Every finding on record at Good Samaritan Hospice Inc

Based on agency Emergency Preparedness Plan (EPP) testing and training, and staff interview, it was determined the agency's EPP failed to maintain documentation of volunteer training and/or demonstrate staff knowledge regarding the EPP for three (3) out of ten (10) volunteer files (Volunteer #'s 16, 17 and 22). --- The findings:The agency's EPP was reviewed in the agency on 05/18/2023 with the Chief Operating Manager. The Medical Facilities Inspector (MFI) reviewed the agency's testing and training for 2022 and 2023. The MFI noted the above volunteers (#16, #17 and #22) failed to have the online training that other agency staff members obtained to demonstrate their knowledge regarding the agency's EPP. The lack of the above noted training information was reviewed with the Chief Operating Officer during the exit on 05/19/2023.

Based on personnel file review and staff interview it was determined the agency failed to obtain a criminal background check on all hospice employees who have direct patient contact or access to patient records for one (1) of (22) personal files reviewed in the survey sample. One (1) of the (22) was a volunteer personnel file (#17). --- Findings: Twenty-two (22) personnel files were reviewed in the agency on 05/17/2023 and 05/18/2023. One (1) - (12) were staff files and (13) - (22) were volunteer files, with the following findings: Personnel file #17 with a date of hire of 01/12/2023 failed to contain a criminal background report from the Virginia State Police. During the personnel file review with the Chief Operating Officer and Volunteer Coordinator conducted on 05/18/2023 at 4:30 PM acknowledged the lack of a criminal background report from the Virginia State Police on the above noted personnel file. The Chief Operating Officer stated, "The computer software processing for volunteers are mislabeled as active status instead of applicant".

Based on personnel file review and staff interview it was determined the agency failed to obtain a criminal background check(s) in accordance with Virginia State requirements for five (5) of (22) personnel files reviewed. (Personnel files: #8, #9 and Volunteer files: #13, #15 and #16). --- Findings:According to Virginia State Hospice licensure regulation 12VAC5-391-110 the Criminal record report shall be obtained within 30 days of compensated employment. One (1) - (12) were staff files and (13) - (22) were volunteer files, with the following findings: Twenty-two personnel files were reviewed in the agency on 05/17/2023 to 05/18/2023 with the following findings: 1. Personnel file #8 with a date of hire of 03/06/2023 contained a criminal background check from the Virginia State Police dated 05/02/2023 (56) days from date of hire. 2. Personnel file #9 with a date of hire of 03/02/2022 contained a criminal background check from the Virginia State Police dated 08/25/2016 (-2035) days from date of hire. On 05/18/2023 at 4 PM, the Chief Operating Officer explained personnel file #9 had resigned on 07/09/2022 and was rehired on 03/02/2022. The Chief Operating Officer acknowledged no criminal record check done for newest rehire date. 3. Personnel file #13 with a date of hire of 01/12/2023 contained a criminal background check from the Virginia State Police dated 05/17/2023 (124) days from date of hire. 4. Personnel file #15 with a date of hire of 01/12/2023 contained a criminal background check from the Virginia State Police dated 04/11/2023 (88) days from date of hire. 5. Personnel file #16 with a date of hire of 10/11/2022 contained a criminal background check from the Virginia State Police dated 04/11/2023 (536) days from date of hire. During the personnel file review with the Chief Operating Officer and Volunteer Coordinator conducted on 05/18/2023 at 4:30 PM, the Chief Operating Officer stated, "The computer software processing for volunteers are mislabeled as active status instead of applicant". The Chief Operating Officer acknowledged the above noted deficiency regarding obtaining criminal background checks according to Virginia State regulations during the exit conference conducted on 05/19/2023.

Based on a review of clinical records, select document review, and staff interviews it was determined the staff failed to maintain accurate clinical records in order to verify an Advance Directive. Specifically, the agency failed to physically visualize an Advance Directive, obtain a copy and/or scan the form into the agency's electronic medical record for one (1) of five (5) patients in the survey sample (Clinical record: #1). --- The findings: Five (5) clinical records were reviewed for DNR and Advance Directive documents recorded and scanned into the electronic medical record systems with staff member #4 as the navigator with the following findings: (Clinical Record #s 1, 2, 3, 4, and 5). 1. The clinical record for patient #1 was reviewed for the certification period of 05/23/2023. Patient #1's plan of care contained a care plan that documented an Advance Directive as a DNR. During the clinical record review with staff member #4, the Medical Facilities Inspector asked to see the patients Advance Directive/DNR. Staff member #4 stated, it is not in our system. Staff member #4 navigated to the agencys Community Liaisons note in the clinical record of 05/19/2022 that read in part as follows: Pts (Patients) daughter (name withheld) has DNR already signed and copy taken to ALF ( Assisted Living Facility -name withheld). The clinical record contained no evidence of an Advance Directive or DNR (Do not resuscitate) order. The agency's policy titled, Advance Directives (13 VAC 5-391 C.4; 418.52(a)(2); 42 CFR 489.102) was reviewed and partially reads as follows: Document in all adult patients medical records whether the individual has executed and advance directive. If the adult patient has affirmed that he or she has an advance directive in his or her medical record, the hospice must maintain a copy of the advance directive in the patients medical record." The Chief Operating Officer acknowledged the above noted findings prior to and during the exit conference on 10/11/2022.