Every finding on record at Angel Rays Hospice Inc

Condition of Participation: Emergency Preparedness

Upon observation, there was no evidence the hospice has developed and maintained an emergency preparedness plan that must be reviewed, and updated at least every two years. The agency does not have an individualized emergency plan. The agency only has current emergency preparedness policies.

Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care Agency has emergency preparedness policies but they have not been individualized to the agency.

Upon observation, there was no evidence the The Emergency Preparedness plan addresses patient population, including, but not limited to: • The type of services the hospice has • The ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans Agency has emergency preparedness policies but they have not been individualized to the agency.

Upon observation, there was no evidence the Emergency Preparedness plan includes a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. Agency has emergency preparedness policies but they have not been individualized to the agency.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon observation, there was no evidence the hospice develops and maintains an emergency preparedness communication plan that complies with federal, state, and local laws and must be reviewed and updated every two years. The agency does not have an individualized emergency communication plan. The agency only has current emergency preparedness policies.

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients' physicians • Other hospices Agency has emergency preparedness policies but they have not been individualized to the agency.

Upon observation, there was no evidence the Emergency Plan communication plan includes contact information for Federal, state, tribal, regional, or local emergency preparedness staff. Agency has emergency preparedness policies but they have not been individualized to the agency.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. Agency has emergency preparedness policies but they have not been individualized to the agency.

Upon observation, there was no evidence of emergency preparedness training and testing program that is based on the emergency plan, policies and procedures and the communication plan. Agency has current Emergency Preparedness policies. Agency does not have evidence of the development and maintenance of an emergency preparedness training or testing program.

Upon personnel record review, 9 of 9 applicable (Personnel # 1,2,3,4,5,9,10,11,12) did not have evidence Emergency Preparedness training. Agency currently does not have an agency specific emergency preparedness plan. Agency only has current policies. There is not evidence staff have been trained on an agency emergency preparedness plan for the procedures necessary to protect patients and others.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. Missing evidence of any agency testing activities for emergency preparedness.

Upon patient record review, 3 of 11 (Patient #1, #2, #9) did not have evidence that the patient chooses a health care provider, including an attending physician.

Upon patient record review, 1 of 11 (Patient #2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to duplicate drug therapy. Patient #2: On 10/21/2021, there is an order for Norco 10/325mg 1 po TID for pain. On 10/29/2021, there is an order for Norco 10/325mg 1 po Q 6 hours for severe pain. No evidence to support an order to discontinue the original order for Norco. Corrected on site

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 9 of 11 (Patient #2,3,4,5,6,7,8,9,10) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). Patient #2: No evidence of an RN visit after SOC visit on 10/16/21. Patient #3: No evidence of an RN visit after SOC visit on 10/2/21. Patient #4: No evidence of an RN visit after SOC visit on 9/17/21. Patient #5: No evidence of an RN visit after SOC visit on 9/14/21. Patient #6: No evidence of an RN visit after 8/24/21. Patient #7: No evidence of an RN visit after 10/28/21. Patient #8: No evidence of an RN visit after SOC visit on 10/12/21. Patient #9: No evidence of an RN visit after SOC visit on 8/1/21. Patient on service until 9/29/21. Patient #10: No evidence of an RN visit after SOC visit on 7/16 until 9/24 which was after the patient was discharged on 9/22/21.

Upon patient record review, 1 of 11 (Patient #2) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: On 10/21/2021, there is an order for Norco 10/325mg 1 po TID for pain. On 10/29/2021, there is an order for Norco 10/325mg 1 po Q 6 hours for severe pain. No evidence to support an order to discontinue the original order for Norco.

Upon patient record review, 4 of 11 (Patient #1,2,3,4,9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: DME and Supply sections on the POC were left blank. During the home visit it was observed that the patient has a hospital bed with rails. Patient #2: DME and Supply sections were left blank on the POC. Patient had a walker Patient #3: DME and Supply sections were left blank on the POC. Patient has an order for oxygen. Patient #4: DME and Supply sections were left blank on the POC. Patient had a walker and nebulizer.

Upon client record review, 9 of 11 (Patient #2, #3, #4, #5, #6, #7, #8, #9, #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: SN 1 time a week and RN to see the patient every 14 days. Last RN visit was the SOC visit 10/16/21. No evidence to support any SN visits were performed 10/31/2021 - 11/6/2021. Patient #3: SN 1 time a week and RN to see the patient every 14 days. Last RN visit was the SOC visit 10/2/21. Week of 10/31/2021, LVN saw the patient twice (10/31/2021 and 11/3/2021). No evidence to support an order for change in frequency or PRN visit. Patient #4: SN 1 time a week and RN to see the patient every 14 days. Last RN visit was the SOC visit 9/17/21. There is no evidence to support any SN visits were performed from 10/11/2021 through 11/10/2021. SC was ordered 1 time a month effective 9/21/2021. No evidence to support a visit was made in the month of October. Patient #5: SN 2 times a week and RN to see the patient every 14 days. Last RN visit was the SOC visit 9/14/21. There is no evidence to support any SN visits were performed after 10/15/2021. SC was ordered 1 time a month effective 9/14/2021. No evidence to support a visit was made in the month of October. The plan of care ordered for SN to change the foley catheter Q month and PRN. No evidence to support that the foley catheter was changed in the month of October. Patient #6: SN 1 time a week and RN to see the patient every 14 days. Last RN visit was the SOC visit 8/24/21. No documentation to support SN visits were made the week of 9/12/2021, 9/19/2021 or 9/26/2021. SC was ordered 1 time a month effective 8/14/2021. No evidence to support a visit was made in the month of October. Patient #7: SN 2 times a week and RN to see the patient every 14 days. Last RN visit was the SOC visit 10/28/21. SN frequency provided was 1 time per week. No evidence to support an order to change the frequency from 2 times per week to 1 time per week. SC was ordered 1 time a month effective 8/10/2021. No evidence to support a visit was made in the month of October. Patient #8: SN 2 times a week and RN to see the patient every 14 days. Last RN visit was the SOC visit 10/12/21. No documentation to support any SN visits were made after 10/13/2021. SW was ordered 1 time a month effective 4/19/2021. No evidence to support a visit was made in the month of October. Patient #9: Plan of care ordered for SN 1 time a week and RN to see the patient every 14 days. Last RN visit was the SOC visit 8/1/21. SW was ordered 1 time a month. No evidence to support a visit was made in the month of October. Patient #10: Patient revoked services and was discharged on 9/22/2021. SN continued to see patient after discharge on 9/24, 9/28, 10/5, 10/12, 10/18 and 10/28.

Condition of Participation: Quality Assessment and Performance Improvement.

Upon observation, there was no evidence the organization develops, implements, and maintains an effective, on-going, organization wide Quality Assessment and Performance Improvement (QAPI) program. No evidence of an active QAPI program in place. Agency had evidence of a QAPI policy last reviewed in 2017. Agency unable to provide evidence of any other QAPI activities.

Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. No evidence of an active QAPI program in place.

Upon observation, there was no evidence QAPI activities focus on high risk ,high volume, or problem prone areas. No evidence of an active QAPI program in place.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by considering incidence, prevalence, and the severity of problems. No evidence of an active QAPI program in place.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by understanding how they affect palliative outcomes, patient safety and quality of care. No evidence of an active QAPI program in place.

Upon observation, there was no evidence the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice's population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice's services and operations. No evidence of an active QAPI program in place.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. No evidence of an active QAPI program in place.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness.

Upon observation, there was no evidence the hospice ensures the implementation of a hospice wide Quality Assessment/Performance Improvement (QAPI) program by the designation of a person responsible for coordinating QAPI activities. No evidence of an active QAPI program in place.

Upon observation, there was no evidence in QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's Quality Assessment and Performance Improvement program.

Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases.

Upon observation, there was no evidence licensed professionals participate in the hospice's QAPI program. No evidence of an active QAPI program in place.

Upon patient record review 2 of 5 applicable (Patient #1, #6) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #1: Plan of care ordered aide services 2 times per week. No evidence to support any visits were performed. Patient #6: Plan of care ordered aide services 2 times per week. Only 1 visit was performed the week of 8/14/2021 and the week of 8/20/2021. Corrected on site.

Upon personnel record review, 1 of 12 (Personnel #12 ) did not have evidence that a skills competency assessment upon hire.

Upon patient client record review, 3 of 11 (Patient #1,2,9) did not have evidence that each patient record contains a signed election statement in accordance with 418.24. Patient #1,2,9: Missing evidence on the election statement regarding the patient's choice of attending physician.