Every finding on record at Avera @ Home

Based on observation, interview, record review, and policy review, the provider failed to follow standard infection prevention practices when transporting reusable supplies and equipment in a nursing bag for one of four sampled hospice patients (1) during a home visit.Findings include: --- 1. Observation on 6/10/25 at 2:10 p.m. of registered nurse (RN) D during a hospice home visit at an assisted living center conducted in the community room with patient 1 revealed:*She greeted patient 1 who was sitting in a chair in front of the television in the community room with several other residents, family members, and staff present. She removed the backpack style nursing bag from her back, sat in a chair next to the patient, placed the nursing bag on her lap, removed and placed a disposable square piece of wax paper as a barrier on a foot stool located in front of her and next to the patient, removed her laptop computer from the nursing bag and placed it on top of the wax paper barrier on the foot stool. She then placed her nursing bag on the floor in front of her next to the foot stool without a barrier under it.*She completed hand hygiene, opened the nursing bag, and removed the following reusable equipment items: stethoscope, thermometer, and an oximeter (a non-invasive device that measures the percent of oxygen in the blood). She placed the stethoscope around her neck and placed the thermometer and oximeter items on the keyboard of the open laptop computer.*She then picked the equipment items up off the open laptop computer and used them on the patient to obtain the patient's temperature, pulse, and oxygen saturation (level of oxygen in the blood), and then sat them back down on the open laptop computer. She then removed the stethoscope from around her neck and listened to the patient’s heart, lungs, and bowel sounds with the stethoscope.*When her visit was completed, she cleaned those equipment items with an alcohol wipe before returning them to her nursing bag and disposed of the wax paper barrier that her laptop computer had been placed on.2. Interview on 6/10/25 at 2:30 p.m. with RN D regarding infection prevention after the hospice home visit with patient 1 revealed:*She had worked at the hospice agency for approximately one year and four months.*She was trained on infection prevention and proper bag technique to maintain infection control during new hire orientation and received additional infection prevention training from the agency.*She agreed that placing her nursing bag on the floor without a barrier and then using it to transport reusable supplies and equipment into other patients' homes did not follow standard infection prevention practices. 3. Interview on 6/11/25 at 2:45 p.m. with nursing manager A regarding infection prevention revealed:*Nurses received infection prevention and nursing bag technique/infection control training as part of their new hire orientation and ongoing during their employment with the agency.*The agency had a Home Health/Hospice RN Orientation Competency Check List form that was completed and signed off by a preceptor/trainer during a nurse’s new hire orientation, that included nursing bag technique/infection control.*RN D had received the nursing bag technique/infection control training and completed a validation competency with a preceptor/trainer during her orientation.*She agreed that the nursing bag placed on the floor without a barrier by RN D during the observed hospice home visit had not followed infection prevention standards, or the provider's Bag Technique policy and posed an infection risk to patients.4. Review of RN D’s employee file with training revealed:*Her hire date was 1/8/2024.*Her Avera@Home Registered Nurse-Hospice & Home Care Orientation Skills Check List, dated as completed between 1/8/24 and 4/5/24, included the nursing bag technique/infection control training as completed with her and her preceptor’s initials on 1/13/24.5. Review of the provider's Bag Technique Policy with a 7/1/2013 origination date, a 9/18/19 last revised date, and a 5/20/25 last approved date revealed:*”PURPOSE:Describe the procedure for maintaining a clean nursing bag/computer bag and preventing cross-contamination.*POLICY:As part of the infection/exposure control plan, Avera@Home personnel will consistently implement principles to maximize efficient use of the patient’s care supply bag when used in caring for patients.”“Bag Technique:1. The bag needs to be placed on a barrier between the surface in the patient’s home and the computer, bag, or any other equipment that goes from home to home. The barrier is to be disposed of after each use. The barrier can be any of the following approved items: wax paper, newspaper, plastic bag, or a disposable chux [underpad].”

Based on interview, record review, and policy review, the provider failed to ensure that volunteers are providing administrative and direct patient care hours equal to or exceeding 5% of the total patient care hours provided by paid hospice employees and contract staff as required by Medicare Condition of Participation at 42 CFR Part 418 (§418.78).Findings include: --- 1. Interview on 6/11/25 at 2:45 p.m. with Nurse Manager A revealed:*The provider was well below the required 5% of volunteer hours.*They had tried to recruit volunteers last fall by putting up posters, making a brochure, and asking at churches.  *She felt that the amount of required volunteer training hours kept people from being interested in volunteering, as it included eight hours of online modules as well as tasks and tests before they could begin one on one training with Social Worker C.*Social Worker C was responsible for volunteer coordination, and was also responsible for bereavement coordination, admissions, and the social work role.  *She stated that Social Worker C “wore a lot of hats” which did not leave much time for recruitment activities. 2. Interview on 6/11/25 at 3:30 p.m. with Social Worker (MSW) and Volunteer Coordinator C revealed:*She was responsible for social work, bereavement, and volunteer coordination duties for the agency.  *They were not near the 5% requirement for volunteer hours and thought they had been at about 0.5% “pretty much forever”.*They had tried to recruit volunteers last fall with a brochure and in church bulletins, and a Certified Nurse Aide with the provider had made and posted some bulletin board posters around town but she would have to look back in her records to find the date that occurred.*Her job duties did not allow her time to complete many volunteer recruitment activities.*Following the interview, she provided a copy of the bulletin board poster and brochure with October 2024 handwritten at the top.*She confirmed they tried to recruit volunteers in October 2024, but had no documentation of further recruiting after that time.  3. Review of the provider’s monthly volunteer hour data collection form for the Medicare Condition of Participation 5% match revealed:*For calendar year 2023, monthly percentages ranged from 0.63% to 2.81%.  *For calendar year 2024, 11 of 12 monthly percentages ranged from 1.16% to 2.12%.  The month of June had a percentage of 4.71% as they held their annual remembrance ceremony. *For January 2025 through May 2025, monthly percentages ranged from 0.00% to 0.65%.*No months met the required volunteer hours equal to a minimum of 5% of staff hours.   4. Review of the provider's Volunteer Information Sheet revealed a total of four volunteers:*One started in 2020.*One started in 2023.*Two started in 2024. 5. Review of the provider's Hospice Volunteer Staff policy last approved on 8/16/23 revealed:*Purpose:  Ensure that qualified volunteers are available to assist with the provision of hospice services.*Policy: Volunteers will be utilized in defined roles to support ancillary, administrative, and/or patient care services.*There will be active and ongoing efforts to recruit, train, and retain volunteers.  *All efforts will be documented.

Based on interview, record review, and policy review, the provider failed to ensure the interdisciplinary group (IDG) care conferences had documented a physician in attendance at least every fifteen days for nine of eleven (1, 2, 3, 4, 6, 7, 9, 10, and 11) sampled active patients. Findings include: 1. Review of patient 1's electronic medical record (EMR) revealed: *He had started hospice services on 5/24/22. *Since his admission there had been four IDG meetings held on 6/7/22, 6/21/22, 7/5/22, and 7/19/22. *An IDG meeting note on 6/7/22 had included a notation that the patient's physician agreed with the plan of care. -That physician was not listed in the "Attendees" section of the IDG meeting. *No physician had been documented as having been in attendance during the remaining three meetings. 2. Review of patient 3's EMR revealed: *She had started hospice services on 2/14/22. *Since her admission there had been twelve IDG meetings held on 2/15/22, 3/1/22, 3/15/22, 3/29/22, 4/12/22, 4/26/22, 5/10/22, 5/24/22, 6/7/22, 6/21/22, 7/5/22, and 7/19/22. *IDG meeting notes on 2/15/22 and 5/24/22 had included a notation that the patient's physician agreed with the plan of care. -That physician was not listed in the "Attendees" section of the IDG meetings. *No physician had been documented as having been in attendance during the remaining ten meetings. 3. Review of patient 4's EMR revealed: *He had started hospice services on 12/01/21. *Since his admission there had been seventeen IDG meetings held on 12/7/21, 12/21/21, 1/4/22, 1/18/22, 2/1/22, 2/15/22, 3/1/22, 3/15/22, 3/29/22, 4/12/22, 4/26/22, 5/10/22, 5/24/22, 6/7/22, 6/21/22, 7/5/22, and 7/19/22. *IDG meeting notes on 12/7/21 and 12/21/21 had included a notation that medical director (B) agreed with the plan of care. -He was not listed in the "Attendees" section of the IDG meetings. *No physician had been documented as having been in attendance during the remaining fifteen meetings. 4. Review of patient 10's EMR revealed: *She had started hospice services on 4/29/22. *Since her admission there had been six IDG meetings held on 5/10/22, 5/24/22, 6/7/22, 6/21/22, 7/5/22, and 7/19/22. *An IDG meeting note on 5/10/22 had included a notation that medical director (B) agreed with the plan of care. -He was not listed in the "Attendees" section of the IDG meeting. *No physician had been documented as having been in attendance during the remaining five meetings. 5. Review of patient 11's EMR revealed: *She had started hospice services on 6/23/22. *Since her admission there had been two IDG meetings held on 7/5/22 and 7/19/22. *The 7/5/22 meeting note included a notation that medical director (B) agreed with the plan of care. -He was not listed in the "Attendees" section of the IDG meeting. *No physician had been documented as having been in attendance of the 7/19/22 meeting. 6. Review of patient 2's EMR revealed: *He had started hospice services on 2/21/22. *Since his admission there had been eleven IDG meetings held on 3/1/22, 3/15/22, 3/29/22, 4/12/22, 4/26/22, 5/10/22, 5/24/22, 6/7/22, 6/21/22, 7/5/22, and 7/19/22. *An IDG meeting note on 3/1/22 had included a notation that the patient's primary physician agreed with the plan of care. -That physician was not listed in the "Attendees" section of the IDG meeting. *No physician had been documented as having been in attendance during the remaining ten meetings. 7. Review of patient 6's EMR revealed: *She had started hospice services on 1/13/22. *Since her admission there had been fourteen IDG meetings held on 1/18/22, 2/1/22, 2/15/22, 3/1/22, 3/15/22, 3/29/22, 4/12/22, 4/26/22, 5/10/22, 5/24/22, 6/7/22, 6/21/22, 7/5/22, and 7/19/22. *IDG meeting notes on 1/18/22, 2/1/22, and 4/12/22 had included a notation that the patient's provider agreed with the plan of care. -That physician was not listed in the "Attendees" section of the IDG meeting. *No physician had been documented as having been in attendance during the remaining eleven meetings. 8. Review of patient 7's EMR revealed: *He had started hospice services on 3/21/22. *Since his admission there had been nine IDG meetings held on 3/29/22, 4/12/22, 4/26/22, 5/10/22, 5/24/22, 6/7/22, 6/21/22, 7/5/22, and 7/19/22. *IDG meeting notes on 3/29/22 and 6/21/22 had included a notation that the patient's primary physician agreed with the plan of care. -That physician was not listed in the "Attendees" section of the IDG meeting. *No physician had been documented as having been in attendance during the remaining seven meetings. 9. Review of patient 9's EMR revealed: *He had started hospice services on 4/28/22. *Since his admission there had been six IDG meetings held on 5/10/22, 5/24/22, 6/7/22, 6/21/22, 7/5/22, and 7/19/22. *IDG meeting notes on 5/10/22, 5/24/22, 6/21/22, and 7/5/22 had included a notation that the patient's primary physician agreed with the plan of care. -That physician was not listed in the "Attendees" section of the IDG meeting. *No physician had been documented as having been in attendance during the remaining two meetings. 10. Interviews on 7/20/22 at 1:00 p.m. and on 7/21/22 at 9:28 a.m. with clinical coordinator C revealed: *IDG meetings were held every other week and all active patients were reviewed during each meeting. *The hospice medical director had attended all IDG meetings. *She had not realized his attendance had not been listed in the "Attendees" section of the IDG meetings. -Thought his attendance had auto-populated into the patient IDG notes. *She had not explained, when the surveyor questioned, why there was no provider input or provider documentation in the IDG patient notes. *Medical director B had been unavailable to interview due to a family emergency. 11. Interview on 7/21/22 at 2:25 p.m. with regional director A revealed: *IDG meetings started at 7:00 a.m. before the hospice medical director conducted patient rounds. *She had not known where else she could find documentation on the medical director's IDG attendance other than his billing for the services. 12. Review of the provider's 9/7/21 policy on "Hospice Interdisciplinary Group Meeting" revealed: *"Policy: The hospice interdisciplinary group is comprised of all disciplines involved in the patients' plan of care, which may include Medical Director, attending physician, RN [registered nurse], SW [social worker], Chaplain, volunteer, bereavement coordinator, pharmacy, and care assistant. Each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or as patient's condition requires." -"8. Problem solving for optimal care of the patient and family/caregiver will occur, and changes will be documented on the interdisciplinary group meeting form."

Based on record review and interview, services were not provided for 6 of 11 sampled active patients (1, 2, 6, 9, 10, and 11) according to their plan of care. Findings include: 1. Review of patient 2's EMR (electronic medical record) revealed: *He was admitted to hospice services on 2/21/22. *His second hospice benefit period Plan of Care beginning 5/22/22 revealed visit orders for: -Hospice aide (HA) visits twice weekly for thirteen weeks. -SN (skilled nurse) visits twice weekly for thirteen weeks. *His visit schedule revealed: -Patient 2 called on 5/29/22 to ask if he was supposed to get an SN visit on 5/30/22 (his usual day) because it was Memorial Day. The SN on call told him he would check. -The SN called him twice on 5/30/22 but did not make a visit. The nurse had documented on 5/30/22 "Visit replaced by phone call due to scheduling difficulties d/t [due to] holiday." There was documentation of scheduling issues, but the nurse had not indicated if the issues were due to the staff or the patient. The physician had been notified on 5/26/22 of missed nursing visits on 5/23/22 and 5/30/22, prior to the missed visits. -On 6/1/22 the HA documented a missed visit due to a scheduling conflicts. The physician had been notified. -On 7/4/22 (Independence Day) the SN documented a missed visit. "Unable to schedule." The physician was notified on 7/1/22 prior to the 7/4/22 visit. There was no indication in any of the above missed visits that the patient had been offered a visit at a different date or time. 2. Review of patient 6's EMR revealed: *She had been admitted to hospice services on 1/13/22. *Her second hospice benefit period was 4/13/22 through 7/11/22. *That plan of care (POC) indicated the following visit schedule beginning 4/13/22: -HA visits for one visit for one week, then two visits every week for twelve weeks. -SN visits for one visit for one week, then two visits every week for twelve weeks. *Her visit schedule revealed a: -Missed HA visit on 6/17/22 due to "Patient sleeping soundly and not waking up when I tried." The physician was not notified until 7/14/22. -Missed SN visit on 6/17/22 was reassigned to a phone call. There was no documentation of why the visit had not occurred. The physician had been notified of the missed visit on 7/14/22. -Missed HA visit on 7/5/22 because the patient had visitors. There was no indication in any of the above missed visits that the patient or family had been offered a visit at a different date or time. 3. Review of patient 9's EMR revealed: *He was admitted to hospice on 4/28/22. *His initial POC indicated the following visit schedule beginning 4/28/22: -HA visits once weekly for one week, then twice weekly for twelve weeks. That order had been discontinued on 6/6/22. -Social services visit once monthly for twelve weeks. -SN visits once weekly for one week, then twice weekly for twelve weeks. *His visit schedule revealed the: -HA documented on 5/24/22 he refused a visit. -HA documented a missed visit on 5/27/22 due to a scheduling conflict. -HA documented a missed visit on 5/31/22 due to refusal. -Patient refused a HA visit on 6/3/22. -SN reported the patient refused a visit on 6/17/22 . --The physician had been notified of the above missed visits, but there was no documentation that the patient had been offered to reschedule the visits for another date or time. Social services had documented missed visits on 6/30/22 and 7/15/22. There was no indication the physician had been notified or the patient had been offered a visit at another date or time in June or July. 4. Review of patient 1's EMR and 5/24/22 POC revealed: *The HA was to visit the patient two times per week for 12 weeks starting the week of 5/29/22. *The SN was to visit the patient two times per week for 13 weeks. *There was documentation sent to the patient's physician regarding missed visits: -On 5/30/22 the HA was "unable to schedule". -On 6/15/22 the HA did not visit because the "bath was performed by [staff] (long term care facility)". --There had been other HA tasks assigned in their plan of care for each visit, but were not offered on this day. - On 7/4/22 the SN was "unable to reschedule". *There was no documentation to clarify who or why the visits had been canceled and if attempts were made to reschedule the visits for those weeks listed above. 5. Review of patient 10's EMR and 4/29/22 POC revealed: *The HA was to visit the patient two times per week for 13 weeks. *The SN was to visit the patient two times per week for 12 weeks starting the week of 5/1/22. *There was documentation sent to the patient's physician regarding missed visits: -On 5/30/22 as the HA was "unable to schedule". -On 7/4/22 as the SN was "unable to reschedule". -On 7/5/22 as the HA was "unable to schedule, holiday". *There was no documentation to clarify who or why the visits had been canceled and if attempts were made to reschedule the visits for those weeks listed above. 6. Review of patient 11's EMR and 6/23/22 POC revealed: *The SN was to visit the patient two times per week for 12 weeks starting the week of 6/26/22. *There was documentation sent to the patient's physician regarding a missed SN visit on 7/5/22. -The SN documented "unable to schedule" on this day. *There was no documentation to clarify who or why the visit had been canceled and if attempts were made to reschedule the visit. 7. Interview on 7/21/22 from 3:12 p.m. to 3:46 p.m. with clinical coordinator C and Avera quality partner E revealed: *The visits had not been rescheduled and should have been. *Clinical coordinator C's response to the surveyors question as to why the visits were not rescheduled was, "Probably because we have so many other patients." -She agreed there could be an improvement in documentation of reasons for the missed visits and provider attempts to reschedule. 8. Review of the provider's June 2022 Care/Service Coordination policy revealed: *Team members were to communicate with the attending primary physician in the case of a missed visit for any ordered discipline. *For a missed visit that could have the potential to result in a negative clinical impact on the patient, the physician was to have been notified the same day or the next day if it was not practical. *For missed visits that reduced the total number of visits that the plan of care called for, the physician was to have been notified as soon as practically possible, but no later than one week after the missed visit.