Every finding on record at Heritage Hospice Inc

Based on record review and interview, the agency failed to demonstrate knowledge of advance directive changes based on current state laws for 1 of 1 home health agency. Findings include: An 8/04 policy titled Heritage Hospice Corporate Compliance was copied from the policy binder on 4/20/2022 at 2:30 p.m. The policy indicated, but was not limited to, "Heritage Hospice will strictly adhere to all state and federal regulations pertaining to hospice care. ..." On 4/19/2022 at 1:00 p.m. reviewed the current agency patient admission packet that included Advanced Directive information dated July 1, 2013. At that time, RN Director C was asked if he/she was aware of the updated Advance Directive information dated July 1, 2021. RN Director C indicated he/she was unaware of the update and would not know where to look to find that information.

Based on observation, record review, and interview, the agency failed to ensure administrative control was clearly delineated in the hospice's organizational structure and in practice regarding officers for the hospice agency and failed to ensure hospice employee vaccination status was separate and secured from other affiliated licensed Entities and failed to ensure personnel files were secured for 1 of 1 hospice agency. Findings include: 1. A revised 2/26/19 policy titled Heritage Hospice Line of Authority was copied from the policy binder on 4/20/2022 at 2:30 p.m. The policy indicated, but was not limited to, "Heritage Hospice organizational structure delineates lines of authority and responsibility. ... a. The governing body (CEO and CFO) appoints an Administrator to carry out the day to day administrative and operation responsibilities of the program. ... c. Exception: ... billing ...". 2. A reviewed 3/2012 policy titled Heritage Hospice Governing Body was copied from the policy binder on 4/20/2022 at 2:30 p.m. The policy indicated, but was not limited to, " ... shall maintain compliance with Centers of Medicare Services Conditions of Participation ... assumes full legal responsibility for determining, implementing, and monitoring policies governing the hospices total operation ... appoints an individual who is responsible to the day-to-day operation of the hospice program. This individual will act as a liaison between the governing body ... The governing body will assure that all services provided are consistent with accepted standards of practice in accordance with local, state, and federal law ... " 3. On 4/18/2022 at 9:30 a.m. Person B indicated he/she had recently acquired a corporate role and participated in agency practice. At 10:36 a.m. Person B provided 2 religious exemptions and 1 binder with Covid-19 vaccination card status for the hospice along with Entity 2, Entity 3, Entity 4, and Entity 5 vaccination information. Person B indicated human resources placed hospice and all entities' vaccination status into one binder separated by tabs. The agency failed to ensure clear delineation of the hospice organization regarding the medical component of the personnel files, which were not separate and secured from other licensed Entities. Review of the state database did not identify Person B as an owner, manager, or governing body member. Review of the agency list of employees did not indicate Person B was a direct or contracted employee for hospice. During an interview on 4/20/2022 at 9:40 a.m. Governing Body member J did not indicate the state agency was notified of Person B's role as an officer of hospice but planned to appoint Person B to the governing body. Governing Body member J indicated there were no governing body meeting minutes that would identify that communication occurred between the governing body and the Administrator. During exit conference on 4/20/2022 at 3:05 p.m. Governing Body member J and the Administrator did not provide any documentation that confirmed Person B as a hospice employee or part of the governing body but continued to allow Person B to participate in exit conference. 4. On 4/20/2022 at 9:25 a.m. observed storage of personnel files along with the Administrator. Personnel files were stored at a separate suite within the building, which was maintained by non-employees of hospice. Observed hospice personnel files along with other licensed affiliated Entity personnel files stored in 1 large file cabinet that was unlocked and unattended. The agency failed to ensure hospice personnel files were secured and were maintained by hospice employees. During exit conference on 4/20/2022 at 3:05 p.m. Person B indicated the agency did not have a specific policy regarding accessing and storage of personnel files and delineation of services. Person B indicated the expectation was that personnel files were to be locked and secured. Person B checked with human resources regarding policies for review but was unable to produce any documents or information.

Based on record review and interview, the agency failed to ensure a written contract between the hospice agency and a licensed nursing home was maintained for 1 of 6 contracts reviewed with the potential to affect all licensed nursing homes / assisted living facilities regardless of agency affiliation. Findings include: A reviewed 2/2/2012 policy titled Hospice Care for Nursing Facility Residents - Written Agreements was copied from the policy binder on 4/20/2022 at 2:30 p.m. The policy indicated, but was not limited to, "Policy Statement: Prior to the provision of hospice services in a LTCF/SNF/licensed [assisted living facility] or ICF/MR, the hospice obtains a written agreement signed by authorized representatives of the facility. Procedures: 1. The provision of hospice care in a [long term care facility]/[skilled nursing facility]/licensed [assisted living facility], or ICF/MR in accordance with the provisions stated in the written contract between hospice and the facility. ... f. A delineation of the hospice's responsibilities, which include, but are not limited to the following: providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; provision of medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions ... j. A delineation of the responsibilities of the hospice and the facility to provide bereavement services to facility staff." A revised 2/26/19 policy titled Heritage Hospice Line of Authority was copied from the policy binder on 4/20/2022 at 2:30 p.m. The policy indicated, but was not limited to, "Heritage Hospice organizational structure delineates lines of authority and responsibility. ... a. The governing body (CEO and CFO) appoints an Administrator to carry out the day to day administrative and operation responsibilities of the program. ... c. Exception: ... billing ...". A reviewed 3/2012 policy titled Heritage Hospice Governing Body was copied from the policy binder on 4/20/2022 at 2:30 p.m. The policy indicated, but was not limited to, " ... shall maintain compliance with Centers of Medicare Services Conditions of Participation ... assumes full legal responsibility for determining, implementing, and monitoring policies governing the hospices total operation ... The governing body will assure that all services provided are consistent with accepted standards of practice in accordance with local, state, and federal law ... The Governing Body shall approve all Agreements for Contracted Services and Policy & Procedures prior to implementation. The Administrator may sign Agreements once verbal approval is obtained by the Hospice President. ... ". During an interview on 4/19/2022 at 10:50 a.m. the Administrator was asked to provide the contract for Entity 1. The Administrator indicated Entity 1 does not require a contract. Review of the state database indicated Entity 1 was a licensed nursing facility. Review of Entity 1's website identified it as an assisted living facility that provided 24/7 nursing care, home health, and hospice. The agency failed to ensure a contract was maintained identifying how hospice provides services, medications, equipment and supplies necessary for pain control and symptom management on a 24-hour basis, and who may receive and write orders for patient care. During exit conference on 4/20/2022 at 3:05 p.m. the Administrator indicated he/she notified Entity 1 regarding a contract between both agencies. The Administrator indicated Entity 1's personnel would not sign the contract and had never had to in the past because the Entity was not comfortable signing anything involving Medicare. The Administrator indicated Entity 1 was not an assisted living facility and the agency treated Entity 1 as if going into someone's home.

Based on record review and interview, the agency failed to ensure a written contract between the hospice agency and a licensed nursing home regarding the delineation of responsibility of bereavement services was maintained for 1 of 6 contracts reviewed with the potential to affect all licensed nursing homes / assisted living facilities regardless of agency affiliation. Findings include: A reviewed 2/2/2012 policy titled Hospice Care for Nursing Facility Residents - Written Agreements was copied from the policy binder on 4/20/2022 at 2:30 p.m. The policy indicated, but was not limited to, "Policy Statement: Prior to the provision of hospice services in a LTCF/SNF/licensed [assisted living facility] or ICF/MR, the hospice obtains a written agreement signed by authorized representatives of the facility. Procedures: 1. The provision of hospice care in a [long term care facility]/[skilled nursing facility]/licensed [assisted living facility], or ICF/MR in accordance with the provisions stated in the written contract between hospice and the facility. ... f. A delineation of the hospice's responsibilities , which include, but are not limited to the following: ... counseling (including spiritual, dietary, and bereavement) ... j. A delineation of the responsibilities of the hospice and the facility to provide bereavement services to facility staff." A revised 2/26/19 policy titled Heritage Hospice Line of Authority was copied from the policy binder on 4/20/2022 at 2:30 p.m. The policy indicated, but was not limited to, "Heritage Hospice organizational structure delineates lines of authority and responsibility. ... a. The governing body (CEO and CFO) appoints an Administrator to carry out the day to day administrative and operation responsibilities of the program. ... c. Exception: ... billing ...". A reviewed 3/2012 policy titled Heritage Hospice Governing Body was copied from the policy binder on 4/20/2022 at 2:30 p.m. The policy indicated, but was not limited to, " ... shall maintain compliance with Centers of Medicare Services Conditions of Participation ... assumes full legal responsibility for determining, implementing, and monitoring policies governing the hospices total operation ... appoints an individual ... This individual will act as a liaison between the governing body ... The governing body will assure that all services provided are consistent with accepted standards of practice in accordance with local, state, and federal law ... The Governing Body shall approve all Agreements for Contracted Services and Policy & Procedures prior to implementation. The Administrator may sign Agreements once verbal approval is obtained by the Hospice President. ... ". During an interview on 4/19/2022 at 10:50 a.m. the Administrator was asked to provide the contract for Entity 1. The Administrator indicated Entity 1 does not require a contract. Review of the state database indicated Entity 1 was a licensed nursing facility. Review of Entity 1's website identified it as an assisted living facility that provided 24 hour nursing care, home health, and hospice. The agency failed to ensure a contract was maintained identifying the delineation of responsibilities of the hospice and the nursing facility regarding bereavement services to nursing facility staff. During exit conference on 4/20/2022 at 3:05 p.m. the Administrator indicated he/she notified Entity 1 regarding a contract between both agencies. The Administrator indicated Entity 1's personnel would not sign the contract and had never had to in the past because the Entity was not comfortable signing anything involving Medicare. The Administrator indicated Entity 1 was not an assisted living facility and the agency treated Entity 1 as if going into someone's home.