Every finding on record at Ssm Health at Home Hospice

Based on record review and interview this agency failed to conduct a full-scale community-based exercise of the emergency plan at least bi-annually, in 1 of 1 Emergency Preparedness Programs reviewed. --- Findings include: During an interview with Substitute Administrator B on 06/19/2024 at 1:00 PM, Substitute Administrator B was asked about the agency's Emergency Preparedness drills and exercises. Substitute Administrator B stated that B would continue to look for this missing information and documentation. Record review of document titled, "Emergency Event Report WI Region Winter Weather DRILL". A review of Emergency Event Report WI Region Winter Weather DRILL, dated 06/21/2023, revealed no information was documented under the following sections, "Incident Commander, Logistics, Operations, and Planning." Additional information under "Home Health and Hospice Scheduled" and "Staff Present" was also left blank on the event report. Additional information regarding the missing information was requested. Upon exit conference on 06/20/2024, no additional information was provided regarding the agency's Emergency Preparedness drills and exercises to reveal evidence of who was involved in the event and after-action reports to identify evaluation of the drill/exercises.

Based on record review and interview, the agency staff failed to ensure that the volunteer level of activity equaled at least 5 percent of the total patient care hours of paid hospice staff for the past year in 1 of 1 volunteer program reviewed. --- Findings include: Review of agency policy titled, "Volunteers" (revised 09/19) revealed in part, "J. Volunteer will provide a minimum of 5% of the total hospice patient care hours of all paid hospice employees and contract staff." Review of the hospice's volunteer program revealed a level of volunteer activity for the year of 2023 of 3 percent which is below the 5 percent required. During an interview conducted on 06/19/2024 at 12:08 PM with Volunteer Coordinator K, K stated, " It did not meet the 5 percent cost savings."

Based on record review and interview, the agency administration failed to ensure administrative oversight for contracts for services that included a method of evaluation of effectiveness through the quality program in 3 of 5 contracts reviewed (Contract N, Contract O and Contract P). --- Findings include: Record review of Contract N (dated 03/04/2022) for pharmacy services, Contract O (dated 02/20/2023) for inpatient unit services, and Contract P (dated 12/31/2022) for inpatient unit services revealed no evidence that outlined a method of evaluation of effectiveness through the quality program. During an interview with Administrator A on 06/19/2024 at 2:10 PM, when asked about Contract N, Contract O, and Contract P missing content of a method of evaluation of effectiveness through the quality program, Administrator A replied, ";I reviewed and no, I dont see it."