Every finding on record at Evergreen Hospice LLC

Based on interview and record review, it was determined that the hospice agency did not ensure that all hospice staff were trained in emergency preparedness (EP) policies and procedures for all new and existing staff and did not provide ongoing training. Specifically, the hospice agency did not maintain documentation of all EP training. (Employee identifiers: 1, 2, 3, 4, 5, 6, 7, 8, and 9) --- Findings include: A review of 9 personnel files was completed from 4/1/2024 through 4/4/2024. EP training documentation was requested from the hospice agency on 4/1/2024, at 2:59 PM. In an interview with the hospice executive director on 4/3/2024, at 2:05 PM, when asked about EP training he stated that he would investigate. On 4/3/2024, at 3:10 PM, an email was received from an administrative assistant that stated the agency had looked at their files for EP training, had been unable to locate the information, and the agency would be be adding this to their next quality assurance and performance improvement (QAPI) meeting.

Based on interview and record review, it was determined the hospice agency did not ensure care and services were provided as identified in the plan of care (POC) for 1 of 19 sampled patients. Specifically, aide visits were not provided as identified in the plan of care (POC). (Patient identifier: 3) --- Findings include: Patient 3 was admitted to the hospice agency on 2/16/2024, with a terminal diagnosis of Alzheimers disease with late onset. Patient 3s medical record was reviewed on 4/3/2024. Review of the plan of care (POC) developed for patient 3 on 2/16/2024, indicated that a hospice aide was to assist with activities of daily living 5 times per week. No documented evidence was found in the medical record to indicate a hospice aide visit was completed or refused from 2/16/2024 to 2/29/2024. An interview was conducted with the director of nursing (DON) on 4/3/2024, at 2:05 PM. The DON stated the hospice aide did not see the patient between 2/16/2024 and 2/29/2024, due to the family refusing aide visits during that period. The DON stated the aide visits were not completed as ordered during those dates. Additionally, the DON stated the family refusal of aide visits should have been documented in the medical record.

Based on interview and record review, it was determined the hospice agency did not measure, analyze, and track quality indicators, including all adverse patient events. Specifically, the hospice did not have a functioning system in place to track adverse events. --- Findings include: Upon entrance on 4/1/2024, at 10:05 AM, the agencys adverse event log was requested. On 4/1/2024, at 12:39 PM, a fall log for the past 6 months was received by surveyors. On 4/1/2024, at 2:10 PM, an email was sent listing information that had not been received by surveyors, including the adverse event log. On 4/1/2024, at 2:22 PM, an email was received by surveyors with a fall log for the past 6 months. On 4/1/2024, at 4:13PM, an email was received by surveyors with a fall log for the past 6 months. On 4/2/2024, at 5:09 PM, in an email communication, surveyors asked for clarification regarding the adverse event log, stating that surveyors had received a fall log multiple times and requesting to know if the fall log was considered a complete adverse event log by the agency. No further information was received regarding the adverse event log. During an interview with the director of nursing (DON) on 4/3/2024, at 2:05 PM, the DON stated that the application in the agencys electronic medical records (EMR) for adverse events only tracked falls. She further stated that if there were any other type of adverse events, the events were added to the individual patients medical record in the EMR, but not listed on an adverse event log.

Based on interview and record review, it was determined that the hospice agency did not maintain documentation that their hospice aides received 12 hours of in-service training per year for 3 out of 3 hospice aides. (Employee identifiers: 1, 2 and 3) --- Findings include: A review of 9 personnel files was completed from 4/1/2024 through 4/4/2024. On 4/1/2024, at 2:59 PM, surveyors requested documentation of all in-service training for the past 12 months for 3 sampled certified nursing assistants (CNAs). An interview was conducted on 4/3/2024, at 2:05 PM, with the executive director. The executive director stated the CNA coordinator had been doing in-service training once a month but the tracking of in-services was inconsistent and did not tie into the files that the agency keeps. The executive director further stated there was no available list showing what in-services had been completed by each CNA. He stated the CNA coordinator had documentation of completed in-services for each CNA on her computer, but the agency had not been able to get the information from her.

Based on interview and record review, it was determined that the hospice agency did not have documentation that an initial orientation that addressed employee's specific job duties was provided for 4 out of 9 employees. (Employee identifiers: 1, 2, 3, and 6) --- Findings include: A review of 9 personnel files was completed from 4/1/2024 through 4/4/2024. Initial orientations with specific job duties for 9 sampled personnel were requested on 4/1/2024 at 2:59 PM. No information was received for 4 of 9 employees which included 3 certified nursing assistants and 1 registered nurse. In an interview with the executive director and director of nursing on 4/3/2024, at 2:05 PM, they stated they would provide surveyors with any information the agency could find on the missing initial orientations. No further information was received.