Every finding on record at Star Valley Healthcare Inc/Dba Symbii Hospice

Based on medical record review, staff interview, and review of policies and procedures, the facility failed to ensure bereavement services were available to the family for one year following the death of the patient for 1 of 4 patients (#13) reviewed for bereavement services. The findings were: --- Review of the medical record showed patient #13 passed away on 4/18/24. Further review of the medical record showed no evidence of a bereavement care plan or evidence of bereavement services provided to the family. During an interview on 1/15/25 at 8:30 AM the director of clinical services stated when she was hired she realized there was a problem with bereavement services. She stated a new social worker was hired and since July 2024 the facility was providing bereavement services. She stated there was no evidence of bereavement services for patient #13 because s/he passed away prior to the facility identifying issues with bereavement services. However, on 1/15/25 at 3:32 PM the director of clinical services stated the facility did not review patients who "were missed" [bereavement services not provided] and were still within the one year timeframe, including patient #13, to assess for any bereavement needs. Review of the facility's policy "Bereavement Services," revised May 2024, showed "...Symbii Home Health and Hospice (WY) will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for up to one (1) year following the death of the patient...If a person is noted as experiencing normal grief, the bereavement counselor will make contact with the bereaved person for ongoing assessment and supposed at three (3), six (6), and nine (9) months after the patient's death and at the anniversary of the patient's death..."

Based on staff interview, review of CMS waivers, and policy and procedure review, the facility failed to ensure volunteers were used in administrative and/or direct patient care roles (refer to L644). In addition, the facility failed to document the cost savings achieved through the use of volunteers (refer to L646). This system failure resulted in the inability of the facility to meet the Condition of Participation for Volunteers. --- Based on staff interview and policy and procedure review, the facility failed to ensure volunteers were used in administrative and/or direct patient care roles (refer to L644). In addition, the facility failed to document the cost savings achieved through the use of volunteers (refer to L646) and failed to ensure volunteer hours equaled at least 5% of the total patient care hours by paid and contract staff (Refer to L647). This system failure resulted in the inability of the facility to meet the Condition of Participation for Volunteers.

Based on review of policies and procedures and staff interview, the facility failed to use volunteers in administrative and/or direct patient care roles. The findings were: --- During an interview on 1/15/25 at 1:45 PM the director of clinical services stated the facility had no volunteer hours for the past year. She stated they just hired a volunteer coordinator and were going to start recruiting volunteers. Review of the facility's policy "Volunteer Services," revised May 2024, showed "...Symbii Home Health and Hospice (WY) will provide volunteer services under the direction of a Volunteer Coordinator and with the assistance of trained hospice volunteers...The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel."

Based on staff interview and policy and procedure review, the facility failed to document cost savings achieved through the use of volunteers. The findings were: --- During an interview on 1/15/25 at 1:45 PM the director of clinical services stated the facility did not have any volunteer hours in the past year. Therefore, there was no cost savings achieved through the use of volunteers. Review of the facility's policy "Volunteer Services," revised May 2024, showed "...Symbii Home Health and Hospice (WY) will provide volunteer services under the direction of a Volunteer Coordinator and with the assistance of trained hospice volunteers...The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel."

Based on staff interview and review of policies and procedures, the facility failed to ensure volunteers provided administrative and/or direct patient care services in an amount that equaled at least 5 percent of the total patient care hours of all paid hospice employees and contract staff. The findings were: --- During an interview on 1/15/25 at 1:45 PM the director of clinical services stated the facility had no volunteer hours for the past year. She stated they just hired a volunteer coordinator and were going to start recruiting volunteers. Review of the facility's policy "Volunteer Services," revised May 2024, showed "...Symbii Home Health and Hospice (WY) will provide volunteer services under the direction of a Volunteer Coordinator and with the assistance of trained hospice volunteers...The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel."

Based on observation, staff interview, professional standard review, and policy and procedure review, the agency failed to ensure supplies available for patient use were not expired for 1 of 1 supply room. The findings were: --- 1. Observation of the supply room on 1/15/25 at 2:39 PM with the office manager showed the following concerns:a. Ten (10) Heparin lock flush solution 30 USP (using a USP reference standard based on units of heparin activity per milligram) units per 3 milliliters (ml) expired on 11/24.b. Heparin Lock flush 500 USP units per 5 ml, 2 expired on 8/1/24, 1 expired on 8/1/23, and 46 expired on 11/30/24. 2. Interview at that time with the office manager revealed the agency checked for expirations monthly. He confirmed the medical supplies were for client use and were expired. 3. Review of the website "fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines"[sec] accessed on 1/24/25 showed ";...The expiration date is a critical part of deciding if the product is safe to use and will work as intended... It is important to know and stick to the expiration date on your medicine. Using expired medicines is risky and possibly harmful to your health." 4. Review of the facilitys policy "Supply management, ambulatory care," reviewed 11/17/24, showed "...Complications ...stockpiling, supplies expiring before use..."

Based on medical record review and staff interview, the agency failed to provide qualified professionals in 2 of 4 roles of the interdisciplinary group for 11 of 13 sample patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11). The findings were: 1. Review of the interdisciplinary group notes for sample patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 showed the agency failed to include the social worker and a pastoral or counselor. 2. Interview with the administrator on 1/4/22 at 2 PM revealed the agency had no pastoral services since November 2021, and no social worker since April 2021.

Based on medical record review and staff interview, the agency failed to provide 2 of 4 core services for 11 of 13 sample patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11). The findings were: 1. Review of the patient medical records for patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 showed no evidence agency included the social worker. In addition, the agency failed to include pastoral care or counseling for patients #1, #2, #3, #4, #5, #6, #7, #8, #10, #11. The pastoral services ended in November 2021, and the social services ended in April 2021. 2. Interview with the administrator on 1/4/22 at 2 PM revealed the agency had no pastoral services since November 2021, and no social worker since April 2021. Further, she stated the agency had not filled the positions.

Based on medical record review and staff interview, the agency failed to provide social services as required by federal regulations for 11 of 13 sample patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11). The findings were: Review of patient medical records for patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 failed to show evidence of medical social services since April 2021. Interview with the administrator on 1/4/22 at 2 PM revealed the agency had not provided social service since April 2021. Further, she stated the agency had not filled the position.

Based on medical record review, staff interview, and review of facility bereavement documentation, the facility failed to develop a bereavement plan of care for 1 of 2 sample patients (#13) reviewed for bereavement. The findings were: 1. Review of the medical record showed patient #13 started hospice services on 8/3/20 and passed away on 8/10/20. Further review of the medical record showed no evidence of a bereavement plan of care or bereavement services provided to the family. 2. Review of the facility's "Bereavement Activity Planning Report" and "Coordination Notes Report" showed no evidence of a bereavement plan of care or bereavement services were provided for patient #13. 3. During an interview on 1/6/22 at 10 AM the administrator stated they were unable to find any evidence a bereavement plan of care was developed for patient #13. In addition, she stated she was unable to find documentation that bereavement services were provided for the family.

Based on medical record review and staff interview, the agency failed to provide spiritual counseling for 10 of 13 sample patients (#1, #2, #3, #4, #5, #6, #7, #8, #10, #11). The findings were: Review of patient medical records for patients #1, #2, #3, #4, #5, #6, #7, #8, #10, #11 failed to show evidence of spiritual counseling since November 2021. Interview with the administrator on 1/4/21 at 2 PM revealed the pastoral services person resigned in November 2021. Further, she stated the agency had not filled the position.

Based on observation and staff interview, the agency failed to ensure supplies available for use were not expired in 1 of 1 supply rooms. The findings were: 1. Observation of the supply room on 1/4/22 at 2:18 PM identified the following concerns: a. Four 12 inch extension set, minibore, male/female luer lock with pinch clamp expired 11/2019. b. Seventy-six BD vacutainer serum blood collection tubes expired 12/31/21. c. Three Promogran Matrix 4.34 inch wound dressings expired 9/30/21. d. Six 20 French (Fr) silicone-elastomer - coated latex foley catheters expired 12/28/21. e. Two 22 Fr silicone-elastomer - coated latex foley catheters expired 11/28/21. 2. Interview with the administrator on 1/4/22 at 2:30 PM confirmed the medical supplies were for client use, and were past the expiration dates.