Every finding on record at Bcp Hospice, Inc.

It is required that the hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually. This standard was not met as evidenced by document review and interview. Review of the agency Emergency Preparedness (EP) plan revealed that the agency did not ensure organizational testing of the EP plan once annually. The agency EP plan included documentation of a drill completed on 10/15/2022 and signed by the Administrator. There was no documentation of what type of drill was conducted, who facilitated the drill, who participated or any follow-up to the drill. During an interview on 2/23/2023, the Administrator stated, "We did the drill and documented it." Review of the agency Emergency Preparedness Plan revealed that the agency did not ensure the emergency plan was tested via participation in a full-scale community-based exercise, the plan was not activated due to a natural or man-made emergency, a mock disaster drill was not documented, and a tabletop exercise or workshop led by a facilitator that included a group discussion with a clinically relevant emergency scenario was not documented.

It is required that during the initial assessment and in advance of providing care the hospice obtains the patient's signature confirming receipt of a copy of the Bill of Rights and Responsibilities statement. This standard was not met as evidenced by a review of clinical records, interviews and observations. 5 of 8 (62%) clinical records reviewed revealed that the agency did not ensure the patient consented to care and obtained confirmation that the patient received a copy of the Bill of Rights and responsibilities statement. Clinical Record 2: The initial assessment was documented as completed 4/19/2022. There was no documentation in the clinical record that the patient signed a consent for care that included documentation of receiving a copy of the Bill of Rights and Responsibilities. Clinical Record 3: The initial assessment was documented as completed 4/19/2022. There was no documentation the clinical record that the patient signed a consent for care that included documentation of receiving a copy of the Bill of Rights and Responsibilities. Clinical Record 6: The initial assessment was documented as completed 2/3/2023. There was no documentation that the patient signed a consent for care that included documentation of receiving a copy of the Bill of Rights and Responsibilities. During the home visit observation (Home Visit 1), the patient and facility administrator were unable to confirm that the patient had signed a consent for care that included documentation of receiving a copy of the Bill of Rights and Responsibilities. Clinical Record 7: The initial assessment was documented as completed 2/3/2023. There was no documentation that the patient signed a consent for care that included documentation of receiving a copy of the Bill of Rights and Responsibilities. During the home visit observation (Home Visit 2), the patient and facility administrator were unable to confirm that the patient had signed a consent for care that included documentation of receiving a copy of the Bill of Rights and Responsibilities. Clinical Record 8: The initial assessment was documented as completed 2/3/2023. There was no documentation that the patient signed a consent for care that included documentation of receiving a copy of the Bill of Rights and Responsibilities. During the home visit observation (Home Visit 3), the patient and facility administrator were unable to confirm that the patient had signed a consent for care that included documentation of receiving a copy of the Bill of Rights and Responsibilities. In an interview during joint clinical record review on 2/22/2023, the Chaplain/Consultant, confirmed that signed Bill of Rights statements were not in the clinical records and stated, "I don't see those forms." During an interview via phone on 2/23/2023, the Alternate Director of Clinical Services stated, "I'm sure we have them."

It is required that the hospice uses quality indicator data to monitor the effectiveness and safety of services and quality of care, and to identify opportunities and priorities for improvement. This standard was not met as evidenced by document review and interviews. Review of the 2022 Agency Quality Plan revealed that the agency had not collected any quality indicator data including patient care data and other relevant data. The agency had not identified any opportunities and priorities for improvement or used any data to monitor the effectiveness and safety of services and quality of care. The agency provided care for the first patient in April 2022 and had provided care for 5 discharged patients. In an interview on 2/23/2032, the Administrator stated, "We will make note of this and address it." During review of the 2022 Agency Quality Plan it was revealed that the agency had not collected any quality indicator data including patient care data and other relevant data and had not identified any opportunities and priorities for improvement or used any data to monitor the effectiveness and safety of services and quality of care.

It is required that the hospice uses quality indicator data, including patient care and other relevant data in the QAPI program. The frequency and detail of the data collection is approved by the hospice's governing body. This standard was not met as evidenced by document review. Review of the 2022 Agency Quality Plan revealed that the hospice failed to ensure that the frequency and details of data collection for the QAPI program was approved by the governing body.

It is required that licensed professionals participate in hospice sponsored in-service training. This standard was not met as evidenced by a review of interviews and personnel records. 6 of 7 (86%) personnel files reviewed revealed the hospice did not ensure that licensed professionals that had been employed or contracted for more than a year participated in hospice sponsored in-service training. Staff 2: The signed physician contract was dated 1/1/2021. There was no documentation in the personnel record that any hospice sponsored in-service training was offered following the initial orientation provided at hire. Staff 3: The signed physician contract was dated 1/1/2021. There was no documentation tin the personnel record that any hospice sponsored in-service education was offered following the initial orientation provided at hire. Staff 4: The date of hire for the RN Director of Clinical Services/Alternate Administrator was 10/17/2019. There was no documentation in the personnel record that any hospice sponsored in-service training was offered to the licensed professional following the initial orientation provided at hire. Staff 5: The date of hire for the RN/ Alternate Director of in the personnel Clinical Services was 3/24/2021. There was no documentation in the personnel file that any hospice sponsored in-service training was offered to the licensed professional following the initial orientation provided at hire. Staff 6: The date of hire for the MSW/Volunteer Coordinator was 5/2/2021. There was no documentation in the personnel file that any hospice sponsored in-service training was offered to the licensed professional following the initial orientation provided at hire. Record 11: The date of hire for the LVN was 2/24/2022. There was no documentation in the personnel file that any hospice sponsored in-service training was offered to the licensed professional following the initial orientation provided at hire. In an interview on 2/22/2023, the Administrator stated, "We have a calendar with the topics and the sign-in sheets." The calendar with topics and sign-in sheets were not presented to the Site Visitor during the site visit.

It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition of Participation was not met as evidenced by review of administrative documents, personnel records, clinical records, and interviews with the administrator and chaplain/consultant, which revealed issues in the way the hospice organizes, manages and administers its resources to provide hospice care and services in the following areas: Failed to ensure the governing body assumed legal authority and responsibility for the continuous quality assessment and improvement program [HSLG.2.I/L651]; Failed to use quality indicator data to monitor the effectiveness and safety of services and quality of care, to identify opportunities and priorities for improvement [HQPI.5.I/L564]; Failed to ensure the frequency and detail of data collection for the QAPI program was approved by the governing body [HQPI.5.I/L565]; Failed to ensure that the agency conducted exercises annually to test the emergency preparedness plan [HSEP.6.I/39]; Failed to ensure clinical records (62%) contained signed copies of the notice of patient rights and hospice election statement [HSIM.3.I/L673]; Failed to obtain patients’ signatures (62%) confirming receipt of a copy of the notice of rights and responsibilities [HPFC.3.I/L504]; Failed to ensure that staff (86%) participated in hospice sponsored in-service training [HSMR.17.I/L586]; and, Failed to ensure that staff performance evaluations (80%) were completed and documented [HSRM.29.D]. The cumulative effect and scope of these deficiencies could negatively impact the agency's ability to provide safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions.

It is required that the hospice's governing body (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization's continuous quality assessment and performance improvement program. This standard was not met as evidenced by document review. Review of the 2022 Agency Quality Plan did not provide evidence that the governing body was involved in the sustainment and ongoing evaluation of the hospice's quality assessment and performance improvement (QAPI) program.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient and includes at a minimum: Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by a review of clinical records, interviews and observations. 5 of 8 (62%) clinical records reviewed, revealed that the agency did not ensure the clinical record included a signed copy of the notice of patient rights and the hospice election of benefits statement. Clinical Record 2: The patient was admitted to hospice services on 4/19/2022 and was transferred to another hospice on 6/9/2022. The signed consent form verifying the patient acknowledged receipt of the statement of rights and a signed copy of the hospice election statement were not located in the clinical record. Clinical Record 3: The patient was admitted to hospice services on 4/19/2022 and was transferred to another hospice on 6/9/2022. The signed consent form verifying the patient acknowledged receipt of the statement of rights and a signed copy of the hospice election statement were not located in the clinical record. Clinical Record 6: The patient was admitted to hospice services on 2/3/2023. The signed consent form verifying the patient acknowledged receipt of the statement of rights and a signed copy of the hospice election statement were not located in the clinical record. During the home visit observation (Home Visit 1), the Site Visitor was not able to access the facility's locked files and the patient/facility was not able to confirm that a hospice election statement was signed at admission. Clinical Record 7: The patient was admitted to hospice services on 2/3/2023. The signed consent form verifying the patient acknowledged receipt of the statement of rights and a signed copy of the hospice election statement were not located in the clinical record. During the home visit observation (Home Visit 2), the Site Visitor was not able to access the facility's locked files and the patient/facility was not able to confirm that the hospice election statement was signed at admission. Clinical Record 8: The patient was admitted to hospice services on 2/3/2023. The signed consent form verifying the patient acknowledged receipt of the statement of rights and a signed copy of the hospice election statement were not located in the clinical record. During the home visit observation (Home Visit 3), the Site Visitor was not able to access the facility's locked files and the patient/facility was not able to confirm that the hospice election statement was signed at admission. During an interview and joint record review on 2/22/2023, the Chaplain/Consultant confirmed the finding and stated, "I don't see those forms."

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by a review of clinical records, documents and interviews. 4 of 5 (80%) records reviewed of patients that were transferred to a different hospice or revoked the hospice benefit, revealed that the agency did not ensure a discharge summary that included all of the required elements was documented in the clinical record. Agency Policy 2-072.1, titled "Discharge Summary" (revised January 2023), stated, in part, "Hospice personnel who provide care will complete a discharge summary at the time that the discipline is discontinued, which may include, as appropriate: The status of problems identified at admission and during the provision of care, the resolution of identified problems, continuing symptom management needs, the overall status of the patient, a summary of care or services provided, the patient's current plan of care, the patient's last physician orders. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service." Clinical Record 1: The patient was admitted to service 4/20/2022 with a diagnosis of Heart Disease. The patient revoked his hospice benefit 5/2/2022 to pursue treatment. There was no documented discharge summary found in the clinical record. Clinical Record 2: The patient was admitted to service 4/19/2022 with a diagnosis of Heart Disease. The patient was transferred to another hospice by request on 6/9/2022. There was no documented discharge summary found in the clinical record. Clinical Record 3: The patient was admitted to service 4/19/2022 with a diagnosis of COPD. The patient was transferred to another hospice by request on 6/9/2022. There was no documented discharge summary found in the clinical record. Clinical Record 4: The patient was admitted to service 4/19/2022 with a diagnosis of Alzheimer's Disease. The patient was transferred to another hospice by request on 6/9/2022. There was no documented discharge summary found in the clinical record. Policy Agency policy 2-072.1, titled Discharge Summary (revised January 2023), stated, in part, "Hospice personnel who provide care will complete a discharge summary at the time that the discipline is discontinued, which may include, as appropriate: The status of problems identified at admission and during the provision of care, the resolution of identified problems, continuing symptom management needs, the overall status of the patient, a summary of care or services provided, the patient's current plan of care, the patient's last physician orders. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service." During an interview on 2/23/2023 with the Alternate Director of Clinical Services via phone, she stated she would look into this finding.

It is required that the hospice obtains a criminal background check in accordance with State requirements on all hospice employees who have direct patient contact or access to patient records. This standard was not met as evidenced by personnel record reviews and interviews. 1 of 11 (9%) personnel records reviewed revealed that the agency did not ensure all staff that had access to patient records or had direct patient contact, had obtained a criminal background check. Staff 7: The background check for the Chaplain/Bereavement Coordinator dated 5/1/2022 was documented as completed for the state of Arizona, not the current state the employee was working in. In an interview on 2/21/2023 during joint personnel record review, Chaplain/Consultant confirmed that the background check was for Arizona and stated, "It does say Arizona."