Every finding on record at All Comfort Hospice Care, Inc.

Observed in Emergency Management Session. The organization could not evaluate and prioritize findings from an HVA, because that had not conducted a comprehensive HVA covering all area of potential vulnerability. This was reviewed with the Administrator Designee Observed in Emergency Management Session. The organization conducted a HVA but it did cover all areas of risk so that priority of highest likelihood for occurrence could be put in their Emergency plan. On the agency's HVA plan the each area was not calculated on the plan to put in a priority in the Emergency plan. While the actual Emergency plan covered COVID, terrorism, fires and earthquakes, this was not based on the prioritized risks from the HVA. This finding was reviewed and discussed with Administrator Designee.

Observed in Record Review. On 1 of 2 bereavement records reviewed, the organization did not complete a bereavement risk assessment per the organizations policy. Agency Bereavement policy (2-010.1) states that a bereavement risk assessment will be completed by the social worker at time of admission. On RRBR #2, it was noted that there was no bereavement assessment completed on admission. This finding was reviewed with Hospice leadership.

Observed in Record Review. On 4 of 10 active patient records reviewed, the plan of care did not reflect the scope and frequency of services for the patient. On RRHV #1, RRHV #2 and RRHV #3, it was noted that the chaplain had made telephone visits with the caregiver, two phone call visits had been made and the frequency of these visits were not reflected on the plan of care. On RRNHV #4, it was noted that the chaplain has been making monthly telephone visits to the patient since admission 10 months ago and the visit frequency is not reflected on the POC.This finding was reviewed with hospice leadership. This finding was reviewed with the hospice leadership.

Observed in Record Review. In 7 of 10 active patient records reviewed, the organization failed to ensure the plan of care was updated based on the patient’s reassessment and progress toward goals. In RRNHV #1, RRNHV #2, RRNHV #3, RRNHV #4, RRNHV #5, RRNHV #6 and RRNHV #7, the plans of care had not been updated to reflect the current assessment, achieving goals that had been achieved. For example, every chart had teaching goals that were unaltered for IDG to IDG since admission 9-11 months ago with no change or update to their progress. This finding was reviewed with hospice leadership.

Observed in Record Review. On 1 of 2 bereaved records reviewed, the organization did not reflect the needs of the bereaved. On RRBR #2, the organization did not reflect the needs of the bereaved because there was no bereaved person identified on the assessment. This finding was reviewed with Hospice Leadership.

Observed in HR File Review. On 3 of 3 HR records reviewed of employees hired over 1 year ago, the organization did not complete an yearly competency assessment of the employee. Agency HR Competency Assessment policy (1.008) states that a competency assessment using the hire skills list will be done every year. On HR #1 and HR #6 and Volunteer #1, it was noted that the employee did not have a yearly competency documented for 2023 and 2022. This finding was reviewed with the Administrator Designee.

Observed in Record Review. In 4 of 5 patient records reviewed, During RR#2 it was noted on the medication profile an order for Tramadol 50mg 1 tab daily or as needed for pain. The order lacked the frequency of as needed order for pain. An order for Meclizine Hydrochloride 25mg Tablet 1 tab twice daily or as needed for vertigo lacked the frequency of the as needed order for vertigo. An order for Diclofenac Sodium 1% Topical Gel 1 % apply to affected area twice daily or as needed for arthritic pain lacked the frequency of the as needed order for pain and also lacked the location to apply the gel. An order for Anoro Ellipta 62.5mcg-25mcg/actuation Powder for Inhalation, 1 inhalation daily or as needed for COPD lacked the frequency of the as needed order for COPD. During HV#1 record review it was noted an order for Triamcinolone topical cream to affected area twice a day that lacked the body location to apply the cream. During HV#2 record review it was noted an order for Albuterol inhalation, 1 inhalation twice daily or PRN lacked the frequency of the PRN order. Gabapentin 300mg 1 tab three times per day or as needed lacked the frequency of the as needed order. During HV#3 record review it was noted an order for Mapap 500mg 1 tab PRN lacked the frequency of the PRN order.

Observed in Infection Control System Tracer. During review of the organization infection control plan it was noted the infection control goal was not measurable and stated the organization is committed to reducing the risk of acquisition of health care associated infections. The goals did not include how it would address prioritized risks. Observed in Infection Control Tracer. The organization's written infection prevention and control plan did not include a goal for limiting the spread of infections associated with the use of medical equipment, devices, and supplies. Observed in Infection Control Tracer. The organization's written infection prevention and control plan did not include a goal for limiting unprotected exposure to pathogens. Observed in Infection Control Tracer. The organization's written infection prevention and control plan did not include a goal for limiting the spread of infections associated with procedures.

Observed in Record Review. In 1 of 1 patient records reviewed, who had an aide assigned for personal care. During RR#1 it was noted on the aide assignment form an order for vital signs every visit. The assignment lacked the vital signs parameters of when the aide should contact the RN. This was discussed with the DPCS designee.

Observed in Document Review. During review of the skilled nursing facility contract it was noted the contract lacked a provision stating that the hospice will report all mistreatment, neglect, or verbal, mental, sexual, and physical abuse to the SNF, NF, or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice.

Observed in Infection Control System Tracer. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(vi) did not have a process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable federal law as evidenced by lack of written policy and process  Observed in Infection Control Tracer. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(ix), did not have a process for ensuring the tracking and securing of documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, as evidenced by lack of written policy and process. Observed in Infection Control Tracer. It was determined that the organization’s documentation of clinical contraindications, as required by Infection Control CoP 418.60(d)(3)(viii)(B), did not include a statement by the authenticating practitioner recommending that the staff member be exempted from the organization’s COVID-19 vaccination requirements for staff based on recognized clinical contraindications, as evidenced by lack of written policy and process. Observed in Infection Control Tracer. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(vii) did not have a process for tracking and securely documenting information provided by those staff who have requested, and for whom the organization has granted, an exemption from the staff COVID-19 vaccination requirements based on recognized clinical contraindications or applicable federal laws as evidenced by lack of policy and process. Observed in Infection Control Tracer. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(v) did not have a process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC as evidenced by lack of written policy and process. The organization has 100% staff verified vaccination compliance, all staff had 2 doses of either Pfizer or Moderna vaccine. Observed in Infection Control Tracer. It was determined that the organization’s documentation of clinical contraindications, as required by Infection Control CoP 418.60(d)(3)(viii)(A), did not include information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications, as evidenced by lack of policy and process. Observed in Infection Control System Tracer. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(viii) did not have a process for ensuring that all documentation that confirms recognized clinical contraindications to COVID-19 vaccines and supports staff requests for medical exemptions from vaccination had been signed and dated by a licensed practitioner who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable state and local laws as evidenced by lack of written policy and process.