Every finding on record at Northpoint Hospice LLC

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes initial training in EP policies and procedures consistent with their expected roles for all new hospice employees and those providing services under arrangement. This standard was not met as evidenced by interview and personnel record review. In 1 of 9 (11%) personnel records reviewed revealed the hospice did not ensure that new employees and those providing services under arrangement received emergency preparedness training upon hire. Personnel Record 9: The personnel record (medical director, hire date 1/2/2022) was reviewed and did not contain evidence of emergency preparedness training. The executive director was interviewed on 8/17/2023 and agreed, there was no documented emergency preparedness training within the record identified. In 1 of 9 (11%) personnel records reviewed revealed the hospice did not ensure that new employees and those providing services under arrangement received emergency preparedness training upon hire.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by interview and personnel record review. In 1 of 9 (11%) personnel records reviewed revealed the hospice did not ensure that employees and contracted providers received education in infection control. Personnel Record 9: The personnel record (Medical Director, date of hire 1/2/2022) was reviewed and did not contain evidence of education in infection control. The executive director was interviewed on 8/17/2023 and agreed, there was no documented infection control training within the record identified. In 1 of 9 (11%) personnel records reviewed revealed the hospice did not ensure that employees and contracted providers received education in infection control.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 1 of 12 (8%) records reviewed in which a hospice aide plan of care was in place revealed the agency did not ensure the hospice aide reported changes in the patient's nursing needs. Clinical Record 2: Patient’s benefit election was dated 6/30/2023. The hospice aide care plan dated 6/30/2023 directed the HA to provide a shower and shampoo. On the patient visit dated 7/5/2023, the HA documented that the "patient refused to shower and shampoo" and that "she did shower last night." There was no documentation as to why the shampoo was not provided or that the RN was notified that the HA did not provide the assigned tasks. On 8/15/2023, the executive director confirmed that the HA did not notify the RN that she did not perform the shower and shampoo. In 1 of 12 (8%) records reviewed in which a hospice aide plan of care was in place revealed the hospice aide (HA) did not notify the RN when they were unable to or did not provide assigned tasks that were indicated on the hospice aide plan of care.

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 CONDITION was not met as evidenced by clinical record review document review and interview the hospice agency failed to use volunteers in day-to-day administrative and/or direct patient care roles [HCDT.21.I /L644]; to document the cost savings achieved through the use of volunteers [HSLG.7.I /L646] and did not maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked [HSLG.7.I /L647]. The failure by the hospice to offer and provide volunteer services impacted the agency's ability to ensure the provision of quality patient care. This is a CMS CONDITION LEVEL DEFICIENCY at 418.78

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care and documented in the patient record. This standard was not met as evidenced by clinical record review and interview. In 7 of 14 (50%) clinical records reviewed, there was no evidence that a volunteer was offered and/or the patient declined volunteer services. Clinical Record 1: The patient’s benefit election was dated 1/2/2023. There was no documentation that a volunteer was offered/declined. Clinical Record 2: The patient’s benefit election was dated 6/30/2023. On 7/31/2023, a request was made for a volunteer. As of 8/17/2023, no volunteer had been assigned to the patient. Clinical Record 6: The patient’s benefit election was dated 5/18/2023. There was no documentation that a volunteer was offered/declined. Clinical Record 8: The patient’s benefit election was dated 5/19/2023. There was no documentation that a volunteer was offered/declined. Clinical Record 10: The patient’s benefit election was dated 8/12/2023. There was no documentation that a volunteer was offered/declined. Clinical Record 11: The patient’s benefit election was dated 11/26/2022. There was no documentation that a volunteer was offered/declined. Clinical Record 12: The patient’s benefit election was dated 2/17/2023. There was no documentation that a volunteer was offered/declined. On 8/15/2023, the executive director confirmed that there was no documentation that volunteers were offered. On 8/17/2023, the executive director confirmed that they do not have volunteers. She stated she spoke with their corporate CNO yesterday who said she thought they" didn't have to have volunteers during COVID." The executive director confirmed that she was "under the same impression that we didn't have to have volunteers during COVID." In 7 of 14 (50%) clinical records reviewed, there was no evidence that a volunteer was offered and/or the patient declined volunteer services.

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. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions and, the estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions. This standard was not met as evidenced by document review and interview. In 1 of 1 (100%) document reviewed revealed the hospice did not ensure that volunteers were provided for direct patient care service/administrative roles, or that cost savings was achieved by volunteers in these roles. Document 1: The hospice volunteer cost savings report (beginning January 2023-survey date of 8/17/2023) was reviewed and revealed that the hospice did not document volunteer positions or time spent in the position. The document further revealed documentation of 0% cost savings. On 8/17/2023, the executive director confirmed that they did not have a volunteer. She stated she spoke with their corporate CNO yesterday who said she thought they "didn't have to have volunteers during COVID." The executive director confirmed that she was "under the same impression that we didn't have to have volunteers during COVID." She also confirmed that currently they do not have any volunteers as part of the hospice team. She stated, "we have 2 in the queue, but they have not been onboarded." In 1 of 1 (100%) document reviewed revealed the hospice did not ensure that volunteers were provided for direct patient care service/administrative roles, or that cost savings was achieved by volunteers in these roles.

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 must maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked. This standard was not met as evidenced by document review and interview. Document 1: The hospice volunteer cost savings report (beginning January 2023-survey date of 8/17/2023) was reviewed and revealed that the hospice did not document the use of volunteers, the type of position (direct care or administrative) they occupied, or time worked. On 8/17/2023 the executive director confirmed they had been documenting 0% as they have not had any volunteers since they lost them all "during COVID."

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. This standard was not met as evidenced by personnel record review. In 1 of 9 (11%) personnel records reviewed revealed the hospice did not ensure that a competency assessment was completed on hire. Personnel Record 9: The personnel record (medical director, hire date 1/2/2022) was reviewed and did not contain documentation of a competency assessment. The executive director was interviewed on 8/17/2023 and confirmed there was no documented competency assessment within the record identified. In 1 of 9 (11%) personnel records reviewed revealed the hospice did not ensure that a competency assessment was completed on hire.