Every finding on record at Aria Hospice LLC

Observed in Tracer Activities. The organization had not conducted exercises to test its emergency operations plan and response procedures. The surveyor found documentation for a fire drill, which does not meet the requirement. This was confirmed by the Administrator.

Observed in Tracer Activities. Spiritual Counselor and Medical Social Worker have not been attending the IDG Meetings since the beginning of August 2023. According to the Director of Patient Care Services, the new Medical Director changed the IDG Meeting time to 8 a.m. and the Spiritual Counselor and Medical Social Worker are employed elsewhere and are only available in the afternoon. Both Spiritual Counselor and Medical Social Worker provide the Director of Patient Care Services with a report the night before to be shared with the IDG team. At the time of survey, Administrator shared a written memorandum with staff stating that the IDG meeting time will now take place in the afternoon and that all members are required to attend. This was confirmed by the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, Plan of care did not include visit frequency order for Aide and Skilled Nursing Visits. In RRNHV#7, the surveyor did not find the written order. This was confirmed by the QA Nurse.

Observed in Patient Home. In 1 of 3 home visits conducted, staff did not follow the organization's recommendation for cleaning stethoscope, thermometer, and blood pressure cuff. In RRHV#1, the nurse use Clorox wipes to disinfect her equipment. According to the organization's Bag Technique Policy No. 9-014.1, stethoscope and thermometer will be cleaned with alcohol and blood pressure cuff will be cleaned in accordance with the manufacturer's guidelines. Staff also did not follow contact time (wet time) as specified by blood pressure cuff and/or disinfectant manufacturer’s IFUs. This was confirmed by the Director of Patient Care Services. Observed in Patient Home. In 1 of 3 home visits conducted, Staff failed to perform hand hygiene consistent with policy. In RRHV#1, the surveyor observed the hospice aide change her gloves twice without performing hand hygiene as per the organization's Hand Hygiene Policy No. 9-009, which states, hand hygiene will be performed after removing gloves. This was confirmed by the Director of Patient Care Services.

Observed in Record Review. In 3 of 3 home visits conducted, organization did not provide the patient with an individualized emergency plan.  In RRHV#1, RRHV#2, and RRHV#3, the surveyor did not find an individualized emergency plan in the home folder. This was confirmed by the Director of Patient Care Services.

Observed in HR File Review. In 3 of 10 HR files reviewed, licenses or certifications, required by law, not validated through primary source at renewal or at time of expiration. In HR#2, HR#3, and HR#8 personnel file review, surveyor noted that there was no documentation to confirm license was validated timely. This was confirmed by the Administrator.