaplain (employee #10), who was present during the patient home visit and by the hospice agency nurse (employee #9) who was present at the facility during the patient home visit. An interview conducted with the agency alternate Administrator on May 22, 2025 at approximately 11:30 a.m. confirmed the above findings.”

“Based on a review of agency policy/procedure, a review of hospice services contracts, and an interview with the agency alternate administrator, agency failed to provide skilled nursing facility staff inservices for one (1) of one (1) skilled nursing facility contracts (SNFC) reviewed (SNFC#1). Agency policy/procedure was reviewed on May 22, 2025 at approximately 10:00 a.m. ‘Care to Residents of a SNF/NF or ICF/MR’ ‘Procedure’ section (8) “Hospice staff will assure orientation of SNF/NF or ICF/MR staff furnishing care to Hospice patients in the Hospice Philosophy, including hospice policies and procedures regarding methods of comfort, pain control and symptom management, as well as the principles about death and dying ...” SNFC #1: Review was conducted on May 21, 2025 at approximately 11:00 am of the agency/facility written agreement. Date of agreement 10/09/24. ‘Appendix A’ ‘Program Descriptions; ‘Nursing Services’ section (3) “Teaching patients/patients families and facility staff the Hospice philosophy and palliative care modalities, including pain control and symptom management...”No documentation provided of the hospice agency orienting facility staff to the hospice philosophy. (Hospice patient Clinical Record #21 currently resides at this facility.)An interview conducted with the agency alternate Administrator on May 22, 2025 at approximately 11:30 a.m. confirmed the above findings.”