Every finding on record at Sunny Days Hospice Care, Inc.

Observed in Individual Tracer. In 4 of 4 patient records reviewed, it was found that the organization had not reassessed the patient and the core disciplines had not updated the comprehensive assessment based on information about the patient's progress towards outcomes and response to care During review of the records it was found that IDG had not been held every 15 days. For example, RR # 1 the IDG was held 6/9/2022 and not again until 8/3/2022 , for RR # 2 IDG was on 6/30/22 and not again until 7/20/22,IDG for RR # 3 IDG 12/23/2021 and not again until 8/3/2022, for RR# 4 IDG was 6/9/2022 and not again until 8/3/2022. this was validated by the Office Manger and the Administrator. Observed in Record Review. In 4 of 4 patient records reviewed, it was found that the organization had not reassessed the patient. During review of the records it was found that IDG had not been held every 15 days. For example, RR # 1 the IDG was held 6/9/2022 and not again until 8/3/2022 , for RR # 2 IDG was on 6/30/22 and not again until 7/20/22,IDG for RR # 3 IDG 12/23/2021 and not again until 8/3/2022, for RR# 4 IDG was 6/9/2022 and not again until 8/3/2022. this was validated by the Office Manager and the Administrator.

Observed in Individual Tracer. In 4 of 4 patient records reviewed, it was found that IDG had not met every 15 days therefore, there was not an interdisciplinary collaborative team to develop the care, treatment and services. For example, during review of RR # 1 the IDG was held 6/9/2022 and not again until 8/3/2022, for RR # 2 IDG was on 6/30/22 and not again until 7/20/22,IDG for RR # 3 IDG 12/23/2021 and not again until 8/3/2022, for RR# 4 IDG was 6/9/2022 and not again until 8/3/2022. This was validated by the Office Manager and the Administrator.

Observed in Individual Tracer. In 4 of 4 patient records reviewed, it t was found that the organization planned the patients' care. For example, during review of the records it was found that IDG had not been held every 15 days. For example, RR # 1 the IDG was held 6/9/2022 and not again until 8/3/2022 , for RR # 2 IDG was on 6/30/22 and not again until 7/20/22,IDG for RR # 3 IDG 12/23/2021 and not again until 8/3/2022, for RR# 4 IDG was 6/9/2022 and not again until 8/3/2022. this was validated by the Office Manger and the Administrator.

Observed in Individual Tracer. In 4 of 4 bereavement records, it was found that the 4 records had not had a bereavement plan of care developed. Review of the policy 2.101.1 identified a process, however, there was no written specific POC for any of the bereaved. Two of the bereavement individuals did receive a condolence care ,but not further interventions were found. For the other two bereaved there was no documentation of interventions. None of the records had a bereavement plan that was written and identified bereavement services to be offered and a frequency of service interventions. This was validated by the Office manager and the Administrator.

Observed in Tracer Activities. the organization failed to prepare for how it would communicate during an emergency. During emergency operations tracer activities, the hospice nurse surveyor observed the plan did not address how it would inform State and Local officials of any on-duty staff it was unable to locate. This was discussed and reviewed with the Hospice Leadership team.

Observed in Tracer Activities. the organization failed to address how it would communicate during emergencies. During Emergency Management tracer activities, the hospice nurse surveyor observed the emergency operations plan did not address how the organization would inform state and local officials of any patient's needing evacuation or that were unable to be reached. This was discussed and reviewed with the Hospice Leadership team.

Observed in Patient Home. the organization failed to prepare for how it would manage staff during an emergency. During staff interview for HV#1 and HV#2 the LVN was asked about training and the role she would play in case an emergency was instituted. Her response was this agency doesn't really focus or train on emergencies but I would just follow common sense. The LVN stated she had been employed with the agency for 3 years. During tracer activities for the volunteer program, the hospice nurse surveyor observed the volunteers had not been trained initially or on-going on their role in the emergency operations plan. This was discussed and reviewed with the Hospice Leadership team.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to inform the patient's of their rights prior to beginning care. During review of all records, the hospice nurse surveyor observed the organization failed to inform its patients of potential costs related to hospice. There was no documentation that the patient was informed in writing of charges that insurance may not cover. This was discussed and reviewed with the Hospice Leadership team.

Observed in Record Review. In 13 of 13 patient records reviewed, the organization failed to reassess its patients. During review of all records, the hospice nurse surveyor observed the agency routinely did not hold IDG and therefore the physician, SW, Chaplain and RN did not routinely update the POC collaboratively. The POC was updated at recertification only by the RN. This was discussed and reviewed with the Hospice Leadership team. Observed in Record Review. In 13 of 13 patient records reviewed, the organization failed to reassess its patients. During review of all records, the hospice nurse surveyor observed the agency routinely did not hold IDG and all core disciplines failed to update the comprehensive assessment based on information about the patient's progress towards desired outcomes and response to care. This was discussed and reviewed with the Hospice Leadership team.

Observed in Record Review. the organization failed to plan the patient's care. During record review for HV#1, RR#1, RR#2, RR#3, the hospice nurse surveyor observed the POC did not contain all needed elements. For example in HV#1 the nursing notes mentioned SOB and at the visit the surveyor noted issues with skin integrity and nutrition but these items were not addressed on the POC. In RR#1 the nursing notes stated SOB but this was not addressed on the POC and in RR#2 and RR#3 there was nothing to address the patient's spiritual or social needs. the organization failed to plan the patient's care. During record review for RR#3, the hospice nurse surveyor observed initial orders for SN was 2 visits weekly for 14 days. No additional visit orders were added to the POC but nursing continued to perform visits. This was discussed and reviewed with the Hospice Leadership team.

Observed in Record Review. In 13 of 13 patient records reviewed, the organization failed to provide interdisciplinary, collaborative care, treatment or services. During record review for all records, the hospice nurse surveyor observed IDG was intermittent at best and mostly missing from all records. For example: in HV#1 the MD and RN documented an IDG on 5/03 ( date of SOC) but no other disciplines were involved and no further IDG was held. In HV#2, no IDG had been held for 4 months. In HV#3, SOC had been 10/15/21 and as of survey date of 6/14/22 no IDG had ever been held. Upon discussion with the Hospice Leadership team, they did not deny it and seemed unaware of the requirement. This was discussed and reviewed with the Hospice Leadership team.

Observed in Record Review. In 3 of 6 patient records reviewed, the organization failed to plan the patient's care. During record review for HV#2, HV#3, and RR# the hospice nurse surveyor observed the POC goal timeframes had expired and were not updated to reflect current information. Upon review, it was noted all timeframes and goals were only being update by the RN at recertification. This was discussed and reviewed with the Hospice Leadership team.

Observed in Record Review. In 13 of 13 patient records reviewed, the organization failed to plan the patient's care. During review of all records, the hospice nurse surveyor observed the agency routinely did not hold IDG to review the POC at least every 15 days. For example- in HV#1 IDG was held via phone with the RN and MD on the day of SOC but nothing further. In HV#2, IDG had not been held for 4 months and in HV#3 IDG had never been held- the patient SOC was 10/2021. This was discussed and reviewed with the Hospice Leadership team.

Observed in Record Review. In 3 of 6 patient records reviewed, the organization failed to provide care, treatment, or services for each patient. During record review for HV#1, RR#2, RR#3 and RR#4, the hospice nurse surveyor observed care was not provided according to the POC. For example- in HV#1 no nursing or aide visits were completed the week of 6/3/22. In RR#2 the aide visited only once the week of 6/9/22 with the POC stating 2x weekly, and in RR#3 the POC read aide 2x daily but the aide had been going 2x weekly. This was discussed and reviewed with the Hospice Leadership team.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to reduce the risk of infection associated with medical equipment, device and supplies. During HV#1 and HV#2, the hospice nurse surveyor observed the LVN placer her blood pressure cuff, pulse oximeter, stethoscope and thermometer back into her bag after use without cleaning per organizational policy. We then went to visit #2, she took the equipment out of her back and it used it on the patient without disinfection. This was discussed and reviewed with the Hospice Leadership team. Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to implement prevention and control activities. During HV#1 and HV#2, the hospice nurse surveyor observed the LVN reach into her bag multiple times without doing hand hygiene per policy and at the end of HV#1 she did not complete hand hygiene before moving on to the visit in the same facility for HV#2. This was discussed and reviewed with the Hospice Leadership team.

Observed in Tracer Activities. the organization failed to plan the patient's care. During the bereavement tracer activity, the hospice nurse surveyor observed the organization was not developing a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. This was discussed and reviewed with the Hospice Leadership team.

Observed in Tracer Activities. In 7 of 10 HR files reviewed, the organization failed to document staff competency. In HR file review, the hospice nurse surveyor observed HR#2, HR#3, HR#4, HR#5, HR#6, HR#7 and HR#8 did not contain documentation of competency at least annually as the organizational policy required. This was discussed and reviewed with the Hospice Leadership team.

Observed in Tracer Activities. Leadership and the governing board failed to understand the degree of risk in §418.100, §418.116, §418.54 and §418.56. This was discussed and reviewed with the Hospice Leadership team.

Observed in Tracer Activities. the organization failed to provide for its planned scope and level of care, treatment, or services. During contract review, the hospice nurse surveyor observed the organization did not have a contract or make arrangements for short term general inpatient or respite care. This was discussed and reviewed with the Hospice Leadership team.

Observed in Record Review. In 1 of 1 patient records reviewed, the organization failed to provide a discharge summary to the provider taking over care. During record review for DC#1, the hospice nurse surveyor observed noted no documentation of a discharge summary being sent to the new provider. This was discussed and reviewed with the Hospice Leadership team.

Observed in Record Review. In 1 of 1 patient records reviewed, the organization failed to comply with law and regulation. During record review for DC#1, the hospice nurse surveyor observed HCO did not have a process in place to ensure that the Notice of Medicare Non-Coverage was signed within 2 days of discharge. The agency was unaware of this requirement. This was discussed and reviewed with the Hospice Leadership team.