Every finding on record at Votive Hospice LLC

Observed in Tracer Activities. The organization was not able to provide documented cost savings achieved using volunteers in the 44 days since their triennial survey ended. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Tracer Activities. The organization was not able to provide documentation of volunteers providing at least 5% of the total patient care hours of all paid hospice employees in the 44 days since their triennial survey ended. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Emergency Management Session. The emergency management program did not include all required elements as it was a generic policy and procedure template dated 2023. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor. Observed in Emergency Management Session. The organization failed to comply with all applicable federal, state, and local emergency preparedness laws and regulations as evidenced by failure to complete drills, and review and update the plan as required. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Emergency Management Session. The organization did not have a hazard vulnerability analysis. As a result, natural, human caused, technological, hazardous materials, and emerging and infectious diseases were not addressed. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor. Observed in Emergency Management Session. The organization did not conduct a hazard vulnerability analysis using an all-hazards approach as evidenced by the organization was not able to produce documentation at the time of survey.This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Emergency Management Session. The organization did not have a written continuity of operations plan (COOP) as evidenced by their inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor. Observed in Emergency Management Session. The organization did not have a written delegation of authority plan that provided the individuals with the legal authorization to act on behalf of the organization for specific purposes as evidenced by their inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor. Observed in Emergency Management Session. The organization did not identify in writing how and where it would continue to provide its essential business functions when critical service had been compromised as evidenced by their inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor. Observed in Emergency Management Session. The organization did not have a written succession plan that identified who had authority to assume particular leadership or management roles when that person was unable to perform their duties as evidenced by their inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor. Observed in Emergency Management Session. The organization emergency operations plan did not identify the patient population it would serve and the types of services it would have the ability to provide in an emergency as evidenced by their inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Emergency Management Session. The emergency operations plan did not have a process for collaboration with the local, state, tribal, regional, and federal emergency preparedness officials as evidenced by their inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Emergency Management Session. The organization’s emergency plan did not include written procedures for determining what services were needed in the event there was an interruption in services due to an emergency as evidenced by their inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Emergency Management Session. The organization did not establish primary and alternate means for communication with staff and relevant authorities as evidenced by the inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Emergency Management Session. The organization’s emergency operations plan did not include policies and procedures that described how it would inform state and local emergency preparedness officials about its patients in need of evacuation from their residences due to an emergency as evidenced by their inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Emergency Management Session. The organization failed to develop a staffing plan and therefore did not address the management of all staff and volunteers as evidenced by their inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor. Observed in Emergency Management Session. The organization did not develop a staffing plan for managing all staff during the duration of an emergency event or patient surge as evidenced by their inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Emergency Management Session. The organization’s emergency operations plan did not include how it would share patient care information and medication documentation as evidenced by their inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Emergency Management Session. The organization did not review and update the emergency operations plan based on after-action reports every two years as evidenced by their inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Emergency Management Session. The organization did not maintain a contact list of individuals and entities that were to be notified in response to an emergency as evidenced by their inability to produce documentation of the list of contacts. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Emergency Management Session. The organization’s communications plan did not include a method for sharing and/or releasing location information and medical documentation as evidenced by their inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Emergency Management Session. The organization’s communications plan did not describe how it would report information about its needs and ability to provide assistance to relevant authorities as evidenced by their inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Emergency Management Session. The organization failed to describe how it would conduct annual testing of its emergency plans as evidenced by their inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Emergency Management Session. The organization leaders failed to review and evaluate all exercises and actual emergency incidents as evidenced by their inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Emergency Management Session. The organization did not have a prioritized hazard vulnerability analysis to identify and implement mitigation and preparedness actions as evidenced by their inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor. Observed in Emergency Management Session. The organization did not evaluate and prioritize the findings of the hazard vulnerability analysis as evidenced by their inability to produce documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Record Review. In 1 of 1 live discharge records reviewed, there was no documentation in RRDC#2 that a Notice of Medicare Non-Coverage was signed two days prior to discharge for extended prognosis as required. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Record Review. In 1 of 10 active patient records reviewed, a spiritual care initial comprehensive assessment was not completed within five calendar days after the election of the hospice benefit. In patient record RRHV#1 there was no documentation until 16 days after admission that the family declined multiple attempts to make the visit. In patient records This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Record Review. In 10 of 10 active patient records reviewed, a registered nurse did not visit the patient every 15 days to conduct a comprehensive re-assessment. In patient records RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, and RRNHV#7 comprehensive re-assessments were not documented as required. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Record Review. In 10 of 10 active patient records reviewed, most plan of care goals were not measurable, and none included a target date for completion. Here are some examples. Patient will be in control of what, how much, and when to eat. Associated symptoms of anorexia and cachexia will be managed. Patient's quality of life will be at an optimal level. Patient will report comfort. This RFI was reviewed with and verified by the Administrator and Nursing Supervisor.

Observed in Record Review. In 7 of 10 active patient records reviewed, prn visits for all disciplines did not include rationale in records RRHV#1, RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#5, and RRNHV#7. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Record Review. In 7 of 10 active patient records reviewed, care was not provided in accordance with the hospice plan of care. In patient records RRHV#1, RRHV#2, RRNH#2, RRNHV#3, RRNHV#4, RRNHV#5, and RRNHV#6 visits by core team members were not documented as often as ordered. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Leadership Session. The QAPI program did not involve all services provided as evidenced by their organization not being able to produce this documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor. Observed in Leadership Session. The organization was not able to demonstrate the operation of its QAPI program as evidenced by their inability to produce documentation of the program at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Tracer Activities. The organization did not analyze and compare data over time to identify performance and trends. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor. Observed in Tracer Activities. The organization did not use the results of data analysis to identify improvement opportunities as evidenced by their inability to produce this documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Leadership Session. The governing body did not approve the frequency and detail of data collection as evidenced by their inability to produce this documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Surveyor review but corrected onsite pending acceptable Evidence of Standards Compliance. The organization did not act on improvement opportunities as evidenced by their inability to produce this documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor. Observed in Tracer Activities. The organization did not act when planned improvements were not achieved or sustained as evidenced by their inability to produce this documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor. Observed in Surveyor review but corrected onsite pending acceptable Evidence of Standards Compliance. The organization did not evaluate the efficacy of their improvement actions as evidenced by their inability to produce this documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Leadership Session. There was no effective, ongoing, organization wide, data-driven QAPI program as evidenced by their inability to produce this documentation at the time of survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Data Session. Performance improvement was not organization wide as evidenced by the absence of any documentation or data collection since the last survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor. Observed in Leadership Session. Leadership did not establish priorities for data collection/performance improvement activities as evidenced by their absence of any documentation or data collection since the last survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Infection Control System Tracer. The organization had no current procedure for identifying infections and communicable disease issues or activities as evidenced by the absence of consistent documentation or data collection since the last survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor. Observed in Infection Control System Tracer. The organization had no current procedure for identifying infections and communicable disease issues or activities as evidenced by the absence of consistent documentation or data collection since the last survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Infection Control System Tracer. The organization did not collect or analyze data, which prevented them from identifying infection control issues and developing and implementing necessary action plan activities as evidenced by the absence of any documentation and minimal data collection since the last survey. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Record Review. In 9 of 10 active patient records reviewed, it was determined that hospice aide supervision was not documented every 14 days. In patient record RRHV#1, RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, and RRNHV#7 supervisory visits not done as required. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Tracer Activities. the organization did not have any active volunteers in the last 15 months and leaders were not able to provide documentation of recruitment efforts. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Tracer Activities. The organization was not able to produce documented cost savings achieved using volunteers for the past 15 months because there were no volunteers despite on-going recruitment efforts. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Tracer Activities. volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff for the last 15 months. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Leadership Session. Leaders did not manage implementation of patient care policies and procedures governing the provision of care as evidenced by condition level findings at §418.54, §418.58, §418.78, §418.113. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Record Review. In 1 of 1 patient transfer records, there was no documentation in RRDC#1 that a summary was sent with the patient to a hospital for treatment of a hip fracture. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Infection Control System Tracer. The organization did not have current written policies and procedures to guide its activities and methods for preventing and controlling the transmission of infections and communicable diseases. This RFI was reviewed with and verified by the Administrator and Nurse Supervisor.

Observed in Document Review. There still has not been an individual identified to act as the alternate DON. The organization has contracted with the SNF next door to provide RN oversight however no individual has been named and there is no documentation of an HR file for credentials, competencies or orientation to the organization. This was confirmed with the DON and the administrator. Observed in Document Review. There still has not been an individual identified to act as the alternate DON in the absence of the DON. They have contracted with the SNF next door to provide RN oversight however no individual has been named and there is no documentation of an HR file for credentials, competencies or orientation to the organization. The only RN employed is the DON. This was confirmed by the DON and the administrator.

Observed in Document Review. There still has not been an individual identified as the Medical Social Worker. They have contracted with the another hospice to provide the Medical Social Work services however no individual has been named and there is no documentation of an HR file for credentials, competencies or orientation to the organization.

Observed in Document Review. There was no documentation that the agency had an active volunteer program. There have been recruitment efforts however at this time there is one individual who has expressed interest but they have not yet been trained. This was confirmed with the DON.

Observed in Document Review. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation and staff interviews: 418.114, 418.64, 418.102, 418.100

Observed in Document Review. The organization did not have an alternate physician designee to perform the responsibilities as the medical director. There was a contract with a physician presented from 3/4/2020 however there was no HR file, no proof of credentials, orientation, competencies and no other documentation available. This was confirmed by the DON and administrator.

Observed in Tracer Visit. In 1 of 1 home visits conducted, it was noted that the hospice medication sheet and the SNF medication profile did not contain the same medications. For example, in home visit #1 the following medications were on the SNF medication profile but not in the hospice record, Biscodyl, Docusate, Fleet enema, Loperamide, MOM and Mylanta. There was one medication, Simethicone which was on the hospice med sheet but not on the SNF medication profile. Lastly, Melatonin was stated as 100mg, 4 tabs every night on the hospice medication profile however the SNF medication sheet listed 100mg 1 tab every night. All of these were discussed with the DON and the Melatonin dosage discrepancy was confirmed by the DON.

Observed in Record Review. There have been no live discharges since prior survey ending on 6/10/22, therefore unable to assess compliance. This was discussed with the DON and Administrator.

Observed in Record Review. There have been no live discharges since prior survey ending on 6/10/22, therefore unable to assess compliance. This was discussed with the DON and Administrator.

Observed in Document Review. During discussion with the DON and administrator it was noted that there were no HR files in place for the contracted Alternate Medical Director, the contracted MSW or the contracted Alternate DON therefore no verification of staff qualifications. Observed in Document Review. During discussion with the DON and administrator it was noted that there were no HR files in place for the contracted Alternate Medical Director, the contracted MSW or the contracted Alternate DON therefore there was no verification of any licensure or credentials.

Observed in Document Review. During discussion with the DON and administrator it was noted that there were no HR files in place for the contracted Alternate Medical Director, the contracted MSW or the contracted Alternate DON therefore there was no verification of criminal background checks.

Observed in Emergency Management Session. The EOP does not describe the agency's arrangement with other organizations in the event that the agency cannot serve it's patients as a result of the emergency. This was discussed with the Administrator and DON.

Observed in Record Review. In 2 of 13 patient records reviewed, There were no initial Chaplin assessment as required by regulation and agency policy. This was discussed with the Administrator and DON. ( RR#7, RR#2)

Observed in Record Review. There was no initial bereavement assessment completed on admission in record RR#7 as required by regulation and agency policy. This was discussed with the Administrator and DON.

Observed in Record Review. In 13 of 13 patient records reviewed, the plans of care did not have measurable outcomes or specific time frames identified for the established goals as required by regulation and agency policy. This was discussed with the Administrator and DON.

Observed in Record Review. In review of clinical record RR#7, the plan of care had not been updated since admission 9 months ago. For example, an original problem related to patient not having appropriate equipment: this problem has not been resolved. This was discussed with the Administrator and DON.

Observed in Data Session. The agency was unable to provide any performance improvement data, outcomes, or meeting minutes as required by regulation. This was discussed with the Administrator and the DON.

Observed in Patient Home. In 1 of 3 home visits conducted, the hospice aide at home visit #3 did not keep her clinical bag closed during her visit nor did she clean her hands before entering the bag as required by agency policy. This was discussed with the Administrator and the DON. Observed in Patient Home. In 1 of 3 home visits conducted, the LVN did not clean her pulse ox device prior to putting it in her clinical bag as required by agency policy. This was discussed with the Administrator and the DON.

Observed in Leadership Session. The agency failed to plan for the DON's vacation. She is the only registered nurse in hospice and left on vacation the day after this survey commenced. She stated that she would be available to her staff via phone and would continue to observe / conduct visits via teleconferencing. This was discussed with the Administrator and the DON. Observed in Document Review. In discussion with agency leadership , the Administrator stated that he had not appointed an alternate DON as required by agency policy.

Observed in Record Review. The organization has not had a qualified medical social worker to provide psychosocial services to their patients for 4 months. This was discussed with the Administrator and the DON. Observed in Record Review. In 7 of 13 patient records reviewed, there was no documentation of an initial psychosocial assessment as required by regulation and no documentation explaining why. This was discussed with the Administrator and the DON.

Observed in Record Review. In 1 of 2 bereavement records reviewed, there was no bereavement plan of care in record BR#2. This was discussed with the Administrator and the DON.

Observed in Document Review. There was no documentation that the agency had achieved cost savings through the use of volunteers in the last 18 months. Nor was there documentation of the dollar value saved through the use of volunteers. This was discussed with the Administrator and the DON.

Observed in Document Review. The Governing Board / Leadership did not ensure that the following Conditions of Participation were met as determined through observation, documentation and staff interviews : 418.56, 418.58, 418.64, 418.78, 418.100, 418.102, 418.104, and 418.116.

Observed in Document Review. There were none of the required verbiage in the Pharmacy contract. For example: delineation of the roles; that services will be delivered in accordance with the patients' plans of care and qualifications of the contractor's employees. This was discussed with the Administrator.

Observed in HR File Review. There was no documentation in the medical director's peronnel file that he had been competenced as required by agency policy and regulation. This was discussed with the Administrator and DON.

Observed in Leadership Session. The organization did not have an alternate physician designee to perform the responsibilities as the medical director. This was discussed with the Administrator and the DON.

Observed in Record Review. In 13 of 13 patient records reviewed, documentation such as discipline visit notes was being written as narrative notes on a progress form that is not uploaded in a timely manner to the electronic health record as required by agency policy. The agency requirement is 2 times a week and all data in the record within 14 days.. This narrative documentation does not always include a head-to-toe assessment, medication review or education provided to the patients. In one facility the documentation is written on the facility's nursing paper note. This was discussed with the Administrator and the DON. Observed in Record Review. In 11 of 12 patient records reviewed, the bi-monthly re-assessments and most re-certifications were being conducted on site and documented by an LVN using a LVN visit note. These notes were signed by the LVN and included a note from the RN who was virtually present to observe the admission. The RN note read: This visit was conducted with the use of an interactive audio and video telecommunication system that permits real time communication with the patient and staff. Patient consent for the virtual visit was obtained at the time of the visit. Original site: Votive hospice. Distant site: patient place of residence. Due to COVID 19 precautions and to decrease the risk of exposure to staff and patient, the RN assessment was completed via telehealth with the assistance of the caregiver at the bedside and the hospice LVN. Nursing assessment verified by RNCM as documented by the LVN.

Observed in Patient Home. In one of 3 home visits conducted, medications at home visit #3 were reviewed with the LVN and the following discrepancies were found: 4medications on the agency MAR (medication administration record) not on facility MAR. There were, 12 medications on the facility MAR but not on the agency MAR -( includes both Rx and OTC; ) There were 3 medications listed as PRN for symptom management but the indications were the same for all dosages. For example, morphine was listed with 4 different doses but all 4 indications say for severe pain; same indication for 3 different dosages of Bisacodyl for constipation and the same indication for 3 different dosages of Ondansetron for nausea. This was discussed with the Administrator and the DON.

Observed in Record Review. In 3 of 3 patient records reviewed, for patients who had been discharge alive, there was no documentation that the agency had provided the receiving agency with the patient's discharge summary or a copy of the clinical record. This was discussed with the Administrator and the DON.

Observed in Record Review. In 3 of 3 patient records reviewed, for patients who were discharged alive, the discharge summaries did not include a summary of the patients' stay, their current plan of care, or instructions for the patient related to follow up with their physician. This was discussed with the Administrator and the DON.

Observed in Document Review. In 2 of 3 contracts reviewed, there were no expectations included in the contract indicating how the agency would monitor the contract as required by regulation. This was discussed with the Administrator. Observed in Document Review. There was no documentation indicating that the agency had monitored their contracts at any time.

Observed in Record Review. In 9 of 9 patient records reviewed, for patients who resided in a nursing care facility, the plans of care did not identify which provider was responsible for performing the care and services that had been agreed upon for each patient. This was discussed with the Administrator and the DON. (RR#1,2,4,6,7,8,10; HV#1,2)

Observed in HR File Review. In 6 of 6 HR files reviewed, for licensed professionals, primary source verification of their licenses was done around the time of hire instead of prior to hire, and not done subsequently at time of renewal as required by policy and regulation. This was discussed with the Administrator and DON. Observed in HR File Review. There was no documentation in the medical director's personnel file that he had an in-date DEA license. The physician attested that this license was available from his medical clinic and he would send a copy next business day. This was discussed with the Administrator and the DON.

Observed in Infection Control System Tracer. An employee has a religious exemption from being vaccinated however he is not following the agency's policy and procedure utilizing preventive measures such as wearing a mask. All other staff are in compliance with the CMS 42.CFR 484.38. This was discussed with the Administrator and the DON. Observed in Record Review. In 1 of 3 live discharges, there was no documentation in the file of patient RR#6 about the patient being educated to the Notice of Medicare Non Compliance 2 days prior to discharge as required by regulation. This was discussed with the Administrator and the DON.