Every finding on record at Agape Hospice & Palliative Care, LLC

Observed in Record Review. During the Volunteer Tracer/Record review, the surveyor noted that documentation of initial (as part of onboarding orientation) Emergency Management (EM) training for volunteers was unavailable. Discussion with organization leadership indicated that while volunteers are provided EM training like that of employed staff, a method for documentation of the EM training of volunteers was not in place.

Observed in Record Review. In 1 of 16 patient records reviewed, During RR# 1's patient record review it was noted the organization had not updated the plan of care interventions to manage symptoms. For example: review of RR# 1's start of care plan of care and five subsequent plans of care revealed interventions for the Medical Social Worker (MSW) that included visit with patient once a month for psychosocial follow up. -Assist family with grieving process. -Assist in coping anticipated loss -Attentive listening. -Counsel for coping mechanisms -Encourage expressions of emotion and feeling. -Encourage participation in the plan of care. However, review of the Plan of care dated approximately 12 days after the start of care revealed the MSW services were declined. This was reviewed, discussed, and validated with the Administrator and DPCs.

Observed in Record Review. In 14 of 16 patient records reviewed, During RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, RR# 7, RR# 9, RRHV# 1, RRHV# 1, RRHV# 3, RRHV# 4, RRD/C# 1, and RRD/C# 2's patient records review it was noted the organization had not ensured the patients' plans of care included a statement of the scope and frequency of the services necessary to meet the patient's and family's needs. For example: review of 14 of 16 patient records revealed Skilled Nurse, Medical Social Worker (MSW), and/or Chaplain with PRN [as needed] visits with no indication for the as needed visits. This was reviewed, discussed, and validated with the Administrator and DPCS.

Observed in Record Review. In 10 of 16 patient records reviewed, During RR# 1, RR# 3, RR# 4,RR# 5, RR# 6, RR# 7, RR# 8, RRHV# 1, RRHV# 2, RRHV# 3's patient records review it was noted the organization had not ensured the plan of care included medications and treatments necessary to meet the patient's needs. For example: review of patients' plans of care revealed an order for O2 at 2-5 Liters per nasal cannula as needed for shortness of breath. However, there were no specific parameters provided. This was reviewed, discussed, and validated with the Administrator and DPCS.

Observed in Patient Home. In 1 of 4 home visits conducted, In SNF visit #1 It was observed during patient care that the LVN did not follow the agency's hand hygiene policy which included hand hygiene between glove change. During patient care the LVN did not use hand sanitizer in between changing gloves as evidences by: in between vital signs and skin assessment, the LVN removed her gloves and reapplies new ones without using hand sanitizer. This was reviewed and validated by LVN and she agreed. This was also validated with leadership

Observed in Patient Home. In 2 of 4 home visits conducted, During HV # 2 and HV # 4 it was observed that the back up oxygen tank was upright in a stand in the clothes closet . HCO  did not provide education to the board of care staff on the safe storage of oxygen cylinders in the home.

Observed in Patient Home. In 1 of 1 home visits conducted in the Skilled Nursing Facility, During HV#1 conducted at the Skilled Nursing Facility it was observed that HCO did not provide the SNF with a plan of care, this was validated with the LVN during the visit. It was also validated by Leadership

Observed in Record Review. In 1 of 13 patient records reviewed, documentation in the clinical record failed to include required elements of supervision of the hospice aide. For example in review of the medical record for HOS 2 there was a period of 5 weeks where the RN documented supervision of the hospice aide by entering a narrative note indicating that the patient/family was satisfied with the HHA services, however there was no evidence that the RN assessed the aide’s ability to demonstrate satisfactory performance in completing the tasks in the plan of care assigned to the hospice aide by the registered nurse, creating successful interpersonal relationships with the patient and family, demonstrating competence with assigned tasks, complying with infection control policies and procedures and reporting changes in the patient’s condition as required by regulation. This was discussed and validated by the CEO/Admin and DPCS.

Observed in Record Review. The organization failed to document the patient's wishes regarding advance directives. For example, in review of the medical record for HOS 2 the surveyor noted the comprehensive psychosocial assessment by the MSW at the start of care stated that the patient had an advance directive and would obtain a copy of the advance directive for the medical record, however there was no evidence in the medical record of the advance directive and the patient's wishes. This was discussed and validated by the CEO/Administrator. Observed in Record Review. In 2 of 13 patient records reviewed, The organization did not document the patient wishes regarding advance directives. For example, in review of the home folder and medical record for HOS 1 the surveyor noted that the consent/service agreement documentation stated that the patient does not have an Advance Directive, however in review of the Psychosocial Assessment completed by the MSW at start of care the record stated that patient has a living will and a copy was requested. There was no evidence in the medical record that the organization had obtained a copy of the Advance Directive. During the survey visit the son in law/caregiver also reported that the patient has an Advance Directive. Also, in review of the medical record for HOS 2 the Psychosocial Assessment completed by the MSW stated that the patient has Advance Directive obtain copy for record however there was no evidence of an Advance Directive. The patient's son/caregiver also reported that the patient has an Advance Directive. This was discussed with and validated with the CEO/Admin.

Observed in Document Review. In review of the contract with the Skilled Nursing Facility (SNF) for routine home care, general in-patient care and respite care the contract did not include a provision stating that the hospice will report all mistreatment, neglect, or verbal, mental, sexual, and physical abuse to the SNF administrator within 24 hours of the hospice becoming aware of the alleged violation, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice. This was discussed and validated with the CEO/Admin.

Observed in Document Review. The hospice organization's contract with a skilled nursing facility did not include all of the required elements. For example there was no stipulation that services would be provided only with the authorization of the hospice, the qualifications of the individuals providing the services and a stipulation that the skilled nursing facility will complete criminal background checks on contracted employees who provide direct patient. This was discussed and validated by the CEO/Administrator.