Every finding on record at Charis Health and Hospice

Observed in Individual Tracer. In 3 of 3 individual tracers, it was noted that the organization did not ensure the recertification assessment included all required information. For example, the organization's policy titled patient assessments included the following information: IV. Information collected during the patient's assessment and reassessment will be based on the patient's condition and the care, treatment and services required to include but not limited to (5) Barriers and safety hazards in the home environment, and (6) Any other relevant information that may affect the patient's goals. A review of the medical records for HV#1, HV#2, and HV#3 revealed that the patient's were assessed at risk for falls and had goals and interventions related to the patient safety identified on the plan of care. The recertification assessments completed for these patients did not include a falls risk assessment. In addition, the recertification assessments did not include an assessment of barriers and safety hazards in the home environment.

Observed in Tracer Activities. the organization failed to prepare for how it would communicate during an emergency. During the emergency management tracer, the hospice nurse surveyor observed the agency did not include who staff would report to in an emergency. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. the organization failed to prepare for how it would manage staff during an emergency. During the emergency management tracer, the hospice nurse surveyor observed the agency did not include how the organization would identify staff and authorized volunteers during an emergency. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization failed to inform the patient, in writing, of the cost of services provided. For all records reviewed, the cost section of the consent was left blank. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization failed to provide a spiritual assessment by a trained spiritual counselor within the 5 days. During review of all records , the hospice nurse surveyor observed the Administrator was performing the comprehensive assessment but did not have the training to do so. This was discussed with the Administrator.

Observed in Record Review. the organization failed to provide interdisciplinary and collaborative services. During survey activities , the hospice nurse surveyor noted that in the 5 records reviewed the Chaplain had not made a visit or made contact with any. Per the Administrator, the patients refused. A note at SOC was acknowledged of refusal but nothing to address the issue beyond the initial note. Per the interview with the Chaplain, no visits had been made since the organization started in 2019. This was discussed with the Administrator.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization failed to plan the patient's care. In all records reviewed, the hospice nurse surveyor observed the written plan of care did not contain goals or timeframes to meet those goals. After discussion with the Administrator, the hospice nurse surveyor observed the documentation includes clinical problems and interventions but no goals were included. This was reviewed with the Administrator.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to implement the infection prevention and control activities it had planned. In HHV#1 the aide/ RN failed to clean her equipment before putting back into her bag as the organization policy stated. During record review for HRR#2, the hospice nurse surveyor observed the patient was placed on doxycycline on 11/29/21 but the organization failed to capture that information for their data management tracking and infection control program. Discussed and reviewed with the Administrator.

Observed in Tracer Activities. the organization failed to plan the patient's care. During survey activities, the hospice nurse surveyor noted the organization failed to provide spiritual counseling to meet the patient's and families needs. Through interview with the Chaplain and discussion with the Administrator , it was noted no visits for spiritual care had been completed since 2019 when the agency opened. This was reviewed with the Administrator.

Observed in Tracer Activities. Leadership and the governing body failed to understand the degree of risk in CFR §418.100, §418.116, §418.56 and §418.54. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(i),did not have a process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC as evidenced by no tracking of overall percentage vaccinated, no documentation of either physician being vaccinated as the Administrator stated they do not see patients, and the minimal documentation received showed two other employees without boosters. Also to note, the agency provided governing board meeting minutes from July 2021 stating the organization was exempt from the Covid vaccination mandate. This was discussed with the Administrator.