Every finding on record at Agape Hospice & Palliative Care

Based on review of facility policy, review of facility documentation and interview, it was determined the facility failed to include names and contact information for patient physicians in the facility communications plan.  Failure to provide contact information that could be needed during an emergency event in the facility communication plan can result in vital services being interrupted during an emergency event for staff and patients. --- Findings include:Policy titled, “Emergency Management Plan Policy No. 6-037.1,” revealed:  “...Policy...The organization will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations…Communication Plan...The organization will maintain an emergency preparedness communication plan that complies with Federal, state and local laws and is reviewed and updated annually. The plan includes the following:...1. Names and contact information for the following:..3. Patients' physicians...." Review of facility Emergency Preparedness binder presented on 8/28/2025 revealed contact names and contact name for patient physicians was not documented. Employee #1 confirmed in an interview on 08/29/2025 the name and contact information for patient's physicians was not included in the emergency preparedness documentation.

Based on record review and staff interviews it was determined the hospice failed to develop procedures outlining primary and specific alternate means for communication with Federal, State, tribal, regional, and local emergency management agencies. This deficient practice has the potential that communication may be delayed or lacking in the event of an emergency posing the risk for negative patient and staff outcomes. --- Review of facility policy titled, "Emergency Management Plan Policy No.6-037.1" revealed: "...The organization will comply with all applicable, Federal, State,  and local emergency preparedness requirement and will establish and maintain an emergency preparedness program that meets those regulations...Communication Plan...The organization will maintain an emergency preparedness plan communication plan that complies with Federal, State, and local laws.....the plan includes the following: 3. Primary and alternate means of communicating with staff, federal, state, tribal and regional and local emergency management agencies (See Addendum 6-037 B)...In the event primary communication methods are down , refer to "When an Emergency is Declared" section below, #2...C. When necessary, alternate communication methods will be employed to continue continuity and collaboration of interventions...When an Emergency is Declared...Once the decision has been made to implement the emergency management plan, the Executive Director/Administrator or designee will initiate the Pyramid Phone Communication Plan (PPCP) to notify personnel and community authorities, as appropriate. (See "Pyramid Phone Communication Plan" Addendum 6-037. A.)..."Review of facility document titled " ADDENDUM 6-037 COMMUNICATION PLAN" revealed: "...Primary Communication Method:520-207-5817 Office Phone... Alternate Communication Method: Refer to Phone Communication Tree Below and also agency contact list..."Review of facility document titled " ADDENDUM 6-037.A COMMAND STRUCTURE PYRAMID COMMUNICATION TREE" revealed, ADMIN/EXECUTIVE DIRECTOR...Calls-Text/emails. Notify community partners/authorities as needed...DCS Calls-Text/Emails...Office Manager Prepare/Direct Office Personnel - Office Safety/Equipment..."Review of facility document titled " ADDENDUM 6-037.B EMERGENCY CONTACT INFO..." revealed: "...Federal, State, Tribal, Regional, and Local Emergency Preparedness Contact **Means of communication**...In the event of an emergency, Agency will contact the below local, tribal, regional, State and Federal emergency preparedness officials for cooperation and collaboration to maintain an integrated response during a disaster or emergency situation...Federal...FEMA Helpline 1-800-621-3362 (primary) https://www.disasterassistance.gov/ (Secondary)....American Red Cross 1 800 RED CROSS/1-800-733-2767 (Primary) https://redcross.org/fund-your-localchapter.html (Secondary)... State-Arizona Department of Emergency and Military affairs 602-267-2700 (Primary) https://dema.az.gov/ (Secondary)...Regional - Pima County Health Department 520-724-7770 (Primary) https://www.pima.gov/2031/Health  (Secondary)...."In interview with employee #1, they were unable to verbalize a specific secondary means of communication for Federal, State, tribal, regional, and local emergency management agencies.

Based on observation, documentation review, and staff interviews, it was determined the hospice agency failed to provide evidence that qualified dietician services are available to patients. This deficient practice has the potential to negatively impacting patient’s nutritional needs and quality of life. --- Findings include:Review of facility policy titled “Nutritional Services Policy No. 4-010.1” revealed: “...POLICY To assist hospice personnel in determining effective ways of managing the nutritional needs of hospice patients, a registered dietician will be available for consultations, inservice (sic) training, and patient/family care…Nutritional care and counseling will be provided in accordance with the plan of care….”Review of facility policy titled “Listing of Services Provided Policy No.1-025.1” revealed:, " PURPOSE To assure that services, whether provided directly or under contractual agreement, adhere to hospice policies and procedures and professional management accountability...PROCEDURE…2. Services will be provided as listed …Registered dietary consultant services…Directly X Under Contract __”  On 8/27/2025, a request was made for a dietitian contract. The contract was not provided.On 08/27/2025, a request for a personnel file for a dietician or a contract for a registered dietician, the personnel file was not provided. In an interview conducted on 8/29/2025 with Employee #1 and #3, they acknowledged that the facility does not have a contract for a registered dietician or a personnel file for a dietician.

Observed in Record Review. In 13 of 13 patient records reviewed, the organization did not develop plans of care that were based on the patient’s goals and the time frames, settings, and services required to meet those goals. In many of the patient plans of care reviewed, goals were not measurable and did not include targeted completion dates. This was reviewed with the Executive Director and other members of the leadership team.

Observed in Record Review. In 6 of 13 patient records reviewed, reasons for prn visits by the Registered Nurse, Social Worker and/or Spiritual Counselor were not included in the orders. This was noted in the records of HV#3, RR#2, RR#4, RR#6, RR#8, and RR#10 and was reviewed with the Executive Director and other members of the leadership team.

Observed in Patient Home. In 1 of 3 home visits conducted, the hospice did not implement its infection prevention and control activities. During HV#2 the surveyor observed that an RN cleaned her equipment with a 10% bleach wipe. According to policy 9-014.2 reusable equipment is to be cleaned with alcohol, soap and water, and/or in accordance with the manufacturer’s information for use. This was reviewed with the Executive Director and other members of the leadership team. Observed in Patient Home. In 1 of 1 home visits conducted, hospice staff failed to perform hand hygiene according to accepted standards of practice. Twice during HV#2 an RN turned the faucet off using her left wrist without a barrier. This was not compliant with standards of practice. This was reviewed with the Executive Director and other members of the leadership team.