Every finding on record at Scope Health Care Services, Inc.

Observed in Tracer Activities. The Hospice Surveyor noted the Emergency Operations Plan had been generic and not individualized to the agency and its specific needs. The Administrator/DOPCS had not been able to speak to the different potential emergencies and actions.

Observed in Tracer Activities. The Hospice Surveyor had been unable to validate the HCO had conducted a test of their Emergency Management Plan including the use of a call tree, as the information had not been made available during the survey.

Observed in Tracer Activities. The Hospice Surveyor had been unable to validate a table top emergency exercise had occurred. There had been written information present; however, there had been no documented discussion with questions, and there had been no attendance sheet to document who had been present. This was validated with the Administrator/DOPCS.

Observed in Record Review. In 11 of 11 patient records reviewed, the Hospice Surveyor noted the Plan of Care (POC) goals had not been specific nor measurable. Examples include: for infection: Infection will resolve with completion of treatment, for Neuro: Patient episodes of confusion will be managed with intervention and medication, for falls: No fall episode, for weakness: Increase strength/energy for optimal functional activities. This was validated with the Administrator/DOPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the Hospice Surveyor noted the Hospice Aide (HA) Plan of Care (POC) had not been updated with the most current care requirements. HOS HV #2, the HA POC indicated the patient had a shoulder immobilizer with orders to: keep right shoulder immobilizer in place , coaptation splint right upper arm , elevate right upper arm /hand with pillow to minimize further swelling to affected area. The patient no longer had a shoulder immobilizer on; however, HA orders had not been updated. This was validated with the Administrator/DOPCS Observed in Record Review. In 1 of 11 patient records reviewed, the Hospice Surveyor noted medication orders with titration based on patient symptoms that had not contained specific parameters for the titration. HOS RR #7, the patient had 2 different doses of Morphine ordered for the same symptoms: Morphine concentrate 100mg/5ml 0.25ml every one hour as needed for severe pain/shortness of breath and Morphine Concentrate 100mg/5ml 0.25 ml every 4 hours as needed pain/shortness of breath. This was validated with the Administrator/ DOPCS.

Observed in Record Review. In 4 of 11 patient records reviewed, the Hospice Surveyor noted the patient plan of care had not been followed. HOS RR #4, the spiritual care provider had orders to see the patient once per month; however, there had been no documentation in January that a visit occurred. HOS RR #5, the Hospice Aide had orders to see the patient 2 times per week; however, the HA only documented 1time per week visits for the first two weeks of February. HOS RR #6, the SC had orders to see the patient monthly, but there had been no documented visit for the month of December. HOS RR #10, the HA had orders for 2 times a week; however, there had been no visits documented for the first week of August. This was validated with the Administrator/DOPCS. Observed in Record Review. In 1 of 3 patient records reviewed, where the family had a bereavement plan of care, the Surveyor had been unable to validate that the plan of care was followed. BR #2 patient expired in September. There had been initial contact and a 1 month follow up, but no documentation that a 3 month letter had been sent. This was validated with the Administrator/DOPCS.

Observed in Patient Home. In 2 of 3 home visits conducted, the Hospice Surveyor noted the equipment utilized during the patient care visits had not been disinfected according to HCO policy prior to returning to the clinical bag. During HV #1, the clinician utilized assessment tools, then placed them on a barrier. The tools were then cleaned and put back on the dirty barrier then transferred into the clinical bag. HV #2, the clinician had not utilized any barriers and set equipment down on a visibly dirty table. The equipment was then used on the patient, cleaned and put back on the dirty table, then transferred into the open clinical bag. The same clinician had not cleaned any inanimate objects utilized during the visit either. For example, the tablet case, cell phone and folder that had been set on the dirty table and were placed into the clinical bag. . This was validated with the Administrator/DOPCS. Observed in Patient Home. In 2 of 3 home visits conducted, the Hospice surveyor noted the HCO had not implemented its infection control policy no 9-009.1 Bag Technique. HOS HV #1 and HOS HV #2 the clinicians both had a single compartment clinical bag without a designated clean and dirty compartment. This was validated with the Administrator/DOPCS

Observed in Tracer Activities. The HCO could not provide evidence that they had been actively monitoring their hand hygiene program. The hand hygiene program had not been updated since 2020, and no active surveillance activities had been present since that time. This was validated with the Administrator/DOPCS.

Observed in Tracer Activities. The Hospice Surveyor noted no volunteer recruitment activities since April 2022. Discussed with the Administrator/DOPCS and she reported none had happened due to Covid; however there had been recruitment activities prior to 4/2022.

Observed in Tracer Activities. The Hospice Surveyor noted no documentation of cost savings from implementation of the volunteer program as no volunteer hours had been recorded. This was validated with the Administrator/DOPCS

Observed in Tracer Activities. The Hospice Surveyor noted no documentation of volunteer hours so the 5% savings related to the implementation of the volunteer program had not been met. This was validated with the Administrator/DOPCS.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.100 and §418.113, §418..60, §418.78.

Observed in HR File Review. In 6 of 9 HR files reviewed, the Hospice Surveyor had been unable to validate initial and ongoing competency completion for field clinicians. HR #2, HR #5, HR #6, HR #7, HR #8 and HR #9 had incomplete competencies as the competency had one date and then a line down the page. This was validated with the Administrator/SOPCS. HCO failed to document initial competencies demonstrating staff knowledge of emergency procedures.

Observed in Patient Home. In 2 of 3 home visits conducted, the Hospice Surveyor noted that the Mediction list in the EMR had not accurately reflected the medications the patient was being administered. HOS HV #1, the patient had been administered Multiple vitamins, Vitamin C and Vitamin D which had not been included on the EMR list. HOS HV #2, the patient was being administered MiraLAX by the care givers; however this had not been on the medication profile. This was validated with the Administrator/DOPCS