Family Pillars Palliative Care Hospice, LLC

“Based on a review of agency policy/procedure, a review of the agency emergency preparedness plan, and an interview with the agency Director of Professional Services, agency failed to ensure the emergency preparedness plan was reviewed and updated at least every 2 years, for one (1) of one (1) emergency preparedness plan documentation (EPP) reviewed (EPP#1). Agency policy/procedure reviewed on August 21, 2024 at approximately 2:30 p.m. ‘Emergency Operations Plan’ ‘Policy’ states “ The Administrator, Director and staff implement emergency operations plan, as appropriate. Hospice will make every effort to ensure the safety of vulnerable patients who are not likely or capable of evacuating without assistance, if evacuation becomes necessary.” (Note: This policy does not include reviewing/updating the emergency preparedness plan at least every two years.) EPP was reviewed on August 21, 2024 at approximately 9:30 a.m. EPP#1: No documentation provided of the agency reviewing/updating the emergency preparedness plan at least every two years. Per the Director of Compliance on August 21, 2024 at approximately 10:30 a.m., the emergency preparedness plan has not been reviewed at least every two years. An interview conducted with the agency Director of Professional Services on August 21, 2024 at approximately 3:15 p.m. confirmed the above findings.”

“Based on a review of agency policy/procedure, a review of the agency emergency preparedness plan, and an interview with the agency Director of Professional Services, agency failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, for one (1) of one (1) emergency preparedness plan documentation (EPP) reviewed (EPP#1). Agency policy/procedure reviewed on August 21, 2024 at approximately 2:30 p.m. ‘Emergency Operations Plan’ ‘Policy’ states “ The Administrator, Director and staff implement emergency operations plan, as appropriate. Hospice will make every effort to ensure the safety of vulnerable patients who are not likely or capable of evacuating without assistance, if evacuation becomes necessary.” (Note: This policy does not include developing and maintaining an emergency preparedness training and testing program based on the emergency plan.) EPP was reviewed on August 21, 2024 at approximately 9:30 a.m. EPP#1: No documentation provided of the agency developing and maintaining an emergency preparedness training and testing program based on the emergency plan. An interview conducted with the agency Director of Professional Services on August 21, 2024 at approximately 3:15 p.m. confirmed the above findings.”

“Based on a review of agency policy/procedure, a review of the agency emergency preparedness plan, and an interview with the agency Director of Professional Services, 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 August 21, 2024 at approximately 2:30 p.m. ‘Emergency Operations Plan’ ‘Policy’ states “ The Administrator, Director and staff implement emergency operations plan, as appropriate. Hospice will make every effort to ensure the safety of vulnerable patients who are not likely or capable of evacuating without assistance, if evacuation becomes necessary.” ‘Procedure’ section (18) states “The plan will be tested and evaluated annually at each site, either in response to an actual emergency or in a planned exercise. .....” EPP was reviewed on August 21, 2024 at approximately 9:30 a.m. EPP#1: No documentation provided of the agency conducting exercises to test the emergency plan annually. An interview conducted with the agency Director of Professional Services on August 21, 2024 at approximately 3:15 p.m. confirmed the above findings.”

“Based on a review of clinical records, request of agency policy/procedure, and an interview with the agency Director of Professional Services, it was determined that the agency failed to establish and/or follow an individualized written plan of care established by the hospice interdisciplinary group for seven (7) of nineteen (19) clinical records (CR) reviewed (CR#3 - CR#5, CR#7, CR#13 - CR#14, CR#19). Agency policy related to physician ordered visit frequencies was requested August 21, 2024 at approximately 2:30 p.m. No specific policy provided. A review of CRs completed on August 21, 2024 at approximately 3:00 p.m. revealed the following: CR#3 Start of Care 05/21/24: ‘IDG (interdisciplinary group) Comprehensive Assessment Details’ dated 07/10/24, 07/24/24, 08/07/24 ‘Discipline’ “Hospice Aide’ ‘Visits’ state “5 visit(s) weekly.” ‘Discipline’ ‘Skilled Nurse’ ‘Visits’ state “2 visit(s) weekly.” A review of agency staff visits during the above time frame revealed the following: Week of 07/21/24 - 07/27/24 = 4/5 aide visits. Week of 08/04/24 - 08/10/24 = 4/5 aide visits, 1/2 Skilled Nurse visits. CR#4 Start of Care 10/25/23: ‘IDG (interdisciplinary group) Comprehensive Assessment Details’ dated 07/10/24, 07/24/24, 08/07/24 ‘Discipline’ “Hospice Aide’ ‘Visits’ state “5 visit(s) weekly.” ‘Discipline’ ‘Skilled Nurse’ ‘Visits’ state “2 visit(s) weekly.” A review of agency staff visits during the above time frame revealed the following: Week of 07/21/24 - 07/27/24 = 1/2 Skilled Nurse visits. Week of 07/28/24 - 08/03/24 = 4/5 aide visits. Week of 08/04/24 - 08/10/24 = 4/5 aide visits, 1/2 Skilled Nurse visits. CR#5 Start of Care 06/18/24: ‘IDG (interdisciplinary group) Comprehensive Assessment Details’ dated 07/10/24, 07/24/24 ‘Discipline’ “Hospice Aide’ ‘Visits’ state “5 visit(s) weekly.” A review of agency staff visits during the above time frame revealed the following: Week of 07/14/24 - 07/20/24 = 4/5 aide visits..Week of 07/21/24 - 07/27/24 = 4/5 aide visits. CR#7 Start of Care 02/06/24: ‘IDG (interdisciplinary group) Comprehensive Assessment Details’ dated 07/03/24, 07/17/24, 07/31/24 ‘Discipline’ “Hospice Aide’ ‘Visits’ state “5 visit(s) weekly.” A review of agency staff visits during the above time frame revealed the following: Week of 07/14/24 - 07/20/24 = 1/5 aide visits..Week of 07/21/24 - 07/27/24 = 1/5 aide visits. Week of 07/28/24 - 08/03/24 = 1/5 aide visits. Week of 08/04/24 - 08/10/24 = 1/5 aide visits. CR#13 Start of Care 03/22/24: ‘IDG (interdisciplinary group) Comprehensive Assessment Details’ dated 07/03/24, 07/17/24, 07/31/24 ‘Discipline’ does not include “Hospice Aide’ physician orders. A review of agency staff visits during the above time frame revealed the following: Week of 07/14/24 - 07/20/24 = 5/0 aide visits..Week of 07/21/24 - 07/27/24 = 5/0 aide visits. Week of 07/28/24 - 08/03/24 = 5/0 aide visits. Week of 08/04/24 - 08/10/24 = 5/0 aide visits. No documentation provided of hospice aide orders being obtained from the physician. CR#14 Start of Care 07/09/24: ‘IDG (interdisciplinary group) Comprehensive Assessment Details’ dated 07/10/24, 07/24/24, 08/07/24 ‘Discipline’ “Hospice Aide’ ‘Visits’ state “5 visit(s) weekly.” A review of agency staff visits during the above time frame revealed the following: Week of 07/14/24 - 07/20/24 = 3/5 aide visits. Week of 07/21/24 - 07/27/24 = 3/5 aide visits. CR#19 Start of Care 07/18/23: ‘IDG (interdisciplinary group) Comprehensive Assessment Details’ dated 10/18/23 and 11/01/23 ‘Discipline’ “Hospice Aide’ ‘Visits’ state “5 visit(s) weekly.” A review of agency staff visits during the above time frame revealed the following: Week of 10/22/23 - 10/28/23 = 2/5 aide visits. Week of 10/29/23 - 11/04/23 = 1/5 aide visits. Week of 11/05/23 - 11/11/23 = 1/5 aide visits. An interview conducted with the agency Director of Professional Services on August 21, 2024 at approximately 3:15 p.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 Director of Professional Services, 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 (VCSD) reviewed (VD#1). Agency policy/procedure reviewed on August 21, 2024 at approximately 2:30 p.m. ‘Volunteer Services’ ‘Policy’ “Hospice uses volunteers in administrative or direct care roles ....”’Procedure’ (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. Hospice will document a continuing level of volunteer activity. ....” VCSD was reviewed on August 21, 2024 at approximately 10:30 a.m. VD#1: Volunteer cost savings was requested for the past (12) months. Documentation provided of June 2024 ‘Volunteer Percentage’ “.39%” and July 2024 ‘Volunteer Percentage’ “.08%”. No other documentation provided. The total cost savings equated to less then five (5) percent of the total patient care hours. An interview conducted with the agency Director of Professional Services on August 21, 2024 at approximately 3:15 p.m. confirmed the above findings.”

“Based on a review of agency policy, employee files, and an interview with the agency Director of Professional Services, the agency failed to ensure orientation about the hospice philosophy for one (1) of two (2) employee files (EF) reviewed (EF#7). Agency policy/procedure reviewed on August 21, 2024 at approximately 2:30 p.m. Policy ‘Volunteer Services’ “procedure’ section (8) states “The personnel file for each volunteer will include, but is not limited to: “Documentation of orientation and initial volunteer training. .... Initial and ongoing competencies for patient care volunteers. ....” A review of EFs was conducted on August 19, 2024 at approximately 11:00 a.m. The volunteers date of hire (DOH) is included below.EF#7 DOH 08/29/23: This is a volunteer. No documentation provided of an orientation about the hospice philosophy being provided. An interview conducted with the agency Director of Professional Services on August 21, 2024 at approximately 3:15 p.m. confirmed the above findings.”

“Based on a review of agency policy, agency employee files, and an interview with the agency Director of Professional Services, the agency failed to assess the skills and competence of all individuals furnishing care for two (2) of two (2) employee files (EF) reviewed (EF#7, EF#8). Agency policy/procedure reviewed on August 21, 2024 at approximately 2:30 p.m. Policy ‘Volunteer Services’ “procedure’ section (8) states “The personnel file for each volunteer will include, but is not limited to: “Documentation of orientation and initial volunteer training. .... Initial and ongoing competencies for patient care volunteers. ....” A review of EFs was conducted on August 19, 2024 at approximately 11:00 a.m. The volunteers date of hire (DOH) is included below.EF#7 DOH 08/29/23: This is a volunteer. No documentation provided of a skills and competency assessment being conducted.EF#8 DOH 08/07/23: This is a volunteer. No documentation provided of a skills and competency assessment being conducted. An interview conducted with the agency Director of Professional Services on August 21, 2024 at approximately 3:15 p.m. confirmed the above findings.”

“Based on a request of agency policy/procedure, skilled nursing facility contracts, a review of clinical records, and an interview with the agency Director of Professional Services, agency failed to provide to the facility with the following: The most recent hospice plan of care specific to each patient, the hospice benefit of election form, and the physician certification and/or recertification of the terminal illness for one (1) of one (1) skilled nursing facilities (SNF) visited (SNF#1). Agency policy/procedure related to providing skilled nursing facility with required hospice documents was requested on August 21, 2024 at approximately 2:30 p.m. No specific policy provided. SNF #1: Review of the agency/facility written agreement was conducted on August 21, 2024 at approximately 11:00 a.m. Documentation provided of a ‘Contract for Professional Services’’ signed by the hospice agency on 01/15/2020 and signed by the facility on 02/14/2020. ‘Appendix A - Scope of Services’ (D)(iv) states “Provider (agency) shall provide (facility) the following information: (1) Hospice election form ... (2) Physician certification and recertification of the terminal illness specific to each resident under their care. (6) Hospice physician orders specific to each resident under their care.” During a home visit (CR#2) conducted at the facility on 08/20/24, the most recent hospice plan of care, the hospice benefit of election form, and the physician certification and/or recertification of the terminal illness was not in the patients chart. This was confirmed by the agency registered nurse (employee #9) who was present during the home visit. An interview conducted with the agency Director of Professional Services on August 21, 2024 at approximately 3:15 p.m. confirmed the above findings.”

“Based on a review of employee files, agency policy/procedure, and an interview with the agency Director of Professional Services, it was determined that the agency failed to ensure a Pennsylvania State police criminal background check was conducted for one (1) of eight (8) employee files (EF) reviewed (EF#7). The Pennsylvania (Pa.) ‘Health and Safety (Title 35)’ ‘Older Adults protective Services Act’ §10225.502 Information relating to prospective facility personnel. (a) General rule, -- A facility shall require all applicants to submit with their applications, ............, who have or may have direct contact with a recipient to submit, there following information obtained within the preceding one-year period: (1) pursuant to 18 Pa.C.S. Ch. 91 (relating to criminal history record information), a report of criminal history record information from the state police or a statement from the State Police that their central repository contains no such information relating to that person”. Agency policy/procedure reviewed on August 21, 2024 at approximately 2:30 p.m. Policy ‘Personnel Records’ ‘Procedure’ section (1) “The personnel record for an employee will include, but not limited to, the following: ....Criminal background checks on all employees who have direct patient contact or access to patient records, as required by state law. (If no state law, checks must be obtained within 3 months of employment for all states in which the individual has lived or worked during the past 3 years. .....” A review of EFs was conducted on August 19, 2024 at approximately 11:00 a.m. The volunteers date of hire (DOH) is included below. EF#7, DOH 08/29/23: This is a volunteer. No documentation of the agency conducting a Pennsylvania State Police criminal background check. An interview conducted with the agency Director of Professional Services on August 21, 2024 at approximately 3:15 p.m. confirmed the above findings.”