Every finding on record at Horizon Hospice

The hospice agency failed to establish an emergency preparedness plan based on record review, observation, and staff interviews. This deficient practice has the potential that patients, patient caregivers, and staff are not prepared in the event of an emergency posing the risk of negative outcomes. --- Findings include: A request was made for the emergency officials' contact list. No documentation was received. A request was made for the emergency preparedness plan specific to the hospice agency. No documentation was received. A request was made for emergency preparedness training for the hospice staff. No documentation was received. A request was made for the emergency drills for the last 2 years that included staff. No documentation was received. A request for the secondary line of communication was asked for and could not be confirmed. No documentation was received. In an interview conducted on May 15, 2024, with Employee #1, he/she confirmed he/she did not know where to locate the emergency preparedness plan. He/she subsequently confirmed that the emergency preparedness plan is kept in "z drive" on the computer and he/she was not trained on how to locate the information requested nor did he/she possess the computer literacy to "pull things up from the Z drive... everything is stored in Utah...". In an interview conducted on May 16, 2024, with Employee #1, he/she stated the backup communication method was "smoke signals" and was unable to produce the emergency preparedness plan specific to the hospice again upon request. In a telephone interview conducted on May 16, 2024, with Employee #2, he/she stated that he/she "...am disappointed..." that Employee #1 could not navigate the "z drive" to find the emergency preparedness plan. He/she confirmed that there was no hospice-specific emergency preparedness plan. In an interview conducted on May 15, 2024, with Employee #3, he/she stated the secondary line of communication was "WhatsApp" messaging application. He/she also stated the secondary meeting location was his/her home. In an interview conducted on May 16, 2024, with Employee #1, he/she could not give the location of Employee 3's home. In an interview conducted on May 16, 2024, with Employee #2, he/she stated the location of Employee #3's home is located on a wall in the hospice office. No such posting could be located. Employee #2, stated TigerText was the secondary line of communication. No contract could be produced for Tigertext.

Based on record review and staff interviews the hospice failed to establish and keep an up-to-date Emergency Preparedness (EP) plan. This deficient practice has the potential that the hospice patients and staff are unprepared for an emergency posing the risk for `negative outcomes. --- Findings include: A request was made for the hospice special Emergency Preparedness(EP) Plan Procedures. No documentation was provided for a hospice-specific EP plan. In interviews conducted on May 14, 2024, and May 15, 2024, Employee #1 confirmed he/she was not able to provide the EP plan.

Based on record review, observation, and staff interviews it was determined the hospice failed to include a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach to include strategies for addressing emergency events identified by the risk assessment. This deficient practice poses the risk that the hospice patients and staff are not prepared for the possibility of an emergency posing the risk of negative and potentially fatal outcomes. --- Findings include: A review of a document titled, "Horizon Home Health-Hospice Emergency Preparedness Plan 8-19", revealed, "...The Agency will do a Hazard and Vulnerability Analysis...." A request was made for the hazard vulnerability analysis on May 14, 2024, and May 15, 2024. No documentation could be provided. In an interview with Employee #1, on May 14, 2024, he/she was unable to access the information from the "...z drive... and the emergency information is based out of Utah...". In a subsequent interview conducted on May 15, 2024, he/she confirmed the information being requested could not be retrieved from the computer and that there was no further documentation available to present. In a phone interview with Employee #2, conducted on May 15, 2024, he/she confirmed that all Emergency Preparedness information was accessible via computer only. The hazard vulnerability analysis was asked for again and was not provided.

Based on record review and staff interviews it was determined the hospice failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency. This deficient practice has the potential that the patients and staff are not prepared when an emergency happens as the failure to plan poses the risk for negative and potentially fatal outcomes. --- Findings include: A request for collaboration with local, tribal, regional, State, and Federal preparedness officials was asked for and not received. In interviews conducted on May 14, and May 15, 2024, with Employees#1 and #2, no information could be provided.

Based on record review and staff interviews the hospice failed to implement procedures to inform State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency. This deficient practice has the potential that staff are not prepared to report the needs of patients to emergency officials posing the risk of negative and potentially fatal outcomes. --- Findings include: A review of a document titled, "HORIZON HOME HEALTH HOSPICE Emergency Preparedness Plan 8-19", revealed, "... Personnel will work with regional or county emergency management planning agencies, where available, in planning priorities among the potential emergencies identified in the hazard vulnerability analysis that mitigation, preparation, response, and recovery activities will be undertaken... 7. Upon admission, all clients will be prioritized for risk. The risk factor will be re-evaluated on an ongoing basis and a list shall be placed in the On-Call book and kept in the possession of the Administrator and other supervisory staff...9. The Executive Director/Administrator will work with the Clinical Managers/Supervisors to determine... and patients that are unable to be contacted. This information will be shared with state and local officials as needed...." A request was made for the On-Call Book, but no document/book was received. In an interview conducted on May 15, 2024, with Employee #1, he/she confirmed there was no On-Call book.

Based on record review and staff interviews it was determined the hospice failed to develop procedures outlining primary and alternate means for communication for assistance. This deficient practice has the potential that communication methods are not being used and the staff are educated on how to communicate in the event of an emergency posing the risk for negative patient and staff outcomes. --- Findings include: A review of a document titled, "HORIZON HOME HEALTH HOSPICE Emergency Preparedness Plan 8-19", revealed, "...Personnel are to listen to the Agency identified Emergency Broadcasting System for Agency instructions and updates if the telephone system is not functioning and leadership personnel are unable to initiate the call tree. Additionally, as able, personnel are to report to the office or alternate site if the office building is not accessible and normal communication systems are not working...." A request for an up to date Hospice call tree was asked for and not received. n an interview conducted on May 14, 2024, with Employee #1, he/she confirmed he/she did not know where to locate the emergency preparedness plan. He/she subsequently confirmed that the emergency preparedness plan is kept in "z drive" on the computer and he/she was not trained on how to locate the information requested nor did he/she possess the computer literacy to "pull things up from the Z drive... everything is stored in Utah...". In an interview conducted on May 15, 2024, with Employee #1, he/she stated the backup communication method was "smoke signals" and was unable to produce the emergency preparedness plan specific to the hospice again upon request. In an interview conducted on May 14, 2024, with Employee #3, he/she stated the secondary line of communication was "WhatsApp" messaging application. In an interview conducted on May 15, 2024, with Employee #2, he/she stated the location of Employee #3's home is located on a wall in the hospice office. No such posting could be located. Employee #2, stated TigerText was the secondary line of communication. No contract could be produced for Tigertext.

Based on record review and staff interviews it was determined the hospice failed to establish policies and procedures for the use of volunteers in an emergency/surge situation. This deficient practice has the potential that staff and patients are at risk of not being adequately prepared for emergencies posing the risk for negative outcomes. --- Findings include: A request was made on May 14, 2024, and May 15, 2024, for a policy on the use of volunteers during an emergency. No documentation could be provided. In an interview conducted on May 14, 2024, and May 15, 2024, with Employee #1, he/she confirmed no policy was available. In an interview conducted on May 15, 2024, with Employee #2, he/she confirmed the agency had no volunteer policy.

Based on record review and staff interview it was determined the hospice failed to establish arrangements with other facilities during an emergency for placement posing the risk of negative patient outcomes. --- Findings include: In a document provided titled, "Horizon Home Health...Hospice Emergency Preparedness Plan 8-19", revealed, "...17. Cooperative Planning_ The Agency participates in cooperative planning with the following healthcare organizations in our geographic area...." A request was made for the healthcare organizations in the hospice's geographic location that the cooperative planning was made. No documentation could be provided. A request was made on May 14, 2024, and May 15, 2024, for arrangements with other facilities that could be utilized during an emergency. No documentation could be provided. In an interview conducted on May 14, 2024, with Employee #1, he/she could not state what organizations the agency works in cooperation with during the event of an emergency. In a subsequent interview with Employee #1, he/she conducted on May 15, 2024, he/she confirmed that no documentation of the requested information could be provided. In a telephone interview conducted on May 15, 2024, with Employee #2, he/she was unable to provide the requested information for the hospice as requested on May 14, 2024, and May 15, 2024.

Based on record review and staff interviews it was determined the hospice failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and must be reviewed and updated at least every 2 years. This negligent and deficient practice has the potential that patients, patients caregivers, and staff will be grossly unprepared in the event of an emergency posing the risk for negative outcomes. --- Findings include: A request was made for the communication plan to be provided in either hard copy or electronic and could not be provided. A review of Horizon Home Health Hospice Policy 8-19. titled, "Emergency Preparedness Plan", revealed, "...Communication Plan- The Agency will develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and needs to be reviewed periodically...." In an interview conducted on May 15, 2024 with Employee #1, he/she confirmed that he/she was untrained on how to access the aforementioned communication plan. He/she further confirmed that the information is kept in Utah and shared in the" Z drive". He/she could not demonstrate how to access any Emergency Preparedness information electronically. In a telephone interview conducted on May 15, 2024, with Employee #2, he/she stated the aforementioned requested information was stored in an electronic format. A request was made to view this information in hard copy or electronic format and was not provided.

Findings include: A request was made for the Emergency Officials Contact information. No information could be provided in electronic or hard-copy format. A review of Horizon Home Health Hospice Policy 8-19, titled, "Emergency Preparedness Plan", revealed, no evidence of Emergency Officials phone numbers. In an interview conducted on May 14, and May 15, 2024, with Employee #1, he/she confirmed being unable to access the aforementioned documentation request. He/she stated "This was printed from an e-mail", referring to the Emergency Preparedness Plan, sent by Employee #2. Employee #1 confirmed no orientation was provided to access the emergency officials' phone numbers or Emergency Preparedness Plan. In a telephone interview conducted on May 15, 2024, with Employee #2, he/she stated the request for the Emergency Officials Contact information was only available in electronic format. A request to view the electronic or hard-copy format was made multiple times and no information was provided.

Based on record review and staff interview it was determined the hospice failed to develop policies and procedures that developed a communication plan that included a method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. This deficient practice has the potential that patients' needs are not met and staff are not trained on how to communicate or share patient information posing the risk of poor patient care and services not being provided. --- Findings include: A request was made for a policy regarding the method used to share information and medical documentation in the event of an emergency. No documentation could be provided. In an interview conducted on May 14, and May 15, 2024, with Employee #1, he/she confirmed no documentation was available to him/her.

Based on record review and staff interview it was determined the hospice failed to ensure Emergency Preparedness training to staff. This deficient practice has the potential that staff members are ill-prepared for an emergency posing the risk for negative patient and staff outcomes. --- Findings include: A review of a document titled, " HORIZON HOME HEALTH HOSPICE Emergency Preparedness Plan 8-19", revealed, "... The Agency will provide all employees training on the Emergency Preparedness Plan at hire and annually. This training will include a system of documentation during an emergency situation and how to keep patient records confidential but records available as needed...." A review of Employee Records #2, #3, #4, and #5 revealed no evidence of annual Emergency preparedness training. In an interview conducted on May 14, 2024, with Employee #1, he/she confirmed that no annual Emergency Preparedness training was present in the aforementioned employee records. No additional documentation could be provided.

Based on record review and staff interviews it was determined the hospice failed to test the emergency preparedness plan annually. This deficient practice has the potential that staff are not prepared when an emergency event happens posing the risk of safety issues for staff and possible negative patient outcomes. --- Findings include: A review of a document titled, " Horizon Home Health...Hospice Emergency Preparedness Plan 8-19", revealed, "... The Agency will follow the Emergency Preparedness Regulations as established by the Centers for Medicare and Medicaid Services (CMS) 42 CFR Parts... 484.102 (home health) and 418.113 (hospice)..14. Preparedness drills are scheduled for each site and response reviewed for readiness...15. The Agency will participate in at least one full-scale community-based drill annually... and relevant to the priority of emergencies identified in the hazard vulnerability analysis... 16. The Agency will also conduct an additional exercise that is a tabletop exercise that includes a group discussion led by a facilitator, using narrated, clinically relevant emergency scenario...." A document titled, "Horizon Home Health & Hospice Evaluation Of A Disaster", revealed, "... X Mock/Table Top Drill Type: Extreme Heat... Date Declared:04/29/2024...Responsible Person:[Name redacted]/[Name Redacted]_Title of person: Admin...." A request was made for the 2023 Emergency Drills. No documentation could be provided. In an interview conducted on May 14, 2024, with Employee #1, he/she confirmed no additional documentation could be provided. In a subsequent interview on May 15, 2024, Employee #1 confirmed that the aforementioned documents were sent via email to her from Employee #2 as he/she was unable to access, or lacked the knowledge to access the "z drive". In a telephone interview conducted on May 15, 2024, with Employee #2, he/she confirmed there was no additional documentation for emergency drills.

Based on record review and staff interviews it was determined the hospice failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program. This deficient practice has the potential that issues regarding patient care and services, and agency-wide quality issues are not being identified, addressed, and corrected posing the risk for negative patient outcomes. --- Findings include: A review of a document presented titled, " HOSPICE CQI", revealed, "...PROCEDURE A. The Hospice's governing body must ensure that the program: 1. Reflects the complexity of its organization and services 2. Involves all Hospice services (Routine Home Care, Respite Care, GIP Care, and Continuous Care). 3. Focuses on indicators related to improved palliative outcomes 4. Focuses on the end-of-life support services provided 5. Takes actions to demonstrate improvement in Hospice performance B. Hospice will measure, analyze, and track quality indicators, including, adverse patient events, and other aspects of performance that enable the Hospice to assess processes of care, hospice services and operation... D. The Hospice's performance improvement activities will: 1. Focus on high-risk, high volume or problem prone areas 2. Consider incidence, prevalence and severity of problems in those areas...5. Actions aimed at performance improvement and after implementing those actions the Hospice must measure its success and track performance to ensure that improvements are sustained E. The Continuous Quality Improvement(CQI) committee will meet quarterly to evaluate and prioritize performance improvement activities based on analysis, patient satisfaction surveys and data collected...Step 4: Based on weaknesses, take actions geared towards performance improvement...." A review of a document titled, "QAPI FEEDBACK LOOP", revealed a hand written "... CQ2" at the bottom of the page presented. A document was presented titled, "PEPPER", revealed, " Hospice PEPPER... YOUR HOSPICE FY 2020 FY 2021 FY2022...." No further documentation to support the QAPI program tracking and interventions could be provided. A document titled "QAPI for 2023 Horizon Hospice", revealed no date as to when the document was made or compiled. A review of a document titled, "Horizon Hospice Governing Body Minutes", dated January 10, 2024, revealed, "... 4. Reviewed QAPI 2023 document...." A 24-page document titled, " An official website of the United States government Here's how you know", was presented to the surveyors in relation the the QAPI program. In an interview conducted on May 14, 2024, with Employee #1, he/she confirmed that he/she was not aware of what the QAPI program entailed, did not participate in the QAPI report, and did not know how to access the requested information as it is stored in Utah and the "z drive". In a subsequent interview conducted on May 15, 2024, Employee #1 stated he/she was not oriented to hospice and did not know what QAPI is for the hospice. In a telephone interview conducted on May 15, 2024, with Employee #2, he/she stated he emailed the QAPI information to Employee #1 and it was presented to the surveyors.

Based on record review and staff interviews it was determined the hospice failed to develop, implement, and evaluate performance improvement projects. This deficient practice has the potential that issues regarding agency issues as well as patient services are not identified, addressed, and corrected posing the risk for negative outcomes. --- Findings include: A review of a document presented titled, " HOSPICE CQI", revealed, "...PROCEDURE A. The Hospice's governing body must ensure that the program: 1. Reflects the complexity of its organization and services 2. Involves all Hospice services (Routine Home Care, Respite Care, GIP Care, and Continuous Care). 3. Focuses on indicators related to improved palliative outcomes 4. Focuses on the end-of-life support services provided 5. Takes actions to demonstrate improvement in Hospice performance B. Hospice will measure, analyze, and track quality indicators, including, adverse patient events, and other aspects of performance that enable the Hospice to assess processes of care, hospice services and operation... D. The Hospice's performance improvement activities will: 1. Focus on high-risk, high volume or problem prone areas 2. Consider incidence, prevalence and severity of problems in those areas...5. Actions aimed at performance improvement and after implementing those actions the Hospice must measure its success and track performance to ensure that improvements are sustained E. The Continuous Quality Improvement(CQI) committee will meet quarterly to evaluate and prioritize performance improvement activities based on analysis, patient satisfaction surveys and data collected...Step 4: Based on weaknesses, take actions geared towards performance improvement...." A request was made for the quarterly Continuous Quality Improvement(CQI) committee notes on May 15, 2024. No documentation was provided. A request was made for Performance Improvement Projects (PIP)were asked for on May 14, 2024. Employee #1 stated in an interview on May 14, 2024, he/she was not aware there were any PIPs for the hospice. A request was made for patient satisfaction surveys was made. No documentation could be provided. On May 15, 2024, a 24-page document titled, " An official website of the United States government Here's how you know", was presented to the surveyors concerning the QAPI program. In an interview conducted on May 15, 2024, with Employee #1, he/she stated the 24-page document was sent via mail to him/her to present to the surveyors as part of the QAPI program. Employee #1 confirmed that no documentation of the CQI committee meeting notes or minutes could be provided. In a telephone interview conducted on May 15, 2024, with Employee #2, he/she confirmed the presented 24-page document was for the hospice QAPI program and this presented document was accurate.

Findings include: A review of a document presented titled, " HOSPICE CQI", revealed, "...PROCEDURE A. The Hospice's governing body must ensure that the program: 1. Reflects the complexity of its organization and services 2. Involves all Hospice services (Routine Home Care, Respite Care, GIP Care, and Continuous Care). 3. Focuses on indicators related to improved palliative outcomes 4. Focuses on the end-of-life support services provided 5. Takes actions to demonstrate improvement in Hospice performance B. Hospice will measure, analyze, and track quality indicators, including, adverse patient events, and other aspects of performance that enable the Hospice to assess processes of care, hospice services and operation... D. The Hospice's performance improvement activities will: 1. Focus on high-risk, high volume or problem prone areas 2. Consider incidence, prevalence and severity of problems in those areas...5. Actions aimed at performance improvement and after implementing those actions the Hospice must measure its success and track performance to ensure that improvements are sustained E. The Continuous Quality Improvement(CQI) committee will meet quarterly to evaluate and prioritize performance improvement activities based on analysis, patient satisfaction surveys and data collected...Step 4: Based on weaknesses, take actions geared towards performance improvement...." A request was made for the quarterly Continuous Quality Improvement(CQI) committee notes on May 15, 2024. No documentation was provided. A request was made for Performance Improvement Projects (PIP)were asked for on May 14, 2024. Employee #1 stated in an interview on May 14, 2024, he/she was not aware there were any PIPs for the hospice. A request was made for patient satisfaction surveys was made. No documentation could be provided. On May 15, 2024, a 24-page document titled, " An official website of the United States government Here's how you know", was presented to the surveyors concerning the QAPI program. In an interview conducted on May 15, 2024, with Employee #1, he/she stated the 24-page document was sent via mail to him/her to present to the surveyors as part of the QAPI program. Employee #1 confirmed that no documentation of the CQI committee meeting notes or minutes could be provided. In a telephone interview conducted on May 15, 2024, with Employee #2, he/she confirmed the presented 24-page document was the PIP for the hospice.

Based on record review and staff interviews it was determined the hospice failed to maintain and document an effective infection control program. This deficient practice has the potential that patients, patient's caregivers, and staff are not being educated nor monitoring is being tracked posing the risk for negative patient and staff outcomes. --- Findings include: A request for the hospice infection program was asked for and not received. A request for the infection tracking program/log(s) was asked for and not received. A fifteen-page document titled" Home Health Infection Control INFECTION CONTROL" was provided. In an interview conducted on May 15, 2024, with Employee #1, he/she confirmed the aforementioned document was all that could be provided. The "Z Drive has outdated information". No additional documentation was provided. Employee #1 confirmed continued difficulty accessing information and that the information is housed in Utah.

A review of Horizon Hospice policy titled, "Bereavement Services", revealed, "... An initial bereavement assessment of the needs of the patient's family and other individuals....will be completed by the bereavement staff. Information gathered from the initial bereavement assessment must be incorporated into the plan of care and considered in the bereavement plan of care.... Bereavement services will be provided for at least thirteen (13) months after the death of the patient to the family members who wish to be part of the program. Procedure (A) The bereavement Based on record review and staff interviews, it was determined the facility failed to provide to make services available to the family and other individuals for 1 year following the death of the patient. A review of Patient #3's clinical record revealed the patient expired on June 23, 2023. Bereavement notes or assessment were not present in the clinical record. The patient record indicates the patient desired to have spiritual care services provided. In an interview conducted with staff member #3, he/she confirmed no bereavement services/spiritual care provided to patient/family. Staff member stated he thought this was the grandmother of the RN on staff and the family did not want spiritual care services. A review of the Hospice "Bereavement Binder" provided by staff member #3 reflected no bereavement services had been provided.

Based on record review and staff interview it was determined the hospice failed to offer therapy services available and offered in a manner consistent with the accepted standards of practice. This deficient practice has the potential that the hospice patients are not being offered the full range of hospice services posing the risk for patient rights violations. --- Findings include: A document titled, "OTHER ARRANGED SERVICES", revealed, "...Whenever the hospice arranges services through contractual arrangement, the hospice retains professional responsibility for those services... and delivered in accordance with the Medicare requirements and accepted standards of practice... Such services will include... Physical therapy...Occupational therapy... Speech and language therapy...." A complete review of pages 1-84, of the Horizon Hospice Patient Admission Book presented on May 14, 2024, revealed no mention of therapy services being available. A request was made for the contract(s) for the company furnishing therapy services was asked for and not received. In an interview conducted on May 14 and May 15, 2024, with Employee #1, he/she confirmed no contract for the aforementioned services could be located or accessed. No additional information could be provided. In a telephone interview on May 15, 2024, with Employee #2, he/she stated that therapy services are contracted with Horizon Home Health. He/she confirmed no contract existed between Horizon Home Health and Horizon Hospice. No additional information could be provided.

Based on record review, observation, and staff interviews it was determined the hospice failed to implement volunteers to facilitate compliance with core services requirements. This deficient practice has the potential that hospice patients and caregivers are not receiving the services that the hospice offers posing the risk that patient care and needs are not being met resulting in poor patient outcomes. --- Findings include: A review of a document titled, " Utah Hospice Specialists Job Description Coordinator, Volunteer...", 2. Develop and maintain volunteer orientation; Develop volunteer training programs individualized to specific positions and consistent with UHS standards...4. Establish and maintain a list of viable sources for ongoing recruitment of volunteers...13.Assure for compliance with local, state, and federal laws, Medicare regulations and establish personnel policies and procedures....". A review of a document titled, "Horizon Hospice Job Description Title: Coordinator, Volunteer...", revealed"... 3. Ability to develop, coordinate, implement, and evaluate Volunteer Services Plan to include recruitment, training, placement, and retention of volunteers to meet patient and organizational needs, and all associated administrative responsibilities. 4. Must be computer literate...13. Satisfactory criminal background check... Responsibilities/Duties/Skills 1. Recruit, educate, and select volunteers...4. Establish and maintain a list of viable sources for ongoing recruitment of volunteers...11. Assure for compliance with local, state, and federal laws, Medicare regulations and established personnel policies and procedures...12. Participate in staff meetings, department meetings, team meetings, briefings, in-services, committees...." A request for the volunteer program was asked for and not received. A request for policies and procedures covering volunteers and volunteer program(s) was asked for and not received. A review of personnel files revealed no volunteer or volunteer coordinator. A review of Employee #3's personnel file, revealed no job description for Volunteer Coordinator. In an interview conducted on May 14, 2024, with Employee #1, he/she confirmed that no volunteer program could be accessed by him/her in the facility " Z Drive". He/she subsequently confirmed in a follow-up interview conducted on May 15, 2024, that there is no volunteer on staff and the hospice has not had a volunteer since his/her start date August 2023. No additional documentation could be provided. In an interview conducted on May 15, 2024, with Employee #2, he/she confirmed that the hospice has no volunteers on staff. He/she was asked to produce the Volunteer Program. No additional documentation could be provided. In an interview conducted on May 14, 2024, with Employee #3, he/she stated that he/she was the Volunteer Coordinator. He/She confirmed there was no volunteer on staff and that the volunteer program should be "in the computer over there" while pointing to a vacant desk with a computer on it. He/she could not explain the use of volunteers in the hospice program.

Based on record review and staff interviews it was determined the hospice failed to use volunteers and there was no documentation of time spent and the services provided by volunteers. This deficient practice has the potential that hospice patients are not receiving the volunteer services posing the risk of patient rights violations. --- Findings include: A policy for the volunteers was asked for and not received. A request was made for documentation recording the use and services provided by volunteers were asked for and not received. A list of personnel was requested on May 14, 2024. No volunteers were listed. In an interview conducted on May 14, 2024, with Employee #3, he/she confirmed he/she was the Volunteer Coordinator (VC) and that there have been no volunteers. He/she also confirmed no documentation of volunteer hours or services could be provided. In an interview conducted on May 14, 2024, with Employee #1, he/she confirmed there are no volunteers on the personnel list of staff with the hospice agency. In a telephone interview conducted on May 15, 2024, with Employee #2, he/she confirmed the hospice has no volunteers and no additional documentation could be provided.

Based on record review, observation, and staff interviews, it was determined that the Governing Body failed to appoint a qualified administrator responsible for the day-to-day operation of the hospice. This deficient practice has the potential that the hospice is at risk for not recognizing, addressing, and correcting potential patient care and hospice operation deficits posing the risk for negative patient and hospice needs outcomes. --- Findings include: A review of a document titled, "Horizon Hospice FLSA: Exempt TITLE: Administrator...", revealed, "... The Administrator is responsible for the overall compliance, operational, financial and clinical results of the organization... 4. Demonstrated knowledge of business management and knowledge of Medicare regulations and benefits of hospice.5....working knowledge of relevant computer programs...8.Must be computer literate9. Satisfactory references from employers and /or professional peers.10.Satisfactory criminal background check...4) Other a) 24/7 accountability for operations of agencies...d) Appoint an Alternate Administrator to act in place of the Administrator when absent...." A personnel file was presented for Employee #1 and was taken back as the file was identified as being a home health agency employee file. The aforementioned personnel file was for the person identified as the hospice Administrator to the surveyors. A request for a hospice personnel file for Employee #1 was asked for and not received. No additional documentation could be provided. In an interview conducted on May 14, 2024, with Employee #1, he/she identified him/herself as the Administrator. In a subsequent interview conducted on May 15, 2024, he/she confirmed the aforementioned job description had not been presented to him/her for signature upon hire. He/she confirmed that the responsibilities in the aforementioned document had not been explained to him/her at any time during the length of his/her employment with the hospice agency. In a telephone interview conducted on May 14, 2024, with Employee #2, he/she confirmed that Employee #1 was the appointed hospice Administrator. In a subsequent telephone interview conducted on May 15, 2024, he/she stated the home health and hospice use the personnel files interchangeably and there was no job description for a hospice-specific administrator. A hospice Administrator job description was presented to the surveyors on May 15, 2024, post-interview with Employee stating there was no hospice-specific Administrator job description.

Based on record review and staff interviews it was determined the hospice failed to provide care and services in a manner that is consistent with accepted standards of practice. This deficient practice has the potential that patients and patient caregivers are not receiving services as explained and promised by the hospice posing the risk of negative patient care and patient rights violations. --- Findings include: A review of Horizon Home Health Hospice admission book revealed, "...Section 11 Hospice Benefits and Philosophy... Services provided by Horizon Hospice... Intermittent visits by your hospice team: physician, nurse, social worker, hospice aide, chaplain, volunteer, and/or other as authorized...." A request was made for a contract for physical therapy, occupational therapy, and speech pathologist services. No documentation was provided. A request was made for a list of volunteers and services offered by volunteers. No documentation was provided. In an interview conducted on May 14, 2024, and May 15, 2024, with Employee #1, he/she confirmed there were no volunteers for hospice services. He/she confirmed the hospice did offer therapy services. In an interview conducted on May 15, 2024, with Employee #2, he/she confirmed no volunteers were on staff at the hospice. He/she stated the hospice uses the Horizon Home Health staff interchangeably for therapy services, and no contract has been executed between Horizon Hospice and Horizon Home Health.

Based on record review and staff interview it was determined the hospice failed to provide hospice orientation to personnel. This deficient practice has the potential that employees are not properly trained in the hospice philosophy posing the risk of poor patient care and outcomes. --- Findings include: A request was made for the hospice philosophy training program provided to staff. No documentation could be provided. A request was made for Employee #1's hospice personnel file. A personnel file was produced for Employee #1, and was taken back as it was a home health personnel file. No hospice personnel file could be provided for Employee #1. In an interview conducted on May 14, 2024, and May 15, 2024, he/she confirmed that no orientation had been provided to him/her.

Based on record review and staff interviews it was determined the hospice failed to obtain criminal background checks. This negligent and deficient practice has the potential that hospice staff are not being screened posing the risk of patients being subjected to dangerous and unqualified individuals. --- Findings include: A request for a policy for criminal background checks was made and no documentation was received. A request was made for Employee #1's hospice personnel record was made on May 14, 2024, and May 15, 2024. No documentation was received. A request was made for Employee #2's hospice personnel record was made on May 14, 2024, and May 15, 2024. No documentation was received. A review of Employee #3's personnel record revealed no documentation of a criminal background check. A review of Employee #4's personnel record revealed no documentation of a criminal background check. In an interview conducted on May 14, 2024, with Employee #1, he/confirmed no criminal background check was present in Employee #3 or Employee #4's personnel record.

Findings include: A document titled " Hospice Scope of Services", revealed, "...OTHER ARRANGED SERVICES whenever the hospice arranges services through contractual arrangement, the hospice retains professional responsibility for those services. Contracted services are monitored by: ...Hospice Satisfaction Survey results... CQI process. All contracted services will be furnished under the direction of the interdisciplinary team*supervised by the Director of Clinical Services or designee, and delivered in accordance with the Medicare requirements and accepted standards of practice. Such services will include, but are not limited to:... Laboratory services...." A request for a reference laboratory's CLIA certificate was asked for and not received. Upon observation when entering the hospice a CLIA certificate was posted. The certificate listed the "Laboratory Director" as a person who was no longer an employee of the hospice as confirmed interview. In an interview conducted on May 14, 2024, with Employee #1, he/she confirmed the aforementioned CLIA certificate had a person listed on it who was not an employee of the hospice. In a telephone interview conducted on May 14, 2024, with Employee #2, he/she confirmed the CLIA certificate displayed was incorrect and the person listed as the Laboratory Director had not been an employee of the hospice since April 2023.