Every finding on record at Basin Home Health & Hospice

Based on interview, record review, and facility policy review, the facility failed to develop a bereavement plan of care for 3 (Patients (P) #3, #4, and #5) of 19 sampled patients. --- The findings are: A facility policy titled, ";Bereavement Assessment," updated 06/2024, revealed ";Policy [Facility name] will provide bereavement services for up to one year after the patients death to surviving family/caregiver members. The hospice bereavement plan of care will be developed based on an initial assessment of the patient and family/caregiver needs, during the course of care, and at the time of the of the patients death as part of the comprehensive assessment." Patient #3s medical record revealed no evidence of a bereavement plan of care. Patient #4s medical record revealed no evidence of a bereavement plan of care. Patient #5s medical record revealed no evidence of a bereavement plan of care. During an interview on 11/06/2024 at 10:35 AM, the Bereavement Counselor/Volunteer Coordinator confirmed there were no bereavement plans of care in place for any patient as she was not aware patients needed to have one. During an interview on 11/06/2024 at 2:35 PM, the Assistant Director of Nursing confirmed there were no bereavement plans of care in place for any patient at the hospice. During an interview on 11/06/2024 at 3:00 PM, the Medical Director (MD) stated he was not familiar with the bereavement plan of care, but expected the facility to offer bereavement support to patients families. The MD stated he was unclear on what the process was or what the requirements were for a bereavement plan of care. According to the MD, he was not as involved with the care plan process as it was not a medical care issue.

Based on interview, document review, and facility policy review, the facility failed to have a volunteer program that accounted for 5% of the total patient care hours of all paid hospice employees and contract staff. This deficient practice affected all patients who were provided services by the facility. --- The findings are: A facility policy titled, ";Volunteer Services," updated 06/2024, revealed ";4. The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel." The ";Volunteer Hours (Hospice)," for the timeframe 10/01/2023 to 09/30/2024, revealed a total of 4,320 minutes. Email correspondence from the Director of Operations, dated 11/06/2024 at 1:31 PM, revealed the total volunteer hours for the timeframe 10/01/2023 to 09/30/2024, revealed the volunteer minutes totaled 4,320 minutes, which equated to 3.6%. During an interview on 11/06/2024 at 10:14 AM, the Bereavement Counselor/Volunteer Coordinator stated she did not know the percentage of total patient care hours the volunteer program and confirmed she was unable to demonstrate compliance with the requirement. During an interview on 11/06/2024 at 3:00 PM, the Medical Director (MD) stated the facility difficulty getting volunteers for years and hiring a new Bereavement Counselor/Volunteer Coordinator was an effort to improve the volunteer services program. The MD stated the facility expectation would be to meet federal requirements.