Every finding on record at Appalachian Hospice Care Inc.

Observed in Emergency Management Session. During the Emergency Management session, , the surveyor noted that the organization had not performed a hazardous vulnerability assessment. The document given to the surveyor for review, written in 2017 indicated this would be done but it had not yet been completed. This was validated in a discussion with and observation by the CEO and the Clinical Director.

Observed in Emergency Management Session. During the Emergency Management session, , the surveyor noted that the organization had not performed an Emergency Management drill or evaluated an actual event in 2022.. This was validated in a discussion with and observation by the CEO and the Clinical Director.

Observed in Record Review. In 8 of 8 patient records reviewed, During the record review, in 9 of 9 records, the surveyor noted that the organization had not performed a fall risk assessment on admission according to organization policy 9.1. The EMR did not have the risk assessment included on the admission note, only the comprehensive assessment. This was validated in a discussion with and observation by the CEO and the Clinical Director.

Observed in Record Review. In 8 of 8 patient records reviewed, During the record review, in 8 of 8 records reviewed, the surveyor noted that the plans of care did not contain individualized goals nor were they measurable. For example, pain will remain at an acceptable level with the specific patent's pain level not identified to make it measurable; will maintain maximum mobility without indicators as how far they ambulate or get out of bed; will breathe comfortably without respiratory rates or number of episodes of SOB; free from constipation without indicators of how often the patient needs a BM. This was validated in a discussion with and observation by the CEO and the Clinical Director.

Observed in Record Review. In 8 of 8 patient records reviewed, During the record review, in 8 of 8 records, the surveyor noted that the plans of care included SN PRN visits of 12-13 and the HHA included PRN visits of 6-8. This is not a detailed frequency in an acceptable range. This was validated in a discussion with and observation by the CEO and the Clinical Director.

Observed in Individual Tracer. In 2 of 3 home visits conducted, During the home visits, the surveyor noted that the organization did not follow correct hand hygiene practices. For example, In HV 2 the SN finished the assessment at the feet and did not change her gloves before proceeding with other areas. In HV 3 the SN finished the assessment at the feet and did not change her gloves, proceeded to the buttock area to assess and did not change gloves before having the patient squeeze her hands with those same gloves on. This was validated in a discussion with and observation by the CEO and the Clinical Director.

Observed in Infection Control System Tracer. During the document review and infection control discussion, the surveyor noted that since the organization had not performed a risk assessment it did not have goals limiting exposure to pathogens. This was validated in a discussion with and observation by the CEO and the Clinical Director. Observed in Infection Control System Tracer. During the document review and infection control discussion, the surveyor noted that since the organization had not performed a risk assessment, it had not prioritized those risks. This was validated in a discussion with and observation by the CEO and the Clinical Director. Observed in Infection Control System Tracer. During the document review and infection control discussion, the surveyor noted that since the organization had not performed a risk assessment, it had not set up goals to minimize the spread of infection. This was validated in a discussion with and observation by the CEO and the Clinical Director. Observed in Infection Control System Tracer. During the document review and infection control discussion, the surveyor noted that since the organization had not performed a risk assessment, it did not have goals to limit the spread of infection with the use of medical equipment. This was validated in a discussion with and observation by the CEO and the Clinical Director. Observed in Infection Control System Tracer. During the document review and infection control discussion, the surveyor noted that the organization had not set up a surveillance program to document improvement with hand hygiene goals. This was validated in a discussion with and observation by the CEO and the Clinical Director. Observed in Infection Control System Tracer. During the document review and infection control discussion, the surveyor noted that since the organization had not performed a risk assessment, it did not have a plan for implementing actions to result in improvement and disease prevention. This was validated in a discussion with and observation by the CEO and the Clinical Director.

Observed in Leadership Session. During the report review, the surveyor noted that the leadership did not ensure compliance with 418.56 and 418.60 This was validated in a discussion with and observation by the CEO and the Clinical Director.