Every finding on record at Hhh Senior Specialist

Based on review of clinical record (CR), staff (EMP) interview, it was determined the hospice failed to ensure the Plan of Care (POC) included medical supplies and appliances necessary to meet the needs of the patient for two (2) of eleven (11) CRs reviewed. (CR#6 & CR#7). --- Findings included: Review of CR #6 on 1/31/25 at approximately 12:50pm revealed start of services (SOS) 1/20/25. Benefit period reviewed 1/20/25-4/19/25. Interview with Clinical Team Lead and Quality Ops. Director on 1/31/25 at approximately 2:00pm confirmed patient has a foley catheter. POC failed to include order for foley catheter and maintenance. Also failed to include DME (durable medical equipment) /supplies. Review of CR #7 on 1/31/25 at approximately 1:15pm revealed start of services (SOS) 1/10/25. Benefit period reviewed 1/10/25-4/9/25. Interview with Clinical Team Lead and Quality Ops. Director on 1/31/25 at approximately 2:00pm confirmed patient has oxygen and a cushion was ordered by clinician. POC failed to include DME/supplies. Exit interview with on 1/31/25, at approximately 3:00pm with executive Director, Quality Ops. Director, Manager of performance/Education, Clinical Coordinator, and clinical Team Lead confirmed above findings.

Based one observation of home visits (HV) and interview with staff (EMP), the agency failed to maintain a system of communication and integration with facilities in which Hospice patients resided for two (2 of three (3) HV conducted (HV 1 & 2). Findings included: Review of agency policy on February 9, 2022, at approximately 12:30pm revealed: "...Policy # A-24.0 Provision of Hospice Care to Nursing Home Residents...PROCEDURE: 2. Plan of care Coordination: ...ii. A copy of his form is left with the facility in the patient ' s clinical record and a copy maintained in the hospice clinical record. the patient's plan of care is coordinated with the nursing home through hospice team member participation at facility care planning meeting..." HV observation 1 conducted with agency Registered Nurse on February 8, 2022, at approximately 8:00am revealed no communication with facility staff prior to or post hospice nurse visit as it relates to patient condition/findings. Inability for agency or facility to produce/reference hospice plan of care or documentation from observed visit or any preceding visits. Hospice nurse reported no charting done by hospice staff at facility to communicate findings. Facility staff, when approached by surveyor, reported, "there are binders in a break room at the back of the hall designated for each hospice company for them to chart in." HV observation 2 conducted with agency Social Worker on February 8, 2022, at approximately 9:00am revealed no communication with facility staff prior to or post hospice social worker visit as it relates to patient condition/findings. Inability for agency or facility to produce/reference hospice plan of care or documentation from observed visit or any preceding visits. When asked by surveyor if there was any communication between hospice staff and facility, hospice social worker replied, "if they don't stumble on us or we don't hunt them down, they don't even know we were here." Findings confirmed in exit interview on February 9, 2022, at approximately 3:00pm with Hospice Executive Director/Administrator, QAPI Manager, Quality Operations Manager, and Clinical Team Leads for both locations.

Based on review of clinical record (CR), agency policy, and staff (EMP) interview, it was determined the hospice failed to document reassessment of bereavement needs of patient's family/caregiver, at the time of death in two (2) of (2) two bereavement records reviewed (CR #7&10) and failed to document follow up with bereaved in accordance with agency policy for two (2) of (2) two bereavement records reviewed (CR #7&10.) Findings included: Review of agency policy/procedure on February 9, 2022, at approximately 12:30pm revealed: ..."Policy # B-1.0 Bereavement Program and Services...PROCEDURE: D. A comprehensive bereavement assessment is completed by the Bereavement Coordinator, or other team member if the patient's length of stay did not permit social work involvement, within two weeks following the patient's death, E. All the bereavement risk assessment date from the Hospice IDT is compiled and transferred to the Bereavement Risk Assessment Form (copy attached) by the Bereavement Coordinator., 2. Results of the Bereavement Risk assessment are used by the Bereavement Coordinator to develop an individualized bereavement plan of care for the bereaved which is entered on the Bereavement Services information and Plan of Care Form (copy attached)...The Hospice Administrative Volunteer sets up the bereavement record labeling a file with the bereaved client's name and placing a Bereavement Checklist 9copy attached) in the file which allows for a system of tracking so that during the thirteen (130 month bereavement period all steps in this policy are being followed and all services laid out in the patient's plan of care have been provided..." Review of CR 7 on February 8, 2022, at approximately 1:00pm revealed no evidence of post death bereavement assessment, plan of care for bereaved, or documentation of follow up calls, mailings, communications with the bereaved. Review of CR 10 on February 8, 2022, at approximately 1:15pm revealed no evidence of post death bereavement assessment, plan of care for bereaved, or documentation of follow up calls, mailings, communications with the bereaved. Interview on February 8, 2022, at approximately 1:30pm with Bereavement Coordinator revealed, "bereavement follow up is managed verbally and the program is somewhat organic..." Interview with Administrator on February 9, 2022, at approximately 1:00pm confirmed that agency has not utilized the bereavement documentation in the electronic medical charting system in use. Further confirms that the agency failed to implement paper documentation that agency bereavement policy/procedure was followed.

Based on review of agency reports and interview with staff (EMP), the agency failed to obtain Medicare approval prior to operating a branch location. Interview with agency QAPI manager on February 7, 2022, at approximately 9:30am revealed agency operating alternate location not being recognized as a branch. EMP provided surveyor census reports and confirmed reports for each location were recognized separately. Interview with agency Administrator on February 7, 2022, at approximately 11:00am confirmed additional agency location 520 West Main Street, Uniontown, Pa 15401. Administrator stated the location was meant to serve "as an office location for staff in that area." EMP confirmed at this time that a second Medical Director is on contract for that location only, reports are run separately for locations, IDG meeting are held separately, and each location is staffed independently with management staff. Interview with Vice President on February 8, 2022, at approximately 12:30pm confirmed above findings and revealed that agency will initiate steps to recognize branch formally through Medicare and State.