Every finding on record at Community Health Concepts, LLC-Dodge

It is required that during the initial assessment visit and in advance of providing care the hospice provides the patient—or his or her representative—with verbal and written notice of the patient’s rights and responsibilities. This information is provided in a language and manner that the patient understands. The hospice obtains the patient’s or representative’s signature confirming that he or she received a copy of the Bill of Rights and Responsibilities statement. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (8%) records reviewed revealed the hospice did not ensure to obtain the patient's or representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. Clinical Record #3: was reviewed and identified the patient elected hospice care on 1/20/2020. The signed hospice election of benefit and consent forms were missing in the record. The patient's signature confirmation of receipt of bill of rights was also missing. During an interview and a joint review of the record on 10/6/2022, the Director of Accreditation confirmed the hospice election of benefit and consent forms were missing. Forms were not located on previous the electronic medical record (EMR) system.

It is required that a hospice aide provides services ordered by the interdisciplinary group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 13 (15%) records reviewed of patients that accepted hospice aide services revealed the hospice did not ensure that hospice aide provided services ordered by the interdisciplinary group and included in the plan of care (POC). Clinical Record #1: was reviewed and identified the patient elected hospice care on 11/26/2021. The POC ordered hospice aide services, "five time per week." The aide care plan dated 11/26/2021, assigned the aide the tasks "nail care and shampoo" to be completed weekly. A review of the aide visits notes revealed dated 2/14/2022, 2/15/2022, 2/16/2022, 2/17/2022, 2/18/2022, 2/21/2022, 2/22/2022 and 2/23/2022, revealed the aide documented completing the tasks of nail care and shampoo at each visit. There was no evidence that the aide's assigned tasks were changed. Clinical Record #11: was reviewed and identified the patient elected hospice care on 8/4/2021. The POC ordered hospice aide services, "six days per week." The aide care plan dated 9/23/2021, assigned the aide the tasks "bed bath three times per week... tub bath three times per week." The aide documented both types of baths were provided during the visits completed on 9/5/2022 and 9/13/2022. During an interview and a joint review of the records on 10/6/2022, the Manager of Accreditation confirmed the hospice aides did not follow the aide care plans.

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 IS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidence by an interviews and clinical record review, which revealed the hospice failed to provide volunteer services in administrative or direct patient care roles [HCDT.21.I/642]; and failed to document and demonstrate ongoing efforts to recruit and retain volunteers.[HSRM.30.I/L645]. The cumulative effect of these deficiencies has resulted in the hospice agency's inability to provide quality care for the Condition of Participation CFR 418.78, Volunteers. The collective deficient practice illustrated not having a process to ensure the provision of Volunteer Services to all patients.

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 a review of clinical records and interview which revealed that the hospice did not ensure Volunteers were used in day-to-day administrative and/or direct patient care roles. There was no evidence of an active volunteer. The records reviewed did not contain documentation that volunteer visits were completed in 2022. A review of personnel records identified that there were no active volunteers. During interviews conducted on 10/4/2022 and 10/5/2022, the Director of Accreditation stated the agency's interpretation of the waiver was volunteer services did not have to be provided. The Director confirmed the agency did not have any active volunteers and seven (7) volunteers were terminated February 2022 due to noncompliance with COVID requirements.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document reviews and interviews. The hospice did not ensure to document and demonstrate ongoing efforts to recruit and retain volunteers. The agency's survey prep binder documented the agency’s review of volunteer services during 4th quarter QAPI meeting dated 1/21/2022, which stated in part, "the current environment with COVID continues to weigh negatively on volunteer activities across the state and we remain on a waiver for volunteer % requirements from CMS." The survey prep binder page 120 stated in part, "volunteer cost saving plans and records to be pulled from the system upon surveyor request." Multiple requests were made during the site visit for any type of volunteer records including personnel files, last documented cost saving hours and recruitment efforts, even requested volunteer documentation prior to acquisition dated September 2021, but the agency did not provide further documentation. During an interview on 10/4/2022, the Regional/Corporate Director of Volunteer Services stated there had not been any local community recruitment efforts due to the pandemic. The Director stated current recruitment efforts were through volunteermatch.com and the agency's website. No documentation of recruitment efforts was provided despite multiple requests during site visit. In addition, during interviews conducted on 10/4/2022 and 10/5/2022, the Director of Accreditation stated the agency's interpretation of the waiver was volunteer services did not have to be provided. The Director confirmed the agency did not have any active volunteers and seven (7) volunteers were terminated February 2022 due to noncompliance with COVID requirements.

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 and interviews. 1 of 13 (8%) records reviewed revealed the hospice did not ensure that a physician's order was obtained for wound care. Clinical Record #2: was reviewed and identified the patient elected hospice care on 2/17/2022. The skilled nursing visit completed on 7/12/2022, documented "inside folds have redness and some irritation with a very small spot that appears to be excoriation or shearing. Cream applied." There was no evidence of a physician’s order for wound care. During an interview and a joint review of the record on 10/4/2022, the Director of Accreditation confirmed there were no wound care orders on plan of care the patient.

It is required that if the care of a patient is transferred to another Medicare/Medicaid-certified facility, the hospice must forward, to the receiving facility, a copy of the hospice discharge summary and the patient's clinical record, if requested. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 2 (50%) records reviewed of transferred patients revealed the hospice did not ensure a copy of the hospice discharge summary was sent to the receiving facility. Clinical Record #6: was reviewed and identified the patient elected hospice care on 1/6/2022. The patient was transferred to a non-contracted facility effective 6/15/2022. The narrative note dated 6/15/2022, documented a phone call with the caregiver requesting the patient be sent to the local hospital for treatment of vomiting coffee ground emesis. In addition, the discharge summary dated 6/15/2022, documented the discharge summary was sent to patient's primary physician and the hospice medical director. There was no documented evidence that the discharge summary was sent to the local hospital. During an interview on 10/6/2022, the Director of Accreditation confirmed the discharge summary for the patient was not sent to the local hospital.

It is required that medical supplies and appliances related to the palliation and management of the patient’s terminal illness and related conditions are checked for expiration dates. This standard was not met as evidenced by interviews and observations. 1 of 2 (50%) observations of the hospice medical supply rooms revealed the hospice did not ensure to check for expired supplies. During the tour of the alternate delivery site's (ADS) medical supply room on 10/5/2022, a review of the medical supplies revealed twenty (20) expired Cure Medical Catheter Insertion Kits: five (5) expired on 9/28/2022; and fifteen (15) expired on 06/28/2022. The Director of Operations of ADS present for the tour, confirmed the kits were expired. The kits were removed and discarded from circulation of the supply room.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. Criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by a review of personnel records, interviews, and document reviews. 7 of 12 (58%) records reviewed revealed the hospice did not ensure to obtain criminal background checks on employees who had direct patient contact and access to patient records. The agency’s policy #HR-007 “Candidate Screening and Background Checks” stated in part, “Policy...the organization will obtain a criminal background check, OIG Exclusion List check and National Sex Offender Registry check on all Hospice employees/volunteers who have direct patient contact or access to patient records. In addition, for professionally licensed candidates, the organization will verify license related information to facilitate proper candidate screening as part of the hiring process. The agency's employment application read in part... “applicants: for this type of employment, State Law requires a national and State background check as a condition of employment.” Staff #5: The Administrator/Director of Nursing was hired on 2/1/2022. The personnel record did not include evidence of a documented criminal background check. Staff #1: The Registered Nurse (RN) was hired on 5/24/2022. The personnel record did not include evidence of a documented criminal background check. Staff #6: The RN was hired on 2/17/2020. The personnel record did not include evidence of a documented criminal background check. Staff #11: Review of the personnel record of the Medical Director, with a contract effective as of 2/1/2022, revealed the record did not include evidence of a documented criminal background check. Staff #9: The Nurse Practitioner was hired on 3/20/2020. The personnel record did not include evidence of a documented criminal background check. Staff #3: The Medical Social Worker was hired on 5/17/2022. The personnel record did not include evidence of a documented criminal background check. Staff #10: Review of the personnel record of the Hospice Physician, with a contract effective as of 2/1/2022, revealed the record did not include evidence of a documented criminal background check. During an interview, the Director of Accreditation confirmed that staff #1, #3, #5, #6, #9, #10, and #11 did not have criminal background checks performed by human resources. The Director stated the agency's interpretation of the standard and state applicable laws exempted licensed professionals from criminal background checks.