Every finding on record at Sycamore Grove Healthcare LLC

Based on interview and record review, the agency failed to conduct the initial assessment within 48 hours for one of 14 sampled patients (Patient 6). This failure placed Patient 6 at risk for not receiving palliative care and for the family members and caregivers to not receive support as soon as possible. --- During a concurrent interview and record review, on 10/21/24 at 10:25 a.m., with the Director of Patient Care Services (DPCS), Patient 6s clinical record was reviewed. The referral was on 10/31/23 but the start of care (SOC) was on 11/6/23. The DPCS could not locate the reason for the delay of service. The DPCS stated the current electronic medical record (EMR) did not show the coordination note justifying the reason for the delay. The DPCS stated she was new to the agency, and she deferred the question to the Intake personal who was familiar with the record keeping. During an interview with the intake personal at 10:30 a.m., the Intake Personal stated, ";If there was a delay in the coordination, a note should be generated." The DPCS confirmed the delay of the service without justification. The DPCS stated it was very important to provide service within 48 hours from the referral for the agency to provide the necessary palliative measure to the patient and the bereavement service to the family members and caregivers. During a review of the agencys policy and procedure (P&P) titled, ";Admission Criteria and Process" dated 5/22, the P&P indicated, ";...Once a patient is admitted to service, the organization will be responsible for providing care and services within its financial and service capabilities, mission , and applicable law and regulations...In the event that time frame for assessment cannot be met, the patients physician and the referral source, as well as the patient , will be notified for approval of the delay. Such notification and approval will be documented."

Based on interview and record review, the agency failed to provide initial bereavement assessment for three of 14 sampled patients (Patients, 1. 3 and 8). These failures placed patients, their family members, and caregivers at risk for not receiving necessary bereavement support identified from the beginning of the service. --- 1.During a concurrent interview and record review on 10/17/24 at 10:40 a.m., with the Director of Patient Care Services (DPCS), Patient 1s initial bereavement assessment record was reviewed. The initial bereavement assessment was not conducted. The DPCS stated she could not locate the documented evidence that the agency identified the bereaved and the level of crisis to develop a bereavement plan of care. The start of care (SOC) was on 9/28/23. The coordination note indicated Patient 1 refused Master Social Work (MSW) 2s visit on 9/29/23. Chaplain 1 tried to contact Patient 1 on 10/3/23 and 10/30/23 but unsuccessful. 2.During a concurrent interview and record review on 10/17/24 at 11:30 a.m., Patient 3s initial bereavement assessment record was reviewed. DPCS stated the initial bereavement assessment was not conducted. The DPCS stated she could not locate the documented evidence that the agency identified the bereaved and the level of crisis to develop bereavement plan of care. The SOC was on 5/22/24. Chaplain 1 made a home visit on 5/23/24 and MSW 2 made a visit on 5/24/24. Three disciplines (Registered Nurse/Case Manager, MSW and Chaplain) made home visits within 5 days of the SOC but did not conduct the bereavement assessment to develop a bereavement plan of care. 3.During a concurrent interview and record review on 10/17/24 at 4 pm, with the DPCS, Patient 8s initial bereavement assessment record was requested to be reviewed. The initial bereavement assessment was not conducted. The DPCS stated she could not locate the documented evidence that the agency identified the bereaved and the level of crisis to develop bereavement plan of care. The SOC was on 9/30/24. MSW 1 made a home visit on 10/3/24 and Chaplain 1 made visit on 10/4/24. Three disciplines made home visits within 5 days since the SOC but did not conduct the initial bereavement assessment to develop a bereavement plan of care. During an interview on 10/16/24 at 9:40 a.m., with Chaplain 1, Chaplain 1 stated his responsibility was to ensure make calls to schedule visits. Chaplain 1 stated once the visit was made, he follows up on the concerns. Chaplain 1 stated currently most of patients were at low risk and no counselling was provided. MSW 2 was no longer employed by the agency and was unable to conduct an interview. During an interview on 10/17/24 at 10:40 a.m., with the DPCS, the DPCS stated, ";Initial bereavement assessment should be done within 5 days from start of care. If death is imminent, I expect the registered nurse case manager (RN/CM) should conduct bereavement assessment on start of care. Currently Chaplain 1 oversees the agencys bereavement program." During a review of the agencys policy and procedure (P&P) titled ";Bereavement Services" date 5/24, the P&P indicated, ";[the agency] will provide an organized bereavement program supervised by a qualified Bereavement Coordinator...A bereavement risk assessment will be completed by the hospice social worker at the time of admission of hospice. Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care. After the bereavement risk assessment is completed, a plan will be developed to address bereavement /grief issues and will be implemented as needed."

Based on observation, interview, and record review, the agency failed to educate primary caregivers the importance of reporting patient care and safety needs during home visits for one of three sampled patients (Pt 2) when board and care staff was unaware to report Pt 2s fall incidents and need for a podiatry consult for overgrown toenails to the agency. This failure placed Pt 2 at risk for serious injury from possible entrapment during a fall from a bed with side rails and experienced pain and discomfort from an overgrown toenail. --- During a concurrent observation and interview, on 10/15/24 at 11:30 a.m., with the Master Social Work (MSW) 1, in Patient 2s boarding care facility, Patient 2 was observed sleeping in her bed. One side of the bed was observed against the wall and the other side was observed with a metal side rail up. The side rail was equipped with padding which was secured by Velcro at several points. Patient 2 was observed small in size in her bed. Patient 2s caregiver stated Patient 2 had a fall on 10/12/24 at 6:10 p.m. causing her bruises but no other injuries. Patient 2s caregiver stated Patient 1 had torn the padding from the side rail and slipped through the side rail and fell. Pt 2s caregiver stated she was unaware the expectation was to call the agency after each fall, regardless if there are no injuries. During a concurrent observation and interview on 10/15/24 at 12 p.m., with the Registered Nurse/Support Clinical Staff (RN/SCS) who accompanied the home visit, Patient 2s feet were observed. Patient 2s right and left big toenails were too thick and long to check the cleanliness of the nail bed. Patient 2s left middle toenail was observed long and curved and Patient 2s right 4th toenail and pinky toenail were observed long and curved. The RN/SCS stated Patient 2s nail care should have been done either by the agencys aide or the facilitys caregiver before it came to this situation requiring a podiatrist. During a review of Patient 2s plan of care (POC) dated from 9/30/24 to 11/28/24, the POC indicated, ";Goals: Patient will have safety needs met...Patient will receive personal care and hygiene other activities of daily living to their optimal level..." During an interview on 10/23/24 at 10 a.m., with Registered Nurse/Case Manager (RN/CM) 1, the RN/CM 1 stated she expected Pt 2s board and care staff to notify the agency of any concerns regarding safety and personal care. The RN/CM 1 stated it was the agencys responsibility to ensure the board and care staff know what to report by ongoing communication. The RN/CM 1 stated Patient 2 was assigned to RN/CM 2 recently. The DPCS stated RN/CM 2 was not available for an interview due to a family emergency. During a review of the document titled ";Important Reasons to Call Hospice" undated, indicated, ";...Has fallen -even if he/she can get up and denies injury..." During a review of the document titled ";Facility & Hospice Coordination of Care" customized for Patient 2, dated 10/14/24, indicated, ";Hospice will provide ...Aide will provide personal care to resident 2 time/week..." During a review of Patient 2s ";Aide Care Plan Report" dated 10/11/24, the Aide Care Plan Report indicated nail care was to be provided once a week. During a review of the agencys policy and procedure (P&P) titled ";Interdisciplinary Group Coordination of Care" dated 5/22, the P&P indicated, ";It will be the responsibility of the Clinical Supervisor to assign a Case Manager who is a registered nurse. The Case Manager will be responsible for coordination of services with the interdisciplinary group from referral to discharge...It will be the responsibility of the case manager to facilitate communication about changes in the patients status..."

Based on interview and record review, the agency failed to provide and ensure the ongoing sharing of information between all disciplines providing care and services for one of 14 sampled patients (Patient [Pt]12) when Pt 12 refused three consecutive Aide service dates and the Aide did not communicate with the Registered Nurse/Case Manager (RN/CM). This failure resulted in not notifying the physician and possible altering the Aide visits to meet the needs of Patient 12. Patient 12 was discharged from the agencys service. --- During a concurrent interview and record review, on 10/15/24 at 3:30 p.m., with the Director of Patient Care Services (DPCS), Patient 12s clinical record was reviewed. Patient 12s Plan of Care (POC) dated from 6/26/24 to 8/24/24 was reviewed and the POC indicated the start of care (SOC) was 6/26/24. The physician ordered the hospice aide to provide visits twice a week. The coordination note indicated that hospice aide visit was missed three consecutive times, on 7/5/24, 7/9/24 and 7/11/24. The DPCS stated there was no evidence of communication between the aide and RN/CM 4 to notify the physician to discuss the situation. The DPCS stated Patient 2 wanted minimal visits from the necessary discipline and disliked busy scheduling. The DPCS stated Patient 2 could have benefited from discontinuing aide visits from physician from the beginning of the service if there were communication between disciplines to honor Patient 2s comfort level of visit frequency and type of service. During a review of Patient 12s ";Discharge Note" dated 7/15/24 and written by Registered Nurse/Case Manager (RN/CM) 4, the discharge note indicated, ";Patient has elected to revoke hospice services at this time...she likes to get out and waiting for visits causes her to alter her daily plans..." RN/CM 4 was no longer employed by the agency and was unavailable for an interview. During a review of the facilitys policy and procedure (P&P) titled ";Interdisciplinary Group Coordination of Care" dated 5/22, the P&P indicated, ";It will be the responsibility of the Case Manager to facilitate communication about changes in the patients status between interdisciplinary group members and the patients attending physician."

Based on interview and record review, the agency failed to document for the previous two-year period what performance improvement (PI) project(s) was being conducted, the reason for conducting these projects, and the measurable progress achieved on these projects. These failures resulted in the agency not evaluating the quality of services being provided to patients which could result in avoidable negative outcomes. These failures affected all patients provided services by the agency. --- During an entrance conference interview on 10/14/24 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she took the position permanently as of 8/15/24 after serving as an interim DPCS. The DPCS stated she had been working on two PI projects by hiring volunteer coordinator to establish volunteer program and establishing hospice aide supervision and training program. The DPCS stated those two PI projects were chosen to meet the federal requirements. The DPCS presented a paper with handwritten projects. The DPCS admitted the agency had been out of compliance with two conditions of participations involving volunteers and hospice aide program. The DPCS stated the agency did not have any PI projects for past two years while the previous Administrator/DPCS was the designee for the PI projects. During a review of the agencys policy and procedure (P&P) titled ";Improving Organizational Performance" dated 5/22, the P&P indicated, ";1. The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity and past performance of the organizations services and operations. 2. The organization must document the quality improvement projects undertaken, the reason for conducting the projects, and the measurable progress achieved on these projects." During a review of the agencys P&P titled ";Governing Body" dated 5/24, the P&P indicated ";The Governing Body will appoint a qualified Executive Director/Administrator and establish procedures of systemic communication between the two. Performance of the Executive Director/Administrator will be monitored annually through a procedure established by the Governing Body...Relevant findings of performance improvement activities are consistently provided to the Governing Body..."

Based on interview and record review, the agencys Governing Body failed to ensure the QAPI (Quality Assessment Performance Improvement) meeting was held quarterly when the agency missed three quarterly meetings, one for the 4th quarter of 2023 and two for the second and third quarter of 2024. These failures placed patients at risk for not receiving quality patient care services in a safe setting. --- During a concurrent phone interview and record review on 10/15/24 at 7 a.m., with the corporate personnel, the corporate personnel explained the agencys poor performance from August 2022 till the current DPCS was designated in August 2024. The corporate personnel stated due to lack of leadership the agency did not have good record keeping for quarterly QAPI meetings. After the phone conversation with the corporate personnel, the agency presented past QAPI meeting minutes. Since the change of the ownership in August 2022 the QAPI meeting was held five times instead of eight times with no QAPI meeting being held for the 4th quarter of 2023 and the 2nd and 3rd quarter of 2024 During a review of the agencys policy and procedure (P&P) titled ";Governing Body" dated 5/24, the P&P indicated, ";The Governing Body will authorize adequate resources and support to establish and maintain an organization-wide quality assessment and performance improvement program (QAPI). Information related to the performance improvement program will be provided to the Governing Body on a quarterly basis...The Governing Body will appoint a Corporate Compliance Committee (The Committee) ...the Committee will meet at least quarterly..."

Based on interview and record review, the agency failed to demonstrate an organized bereavement program for one of two expired patients (Patient 13) when the bereavement care plan for Patient 13 was not updated after Patient 13s death to support the bereaved according to bereavement activity records. This failure placed the bereaved not receiving needed grief and loss counselling. --- During a review of Patient 13s ";Bereavement Activity Report (BAR)" dated from 12/26/23 to 3/8/24 indicated Patient 13s date of death was 12/22/23. The BAR indicated Chaplain 1 made a phone visit to Patient 1s bereaved on 12/26/23. The ";Visit Note Report" dated 12/26/24 indicated, ";CP (chaplain) called granddaughter to offer condolences and bereavement support. Granddaughter reported that family has some challenges in adjusting to loss. Granddaughter and spouse are open to bereavement support. Bereavement Coordinator will follow up with family to schedule bereavement support after the holiday season. Granddaughter said that they will begin final arrangement plans today." During a concurrent interview and Patient 13s clinical record review on 10/15/24 at 3:30 pm, with the Director of Patient Care Services (DPCS), Patient 13s Plan of Care (POC) dated from 10/3/23 to 12/31/23 was reviewed. The POC indicated the start of care was 10/3/23 and the Medical Social Work (MSW) 2 made a visit on 10/5/23. The DPCS confirmed the second visit by MSW 2 was 6 days prior to patients death on 12/22/23. The DPCS stated there was no evidence of MSW 2 or Chaplain 1 called or visited the Bereaved to support as death was imminent. The DPCS confirmed there was no follow up visit by either Chaplain 1 or MSW 2 to support Patient 13s granddaughter who expressed need for counselling service. The IDG (interdisciplinary Group) meeting note dated 12/27/23 written by MSW 2, the note indicated, ";Psychosocial status at time of death: Patient passed at home with family bedside. Family/caregiver coping/ support system: granddaughter has large family support system. Any need for counselling? Grief counselling offered." The DPCS stated that time the Bereavement Coordinator was Chaplain 1. During a review of the agencys policy and procedure (P&P) titled ";Bereavement Services" dated 5/24, the P&P indicated, ";[the agency] will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for up to one (10 year following the death of the patient. A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice...Information generated will be incorporated into the plan of care and considered in the bereavement plan of care...After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented as needed...The bereavement counsellors may provide supportive counselling to the patient and family/caregiver prior to death...persons deemed to be experiencing moderate or severe grief will be followed by the bereavement program with increased services and contact offered as noted in the plan of care. Persons identified will be referred to the Bereavement Coordinator and intervention will be followed as follow: A. The Bereavement Coordinator will evaluate each bereaved on a case by case and evaluate the need for individual counselling...A bereavement file will be maintained...Each file will contain the following information...A bereavement plan of care that includes needs and goals for ongoing support..."

Based on interview and record review, the agency failed to demonstrate evidence of annual 12 hours in-service requirement for three of six hospice aides (Hospice Aide 1, 2 and 3). These failures placed patients at risk for receiving personal care from personnel without updated skills and could possibly negatively affect patients. --- During a concurrent interview and record review on 10/21/24 at 2:30 p.m., with the Director of Patient Care Services (DPCS), hospice aide (HA)s annual in-service record was reviewed. The DPCS stated the agency did not have a readily available organized tracking system for review. The DPCS stated since she took over the position a few months ago she had been working on this project. The DPCS contacted each HA and provided copies of evidence of in-service. Three of six HAs had in-service hours that have been met. The following three HAs did not meet the annual 12 hours in-service requirements from their date of hire (DOH). HA 1 DOH 7/1/23 In-service hours completed 5.26 hours. HA 2 DOH 3/6/23 In-service hours completed 4.85 hours. HA 3 DOH 5/8/23 In service hours completed 0.00 hours. During a review of the agencys policy and procedure (P&P) titled ";Director of Patient Care Services-Hospice" undated, the P&P indicated, ";Plans and implements in-service and continuing education programs to meet education and training needs of organization personnel."

Based on observation, interview, and record review, the Registered Nurse/Case Manager (RN/CM) 2 who was responsible for the supervision of Hospice Aide (HA) 4 failed to provide written patient specific plan of care (POC) for one of three sampled patients with home visit (Patient 2) when instructions were not provided to perform both fingernail and toenail care. Toenail care was not done by HA 4 on Pt 2s toenails. These failures placed Patient 2 at risk to experience discomfort and pain while ambulating and worsened the condition of the toenails and required podiatrist consultation. --- During a concurrent observation and interview on 10/15/24 at 12 p.m., with Registered Nurse/Support Clinical Staff (RN/SCS) who accompanied the home visit, Patient 2s feet were observed. Patient 2s right and left big toenails were too thick and long to check the cleanliness of the nail bed. Patient 2s left middle toenail was observed flipped and Patient 2s right ring toenail and pinky toenail were observed long and curved. The RN/SCS stated Patient 2s nail care should have been done either by the agencys aide or the facilitys caregiver before the situation worsened requiring a podiatrist. During a phone interview on 10/21/24 at 4:10 p.m., with HA 4, HA 4 stated, ";...Nail care means file the nails and check the nail beds for cleanness. We are not allowed to cut the nails. I have been doing only fingernails...supposed to check toenails as well..." During an interview on 10/21/24 at 4:10 p.m., with the Director of the Patient Care Services (DPCS), the DPCS stated, ";I expect the case manager give the aides specific guidance about nailcare...its not clear to the aide assignment...should have better plan of care for aide to follow..." During a review of Patient 2s ";Aide Care Plan Report" dated 9/30/24, the Aide Care Plan Report indicated nail care was to be provided once a week. It did not indicate fingernails or toenails or what to do and what not to do. During a review of Patient 2s aide visit note dated 10/10/24, the aide visit note entered by HA 4 indicated, ";Service Nail Care Completed: Y {yes). ";No narrative documents were entered on this visit. During a review of Patient 2s ";Client Coordination Note Report" dated 10/20/24 and 10/22/24 entered by RN/CM 2, did not contain observation of Client 2s toenails requiring podiatrists intervention. During an interview on 10/22/24 at 9:15 a.m., with the RN/CM 3, RN/CM 3 stated she expected the aide to provide nailcare for both fingernails and toenails and for the aids to check the nails and if they were too brittle or unable to keep them clean for any reason to report to their case managers. The RN/CM 3 stated unless the aide care plan specified not to do toenail care due to diabetes, she expected the patients feet to be maintained clean and toenails to be filed. During an interview on 10/22/24 at 10 a.m., with RN/CM 1, RN/CM 1 stated she expected HA 4 to provide nail care. When asked about Patient 2s overgrown toenails RN/CM 1 stated Patient 2 was no longer her patient. RN/CM 1 stated Patient 2 was reassigned to RN/CM 2 recently. The DPCS stated RN/CM 2 coded her visits as supervisory visits, but she did not identify the issues with Patient 2s toenails. The DPCS stated RN/CM 2 was not available for an interview due to a family emergency. During a review of the agencys policy and procedure (P&P) titled ";Registered Nurse" dated 6/26/24, the P&P indicated, ";...Instructs, supervises and evaluates home health [hospice] aide care provided every (2) weeks..." During a review of the agencys P&P titled ";Responsibilities/Supervision of Clinical Services" dated 5/24, indicated, ";Nursing and hospice aide services will be under the supervision of a registered nurse who has at least two (2) years of hospice or community-based health care experience...Hospice aide supervisory visits will be conducted on site at least every two weeks by a hospice registered nurse. Supervisory visits can be made in conjunction with the hospice aide or in his/her absence. A direct observation supervisory visit will be made at least annually..."

Based on interview and record review, the agency failed to conduct an annual on-site visit to evaluate hospice aide (HA) s performance for two of six hospice aide (HA 2 and HA 3). This failure placed the patients care needs to not be met. --- During a concurrent interview and record review on 10/21/24 at 2:30 p.m., with the Director of Patient Care Services (DPCS), hospice aides annual on-site performance evaluation record was reviewed. The DPCS stated two of six HAs did not have their annual evaluations. The following two HA did not have the annual on-site evaluation from their date of hire (DOH). HA 2 DOH 3/6/23 annual on-site evaluation due 3/6/24 (7 months overdue) HA 3 DOH 5/8/23 annual on-site evaluation due 5/8/24 (5 months overdue) During a review of the agencys policy and procedure (P&P) titled ";Responsibilities/Supervision of Clinical Services" dated 5/24, the P&P indicated, ";Nursing and hospice aide services will be under the supervision of a registered nurse who has at least two (2) years of hospice or community-based health... A direct observation supervisory visit will be made at least annually..."

Based on interview and record review, the agency did not have a volunteer program from August 2022 until present since the change of the ownership. This failure placed the agency out of compliance for CFR (code of federal regulation) 418.78 Conditions of participation: Volunteers. --- During an entrance conference on 10/14/24 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she took the position permanently as of 8/15/24 after serving as an interim DPCS. The DPCS stated she had been working on two PI projects. One of two projects was hiring a volunteer coordinator to establish the volunteer program. The DPCS stated she found a good candidate to hire to designate the position as volunteer coordinator. The DPCS presented a paper with handwritten projects with priorities she had been working on for the past few months. The DPCS admitted the agency had been out of compliance with the conditions of participations for Volunteers. During a phone interview on 10/15/24 at 1:36 p.m., with the Administrator (ADM), the ADM stated he was just appointed as the new administrator a month ago and the agency was in process of correcting many issues. The ADM stated since the change of ownership occurred in August 2022 the agency decided to withdraw from being deemed. The ADM stated since the change of ownership, the agency had been out of compliance for Volunteers program. The ADM stated he was working on hiring a candidate for the position for Volunteer Coordinator with the DPCS to start the program. During an interview on 10/22/24 at 2:30 p.m., with the DPCS and the candidate for volunteer coordinator, the DPCS was reminded the required components of the volunteer programs including training, role, recruiting and retraining, cost saving and level of activity. The DPCS understood the requirements to meet the condition of participation upon re-visit. During a review of the agencys policy and procedure (P&P) titled ";Volunteers" dated 5/22, the P&P indicated, ";[the agency] will provide volunteer services under the direction of a Volunteer Coordinator and the assistance of trained hospice volunteers."

Based on interview and record review, the agency failed to maintain, document and provide volunteer orientation and training for two years (since August 2022 until present). This failure placed the agency unable to provide qualified volunteers to provide appropriate services in accordance with the plan of care and hospice program. --- During an entrance conference on 10/14/24 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she took the position permanently as of 8/15/24 after serving as an interim DPCS. The DPCS stated she had been working on two PI (performance Improvement) projects and one of them is to hire a qualified volunteer coordinator who can establish the volunteer training program. The DPCS stated the two PI projects were chosen to meet the federal requirements. The DPCS stated the agency had been out of compliance by not having a volunteer program. During a review of the agencys policy and procedure (P&P) titled ";Volunteer Services" dated 5/22, the P&P indicated, ";to ensure that qualified volunteers provide appropriate services...The Volunteer Coordinator will develop, implement, and evaluate the volunteer services program on an ongoing basis but at least annually...The Volunteer Coordinator will document ongoing efforts to...train..."

Based on interview and record review, the agency failed to utilize volunteers in day to day administrative and/or direct patient care roles for 14 of 14 sampled patients. This failure placed the agency out of compliance for the condition of participation for Volunteers. --- During an entrance conference on 10/14/24 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she took the position as permanently as of 8/15/24 after serving as an interim DPCS. The DPCS stated she had been working on two PI projects, one of them is to hire a volunteer coordinator to establish the volunteer program. The DPCS stated the agency did not utilize volunteers at all for past two years. During a review of the agencys policy and procedure (P&P) titled ";Volunteer Services" dated 5/22, indicated, ";...Volunteers may work in variety of capacities, including 1. Patient care volunteers 2. Bereavement volunteers 3. Errands and transportation volunteers 4. Office volunteers..."

Based on observation, interview, and record review, the agency failed to demonstrate the effort to recruit and retain volunteers. This failure placed the agency being out of compliance with the condition of participation for Volunteers. --- During an entrance conference on 10/14/24 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she took the position as permanently as of 8/15/24 after serving as an interim DPCS. The DPCS stated she had been working on two PI (performance improvement) projects and one of the projects was to hire a volunteer coordinator to establish a volunteer program. There was no brochure observed in the lobby area for a volunteer program. When asked to provide any brochure or advertisement to recruit volunteers, the DPCS stated the agency had none. The DPCS stated she would be hiring the volunteer coordinator and start the recruitment process and advertise for volunteers. During a review of the agencys policy and procedure (P&P) titled ";Volunteers Services" dated 5/22, the P&P indicated, ";The Volunteer Coordinator will document ongoing efforts to recruit, train and retain volunteers of all ages and ethnic backgrounds."

Based on interview and record review, the agency failed to document the cost savings achieved using volunteers. This failure placed the agency out of compliance for the condition of participation for Volunteers. --- During an entrance conference on 10/14/24 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she took the position permanently as of 8/15/24 after serving as an interim DPCS. The DPCS stated she had been working on two PI (performance improvement) projects and one of the projects was to hire a volunteer coordinator to establish a volunteer program. The DPCS stated the agency had been out of compliance for the condition of participation for Volunteers since the agency did not have an active volunteer program for two years (since 8/2022). During a review of the agencys policy and procedure (P&P) titled ";Volunteer Services" dated 5/22, the P&P indicated, ";Volunteers will document their activities on volunteer activity/clinical notes and submit this documentation for the patients clinical record...the Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer service will exceed 5 % of the total patient care hours of paid and contracted hospice personnel."

Based on interview and record review, the agencys volunteers failed to provide day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 % of the total patient care hours for all paid hospice employees and contract staff and maintain records of hours and type of service. This failure placed the agency out of compliance for the condition of participation for Volunteers. --- During an entrance conference on 10/14/24 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she took the position permanently as of 8/15/24 after serving as an interim DPCS. The DPCS stated she had been working on two PI (performance improvement) projects one of the projects was to hire a volunteer coordinator to establish a volunteer program. The DPCS stated the agency had been out of compliance for the condition of participation for Volunteers since the agency did not have an active volunteer program for two years (since 8/2022). During a review of the agencys policy and procedure (P&P) titled ";Volunteer Services" dated 5/22, the P&P indicated, ";the Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer service will exceed 5 % of the total patient care hours of paid and contracted hospice personnel."

Based on interview and record review, the agency failed to ensure the governing body oversees the management, operations and services provided to patients when the agency did not have a volunteer program since 8/2022. This failure placed patients and their families at risk for not receiving the physical and emotional assistance needed during end of life. --- During an entrance conference on 10/14/24 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she took the position as permanent as of 8/15/24 after serving as an interim by cooperate office. The DPCS stated the agency had been out of compliance for the condition of participation for Volunteers since the agency did not have an active volunteer program for two years (since 8/2022). During a phone interview on 10/15/24 at 1:36 p.m., with the Administrator (Adm), the Adm stated he was just appointed as the new administrator a month ago. The Adm stated since the change of ownership on 8/2022, the agency had been out of compliance for Volunteers program. During a review of the agencys policy and procedure (P&P) titled ";Governing Body" dated 5/24, the P&P indicated, ";The Governing Body will assume full legal authority, responsibility, decision-making and accountability for the overall management and operations, the provision of services, fiscal operations, human resources management, review of the organizations budget and operational plans, and its quality assessments and performance improvement (QAPI) program."

Based on interview and record review the agency failed to provide Volunteer services for patients as a standard service when the agency did not have a designated volunteer coordinator to establish the program necessary for two years since the change of the ownership occurred in August 2022. This failure placed the agency out of compliance for the condition of participation for Volunteers. --- During an entrance conference on 10/14/24 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she took the position permanently as of 8/15/24 after serving as an interim DPCS. The DPCS stated she had been working on two PI (performance improvement) projects and one of the projects was to hire a volunteer coordinator to establish a volunteer program. The DPCS stated the agency had been out of compliance for the condition of participation for Volunteers since the agency did not have an active volunteer program for two years (since 8/2022). During a review of the agencys policy and procedure (P&P) titled ";Governing Body" dated 5/24, the P&P indicated, ";The Governing Body will assume full legal authority, responsibility, decision-making and accountability for the overall management and operations, the provision of services, fiscal operations, human resources management, review of the organizations budget and operational plans, and its quality assessments and performance improvement (QAPI) program."

Based on interview and record review, the agency failed to perform the annual evaluation for two of six Hospice Aides (HA 2 and HA 3) and one of four Registered Nurse/Case Managers (RN/CM 1). These failures placed patients care needs to not be met. --- During a concurrent interview and record review, on 10/23/24 at 9:50 a.m., with the Human Resources (HR), the agencys personnel files for competency evaluation were reviewed. The HR was not able to locate the annual competency evaluation for the following employees. The HR stated the annual competency date should have been done on or near the date of hire (DOH) every year. The following employees were found to not have a competency evaluation for 2024 in their files. HA 2 DOH 3/6/23 HA 3 DOH 5/8/23 RN CM2 DOH 8/16/22 During an interview on 10/23/24, at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she performed annual competency evaluation for HA 2s on 10/14/24 (survey entrance date). The DPCS stated it was the DPCSs responsibility to evaluate clinicians and ensure RN/CMs evaluate their HAs competency annually. During a review of the agencys policy and procedure (P&P) titled ";Performance Evaluation" dated 5/24/24, the P&P indicated, ";Performance evaluations will be completed (and dated) on all personnel as follows...annually, based on personnels annual evaluation date...At least annually, clinical personnel must demonstrate proficiencies in the appropriate core competency..." During a review of the agencys job description titled ";Director of Patient Care Services-Hospice" undated, indicated, ";Conducts clinician performance evaluations annually, or more frequently if indicated...Evaluates performance of Clinical Supervisors [RN/CM] ..."