Every finding on record at Encore Hospice Corp.

Observed in Patient Home. In 7 of 11 HR files reviewed, the organization failed to provide emergency preparedness training to staff who provide on-site services related to the roles and responsibilities of each employee when an emergency is issued. During a staff interview's with the LVN and the SW , the hospice nurse surveyor asked about training for the organizations emergency operations plan and what role they would plan. Both stated they had not been trained on the organization's emergency operations plan and had not been included in any drills. During HR file review, the hospice nurse surveyor observed 5/8 HR files did not have documentation of the organizational required annual emergency management training. This was discussed and reviewed with the Acting Administrator and the Director.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization failed to assess its patients. During record review for HV#1, the hospice nurse surveyor observed the initial bereavement assessment was not completed. This was discussed and reviewed with the Acting Administrator and the Director.

Observed in Regulatory Review. In 11 of 11 patient records reviewed, the organization failed to update the comprehensive assessment to include information about the patient's progress towards desired outcomes. During review for all records, the hospice nurse surveyor observed there was no documentation of progress towards goals. For example in HV#3 the SW visits and made a referral to adult protective services but the SW did not update the care plan. In RR#1 all goals were resolved on 8/16/22 but there was no documentation of progress towards goals and no documented visit that day. And in RR#7, the patient was discharged for extended prognosis but the goals were never resolved. This was discussed and reviewed with the Acting Administrator and

Observed in Regulatory Review. In 7 of 11 patient records reviewed, the organization failed to plan the patient's care. During record review for HV#1, HV#2, RR#1, RR#2, RR#4, RR#6, RR#7, the hospice nurse surveyor observed not all disciplines were adding or updating written plan of care. For example in HV#1, HV#2, RR#1, RR#2, RR#4 and RR#7 the Social Worker and SC/ Chaplain were not adding to the written plan of care. In RR#6 the SW was making visits but had not added or updated the plan of care. This was discussed and reviewed with the Acting Administrator and the Director.

Observed in Record Review. In 10 of 11 patient records reviewed, the organization failed to plan the patient's care. During record review for HV#1, HV#2, HV#3, RR#1, RR#2, RR#3, RR#4, RR#6, RR#7 and RR#8, the hospice nurse surveyor observed the plan of care did not contain goals with time frames required to meet those goals. For example in HV#1, HV#2, HV#3, RR#2, RR#3, RR#4, RR#6 and RR#8 each goal was to be achieved by the same date. For example, in HV#1, all goals were to be met by 10/27 and in HV#2 all goals were to be met by 8/15 ( which was the day before survey but was not updated). In RR#1 all goals were resolved on 8/16 but no progress towards goals was noted and no visits had been made that week. In RR#7 the patient was discharged from service for extended prognosis but there was no documentation of goals met. This was discussed and reviewed with the Acting Administrator and the Director.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to plan infection prevention and control activities to minimize or eliminate the risk of infection. During HV#1, the hospice nurse surveyor observed the RN clean her equipment with wipes from her bag. When questioned about the product used, it was discovered the products manufacturer instructions stated for disinfection use a 4 minute wet time, which was not followed. This was discussed and reviewed with the Active Administrator and the Director.

Observed in HR File Review. In 8 of 8 HR files reviewed, the organization failed to document on-going education and training. During tracer activities for HR, the hospice nurse surveyor observed that the organization had not documented any in-service education within the last 3 years. This was discussed and reviewed with the Acting Administrator and the Director.

Observed in Record Review. The organization failed to provide an organized program for the provision of bereavement services. During record review, the hospice nurse surveyor observed partially completed initial bereavement assessments for RR#1, RR#4 and RR#6 all of which were missing the name, relationship and contact information for the bereaved. The hospice nurse surveyor observed no post death assessment for RR#5 RR#8, BR#1 and BR#2. The hospice nurse surveyor observed no post death IDG for BR#1. And the hospice nurse surveyor observed no bereavement care plans developed or followed for BR#1, BR#2, RR#5 and RR#8. There was bereavement letters sent by office staff but no organized plan to follow or no process for low/medium/ high risk assessments. This was discussed and reviewed with the Acting Administrator and the Director.

Observed in Tracer Activities. In 1 of 1 HR files reviewed, the organization failed to evaluate the hospice aide competency annually as required. During HR file review, the hospice nurse surveyor observed HR file #5 ( HHA) did not have documentation of an evaluation through written examination, oral examination, or after observation of a home health aide or hospice aide with a patient or a pseudo-patient during a simulation. The HHA had not had an on-site competency for the current year. It was last done 2/2021. This was discussed and reviewed with the Acting Administrator and the Director.

Observed in HR File Review. In 6 of 8 HR files reviewed, the organization failed to assess and document staff competence as required annually per organizational policy. During HR file review, the hospice nurse surveyor observed no documented annual competence assessment for HR #2, #4, #5, #6, #7, and #8. This was discussed and reviewed with the Acting Administrator and the Director.

Observed in Tracer Activities. The organization failed to provide services to meet the patient's needs. During tracer activities for the Volunteer Program, the hospice nurse surveyor observed the organization failed to document volunteer recruitment efforts for 2020, 2021 and to date in 2022. This was discussed and reviewed with the Acting Administrator and the Director.

Observed in Tracer Activities. The governing body/ leadership did not ensure that the following Conditions of Participation were met as determined through observation, documentation, and staff interviews: §418.100, §418.116, §418.56 and §418.64. This was discussed and reviewed with the Active Administrator and the Director.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to comply with law and regulation. During record review for HV#2, the hospice nurse surveyor observed the ABN was signed at admission and in RR#7 the patient was discharged for extended prognosis but no ABN was obtained. This was discussed and reviewed with the Acting Administrator and the Director.