Every finding on record at Interim Healthcare Hospice of Ohio, Inc.

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; other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 14 (14%) clinical records reviewed, the hospice did not ensure that the patient's current medications were reviewed as part of the comprehensive assessment and the medication profile was updated. Clinical Record 3/Home Visit 3: The patient elected hospice care on 5/30/2023. During the home visit with the Hospice Aide on 9/13/2023, the medications were reviewed with the patient. The patient had medication bottles for "Jardiance 25mg tablet, take 1 tablet by mouth every morning," last filled 8/31/2023, and Loperamide 2mg capsule, take two capsules now then take one after each stool, max of 8 caps a day. The spouse reported the patient has been taking Jardiance “for at least a month, probably two or three months and the patient took the Loperamide “last week for loose stool.” The spouse reported the patient has not taken Calcium Carbonate Vitamin D3 and Magnesium Oxide “for at least 2-3 months.” The agency's medication profile dated 9/13/2023 documented: Calcium Carbonate Vitamin D3 600mg-400IU take one tablet daily effective 3/31/2023; Magnesium Oxide 400mg take one tablet daily effective 3/31/2023; and Loperamide 2mg capsule, take 1 capsule daily as needed with a max dose 8mg day. There was no documented evidence that the medication profile was updated to include documentation of Jardiance or changes to the medications Calcium Carbonate, Vitamin D3, Magnesium Oxide, and Loperamide. There was no evidence that Jardiance was reviewed as part of the comprehensive assessment. During a joint review of the medications and interview, the Administrator present at the visit confirmed the medications were not updated. Clinical Record 13: The patient elected hospice care on 12/20/2022. The comprehensive assessment completed by the RN on 1/16/2023 documented the patient was on "2 liters (L) of oxygen PRN." The comprehensive assessments completed by the RN on 1/31/2023 and 2/9/2023 documented the patient used "2L oxygen." The agency's medication profile reviewed for 12/20/2022 through 2/16/2023 did not include documentation of oxygen. During a joint review of the record and an interview on 9/13/2023, the Administrator confirmed there was no documented evidence that the medications were reviewed as part of the comprehensive assessment and the medication profile was not updated.

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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy Chapter 6 "Care Delivery. Interdisciplinary Group Services, Bereavement Counseling Service," stated in part, "An initial bereavement risk assessment is completed for each patient/family by the hospice registered nurse or medical social worker as part of the initial comprehensive assessment conducted within five (5) calendar days of the start of care." In 4 of 14 (29%) clinical records reviewed, the hospice did not ensure an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 1: The patient elected hospice care on 3/13/2023. There was no documented evidence that an initial bereavement assessment was completed within five (5) calendar days of the patient’s election of hospice care. Clinical Record 2: The patient elected hospice care on 2/13/2023. There was no documented evidence an initial bereavement assessment was completed. Clinical Record 5: The patient elected hospice care on 3/18/2023. There was no documented evidence that an initial bereavement assessment was completed within five (5) calendar days of the patient’s election of hospice care. Clinical Record 8: The patient elected hospice care on 9/6/2022. There was no documented evidence that an initial bereavement assessment was completed within five (5) calendar days of the patient’s election of hospice care. During a joint review of the record and an interview on 9/13/2023, the Administrator agreed there was no evidence the initial bereavement assessments were completed timely.

It is required that each patient’s individualized written plan of care reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the hospice did not ensure the plan of care included planned interventions and goals based on problems identified in the comprehensive assessments. Clinical Record 10: The patient elected hospice care on 8/19/2023 with the primary hospice diagnoses of diastolic congestive heart failure and Type 1 Diabetes. The physician’s certification and admission documentation revealed the patient was a brittle diabetic, insulin-dependent, and low intake had contributed to the patient’s recent hospitalizations for hypoglycemia. The medication record revealed Lantus with meals on a sliding scale and Humalog with meals. The plan of care effective 8/19/2023 through 9/14/2023 did not include problems, goals, and interventions for hypoglycemia. Clinical Record 13: The patient elected hospice care on 12/20/2022 with the primary hospice diagnosis of malignant neoplasm of the liver. The comprehensive assessment completed on 1/11/2023 by the Registered Nurse (RN) documented "2+ edema in BLE (both lower extremities), patient reporting his shoes are tight." The RN assessments completed on: 1/25/2023 documented "2+ edema" and 2/12/2023 documented "4+ pitting edema." The plan of care effective 12/20/2022 through 2/16/2023 did not include problems, goals, and interventions for edema. During a joint review of the record and an interview on 9/14/2023, the Administrator agreed there was no evidence the plans of care included planned interventions and goals based on the problems identified in the comprehensive assessments.

It is required that each patient’s individualized written plan of care Includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 14 (7%) clinical records reviewed, the hospice did not ensure the written plan of care included drugs necessary to meet the needs of the patient. Clinical Record 3/Home Visit 3: The patient elected hospice care on 5/30/2023. During the home visit with the Hospice Aide on 9/13/2023, the medications were reviewed with the patient. The patient had a medication bottle for "Jardiance 25mg tablet, take 1 tablet by mouth every morning," last filled 8/31/2023, and Loperamide 2mg capsule, take two capsules now then take one after each stool, max of 8 caps a day. The spouse reported the patient has been taking Jardiance “for at least a month, probably two or three months and the patient took. The POC did not include documentation of the medication Jardiance. During a joint review of the record and an interview on 9/13/2023, the Administrator present for the visit confirmed Jardiance was not included in the plan of care and medication profile.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care; and documented in the patient record, including time spent. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by clinical record review, document review, personnel record review, and interview with the Volunteer Coordinator and Administrator which revealed the following issues with the volunteer program: Failed to ensure maintenance, documentation, and provision of hospice volunteer orientation and training [HSRM.31.I/L643]; Failed to provide volunteer services in day-to-day administrative and/or direct care roles [HCDT.21.I/L644]; and Failed to ensure documentation and demonstration of ongoing efforts to recruit and retain volunteers [HSRM.30.I/L645]. The cumulative effect of this issue has resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.78: Volunteers. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that the hospice maintains, documents, and provides hospice volunteer orientation and training that is consistent with hospice industry standards; it includes the volunteer’s duties and responsibilities; [and] hospice goals, services, and philosophy. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy Chapter 2, "Managing Employee Caregivers. Orientation of Employees Who Provide or Manage Patient/Family Care,” stated in part, “Hospice provides orientation to all employees who provide or manage patient/family care prior to their initial assignment. Orientation of employees who provide or manage patient/family care includes at a minimum: Hospice policies and procedures, Hospice philosophy of care, applicable law, regulation, and contract requirements as they relate to the employee’s duties, or job responsibilities.” 1 of 1 (100%) personnel record review of a volunteer that was hired more than 30 days ago, the hospice did not ensure the employee received orientation on the volunteer’s duties and responsibilities, and hospice goals, services, and philosophy. Personnel Record 12: The Volunteer was hired on 11/3/2020 and termed on1/28/2022. There was no documented evidence that an initial orientation included basic hospice philosophy, volunteer training, and hospice volunteer role. During an interview on 9/13/2023, the Administrator agreed there was no documented evidence the volunteer was provided with an initial orientation per the policy.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy Chapter 6, "Service Delivery, Volunteer Services, Regulatory Requirements for Volunteer Services, 418.78 Condition of Participation - Volunteers,” stated in part, “The hospice must use volunteers to the extent specified in paragraph (e) of this section. These volunteers must be used in defined roles and under the supervision of a designated hospice employee. A Volunteer Coordinator also coordinates with the leadership team to ensure that the volunteer program is carefully integrated within the overall hospice operation, that policies and procedures regarding volunteers are clearly understood, and that appropriate accountability for volunteer activities is maintained. Volunteers must provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff. The hospice must maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked.” In 2 of 2 (100%) personnel records reviewed of volunteers, the hospice did not ensure volunteers were available to provide day-to-day administrative or direct patient care. Personnel Record 10: The Volunteer was hired on 8/31/2023. The background check was pending results. The new hire has not started the required volunteer training. Personnel Record 12: The Volunteer was hired on 11/3/2020 and termed on 1/28/2022. There was no documented evidence that the volunteer provided direct patient or administrative volunteer services between 11/3/2020 and 1/28/2022. During an interview on 9/13/2023, the Volunteer Coordinator stated, “I have not completed training to be a volunteer. I can’t make volunteer visits. I don’t offer a volunteer; just explain what they can do when we have one, but no one has asked for one. I know admissions asks. I wouldn’t know how to offer a volunteer; it’s not on SW assessment. We don’t discuss patient volunteer needs in IDG; sometimes, once or twice, we discuss that we need to buckle down on the volunteer program. We don’t currently have a volunteer available to see patients. I heard we have someone interested and in the early stages.” During an interview on 9/13/2023, the Administrator confirmed there was no documented evidence volunteers were used to provide volunteer services, administrative or direct patient, between October 2020-September 14, 2023. The Administrator stated, "Everyone has declined a volunteer, but if a patient needed one, we would just send one of our staff. We discovered the volunteer coordinator wasn’t acting as a volunteer coordinator, not tracking, not recruiting. A previous Administrator was covering but we have no documentation to provide; we have a PIP now. There are no current staff that have completed the volunteer training; we would send a paid staff if we need to meet the need. All patients have declined a volunteer. We have no further information to provide.”

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. Agency policy Chapter 6, "Service Delivery. Volunteer Services," stated in part, “The hospice must document and demonstrate viable and ongoing efforts to recruit and retain volunteers.” The hospice did not ensure that ongoing efforts to recruit and retain volunteers were demonstrated and documented. A review of administrative documents revealed no documented evidence that the hospice has attempted to recruit or retain volunteers for 2021, 2022, and 2023. During an interview on 9/13/2023, the Volunteer Coordinator agreed there was no documented evidence of recruitment or retention, stating, “I know I have had the position since I was hired, but received no training as volunteer coordinator. Just had the title attached. I have not been recruiting because I was never trained.” During an interview on 9/13/2023, the Administrator confirmed there was no evidence of recruitment or retention and stated, “We discovered the volunteer coordinator wasn’t acting as a volunteer coordinator, not tracking, not recruiting. A previous Administrator was covering, but we have no documentation to provide; we have a PIP now.” The hospice did not ensure that ongoing efforts to recruit and retain volunteers were demonstrated and documented. There was no documentation provided to indicate the hospice attempted to recruit or retain volunteers during the year 2021, 2022 and 2023 to date.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation includes the following, as appropriate to the employee’s specific job duties. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy Chapter 2, "Managing Employee Caregivers. Orientation of Employees Who Provide or Manage Patient/Family Care,” stated in part, “Hospice provides orientation to all employees who provide or manage patient/family care prior to their initial assignment. Orientation of employees who provide or manage patient/family care includes at a minimum: Hospice policies and procedures, Hospice philosophy of care, applicable law, regulation, and contract requirements as they relate to the employee’s duties, or job responsibilities.” In 2 of 11 (25%) personnel records reviewed of employees hired more than 30 days ago, the hospice did not ensure employees received an initial orientation that addressed the specific job duties. Personnel Record 2: The Hospice Medical Director was hired on 2/15/2021. There was no documented evidence that an initial orientation was provided prior to 7/11/2023. During an interview on 9/13/2023, the Administrator agreed there was no documented evidence the hospice medical director was provided with an orientation upon hire prior to 7/11/2023, stating, “It was missed and completed late once discovered.” Personnel Record 5: The Social Worker/Volunteer Coordinator was hired on 2/5/2020. The Volunteer Coordinator job description signed by the employee on 2/5/2020 stated, “Responsible for planning, coordinating, and managing all elements of the volunteer program including the training and supervision of volunteers. Knowledge, Skills & Abilities Required: Able to supervise, coordinate, and evaluate volunteer services, able to organize and develop volunteers for both patient and organizational needs, able to manage a group of individuals providing volunteer services.” There was no documented evidence that the initial orientation addressed the specific job duties as a Volunteer Coordinator. During an interview on 9/13/2023, the Volunteer Coordinator stated, “I know I have had the position since I was hired, but I received no training as a volunteer coordinator. Just had the title attached. I haven’t been doing anything because I have not been trained.” During an interview on 9/13/2023, the Administrator confirmed there was no evidence the volunteer coordinator received an orientation that addressed the specific job duties as volunteer coordinator.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy Chapter 6 "Care Delivery. Transfer, Benefit Revocation and Discharge," stated in part, "In the event that the patient has revoked the benefit or is seeking discharge from hospice services, the Hospice DHCS or designated RN ensures that the following information is forwarded to the patient's attending physician or physician designee: a copy of the hospice discharge summary." In 2 of 2 (100%) clinical records reviewed of discharged patients, the hospice did not ensure that the patient’s attending physician received a copy of the discharge summary. Clinical Record 11: The patient elected hospice care on 11/28/2022 and was discharged from hospice care on 5/24/2023 as no longer terminally ill. There was no documented evidence the discharge summary was forwarded to the patient’s attending physician. Clinical Record 12: The patient elected hospice care on 11/4/2022 and revoked the election of hospice care on 11/8/2022 to seek aggressive treatment. There was no documented evidence the discharge summary was forwarded to the patient’s attending physician. During a joint review of the record and an interview on 9/14/2023, the Administrator agreed there was no evidence that the discharge summary was forwarded to the patient's physician.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the most recent hospice plan of care, physician certification, and recertification of the terminal illness. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 1 (100%) home visit observed of a patient that resided and received hospice services at a SNF, the hospice did not ensure to provide the SNF with a copy of the patient's most recent hospice plan of care and physician’s recertification of the terminal illness. Home Visit 1/Clinical Record 2: The patient elected hospice care on 2/13/2023 and resided in a Skilled Nursing Facility (SNF). During the home visit with the Social Worker (SW) [Personnel Record 5], a joint review of the hospice binder with the hospice Administrator revealed documentation, including the physician’s recertification of the terminal illness and the hospice plan of care for the benefit period 5/7/2023 through 7/5/2023. There was no documented evidence the physician’s recertifications of the terminal illness and hospice plans of care for the benefit periods 7/6/2023 through 9/3/2023 and the current benefit period starting 9/4/2023 were provided to the SNF. During an interview on 9/13/2023, the Administrator confirmed there was no evidence the hospice provided the SNF with the most recent hospice plan of care and physician’s recertification of the terminal illness.