Every finding on record at St. Helena Hospice LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure that the medication profile on each clinical record contained all of the prescriptions, supplements, and alternative treatments. Clinical Record 1: The patient elected the hospice benefit on 01/02/2024. The admission order included an order for Oxygen 2L per NC PRN on 01/02/2024. A nursing note on 08/23/2024 revealed that the patient is utilizing oxygen at 2L per NC PRN. A review of the medication profile dated 08/30/2024 for the episode 08/30/2024 through 10/30/2024 did not include Oxygen . In an interview on 09/03/2024, the director of nursing stated, " I must have missed that it was not on the medication profile, I will get it on there immediately."

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records with aide services reviewed revealed that the agency did not ensure that the aides notified the RN of changes in patient needs or the plan of care. Clinical Record 5: The patient was admitted on 07/03/2024 with a diagnosis of malignant neoplasm of connective tissue and a secondary diagnosis of brain metastasis. The hospice aide notes on 08/26/2024 and 08/29/2024 revealed that the patient declined shampoo, hair combed, oral care, nail care, shave, linen change, bed made, and assisting with bedside commode. The clinical record contained no documentation to indicate that the aide notified the registered nurse (RN) that they were unable to complete the aide care plan tasks due to patient condition and refusal. Clinical Record 6: The patient was admitted on 11/25/2023 with a diagnosis of COPD. The hospice aide care plan developed 07/09/2024 by RN included the task shampoo hair every visit. Hospice aide notes revealed that the patient declined shampoo hair on aide visits 08/05/2024, 08/06/2024, 08/07/2024, 08/08/2024, 08/09/2024, 08/12/2024, 08/13/2024, 08/14/2024, 08/15/2024, and 08/16/2024. There is no documentation in the clinical record to indicate that the RN was notified that the patient was refusing hair washing and the aide plan of care could not be followed. The Director of Nursing stated in an interview after chart review on “09/04/2024, “Yeah I see they have not documented any notification to the RN.”

The hospice must use volunteers to the extent specified in paragraph (e) of this section. These volunteers must be used in defined roles and under the supervision of a designated hospice employee. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review and interview. Review of administrative documents, and interviews with leadership revealed the hospice: Failed to ensure that volunteers were used in day-to-day administrative and/or direct patient care {HCDT.21. I/L644}; Failed to ensure that the agency-maintained records of work time of volunteers and the estimated dollar cost savings {HSLG.7. I/L646}; and Failed to ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff {HSLG.7. I/L647}; and Failed to ensure that volunteer services were provided within acceptable standards of practice {HC DT.1.I/L 652}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.78: Volunteers. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that Volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are: 1. Noted in the plan of care This standard was not met as evidenced by document review and interview. A review of the agency documents related to volunteers revealed the agency did not ensure that volunteers were used in day-to-day administrative and/or direct patient care. Document 7: The volunteer program binder included a list of volunteers but there was no documentation of hours worked or cost savings. The last documented evidence of volunteer records was prior to covid. Volunteer Coordinator stated in part, an interview on 09/05/2024 " We had a volunteer work about 5 hours in May." and confirmed that cost savings were not documented. The Director of Nursing stated in an interview on 09/04/2024, "We are working on getting a volunteer program together. We really have not had much." A volunteer had been recruited but had not completed the orientation process. A PIP has been in place since June 2024.

The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions. This standard was not met as evidenced by document review and interview. A review of the agency documents related to volunteers revealed that the agency did not ensure that the agency-maintained records of work time of volunteers and the estimated dollar cost savings. Document 7: The volunteer program binder included a list of volunteers but there was no documentation of hours worked or cost savings. The last documented evidence of volunteer records was prior to covid. Volunteer Coordinator stated in part, an interview on 09/05/2024 " We had a volunteer work about 5 hours in May." and confirmed that cost savings were not documented. The Director of Nursing stated in an interview on 09/04/2024, "We are working on getting a volunteer program together. We really have not had much." A volunteer had been recruited but had not completed the orientation process. A PIP has been in place since June 2024. A review of the agency documents related to volunteers revealed that the agency did not ensure that the agency maintained records of work time of volunteers and the estimated dollar cost savings.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. Review of the volunteer binder documents revealed that the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. Document 7: Volunteer program binder contained no evidence of volunteer hours worked. The Director of Nursing stated in an interview on 09/04/2024, "We are working on getting a volunteer program together. We really have not had much." The Volunteer Coordinator stated in part, an interview on 09/05/2024 " We had a volunteer work about 5 hours in May." Review of the volunteer binder documents revealed that the agency did not ensure that volunteers provided 5% of the total patient care hours.

It is required that a hospice must be primarily engaged in providing the following care and services and must do so in a manner that is consistent with accepted standards of practice. This standard was not met as evidenced by document review and interview. A review of the agency documents related to volunteers revealed the agency did not ensure that volunteer services were provided within acceptable standards of practice. The Director of Nursing stated in an interview on 09/04/2024, "We are working on getting a volunteer program together. We really have not had much." A volunteer had been recruited but had not completed the orientation process. A PIP has been in place since June 2024.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed of a revocated patient revealed that the agency did not ensure that the patient's attending physician was provided a copy of a discharge summary. Clinical Record 13: The patient was admitted on 08/07/2023 with a diagnosis of malignant neoplasm of connective and soft tissue. The patient revoked hospice services on 06/10/2024. The clinical record did not contain a discharge summary and did not contain any documentation related to sending a discharge summary to the physician. During a joint record review with the director of nursing on 09/04/2024, the director of nursing said, "No there is nothing (discharge note/summary) there.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. In 2 of 2 (100%) contracts that involve contract staff providing direct patient care reviewed revealed that the agency did not ensure that contract language included the requirement for background checks. Contract 3: The Medical Director contract signed on 12/01/2023 did not include language requiring the medical director to have a criminal back check. Contract 6: The physical therapy, occupational therapy and speech therapy services’ contract signed on January 18, 2018. In an interview on 09/04/2024, the director of nursing stated, "we have been trying to get the owner to get all the contracts updated.