Every finding on record at Dmsc Management Partners

It is required that the hospice Registered Nurse completes an initial assessment within 48 hours of the patient’s election of hospice care, in accordance with CMS 418.24 (the elements of the hospice care election statement). This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the hospice did not ensure the Registered Nurse (RN) completed the initial assessment within 48 hours of the patient's election of hospice care. Clinical Record 2: The patient elected the hospice benefit election on 7/28/2023, with a terminal diagnosis of Multiple Sclerosis. Clinical record review revealed the RN began the initial assessment on 7/28/2023. The initial assessment in the Electronic Medical Record (EMR) system was marked as “started.” As of record review on 8/8/2023 the initial assessment continued to be marked as "started" in the EMR and had not been completed. The Vice President of Clinical Operations was interviewed on 8/8/2023 and stated the RN did not complete her initial assessment yet. She stated that "started" meant the RN started but did not complete the assessment. In 1 of 5 (20%) clinical records reviewed revealed the RN did not ensure the initial assessment was completed within 48 hours of the patient's election of hospice care.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS 418.24-elements of the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within five calendar days after the election of hospice care. Clinical Record 1: The patient elected the hospice benefit on 3/4/2022, with a terminal diagnosis of Alzheimer’s Disease. The comprehensive assessment documented the patient's need for a Medical Social Worker (MSW) evaluation/assessment. There was no documented evidence in the clinical record that the MSW completed an evaluation/assessment of the patient within 5 calendar days after the election of hospice care. Clinical Record 2: The patient elected the hospice benefit on 7/28/2023, with a terminal diagnosis of Multiple Sclerosis. The comprehensive assessment documented the patient's need for a MSW evaluation/assessment. There was no documented evidence in the clinical record that the MSW completed an evaluation/assessment of the patient within 5 calendar days after the election of hospice care. The Vice President of Clinical Operations was interviewed on 8/8/2023 and stated she did not know why the assessments were not done. This is a continuing required action. In 2 of 5 (40%) clinical records reviewed in which a comprehensive assessment was performed, revealed the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the hospice did not ensure that the comprehensive assessment included an initial bereavement assessment. Clinical Record 1: The patient elected the hospice benefit on 3/4/2022, with a terminal diagnosis of Alzheimer’s Disease. Clinical record review revealed the initial bereavement assessment was dated 7/5/2022 and was not completed as part of the comprehensive assessment at the start of care dated 3/4/2022. Clinical Record 2: The patient elected the hospice benefit on 7/28/2023, with a terminal diagnosis of Multiple Sclerosis. The clinical record contained no documented evidence that an initial bereavement assessment was completed, as of the date of record review on 8/8/2023. The Vice President of Operations was interviewed on 8/8/2023 and stated she did not know why the assessment was not done on admission or why the other record was missing the initial bereavement assessment. This is a continuing required action. In 2 of 5 (40%) clinical records reviewed it was revealed that the hospice did not ensure that the interdisciplinary group completed the initial bereavement risk assessment.

It is required that each patient’s individualized written plan of care reflects patient and family goals, and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the hospice did not ensure the written plan of care included goals and interventions based on problems identified in the initial assessment. Clinical Record 2: The patient elected the hospice benefit on 7/28/2023, with a terminal diagnosis of Multiple Sclerosis. Clinical record review revealed the initial assessment dated 7/28/2023 was marked as “started” in the Electronic Medical Record (EMR) system. The hospice plan of care dated 7/28/2023 did not include goals and interventions for the patient, due to the initial assessment being incomplete. As of record review on 8/8/2023 the initial assessment continued to be marked as "started" in the EMR and the plan of care did not include goals and interventions for the patient’s care. The Vice President of Clinical Operations was interviewed on 8/8/2023 and stated there were “no goals or interventions as the nurse had not completed her initial assessment." This is a continuing required action. In 1 of 5 (20%) clinical records reviewed, the hospice did not ensure the written plan of care included goals and interventions based on problems identified in the initial assessment.

It is required that one or more individual(s) is appointed by the governance as responsible for operating the QAPI (Quality Assessment Performance Improvement) program. This standard was not met as evidenced by document review and interview. Review of the Governing Body meeting minutes revealed no documented evidence that the Governing Body had appointed an individual(s) to be responsible for the operating the hospice agency’s QAPI program. The Vice President of Clinical Operations was interviewed on 8/8/2023 and stated she read the minutes and agreed that a specific individual was not appointed. This is a continuing required action. In 1 of 1 (100%) governing body meeting minutes documents reviewed did not ensure an individual was appointed by the governance as responsible to operate the QAPI program

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by interview and personnel record review. In 1 of 7 (14%) personnel records reviewed, the hospice did not ensure that employees received education in infection control. Personnel Record 3: The employee date of hire was 6/26/2023 for Chaplain/Bereavement Coordinator. Review of the personnel file revealed no documented evidence that the employee received education in infection control. The Vice President of Clinical Operations was interviewed on 8/8/2023 and stated she did not know why the employee had not completed infection control education. This is a continuing required action. In 1 of 7 (14%) personnel records reviewed revealed the hospice did not ensure that employees received education in infection control.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed, the hospice did not ensure nursing services were provided according to the plan of care. Clinical Record 2: The patient elected the hospice benefit on 7/28/2023, with a terminal diagnosis of Multiple Sclerosis. The plan of care included orders for Skilled Nurse (SN) visit frequency two times a week. There was no documented evidence that the SN provided two visits the week of 7/30/2023. Clinical Record 3: The patient elected the hospice benefit on 5/31/2023, with a terminal diagnosis of Pancreatic Cancer. The plan of care included orders for SN visit frequency two times a week. There was no documented evidence that the SN provided two visits the week of 7/30/2023. Clinical Record 5: The patient elected the hospice benefit on 4/20/2023, with a terminal diagnosis of Protein Calorie Malnutrition. The plan of care included orders for SN visit frequency of two times a week. There was no documented evidence that the SN provided two visits the week of 7/30/2023. The Vice President of Clinical Operations was interviewed on 8/8/2023. She stated she was sure the nurse made the visits and was probably behind on her documentation. This is a continuing required action. In 3 of 5 (60%) clinical records reviewed did not include documented evidence the skilled nurse followed the plan of care as ordered.

It is required that medical social services are provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, per the plan of care and under the direction of a physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the hospice did not ensure that medical social services were provided based on a psychosocial assessment of needs and according to patient/family needs and acceptance of services. Clinical Record 1: The patient elected the hospice benefit on 3/4/2022, with a terminal diagnosis of Alzheimer’s Disease. The nursing assessment identified the need and family's desire for a Medical Social Worker (MSW) assessment/visit. There was no documented evidence in the clinical record that a psychosocial assessment was completed by the MSW based on the nurse's identified need and family’s desire. The Vice President of Clinical Operations was interviewed on 8/8/2023 and stated she did not know why the psychosocial assessment was not completed by the MSW. This is a continuing required action. In 1 of 5 (20%) clinical records reviewed did not include documented evidence that the social worker followed the plan of care according to the patient's and family's needs and acceptance of services.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the hospice did not ensure that spiritual counseling was provided according to assessed needs and patient/family acceptance of services. Clinical Record 4: The patient elected the hospice benefit on 6/21/2023, with a terminal diagnosis of Alzheimer’s Disease. A spiritual care assessment was completed with the patient on 7/10/2023, and spiritual care services were ordered 2 times a week to begin on 8/1/2023. As the date of review on 8/8/2023, there was no documented evidence of spiritual care visits provided to the patient. The Vice President of Clinical Operations was interviewed on 8/8/2023 and stated she is having difficulty getting the chaplain to document stating, "He just doesn't get it." and "He jots notes on a piece of paper." In 1 of 5 (20%) clinical records reviewed, it was revealed that the hospice did not ensure that a spiritual care assessment was completed as ordered.

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 clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the hospice did not ensure the hospice aide followed the plan of care as ordered. THIS IS A CONTINUING REQUIRED ACTION. Clinical Record 2: The patient elected the hospice benefit on 7/28/2023, with a terminal diagnosis of Multiple Sclerosis. Hospice aide (HA) visits were ordered four times a week. During the week of 7/30/2023 to 8/6/2023, there was no documented evidence of a hospice aide visit in the clinical record. Clinical Record 5: The patient elected the hospice benefit on 4/20/2023, with a terminal diagnosis of Protein Calorie Malnutrition. HA visits were ordered three times a week. During the week of 7/30/2023 to 8/6/2023, the HA documented visits on 7/31/23 and 8/1/23. There was no documented evidence of a third hospice aide visit for that week. The Vice President of Clinical Operations was interviewed on 8/8/2023 and stated she was sure the hospice aide made the visits but did not know why the documentation was not in the record. This is a continuing required action. In 1 of 5 (20%) clinical records reviewed did not include documented evidence the hospice aide followed the plan of care as ordered.

It is required that orientation on the hospice philosophy is provided to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by interview and personnel record review. In 2 of 7 (29%) personnel records reviewed, it was revealed that the hospice did not ensure that an orientation to hospice philosophy was provided to employees. Personnel Record 3: The employee date of hire was 6/26/2023 for Chaplain/Bereavement Coordinator. Review of the personnel file revealed no documented evidence that an orientation to hospice philosophy was provided upon hire. Personnel Record 6: The employee date of hire was 3/13/2023 for Registered Nurse Case Manager. Review of the personnel file revealed no documented evidence that an orientation to hospice philosophy was provided upon hire. The Vice President of Clinical Operations was interviewed on 8/8/2023 and stated there was no orientation checklist upon hire. This is a continuing required action. In 2 of 7 (29%) personnel records reviewed, it was revealed that the hospice did not ensure that an initial orientation was provided to employees.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties. This standard was not met as evidenced by interview and personnel record review. In 2 of 7 (29%) personnel records reviewed, the hospice did not ensure that a job description addressing the employee's specific job duties was provided to the employee. Personnel Record 2: The employee date of hire was 6/9/2023 for Intake Coordinator. There was no documented evidence in the personnel record that the employee was provided with a job description which outlined the specific job duties for the Intake Coordinator upon hire. Personnel Record 3: The employee date of hire was 6/26/2023 for Chaplain. There was no documented evidence in the personnel record that the employee was provided with a job description which outlined the specific job duties for the Chaplain upon hire. The Vice President of Clinical Operations was interviewed on 8/8/2023 and stated she did not know why the job descriptions were not in the personnel records. This is a continuing required action. In 2 of 7 (29%) personnel records reviewed, it was revealed that the hospice did not ensure that a job description addressing the employee's specific job duties was provided to employees.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by interview and personnel record review. In 1 of 7 (14%) personnel records reviewed, the hospice did not ensure that a competency assessment was completed upon hire, prior to providing care to hospice patients. THIS IS A CONTINUING REQUIRED ACTION. Personnel Record 3: The employee date of hire was 6/26/2023 for Chaplain/Bereavement Coordinator. Review of the personnel file revealed no documented evidence that a competency assessment was completed. The Vice President of Clinical Operations was interviewed on 8/8/2023 and stated, "He should have completed the competencies, he's a good chaplain." This is a continuing required action. In 1 of 7 (14%) personnel records revealed the hospice did not ensure that a competency assessment was completed on hire, prior to providing care to hospice patients.

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. This standard was not met as evidenced by document review and interview. Review of the Physical Therapy/Occupational Therapy/Speech Therapy contract revealed the contract did not contain evidence of language that required that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. The hospice did not ensure the contract for therapy services required contracted employees who have direct patient contact or access to patient records obtain criminal background checks. The Vice President of Clinical Operations was interviewed on 8/8/2023 and stated she would contact the contract administrator and get the necessary language added. In 1 of 1 (100%) contracts reviewed, the hospice did not ensure the contract contained language requiring the hospice obtain criminal background checks on all contracted employees having direct contact or access to patient records.

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; the primary caregiver in accordance with the patient’s needs. THIS IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 5 (40%) clinical records reviewed the hospice did not ensure registered nurse visits were completed as ordered on the plans of care. Record 2: The patient’s date of election was 3/4/2022. A physician’s order on 3/4//2022 ordered Registered Nurse/Skilled Nurse 1 x weekly. During the week of 6/12/2022-6/18/2022, there was no documented evidence of a nursing visit or documented reason for the missed visit. Record 3: The patient’s date of election was 4/21/2022. A physician’s order on 4/21/2022 ordered Registered Nurse/Skilled Nurse 2 x weekly. During the week of 5/1/2022-5/7/2022, a nursing visit was completed on 5/2/2022. There was no documented evidence of a second nursing visit or documented reason for the missed visit. During the week of 5/29/2022-6/4/2022, a nursing visit was completed on 6/4/2022. There was no documented evidence of a second nursing visit or documented reason for the missed visit. The Administrator was interviewed on 10/11/2022 and agreed that registered nurse visits were not completed in accordance with orders on the plan of care. Record 2: The patient’s date of election was 3/4/2022. A physician’s order on 3/4//2022 ordered Registered Nurse/Skilled Nurse 1 x weekly. During the week 6/12/2022-6/18/2022, there was no documented evidence of a nursing visit or documented reason for the missed visit. Record 3: The patient’s date of election was 4/21/2022. A physician’s order on 4/21/2022 ordered Registered Nurse/Skilled Nurse 2 x weekly. During the week 5/1/2022-5/7/2022, there was a nursing visit on 5/2/2022. There was no documented evidence of a second nursing visit or documented reason for the missed visit. During the week 5/29/2022-6/4/2022, there was a nursing visit on 6/4/2022. There was no documented evidence of a second nursing visit or documented reason for the missed visit. The Administrator was interviewed on 10/11/2022 and agreed, the registered nurse did not follow the plan of care as ordered. The Administrator was interviewed on 10/11/2022 and stated, “I was not aware of the action plan until a month ago.” The Administrator agreed there was no evidence the agency implemented the action plan with an implementation date of 12/30/2021.

It is required that a qualified hospice aide has successfully completed a competency evaluation program that: 1) Evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or pseudo-patient: a) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; b) Reading and recording temperature, pulse, and respiration; c) Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: i. Bed bath; ii. Sponge, tub, and shower bath; iii. Hair shampoo (sink, tub, and bed); iv. Nail and skin care; v. Oral hygiene; vi. Toileting and elimination; d) Safe transfer techniques and ambulation; e) Normal range of motion and positioning. 2) Evaluates the aide’s competency in the following subject areas by written exam, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation: a) Observation, reporting, and documentation of patient status and the care or service provided; b) Basic infection control procedures; c) Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor; d) Maintenance of a clean, safe, and healthy environment; e) Recognizing emergencies and the knowledge of emergency procedures and their application; f) The physical, emotional, and developmental needs of—and ways to work with—the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property; g) Adequate nutrition and fluid intake; h) Any remaining task(s) that the hospice chooses to have an aide perform. AND 3) The competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate. This standard was not met as evidenced by review of documents, records and interview. Review of 1 of 1 (100%) clinical record of a hospice aide revealed there was no documented evidence of a skills competency assessment completed at the time of hire in accordance with the agency's policy. Agency policy, “Initial Competency Assessment,” stated in part, “The organization ensures the competency of all personnel is assessed on hire, prior to providing care to organization patients.” Record 3: (Hospice Aide): hire date 12/6/2021. There was no documented evidence that a competency assessment was completed upon hire. The Administrator was interviewed on 10/11/2022 and agreed, there was no documented evidence that a competency assessment was completed upon hire, prior to providing care to patients.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. THIS IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 5 (60%) records reviewed with a hospice aide ordered, the hospice did not ensure the hospice aide visits were completed as ordered on the plans of care. Record 1: The patient’s date of election was 1/13/2021. A physician’s order on 8/1/2021 ordered a hospice aide 1 x weekly. During the week of 1/16/2022-1/22/2022, there was no documented evidence of a hospice aide visit or documented reason for the missed visit. Record 2: The patient’s date of election was 3/4/2022. A physician’s order on 3/4//2022 ordered a hospice aide 2 x weekly. During the week of 6/19/2022-6/25/2022, a hospice aide visit was conducted on 6/23/2022. There was no documented evidence of a second hospice aide visit or documented reason for the missed visit. Record 4: The patient’s date of election was 7/7/2022. A physician’s order on 7/7/2022 ordered a hospice aide 2 x weekly. During the week of 8/21/2022-8/27/2022, a hospice aide visit was conducted on 8/24/2022. There was no documented evidence of a second hospice aide visit or documented reason for the missed visit. A physician’s order on 9/4/2022 ordered a hospice aide 3 x weekly. During the week of 9/4/2022-9/10/2022, hospice aide visits were completed on 9/7/2022 and 9/9/2022. There was no documented evidence of a third hospice aide visit or documented reason for the missed visit. The Administrator was interviewed on 10/11/2022 and agreed that hospice aide visits were not completed as ordered on the plans of care. Record 1: The patient’s date of election was 1/13/2021. A physician’s order on 8/1/2021 ordered a hospice aide 1 x weekly. During the week 1/16/2022-1/22/2022, there was no documented evidence of a hospice aide visit or documented reason for the missed visit. Record 2: The patient’s date of election was 3/4/2022. A physician’s order on 3/4//2022 ordered a hospice aide 2 x weekly. During the week 6/19/2022-6/25/2022, there was a hospice aide visit on 6/23/2022. There was no documented evidence of a second hospice aide visit or documented reason for the missed visit. Record 4: The patient’s date of election was 7/7/2022. A physician’s order on 7/7/2022 ordered a hospice aide 2 x weekly. During the week 8/21/2022-8/27/2022, there was a hospice aide visit on 8/24/2022. There was no documented evidence of a second hospice aide visit or documented reason for the missed visit. A physician’s order on 9/4/2022 ordered a hospice aide 3 x weekly. During the week 9/4/2022-9/10/2022, there was a hospice aide visit on 9/7/2022 and 9/9/2022. There was no documented evidence of a third hospice aide visit or documented reason for the missed visit. The Administrator was interviewed on 10/11/2022 and agreed, the hospice aide did not follow the plan of care as ordered. The Administrator was interviewed on 10/11/2022 and stated, “I was not aware of the action plan until a month ago.” The Administrator agreed there was no evidence the agency implemented the action plan with an implementation date of 12/30/2021.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. This standard was not met as evidenced by a review of clinical records, document review and interviews which revealed there was no evidence of volunteer services used in either day-to-day administrative activities or direct patient care roles. In 4 of 4 (100%) clinical records reviewed of patients admitted to hospice in 2022, there was no documented evidence to confirm that volunteer services were offered, requested or declined by the patients and/or families. Record 2: The patient’s date of hospice election was 3/4/2022. There was no documented evidence that a volunteer was offered to the patient or the family. There was also no evidence that the patient or family had requested or declined an offer for volunteer services. Record 3: The patient’s date of election was 4/21/2022. There was no documented evidence that a volunteer was offered to the patient or the family. There was also no evidence that the patient or family had requested or declined an offer for volunteer services. Record 4: The patient’s date of election was 7/7/2022. There was no documented evidence that a volunteer was offered to the patient or the family. There was also no evidence that the patient or family had requested or declined an offer for volunteer services. Record 5: The patient’s date of election was 9/28/2022. There was no documented evidence that a volunteer was offered to the patient or the family. There was also no evidence that the patient or family had requested or declined an offer for volunteer services. The Volunteer Coordinator was interviewed on 10/10/2022 and stated that the offer of volunteer services is done by the admitting nurse. She also reported that the hospice does not currently have a volunteer available to provide services in an administrative capacity as well. The Administrator was interviewed on 10/10/2022 and confirmed she completes many of the RN initial admission visits and stated, “I don’t offer volunteers on admit because the volunteer coordinator does that on their visit.” The Administrator was also interviewed on 10/11/2022 and agreed, there was no documented evidence that a volunteer was offered to the patients or families, and stated, “We have not had any volunteers available since at least June 1st, probably longer.” Record 2: The patient’s date of election was 3/4/2022. There was no documented evidence that a volunteer was offered to the patient/family. Record 3: The patient’s date of election was 4/21/2022. There was no documented evidence that a volunteer was offered to the patient/family. Record 4: The patient’s date of election was 7/7/2022. There was no documented evidence that a volunteer was offered to the patient/family. Record 5: The patient’s date of election was 9/28/2022. There was no documented evidence that a volunteer was offered to the patient/family. The Volunteer Coordinator was interviewed on 10/10/2022 and stated, “I don’t offer volunteers because we don’t have one. I know of a few patients that could benefit from one,” “I don’t offer volunteers because the admit nurse does that.” The Administrator was interviewed on 10/10/2022 and confirmed she also completes many of the RN initial admit visits. The Administrator stated, “I don’t offer volunteers on admit because the volunteer coordinator does that on their visit.” The Administrator was interviewed on 10/11/2022 and agreed, there was no documented evidence that a volunteer was offered to the patient/family. The Administrator was interviewed on 10/11/2022 and stated, “We have not had any volunteers available since at least June 1st, probably longer.”

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. THIS IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by document review and interviews. Review of the agency's volunteer policy revealed the hospice did not ensure adherence to the agency's policy for volunteer recruitment and retention activities. Agency policy, “Volunteer Staff,” stated in part: “There will be active and ongoing efforts to recruit, train and retain volunteers. All efforts will be documented.” The Volunteer Coordinator was interviewed on 10/10/2022 and stated, “I have not completed any volunteer recruitment or retention.” The Administrator was interviewed on 10/11/2022 and agreed, there was no evidence of any volunteer recruitment or retention activities, and stated, “We have not had any volunteers available since at least June 1st.” Agency policy, “Volunteer Staff,” stated in part, “There will be active and ongoing efforts to recruit, train and retain volunteers. All efforts will be documented.” The Volunteer Coordinator was interviewed on 10/10/2022 and stated, “I have not completed any volunteer recruitment or retention.” The Administrator was interviewed on 10/11/2022 and agreed, there was no documented evidence of any volunteer recruitment or retention activities.” The Administrator was interviewed on 10/11/2022 and stated, “I was not aware of the action plan until a month ago.” The Administrator agreed there was no evidence the agency implemented the action plan with an implementation date of 12/30/2021.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. THIS IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by document reviews, interviews and personnel records. In 2 of 3 (66%) personnel records reviewed the hospice did not ensure adherence to the agency's policy for completion of initial competency assessments. Agency policy, “Initial Competency Assessment,” stated in part, “The organization ensures the competency of all personnel is assessed on hire, prior to providing care to organization patients.” Record 1: (Chaplain): hire date 5/12/2022. There was no documented evidence that a competency assessment was completed upon hire. Record 2: (Social Worker): hire date 5/10/2022. There was no documented evidence that a competency assessment was completed upon hire. The Administrator was interviewed on 10/11/2022 and agreed, there was no documented evidence that a competency assessment was completed upon hire, prior to providing care to patients. Agency policy, “Initial Competency Assessment,” stated in part, “The organization ensures the competency of all personnel is assessed on hire, prior to providing care to organization patients.” Record 1: (Chaplain): hire date 5/12/2022. There was no documented evidence that a competency was completed upon hire. Record 2: (Social Worker): hire date 5/10/2022. There was no documented evidence that a competency was completed upon hire. Record 3: (Hospice Aide): hire date 12/6/2021. There was no documented evidence that a competency was completed upon hire. The Administrator was interviewed on 10/11/2022 and agreed, there was no documented evidence that a competency assessment was completed upon hire, prior to providing care to patients. The Administrator was interviewed on 10/11/2022 and stated, “I was not aware of the action plan until a month ago.” The Administrator agreed there was no evidence the agency implemented the action plan with an implementation date of 12/30/2021.

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. a) 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 IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by a review of interviews and personnel records. In 2 of 4 (50%) personnel records reviewed the hospice did not ensure a background check was obtained upon hire. Record 1: (Chaplain): hire date 5/12/2022. There was no documented evidence that a background check was completed upon hire. Record 2: (Social Worker): hire date 5/10/2022. There was no documented evidence that a background check was completed upon hire. The Administrator was interviewed on 10/11/2022 and agreed, there was no documented evidence that a background check was completed upon hire. Record 1: (Chaplain): hire date 5/12/2022. There was no documented evidence that a background check was completed upon hire. Record 2: (Social Worker): hire date 5/10/2022. There was no documented evidence that a background check was completed upon hire. The Administrator was interviewed on 10/11/2022 and agreed, there was no documented evidence that a background check was completed upon hire. The Administrator was interviewed on 10/11/2022 and stated, “I was not aware of the action plan until a month ago.” The Administrator agreed there was no evidence the agency implemented the action plan with an implementation date of 12/30/2021.

It is required that organization policy and procedure define: The process for an individual to request a temporary delay in being fully vaccinated for COVID-19 per CDC guidelines; an exception to being fully vaccinated for COVID-19 due to job responsibilities; or a medical or spiritual exemption from being fully vaccinated for COVID-19 per state and federal law and regulation; Who receives and reviews the documentation, and accepts or declines the vaccination delay, the job responsibility exception, or the medical exemption or spiritual belief exemption; The process to track the documentation received and each individual’s vaccination status, including the acceptance or denial of any request as noted above; The contingency plan(s) for an individual who is not fully vaccinated for COVID-19 and its documentation; A process for ensuring the implementation of additional precautions intended to mitigate the transmission and spread of COVID-19 for individuals who are not fully vaccinated for COVID-19; and how each individual’s information is securely maintained. This standard was not met as evidenced by document reviews and interviews. Review of agency and infection control policies and procedures revealed there was no evidence of a COVID vaccination policy that includes: a process for an individual to request a temporary delay or medical or spiritual exemption from being fully vaccinated; a process to track the documentation received, including the acceptance or denial of the request; a contingency plan for an individual who is not fully vaccinated; a process for ensuring the implementation of additional precautions intended to mitigate the transmission and spread of COVID-19 for individuals who are not fully vaccinated for COVID-19; and how each individual’s information is securely maintained. The Administrator was interviewed on 10/11/2022 and agreed, there was no evidence of a COVID vaccination policy to ensure a process for an individual to request a delay or exemption, or a contingency plan for an individual who is not fully vaccinated. The Administrated stated, “we don’t have a COVID vaccination policy.” Review of agency binders on policies, infection control and COVID-19 revealed there was no evidence of a COVID vaccination policy to include a process for an individual to request a temporary delay or medical or spiritual exemption from being fully vaccinated, a process to track the documentation received, including the acceptance or denial of the request, a contingency plan for an individual who is not fully vaccinated, a process for ensuring the implementation of additional precautions intended to mitigate the transmission and spread of COVID-19 for individuals who are not fully vaccinated for COVID-19; and how each individual’s information is securely maintained. The Administrator was interviewed on 10/11/2022 and agreed, there was no evidence of a COVID vaccination policy to ensure a process for an individual to request a delay or exemption, or a contingency plan for an individual who is not fully vaccinated. The Administrated stated, “we don’t have a COVID vaccination policy.”