Every finding on record at Billet Hospice Inc. - Peoria

Observed in Record Review. In 4 of 14 patient records reviewed, the Hospice Surveyor had not been able to validate that the patient need for Volunteers services had been reassessed throughout the plan of care (POC). For example, In RRNHV #5 the patient had orders in the POC for a Volunteer to provide support, socialization and/or respite for caregiver(s) since early march. There had been no volunteer services provided to the patient, so the HCO had not been meeting the needs of the patient. In RRNHV #6 the patient also had orders for a volunteer since start of care in December; however, no volunteer provided and no follow up assessment had been documented indicating the patient had not needed the volunteer services. In RRNHV #8, the patient also had Volunteer services ordered since start of care in December; however, no services had been provided. RRNHV #9 the patient had volunteer services ordered since January, and no volunteer has been provided, nor has the patient been reassessed for the need for the services. Of note, per the HCO, There are no volunteer services present for any patient in their current census of 101 patients. This was validated with the QAPI Director

Observed in Patient Home. In 1 of 4 home visits conducted, the Hospice Surveyor noted patient/care giver assessment needs that had not been included on the plan of care with interventions and goals. For example, RRHV #4, the patient had been wheelchair bound and wearing multiple splints related to left hemiplegia and was having issues with skin integrity and had been documented as high risk for skin breakdown; however, this had not been included on the patient plan of care. This was validated with the DPCS performing the visit.

Observed in Record Review. In 5 of 14 patient records reviewed, the Hospice Surveyor noted patient plans of care (POC) that had not been updated during IDG or recertification of services with patient specific issues. For example, in RRHV #1 there had been a statement on each IDG that: ‘the Chaplain will continue to visit monthly and as needed or requested for spiritual support for pt and affected family at this time of need to assure that beliefs, practices and relationships are nurtured and supported.’ The Chaplain had been declined in April and had not been making patient visits. In RRNHV #5, the Plan of Care (POC) had a problem listed of 'infusion' with interventions related to proper care of vascular access device, IV medication or fluid administration, infusion equipment and complications related to infusion or infusion device; however, the patient had never had a vascular access device nor an infusion. This had been present since the patient start of care in March. In RRNHV #6, there had been orders for wound care; however, the patient had not had a wound. The order had been present since the first POC in December and carried through 2 recertification periods. RRNHV #7 the patient also had orders for a wound that had not been present since the start of care in December. The same patient had IDG notes that indicated ‘the Chaplain will continue to visit monthly and as needed or requested for spiritual support for pt and affected family at this time of need to assure that beliefs, practices, and relationships are nurtured and supported, even though the chaplain had been declined and not in the plan of care since December. In RRNHV #12 that patient had orders in place for a wound care; however, the patient had not had a wound. This was validated with the Policy Analyst/Survey Coordinator and DOPCS Observed in Record Review. In 2 of 3 patient records reviewed, of patients who had expired on service, the Hospice Surveyor noted that documentation in the IDG had not been updated to accurately reflect the current patient condition. For example, In RRBR #2, there was a fully documented IDG note that included frequencies and discussions documented 11 days post patient death. In RRBR #3, there was a fully documented IDG present that occurred 13 days post death with ongoing visit frequency and no documentation that the patient had passed. This was validated with the Policy Analyst/Survey Coordinator and DOPCS

Observed in Record Review. In 4 of 14 patient records reviewed, the Hospice Surveyor had been unable to validate the patient need for Volunteers services had been provided or reassessed throughout the plan of care (POC). For example, In RRNHV #5 the patient had orders in the POC for a Volunteer to provide support, socialization and/or respite for caregiver(s) since start of care in early March; however, there had been no documented volunteer services provided to the patient nor communication related to volunteer services. In RRNHV #6 the patient also had orders for a volunteer since start of care in December; however, no volunteer provided, and no follow up assessment had been documented indicating the patient had not needed the ordered volunteer services. In RRNHV #8, the patient also had Volunteer services ordered since start of care in December; however, no services had been documented as provided. RRNHV #9 the patient had volunteer services ordered since January, and no documentation of volunteer services provided. The patient has also not been reassessed for the need of the services. Of note, per the HCO, there are no volunteer services present for any patient in their current census of 101 patients. This was validated with the Policy Analyst/Survey Coordinator and DOPCS

Observed in Tracer Activities. The Hospice Surveyor noted that the HCO had been performing passive recruitment of volunteers through their Human Resources Department, but there had been no documented active volunteer recruitment noted.

Observed in Tracer Activities. All of the current volunteers are employees of the HCO which is not allowable through the Medicare Conditions of Participation; therefore, the HCO was not able to demonstrate a cost savings related to the use of volunteers.

Observed in Tracer Activities. The Hospice Surveyor noted that the HCO had been using employees as volunteers and had not been able to meet the 5% minimum volunteer to patient care hours. This was validated with the QAPI Director.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by CLD's at §418.54 (Assessed Patient Needs), §418.78 (Volunteer Services) and §418.104 (Accurate Record of Care).

Observed in Record Review. In 7 of 14 patient records reviewed, the Hospice Surveyor noted documentation in the patient record that had not been individualized to the patient and/or had not been accurate to the patient discussed. For example, in RRHV #1, the IDG meeting notes had the Statement 'Chaplain will continue to visit monthly and as needed or requested for spiritual support for pt and affected family at this time of need to assure that beliefs, practices and relationships are nurtured and supported'; however, the patient had declined Chaplain services over multiple certifications periods. The same IDG note contained notes for a different patient and described wounds and spiritual care visits that had not occurred. In RRNHV #5, the Plan of Care (POC) had a problem listed of 'infusion' with interventions related to proper care of vascular access device, IV medication or fluid administration, infusion equipment and complications related to infusion or infusion device; however, the patient had never had a vascular access device nor an infusion. In RRNHV #7, the IDG notes had the statement: 'Chaplain will continue to visit monthly and as needed or requested for spiritual support for pt and affected family at this time of need to assure that beliefs, practices and relationships are nurtured and supported. Chaplain had been declined since the patient start of care in December 2023. In RRNHV #10 the IDG notes had the statement: 'Chaplain will continue to visit monthly and as needed or requested for spiritual support for pt and affected family at this time of need to assure that beliefs, practices and relationships are nurtured and supported. Chaplain had been declined since the patient start of care in May. Also in the initial Bereavement Risk Assessment the family was documented as scoring at a high risk, then in the same clinical note, the family was documented as a low risk.RRNHV #13, the same statement related to the Chaplain would continue to make visits, however, the chaplain had been declined by the patient and/or family in early March. In RRBR #2, there was a fully documented IDG note that included frequencies and discussions documented 11 days post patient death. In RRBR #3, there was a fully documented IDG present that occurred 13 days post death with ongoing visit frequency and no documentation that the patient had passed. This was validated with the Policy Analyst/Survey Coordinator and DOPCS

Observed in Tracer Activities. The Hospice Surveyor noted that the HCO had a process in place to evaluate the written contracts annually; however, they had not been evaluating whether the implemented contract had been meeting the needs of the HCO and the needs of the patients. They had been evaluating the wording of the contract only. This was validated with the Administrator present.