Every finding on record at Precious Hospice, LLC

Based on record reviews, interviews, and review of policy titled ";Complaint Resolution," it was determined the hospice failed to investigate and document a complaint for one patient (P) (P1). --- Findings include: Review of the undated policy titled ";Complaint Resolution," Policy No. 227, reveals the following: Policy Statement: Precious Hospice has a complaint resolution process that is implemented whenever a complaint is received. Procedures: 4. All complaints are documented in a complaint log by the RN Clinical Supervisor no more than 5 business days from the date the complaint was first received. 5. A documented investigation is conducted by the appropriate personnel of all written or verbal complaints received by the hospice. Review of the clinical record revealed P1 was admitted to hospice on 8/7/2023. A revocation (end Medicare-covered hospice care) form was signed on 6/18/2024 with an effective date of 6/28/2024. Review of the form titled ";Revocation of the Hospice Benefit" reveals hospice benefit revoked (end Medicare-covered hospice care) because of ";safety concerns for my (family member), failure to provide supplies and equipment." Review of the agencys complaint log for 2024 year to date reveals the complaint log failed to contain an entry related to this complaint. Family of P1 provided email dated 5/31/2024 revealing the familys complaints regarding supplies and care provided by the hospice and notes the request to revoke services effective 6/28/2024. On 9/3/2024 at approximately 1:10 pm, a telephone interview with a family member of P1 revealed multiple complaints and ongoing concerns regarding supplies and care provided by the agency. Family member further revealed she sent multiple texts regarding her complaints to the Administrator before revoking hospice. On 9/4/2024 at approximately 1:15 pm, an interview with the Administrator confirmed the complaint from P1 was not logged as a complaint and that all documentation had been provided.

Based on record reviews and staff interviews, it was determined the hospice failed to develop an individualized plan of care that includes all services necessary for the management and palliation of the terminal illness and related conditions for two patients (P) (P1, P2) of five sampled patients. --- Findings include: 1. Record review reveals P1 was admitted to hospice on 6/28/2023 and revoked (end Medicare-covered hospice care) 6/28/2024. The clinical record failed to reveal a medication profile for the patient. Review of document titled ";Palliative Drug Care Billing Report", dated May 2024 reveals two medications were dispensed to the patient on 5/20/2024 as follows: • E kit (a small supply of medications that is kept in a patient's home to treat symptoms that may occur) • Hyoscyamine (a drug that reduces the amount of sweat, saliva, and stomach acid your body makes, used in hospice to help control secretions). 2. P2 was admitted to hospice on 8/25/2023 and revoked on 6/7/2024. A review of the clinical record failed to reveal a medication profile for the patient. Review of documents titled ";Palliative Drug Care Billing Report," dated April and May 2024 reveals medication Alprazolam (a medication used to treat anxiety) was dispensed by the pharmacy on 4/3, 4/18, and 5/22/2024. Interview with the Director of Nursing (DON) on 9/3/2024 at approximately 2:00 pm confirmed the clinical records for P1 and P2 failed to reveal medication profiles.

Based on clinical record reviews and staff interview, it was determined the hospice failed to generate a hospice discharge summary for four patients (P) (P1, P2, P3, P6) of six discharged patients reviewed. --- Findings include: 1. Review of clinical records reveals P1 was admitted to hospice on 6/28/2023 and revoked on 6/28/2024. A review of the clinical record failed to reveal a discharge summary. 2. Review of clinical records reveals P2 was admitted to hospice on 8/25/2023 and revoked on 6/7/2024. A review of the clinical record failed to reveal a discharge summary. 3. Review of clinical records reveals P3 was admitted to hospice on 3/25/2024 and revoked on 7/4/2024. A review of the clinical record failed to reveal a discharge summary. 4. Review of clinical records reveals P6 was admitted to hospice on 3/20/2024 and was discharged on 4/19/2024. A review of the clinical record failed to reveal a discharge summary. On 9/4/2024 at approximately 1:15 pm, an interview with the (Director of Nursing) DON confirmed the records lacked discharge summaries.

Based on review of policy titled, ";Precious Hospice Emergency Preparedness Plan," record review, and staff interview, it was determined the hospice failed to develop an emergency preparedness plan based on a documented risk assessment utilizing an all-hazards approach. The emergency preparedness plan lacked a documented risk assessment. --- Findings include: Review of policy titled, ";Precious Hospice Emergency Preparedness Plan," revised 2/21/2019, failed to reveal a provision for completing and documenting a facility-based and community-based all hazards risk assessment. Review of documents in binder labeled ";Emergency Plan" failed to reveal a risk assessment for the agency and surrounding community. On 7/3/2024 at approximately 10:00 am, an interview with the Administrator confirmed no risk assessment had been completed as part of the emergency plan.

Based on review of policy titled, ";Precious Hospice Emergency Preparedness Plan," record review, and staff interview, it was determined the hospice failed to conduct exercises to test the emergency plan at least annually. The hospice failed to conduct emergency drills to test the emergency plan. --- Findings include: Review of the policy titled, ";Precious Hospice Emergency Preparedness Plan," revised 2/21/2019, failed to reveal a procedure for regular testing of the emergency plan. Review of documents in binder labeled ";Emergency Plan" failed to reveal emergency plan testing exercises. On 7/3/2024 at approximately 10:00 am, an interview with the Administrator and Director of Nursing (DON) confirmed no exercises testing the emergency plan had been conducted.

Based on clinical record reviews and staff interview, it was determined the hospice failed to include a qualified Chaplain/spiritual counselor and a qualified Social Worker (SW) in the interdisciplinary group (IDG) meetings for ten patients (P) (P1, P2, P4, P5, P6, P7, P8, P9, P10, P12) of 16 sampled patients. Additionally, IDG meeting notes failed to reveal signatures from the Social Worker or chaplain. --- Findings include: Review of documents titled ";Plan of Care/ IDG Review" dated 6/20/2024, for P1, P2, P4, P5, P6, P7, P8, P9, P10, P12 failed to reveal signatures (indicating participation in the IDG meeting) of a Chaplain or SW. On 7/2/2024 at approximately 2:00 pm, an interview with the Administrator and Director of Nursing (DON) revealed the hospices only Chaplain is out, and the only SW has been out. No other chaplain or SW was employed or available to cover ongoing needs of patients. The Administrator and DON confirmed the IDG meeting lacked the required SW and Chaplain.

Based on record reviews, and staff interview, it was determined the hospice failed to document what performance improvement projects (PIPs) are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. --- Findings include: Review of records failed to reveal PIPs conducted and the measurable progress achieved. On 7/2/2024 at 3:00 p.m., an interview was conducted with the Administrator in a conference room revealed that the Director of Nursing (DON) resigned, and PIPs were not done. The Administrator said he just hired a new DON.

Based on review of the policy titled, ";Bereavement Services," staff interview, and clinical record reviews, it was determined the hospice failed to develop a bereavement plan of care with bereavement services to be offered and the frequency of services for three patients (P (P13, P14, P16) of three sampled bereavement records. --- Findings include: Review of the undated policy titled ";Bereavement Services," #39, reveals the following: Procedure: 4. A bereavement assessment and plan of care will be completed for each family at the time of admission. 5. Within two (2) weeks of the patients death. 1. P13 was admitted to hospice on 3/8/2024 with a date of death of 4/1/2024. A review of the Interdisciplinary Care Plan failed to reveal specific plans of care for the identified bereaved that included services to be offered and the frequency of delivery of those services. 2. P14 was admitted to hospice on 5/4/2024 with a date of death of 5/19/2024. A review of the Interdisciplinary Care Plan failed to reveal specific plans of care for the identified bereaved that included services to be offered and the frequency of delivery of those services. 3. P16 was admitted to hospice on 4/16/2024 with a date of death of 5/1/2024. A review of the Interdisciplinary Care Plan failed to reveal specific plans of care for the identified bereaved that included services to be offered and the frequency of delivery of those services. On 7/2/2024 at 3:15 p.m., an interview with the Administrator revealed that bereavement care plans and documentation were not done, but the services were provided to patients and patients families.

Based on record reviews, and staff interview, it was determined the hospice Registered Nurse (RN) failed to make an on-site 14 days supervisory visit to the patient's home for one Patient (P) (P6) of 16 sampled patients. --- Findings include: P6 was admitted to hospice service on 5/15/2024. Review of ";Physician Order" revealed hospice aide will visit two times per week and two as needed. Registered Nurse (RN) AA failed to complete a supervisory visit during June 2024. On 7/2/2024 at 1:45 p.m., an interview was conducted with RN AA revealed that he has no reason he did not conduct 14 days supervisory visits during the month of June 2024.

Based on review of policy titled ";Cost-Saving Documentation," and staff interview, it was determined the hospice failed to document cost savings achieved through the use of volunteers. --- Findings include: A review of the facility's undated policy titled ";Cost-Saving Documentation", Policy 509, reveals the following: Procedure: The Precious Hospice will: 1. PH shall use volunteers under the supervision of the Volunteer Coordinator/Administrator. 2. Employees and volunteers will submit their productivity logs to the Administrator on a bi-weekly basis. 3. PH will maintain copies of all productivity logs at the office. 4. PH will receive a summary of the productivity reports from the volunteer coordinator which will provide the office with the total direct time put in by employees as well as the total number of hours put in by volunteers. 5. The Volunteer Coordinator will calculate the cost savings by adding up all the volunteer hours and dividing this number by the total number of direct hours provided by paid employees. On 7/1/2024 at 3:08 p.m., an interview was conducted with the Administrator at the conference room revealed the hospices Volunteer Coordinator position is currently filled by the Administrator. The Administrator revealed was unfamiliar with volunteer cost savings report requirements or calculations and was unable to provide any cost savings reports.

Based on review of policy titled ";Cost-Saving Documentation," and staff interview, it was determined the hospice failed to provide records on the use of volunteer for day-to-day administrative or direct patient care services in an amount that at a minimum equals 5% of the total patient care hours. --- Findings include: A review of the undated policy titled ";Cost-Saving Documentation", Policy 509, reveals the following: Hospice Agency shall maintain a consistent volunteer program to provide direct patient care or administrative duties in the amount that is at least equal to 5% of the total patient care hours of all salaried hospice employees. The Hospice Agency will document the cost savings achieved through the usage of volunteers on a monthly basis and conclude at the end of the fiscal year. The Hospice Agency will document ongoing efforts to recruit and retain volunteers that will be kept in a cost savings book. Procedure: 8. Volunteer staff will be sufficient to provide administration support or direct patient care in an amount that equals 5% or more of the total patient care hours of all paid employees and contract staff. Hospice agency failed to provide volunteer day-to-day administrative or direct patient care services in an amount that at a minimum equals 5% of the total patient care hours. On 7/1/2024 at 3:08 p.m., an interview was conducted with the Administrator at conference room revealed the hospices Volunteer Coordinator position is currently filled by the Administrator. The Administrator was unable to meet 5% due to difficulty in hiring someone to occupy volunteer coordinator and volunteer position.

Based on record reviews, and staff interviews, it was determined the hospice governing body failed to assume responsibility for the management of the hospice and the provision of all hospice services including the records on the use of volunteer for administrative or direct patient care services to meet 5%, develop a bereavement plan of care for three patients (P) (P13, P14, P16), no record of performance improvement projects (PIP), 14 day Registered Nurse supervisory visits for one patient (P6), and cost savings achieved through the use of volunteers. --- Findings include: 1. Hospice agency failed to provide volunteer day-to-day administrative or direct patient care services in an amount that at a minimum equals five percent of the total patient care hours. Refer to L0647 as it relates to level of activity. 2. P13 was admitted to hospice on 3/8/2024 with a date of death of 4/1/2024. A review of the Interdisciplinary Care Plan failed to reveal specific plans of care for the identified bereaved that included services to be offered and the frequency of delivery of those services. P14 was admitted to hospice on 5/4/2024 with a date of death of 5/19/2024. A review of the Interdisciplinary Care Plan failed to reveal specific plans of care for the identified bereaved that included services to be offered and the frequency of delivery of those services. P16 was admitted to hospice on 4/16/2024 with a date of death of 5/1/2024. A review of the Interdisciplinary Care Plan failed to reveal specific plans of care for the identified bereaved that included services to be offered and the frequency of delivery of those services. Refer to L0596 as it relates to counseling services. 3. On 7/2/2024 at 3:00 p.m., an interview was conducted with the Administrator in a conference room revealed that the Director of Nursing (DON), resigned and PIPs was not done. The Administrator said he just hired a new DON. Refer to L0573 as it related to Performance Improvement Projects 4. Review of care plan ";Physician Order" revealed hospice aide will visit two times per week and two as needed ordered. Registered Nurse (RN) AA failed to do complete a supervisory visit during June 2024. Refer to L0629 as it relates to Supervision of Hospice Aides 5. On 7/1/2024 at 3:08 p.m., an interview was conducted with the Administrator at the conference room revealed the hospices Volunteer Coordinator position is currently filled by the Administrator and was unfamiliar with volunteer cost savings report requirements or calculations and was unable to provide any cost savings reports. Refer to L0646 as it relates to cost saving.

Based on clinical record review and staff interview, it was determined the hospice failed to ensure the Medical Director or designee provided an initial written certification stating that the patients life expectancy is six months or less for three patients (P) (P4, P5, P6) of 16 sampled patients. --- Findings include: 1. P4 was admitted to hospice on 3/14/2024. The clinical record failed to reveal an initial certification by the physician. 2. P5 was admitted to hospice on 5/27/2024. The clinical record failed to reveal an initial certification by the physician. 3. P6 was admitted to hospice on 5/15/2024. The clinical record failed to reveal an initial certification by the physician. On 7/2/2024 at approximately 1:00 pm, an interview with the Director of Nursing (DON) and Administrator confirmed that the written certifications were not in the clinical records. The DON revealed the physician was behind in doing certifications.