Urgent Care Hospice Inc.

“Based on observation, record review and interview, the agency failed to develop a written emergency preparedness and response plan based on an all-hazards risk assessment which identified disasters from natural and man-made causes likely to occur in the agency’s service area for years 2022, 2023 and 2024. This failure placed the agency’s clients at risk for neglect and/or harm should a natural or man-made disaster occur. Findings include: During an observation on 1/28/2025 at 1:00 pm, the surveyor noted a large oil and gas refinery located downtown in a residential area. During a record review with the agencys written emergency preparedness and response plan that the Alternate Administrator provided, the agencys emergency response plan with all hazard risk assessment labeled “;Hazard Vulnerability Assessment Tool,” dated 7/19/2024. Further review of the Hazard Vulnerability Assessment Tool listed the probability of a Pipeline/Refinery leak as “;unlikely to occur, with a vulnerability disruption level of a Pipeline/Refinery leak listed as “;low.” Further record review listed the agency’s preparedness level for a Pipeline/Refinery leak listed as “;poor.” During an interview on 1/30/2025 at 3:00 p.m. with the Alternate Administrator, the Alternate Administrator was informed of the above findings. The Alternate Administrator stated that the city has never had a problem with the refinery downtown but now she can understand the risk. Record review of an agency policy titled, “Emergency Preparedness Policy and Plan,” dated 7/11/2023, revealed in part, “;...The Emergency Plan will be based on and include a document, facility-based and community-based risk assessment, utilizing and all hazards approach. This approach is specific to the location of the Agency and considers hazards most likely to occur in the surrounding area...””

“Based on record review and interview, the agency failed to meet federal guidelines to provide volunteer services in an amount that equaled 5 percent of the total patient care hours of all paid hospice employees for 2023 and 2024. This failure could place Agency clients at risk of inadequate care by not ensuring that Agencys volunteers are being adequately staffed for hospice patients. Findings included: According to 42 CFR §418.78, Conditions of Participation for hospice agencies: Volunteers must 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 of all paid hospice employees and contract staff. The hospice must maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked. Record review of the Agencys volunteer report titled, “;Volunteer Tracking Log,” second quarter of 2023, revealed the total patient care hours provided by paid employees as 1619, with volunteer hours totaling 5 hours (0.003%). Record review of the Agencys volunteer report titled, “;Volunteer Tracking Log,” third quarter of 2023, revealed the total patient care hours provided by paid employees as 1721, with volunteer hours totaling 0 hours (0.00%). Record review of the Agencys volunteer report titled, “;Volunteer Tracking Log,” fourth quarter of 2023, revealed the total patient care hours provided by paid employees as an average of 1878, with volunteer hours totaling 6 hours (0.003%). Record review of the Agencys volunteer report titled, “;Volunteer Tracking Log,” first quarter of 2024, revealed the total patient care hours provided by paid employees as an average of 1743, with volunteer hours totaling 70 hours (3.87%). Record review of the Agencys volunteer report titled, “;Volunteer Tracking Log,” second quarter of 2024, revealed the total patient care hours provided by paid employees as an average of 1840, with volunteer hours totaling 36 hours (2.4%). Record review of the Agencys volunteer report titled, “;Volunteer Tracking Log,” fourth quarter of 2024, revealed the total patient care hours provided by paid employees as an average of 1537, with volunteer hours totaling 36 hours (0.5%). In an interview with the Volunteer Coordinator on 11/30/2024 at 2:00 p.m. the Volunteer Coordinator was informed of the above findings. The Volunteer Coordinator stated that she is performing a dual role right now due to the restructuring in the office and has difficulty with recruitment at times. In an interview with the Alternate Administrator on 1/30/2025 at 3:00 p.m., the Alternate Administrator stated that the Volunteer Coordinator did not inform her that she was having difficulty with volunteer recruitment and meeting the cost savings requirement of 5%. Record review of the Agencys policy titled, “;Volunteer Services” dated1/31/2015, revealed in part, “;3. The Volunteer Coordinator will...e. Monthly tracking and documenting volunteer services, the cost savings achieved throughout the use of volunteers and the percentage of patient care hours provided by volunteers. F. To calculate the total volunteer hours provided (with goal of 5%) ...”