Every finding on record at Lifesource Services Hospice LLC

exercises to test the emergency preparedness plan annually, including: Participation in a full-scale exercise that is community-based every two (2) years, When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years; If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include but is not limited to: A second full-scale exercise that is community-based or a facility-based functional exercise; or A mock disaster drill; or A tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. The agency did not ensure that emergency preparedness plan testing was documented annually. EMERGENCY PREPAREDNESS: A review of the agency's Emergency Preparedness binder revealed that no exercises to test the emergency preparedness plan were documented in the past three years. The Administrator (Personnel Record 1) was interviewed on 05/08/2025 and stated, "We have not had to activate the Emergency Plan in the last three years. We also have not done any tabletop drills. The only thing we have done was fire drills for the office." The agency did not ensure that emergency preparedness plan testing was documented annually.

It is required that the written Patient Bill of Rights include the right to receive information about the services covered under the hospice benefit. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) of clinical records reviewed, where the patient was discharged because the patient was no longer terminally ill, the agency did not ensure that the patient was provided, in writing, information on how to appeal to the Quality Improvement Organization (QIO). CLINICAL RECORD 12: A clinical record review revealed documentation in the nursing note dated 03/09/2025 that the hospice interdisciplinary group (IDG) had determined that the patient was no longer terminally ill. The patient was discharged on 03/09/2025. There was no Notice of Medicare Non-Coverage document present in the record. The patient was not provided with written notice on how to appeal the hospice discharge. The Administrator (Personnel Record 1) was interviewed on 05/08/2025 and stated, "The Notice of Non-Coverage was not provided to this patient."

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 4 (100%) patients who received Skilled Nursing services by a Licensed Practical Nurse (LPN), the agency did not ensure that the LPN was supervised per the agency's policy. POLICY: The agency's "Responsibilities/Supervision of Clinical Services" policy (Policy No.1-031, dated November 2024) stated in part, " A monthly patient visit will be completed by a registered nurse to supervise licensed practical/vocational nursing services." CLINICAL RECORD 3: A clinical record review revealed that the Skilled Nursing (SN) visit frequency ordered on the Plan of Care (POC) dated 03/05/2025 was two visits weekly. The licensed practical nurse (LPN) documented visit notes dated 04/16/2025, 04/18/2025, and 04/21/2025. The Registered Nurse (RN) documented all other clinical visits within the ordered SN frequency. There was no documentation in the RN visit notes of the LPN's supervision. The LPN was not supervised by the RN per the agency's policy. CLINICAL RECORD 5: A clinical record review revealed that the Skilled Nursing (SN) visit frequency ordered on the Plans of Care (POC) dated 01/23/2025 and 04/23/2025 was two visits weekly - one visit by the Registered Nurse (RN) Case Manager and one by the Licensed Practical Nurse (LPN). There was no documentation in the RN visit notes of supervision of the LPN. The LPN was not supervised by the RN per the agency's policy. CLINICAL RECORD 6: A clinical record review revealed that the Skilled Nursing (SN) visit frequency ordered on the Plan of Care (POC) dated 03/26/2025 was one to two visits weekly. The licensed practical nurse (LPN) documented visit notes dated 04/05/2025, 04/15/2025, and 04/18/2025. The Registered Nurse (RN) documented all other clinical visits within the ordered SN frequency. There was no documentation in the RN visit notes of the LPN's supervision. The LPN was not supervised by the RN per the agency's policy. CLINICAL RECORD 9: A clinical record review revealed that the Skilled Nursing (SN) visit frequency ordered on the Plan of Care (POC) dated 04/14/2025 was two visits weekly. The licensed practical nurse (LPN) documented visit notes dated 04/01/2025, 04/11/2025, and 04/18/2025. The Registered Nurse (RN) documented all other clinical visits within the ordered SN frequency. There was no documentation in the RN visit notes of the LPN's supervision. The LPN was not supervised by the RN per the agency's policy. The Administrator (Personnel Record 1) was interviewed on 05/08/2025 and stated, "There currently is no place in the electronic medical record RN visit note to document LPN supervision."

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. This standard was not met as evidenced by document review and interview. The agency did not ensure that volunteer services equaling five percent (5%) of the total patient care hours of all paid hospice employees and contract staff were provided. During a review of the volunteer program, the documentation lacked evidence of day-to-day administrative or direct patient care services at a minimum of 5% of the total patient care hours of all paid hospice employees. VOLUNTEER PROGRAM: A review of the agency's Volunteer Program binder revealed no documentation of volunteer use in the past three years. There was no documented tracking to measure the volunteer hours that the agency provided to measure the percentage (%) of the total patient care hours of all paid hospice employees and contract staff for each of the past three years.The newly appointed Volunteer Coordinator (Personnel Record 9) confirmed that a qualified volunteer was available. There was no documented evidence that the hospice volunteer services provided equalled 5% of the total patient care hours of all hospice employees and contract staff; The Volunteer Coordinator (Personnel Record 9) was interviewed on 05/07/2025 and stated, "I just took over this position a few months ago. There was no documentation of volunteer use from the previous Volunteer Coordinator" stating that they have begun recruitment efforts to grow the volunteer program. The Administrator (Personnel Record 1) was interviewed on 05/07/2025 and stated, "We need to increase the use of volunteer services." She stated that there was very little volunteer utilization in the past three years". The agency did not ensure that volunteer services equaling five percent (5%) of the total patient care hours of all paid hospice employees and contract staff were provided.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by interview and personnel record review. 6 of 8 (75%) clinical personnel records reviewed revealed that the agency did not ensure clinical staff that provided patient care received annual competency assessment as per the agency policy. POLICY: The agency's "Competency Program" policy (Policy No. 3-001, dated November 2024) stated in part, " The organization will establish and annually evaluate a group of specific skills related to the patient care/service responsibilities and complexity of care/service provided by personnel." PERSONNEL RECORD 2: A review of the Clinical Coordinator's personnel record (Date of hire [DOH] 02/03/2007) included one documented annual competency dated 02/03/2008.There was no documented evidence of annual competency assessments in 2009- 2024. PERSONNEL RECORD 3: A review of the Registered Nurse's (RN) personnel record (DOH 05/05/2016) revealed the presence of annual competency evaluation forms annually from 2018 through 2024. However, only the self-evaluation portion of the forms was completed. The section of the form to be completed by the evaluator was blank (undated and unsigned by the evaluator). There was no documented evidence that the RN received annual competency assessments. PERSONNEL RECORD 4: A review of the Registered Nurse's (RN) personnel record (DOH 04/01/2022) revealed the presence of annual competency evaluation forms dated 07/25/2022 and 07/25/2024. However, only the self-evaluation portion of the forms was completed. The section of the form to be completed by the evaluator was blank (undated and unsigned by the evaluator). There was no documented evidence that the RN received annual competency assessments. PERSONNEL RECORD 6: A review of the Spiritual Counselor's (SC) personnel record (DOH 02/02/2022) revealed the presence of annual competency evaluation forms dated 05/02/2022 and 02/03/2023. However, only the self-evaluation portion of the forms was completed. The section of the form to be completed by the evaluator was blank (undated and unsigned by the evaluator). The personnel record did not contain evidence of completed competency assessment in 2024 and 2025. There was no documented evidence that the SC received annual competency assessments. PERSONNEL RECORD 7: A review of the Hospice Aide's (HA) personnel record (DOH 02/02/2024) revealed the presence of an annual competency evaluation form dated 02/07/2025. However, only the self-evaluation portion of the form was completed. The section of the form to be completed by the evaluator was blank (undated and unsigned by the evaluator). There was no documented evidence that the HA received an annual competency assessment. PERSONNEL RECORD 10: A review of the Volunteer's personnel record (DOH 06/22/2023) revealed that the Volunteer had not received a competency assessment. The clinical record did not contain evidence that the RN received annual competency assessments. The Volunteer Coordinator (Personnel Record 9) was interviewed on 05/07/2025 and stated, "I just took the Volunteer Coordinator role, so there may not have been competencies done before." The Clinical Coordinator (Personnel Record 2) was interviewed on 05/07/2025 and stated, "After the clinician completed the self-evaluation on the competency form, I brought them into the office to discuss the items on the form. No field visits were made with the clinical staff."

It is required 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. In 2 of 2 (100%) discharged records reviewed revealed that the agency did not ensure a discharge summary was sent to the patient's attending physician following a revocation or discharge from hospice. CLINICAL RECORD 11: The patient elected hospice services on 02/14/2025 and chose to revoke hospice services on 02/18/2025. The clinical record did not contain evidence that the discharge summary was sent to the attending physician. CLINICAL RECORD 12: The patient elected hospice services on 11/16/2023 and was discharged on 03/09/2025 because the patient was no longer terminally ill. The clinical record did not contain evidence that the discharge summary was sent to the attending physician. During an interview with the Administrator (Personnel Record 1) on 05/08/2025 stated, "We are still learning how to use the electronic medical record. We need to contact the electronic medical record vendor to figure out how to create a discharge summary."

Observed in Record Review. In 5 of 11 patient records reviewed, The organization did not provide the patient with care, treatment, or services according to the patient's individualized plan of care. During review of records 3, 4, 6, 7 and 10 it was noted that the orders for frequency for aide visits did not match the visits provided. For example in record 4 aide visits were ordered for 2-5 times per week but were provided at 7 x week on 5 different periods. This was confirmed by the Executive Director. Observed in Record Review. In 5 of 11 patient records reviewed, The organization did not provides the patient with care, treatment, or services according to the patient's individualized plan of care. During review of records 6, 7,8,10 and 11 it was noted that the skilled nursing frequencies did not always match the orders in the plan of care. For example in record 6 the skilled nurse visits were ordered for 1-2 x per week with 1 PRN and there were three different weeks when no visits were provided. This was confirmed by the Administrative Assistant.

Observed in Individual Tracer. The organization did not implement infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. During home visit 3 it was observed that the nurse disinfected equipment with Nice & Clean wipes which require a 15 second dry time. The equipment was placed immediately back in the nursing bag without dry time. This was confirmed by the LPN Marketing Nurse. Observed in Individual Tracer. The organization did not implement its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. During home visit 3 it wa observed that the nurse dropped a pen on the floor and picked it up and placed it in her pocket without cleaning it. This was confirmed by the LPN Marketing Nurse. Observed in Individual Tracer. The organization did not implement the infection prevention and control activities it had planned. During home visit 1 it was observed that the nurse entered the nursing bag twice with out first cleansing her hands per policy. This was confirmed by the LPN Marketing Nurse.

Observed in Record Review. In 5 of 11 patient records reviewed, The home health aide or hospice aide did not provide services that were ordered by the physician or allowed practitioner in the plan of care. During review of records 1, 3, 5 7 and 9 it was noted that the aide did not follow the care plan written by the RN. For example in record 1 the aide documented incontinence care which was not on the care plan and transfer to wheel chair which was not on the care plan. This was confirmed by the Executive Director.

Observed in Record Review. Staff were not supervised effectively. During review of record 1 it was noted that aide supervisory visits did not occur every 14 days. This was confirmed by the Executive Director.

Observed in Record Review. In 2 of 2 patient records reviewed, For hospices that elect to use The Joint Commission deemed status option: Law and regulation require that the hospice inform the attending physician of the availability of a summary. The summary was not provided to the physician upon the physician’s request and includes the patient's medical and health status at the time of discharge. During review of discharged records 12 and 13 it was noted that the physician had not been notified of the availability of a discharge summary or was not sent a discharge summary.This was confirmed by the Executive Director