Every finding on record at Health at Home Hospice - Cleveland, LLC

Based on record review, interview and policy review, the agency failed to ensure physician ordered therapies were delivered per the plan of care and physician orders. This affected one (Patient #1) patient and had the potential to affect any patient who was ordered non core services. The agency census was 12; Findings include: --- Record review revealed Patient #1 had a signed Hospice Election of Benefit dated 08/20/24. The patient had certified terminal illness signed by the physician on 08/22/24 with primary diagnoses of congestive heart failure. The Medicare Certification period under review was 08/20/24 through 11/19/24. The patient was admitted with diagnoses which included congestive heart failure, cardiovascular accident (stroke), hypertension, Parkinsons Disease, pneumonia and acute kidney injury, and dysphagia. Review of the physicians order revealed Patient #1 had an orders dated 08/20/24 for Occupational Therapy (OT), Physical (PT) and Speech therapy (ST) evaluation and treatment. Speech therapy was ordered one time a week effective 08/25/24. Physical therapy (PT) and occupational therapy (OT) was ordered once a week for the first week then twice a week for the next four weeks effective 08/20/24. Patient #1 received physical therapy on 08/22/24 but the agency was unable to provide documentation the patient received any PT the week of 08/25/24 per the physicians order. The agency was unable to provide any documentation the patient received OT or speech therapy per the physicians order. During an interview on 10/30/24 at 11:28 AM, Staff A confirmed the agency was unable to provide any documentation therapy services were delivered per the physicians order. Review of the policy titled "Physician Orders", dated 10/01/24, stated services were provided according to the most recent orders updating the patients plan of care.

Based on record review, interview and policy review, the agency failed to ensure the medical records were an accurate recapitulation of the patients care, services provided and reflected continuity of care. This affected one (Patient #1) patient and had the potential to affect any patient. The agency census was 12. Findings Include: --- Record review revealed Patient #1 had a signed Hospice Election of Benefit dated 08/20/24. The patient had certified terminal illness signed by the physician on 08/22/24 with primary diagnoses of congestive heart failure. The Medicare Certification period under review was 08/20/24 through 11/19/24. The patient was admitted with diagnoses which included congestive heart failure, cardiovascular accident (stroke), hypertension, Parkinsons Disease, pneumonia and acute kidney injury, and dysphagia. Review of the medical record revealed Social Services Staff Member C had conducted the initial evaluation on 08/22/24. The medical record documented Patient #1s responsible party requested information on cremation services. Staff Cs documented that he would obtain availability of cremation services information and get back to the responsible party within two weeks. Review of the agencys complaint notes and review of the Inter-disciplinary group (IDG) notes dated 08/29/24 also documented the team was aware of this request by Patient #1s family. There was no further documentation related to communication with the Patient #1s family until 09/11/24 when the family called to express there had been no follow up received. Review of the agencys call log system revealed the family had made calls to the agency and that the calls had been forwarded to Social Services Staff Cs telephone extension. The medical record failed to reflect there were any further attempts to communicate between Patient #1s family and Staff C. During an interview on 10/30/24 at 11:28 AM, Staff A and Staff B confirmed the medical record failed to contain documentation of telephone calls left for Patient #1.

Based on record review, interview and policy review, the agency failed to utilize volunteers in an amount equal to 5 percent of the agency's total patient care hours. The agency's census was 11. Findings include: --- The agency's 2024 Volunteer Monthly Hours Report revealed the agency had utilized volunteers for 2.2 percent of the agency's total patient care hours form January through April. The agency's 2023 Hospice Volunteer Requirement Report revealed the agency utilized volunteer services for a total of 1.31 percent of the agency's total patient care hours. The findings were shared with Staff B on 08/08/24 at 8:59 AM and confirmed. The agency's policy titled "Volunteer program Reporting Process", effective 07/01/07, stated a hospice agency must document and maintain a volunteer staff sufficient to provide administrative or direct patient care in an amount that, at minimum, equals 5 percent of the total direct patient care hours of all paid hospice employees and contract staff.

Based on record review, interview and policy review, the agency failed to ensure a criminal background check was completed for staff within three months of hire. This affected one (Staff C) of ten personnel files reviewed. The agency's census was 11. Findings include: --- Review of personnel files revealed Staff C was hired by the agency on 05/22/23. The agency did not have evidence a criminal background check was completed within three months of hire. The findings were shared with Staff A on 08/08/24 at 12:06 PM and confirmed. Review of the agency policy titled "Background Checks (Ohio Only)", dated 02/28/20, stated in part, inn addition to background checks processed through the agencys background check vendor, applicants and employees in Ohio must successfully complete a criminal background check administered by the Ohio Superintendent of the Bureau of Criminal Identification (BCI) and investigation ("BCI Background Check"). ln the event that the results of a BCI Background Check are not obtained within sixty days, the applicant/employee/contract worker must be separated, but will be eligible for rehire if the results, once obtained, do not contain one or more disqualifying offenses.