Every finding on record at Evergreen Hospice, LLC

Based on record review and interview, the hospice failed to ensure a bereavement care plan was developed and implemented or were included as a part of the overall POCs after the initial bereavement assessments for 10 (Patients #1, 2, 6, 8, 9, 11, 12, 14, 15 and #18) of 19 patients. --- Findings: Patient #1A review of the clinical record showed an election of the hospice benefit and completion of the bereavement assessment on 12/18/24, psychosocial assessment on 12/18/24 and spiritual assessment on 12/20/24. A review of a POC dated 04/12/26 to 06/10/26 and IDG updates to the POC on 04/03/26, 04/17/26, 05/01/26, 05/15/26 and on 05/29/26 showed no bereavement care plan or bereavement interventions and goals included as a part of the overall POC and showed no changes in physician orders. Patient #2A review of the clinical record showed an election of the hospice benefit and completion of the bereavement assessment on 09/11/25, psychosocial and spiritual assessments on 09/12/25. A review of a POC dated 05/09/26 to 07/07/26 and IDG updates to the POC on 05/01/26, 05/15/26 and on 05/29/26 showed no bereavement care plan or bereavement interventions and goals included as a part of the overall POC and showed no changes in physician orders. Patient #6A review of the clinical record showed an election of the hospice benefit and completion of the bereavement assessment on 08/14/25, psychosocial and spiritual assessments on 08/18/25. A review of a POC dated 04/11/26 to 06/09/26 and IDG updates to the POC on 04/03/26, 04/17/26, 05/01/26, 05/15/26 and on 05/29/26 showed no bereavement care plan or bereavement interventions and goals included as a part of the overall POC and showed no changes in physician orders. Patient #8A review of the clinical record showed an election of the hospice benefit and completion of the bereavement assessment on 11/04/25, psychosocial and spiritual assessments on 11/05/25. A review of a POC dated 05/03/26 to 07/01/26 and IDG updates to the POC on 04/30/26, 05/14/26 and on 05/28/26 showed no bereavement care plan or bereavement interventions and goals included as a part of the overall POC and showed no changes in physician orders. Patient #9A review of the clinical record showed an election of the hospice benefit and completion of the bereavement assessment on 12/02/25, psychosocial assessment on 12/05/25 and spiritual assessment on 12/03/25. A review of a POC dated 05/07/26 to 07/05/26 and IDG updates to the POC 05/01/26, 05/15/26 and on 05/29/26 showed no bereavement care plan or bereavement interventions and goals included as a part of the overall POC and showed no changes in physician orders.Patient #11A review of the clinical record showed an election of the hospice benefit and completion of the bereavement assessment on 03/08/26, psychosocial assessment on 03/05/26 and spiritual assessment on 03/06/26. A review of a POC dated 03/03/26 to 05/31/26 and IDG updates to the POC 03/12/26, 03/26/26, 04/09/26, 04/23/26, 05/07/26 and on 05/21/26 showed no bereavement care plan or bereavement interventions and goals included as a part of the overall POC and showed no changes in physician orders. Patient #12A review of the clinical record showed an election of the hospice benefit and completion of the bereavement assessment on 03/06/26, psychosocial assessment on 03/10/26 and spiritual assessment on 03/11/26. A review of a POC dated 05/05/26 to 07/03/26 and IDG updates to the POC 03/12/26, 04/30/26, 05/14/26 and on 05/28/26 showed no bereavement care plan or bereavement interventions and goals included as a part of the overall POC and showed no changes in physician orders. Patient #14A review of the clinical record showed an election of the hospice benefit and completion of the bereavement assessment on 05/15/26, psychosocial and spiritual assessments on 05/19/26. A review of a POC dated 05/15/26 to 08/12/26 and IDG updates to the POC on 05/21/26 showed no bereavement care plan or bereavement interventions and goals included as a part of the overall POC and showed no changes in physician orders. Patient #15A review of the clinical record showed an election of the hospice benefit and completion of the bereavement assessment on 06/25/25, psychosocial assessment on 06/12/25 and spiritual assessment on 06/13/25. A review of a POC dated 11/08/25 to 01/06/26 and IDG updates to the POC 11/20/25, 12/04/25 and on 12/18/25 showed no bereavement care plan or bereavement interventions and goals included as a part of the overall POC and showed no changes in physician orders. Patient #18A review of the clinical record showed an election of the hospice benefit and completion of the bereavement assessment on 11/20/25, psychosocial assessment on 11/28/25 and spiritual assessment on 11/21/25. A review of a POC dated 11/20/25 to 02/17/26 and IDG updates to the POC 11/28/25, 12/11/25, 12/26/26, 01/08/26, 01/22/26 and on 02/05/26 showed no bereavement care plan or bereavement interventions and goals included as a part of the overall POC and showed no changes in physician orders. On 06/03/26 at 1:30 p.m., Staff K stated:The patients and any identified bereaved persons were given a bereavement risk score at the time of the initial bereavement assessment and were advised of spiritual and bereavement services provided by the hospice at the start of care. The hospice does not maintain a written POC for bereavement. Any pre-death bereavement counseling was addressed by the social worker or the chaplain.The bereavement program consisted of intermittently timed mail outs by the eMR system and telephone calls by staff which begin after the patient’s death.

Based on record review and interview, the hospice failed to ensure services were provided in accordance with the POCs for seven (Patients #2, 3, 5, 8, 11 and #15) of 19 patients. --- Findings: Patient #2A review of the plan of care dated 05/09/26 to 07/07/26 ordered SN visits at a frequency of two times a week. The clinical record showed during the week of05/24/26 to 05/30/26 a SN visit was missed due to “holiday scheduling” on 05/25/26 and a SN visit was conducted on 05/28/26 (two visits ordered, one visit conducted). The missed visit note dated 05/25/26 showed no patient or family refusal of visits, no attempts to make up the visits and no changes in the physician orders. Patient #3A review of the plan of care dated 04/18/26 to 06/16/26 ordered SN visits at a frequency of two times a week. The clinical record showed during the week of05/24/26 to 05/30/26 a SN visit was missed due to “holiday scheduling” on 05/25/26 and a SN visit was conducted on 05/28/26 (two visits ordered, one visit conducted). The missed visit note dated 05/25/26 showed no patient or family refusal of visits, no attempts to make up the visits and no changes in the physician orders. Patient #5A review of the plan of care dated 03/09/26 to 06/06/26 ordered SN visits at a frequency of two times a week. The clinical record showed during the week of05/24/26 to 05/30/26 a SN visit was missed due to “holiday scheduling” on 05/25/26 and a SN visit was conducted on 05/26/26 (two visits ordered, one visit conducted). The missed visit note dated 05/25/26 showed no patient or family refusal of visits, no attempts to make up the visits and no changes in the physician orders. Patient #8A review of the plan of care dated 05/03/26 to 07/01/26 ordered SN visits at a frequency of two times a week. The clinical record showed during the week of05/24/26 to 05/30/26 a SN visit was missed due to “holiday scheduling” on 05/25/26 and a SN visit was conducted on 05/27/26 (two visits ordered, one visit conducted). The missed visit note dated 05/25/26 showed no patient or family refusal of visits, no attempts to make up the visits and no changes in the physician orders. Patient #11A review of the plan of care dated 03/03/26 to 05/31/26 ordered SN visits at a frequency of two times a week. The clinical record showed during the week of05/24/26 to 05/30/26 a SN visit was missed due to “holiday scheduling” on 05/25/26 and a SN visit was conducted on 05/28/26 (two visits ordered, one visit conducted). The missed visit note dated 05/25/26 showed no patient or family refusal of visits, no attempts to make up the visits and no changes in the physician orders. Patient #12A review of the plan of care dated 05/15/26 to 08/12/26 ordered aide visits at a frequency of two times a week. The clinical record showed during the week of 05/24/26 to 05/30/26 an aide visit was missed due to “holiday scheduling” on 05/25/26 (two visits ordered, no visits conducted). The missed visit note dated 05/25/26 showed no patient or family refusal of visits, no attempts to make up the visits and no changes in the physician orders. Patient #15A review of the plan of care dated 11/08/25 to 01/06/26 ordered SN visits at a frequency of two times a week and aide visits at a frequency of two times a week. The clinical record showed during the week of 11/22/25 to 11/28/25:A SN visit was missed due to “holiday scheduling” on 11/27/25 and a SN visit was conducted on 11/24/25 (two visits ordered, one visit conducted).An aide visit was missed due to “holiday scheduling” on 11/27/25 and an aide visit was conducted on 11/25/25 (two visits ordered, no visits conducted).  The missed visit notes dated 11/27/25 showed no patient or family refusal of visits, no attempts to make up for the visits and no changes in the physician orders.  On 06/04/26 at 10:37 a.m. to 11:26 a.m., Staff A stated:Skilled nurse visit frequencies were not followed as ordered for patients #2, 3, 5, 8, 11 and #15.Aide visit frequencies were not followed as ordered for patients #12 and #15.No attempts were made to make up the missed visits on patients #2, 3, 5, 8, 11 and #15.

Based on record review and interview, the hospice failed to ensure volunteers provided services in an amount that equaled 5% of the total patient care hours of hospice employees in calendar years 2024 and 2025 for all patients on services during the calendar years of 2024 and 2025. --- Findings: A review of volunteer records for calendar year 2024 showed no volunteer hours for the months of January through June, a volunteer utilization rate of 0.1% for the months of July through September and a volunteer utilization rate of 2% for the months of October through December and showed no volunteer recruitment activities from January through June in calendar year 2024. A review of volunteer records for calendar year 2025 showed an overall volunteer utilization rate of 4.2% in calendar year 2025. On 06/03/26 at 1:30 p.m., Staff K stated:The volunteer program did not meet the 5% requirement in 2024 and 2025. The volunteer coordinator was hired in June of 2024 and has been focused on recruiting volunteers for the program.

Based on review of administrative records and interview, the Agency failed to provide Emergency Preparedness training to new hire staff and at least every 2 years to all staff. --- Review of Emergency Preparedness Program documents and personnel records failed to provide evidence of Emergency Preparedness Plan staff training for new hire staff and additional staff training for the years 2020, 2021, 2022 and 2023, On 09/07/23 at 10:30 AM, the Alternate Administrator confirmed the agency did not include Emergency Preparedness training to new hire staff and no training was provided to additional staff by the Agency as required.

Based on record review and interview, the hospice failed to ensure imminence of death was assessed during the initial comprehensive assessment for eight (#1, #3, #6 - #8, #11, #13 and #14) of 15 (#1 - #15) patients records reviewed. --- Patient #1A review of the Initial Assessment dated 08/04/23 showed no assessment of imminence of death.Patient #3A review of the Initial Assessment dated 04/14/23 showed no assessment of imminence of death.Patient #6A review of the Initial Assessment dated 08/29/23 showed no assessment of imminence of death.Patient #7A review of the Initial Assessment dated 03/03/23 showed no assessment of imminence of death.Patient #8A review of the Initial Assessment dated 08/28/23 showed no assessment of imminence of death.Patient #11A review of the Initial Assessment dated 01/10/23 showed no assessment of imminence of death.Patient #13A review of the Initial Assessment dated 07/27/21 showed no assessment of imminence of death.Patient #14A review of the Initial Assessment dated 03/02/23 showed no assessment of imminence of death.On 09/07/23 at 11:15 AM, the Clinical Director stated imminence of death was not assessed on the comprehensive assessments for Patients #1, #3, #6 - #8, #11, #13 and #14.

Based on administrative record review and interview, the Clinical Director failed to ensure the hospice aide completed l2 hours of in-service training during a 12-month period. --- Review of personnel record for the Hospice Aide failed to provide evidence of 12 hours of in-service training for a 12- month period. On 09/07/23 at 11:15 AM, the Clinical Director stated the Hospice Aide was assigned in-service training, but the Clinical Director failed to ensure the Hospice Aide completed the 12 hours per year as required.