Every finding on record at Pearl Hospice LLC

A. Based on Agency's Emergency Preparedness Plan review and staff interview it was determined that the Hospice failed to ensure the Emergency Plan contains a communication plan that includes the names and contact information of staff, volunteers and patients' physicians. --- Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 11/30/22 at 1:00PM. The Emergency Plan did not include a communication plan. 2. During an interview with the Administrator and Assistant Administrator on 12/01/22 at 11:30 AM, finding of the Agency's Emergency Plan not containing a communication plan was confirmed.

A. Based on Hospice Emergency Preparedness Plan review and staff interview it was determined that Hospice failed to conduct testing of the Emergency Plan since 2019. --- Findings include: 1. The Hospice Emergency Preparedness Plan was reviewed on 11/30/2022 at 1:00 PM. The Emergency Plan did not include evidence that Hospice conducted any testing of the Emergency Plan since 2019. 2. During an interview with the Administrator and Assistant Administrator on 12/01/2022 at 11:30 AM, the finding of the Hospice failing to conduct testing since 2019 of the Emergency Plan was confirmed.

A. Based on home visit interview, clinical record review and staff interview it was determined that Hospice failed to maintain ongoing communication between all disciplines involved in patient care. This was found in 1 of 2 home visits. (Pt #1) --- Findings include: 1. Pt. #1 SOC 11/15/2022 Diagnosis: Prostate CA. A SN home visit was conducted on 11/30/2022 at 10:00 AM. During the home visit interview the SN stated that currently patient is only receiving SN services, and patient declined Aide services. The clinical record for patient #1 was reviewed on 11/30/2022 at 12:00 PM. The clinical record contained Aide visit notes dated 11/22/2022 and 11/25/2022. 2. During an interview with the Administrator and Assistant Administrator on 12/01/2022 at 11:30AM it was confirmed that Hospice staff failed to maintain ongoing coordinated communication.

A. Based on the review of Governing Body minutes and Staff interview, it was determined the Governing Body failed to approve the data collection, frequency and details. --- Findings include: 1. The Governing Body minutes were reviewed on 11/29/22 at 2:20 PM. The minutes lacked documentation that the Governing Body approved the data collection, frequency and details of the Hospice QAPI projects. 2. The above finding was confirmed with the Hospice Administrator on 11/29/22 at 2:30 PM.

A. Based on the review of the QAPI documents and Staff interview, it was determined the Hospice failed to track/analyze adverse events and implement preventive actions. --- Findings include: 1. The QAPI documents were reviewed on 11/29/22 at 2:20 PM, and lacked documentation to track/analyze adverse events and implement preventive actions. 2. The above finding was confirmed with the Hospice Administrator on 11/29/22 at 2:30 PM.

A. Based on the review of the bereavement record, policy review and Staff interview, it was determined the Hospice failed to provide and document the bereavement plan of care and services offered/available for 12 months following the patients death. This was found in 1 of 1 (Pt. #3) bereavement records reviewed. --- Findings include: 1.Pt. #3 SOC 08/27/20 Terminal Diagnosis: Chronic diastolic (congestive) heart failure. On 11/30/22 at 12:30 PM, the bereavement record of Pt.#3 was reviewed and lacked documentation of the bereavement plan of care (death reported on 06/07/21). The bereavement record lacked the 12 month documentation that the services were offered as required by the Hospice policy, following the patient's death. 2. On 11/30/22 at 12:30 PM, the Hospice bereavement policy titled "Bereavement Program" was reviewed and required 12 months of services: Bereavement progress note, 1 week mailing, 2 week mailing, 2 week packet, 1 month phone call, 3 month phone call, 6 month letter and mailing packet, 9 month call and letter, 12 month letter, ";Bereavement Program Satisfaction Survey".... 3.The findings regarding the lack of bereavement services provided were confirmed with the Hospice Assistant Administrator/ Bereavement Coordinator, on 12/01/22 at 10:45 AM.

A. Based on the review of the Hospice documents and Staff interview, it was determined the Hospice failed to provide and document training and orientation for the Volunteers. --- Findings include: 1. The Hospice Volunteer documents were reviewed on 11/29/22 at 12:00 PM and lacked documentation of the Volunteer training and orientation. During the interview with the Volunteer Coordinator, on 11/29/22 at 12:10 PM, it was stated that the Hospice has not yet oriented any volunteers. 2. The above findings were confirmed with the Hospice Administrator on 11/29/22 at 1:00 PM.

A. Based on the review of the Hospice documents and Staff interview, it was determined the Hospice failed to document use in the day to day administrative or direct patient care roles for the Volunteers. --- Findings include: 1. On 11/29/22 at 12:10 PM, the Hospice Volunteer Coordinator presented a list of potential volunteers. During the interview with the Volunteer Coordinator, on 11/29/22 at 12:10 PM, it was stated that the Hospice has a list of 3 Volunteers but lacked documentation of the Volunteer roles (patient care or administrative). 2. The above findings were confirmed with the Hospice Administrator on 11/29/22 at 1:00 PM.

A. Based on Staff interview, it was determined the Governing body failed to designate an alternate physician to serve as hospice physician designee in the absence of the medical director. --- Findings include: 1. During the interview with the Medical Director (Staff #10) on 11/30/22 at 10:30 AM, it was unclear if the Hospice had a physician designee to serve in the absence of the Medical Director. 2. The findings regarding the lack of a physician designee was confirmed with the Administrator, during the interview on 11/30/22 at 10:35 AM.

A. Based on clinical record reviews and Staff interview, it was determined the Hospice Agency failed to ensure that a written Certification of Terminal Illness was provided. This was found in 2 of 2 (Pts. #2 and #1) active clinical records reviewed. --- 2. Pt. #1 SOC 11/15/22 Diagnosis: Prostate CA. The clinical record was reviewed on 11/30/2022 at 12:00 PM as of 12/01/2022 at 10:30 AM. The clinical record lacked a written initial certification of Terminal Illness. 3. During interviews with the Administrator and Assistant Administrator on 12/01/22 between 11:00 AM and 1:30 PM, findings of the Medical Director or physician designee not completing the Certification of Terminal Illness were confirmed. Findings include: 1. Pt. #2 SOC 11/16/2022 Diagnosis: Malignant Neoplasm of Pancreas. The clinical record was reviewed on 11/30/2022 at 11:30 AM and 12/01/2022 at 11:00 AM. The record lacked a written initial certification of Terminal Illness.

A. Based on clinical records review, home visit interview, and staff interview it was determined that the Hospice failed to ensure clinical records were complete and accurate. This was found in 2 of 2 clinical records reviewed (Pts #1 and 2). --- Findings include: 1. Pt#1. SOC 11/15/2022. Diagnosis: Prostate CA. A home visit was conducted on 11/30/2022 at 10:00 AM with SN. During the home visit Pt# 1 medications were reviewed with patient caregiver. The patient caregiver stated that patient has and takes morphine 15mg tablets oral every 6 hours or as needed for pain. The clinical record for patient #1 was reviewed on 11/30/2022 at 12:00 PM. The clinical record contained a Plan of Care for certification period 11/15/2022 to 02/11/2022 that contained - Medications: Morphine 5mg every 4 hours as needed for pain. Pt# 1 clinical record also contained an incomplete and inaccurate SN assessment dated 11/15/2022. The SN assessment did not include patient diagnoses, and inaccurate GU status assessment. 2. Pt. #2 SOC 11/16/2022. Diagnosis: Malignant Neoplasm of Pancreas. The clinical record was reviewed on 11/30/2022 at 11:30 AM and 12/01/2022 at 11:30 AM. The Hospice Plan of Care dated 11/16/2022 lacked authors signature. The initial SN Assessment dated 11/16/2022 lacked the authors signature. The initial assessment lacked lacked an assessment of Pt. #2s psychosocial needs. 3. During interviews with the Assistant Administrator/Registered Nurse and Administrator/Registered Nurse on 12/01/2022 from 11:00 AM to 1:30 PM, both confirmed the above findings.