Every finding on record at Visiting Nurse Home Care & Hospice of Carroll County

Based on interview and review of the Emergency Preparedness Plan (E.P.P.), it was determined that the facility failed to ensure a policy for use of the 1135 waiver process during a declared public emergency. --- Review of the Emergency Preparedness Program (E.P.P.) during survey on 4/22/25 between 8:00 a.m. and 10:00 a.m. with Staff A (Executive Director) revealed the facility failed to include the process and procedures to include the 1135 waiver act for provisions of care and treatment at an alternative care site identified by emergency management officials.Interview on 4/22/25 with Staff A confirmed the above findings and the failure to include the 1135 waiver policies and procedures.

Based on record review and interview, it was determined that the Hospice Agency failed to have a Quality Improvement and Performance Improvement (QAPI) program that used quality indicator data, including patient care, and other relevant data, in the design of its program. --- Review on 4/23/25 of Quality Assurance and Performance Improvement records revealed QAPI meetings in January 2025, October 2024, and July 2024 showed minutes that included a review of pain, general inpatient stays, bowel management, and satisfaction. Further review showed there was no documentation of aggregated data or analysis of data that included all patient services and all activities that may impact patient/family care. There was no documentation of the following services or activities in the QAPI minutes: physician services, medical social services, counseling services, clinical records, infection control, patient rights, administrative services, contract services, volunteers, and hospice aides. There was no evidence that data was used to identify and prioritize opportunities for improvement.  Interview on 4/23/25 at approximately 11:00 a.m. confirmed the above findings.

Based on record review and interview it was determined that the hospice agency failed to ensure that counseling services included bereavement services for 1 of 2 patients in the survey sample. (Patient identifier is #4.)Findings include: --- Review on 4/22/25, of the medical record of Patient #4 revealed that they were accepted onto hospice on 7/24 and the family had accepted bereavement services. Further review of Patient #4's medical record revealed that he/she passed away 8 days later. Interview on 4/22/25 at approximately 11:00 a.m. with Staff A (Clinical Services Director) and Staff B (Administrator), confirmed that the family did not have any bereavement counseling follow up after Patient #4's death. Staff A and Staff B confirmed that no phone calls, offer of support, or letters were sent to the family.

Based on interview and record review, it was determined that the facility failed to ensure skills and competence were evaluated annually for 7 out of 11 employee files reviewed. --- Review on 4/22/25 of Employee Files revealed:Staff G (Speech Therapist), hire date 7/8/13, last annual evaluation done on 9/26/23Staff E (Licensed Nursing Assistant, hire date 11/30/15, last annual evaluation on 9/22/23Staff C (Registered Nurse), hire date 6/13/16, last annual evaluation on 3/3/24Staff A (Volunteer Coordinator) hire date 2/12/18, last annual evaluation on 8/29/19Staff F (Occupational Therapist) hire date 12/14/17, last annual evaluation on 9/26/23Staff D (Medical Social Worker) hire date 8/2/18. last annual evaluation on 12/15/19Staff H (Physical Therapy Assistant) hire date 3/31/15, last annual evaluation 4/26/23Interview on 4/22/25 at approximately 12:15 p.m. with Staff B (Human Resources) confirmed the above findings.Review on 4/22/25 of the facility policy titled, Performance Evaluations, undated revealed: … Procedures… 3. Formal performance evaluations are scheduled every 12 months, coinciding generally with the anniversary of the employee’s original date of hire….