Every finding on record at Centercare Hospice, LLC

Based on interview and record reviews, the agency failed to develop and maintain a comprehensive emergency preparedness plan that met the requirements and was reviewed and updated at least every two years. Specifically, the agency failed to ensure the emergency plan included agency and community based risk assessments utilizing an all-hazards approach and addressed identified risks within the assessment. --- Findings include: AGENCY POLICY According to the policy, "QS.13 Emergency Management Plan," undated (in part): "An annual evaluation of the emergency management plan's objective, scope, performance, and effectiveness." 1. During an interview on 6/18/21 at 10:10 a.m., the administrator provided the emergency management program for review from 2021 to June 2024. Review of the emergency management plan revealed an undated communication process delineating which agency staff would contact case managers, field staff and patients in the event of an emergency; phone numbers for local fire department, paramedics, police and the building manager; utility company contacts and staff designation of emergency personnel within the agency. Record review revealed the designated staff; which included an administrator, alternate administrator and emergency coordinator, were no longer employed at the agency. Further record review revealed incomplete procedures for emergencies such as medical emergency, extended power loss, severe weather and natural disasters, fire emergency, chemical spills, critical operations and evacuation routes. a. The agency failed to ensure the emergency plan included agency and community based risk assessments utilizing an all-hazards approach and addressed identified risks within the assessment. Review of the emergency plan provided by the agency failed to reveal any completed risk assessments had been completed which identified natural, man-made or agency-based disasters which may occur as well as emerging infectious diseases. During an interview on 6/18/24 at 10:30 a.m., the administrator and Employee #7 stated they were not aware if the previous administrator had completed risk assessments for the agency; however, the current administration had no access to the shared drive in which that information was stored. The administrator and Employee #7 acknowledged the agency administration would need to complete a risk assessment and develop interventions in order to be compliant with the regulations During an interview on 6/19/24 at 1:10 p.m., Employee #11 presented a completed hazard and vulnerability risk assessment for review; which was completed following the interview on 6/18/24. The risk assessment provided revealed the agency had completed an assessment of historical data, climate trends and regional infrastructure and had identified flooding, blizzards and major electrical outings as primary risks to the agency's ability to provide continuous, uninterrupted care to patients. The risk assessment failed to include strategies for addressing the emergency risks identified within the assessment. b. The agency failed to ensure an emergency preparedness plan was reviewed and updated at least every two years. During an interview on 6/18/24 at 11:13 a.m., the administrator and Employee #7 stated they were not aware if the previous administration had reviewed the emergency plan every two years and the current administration had no access to the shared drive in which that information was stored. The administrator stated agency policy included annual review of the emergency management plan within the agency's quality assurance and performance improvement program (QAPI) as well as with the agency governing body; however, review of the QAPI and governing body documentation between October 2023 to June 2024 failed to show the emergency plan had been reviewed. The agency administration acknowledged the agency was not able to verify the emergency management plan had been reviewed at least every two years. During an interview on 6/19/24 at approximately 1:15 p.m., Employee #11 stated the hazard and vulnerability risk assessment had been shared with all staff and the agency's governing body for review on 6/18/24 following interview with surveyors earlier that date; however, agency administration and the governing body acknowledged the emergency plan was not complete and continued to need improvements in order to be compliant with the regulations.

Based on interviews and record reviews, the agency failed to develop and implement emergency management policies and procedures for follow up with on-duty staff and patients to determine services that are needed, in the event there is an interruption in services during or due to an emergency, in order to be able to notify State and local officials of any staff or patients that were unable to be contacted; and have reviewed and updated this policy at least every two years. --- Findings include: AGENCY POLICY According to the record, "Policy and Procedure Manual- Emergency Management Plan", dated 2018 (in-part): "To ensure ongoing compliance with regulatory requirements, the Agency will have procedures for the agency to communicate with staff, clients, state, and federal agencies other healthcare providers and suppliers." 1. During an interview on 6/18/21 at 10:10 a.m., the administrator provided the emergency management program, including associated policies and procedures, for review from 2021 to June 2024. a. The agency failed to ensure the emergency plan included a policy or procedure for the follow up with on-duty staff and patients to determine services that are needed, in the event there is an interruption in services during or due to an emergency. Review of the emergency plan policy book provided by the agency failed to reveal any procedures for follow up with on-duty staff and patients to determine services that are needed, in the event there is an interruption in services during or due to an emergency. Further review of the emergency plan provided failed to reveal policies or procedures which considered staffing shortages, staff ability to provide safe care or specific inpatient or home-based and equipment needs of patients as part of the hospice's role during emergencies in order to provide continuity in care. During an interview on 6/18/24 at 11:25 a.m., Employee #7 stated the agency did not have a policy for follow up with on-duty staff and patients regarding services needed in an emergency. In a further interview, the administrator and Employee #7 stated that the agency's policies and procedures needed updating to address all patient and agency needs during an emergency, and a contingency plan. This includes aligning with the agency's communication plan to work effectively with state and local officials. b. The agency failed to ensure a policy for follow up with on-duty staff and patients regarding services needed in an emergency was reviewed and updated at least every two years. During an interview on 6/18/24 at 11:13 a.m., the administrator and Employee #7 stated they were not aware if the previous administration had reviewed the emergency plan at least every two years and the current administration had no access to the shared drive in which that information was stored. The agency administration acknowledged the agency was not able to verify the emergency management plan had been reviewed at least every two years. During an interview on 6/19/24 at approximately 1:15 p.m., Employee #11,the director of operations, acknowledged the emergency plan continued to need improvements in order to be fully compliant with the regulations.

Based on interviews and record review, the agency failed to develop and maintain an emergency preparedness communication plan that included the names and contact information for staff, entities providing services under arrangement, patients' physicians, other facilities or hospices and volunteers and must be reviewed, and updated, at least every 2 years. --- Findings include: 1. During an interview on 6/18/21 at 10:10 a.m., the administrator provided the emergency management program, including associated policies and procedures, for review from 2021 to June 2024. a. The agency failed to develop an emergency preparedness communication plan that included the names and contact information for staff, entities providing services under arrangement, patients' physicians, other facilities or hospices and volunteers. Review of the agency's emergency plan revealed a communication plan, undated, titled "Emergency Personnel Names and Phone Numbers". The document revealed designated responsible officials and the emergency coordinator for the agency; however, the listed personnel were no longer employed with the agency. Further review of the emergency plan revealed an undated communication process, titled "Phone pyramid" delineating which agency staff position would contact case managers, field staff and patients in the event of an emergency. Both communication plans failed to reveal contact information for designated staff. Further review of the communication plan failed to reveal documentation of names or contact information for all staff, entities providing services under arrangement, patients' physicians, other facilities or hospices or volunteers. During an interview on 6/18/24 at 12:00 p.m., Employee #7 reviewed agency policies and stated the agency did not have a communication plan that included the names and contact information for staff, entities providing services under arrangement, patients' physicians, other facilities or hospices and volunteers. She said she was going to familiarize herself with the emergency preparedness communication plan requirements in order to implement and maintain the agency communication plan. b. The agency failed to ensure an emergency preparedness communication plan is reviewed and updated at least every two years. During an interview on 6/18/24 at 11:13 a.m., the administrator and Employee #7 stated they were not aware if the previous administration had reviewed the emergency plan at least every two years and the current administration had no access to the shared drive in which that information was stored. The agency administration acknowledged the agency was not able to verify the emergency management plan had been reviewed at least every two years. During an interview on 6/19/24 at approximately 1:15 p.m., Employee #11,the director of operations, acknowledged the emergency plan continued to need improvements in order to be fully compliant with the regulations.

Based on interview and record review, the agency failed to ensure the emergency preparedness plan; including the risk assessment with identified interventions, agency policies and procedures in an event of an emergency and communication plan had been trained and tested upon utilizing a drill testing exercise annually and full-scale exercise every two years. Additionally, the agency failed to ensure the testing and training plan had been reviewed and updated at least every two years. --- Findings include: AGENCY POLICY According to the record, "QS.13 Emergency Management Plan," undated (in-part): "Implementation of the agency's emergency management plan will be conducted at least annually, either in response to an emergency or as a planned drill." 1. During an interview on 6/18/21 at 10:10 a.m., the administrator provided the emergency management program, including associated policies and procedures, for review from 2021 to June 2024. a. The agency failed to ensure staff had been trained on the agency's emergency preparedness plan annually. A review of training documentation on 6/18/24 showed that emergency preparedness was included in the orientation training and was conducted annually online. The orientation training included a test with questions about a facility-based emergency preparedness plan, which referenced physical locations not applicable to the agency as an outpatient hospice provider. Further review of the agency's emergency plan revealed the absence of a comprehensive risk assessment, interventions for identified risks, policies and procedures for on-duty staff and patients, and a communication plan, all of which were required in the agency's annual training program. During an interview on 6/18/24 at 10:15 a.m., Employee #7 stated the agency completed training online annually for emergency preparedness; however, this was an overview of the emergency preparedness program and not specific to the agency's emergency plan. b. The agency failed to ensure the agency had conducted testing of the emergency preparedness plan to identify areas for improvement within the plan. Review of the emergency plan failed to reveal documentation that testing of the emergency preparedness plan had been conducted either utilizing drills or through implementation of the plan during a natural, man-made, agency-based disaster or emerging infectious disease(s) within the community. On 6/20/24, a review of the agency's policy and procedure manual, dated 2018, separate from te emergency preparedness program; revealed a policy titled "Policy and Procedure Manual- Emergency Management Plan," which revealed the agency policy had not included the requirement to perform a full-scale community based exercise every two years to test the emergency plan as required. During an interview on 6/18/24 at 10:15 a.m., Employee #7 and the administrator stated that the agency tested the emergency plan through mock drills and implemented it during a wildland fire in the past year. However, Employee #7 noted that neither the mock drills nor the implementation during the fire had been documented. As a result, the agency could not verify that it conducted testing of the emergency plan every two years. During the interview on 6/18/24 at 12:27 p.m., Employee #7 stated the agency had informally discussed, though undocumented,the need to improve the agency emergency plan within quality assurance and performance improvement (QAPI) program, including training and testing; however, had not been able to complete improvements prior to the recertification survey and had not identified specifically what improvements had been needed to make to the plan. c. The agency failed to ensure emergency preparedness testing and training was reviewed and updated at least every two years. During an interview on 6/18/24 at 11:13 a.m., the administrator and Employee #7 stated they were not aware if the previous administration had reviewed the emergency plan at least every two years and the current administration had no access to the shared drive in which that information was stored. The agency administration acknowledged the agency was not able to verify the emergency management plan had been reviewed at least every two years.