Tlc Hospice Services

“Based on record review and interview, the Agency failed to review and update at least annually it’s Emergency Preparedness Training and Testing program for 1 (2023) of 3 years for which documentation was requested. This failure had the potential that Agency employees would not know their role in an emergency and has the potential to place clients at risk of harm. Findings include:During the Entrance Conference conducted with the Administrator and the Supervising Nurse on 04/29/2025 at approximately 10:30 AM, Surveyor requested documentation of Emergency Preparedness Planning and Implementation including drills for 2022, 2023 and 2024. Documentation provided by the Supervising Nurse revealed Emergency Preparedness Planning and Implementation for the years of 2022 and 2024. The documentation failed to include evidence that a drill was conducted for the year of 2023. On 04/29/2025 at approximately 4:20 PM, the Supervising Nurse stated that she had located documentation of Emergency Preparedness Drills for 2022 and 2024, however was unable to find documentation for the year of 2023. The Supervising Nurse stated that she was recently hired as the Supervising Nurse four weeks ago and was unsure if the Agency had conducted a drill in 2023. During the exit conference on 05/02/2025 at 5:00 PM, the findings were discussed with the Administrator. The Administrator stated during 2023, the Former Supervising Nurse was responsible for maintaining documentation of Emergency Preparedness. The Administrator stated the Agency did conduct evaluations of their Emergency Preparedness Plan in 2023, however documentation had been misplaced in the move when the Agency moved from Address A to Address B. No additional information was provided.Review of the Agency’s policy and procedure manual revealed a policy titled “Testing Program for Emergency Operations Plan (EOP),” with a revision date of 02/2021, which read in part, “Hospice will conduct exercises to test the EOP at least biennially. Hospice will do the following: Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based exercise….Conduct an additional exercise that may include, but is not limited to the following: - A second full-scale exercise that is community-based or individual, facility-based. A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages or prepared questions designed to challenge the EOP…Analyze Hospice’s response to and maintain documentation of all drills, tabletop exercises and emergency events.””

“Based on record review and interview, the Hospice failed to maintain documentation of cost savings achieved through the use of volunteers for 1 of 2 calendar years requested (2023), for which documentation of cost savings achieved through the use of volunteers was requested.This failure resulted in the Hospice being unable to provide documentation of utilization of volunteers for the calendar year of 2023 and has the potential to result in substandard care in that it is unknown who was occupying a position as a volunteer, and what time they spent occupying those positions. Findings included:During the Entrance Conference conducted with the Administrator and the Supervising Nurse on 04/29/2025 at approximately 10:30 AM, Surveyor requested documentation of cost savings achieved through the use of volunteers for the years of 2023 and 2024. On 04/29/2025 at approximately 4:20 PM, the Supervising Nurse stated that she had located documentation of cost savings achieved through the use of volunteers for the year of 2024, however was unable to find documentation for the year of 2023.On 05/02/2025 at approximately 4:50 PM, an interview was conducted with the Administrator. The Administrator stated that Hospice Aide A was the volunteer coordinator and was responsible for maintaining documentation of volunteer utilization during the year of 2023. The Administrator stated Hospice Aide A was no longer employed by the Agency. The Administrator stated that volunteers were utilized during the year of 2023, however the Agency had misplaced the documentation when they moved from Address A to Address B. Review of the Agency’s policy and procedure manual revealed a policy titled “Volunteer Services,” with a revision date of 02/2021, which read in part, “Hospice will document the cost savings achieved through the use of volunteers and will include: Identification of each position occupied by volunteers. The work time spent by volunteer occupying those positions. Estimate of the dollar cost that Hospice would have incurred if paid employees occupied positions identified. 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. Hospice will maintain records on the use of volunteer for patient care and administrative services, including the type of services and time worked.””

“Upon personnel record review, 10 of 13 (Personnel #1,#2,#3,#4,#5,#6,#7,#8,#9,#10 ) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel #1,#2,#3,#4,#5,#6,#7,#8,#9,#10: No evidence of Emergency preparedness training.”

“Upon patient record review 9 of 14 (Patient #1,#4,#7,#8,#9,#10,#11,#13,#14) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1: SOC 3/21/2024. no evidence of a spiritual assessment by SC until 5/2/2024 (not enough info in SN SOC assessment). Patient #4: SOC 4/26/2024. no evidence of a spiritual assessment by SC until 10/29/2024 (not enough info in SN SOC assessment). Patient #7: SOC 10/19/2024. no evidence of a spiritual assessment by SC until 10/25/2024 (not enough info in SN SOC assessment). Patient #8: SOC 10/5/2024. no evidence of a spiritual assessment by SC until 10/15/2024 (not enough info in SN SOC assessment). Patient #9: SOC 8/31/2023. no evidence of a spiritual assessment by SC until 9/13/2023 (not enough info in SN SOC assessment). Patient #10: SOC 12/6/2024. no evidence of a spiritual assessment by SC until 12/18/2024 (not enough info in SN SOC assessment). Patient #11: SOC 1/4/2024. no evidence of a spiritual assessment by SC until 1/23/2024 (not enough info in SN SOC assessment). Patient #13: SOC 8/13/2024. no evidence of a spiritual assessment by SC until 8/26/2024 (not enough info in SN SOC assessment). Patient #14: SOC 9/25/2024. no evidence of a spiritual assessment by SC until 10/4/2024 (not enough info in SN SOC assessment)”

“Upon patient record review, 2 of 14 (Patient #2, #6) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2: On home visit medication reconciliation found pt. to be taking Aspirin 81mg PO QD, No evidence on Hospice profile for this medication. Corrected on site. Patient #6: Medication profile dated 12/26/2024 included Voltaren gel 1% apply 1GM 3x day for osteo arthritis. There was no evidence of an area to apply. Corrected on site.”

“Upon patient record review, 9 of 14 (Patient #1,#2,#4,#7,#8,#9,#10,#11,#13) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1: SOC 3/21/2024. Bereavement assessment done 5/2/2024. Patient #2: No evidence of a bereavement assessment completed. Patient #4: No evidence of a bereavement assessment completed. Patient #7: SOC 10/19/2024. Bereavement assessment done 10/25/2024. Patient #8: SOC 10/5/2024. Bereavement assessment done 10/15/2024. Patient #9: No evidence of a bereavement assessment completed. Patient #10: No evidence of a bereavement assessment completed. Patient #11: No evidence of a bereavement assessment completed. Patient #13: SOC 8/13/2024. Bereavement assessment done 9/17/2024.”

“Upon patient record review, 3 of 14 (Patient #1,#12,#13) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #1: No evidence of a comprehensive assessment from 6/10/2024-11/14/2024. Patient #12: No evidence of a comprehensive assessment from 2/8/2024-through end of care (no visit for dc date of 2/28/2024). Patient #13: No evidence of a comprehensive assessment from 8/19/2024-9/6/2024.”

“Upon patient record review, 9 of 14 (Patient #1,#3,#4,#7,#8,#10,#11,#12,#13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1:On SN SOC identified pt. taking Plavix, issues with dysphagia and no funeral planning done. No evidence of POC for problem/interventions/goals for bleeding precautions, dysphagia or funeral planning. Corrected on site. Patient #3:On SN SOC identified pt. had no funeral planning done. No evidence of POC for problem/interventions/goals for funeral planning. Corrected on site. Patient #4:On SN SOC identified pt. had no funeral planning done. No evidence of POC for problem/interventions/goals for funeral planning. Corrected on site. Patient #7: On SN SOC identified pt. has G-tube, No evidence on POC for problem/intervention/goals for G-tube. Corrected on site. Patient #8:On SN SOC identified issues with dysphagia. No evidence of POC for problem/interventions/goals for dysphagia. Corrected on site. Patient #10: ON SN SOC identified history if aspiration and taking Eliquis. No evidence of POC for problem/interventions/goals for dysphagia/aspiration and bleeding precautions. Corrected on site. Patient #11: On SN SOC identified pt. has O2 and Clopidogrel. No evidence of POC for problem/interventions/goals for O2 and bleeding precautions. Patient #12: On SN SOC identified pt on O2, Eliquis, aspiration precautions, elimination problems and need for funeral planning. POC generated only had titles for these items and no problem/interventions/goals were included. Patient #13: On SN SOC identified pt. taking Eliquis. No evidence of POC for problem/interventions/goals for bleeding precautions.”

“Upon patient record review, 2 of 14 (Patient #2,#6) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: On home visit medication reconciliation found pt. to be taking Aspirin 81mg PO QD, No evidence of a Hospice order for this medication. Corrected on site. Patient #6: Order dated 12/26/2024 included Voltaren gel 1% apply 1GM 3x day for osteo arthritis. There was no evidence of an area to apply. Corrected on site.”

“Upon client record review, 9 of 14 (Patient #1,#5,#6,#7,#8,#9,#11,#12,#14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Order for SN visits dated 3/21/2024, no evidence of SN visits from 6/10/2024-11/14/2024. Patient #5: Order for SC dated 11/27/2024 1x month and 3 PRN. No evidence of SC visit month of December 2024. Patient #6: Order for SN dated 12/23/2024 1x week. No evidence of a visit or missed visit week of 1/19/2025. Patient #7: Order for SC dated 10/21/2024 1x month and 3 PRN. No evidence of visits months of November or December 2024. Patient #8: Order for SN dated 12/12/2024 1x week. No evidence of a visit or missed visit week of 1/19/2025. Patient #9: Order for SC dated 12/12/2024 1x month. No evidence of a SC visit for month of December 2024. Patient #11: Order for SN dated 1/10/2024 1x week. No evidence of visits or missed visits weeks of 3/10/2024, 3/24/2024 and 4/7/2024. Patient #12: Order for SN dated 1/22/2024 1x week. No evidence of SN visits for weeks of 1/28/24, 2/11/2024 and 2/25/2024. Patient #14: Pt SOC 9/25/2024. No evidence of order for SN visit frequency until 11/24/24 order of 1x week with 2 PRN. Visits were made weekly from start of care through 11/24/2024. Week of 11/24/2024 SN visited 2x with an additional PRN.”

“Upon patient record review, 6 of 14 (Patient #1,#2,#3,#5,#6,#7) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: Per SN assessment, patient is on Plavix, has risk of falls, and is at risk of aspiration with dysphagia. No evidence on the aide assignment of fall, bleeding, or aspiration precautions. Corrected on site. Patient #2: Pt has order for O2, no evidence on the aide assignment for O2 precautions. Corrected on site. Patient #3: Pt has order for O2 and Clopidogrel, no evidence on the aide assignment for O2 and bleeding precautions. Corrected on site. Patient #5: Pt has order for O2 and SN assessed for seizure precautions, no evidence on the aide assignment for O2 and seizure precautions. Corrected on site. Patient #6: Pt has order for O2 and Eliquis, no evidence on the aide assignment for O2 and bleeding precautions. Corrected on site. Patient #7: SN identified pt. at risk for falls, no evidence on aide assignment of fall precautions. Corrected on site.”

“Upon patient record review 8 of 14 (Patient #1,#2,#5,#6,#7,#9,#10,#14) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1:Order 12/23/2024 Aide visit 2x week. Visits were performed 3x week for weeks of 12/29/2024, 1/5/2025 and 1/12/2025. No visits documented for week of 1/19/2025. Patient #2:Order 12/3/2024 aide 2 x week, order 12/8/2024 aide visits 3x week. Last IDG of 1/23/2025 continues to have aide visit frequency at 3x week. there is no evidence of any aide visits since start of care (supervisory visits were done). Patient #5: Order on IDG POC dated 12/12/2024 aide visit frequency 3x week. Week of 12/29/2024 two visits were made with no evidence of a missed visit. Patient #6: Order 12/23/2024 aide visits 3x week. Week of 1/20/2025 one visit made with no evidence of missed visits. Patient #7: Order dated 10/19/2024 aide visits 2x week. Weeks of 12/22/2024 and 1/5/2025 one visit made with no evidence of missed visits. Patient #9: Order dated 9/15/2024 aide visits 2x week. Weeks of 12/15/24, 12/22/24, 1/5/25, 1/12/25 and 1/19/2025 3 visits per week were made. Patient #10: Order dated 12/12/2024 aide visits 3x week. Weeks of 12/15/24 and 12/18/24 2 visits per week were made. No visits were made for weeks of 12/29/24, 1/5/24, 1/12/25, 1/19/25. Patient #14: Order dated 9/25/2024 aide visits 2 x week. No evidence of any aide visits made (supervisory visits made by RN).”