Every finding on record at Alamogordo Home Health Care & Hospice, Inc

Based on document review, interview, and policy review, the agency failed to ensure that the "Spiritual Counselor Comprehensive Assessment" was completed within five days of the election of the hospice benefit for 10 of 19 hospice patients (Patient (P)1, P2, P3, P6, P10, P11, P12, P15, P16, and P19.) Failure to complete a spiritual assessment had the potential to miss the identification of a patient or caregivers spiritual needs. --- Review of the "Patient Charts" section in the electronic medical record (EMR) for P1, P2, P3, P6, P10, P11, P12, P15, P16, and P19 revealed a "Spiritual Counselor Comprehensive Assessment" had not been completed by the agency's Chaplain for these patients who had been on hospice care for at least five days and had not refused spiritual counselor services. During an interview on 08/16/23 at 12:45 PM, the Chaplain stated he/she had not completed an initial spiritual assessment and was not aware it was required. Review of the Hospice agency policy titled, "Plan of Care Process," dated 10/20/22, revealed, "A comprehensive assessment will be completed by the IDG/IDT [interdisciplinary group/interdisciplinary team] no later than five calendar days after the election of hospice care in consultation with the attending Physician (if any) ... The IDG/IDT must include but is not limited to individuals who are qualified and competent to practice in the following professional roles. A. A Doctor of Medicine or Osteopathy ... B. A Registered Nurse. C A Social Worker. D. A pastoral or other counselor."

Based on document review, interview, and policy review, the agency failed to ensure an initial bereavement risk assessment was completed for 14 of 19 patients (Patient (P)1, P2, P3, P6, P7, P8, P9, P10, P11, P12, P13, P15, P16, and P19). The failure to complete an initial bereavement risk assessment had the potential for the family or other individuals' bereavement needs to not be recognized or addressed in the plan of care. --- Review of the "Patient Charts" section in the electronic medical record (EMR) revealed that an initial "Bereavement Assessment" was not completed for P1, P2, P3, P6, P7, P8, P9, P10, P11, P12, P13, P15, P16, and P19 who had received hospice services for at least five days. During an interview on 08/16/23 at 12:45 PM, the hospice Social Worker (SW) confirmed the agency had not been completing an initial bereavement risk assessment and did not know about it until today. Review of the Hospice agency polity titled, "Plan of Care Process," dated 10/20/22, revealed, "A comprehensive assessment will be completed by the IDG/IDT [interdisciplinary group/interdisciplinary team] no later than five calendar days after the election of hospice care ...The comprehensive assessment will take into consideration the following factors but is not limited to : ...An initial bereavement assessment of the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment will be incorporated into the POC [plan of care] and considered in the bereavement POC.

Based on document review, interview, and policy review, the agency failed to include supplies and equipment on the plan of care for 19 of 19 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, P16, P17, P18, and P19). Failure to identify the supplies and equipment on the plan of care had the potential for the patient's safety and comfort needs to not be met. --- Review of the "Initial Plan of Care" (POC) located in the "Patient Charts" section of the electronic medical record (EMR) for P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, P16, P17, P18, and P19 revealed the sections labelled "DME" (Durable medical equipment" and "Supplies" were left blank. During an interview on 08/17/23 at 12:30 PM, the Registered Nurse/Administrator confirmed that the sections marked "DME" and "Supplies" had not been completed. Review of the Hospice agency's policy titled, "Plan of Care Process," dated 10/20/22, revealed, "The POC includes, but is not limited to: ... Medical supplies, equipment, and appliances necessary to meet the needs of the patient."

Based on document review, policy review, and interview, the agency did not include adverse patient events in its quality assessment performance improvement program (QAPI). Failure to include adverse patient events in QAPI had the potential for concerns that impact the safety and well-being of patients to not be recognized or measures implemented to improve the quality of care. --- Review of data presented by the Director of the hospice agency's QAPI program revealed that it did not include adverse patient events. Review of adverse event data printed on 08/16/23 during the survey from data in the electronic medical record (EMR) showed nine patient falls from 07/01/22 to 08/31/23. No other adverse patient event data was presented. During an interview on 08/18/23 at 09:00 AM, the Clinical Manager confirmed that there was no analysis of the adverse event data, and that the data was not included in QAPI. Review of the hospice agency policy titled, "Quality Assessment Performance Improvement Program," dated 10/01/21, revealed, "The QAPI Plan will be developed based on: ... Measure, analyze, and tack quality indicators, including adverse patient events, and other aspects of performance that enable the hospice to assess processes of care, Hospice services, and operations ... Performance improvement activities will track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice."

Based on document review, interview, and policy review, the agency failed to include infection tracking, trending, and analysis as a component of its quality assessment performance improvement (QAPI) program. Failure to include infection surveillance in QAPI had the potential for the agency to miss opportunities to improve patient outcomes for all patients receiving hospice care. --- Review a document titled, "FY23 Monthly Statistical Report," revealed monthly data from July 2022 to June 2023. The data did not include information on infection tracking or trending. During an interview on 08/16/23 at 11:30 AM, the Director stated that the document presented was the hospice agencies QAPI program and that it was presented at the board meeting every month. The Director stated that the board meeting is the agency's governing body. The Director also confirmed that the QAPI data did not include infection tracking or trending. Review of the agency policy titled, "Quality Assessment Performance Improvement Plan," dated 10/01/18, revealed, "At least quarterly, QAPI activities include an assessment of processes that involve the following risks: 1. Infections (patient and employee)."