Every finding on record at Gateway Hospice & Palliative Care, Inc.

Based on the review of clinical records (CR), facility policy and procedure, facility documentation and staff interview (EMP), the hospice failed to ensure covered services were available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family in accordance with facility policy and procedure for one (1) of three (3) clinical records reviewed (CR1). Findings included: Policy review on 1/19/2022 revealed the following: " ...On-Call/Weekend Services ...Policy No. H:2-040.1 ...Policy ...There will be on-call staff available after hours, Monday through Friday, and 24 hours a day on weekends ...Procedure:..7. On-call staff will respond to a page within 15 minutes and must be able to reach a patient within one (1) hour whenever possible. (There may be rare exceptions, depending on how far away the patient lives and if the staff member is with another patient at the time of the call.) ..." Review of CR1 on 1/19/22 at approximately 9:45 AM revealed the following: Patient resided in Assisted Living Facility. Start of care 11/2/2021. Certification period 11/2/2021 to 1/30/2022. Facility on-call log revealed a phone call by patient family member requesting hospice visit taken on 11/30/21 at 5:03 AM with on-call skilled nurse (SN) "patched" to call. SN narrative note for on-call PRN (as needed) visit 11/30/21 revealed the following: " ... [phone call] to [family member] ...nurse reassured ...would be on ...way to make visit ...0700 hrs (7:00 am) arrived at facility ..." Further review of facility documentation on 1/19/22 of on-call nursing logs and communication notes for CR1 did not reveal a reason why on-call nursing visit arrival at facility was 7:00 AM on 11/30/21 after phone call was received at 5:03 AM for nurse visit request (from CR1 family member). Time from family member phone call to facility and skilled nurse visit conducted was approximately 2 hours, outside of timely parameters established by facility policy and procedure. An exit conference was conducted on 1/19/2022 at approximately 1:15 PM with EMP1, administrator and EMP2, alternate administrator. Above findings were reviewed.