Every finding on record at Evergreen Health Care Management, LLC

The hospice must use volunteers to the extent specified in paragraph (e) of this section. These volunteers must be used in defined roles and under the supervision of a designated hospice employee. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review and interview. Review of administrative documents, and interviews with leadership revealed the hospice: Failed to use volunteers in a day-to-day administrative and/or direct patient care role {HCDT.21. I/L644}; Failed to ensure that volunteers provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff {HSLG.7. I/L647}; and Failed to provide the following care and services consistent with accepted standards of practice volunteer services {HCDT.1. I/L652}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.78: Volunteers. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency. During a joint review of the Volunteer Program manual with the CEO and Administrator/Volunteer Coordinator, it was revealed that the agency had no volunteers that could be used in administrative or direct patient care roles. CEO and Administrator/Volunteer Coordinator stated that the agency did not ensure that volunteers were used in day-to-day administrative and/or direct patient care roles.

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 document review and interview. During a joint review of the Volunteer Program manual with the CEO and Administrator/Volunteer Coordinator on 03/05/2024, it was revealed that the agency had no volunteers that could be used in administrative or direct patient care roles. CEO and Administrator/Volunteer Coordinator stated that the agency did not ensure that volunteers were used in day-to-day administrative and/or direct patient care roles.

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 document review and interview. During a joint review of the Volunteer Program manual on 03/05/2024, with the CEO and Administrator/Volunteer Coordinator, it was revealed that the agency had no volunteers that could be used in administrative or direct patient care roles. CEO and Administrator/Volunteer Coordinator stated that the agency did not ensure that volunteers were used in day-to-day administrative and/or direct patient care.

It is required that the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice, volunteer services. This standard was not met as evidenced by document review and interview. During a joint review of the Volunteer program binder on 03/05/2024 with the CEO and Administrator there was no documented evidence that the agency had volunteer staff available if needed for patient needs. The Administrator who is currently filling the role of volunteer coordinator states they have not followed up on any applications for volunteers submitted to date. During joint review of the Volunteer program binder on 03/05/2024 with the CEO and Administrator there was no documented evidence that the agency had volunteer staff available if needed for patient needs. The Administrator who is currently filling the role of volunteer coordinator states they have not followed up on any applications for volunteers submitted to date.

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–the elements of the hospice care election statement. This standard was not met as evidenced by document review and interview. In 1 of 15 (6%) clinical records reviewed, it was revealed that the agency did not ensure that the initial comprehensive assessment was completed by all members of the interdisciplinary group within 5 calendar days after the election of hospice care. Clinical Record 1: The election of benefit was completed on 1/12/24. The initial plan of care (POC) dated 1/12/2024 had an order for the social worker and the Chaplain to evaluate and develop a plan of care. There was no documentation of an initial psychosocial, bereavement or spiritual assessment as of 1/24/24.

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, document review and interview. In 5 of 15 (33%) clinical records reviewed, it was revealed that the agency did not ensure the comprehensive assessment included an initial bereavement assessment. Document 3: Policy 4.26.1, Bereavement Services (Dated: 6/2019), stated in part, "Procedure: 2. An initial Bereavement Risk Assessment will be performed as part of the Comprehensive Assessment. Depending on the initial assessment, a plan of care will be developed to include specific counselling to patient and family members to be provided by the Social Worker, Chaplain, or Bereavement Counsel or Hospice Chaplain. The plan will reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery." Clinical Record 1: The election of benefit was completed on 1/12/24. There was no documentation of a completed initial bereavement assessment as part of the comprehensive assessment. Clinical Record 2: The election of benefit was completed on 10/12/23. There was no documentation of a completed initial bereavement assessment as part of the comprehensive assessment. Clinical Record 6: The election of benefit was completed on 7/10/23 and the patient died 8/14/23. There was no documentation of a completed initial bereavement assessment as part of the comprehensive assessment. Clinical Record 10: The election of benefit was completed on 9/19/23 and the patient was discharged 1/10/24. There was no documentation of a completed initial bereavement assessment as part of the comprehensive assessment. Clinical Record 11: The election of benefit was completed on 9/15/23 and the patient died 10/25/23. There was no documentation of a completed initial bereavement assessment as part of the comprehensive assessment. During interview with the CEO/Administrator/Registered Nurse, Alternate Administrator/Physical Therapist, Vice President of Operations, Director of Nursing/Registered Nurse, and Project Manager on 1/24/24, it was confirmed that the records did not include an initial bereavement assessment.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plans as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment, and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 15 (13%) Clinical records reviewed, revealed that the agency did does not ensure the patients individualized care plan was reviewed every 15 days. Document 2: Policy 9.12.1, IDG Care Planning Process (Dated: 1/2020), stated in part, "Procedure: 9. The IDG, (in collaboration with the individual's attending physician if any), reviews, revises, and documents the individualized care plans as frequently as the patient's condition requires; but no less frequently than every 15 calendar days." Clinical Record 2: The Interdisciplinary Group (IDG) documented review and revision of the patients individualized care plans in IDG meetings dated 12/3/23, and 12/22/23. 19 days apart and 4 days past the required 15 days minimum. Clinical Record 12: The Interdisciplinary Group (IDG) documented review and revision of the patients individualized care plans in IDG meetings dated 6/23/23, and 7/21/23. 28 days apart and 13 days past the required 15 days minimum. The CEO/Administrator/Registered Nurse, Alternate Administrator/Physical Therapist, Vice President of Operations, Director of Nursing/Registered Nurse, and Project Manager stated in an interview on 1/24/24 that the individualized care plan was not reviewed every 15 days.

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. THIS IS A CMS CODITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review and interview revealed the agency failed to ensure volunteer services were in place to be provided [HCDT.1.I/L652]; failed to provide volunteer services in administrative roles and direct care roles [HCDT.21.I/L644]; failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers [HSRM.30.I/L645]; and failed to document a cost savings through the use of volunteers {HSLG.7.I/L646]. The cumulative effect and scope of these deficiencies could impact the organization's ability to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s terminal and palliative care needs.

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. This standard was not met as evidenced by document review and interview. During a joint review of the Volunteer Program manual with the Chaplain/Bereavement Coordinator/Volunteer Coordinator, and Vice President of Operations on 1/24/23 it was revealed that the agency had no volunteers that could be used in administrative or direct patient care roles . The Chaplain/Bereavement Coordinator/Volunteer Coordinator, and Vice President of Operations stated that the agency did not ensure that volunteers were used in day-to-day administrative and/or direct patient care roles. In a joint review of the Volunteer Program manual with the Chaplain/Bereavement Coordinator/Volunteer Coordinator, and Vice President of Operations on 1/24/23 it was revealed that the agency had no documentation of volunteer program or volunteer recruitment efforts. The Chaplain/Bereavement Coordinator/Volunteer Coordinator, and Vice President of Operations stated that the agency did not ensure that volunteers are used in day-to-day administrative and/or direct patient care roles.

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 review and interview. During review of the Volunteer Program manual, it was revealed that the agency had no documentation of volunteer recruitment and retention efforts. In a joint review of the Volunteer Program manual with the Chaplain/Bereavement Coordinator/Volunteer Coordinator, and Vice President of Operations on 1/24/23, the agency had no documentation of volunteer recruitment efforts. The Chaplain/Bereavement Coordinator/Volunteer Coordinator, and Vice President of Operations stated that the agency did not ensure there was any active ongoing volunteer recruitment activity. In a joint review of the Volunteer Program manual with the Chaplain/Bereavement Coordinator/Volunteer Coordinator, and Vice President of Operations on 1/24/23 it was revealed that the agency had no documentation of volunteer recruitment efforts. The Chaplain/Bereavement Coordinator/Volunteer Coordinator, and Vice President of Operations stated that the agency did not ensure an active ongoing volunteer recruitment activity, and this is why recruitment efforts have not been documented.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. The documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions. This standard was not met as evidenced by document review and interview. During review of the Volunteer Program it was revealed that the agency did not ensure that the agency employed hospice volunteers to provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equalled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. In a joint review of the Volunteer Program manual with the Chaplain/Bereavement Coordinator/Volunteer Coordinator, and Vice President of Operations on 1/24/23 it was revealed that the agency had no documentation of a volunteer program. The Chaplain/Bereavement Coordinator/Volunteer Coordinator, and Vice President of Operations stated that the agency did not ensure that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equalled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. In a joint review of the Volunteer Program manual with the Chaplain/Bereavement Coordinator/Volunteer Coordinator, and Vice President of Operations on 1/24/23 it was revealed that the agency had no documentation of volunteer program or volunteer recruitment efforts. The Chaplain/Bereavement Coordinator/Volunteer Coordinator, and Vice President of Operations stated that the agency did not ensure that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

It is required that the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice: Nursing services, medical social services, physician services, hospice aide, volunteer, and homemaker services, physical therapy, occupational therapy, and speech-language pathology services, short-term inpatient care, counseling services, including spiritual counseling, bereavement counseling, and dietary counseling. This standard was not met as evidenced by document review and interview. Review of the Volunteer Program manual revealed there was no documentation of available volunteer staff that would be able to provide volunteer services. In a joint review of the Volunteer Program manual with the Chaplain/Bereavement Coordinator/Volunteer Coordinator, and Vice President of Operations on 1/24/23 it was revealed that the agency had no documentation of a volunteer program, volunteer recruitment efforts or any active volunteers. The Chaplain/Bereavement Coordinator/Volunteer Coordinator, and Vice President of Operations stated that the agency did not ensure that volunteer services were being provided. In a joint review of the Volunteer Program manual with the Chaplain/Bereavement Coordinator/Volunteer Coordinator, and Vice President of Operations on 1/24/23 it was revealed that the agency had no documentation of volunteer program, volunteer recruitment efforts or any active volunteers. The Chaplain/Bereavement Coordinator/Volunteer Coordinator, and Vice President of Operations stated that the agency did not ensure that volunteer services are being provided.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 4 of 5 (80%) clinical records reviewed, of patients that had revoked the election of hospice care and was discharged, it was revealed that the agency did not ensure there was documentation that the discharge summaries were sent to the primary care physicians. Clinical Record 5: The patient was discharged on 3/23/23. The record lacked evidence that the discharge summary was sent to the primary care physician. Clinical Record 9: The patient was discharged on 5/3/23. The record lacked evidence that the discharge summary was sent to the primary care physician. Clinical Record 10: The patient was discharged on 1/10/24. The record lacked evidence that the discharge summary was sent to the primary care physician. Clinical Record 12: The patient was discharged on 8/29/23. The record lacked evidence that the discharge summary was sent to the primary care physician. Interview: The Administrator/Registered Nurse, Alternate Administrator/Physical Therapist, Vice President of Operations, Director of Nursing/Registered Nurse, and Project Manager stated in an interview on 1/24/24 that the agency did not send the discharge summaries to the attending physicians. Interview: The Administrator/Volunteer Coordinator (personnel record 4), Director of Nursing/Alternate Administrator (personnel record 6), and Consultant stated in an interview on 12/7/23 that the agency did not send the discharge summaries to the attending physician. CMS: L-683 CFR: 418.104(e)(2)(ii) [If a patient revokes the election of hospice care, or is discharged from hospice in accordance with 418.26, the hospice must forward to the patient's attending physician, a copy of-] (ii) The patient's clinical record, if requested. Condition Level:

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed of discharged patients, it was revealed that the agency did not ensure there was documentation of a discharge summary. Clinical Record 5: The patient was discharged on 3/23/23. The record lacked evidence that a discharge summary was documented. Clinical Record 9: The patient was discharged on 5/3/23. The record lacked evidence that a discharge summary was documented. Clinical Record 10: The patient was discharged on 1/10/24. The record lacked evidence that a discharge summary was documented. Clinical Record 12: The patient was discharged on 8/29/23. The record lacked evidence that a discharge summary was documented. The CEO/Administrator/Registered Nurse, Alternate Administrator/Physical Therapist, Vice President of Operations, Director of Nursing/Registered Nurse, and Project Manager stated in an interview on 1/24/24 that there was no documentation of discharge summaries.