Every finding on record at Care First Hospice, LLC

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care; and documented in the patient record, including the time spent. This standard was not met as evidenced by document reviews and interviews. During review of the Volunteer Program and an interview with the Area Executive of Clinical Services it was revealed that there are no Volunteers on staff for this office. Policy C20 "Volunteer Services" states in part, "(Agency name) provides volunteer services under supervision of the volunteer coordinator, provide both patient support and administrative support in a manner and amount consistent with the program's identified needs." During review of performance improvement plans it was found that a PIP has been put in place to recruit volunteers with a goal of 3 active volunteers by end of quarter 4. The agency presented evidence that showed they are actively working to recruit volunteers for this area. They have held one community event on 11/3/2022 and another is planned for 11/30/2022. They are active on volunteermatch.com and also have listings for volunteer needs on the agency website. The former Volunteer Coordinator resigned August 2022; a new volunteer coordinator was hired 11/17/2022. This individual will complete orientation 12/1/2022. In the interim the Area Executive of Clinical Services is serving as the Volunteer Coordinator. During an interview with Area Executive of Clinical Services it was stated that any patient needing volunteer services will be covered by Area Executive of Clinical Services afterhours. The Area Executive of Clinical Services has a Volunteer Coordinator job description present in personnel file as well as proof that all volunteer training required by the agency has been completed. There is no evidence that any current patient is in need of Volunteer Services. During review of the Volunteer Program and an interview with the Area Executive of Clinical Services it was revealed that there are no Volunteers on staff for this office. Policy C20 Volunteer Services states in part, "Compassus provides volunteer services under supervision of the volunteer coordinator, provide both patient support and administrative support in a manner and amount consistent with the program's identified needs." During review of performance improvement plans it was found that a PIP has been put in place to recruit volunteers with a goal of 3 active volunteers by end of quarter 4. The agency presented evidence that showed they are actively working to recruit volunteers for this area. They have held one community event on 11/3/2022 and another is planned for 11/30/2022. They are active on volunteermatch.com and also have listings for volunteer needs on the agency website. The former Volunteer Coordinator resigned August 2022; a new volunteer coordinator was hired 11/17/2022. This individual will complete orientation 12/1/2022. In the interim the Area Executive of Clinical Services is serving as the Volunteer Coordinator. During an interview with Area Executive of Clinical Services it was stated that any patient needing volunteer services will be covered by Area Executive of Clinical Services afterhours. The Area Executive of Clinical Services has a Volunteer Coordinator job description present in personnel file as well as proof that all volunteer training required by the agency has been completed. There is no evidence that any current patient is in need of Volunteer Services.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes: Physician orders. This standard was not met as evidenced by a review of clinical records, document review and interview. The agency's policy C30 "Written and Verbal Orders", states "(Agency name) ensures properly recorded orders are in place for the provision or administration of medications, biologicals, durable medical equipment, treatments, live discharges, changes in level of care, and resuscitation status per state law." 2 of 11 (18%) records revealed the agency did not obtain physician orders for treatments provided. Clinical Record 4: The record documented that the patient had a foley catheter inserted by a registered nurse on 10/22/2022. On 10/26/2022 and 10/28/2022, it was documented that the patient pulled the foley catheter out and, in both instances, it was replaced by registered nurse. No documented evidence was found that there was an order for a foley catheter or for replacing the catheter. Clinical Record 6: The record documented that a foley catheter was inserted on 5/2/2022. The foley catheter was removed and replaced on 6/3/2022. There was no documented evidence of a physician's order for the foley catheter. During an interview with the Director of Clinical Services it was stated that the process for any treatment the patient receives, an order is to be obtained from the physician first and documented. Agency policy C30 Written and Verbal Orders, states "Compassus ensures properly recorded orders are in place for the provision or administration of medications, biologicals, durable medical equipment, treatments, live discharges, changes in level of care, and resuscitation status per state law." During an interview with the Director of Clinical Services it was stated that the process for any treatment the patient receives an order is to be obtained from the physician first and documented.

It is required that durable medical equipment (DME) related to the palliation and management of the patient’s terminal illness and related conditions is: identified in the plan of care. This standard was not met as evidenced by a review of clinical records, document review and interview. Agency policy C29-"Drugs, Biologicals, Medical Supplies, and DME" states in part, "(Agency name) ensures durable medical equipment (DME), related to the palliation and management of the terminal illness and related conditions are identified in the hospice plan of care and are provided to the hospice patient while under the care of (the agency)." 11 of 11 (100%) records revealed, while DME was provided to patients, no DME were documented on the plans of care. Clinical Record 4: The Stateserv (DME company) report evidenced equipment was delivered to the patient's home on 10/13/2022. This equipment included an oxygen concentrator, electric bed, bed mattress, bed rails, commode, gel mattress overlay, nebulizer, over bed table, portable oxygen, wheelchair, and suction machine. The agency failed to list these items on the patient's plan of care. Clinical Record 3: The Stateserv report showed evidence that on 9/7/2022 a nebulizer, oxygen concentrator, portable oxygen, suction machine, electric bed, bed mattress, and bed rails were delivered to the patient's home. On 10/3/2022 a commode and over bed table was delivered to the home. There is no documented evidence of these items on the plan of care. Clinical Record 1: The Stateserv report showed evidence that on 7/20/2022, an oxygen concentrator, nebulizer, suction machine, and a transport chair were delivered to the patient's home. The agency failed to list these items on the patient's plan of care. Clinical Record 2: As evidenced by the Stateserv report, an oxygen concentrator nebulizer, oxygen refill cylinder, and suction machine were delivered to patient's house on 6/13/2022. On 8/15/2022 a rollator and over-bed table were delivered to the patient's home. There is no documented evidence of these items on the patient's plan of care. Clinical Record 5: As evidenced by the Stateserv report, an oxygen concentrator, nebulizer, oxygen cylinder cart, oxygen regulator, portable oxygen, and transfer bench were delivered to the patient's home on 8/30/2022. On 9/12/2022 a commode was delivered. On 10/14/2022 an electric bed, low air loss mattress, bed rails and over-bed table were delivered to the patient's home. The agency failed to list any of these items on the patient's plan of care. Clinical Record 6: The Stateserv report showed evidence that on 5/3/2022 an oxygen concentrator, electric bed, commode, footrests, nebulizer, oxygen refill cylinder, over bed table, portable oxygen, and suction machine were delivered to the patient's home. The agency failed to list these items on the patient's plan of care. Clinical Record 7: As evidenced by the Stateserv report, an oxygen concentrator, electric bed, low air mattress, nebulizer, over bed table, patient lift with sling, portable oxygen, and a suction machine were delivered to the patient's home on 6/26/2022. The agency failed to list items on the patient's plan of care. Clinical Record 9: The Stateserv report showed evidence that on 8/29/2022 an oxygen concentrator, nebulizer, oxygen cylinder cart, oxygen regulator, portable oxygen, and a suction machine was delivered to the patient's home. On 11/8/2022 an electric bed, bed mattress, bed rails and over bed table were delivered to the patient's home. The agency failed to list these items on the patient's plan of care. Clinical Record 10: The Stateserv report showed evidence that on 8/15/2022 an oxygen concentrator, portable oxygen, oxygen refill cylinder, and a suction machine were delivered to the patient's home. The agency failed to list these items on the patient's plan of care. Clinical Record 8: As evidenced by Stateserv report, an oxygen concentrator, oxygen cylinder cart, oxygen refill cylinder, and oxygen regulator were delivered to the patient's home on 7/25/2022. The agency failed to list these items on the patient's plan of care. Clinical Record 11: The Stateserv report showed evidence that on 6/16/2022 an oxygen concentrator, nebulizer, oxygen refill cylinder, and a suction machine were delivered to the patient's home. The agency failed to list these items on the patient's plan of care. In an interview with the Director of Clinical Services it was discovered that the agency does not utilize the durable medical equipment section of the electronic medical record. The agency only tracks the durable medical equipment through the DME company's website and ordering portal. Agency policy C29-Drugs, Biologicals, Medical Supplies, and DME states in part, "Compassus ensures durable medical equipment (DME), related to the palliation and management of the terminal illness and related conditions are identified in the hospice plan of care and are provided to the hospice patient while under the care of Compassus." In an interview with the Director of Clinical Services it was discovered that the agency does not utilize the durable medical equipment section of the electronic medical record. The agency only tracks the durable medical equipment through the DME company, Stateserv Medical, website and ordering portal. Surveyor reviewed Stateserv report ran on 11/15/2022 for all 11 records reviewed.