Every finding on record at Rest Haven Illiana Christian Convalescent Home, Inc

Based on record review and interview, the agency failed to ensure an emergency preparedness plan was developed and maintained to include a process for cooperation and collaboration with local, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency. The findings include: --- A review of the agencys emergency preparedness plan ,on 9/15/2023, failed to evidence documentation of collaboration with local, state, and federal emergency preparedness officials. During an interview, on 9/15/2023 at 11:36 AM, the Administrator indicated the agency had not contacted anyone for the collaboration with local, state, and federal emergency preparedness officials.

Based on record review and interview, the agency failed to ensure the emergency preparedness policy and plan included how the agency would contact local and state emergency preparedness officials if unable to contact on-duty staff and patients. The findings include: --- A review of the agencys emergency preparedness, plan on 9/15/2023, failed to evidence a plan to contact local and state emergency preparedness officials if unable to contact on-duty staff and patients. During an interview, on 9/15/2023 at 12:23 PM, the Administrator indicated the plan did not include contacting the local and state emergency preparedness officials, if unable to contact on-duty staff and patients.

Based on record review and interview, the agency failed to ensure the emergency preparedness policy and plan included contacting local and state emergency preparedness officials of patients in need of evacuation for 1 of 1 hospice. The findings include: --- Review of the agencys emergency preparedness plan on 9/15/2023, failed to evidence the policy included the agencys responsibility for contacting local and state emergency preparedness officials of patients in need of evacuation. During an interview on 9/15/2023, at 12:30 PM, the Administrator indicated the policy did not include contacting the local and state emergency preparedness officials of patients in need of evacuation.

Based on record review and interview, the agencys communication plan failed to include the contact information for the agency volunteers. The findings include: --- Review of the agencys emergency preparedness communication plan on 9/15/2023, failed to evidence contact information for the agency volunteers. During an interview on 9/15/2023, at 11:55 AM, the Administrator indicated the contact information for volunteers was not included in the communication plan.

Based on record review and interview, the hospice agency failed to ensure services and visits were provided as ordered on the plan of care for 3 of 8 active clinical records reviewed where hospice aide services were received (Patient #4, #5, #12). The findings include: --- 4. Clinical record review on 9/17/2023, for Patient #12, evidenced an agency document titled ";Hospice Plan of Care" for certification period 7/14/2023-10/11/2023, which indicated the agency was to provide skilled nursing services 2 times a week for 12 weeks and hospice aide services 1 time a week for 12 weeks. Review failed to evidence the agency provided skilled nursing 2 times and hospice aide 1 time during the week of 9/3/2023 as directed by the plan of care. Review of an agency document titled ";Skilled Nursing Visit Note" signed by the registered nurse and dated 9/4/2023, indicated the visit was rescheduled due to the holiday. Review failed to evidence for what date the visit was rescheduled and failed to evidence when the rescheduled visit was completed. Review of an agency document titled ";Aide Visit Note" signed by the hospice aide and date of visit of 9/6/2023, indicated the facility where the patient resided did not have hot water to bathe the patient. During an interview on 9/18/2023, at 10:03 AM, the Administrator indicated the nurse should have rescheduled the missed visit for later in the week and indicated a second visit was not provided during the week of 9/3/2023. At 10:08 AM, the Administrator indicated the aide did not complete a visit during the week of 9/3/2023. 1. Record review of an agency policy titled ";The Plan Of Care" revised March 2023, stated ";A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process ...." 2. Clinical record review on 9/15/2023, for Patient #4, election sate 7/27/2023, evidenced a document titled ";Hospice Plan of Care" for certification period 7/27/2023 – 10/24/2023, which indicated the frequencies for the Hospice Aide were ordered once a week for 12 weeks. Record review evidenced missed visits for the Hospice Aide on 8/1/2023, 8/9/2023, 8/15/2023, 8/25/2023, 9/1/2023, and 9/5/2023. Record review failed to evidence Hospice Aide services were provided as ordered on the plan of care. Review failed to evidence the physician was notified of missed visits which deviated from the plan of care. During an interview on 9/18/2023, at 10:19 AM, the Administrator indicated physician notification should be mentioned in a communication note but did not exist upon review. 3. Clinical record review on 9/15/2023, for Patient #5, election sate 6/20/2023, evidenced a document titled ";Hospice Plan of Care" for certification period 6/20/2023 – 9/17/2023, which indicated the frequencies for Skilled Nursing and the Hospice Aide were ordered twice a week for 12 weeks. Record review evidenced missed visits for the Skilled Nurse on 7/6/2023, and 9/4/2023. Record review failed to evidence Skilled Nursing services were provided as ordered on the plan of care, without physician notification. Record review evidenced missed visits for the Hospice Aide on 7/24/2023, and 9/5/2023. Record review failed to evidence Skilled Nursing services were provided as ordered on the plan of care, without physician notification. During an interview on 9/18/2023, at 10:20 AM, the Administrator indicated the clinicians should have documented attempts to reschedule visits and physician notification.

Based on record review and interview, the hospice agency failed to ensure a discharge/transfer summary sent to the receiving facility and physician per agency policy for 1 of 1 clinical records reviewed where a patient was transferred to an inpatient facility (Patient #6). The findings include: --- A record review of an agency policy titled ";Discharge from Hospice Program" revised October 2016, stated ";Procedure ... 3. When a patient is discharged, transferred, or referred to another organization relevant information may include: ... B. Summary of the care provided and progress toward achieving goals, including both positive and adverse patient responses to treatment or services ... 8. A copy of the discharge summary will be sent to the attending physician ...." A record review of an agency policy titled ";Transfer/Referral Criteria and Process" revised April 2020, stated ";Transfer/Referral Criteria ...The patient may be transferred/referred only for the following reasons ... 1. A change in condition requiring emergent care, hospitalization, or placement in an alternate care setting ... Procedure ... 6. Upon notification of the patients transfer, the clinician will complete a transfer summary ...." A clinical record review for Patient #6 evidenced an election date 5/27/2023, and was transferred to an inpatient hospice facility on 5/30/2023. The record failed to evidence a discharge or transfer summary was provided to the receiving provider until 6/13/2023, 14 days post transfer. During an interview on 9/18/2023, at 10:25 AM, the Administrator indicated the discharge/transfer summary should have been sent to the physician and receiving facility on the day of transfer. The Administrator indicated the clinician missed the mark for sending the discharge/transfer summary timely for this patient.