Every finding on record at Alpha Homecare Hospice Inc

Based on interview and record review, it was determined the hospice agency (HA) failed to maintain a HA-wide, data-driven quality assurance and performance improvement (QAPI) program. Refer to L560.

Based on interview and record review, it was determined the hospice agency (HA) failed to maintain a HA-wide, data-driven quality assurance and performance improvement (QAPI) program. Specifically, the HA failed to fully develop, implement, evaluate, and maintain an effective, ongoing QAPI program which reflected the complexity of its organization and services. This resulted in a finding of immediate threat to patient health and safety (immediate jeopardy) (IJ) on 12/27/2022. --- Findings Include: 1. On 12/19/2022, an entrance interview was conducted with the administrator. During entrance, QAPI meeting for the last 12 months were requested. 2. On 12/22/2022 at 3:51 PM, an interview was conducted with the administrator. The administrator stated the HA had not completed QAPI or performance improvement projects. 3. By 12/27/2022, the HA had failed to provide evidence, by interview or documentation; they had developed, implemented, evaluated, and maintained an effective, ongoing, HA-wide data-driven QAPI program which reflected the complexity of its organization and services.

Based on observation, interview, and record review, it was determined the agency failed to appoint a clinical manager (director of nursing (DON)) that was responsible for the day-to-day operations of the agency. Including making patient and personnel assignments, coordinating patient care, assuring that patient needs are continually assessed and assuring the development, implementation, and updates of the individual plan of care. Refer to L588.

Based on observation, interview, and record review, it was determined the agency failed to appoint a clinical manager (director of nursing (DON)) that was responsible for the day-to-day operations of the agency. Including making patient and personnel assignments, coordinating patient care, assuring that patient needs are continually assessed and assuring the development, implementation, and updates of the individual plan of care. (Patient identifiers: 1, 2, 3 and 4). This resulted in a finding of immediate threat to patient health and safety (immediate jeopardy) (IJ) on 12/27/2022. --- Findings include: 1. On 12/19/2022 at 2:30 PM, an interview was conducted with the administrator (ADM). The ADM was asked who the hospice agency's (HA) DON was. The ADM stated, "I guess (name of registered nurse (RN)1)." RN 1 stated, "That's news to me." 2. In an interview conducted on 12/20/2022 at 2:59 PM with RN1, he stated, when ask what his position was: ";I am the only RN with the company, so I am doing all office stuff that requires a nurse, filling in for visits and doing admits. I think the ADM called me the clinical director." He further stated ";This is actually my fourth job. I work 4 nights a week, night shifts, at a care center. So, I have a couple hours available in the afternoon. Then I can work Thursday and Friday. My availability is pretty limited. I gave my two weeks notice; my last day is the end of the week." (12/23/2022). The interview with RN1 was not complete before he stated, about halfway through the interview, that he needed to wrap things up. 3. A review of the personnel record for RN1 contained no documented evidence of a job description for clinical manager. 4. In an interview with the ADM he stated that he had hired a nurse that day but that there was not a plan for a clinical manager in the future.

Based on interview and record review, it was determined the governing body failed to ensure that the administrator (ADM) was responsible for the agency's overall management and operation, the provision of all hospice services, fiscal operation, review of the agency's budget and its operation plans, and its quality assessment and performance improvement (QAPI) program. Refer to L651.

Based on interview and record review, it was determined the governing body failed to ensure the administrator (ADM) was responsible for the agency's overall management and operation, the provision of all home health services, fiscal operation, review of the agency's budget and its operation plans, and its quality assessment and performance improvement (QAPI) program. Specifically, the governing body (GB) consisted only of the ADM and had not had a governing body meeting according to records. Additionally, throughout the survey process, the ADM was confused, disorganized, forgetful and required multiple reminders to submit requested information in a timely fashion. This resulted in a finding of immediate threat to patient health and safety (immediate jeopardy) (IJ) on 12/27/2022. --- Findings include: 1. On 12/19/2022 at 1:35 PM, an abbreviated survey was attempted at the hospice agency (HA) address on file, in St. George, UT. The sign posted on the door was for a real estate company. The door was locked. There was no answer to repeated knocks on the door. A telephone call was placed to the ADM/owner on 12/19/2022 at 1:50 PM. The ADM stated the HA had moved to a new location. The address of the new location was provided. 2. An entrance conference with the ADM and registered nurse (RN) 1 was conducted on 12/19/2022 at 2:30 PM. Written and verbal instructions were given related to the information that needed to be electronically submitted to the survey team. The ADM was unable to focus on the information that was being presented and repeatedly asked the surveyor why he was at the HA. When the ADM was asked questions related to the entrance requirements, the ADM referred the questions to RN 1 who appeared to be doing work at a computer. At one point, the ADM asked RN 1 to "pay attention". RN 1 responded with, "There is no need to. My last day is Friday, three days from now." The ADM was unable to provide the requested documents to the survey team and stated that he had contracted with a "friend" to assist him with gathering the required documents. On 12/19/2022 at 3:30 PM, the entrance request guidelines were again reviewed with the ADM. The ADM was encouraged to comply with submitting required information within the 1 hour and 3-hour time frames. The ADM acknowledged his understanding. 2. On 12/19/2022 at 8:25 PM, the ADM sent a text message to one of the surveyors. The ADM stated there was no HA employees that were scheduled to do patient visits during the week of the survey. No other information was submitted as required on the entrance request form. 3. On 12/20/2022 at 9:05 AM, an attempt to gain access to the HA office was made. The office was locked. There was no answer to repeated knocks on the door. A telephone call was placed to the ADM at 9:07 AM. The ADM stated he had to leave the office and return home to obtain information that was requested on the entrance document. The ADM stated he would be back at the office in ten minutes. Another attempt to gain access to the HA office was made at 12:26 PM. The office was locked. There was no answer to repeated knocks on the door. Another call was placed to the ADM. The ADM stated he had gone to lunch and would be returning to the office in five minutes. 4. On 12/20/2022 at 12:47 PM, a google meeting with the survey team and the ADM was conducted. One surveyor was on-site with the ADM and two surveyors as well as the Director of Medicare Services were off-site. The missing documents that were requested during the entrance conference on 12/19/2022 was reviewed. The ADM was given one hour to provide the survey team with all documents in an electronic format. 6. The ADM was asked to provide governing body minutes for the last 12 months. The ADM was unable to provide documented evidence of governing body minutes. The ADM was interviewed on 12/22/2022 a 3:15 PM. The ADM was asked if the governing body had a meeting in the last 12 months. The ADM stated, "No." The ADM was asked who the governing board members were. The ADM stated, "Me and my wife". Note: The ADM's wife was not alert and oriented and unable to be interviewed related to the functioning of the HA. 7. The ADM was asked to provide the agency's QAPI plan, performance improvement projects (PIPs) and evidence of QAPI meetings. On 12/22/2022 at 3:15 PM, the ADM stated there were no PIPs or QAPI meetings.

Based on interview and record review, the agency did not ensure they reviewed and updated their emergency preparedness plan at least every two years. Findings include: On 7/12/22, the agency emergency preparedness plan was reviewed. Documentation indicated the plan was last updated on 4/7 to 4/8/2020. A review of the emergency communication plan revealed that it was last updated at the same time. The communication plan contained names of personnel who no longer worked at the agency. On 7/13/22 at 9:30 AM, an interview was conducted with the administrator and the owner of the agency. The administrator stated she started working at the agency on 6/6/22. She stated she thought the emergency preparedness plan and the communication plan had been updated in January 2022. She stated most everyone at the agency were newly hired to the agency and did not realize the communication plan had been updated to include the new staff. No documented evidence was provided to indicate the emergency plan had reviewed and updated as required.

Based on interview and record review, it was determined the hospice agency did not include an initial bereavement assessment as part of the comprehensive assessment for 2 of 2 current patients. Specifically, there was no documented evidence that the needs of the patients' or family members were assessed, focusing on social, spiritual and cultural factors. (Patient identifiers: 1 and 2) Findings include: A medical record review was conducted for the two hospice patients on service with the hospice agency. 1. Patient 1 was admitted to the agency on 7/5/2022 with a terminal diagnosis of Alzheimer's disease. Patient 1's medical record was reviewed on 7/12/2022. No documentation could be located in the medical record to indicate that an initial bereavement assessment, that included social, spiritual and cultural factors, that may impact family or individual's ability to cope, had been completed. An email correspondence was sent to the administrator (ADM)/director of nursing (DON)as well as the business office manager (BOM) inquiring about the bereavement assessment. The BOM stated the agency social worker (SW) completed the assessment on 7/7/2022, but had not completed the required charting. 2. Patient 2 was admitted to the agency on 6/23/2022 with a terminal diagnosis of Wernicke's encephalopathy. Patient 2's medical record was reviewed on 7/12/2022. No documentation could be located in the medical record to indicate that an initial bereavement assessment, that included social, spiritual and cultural factors, that may impact a family or individual's ability to cope, had been completed. An interview was conducted with the ADM/DON on 7/13/2022 at 9:30 AM related to the bereavement assessment for patient 2. The ADM/DON stated, "It appears that the bereavement assessment was not assigned." The ADM/DON further stated patient 2 was seen by the agency SW on 7/6/2022 and that the SW would be assigned the task of completing the bereavement assessment. On 4/20/22 at 4:11 PM, an email reply was received from the agency and reviewed. It stated: "Unfortunately you will not always find a bereavement assessment at the start of care. They will always be done as deemed necessary by the IDG(Interdisciplinary Group)or at the patients death if not before."

Based on interview and record review, it was determined the hospice agency did not ensure care and services were provided as identified in the plan of care (POC) for 2 of 2 current patients. Specifically, aide visits were not provided as identified in the POC. (Patient identifier's: 1 and 2) Findings include: 1. Patient 1 was admitted to the hospice agency on 7/5/2022 with a terminal diagnosis of Alzheimer's disease. Patient 1's medical record was reviewed on 7/12/2022. Review of the plan of care (POC) developed for patient 1 indicated that a hospice aide was to assist with activities of daily living once a week. No documented evidence was found in the medical record to indicate a hospice aide visit was completed or refused the week of 7/3/2022 through 7/9/2022. An e-mail correspondence was submitted to the administrator (ADM)/director of nursing (DON) and business office manager (BOM) on 7/12/2022 at 8:08 AM related to the missing hospice aide visit. A response was received on 7/12/2022 at 2:35 PM. The BOM documented, "Family requested aide visits to start week of 7/11/2022. Communication in chart. MD (medical doctor) order in chart to be signed." The BOM documented, "Spoke with Family on 7/8/22. Family requested Aide services to start the week of 7/11/22..." Note the documentation was not completed until after the concern was identified by the survey team. 2. Patient 2 was admitted to the agency on 6/23/2022 with a terminal diagnosis of Wernicke's encephalitis. Patient 2's medical record was reviewed on 7/12/2022. Review of the plan of care (POC) developed for patient 2 indicated that a hospice aide was to assist with activities of daily living 2-3 times a week. No documented evidence was found in the medical record to indicate two hospice aide visits were completed or refused the week of 6/19/2022 to 6/25/2022. An email correspondence was submitted to the ADM/DON and BOM on 7/12/2022 at 8:55 AM related to the missing hospice aide visit the week of 6/19/2022 to 6/25/2022. An interview was conducted with the ADM/DON on 7/13/2022 at 9:30 AM related to the missing hospice aide visit. The ADM/DON stated, she should have written the hospice aide visit order to read, "One week one" for the first week of admission then 2-3 times a week.

Based on interview and record review, it was determined the hospice agency failed to maintain a hospice-wide, data-driven quality assurance and performance improvement (QAPI) program. Specifically, the hospice agency failed to fully develop, implement, evaluate, and maintain an effective, ongoing QAPI program which reflected the complexity of its organization and services and concentrating on infection control issues. Findings include: 1. The hospice agency failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement (QAPI) program. Specifically, the hospice agency and governing body did not maintain documentary evidence that could demonstrate operations of a functioning QAPI program that included: tracking, measuring, and analyzing quality indicators and adverse events, that was then implemented into performance improvement activities that would improve quality of care and patient safety. (Refer to Tag L-0560) 2. The hospice agency failed to implement and evaluate performance improvement projects. Specifically, performance improvement projects were developed related to missing bereavement assessments and missing aide visits. The completion date documented for the bereavement assessments and missing aide visits was 7/1/2022. There was no documentation the hospice agency implemented and evaluated the performance improvement plans to ensure/track compliance. (Refer to Tag L-0571) 3. The hospice agency failed to fully implement, maintain, and document an infection control (IC) program. Specifically, the hospice agency failed to provide sufficient documented evidence that they had fully implemented and maintained a coordinated agency-wide program for surveillance, identification, prevention, control and investigation of infections and communicable diseases; that was an integral part of the hospice agency's quality assurance performance improvement (QAPI) program. (Refer to Tag L-0577)

Based on interview and record review, it was determined the hospice agency did not develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement (QAPI) program. Specifically, the hospice agency and governing body did not maintain documentary evidence that could demonstrate operations of a functioning QAPI program that included: tracking, measuring, and analyzing quality indicators and adverse events, that was then implemented into performance improvement activities that would improve quality of care and patient safety. Findings include: On 7/11/22, the agency QAPI plan was requested for review. The agency provided a copy of 18 process improvement plans (PIPs), all dated 6/27/22. The agency also provided the QAPI meeting minutes for 6/27/22. A review of the meeting minutes revealed the following: "We met as a QAPI Committee to discuss the 2022 QAPI plan and the state of Alpha HomeCare Hospice. After the exodus of the Director of Operations in March of this year, a full company overview was/is being conducted. All patients were discharged as some alarming practices were found to be occurring. Until such time that it was determined that adequate staff could be hired and sufficiently trained, no patients were allowed to be admitted. We hired a new DONn (sic)(director of nursing)/Administrator, Office Manager and Social Worker. All of which are currently being trained. There are currently 18 PIP's in process with individual Plan of Corrections. On June 23, 2022, the Governing Body felt confident that we could responsibly take on 1 hospice patient to put all of the Plan of Corrections into practice." No further documentation was provided at that time. On 7/13/22 at 9:30 AM, an interview was conducted with the administrator/director of Nursing (ADM/DON) and the owner. The ADM/DON stated they had a written QAPI plan and she would provide a copy to the surveyors. The document provided was a guide to developing a QAPI program.

Based on interview and medical record review, it was determined the hospice agency did not implement and evaluate performance improvement projects. Specifically, performance improvement projects were developed related to missing bereavement assessments and missing aide visits. The completion date documented for the bereavement assessments and missing aide visits was 7/1/2022. There was no documentation the hospice agency implemented and evaluated the performance improvement plans to ensure/track compliance. (Patient identifiers: 1 and 2) Findings include: 1. A Quality Assurance Improvement Plan was developed by the agency on 6/9/2022 related to bereavement assessments and bereavement follow up's not being completed. The plan of action/correction plan documented was, "We are currently looking to hire a new SW (social worker). Once hired and trained the Office Manager will assign a Bereavement Assessment upon the death of a patient and track it's progress on the Chart Audit Tracker. Tasks will also be created to insure (sic) follow-up via phone calls, mailing, visits, etc. This will be tracked by the Social Worker and reviewed quarterly by the DON (director of nursing)/Administrator (ADM)." The target date of compliance was "7/1/22 of upon the death of our 1st patient." Note: The bereavement assessment was to be completed within five days from the date of admission. 2. On 6/8/2022, the hospice agency developed a "Quality Assurance Improvement Plan" related to missed visits not being signed by the physician. The plan of action/correction plan indicated, "Any missed visits will be pushed to the MD (medical doctor) for signature and tracked by the Office Manager." The target date of compliance documented was 7/1/22. Note: The office manager did not identify there were missed visits that had not been documented. An interview was conducted with the ADM/DON on 7/13/2022 at 9:30 AM related to the quality assurance improvement plan developed on 6/9/22. The ADM/DON stated that chart audits were to be completed monthly and that a complete audit of patient 1 and 2's medical records had not been completed. The ADM/DON stated there was a check list that was to be completed after a patient was admitted, but that it had not been utilized.

Based on interview and record review, it was determined the hospice agency failed to fully implement, maintain, and document an infection control (IC) program. Specifically, the hospice agency failed to provide sufficient documented evidence that they had fully implemented and maintained a coordinated agency-wide program for surveillance, identification, prevention, control and investigation of infections and communicable diseases; that was an integral part of the hospice agency's quality assurance performance improvement (QAPI) program. Findings include: During entrance conference, on 7/11/22, a request was made for the agency infection control plan, infection tracking logs for both patients and employees, the COVID infection control plan, and staff and patient infection control education. On 7/11/22, the agency provided a document titled Infection control. The title of the document was "CMS (Centers for Medicare and Medicaid Services) COVID-19 Health Care Staff Vaccination Interim Final Rule" along with a blank proof of staff vaccination form. No other documentation was provided. On 7/12/22 at 9:30 AM, an interview was conducted with the agency administrator/director of nursing (ADM/DON). The ADM/DON stated the agency had an infection control plan with policies and procedures. She stated that they do track infections for the patients. The infections were to be documented in the electronic medical record. She stated the agency had no documented infections for any of the patients at that time. The ADM/DON provided a blank infection report from the EMR. No further documented evidence was provided to indicate that the agency had a developed and implemented infection control plan. The hospice agency failed to provide sufficient evidence, by interview or documentation, that they had fully implemented and maintained a coordinated agency-wide program for surveillance, identification, prevention, control and investigation of infections and communicable diseases; that was an integral part of the hospice agency QAPI program. Based on documented evidence, none of the standards (tags: L578, L579, L580, L581, and L582) under this condition (tag: L577) were met.

Based on observation, interview, and record review, it was determined that the hospice agency failed to meet Federal Medicare regulations governing hospice agencies. Specifically, they did not meet the Condition of Participation for organization and administration of services. Findings include: 1. The hospice GB failed to have a signed contract for the physician covering in the absence of the medical director, to ensure the provision of quality of care. (Refer to tag L-0655) 2. The hospice GB failed to maintain a hospice-wide, data-driven QAPI program. Specifically, the hospice agency failed to fully develop, implement, evaluate, and maintain an effective, ongoing QAPI program which reflected the complexity of its organization and services. (Refer to tag L-0559) 3. The hospice GB failed to provide sufficient documented evidence that they had fully implemented and maintained a coordinated agency-wide program for surveillance, identification, prevention, control and investigation of infections and communicable diseases; that was an integral part of the hospice agency's QAPI program. (Refer to tag L-0577)

Based on interview and record review, it was determined the agency did not ensure that a physician was designated by the hospice to assume the same responsibilities as the medical director when the medical director was unavailable. Findings include: On 7/12/22 review of the contract for the physician who would cover for the medical director when the medical director was unavailable was reviewed. The contract was for the medical director of a sister agency that was no longer in service. The sister agency had been located in a city approximately 270 miles from the agency. No documented evidence was provided to indicate the agency had valid contract for the physician. On 7/13/22 at 9:30 AM, an interview was conducted with the administrator/director of nursing (ADM/DON) and the owner of the agency. The ADM/DON stated she thought since both agencies had the same tax number, the contract would work for their agency also. The owner stated the agency needed to find a new physician to cover for the medical director when he was unavailable.