Every finding on record at Afi Hospice, LLC

Based on interview and record review, it was determined for 5 of 15 sampled patients, that the agency did not ensure that visits were made as ordered. Specifically, Skilled Nursing visits; Social Worker visits; and Chaplain visits were not completed as care planned. (Patient identifiers: 1, 2, 6, 8, and 13) --- 1. Patient 1 was admitted to the agency on 2/10/2021 with a terminal diagnosis of senile degeneration of brain. Patient 1's medical record was reviewed on 8/15/2023. Patient's 1's plan of care (POC) for the period of 4/10/2023 through 6/8/2023 had a skilled nursing (SN) to assess the patient twice a week for 5 weeks. There was an increase in the SN visits beginning 5/7/2023 through 5/13/2023 at which time the patient passed away. The administrator (ADM) was interviewed on 8/16/2023 at approximately 3:50 PM, related to the increase in visits. The ADM was not able to provide documentation as to why there was an increase in the frequency of the SN visits. 2. Patient 2 was admitted to the hospice agency on 2/3/2023, with a terminal diagnosis of Alzheimers disease unspecified. A review of patient 2s medical record was completed on 8/21/2023. Patient 2's POC for the certification period of 5/4/2023 to 8/1/2023 revealed patient 2 was to receive medical social worker (MSW) visits 2 times per month starting on 5/4/2023 and Hospice aide visits 1 visit per week for 1 week, 3 visits per week for 12 weeks, and then 1 visit per week for one week starting the week of 5/4/2023. Further review of the MSW documentation revealed patient 2 only received 1 visit for the month of May on 5/28/2023. Documented evidence shows a missed visit note on 5/31/2023 by the MSW stating ";recent visit with patient." No further explanation was given. Patient 2 also had a missed hospice aide visit for the week of 6/4/2023. Aides missed visit note stated, ";I got into a motorcycle accident and was in the hospital." In an interview with the administrator on 8/16/2023 at 4:40 PM. He stated yes, they are missed visits. For the missed aide visit we should have reached out to show that we tried to cover the visits, but we do not have any documentation to show that this happened. 3. Patient 6 was admitted to the agency on 5/29/2023 with a terminal diagnosis of heart failure. Patient 6's medical record was reviewed on 8/17/2023. The plan of care for the cert period of 5/29/2023 to 8/26/2023 had SN visits were to be 2 times a week for 8 weeks, then once a week for 1 weeks beginning 5/28/2023. Aide visit were to be 3 times per weeks for 8 weeks and then twice a week for 1 week. The MSW frequency was to be 2 times per month for 1 month beginning 6/1/2023, and then 2 times per month beginning 7/1/2023. On 6/24/2023, it was documented, "MSW rescheduled visits." There was no additional documentation available for review to indicate why the visit was rescheduled. On 6/29/2023, the SN documented, "unable to find coverage, called facility and checked in on the patient." On 7/12/2023, it was documented, "MSW recently visited." There was no MSW visit rescheduled. 4. Patient 8 was admitted to the agency on 6/16/2022 with a terminal diagnosis of chronic obstructive pulmonary disease. A review of patient 8s medical record was completed on 8/21/2023. Patient 8's POC for the certification period of 6/11/2023 to 8/9/2023 revealed patient 8 was to receive Skilled nursing (SN) visits 2 visit per week for 8 weeks starting 6/11/2023. Further review of patient 8's medical record revealed patient 8 only had 1 SN visit during the week of 7/2/2023 on 7/5/2023. Documented evidence showed a nursing missed visit note stating, ";no visit needed." In interview with the administrator on 8/16/2023 at 4:40 PM. He stated according to frequencies yes there should have been 2 visits during the week of 7/2/2023. 5. Patient 13 was admitted to the agency on 2/11/2023 with a terminal diagnosis of Parkinsons disease. A review of patient 13s medical record was completed on 8/21/2023. Patient 13's POC for the certification period of 5/12/2023 to 8/9/2023 revealed patient 13 was to receive MSW visits 2 times per month starting on 6/1/2023, and 2 visits per month starting on 7/1/2023. Further review of the MSW documentation revealed patient 13 only received 1 visit during the month of June on 6/30/2023 and only 1 visit during the month of July on 7/31/2023. In an interview with the administrator on 8/16/2023 at 4:40 PM. He stated ";it is pretty conclusive they are missed visits." The agency's missed visit policy had that the clinician who was scheduled to complete the visit, was to find another qualified clinician to do the visit. If the clinician was unable to find a qualified replacement, attempts to reschedule the visit with the patient were to occur and be documented.

Based on interview and record review, it was determined the Quality Assessment/Performance Improvement (QAPI) Committee did not monitor the effectiveness and safety of the services and quality of care; and did not identify opportunities and priorities for improvement. Specifically, the QAPI committee did not review employee infections, did not track or trend patient infections, and data was co-mingled with other certified agency within the Corporation. --- Finding include: An entrance conference was conducted with the Administrator (ADM) on 8/15/2023 at approximately 9:26 AM. The administrator was asked to provide information regarding the infection control program and surveillance data for monitoring infections for patients and employees and evidence of QAPI meetings. The QAPI meeting conducted on 10/6/2022 had a performance improvement project (PIP) of Aide Services Communication Initiative related to Patient Care/Improved communication. It was reported to the QAPI committee that there were 17 wounds, 17 infections and 42 incidents The QAPI meeting conducted on 1/6/2023 at a PIP of of Aide Services Communication Initiative related to Patient Care/Improved communication. It was reported to the QAPI committee that there were 15 wounds, 10 infections, and 20 incidents. The QAPI meeting conducted on 4/1/2023 had a PIP of Aide Services Communication Initiative related to Patient Care/.Improved communication. It was reported to the QAPI committee that there were 2 wounds, 18 infections and 48 incidents. The QAPI meeting conducted 7/5/2023 had a PIP of Aide Services Communication Initiative related to Patient Care/Improved communication. It was reported to QAPI committee that there were 14 wounds, 21 infections, 72 incidents and 21 discharges. An interview was conducted with the administer on 8/17/2023 related to the high number of wounds, infections and incidents reported on 7/5/2023 as well as to check and see if the data included other certified facilities within the corporation. On 8/18/2023 at 3:07 PM, the ADM submitted the following for 7/5/2023, 2 wounds; 1 infection; and 39 incidents. Which indicated that information was co-mingled with other certified agencies within the corporation. There was no further documentation that the QAPI committee analyzed the data being presented or made recommendations based on the analyzed data.

Based on interview, it was determine the agency did not have a registered nurse supervise all nursing care. --- Findings include: In the entrance interview, conducted on 8/15/2023 at approximately 9:26 AM, the Administrator (ADM) was asked who the Director of Nursing (DON) was. The ADM stated that there was not a DON and that the previous DON's employment was terminated on 8/14/2023. The ADM stated that the agency had hired another registered nurse to be the DON, but that the nurse would not be starting until 9/5/2023. The ADM had not appointed another agency nurse to be the acting DON until the new nurse started.

Based on interview and record review, it was determined the Medical Director did not appoint another doctor of medicine or osteopathy to act on the behalf of the Medical Director when not available. --- Findings include: An entrance interview was conducted with the agency Administrator (ADM) on 8/15/2023 at approximately 9:26 AM. The ADM was asked who was appointed to act on behalf of the Medical Director, when not available. The ADM stated there was not one. The ADM stated, "The Medical Director is always available." The ADM then stated that one of the two Nurse Practitioners would provide coverage when the Medical Director was not available. The "Medical Director Agreement" was reviewed. Responsibility for the Medical Director included, "...Another on-call physician, [name redacted], NP (Nurse Practitioner) may be appointed by Medical Director and approved by AFI Advanced Care in the event that Medical Director is not available.'"

Based on interview and record review, it was determined the agency did not ensure all entries in the medical records were legible, clear, complete, and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice for 3 of 15 patients. Specifically, visit notes were not documented within the agency policy of 24-48 hours. (Patient identifiers: and ) --- Findings Include: 1 Patient 1 was admitted to the agency on 2/19/2021 with a terminal diagnosis of senile degeneration of the brain. Patient 1's medical record was reviewed on 8/16/2023. The agency staff documented late visit notes as follows: a. A skilled nurse (SN) note for 5/5/2023 was not documented until 5/18/2023; b. A SN note for 5/8/2023 was not documented until 5/18/2023; c. A SN note for 5/9/2023 was not documented until 5/18/2023; d. A SN note for 5/10/2023 was not documented until 5/31/2023; e. A SN note for 5/11/2023 was not documented until 5/31/2023; and f. A SN for 5/12/2023 was not documented until 5/31/2023. [Note: Patient 1 passed away on 5/13/2023.] 2. Patient 5 was admitted to the agency on 7/17/2023 with a terminal diagnosis of chronic obstructive pulmonary disease. Patient 5's medical record was reviewed on 8/16/2023. The agency staff documented late visit notes as follows: a. A Certified Nurse Aide (CNA) note for 7/3/2023 was not documented until 7/8/2023; b. A SN note for 7/7/2023 was not documented until 7/16/2023; c. A CNA note for 7/12/2023 was not documented until 7/17/2023; d. A CNA note for 7/10/2023 was not documented until 7/17/2023; e. A Medical Social Worker (MSW) note for 7/13/2023 was not documented until 7/21/2023; f. A Chaplain visit note for 7/25/2023 was not documented until 7/29/2023; g. A SN visit note for 7/21/2023 was not documented until 7/29/2023; h. A SN visit note for 7/25/2023 was not documented until 7/30/2023; i. A SN note for 7/25/2023 was not documented until 7/30/2023; j. A CNA note for 7/17/2023 was not documented until 7/30/2023; k. A CNA note for 7/19/2023 was not documented until 7/30/2023; l. A CNA note for for 7/21/2023 was not documented until 7/30/2023; m. A SN note for 8/3/2023 was not documented until 8/14/2023; n. A CNA note for 8/9/2023 was not documented until 8/16/2023; and o. A CNA note for 8/11/2023 was not documented until 8/16/2023. 3 Patient 12 was admitted to the agency on 4/5/2023 with a terminal diagnosis of cerebral infarct, hemiplegia with hemiparesis, dysphagia and stage 3 chronic kidney disease. Patient 12's medical record was reviewed on 8/17/2023. a. A CNA note for 7/17/2023 was not documented until 8/1/2023; b. A CNA note for 7/21/2023 was not documented until 8/1/2023; c. A CNA note for 7/24/2023 was not documented until 8/1/2023; d. A CNA note for 7/27/2023 was not documented until 8/1/2023; e. A CNA note for 8/4/2023 was not documented until 8/13/2023; f. A CNA note for 8/7/2023 was not documented until 8/13/2023; and g. A CNA note for 8/9/2023 was not documented until 8/13/2023. An interview with the Administrator (ADM) was conducted on 8/16/2023 at approximately 3:50 PM, the ADM stated that agency policy on submitting visit notes was 24-48 hours. The ADM stated that the Director of Nursing was supposed to be monitoring when documentation was submitted.

Based on observation and interview, it was determined the agency's Clinical Laboratory Improvement Amendments (CLIA) waiver had expired. --- Findings include: An entrance interview was conducted with the agency administrator (ADM) on 8/15/2023 at approximately 9:26 AM. The ADM was asked to provide a copy of the agency CLIA waiver. A copy of the CLIA waiver was received on 8/15/2023 at 1:12 PM. The expiration date on the waiver was 6/12/2023. In an e-mail, dated 8/15/2023 at 2:54 PM, the DM stated he did not know the CLIA waiver had expired until today.

Based on interview and record review, it was determined the agency did not maintain an infection control program that protected patients, staff and others by preventing and controlling infections and communicable diseases. Specifically, there was no tracking, trending or analysis of infection, including patient COVID-19 infections. --- Findings include: A. ON 8/15/2023, during the entrance interview, the Administrator (ADM) was asked to provide the agency's infection control (IC) program and surveillance data for monitoring infections for patients and employees. The IC policy was received and reviewed. It was documented in the policy that the following was procedures were to be implemented: "...Patient infections to be reported while patient is on service: wound infections that develop 30 days or greater after admission which require an antibiotic or identified by lab test or MD (Medical Doctor) that may or may not require an antibiotic... Employee infections to be reported: if an employee develops or has a known exposure to: conjunctivitis, MRSA (methicillin resistant staphylococcus aureus), VRE (vancomycin resistant enterococcus), and any reportable communicable disease as defined by the local health department. 2. Written reporting of infections will occur through documentation on the applicable log..." The only information submitted was a COVID-19 log for employees (this log also included information from another certified agency within the corporation). B. An interview was conducted with the ADM on 8/16/2023 at 3:50 PM. The ADM was asked how the agency completed tracking and trending of non-covid 19 infections for employees and patients. The ADM stated the number of infections was documented in the quality assurance and performance improvement (QAPI) meetings. The ADM stated further follow up had not occurred. Additionally, employee infections are not documented or analyzed during the QAPI meetings.