Every finding on record at S & G Hospice of Idaho, LLC

Based on staff interview and review of administrative documents and agency policies, it was determined the hospice failed to ensure an adverse event was tracked and analyzed for 1 of 3 patients (Patient #13) whose incident reports were reviewed, and had the potential to affect all hospice patients. This prevented the hospice from recognizing all incidents and adverse events and implementing measures to decrease the likelihood of repeat incidents. Findings include: An agency policy titled, "INCIDENT REPORTS," undated, stated, "An Incident Report Form is to be completed by the staff member or volunteer present at the time of the incident or taking the telephone report of the incident from a patient, family member, or caregiver." This policy was not followed. An example includes: The agency's call logs were reviewed. Incident reports were requested for 4 incidents, involving 3 patients, which were documented in the logs. One incident report for Patient #13, dated 10/26/21 and signed by the RN, stated, "ALF [Assisted Living Facility] notified that patient had another fall with no injuries." The area for the description of the incident and the agency's action taken were left blank. On 2/16/22, beginning at 1:00 PM, the Administrator and the DON were interviewed together. Patient #13's incident report was reviewed in their presence. They confirmed the report was incomplete. The agency failed to track and analyze Patient #13's incident.

Based on review of organizational charts and staff interview, it was determined the agency failed to ensure hospice physicians functioned under the supervision of the hospice Medical Director. This caused a lack of oversight from the hospice Medical Director to the branch physicians. Findings include: The organizational chart for Alliance Hospice was reviewed. The organizational chart did not include the hospice Medical Director and the other IDG physicians. The organizational charts did not show the IDG physicians reporting to a medical director. The Administrator was interviewed on 2/16/22 beginning at 3:30 PM. When asked who the Medical Director was she stated Physician A. When asked how the medical director provided oversight over the IDG physicians she stated she was not aware of any oversight provided by the Medical Director. Physician A, the listed Medical Director, was interviewed on 2/16/22 beginning at 3:00 PM. When asked what his oversight IDG physicians in the Pocatello, ID, and Gooding, ID areas, he stated he had very limited interactions and was over the Idaho Falls, ID and Blackfoot, ID areas only. When asked if he provided oversite of the IDG physicians he stated "no." Physician B, an IDG physician, was interviewed on 2/16/22 beginning at 1:00 PM When asked if he has any interactions with the Medical Director regarding oversight or overall physician services, he stated he had not had any interactions. The agency failed to ensure hospice physicians functioned under the supervision of the Medical Director.

Based on review of agency organizational chart, CFRs, agency document review, and staff interview, it was determined the agency failed to ensure organization and administration of services were conducted in a manner which provided direction and oversight of the agency's operations. This resulted in the inability of the agency to develop and maintain systems necessary for the safe and efficient operation of the hospice. Findings include: 1. Refer to L - 590 as it relates to the failure of the agency to ensure all hospice contracted physicians functioned under the supervision of the Medical Director. 2. Refer to L - 656, as it relates to the failure of the agency to obtain Medicare approval for a multiple location. 3. Refer to L - 664 as it refers to the agency's failure to ensure there was a single hospice physician to serve as medical director of the agency.

Based on observation, agency document review, CFR review, agency website review, and staff interview, it was determined the agency failed to obtain Medicare approval for multiple locations. This resulted in confusion to patients and their representatives as to agency locations which provided patient care and resources. Findings include: An agency patient brochure titled "Alliance Hospice," listed 3 agency offices located in Idaho Falls, ID, Pocatello, ID and Gooding, ID. The 3 locations had different addresses and telephone numbers. All locations were located in separate counties. The Pocatello, ID office was approximately 52 miles from the Idaho Falls location. The Twin Falls/Gooding, ID office was approximately 186 miles from the Idaho Falls location. The organizational chart for Alliance Hospice was reviewed. It included the agency Administrator over the DON for Idaho Falls, a DON for Pocatello, and DON for Twin Falls/ Gooding, ID. The agency staff was listed as "Idaho Falls Staff," "Pocatello Staff," and "Gooding Staff." The agency website was reviewed 2/14/22. Under the "Contact Us" portion of the website it included: - "Idaho Falls Location," with a corresponding address and phone number. - "Pocatello Location," with a corresponding address and phone number. - "Twin Falls location," with a corresponding address and phone number. Surveyors arrived on-site to the Pocatello office on 2/16/22, at approximately 6:00 PM. The office had prominent signage displayed including agency name, and the Pocatello, ID specific phone number. Upon direct visualization, the inside of the office had phones and a conference table. The doors were locked, and no staff were present. The DON of the Gooding/Twin Falls, ID area was interviewed on 2/16/22 beginning at 3:00 PM. When asked if she utilized an office in the Twin Falls/Gooding, ID area, she stated there is a little space they rent and there is storage supplies and a computer with a workspace to hold IDG. She stated she would come to the Idaho Falls office approximately once a year but were in regular communication through Zoom and phone calls. The DON of the Pocatello area was interviewed on 2/16/22 beginning at 3:05 PM. When asked if she utilized an office in Pocatello, she stated they had an area where they would hold staff meetings and had a storage area with a desk and place where a nurse can come in and chart. During an interview with the Administrator on 2/16/22 beginning at 3:00 PM, The Administrator confirmed signage identifying the agency was prominently displayed at the Pocatello, ID location. Additionally, the Administrator confirmed agency brochures handed out to patients and their representatives included the Gooding, ID, and Pocatello, ID office as a distinct location. She confirmed the website included separate addresses and phone numbers for locations. She stated all of the phone numbers routed through the Idaho Falls office. She stated the agency kept the numbers so when patients or local hospitals call they are not calling an out of area number. She confirmed the locations in Gooding/Twin Falls, ID, and Pocatello, ID were being advertised as a multiple location. 42 CFR 418.3 lists a multiple location as: "Multiple location means a Medicare-approved location from which the hospice provides the same full range of hospice care and services that is required of the hospice issued the certification number." It appeared through administrative review, staff interview, and definition that the agency was operating multiple locations without Medicare approval. The agency's Pocatello, ID and Twin Falls/Gooding, ID multiple locations were not approved by Medicare.

Based on review of organizational charts, review of physician contracts, and staff interview, it was determined the hospice failed to designate a single hospice physician to serve as Medical Director of the agency. This resulted in a lack of clear lines of authority, a lack of accountability, and a lack of sufficient oversight and supervision of patient care. Findings include 1. Refer to L - 590 as it refers to the agency's failure to ensure the listed Medical Director provided oversight of the other agency physicians. 2. Refer to L - 666 as it relates to the agency's failure to ensure the Medical Directors contracts specified overall Medical Director responsibilities and obligations. 3. Refer to L - 669 as it refers to the agency's failure to ensure the listed Medical Director assumed overall responsibility for the medical component of the entire hospices patient care program.

Based on review of physician contracts and staff interview, it was determined the agency failed to ensure the agency's medical director contracts specified the physician who assumed the responsibilities and obligations of the role. This failure resulted in a lack of clear lines of authority among physician staff and had the potential to interfere with quality and coordination of patient care. Findings include: An organizational chart for the provider was requested. The organizational chart did not include the hospice Medical Director and other IDG physicians. The Medical Director and additional physician contracts were requested. The agency provided a "Medical Director Contract Agreement." Additionally, the agency provided 5 contracts titled "IDG Doctor Contract Agreement," and 4 contracts titled "Hospice IDG physician Contract Agreement." The content of all the contracts were the same, with just the name of the physician and dates signed being different. The contracts did not outline specific roles and responsibilities of the Medical Director including supervision over the other 9 physicians. The 9 IDG physician contracts included: "Alliance Hospice desires to contract with IDG doctor to provide overall direction and oversite for the delivery of medical services to Alliance Hospice patients." The listed Medical Directors contract included: "Alliance Hospice desires to contract with Medical Director to provide overall direction and oversite for the delivery of medical services to Alliance Hospice patients." Physician A, the listed Medical Director, was interviewed on 2/16/22 beginning at 1:00 PM. When asked his role he stated he was the Medical Director and reviewed treatment plans for patients. He stated he was over the Idaho Falls and Blackfoot areas only, When asked what his oversight IDG physicians in the Pocatello and Twin Falls/Gooding, Idaho areas, he stated he had very limited interactions and was over the Idaho Falls and Blackfoot, ID areas only. When asked if he provided oversight of the IDG physicians he stated "no." Physician B and IDG physician was interviewed on 2/16/22 beginning at 1:00 PM When asked if he had any interactions with the Medical Director regarding oversight or overall physician services, he stated he had not had any interactions. During an interview with the Administrator on 2/16/22 beginning at 3:00 PM, she identified Physician A as the agency's single Medical Director. She stated the other IDG physicians were covering the Pocatello and Gooding, Idaho areas. She confirmed the content of the contracts were the same and the Medical Director's contract should outline his specific roles and responsibilities. The agency failed to ensure physician contracts clearly identified the Medical Director roles and responsibilities including oversight over the other agency physicians.

Based on review of organizational charts, review of physician contracts, and staff interview, it was determined the hospice failed to ensure the Medical Director was responsible for the medical component of the hospice's patient care program. This caused a lack of physician oversight of services, and had the potential to lead to poor patient outcomes. Findings include: An organizational chart for the provider was requested. The organizational chart did not include the hospice Medical Director and other IDG physicians. The Medical Director and additional physician contracts were requests. The agency provided a "Medical Director Contract Agreement." It provided 5 contracts titled "IDG Doctor Contract Agreement," and 4 contracts titled "Hospice IDG physician Contract Agreement." The content of all the contracts were the same, with just the name of the physician and dates signed being different. The contracts did not outline specific roles and responsibilities of the medical director including supervision over the other 9 physicians. It was unclear from the contracts who provided Medical Director responsibilities of the agency. The Director of Nursing over the Gooding, Idaho area was interviewed 2/16/22 beginning at 3:00 PM. When asked who the Medical Director of the agency was she stated Physician B. The Director of Nursing over the Pocatello, Idaho area was interviewed 2/16/22 beginning at 3:05 PM. When asked who the Medical Director of the agency was she stated Physician C. During an interview with the Administrator on 2/16/22 beginning at 3:00 PM, she identified the listed Medical Director, Physician A, as the agency's single Medical Director. However, confirmed the Medical Director and IDG physicians operated independently and rarely interacted. The hospice failed to ensure the listed Medical Director assumed overall responsibility for the medical component of the entire hospices patient care program.