Every finding on record at Northeast Ohio Hospice, Inc

Based on review of the agency's Emergency Preparedness Tabletop Exercises, review of agency policy and staff interview, the agency failed to conduct table top drills that were led by a facilitator which included a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan and failed to analyze the agency's response to and maintain documentation of tabletop exercises. The agency's census was 60. Findings include: Review of the agency's emergency preparedness plan's Emergency Preparedness Tabletop Drills, dated 08/20/21 and 08/24/22, revealed the drills were not led by a facilitator. There was no evidence of a group discussion using a narrated, clinically-relevant emergency scenario, set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. The agency did not analyze the response to the tabletop drills and/or revise the emergency plan, as needed. Interview on 09/01/22 at 12:11 P.M. of Staff A verified the findings. Review of agency policy titled "Emergency Preparedness/Disaster Plan," dated 06/13/17, revealed the hospice agency will conduct two Emergency Disaster Drills per year and document dates of the drills.

Based on medical record review, policy review and staff interview, the agency failed to complete the comprehensive assessment no later than five calendar days after the election of hospice care for one patient (Patient #13) of 13 current medical records reviewed. The agency's active census was 60 at the time of the survey. Findings include: Review of the medical record revealed Patient #13 elected hospice benefits on 07/02/22. The initial social worker initial comprehensive assessment was completed on 7/11/22. Review of agency policy titled "Social Work Services Overview," dated 06/13/17, revealed the Social Worker would complete the initial assessment as part of the psychosocial component of the comprehensive assessment within five days of the patient's election of hospice care unless social work services were refused by the patient or family/caregiver. Review of agency policy titled "Referral, Admission, Assessment and Establishment of Care," dated 06/13/17, revealed the comprehensive assessment was completed within five days or less of the patient's election of hospice care and was a thorough evaluation of the patient's physical, psychosocial, emotional and spiritual status. In addition the hospice social worker would completed a comprehensive assessment within five days of the patient's election of hospice benefits. Interview on 08/31/22 at 2:02 PM, Staff A and B confirmed the findings.

Based on medical record review, review of agency policy and staff interview, the agency failed to ensure initial bereavement risk assessments were completed. This affected three (#5, #7 and #16) of 13 current and three closed medical records reviewed for initial bereavement risk assessments. The agency's active census was 60 at the time of the survey. Findings include: 1. Review of the medical record for Patient #5 revealed an election of hospice benefits date of 05/05/22. The medical record did not contain an initial bereavement risk assessment. Interview on 08/30/22 at 1:20 PM, the findings were shared with Staff A and B and confirmed. 2. Review of the medical record for Patient #7 revealed an election of benefits date of 04/20/22. Additional review of the medical record revealed it did not contain an initial bereavement risk assessment. Interview on 08/30/22 at 2:20 P.M. of Staff A verified Patient #7's medical record did not contain and initial bereavement risk assessment. 3. Review of the medical record for Patient #16 revealed an election of benefits date of 07/02/21. Additional review revealed Patient #16 expired on 07/06/21. Review of the initial comprehensive nursing assessment, dated 07/02/22, revealed the initial bereavement risk assessment was not completed. Interview on 08/31/22 at 2:59 PM of Staff A and B verified an initial bereavement risk assessment was not completed for Patient #16. Review of agency policy titled "Bereavement Program Services," dated 06/13/17, confirmed the initial bereavement risk assessment was completed during the initial comprehensive nursing assessment, which was completed within forty-eight hours of the patient's hospice election. Review of agency policy titled "Referral, Admission, Assessment and Establishment of Care," dated 06/13/17, revealed the comprehensive assessment included an initial bereavement assessment of the needs of the patient, family and/or significant other individuals focusing on the social, spiritual, and cultural factors that may impact his/her ability to cope with the patient's death.

Based on medical record review, review of agency policy and staff interview, the agency failed to ensure hospice aide visits were provided at the care planned frequency for four (#4, #5, #7 and #11) of 13 current patient medical records reviewed. The agency census was 60. Findings include: 1. Review of Patient #5's plan of care for the certification period of 05/05/22 through 08/02/22 contained orders for hospice aide services two time a week. During the week of 05/15/22 only one hospice aide visit was completed. Interview on 08/30/22 at 10:07 AM, Staff B verified the finding and stated the agency did not have a back-up for the aide. 2. Review of Patient #4's plan of care for certification periods 06/14/22 to 08/12/22 and 08/13/22 to 10/11/22 revealed Patient #4 was to receive hospice aide visits one time weekly. Patient #4's hospice aide visits were missed the weeks of 07/10/22, 07/17/22 and 08/14/22. 3. Review of Patient #7's plan of care for certification periods 04/20/22 to 07/18/22 and 07/19/22 to 10/16/22 revealed Patient #7 was to receive hospice aide visits one time weekly. Patient #7's hospice aide visits were missed the weeks of 07/17/22 and 08/14/22. 4. Review of Patient #11's plan of care for certification period of 05/13/22 to 08/10/22 revealed Patient #11 was to receive hospice aide visits one time weekly. Patient #11's hospice aide visit was missed the week of 07/17/22. Interview on 08/30/22 at 8:30 AM, Staff B verified Patient #4, #7, and #11's hospice aide visits were missed due to the assigned hospice aide being on vacation and the agency did not have staff to cover those visits. Review of agency policy titled "Referral, Admission, Assessment and Establishment of Care," dated 06/13/17 revealed the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions and included the scope and frequency of services necessary to meet the specific patient and family needs.

Based on medical record review, staff interview and review of agency policy, the agency failed to provide appropriate bereavement services. This affected three (#14, #15, #16) of three patients reviewed for bereavement services. The agency's census was 60. Findings include: 1. Review of Patient #14's initial bereavement risk assessment, dated 05/04/21, revealed Patient #14 was assessed at low bereavement risk. Additional review of the medical record revealed Patient #14 expired on 07/07/21. Further review revealed no phone or visit contact was made with Patient #14's bereaved following the patient's death. 2. Review of Patient #15's initial bereavement risk assessment, dated 06/22/21, revealed Patient #15 was assessed at low bereavement risk. Additional review of the medical record revealed Patient #15 expired on 07/14/21. Further review revealed one phone call was placed to the bereaved on 07/15/21. The medical record was silent for any addition phone or visit contact with the bereaved. 3. Review of the medical record for Patient #16 revealed an election of benefits date of 07/02/21. Additional review revealed Patient #16 expired on 07/06/21. Review of the initial comprehensive nursing assessment, dated 07/02/22, revealed the initial bereavement risk assessment was not completed. Review of a communication note dated 07/06/22 revealed the agency made one phone call to the bereaved. Patient #16's medical record was silent for any additional phone or visit contact with the bereaved. Review of agency policy titled "Bereavement Program Services," effective 06/13/17, confirmed the initial bereavement risk assessment was completed during the initial comprehensive nursing assessment, which was completed within forty-eight hours of the patient's hospice election, to determine bereavement needs at the time of death. Additionally, the bereavement program consisted of intermittent phone contact beginning approximately four to six weeks following death. Interview on 08/31/22 at 2:59 PM, Staff A and B stated following a patient's death, a follow up phone call was made to the bereaved, a sympathy card sent, and mailings throughout the year. Staff A confirmed the agency policy stated bereavement services included periodic phone calls, with the initial phone call made to the bereaved at four to six weeks following the patient's death. Staff A verified Patients #15 and #16 did not receive follow up phone calls after the initial contact made at the time of death and Patient #14's bereaved had no phone or visit contact from the hospice following the Patient's death. Additionally, Staff A verified Patient #16 did not have in initial bereavement risk assessment completed during the initial comprehensive nursing assessment, per facility policy, to determine bereavement risk.

Based on volunteer record review, staff interview, and review of agency policy, the agency failed to ensure volunteers were screened annually for signs and symptoms of tuberculosis. This had the potential to affect all 60 patients of the agency. The agency census was 60. Findings include: 1. Review of the volunteer record for Staff H revealed a completed orientation dated of 03/01/18. Additional review revealed Staff H completed two step mantoux tuberculin (TB) testing on 03/19/18. The record contained no evidence of any annual TB screenings being completed. 2. Review of the volunteer record for Staff J revealed a completed orientation date of 04/15/19. Additional review revealed Staff I completed two step mantoux TB testing on 04/03/19. The record contained no evidence of any annual TB screenings being completed. 3. Review of the volunteer record for Staff K revealed a completed orientation date of 03/01/18. Additional review revealed Staff K completed two step mantoux TB testing on 05/17/18. The record contained no evidence of any annual TB screenings being completed. 4. Review of the volunteer record for Staff L revealed a completed orientation date of 05/01/19. Additional review revealed Staff L completed two step mantoux testing on 03/20/19. The record contained no evidence of any annual TB screenings being completed. Interview on 09/01/22 at 12:22 PM, Staff A confirmed Staff H, J, K and L were actively volunteering with patients. Staff A verified Staff H, J, K and L had not received annual screenings for TB. Review of agency policy titled "Screening Staff Members for Tuberculosis," dated 06/13/17, confirmed all staff members, office staff or contractors who had, or expected to have, direct consumer contact must update their screening documentation to determine if the staff member had exposure to active TB or their risk had changed. The screening documentation was to be completed not less than every 12 months, with the 12 month period running from the date of the last evaluation.