Every finding on record at Affective Hospice Care, Inc.

Observed in Patient Home. In 3 of 3 home visits conducted, the hospice had not provided the patient with written information about its policies on advance directives. In review of the home folder for RRHV #1 there was no evidence that the organization had provided the patient/family with their policy no. 1-004.1 Advance Directives. This was also observed in review of the home folders for RRHV #2 and RRHV #3 and validated with the Administrator Designee who was present on the home visits.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization had not completed the comprehensive assessment no later than five calendar days after the election of hospice care. In review of the medical record for RRNHV #1 the spiritual care assessment was completed 24 days after the election of the hospice benefit. Additionally in review of the medical record for RRNHV #3 the psychosocial assessment was completed was completed 10 days following the start of hospice care and the spiritual assessment was completed 21 days following the start of care. Finally, in review of the medical record for RRNHV #4 the spiritual assessment was completed 33 days following the election of the hospice benefit. This was discussed with the Owner/Administrator.

Observed in Record Review. In 6 of 10 patient records reviewed, the organization had not assessed survivor risk factors. In review of the medical records for RRNHV #1, RRNHV #2, RRNHV #3, RRNHV #4, RRNHV #6 and RRNHV #7 there was no evidence that an initial bereavement risk assessment had been completed as part of the comprehensive assessment following election of the hospice benefit. This was validated with the Owner/Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, of discharged patients, the organization did not inform the patient of the kinds of continuing care, treatment, or services at the time of discharge in accordance with their policy no. 2-071.1 Discharge from Hospice Program. In review of the medical record for RRDC #1 there was no evidence that the hospice provided the patient with discharge instructions or with the necessary contact information to facilitate continuity of care. This was discussed with the Owner/Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization had not revised the plan of care in based on changes in the patient’s condition. In review of the medical record for RRHV #2 a SN visit that occurred during the 4th week following the start of care documented a skin tear to right arm with a physician order to cleanse with Normal Saline, pat dry, apply Triple antibiotic ointment, cover with non adherent dressing, wrap with kerlix and secure with tape daily and as needed when soiled / loss integrity until resolved. The plan of care included a problem that was initiated at the start of care of potential for skin breakdown or development of pressure ulcers due to poor skin turgor. with a goal for caregiver(s) will demonstrate appropriate compliance with skin care regimen, as instructed, resulting to zero occurrence of pressure ulcer(s) throughout the certification period, and an intervention to assess alteration in skin integrity every visit. Educate/assess/monitor Caregiver’s ability to perform proper skin care. Teach family/PCG ways to prevent skin breakdown, appropriate nutrition and hydration. Teach ways to use skin barriers and expeditiously changing wet diapers. May apply A&D ointment on bony prominence or dry skin as needed daily. There was no evidence that the plan of care had been revised to address the change in the patient's condition in accordance with their policy no. 2-044.1 Plan of Care which states, any change in the patient's condition must result in a change in the plan of care prior to the implementation of the new service/treatment. This was validated with the Owner/Administrator.

Observed in Record Review. In 2 of 14 patient records reviewed, care was not provided according to hospice plan of care. For example, in review of the medical record for RRNHV #6 the plan of care included social work visits 2 times a month and spiritual care visits two times a month however only one visit a month was provided by the social worker and the spiritual care counselor since the start of care three months ago. Additionally, in review of the medical record for RRNHV #7 the plan of care included SN visits 1-2 times a week however there was no evidence of SN visits the 4th week following the election of the hospice benefit. Also, home health aide visits were to be provided two times a week and there was no evidence in the medical record that the patient received home health aide visits the 6th week following the election of the hospice benefit This was discussed with the Owner/Administrator.

Observed in Leadership Session. The organization has not maintained an infection control program that includes surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. In review of the infection control program and QAPI program the surveyor noted that the organization had not collected data as planned and that there was no evidence of analyzing or trending data. This was discussed with the Owner/Administrator.

Observed in Patient Home. In 2 of 2 home visits conducted, with nurses, staff did not follow the organization's bag technique policy. no. 9-014.1. The policy states that equipment will be cleaned and returned to the clinical bag at the completion of the visit however for RRHV #1 the LVN removed the equipment at the start of the visit cleaned it, performed her visit and returned the dirty equipment to the clinical bag and then proceeded to see RRHV #2 with the same process. This was validated with the Administrator Designee who was present on the home visits. Observed in Patient Home. In 3 of 3 home visits conducted, staff failed to perform hand hygiene at times required by standard precautions, manufacturer instructions or organizational policy no. 9-009.1 Hand Hygiene as evidenced by: during the home visit for RRHV #1 the LVN failed to perform hand hygiene after removing gloves. For RRHV #2 the LVN performed a glove change and failed to perform hand hygiene after removing gloves and before donning a clean pair of gloves. for both RRHV #1 and RRHV #2 the LVN was observed re-entering the clinical bag without performing hand hygiene as required by organization policy. For RRHV #3 the Social Worker failed to perform hand hygiene throughout the home visit including entering the home, after contact with the patient and upon leaving the home. This was validated with the Administrator Designee who was present on the home visits.

Observed in Leadership Session. The organization had not implemented its infection prevention and control activities, including surveillance. In review of the hospice organization's QAPI and Infection Control Plan the surveyor noted that infection prevention and control activities did not include any surveillance or recording of data for the priorities identified in their QAPI and Infection Control Plan including; preventing UTI within 30-60 days after admission, preventing GT site infection within 15-30 days after admission, preventing UR infection within 15-30 days after admission. prevention wound infection within 15-30 days after admission, prevention of diarrhea within 15-30 days after admission. Additionally, the Infection Control Plan identified goals for handwashing, cleaning and disinfecting equipment, bag technique and flu vaccination however there was no evidence that data had been collected as planned. This was validated with the Owner/Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, for bereavement services, the hospice had not developed a bereavement plan of care that specifies the type of bereavement services to be offered and the frequency of service delivery. For RRBR #2 there was no evidence in the medical record that a bereavement plan of care had been developed to meet the needs of the daughter who was the primary bereaved. This was discussed with the Owner/Administrator.

Observed in Document Review. The organization had not documented its efforts to recruit and retain volunteers. In review of the Volunteer Program the program evaluation for 2023 stated that no recruitment efforts were made due to CMS waiver section 1135 and there was no evidence of recruitment efforts year to date for 2024. This was validated with the Volunteer Coordinator.

Observed in Leadership Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by the implementation of policies and procedures including the infection control program and QAPI program and did not ensure that the following Conditions of Participation were met 418.60. This was validated with the Owner/Administrator.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization had not Informed and educated the patient about the following safe storage of oxygen. During the home visit for RRHV #2 it was noted that the patient had more than 30 canisters of oxygen stored on the patio in temperatures exceeding 90 degrees. In review of the medical record there was evidence of Oxygen Safety Assessments completed every 14 days by the Registered Nurse which included; Are O2 cylinders stored securely.- yes for every assessment completed since the start of care over 12 months ago. There was no documentation of the number of oxygen canisters the patient was storing or any education that the oxygen should be moved into the house where the temperature was cooler. The LVN did provide education during the survey visit. This was validated by the Administrator Designee who was present at the home visit. Observed in Patient Home. In 3 of 3 home visits conducted, the hospice had not provided the patient with an individualized emergency plan. In review of the home folder for RRHV #1 the surveyor noted that the hospice had provided emergency information and resources however the document was not individualized to include the patient's specific DME such as oxygen and assistive devices. This was also observed in review of the home folders for RRHV #2 who was oxygen dependent and RRHV #3 who was bedbound and oxygen dependent. This was validated with the Administrator Designee who was present on the home visits.