Every finding on record at Amare' Vista Hospice

Observed in Record Review. In 2 of 3 patient records reviewed, it was noted that care was not provided as ordered. For example in review of record for home visit #1 it was noted that orders for SN visits stated twice weekly however there was only documentation of SN visits weekly for the past two weeks since admission. In record review #2 it was noted that SN visits were to be made weekly however in week one 2 visits were made, in week two 1 visit was made and there was documentation of a missed visit indicating two visits attempted this week and lastly, there was no documentation of any SN visits for the past two weeks. This was discussed with the DPCS.

Observed in Document Review. During review of documents and data it was noted that while activities for improvements had been underway, there was no documentation of distinct performance improvement projects. This was discussed with the DPCS.

Observed in Data Tracer. During review of documents and data it was noted that while activities for improvements had been underway, there was no documentation of distinct performance improvement projects to include what projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on them. This was discussed with the DPCS.

Observed in Emergency Management Session. During review of Emergency Management Plan and related documents as well as in discussion with agency leadership, there has been no full scale community based exercise. For example it was noted that in 2021 there was only a review of Emergency Management Plan, in 2022 there was no activation of the plan for either a real event or a drill, in 2023 there was documentation of a tabletop drill and there had been no activation of the plan thus far in 2024.

Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that in RR#4 and RR#5 an RN had not visited at least every 15 days to update the assessment. There had been no RN visit for 5 weeks since the start of care in RR#4 and no RN visit for 8 weeks in RR#5. In RR#7 there was no documentation of an RN visit for 8 weeks. This was discussed with the DPCS.

Observed in Record Review. In 11 of 11 patient records reviewed, it was noted that the plan of care did not include measurable goals which were timed. For example, in RR#1 one goal was written as pt will have adequate food and fluids by next IDG and BP will be within normal limits. In RR#2, a goal for respiratory issues was written as Pt. will have optimum level of oxygen. In RR#3, a goal was written as Caregiver will verbalize elimination needs are met at an acceptable level. In RR#4 a goal for sleep issues was written as Promote rest status for Pt/Family/PCG. In RR#5 a spiritual goal was written as Facilitate a spiritual environment for patient to begin the bereavement process. In RR for HV#1 and goal for respiratory issue was written as Patient's seasonal allergy will be relieved as reported by next IDG meeting. In RR for HV#2 the pain goal was stated as Patient will have no S/S of pain as reported by next IDG meeting. In RR for HV#3 the following goal was stated for wound, Right posterior hand traumatic ulceration will be resolved as reported by next IDG meeting. This was discussed with the DPCS.

Observed in Record Review. In 11 of 11 patient records reviewed, it was noted that every record contained the following incomplete orders, Calmoseptine to affected areas for incontinence as needed and Vitamin A & D ointment to affected sites as needed. This was discussed with the DPCS.

Observed in Record Review. In 5 of 11 patient records reviewed, it was noted that care was not provided as ordered. For example, in RR#2 both the MSW and SC visits were documented on the Plan of Care as 1 time every 2 weeks. Neither discipline visited at that frequency since the start of care. The SC visited once per month and the MSW had missed a visit in one of the months but otherwise had been visiting monthly. In RR#4 the RN was to visit every 2 weeks however it was noted that there was no documentation of an RN visit since the start of care 5 weeks ago. In RR#5 the RN was to visit every 2 weeks however it was noted that there was no documentation of an RN visit since the start of care 8 weeks ago. In RR for HV#1 it was noted that the orders for both MSW and SC were to be 1 as needed and Recert however in review of record it was noted that both disciplines had routinely visited once per month for the last 6 months. In RR# 7 there had been no RN visit notes since start of care two months ago and the orders were for every other week. This was discussed with the DPCS.

Observed in Leadership Session. During the leadership and data session it was noted that the organization had not documented any meeting minutes for the QAPI program for the past three years. While there was data which was collected via the electronic medical record, there was no documentation to support that any of the data was used to improve performance. This was discussed with the CEO, Alt. DPCS and CFO. Observed in Leadership Session. During the leadership and data session it was noted that the QAPI plan did not involve all services provided by the organization. For example, it did not include the services for Bereavement or Volunteers. This was discussed with the CEO, Alt. DPCS and CFO.

Observed in Leadership Session. During leadership and data session it was identified that the organization had not collected any patient satisfaction data for the past three years to monitor the effectiveness and safety of the services or quality of care. This was confirmed by the CEO and Alt. DPCS.

Observed in Leadership Session. During the leadership and data session it was noted that the organization had not documented and were unable to discuss any performance improvement projects for the past three years. This was discussed with the CEO, Alt. DPCS and CFO.

Observed in Leadership Session. During the leadership and data session it was noted that the organization had not documented and were unable to discuss any performance improvement projects for the past three years. This was discussed with the CEO, Alt. DPCS and CFO.

Observed in Leadership Session. During the leadership and data session it was noted that the organization governing body had not been accountable for making sure priorities for improvements were appropriately selected. For example, during a one month time period in the second quarter of 2024 data was collected which indicated that 50% of the patient's had developed wounds. There was no performance improvement activity implemented to address this issue. This was discussed with the CEO, Alt. DPCS and CFO.

Observed in Patient Home. In 2 of 3 home visits conducted, staff was observed not following hand hygiene guidelines. For example, in home visit #2 the RN was observed washing her hands at the patient sink and three times during the hand washing process she touched the top of the soap dispenser to obtain more soap. She did not wash her hands for an additional 20 seconds after the last time she touched it. In home visit #3 the LVN was observed not performing hand hygiene following glove removal and entering his bag for his stethoscope. Additionally, two more breaches were observed when entering the bag after touching the patient and not performing hand hygiene. This was discussed with the DPCS. Observed in Patient Home. In 1 of 3 home visits conducted, it was noted that the LVN in HV#3 did not appropriately clean equipment after patient use. For example, he was observed cleaning the BP cuff, pulse oximeter, and thermometer and then placing the items back onto the same area where he placed them following use on the patient. This was discussed with DPCS. Observed in Patient Home. In 1 of 3 home visits conducted, it was noted that the LVN did not follow agency guidelines for barrier use. For example, in home visit #3 he was observed initially placing his nursing bag on the sofa cushion without a barrier and then moved it into the patient bedroom and placed it on a chair without a barrier. This was discussed with the DPCS.

Observed in Data Session. During review of data and infection control protocols it was noted that while individual hand hygiene competencies and observations were done there was no aggregated data for the entire organization to demonstrate overall compliance with hand hygiene for the past three years. This was confirmed by the CEO and DPCS

Observed in HR File Review. In 2 of 2 HR files reviewed, for hospice aides it was noted that the competency evaluations done for both aides were evaluated verbally and not by observing the aide's performance with a patient or pseudo-patient. This was discussed with and confirmed by the DPCS who performed the competency by documenting V for verbal assessment on all areas of the competency form.

Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that in RR# 4, 5 and 7 there had been no RN visit for more that 5 weeks therefore no supervisory visits had been documented. This was discussed with the CEO and DPCS.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support the implementation of policies related to patient care, treatment and services as evidenced by condition level findings at 418.58, 418.60 and 418.100. This was discussed with leadership team.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted that during medication reconciliation in HV#2 there was no comfort kit available in the home however it was listed on the current medication list. This was observed by the CEO present on the visit.

Observed in Record Review. In 1 of 11 patient records reviewed, it was noted that there was no documentation of physician certification for terminal illness in RR#4 and the patient start of care was 5 weeks ago. There was verbal certification signed by an RN however the physician narrative and signature on both the verbal and written certification were not present at time of record review. This was confirmed by the DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted in home visit #1 that the backup oxygen tank was stored in a closed and cluttered closet. The caregivers were unaware that this was not safe storage and upon discussion immediately moved the tank to an open area. This was observed by the CEO present on the visit.

Observed in Document Review. In review of contract with SNF it was noted that the contract did not include a provision stating that the hospice be notified of the need to transfer a patient from the SNF/NF or ICF/IID arises, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related conditions. This was discussed with the DPCS.

Observed in Document Review. In review of contract with SNF it was noted that the contract did not include a provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. This was discussed with the DPCS.

Observed in Document Review. In review of the SNF contract it was noted that the contract did not include a stipulation that the hospice must require that all contracted entities obtain criminal background checks on contracted employees who have direct patient contact or access to patient records. This was discussed with the DPCS.

Observed in HR File Review. In 7 of 8 HR files reviewed, it was noted that criminal background checks were not done upon hire. For the following individuals who have been employed between 2022 and current date the only criminal background check available for review had been completed in May 2024; Alternate Medical Director, RN, Spiritual Counselor, and 2 hospice aides. Additionally, for an LVN hired in February 2024 the background check was not submitted until July 2024 and for the volunteer there was no background check obtained since 2019. This was discussed at length with CEO and DPCS.