Every finding on record at Hospice of Oc, Inc

It is required that the hospice conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. This standard was not met as evidenced by document review and interview. On July 10th, 2024, a review of the Agency's Emergency Preparedness Plan with the Administrator and Director of Patient Care Services revealed an in-service had been conducted regarding emergency preparedness on 05/24/2023. An emergency preparedness drill was conducted on 05/10/2024. The Agency did not have evidence of a drill, tabletop exercise, or community-based exercise in 2022. The Administrator stated he acquired the hospice in July of 2022. He did not know if there was a community-based exercise completed in 2022 before the acquisition. On July 10th, 2024 a review of the Agency's Emergency Preparedness Plan with the Administrator and Director of Patient Care Services revealed an in-service had been conducted regarding emergency preparedness on 05/24/2023. An emergency preparedness drill was conducted on 05/10/2024. The Agency did not have evidence of a drill, tabletop exercise, or community-based exercise in 2022. The Administrator stated he acquired the hospice in July of 2022. He did not know if there was a community based exercise completed in 2022 before the acquisition.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 3 (33%) home visits performed revealed the agency did not ensure the drug profile contained the patient's current prescription and over the counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Home Visit 1/Clinical Record 1: During Home Visit 1 on 07/10/2024 to observe Staff 5 (SW), the Site Visitor compared the hospice medication list to the assisted living facility medication list. The facility medication list contained 2 medications not listed on the hospice medication list: Promethazine every 6 hours as needed for cough and hydroxyzine every 6 hours as needed for itching. The hospice medication list contained 7 medications not listed on the facility list. These were the comfort kit medications: Tylenol, Albuterol, Bisacodyl, Levsin, Ativan, Morphine, and Zofran. The facility Alternative Administrator was working as the medication nurse during the site visit and reviewed the medications with the site visitor. During the review and interview, she stated "Usually didn't list the comfort kit on their medication list until they used it" but did confirm they had them in the patient's medications. During an interview and joint record review with the Director of Patient Care Services on 07/10/2024, it was confirmed the medication lists had not been reconciled. The Director of Patient Care Services stated she knew the facility "didn't list the comfort kit meds until they had called hospice."

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure the clinical record contained an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Clinical Record 12: The patient elected the hospice benefit on 04/17/2024 for malignant neoplasm of the rectum. A clinical record review on 07/10/2024 revealed the comprehensive assessment did not include documentation of an initial bereavement assessment. During an interview and joint record review with the Director of Patient Care Services on 07/10/2024, it was confirmed this clinical record did not contain an initial bereavement assessment. The Director of Patient Care Services did not "understand why this had not been completed."

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure the individualized plan of care was reviewed and revised as frequently as the patient's condition required. Clinical Record 8: The patient elected the hospice benefit on 03/21/2024 for the diagnosis of senile degeneration of the brain. On 05/12/2024 there was an on-call nursing visit for "a fall and confusion," On 05/13/2024 there was an on-call nursing visit for "follow up for wound care after fall". On 05/15/2024 there was an on-call nursing visit for "patient becoming more confused and hallucinating." The plan of care (POC) dated 3/21/2024 included the following: "Problem: Neurological/Mental Potential risk of harm r/t (related to) senile degeneration. Goal: Patient to remain in a safe environment. Intervention: Assess alteration in mobility." The POC was not revised to account for the increased agitation, hallucinations, medication changes, falls, wounds noted during the on-call visits that occurred in May 2024. During an interview and joint record review with the Director of Patient Care Services on 07/10/2024, she stated the Plan of Care should have been updated to include "more robust goals and interventions after those visits."

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties. This standard was not met as evidenced by interview and personnel record review. In 3 of 10 (30%) personnel records reviewed revealed the agency did not ensure the skills and competence of all individuals furnishing care, including volunteers furnishing services were assessed. Document 2: Agency Policy titled Scope of the Program/Process Methodology. Policy No 3-001.1 Revised Jan 2021 stated in the relevant part: "3. Hospice will clearly identify and define the skills which are essential to observe for the determination of competencies for each job category. In the identification of core competencies, the essential skills will be demonstrated upon hire" Personnel Record 4: An employee who has direct patient contact (Alternate Director of Patient Care Services) transitioned into the Alternative Director of Patient Care Services role in March 2023. A review of the personnel file 07/09/2024 revealed it did not contain competencies for that role. Personnel Record 8: An employee who has direct patient contact (Social Worker/Bereavement Coordinator) was hired on 03/04/2024. A review of the personnel file 07/09/2024 revealed it did not contain competencies for the role of bereavement coordinator. Personnel Record 9: An employee who has direct patient contact (Volunteer Coordinator) was hired on 01/08/2024. The initial competencies are signed on the date of hire however none of the boxes are checked off as completed. During an interview and joint record review with the Director of Patient Care Services and Human Resources on 07/10/2024 they stated they did not realize that personnel with "two job descriptions needed two competencies." They confirmed the competency on Staff 9 had not been completed and only had been signed.