Every finding on record at Family Home Hospice Inc

Based on record review, review of agency policy and staff interview, the hospice agency failed to ensure the plan of care included measurable outcomes anticipated from implementing the plan of care for 13 of 13 Patient (P) (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, and P13) records reviewed of a total 13 patient sample. Failure to identify measurable outcomes presents a potential inability to accurately evaluate the patient's progress in meeting goals of care. This had the potential to affect the 117 patients who were currently receiving hospice services and all future hospice patients/patient family units. Findings include: The agency policy titled "Written Interdisciplinary Plan of Care 600.30," dated 07/06/2015 indicated "The written interdisciplinary plan of care is developed with measurable goals and outcomes for planned interventions." 1.Record review revealed P1 was admitted to the hospice agency on 12/22/2021. During a review of the plan of care dated 12/22/2021, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 12/22/2021 plan included "will experience regular bowel movements throughout the course of care," "respiratory symptoms will be managed to acceptable level," and "pain will be managed/controlled in a setting to meet patient/caregiver needs." 2. Record review revealed P2 was admitted to the hospice agency on 03/30/2022. During a review of the plan of care dated 03/30/2022, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 03/30/2022 plan included "respiratory symptoms will be managed to patient's acceptable limit" and "experience regular bowel movements." 3. Record review revealed P3 was admitted to the hospice agency on 11/13/2021. During a review of the plan of care dated 11/13/2021, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 11/13/2021 plan included "acceptable level of comfort will be attained," and "experience regular bowel movements." 4. Record review revealed P4 was admitted to the hospice agency on 01/04/2022. During a review of the plan of care dated 01/04/2022, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 01/04/2022 plan included "quality of life will be maximized" and "acceptable level of patient comfort will be attained." 5. Record review revealed P5 was admitted to the hospice agency on 02/14/2022. During a review of the plan of care dated 02/14/2022, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 02/14/2022 plan included "acceptable level of patient comfort will be attained," and "will remain safe in environment." 6. Record review revealed P6 was admitted to the hospice agency on 02/16/2022. During a review of the plan of care dated 02/16/2022, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 02/16/2022 plan included "respiratory symptoms will be managed to acceptable level," and "all legal paperwork will be completed." 7. Record review revealed P7 was admitted to the hospice agency on 03/07/2022. During a review of the plan of care dated 03/07/2022, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 03/07/2022 plan included "optimal nutrition achieved," and "all legal paperwork will be completed." 8. Record review revealed P8 was admitted to the hospice agency on 03/14/2022. During a review of the plan of care dated 03/14/2022, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 03/14/2022 plan included "pain will be managed/controlled in a setting to meet patient/caregiver needs" and "quality of life will be maximized." 9. Record review revealed P9 was admitted to the hospice agency on 03/13/2022. During a review of the plan of care dated 03/13/2022, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 03/13/2022 plan included "acceptable level of comfort will be attained" and "quality of life will be maximized." 10. Record review revealed P10 was admitted to the hospice agency on 03/16/2022. During a review of the plan of care dated 03/16/2022, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 03/16/2022 plan included "all legal paperwork will be completed" and "symptoms will be controlled." 11. Record review revealed P11 was admitted to the hospice agency on 04/19/2022. During a review of the plan of care dated 04/19/2022, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 04/19/2022 plan included "optimal nutrition intake achieved," and "quality of life will be maximized." 12. Record review revealed P12 was admitted to the hospice agency on 04/13/2022. During a review of the plan of care dated 04/13/2022, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. An example of outcomes in the 04/13/2022 plan included "patient needs will be met." 13. Record review revealed P13 was admitted to the hospice agency on 04/29/2022. During a review of the plan of care dated 04/29/2022, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 04/29/2022 plan included "pain control will be at the level acceptable" and "acceptable level of comfort." During an interview on 06/17/2022 at approximately 3:00 PM, these findings were discussed with the Executive Director. The Executive Director confirmed the findings and stated, "we know our plan of care outcomes are not measurable enough. . .it's very hard to do."

Based on interview, personnel file review and review of agency policy, the hospice agency failed to implement accepted standards of practice to prevent the transmission of infections and communicable diseases such as Tuberculosis (TB) screening and Hepatitis B prevention in two of 10 professional staff members (Medical Social Worker (MSW)2, and Hospice Chaplain (HC)1) and in three of three direct patient care volunteers (Vol) files reviewed (Vol1, Vol2, and Vol3). Failure to implement required TB and Hepatitis B screening and prevention presents missed opportunities to mitigate disease and protect patients. This deficient practice had the potential to affect all 117 current patients receiving hospice care and all other agency staff. Findings include: MSW2: Date of hire was documented as 07/06/2021. There was no evidence in the personnel file that the employee had been screened for TB upon hire as required. HC1: Date of hire was documented as 02/15/2021. There was no evidence in the personnel file that the employee had been screened for TB upon hire as required. Vol1: Date of hire was documented as 04/08/2021. Personnel file review revealed there was no evidence that the employee had been screened for TB upon hire as required. Additionally, there was no evidence the hepatitis vaccine had been offered, accepted, or declined by this volunteer. Vol2: Date of hire was documented as 04/26/2021. Personnel file review revealed there was no evidence that the employee had been screened for TB upon hire as required. Additionally, there was no evidence the hepatitis vaccine had been offered, accepted, or declined by this volunteer. Vol3: Date of hire was documented as 03/01/2021. Personnel file review revealed there was no evidence the hepatitis vaccine had been offered, accepted, or declined by this volunteer The agency policy titled "Tuberculosis Screening Policy 6.0," dated 08/09/2021, read: "Pre-hire and baseline TB screening requirements include all components listed below: 1. An individual TB risk assessment 2. Testing for the presence of infection with TB by administering an Interferon-Gamma Release Assay (IGRA) or a two-step Tuberculin Skin Test." The agency policy titled "Employee Hepatitis B Vaccination Program," dated 03/30/2020, read: "will provide Hepatitis B vaccine to all employees who have potential for exposure to blood or body fluids." The agency policy titled "Volunteers 2100.70," dated 07/06/2015, read: "Volunteers are members of the Interdisciplinary Group (IDG) and are considered unpaid employees. The Volunteer Coordinator is primarily responsible to ensure compliance with Medicare regulatory requirements including but not limited to: Monitoring compliance with corporate and regulatory volunteer on-boarding including but not limited to, initial virtual volunteer training, background check, drug test, vaccine requirements, TB screening/test, and fingerprinting."

Based on record review and staff interview, the hospice agency failed to ensure the duties of volunteers used in direct patient care services or helping patients and families were evident in the patient's plan of care for three of three patient (P) records reviewed (P5, P6, P9) in which volunteer services were provided in a total sample of 13 patients. Failure to include specific duties of the volunteers in the plan of care provides the potential for incomplete care delivery. This had the potential to affect the 117 patients who were currently receiving hospice services and all future hospice patients/patient family units. Findings include: During an interview conducted on 06/15/2022 at approximately 2:30 PM, the Volunteer Coordinator (VC) and the Community Program Manager (CPM) were queried about how the volunteer plan of care was developed and implemented. VC1 responded "I'm not familiar with that." When asked how the volunteers were instructed and directed in the provision of direct patient services, CPM stated "We talk to them about it and provide verbal instruction." Record review revealed P5 was admitted to hospice on 02/14/2022. The volunteer documented providing two home visits for this patient on 05/11/2022 and 06/08/2022. Clinical record review revealed there was no evidence of a volunteer plan of care in the record which provided patient specific information and instructions, or an order for frequency of visits to direct the volunteer in care delivery. Record review revealed P6 was admitted to hospice on 02/16/2022. The volunteer documented providing two home visits for this patient on 03/16/2022 and 03/25/2022. No further volunteer visits were documented after 03/25/2022. Clinical record review revealed there was no evidence of a volunteer plan of care in the record which provided patient specific information and instructions, or an order for frequency of visits to direct the volunteer in care delivery Record review revealed P9 was admitted to hospice on 03/13/2022. The volunteer documented providing two home visits for this patient on 05/25/2022 and 06/08/2022. Clinical record review revealed there was no evidence of a volunteer plan of care in the record which provided patient specific information and instructions, or an order for frequency of visits to direct the volunteer in care delivery. During an interview on 06/17/2022 at approximately 3:00 PM, these findings were verified with the Executive Director. The Executive Director added "I do believe we have the form; I just don't think it's being utilized."