Every finding on record at Az Superior Hospice Care, LLC

Based on review of the Emergency Program, it has been determined that the facility has failed to establish the requirements of an emergency plan. This deficiency poses a risk to the safety of the staff and patients associated with the facility. --- Findings include: The emergency preparedness program did not describe a facility's comprehensive approach to meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. The program failed to address how the facility would coordinate with other healthcare facilities, as well as the whole community during an emergency or disaster (natural, man-made, facility). The emergency preparedness program must be reviewed every two years for all providers and suppliers, this facility had not reviewed the EP in more than two years. Interview with the Administrator, DON confirmed that the EP has not been reviewed in the past two years.

Based on an interview and facility documents it has been determined that the provider failed to perform IDG meetings as required by federal requirement. This deficient practice poses a risk to safety and patient care. --- An interview with the administrator, DON and document review confirmed that IDG meetings were not held as required. Pre-signed attendance logs were located for future meetings. Only one signature was present on the past three months of IDG meetings, that of the former administrator.

L0584: Based on interview and personnel files it has been determined that the facility failed to ensure that the licensed professional services was verified prior to patient care. This failure to keep personnel qualifications up to date poses a risk to the safety and accuracy of patient care. --- Findings include: Personnel files for 2 of the 7 clinical personnel failed to include license verification. Personnel files for 4 of the 7 patient care personnel failed to include CPR certification. Personnel files for 3 of the 7 personnel failed to include fingerprint clearance cards.

Based on personnel record reviews and interview with administrator and DON, it has been determined that the facility has failed to ensure that licensed professionals have the required qualifications for patient care. This practice poses a risk to the effective clinical care of patients. --- Findings include: Personnel files for 2 of the 7 clinical personnel failed to include license verification. Personnel files for 4 of the 7 patient care personnel failed to include CPR certification. Personnel files for 3 of the 7 personnel failed to include fingerprint clearance cards.

Based on record review and interview it was confirmed that the facility failed to ensure the skills of clinical staff prior to patient care. This deficiency poses a risk to patients of receiving substandard hospice services and clinical care. --- 7 out of 14 employee personnel files reviewed revealed that there was no skills evaluation for clinical personnel before patient care was initiated. Interview with administrator confirmed that the skills evaluation was not in the personnel files and could not produce any documentation for verification.

Failure on the part of the administration to ensure hospice care services to patients and families have resulted in the facility voluntarily surrendering their MCS provider agreement.

L0784 Based on personnel record reviews and interview with administrator and DON, it has been determined that the facility has failed to ensure that licensed professionals have the required qualifications for patient care. This practice poses a risk to the effective clinical care of patients. --- Findings include: Personnel files for 2 of the 7 clinical personnel failed to include license verification. Personnel files for 4 of the 7 patient care personnel failed to include CPR certification. Personnel files for 3 of the 7 personnel failed to include fingerprint clearance cards.

The Department has determined through interview and document review that the facility has failed to maintain compliance with Federal, State, and local laws and regulations related to the health and safety of patients. --- Based on interview and facility documentation it has been determined that the facility has failed to submit 30 day written notification to the state of a change in administration. The facility has also failed to submit a resume for a change in administration to the state with 30 days written notification.

Upon observation, there was no evidence the hospice complies with all applicable federal, state, and local emergency preparedness requirements by establishing and maintaining an emergency preparedness program that meets the requirements of 42 CFR 418.113.

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.

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

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

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.

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.

Upon personnel record review, 6 of 12 (Personnel #4,#5,#6,#7,#8,#10) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel 4,5,6,7,8,10: There was no evidence of emergency preparedness training since initial orientations.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. The last drill provided occurred in 2021.

Upon patient record review, 3 of 14 (Patients #1,#3,#5) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient 1: There was no identification of responsible party signing to explain legal authority. Patient 3: There was no evidence of legal documentation to substantiate POA authority of responsible party signing election and consents. Patient 5: The medical record contained election and consent forms signed by the patient's sister. There was no documentation of legal authority.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 1 of 14 (Patient #2) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 2: The medical record contained a comprehensive spiritual assessment completed 3/1/24 with start of care 2/23/24.

Upon patient record review 3 of 14 (Patients #2,#4,#13) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 2: There was no evidence of a comprehensive psychosocial assessment. Corrected on site with SW visit completed 3/19/24. Patient 4: There was no evidence of a comprehensive psychosocial assessment. Corrected on site with late data entry of documentation. Patient 13: There was no evidence of a comprehensive spiritual assessment.

Upon patient record review, 5 of 14 (Patients #1,#4,#7,#9,#10) 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: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: The medication profile contained Bengay and diclofenac topical ointments with no area defined for administration. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. The profile also contained Lispro insulin with sliding scale instructions and no frequency defined, Voltaren topical ointment with no area defined for administration and clotrimazole for daily administration until infection resolved started 11/11/22 and still active on medication profile. Corrected on site. Patient 7: The medication profile contained oxygen with no defined delivery method. Patient 9: The medication profile contained triamcinolone topical ointment with no area defined for administration. Patient 10: The medication profile contained calmoseptine topical ointment with no area defined for administration.

Upon patient record review, 2 of 14 (Patients #2,#13) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 2: The medical record contained a bereavement assessment completed 3/2/24 with start of care 2/23/24. Patient 13: There was no evidence of a bereavement assessment.

Upon patient record review, 1 of 14(Patient #11) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 11: There was no evidence of RN visits between 11/8/23 and 12/29/23.

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

Upon client record review, 4 of 14(Patient #1,2,3,4) did not have evidence that the hospice follows the individualized plan of care developed in in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. Patient 1,2,3,4: There was no evidence of the attending physician's involvement in development of the plan of care.

Upon patient record review, 5 of 14 (Patients #1,#2,#3,#4,#10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: The medical record contained nursing documentation upon admission identifying patient issues with risk for aspiration, dyspnea, pain, and Alzheimer's diagnosis. There was no evidence of problems, goals, and interventions related to risk for aspiration, respiratory dysfunction and neurological dysfunction, or pain management included in the plan of care. Corrected on site. Patient 2: The medical record contained nursing documentation upon admission identifying patient issues with dyspnea and psychosocial needs from social worker. There was no evidence of problems, goals, and interventions related to respiratory dysfunction or psychosocial needs included in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon admission identifying patient issues with dyspnea, cardiac diagnosis, pain and risk for falls. There was no evidence of problems, goals, and interventions related to pain, respiratory dysfunction, cardiac dysfunction, and risk for falls included in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient issues with cardiac diagnosis, psychosocial needs for social worker, insulin dependence, modified diet needs, and impaired skin. There was no evidence of problems, goals, and interventions related to psychosocial needs, cardiac dysfunction, endocrine dysfunction, modified diet needs, and impaired skin included in the plan of care. Corrected on site. Patient 10: The patient was on hospice for heart disease. There was no evidence of problems, goals, and interventions related to cardiac dysfunction included in the plan of care.

Upon patient record review, 5 of 14 (Patients #1,#4,#7,#9,#10) 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 1: The medical record contained orders for Bengay and diclofenac topical ointments with no area defined for administration. Corrected on site. Patient 4: The medical record contained orders for Lispro sliding scale doses with no frequency defined, and Voltaren topical ointment with no area defined for administration. Corrected on site. Patient 7: The medical record contained an order for oxygen with no defined delivery method. Patient 9: The medical record contained an order for triamcinolone topical ointment with no area defined for administration. Patient 10: The medical record contained an order for calmoseptine topical ointment with no area defined for administration.

Upon patient record review, 5 of 14 (Patients #1,#2,#3,#4,#7) 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: The medical record contained nursing documentation upon admission identifying patient use of a shower bench, commode, hospital bed, walker, wheelchair, and raised toilet seat. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of a shower bench, hospital bed, bedside table, and walker. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of a walker, hospital bed, bedside table, commode, and shower bench. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of a bed, specialty mattress, wheelchair, and oxygen equipment. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of a specialty mattress. There was no evidence of an order for the mattress included in the plan of care.

Upon patient record review, 2 of 14 (Patients #12,#13) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 12,13: There was no evidence of updates to the plans of care regarding discharge planning.

Condition of Participation: Quality Assessment and Performance Improvement.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon observation, there was no evidence a written plan of correction is developed in response to any QAPI activity that does not meet an acceptable threshold. QAPI identified patient satisfaction goal was not met quarter 1 of 2023. There was no evidence of a plan of correction developed, actions taken and performance measured.

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.

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.

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 licensed professionals participate in the hospice's QAPI program.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 6: There was no evidence of a bereavement care plan.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all non-core services which includes speech-language pathology as there was no evidence of a contract or employee to provide.

Upon observation, there was no evidence the hospice ensures that non-core services are provided to hospice patients and their families according to applicable laws and regulations. Non-core services include Speech-Language Pathology. The therapy contract did not include speech pathology as an available service. Agency confirmed they do not have any separate contract for speech therapy.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 12 (Personnel #5) did not have evidence in the personnel file that the hospice aide had received at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. Personnel 5: There was no evidence of in-service trainings.

Upon observation, there was no evidence the hospice must maintain a written description of the in-service training provided during the previous 12 months.

Upon patient record review, 5 of 14 (Patients #1,#2,#6,#8,#10) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1: The aide care plan contained 2 bathing tasks of bed bath and shower every visit, and did not contain instructions for transfer and ambulation assistance needed. Patient 2: The aide care plan contained 2 bathing tasks for partial bath/shower and complete shower every visit, and did not contain instructions for transfer and ambulation assistance needed. Additionally, the aide care plan contained unclear VS parameters stating systolic BP 80 >or<160, diastolic BP 50>or<110, pulse 50>or<110, resp 16>or<23, temp 96/5>or<98.9, O2 90?or <. Patient 6,8,10: The aide care plans did not contain instructions for transfer assistance needed.

Upon patient record review 3 of 14 (Patients #1,#2,#3) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient 1: The medical record contained an ordered aide frequency of five times weekly. There was no evidence of aide visits completed since admission. Patient 2,3: The medical records contained an ordered aide frequency of one time the first week of service and two times weekly thereafter. There was no evidence of an aide visit completed the first week of service.

Upon patient record review 1 of 14 (Patients #4) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 4: There was no evidence of an aide supervisory visit completed. First aide visit was completed 2/27/24.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The governing body meeting minutes did not reflect review and oversight of bylaws, policies, procedures, QAPI, and fiscal affairs. In addition, the governing body/administrator did provide oversight for QAPI, emergency preparedness, qualified individuals, non-core services, and proper billing.

Upon patient client record review, 2 of 14 (Patients #1,#2) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 1,2: The medical record contained Notification of Non-Covered Items that did not identify unrelated diagnosis and medication not covered as described in the patient profile.

Upon patient client record review, 1 of 14 (Patient #3) did not have evidence that each patient record contains Advance Directives. Patient 3: The medical record contained an invalid DNR signed by acclaimed POA and witnessed by same person. The form requires a separate witness to confirm decisions made on the form.

Upon patient client record review, 5 of 14 (Patients #9,#10,#12,#13,#14) did not evidence that each patient record contains physician orders. Patient 9,10,12,13,14: There was no evidence of an order to discharge.

Upon patient client record review, 2 of 14 (Patients #7,#9) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 7: The medical record contained documentation of a face to face visit 4/5/23 that stated it was for benefit period starting 3/1/23 in error. Patient 9: The medical record contained documentation of a face to face visit 6/20/23 that stated it was for benefit period starting 5/6/23 in error.

Upon client record review, 2 of 14 (Patients #9,#10) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient 9,10: There was no evidence the agency forwarded a transfer summary to the receiving agencies.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the discharge summary includes all required information. Patient 11: There was no evidence of a discharge summary.

Upon inpatient contract review, 1 of 5 (Silverwood Post acute) did not have evidence that the hospice supplies the inpatient provider with a copy of the patient's plan of care and specifies the inpatient services to be furnished.

Upon inpatient contract review, 1 of 5 (Silverwood Post acute) did not have evidence that the inpatient provider has established patient care policies consistent with those of the hospice and agrees to abide by the palliative care protocols and plan of care established by the hospice for its patients.

Upon inpatient contract review, 1 of 5 (Silverwood Post acute) did not have evidence that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge.

Upon inpatient contract review, 1 of 5 (Silverwood Post acute) did not have evidence that the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement.

Upon inpatient contract review, 1 of 5 (Silverwood Post acute) did not have evidence of a method for verifying that the requirements for ACHC standard HSP1-8B and CFR 418.108c (1)-418.108c(5)are met.

Upon personnel record review, 1 of 12 (Personnel #6) did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state's Social Work Practice Act, the hospice's policies and procedures and/or job descriptions. Personnel 6: There was no evidence of proof of education.

Upon personnel record review, 2 of 12 (Personnel #11,#12) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 11,12: There was no evidence of criminal background checks.

Upon personnel record review, 1 of 12 (Personnel #7) did not have evidence of criminal background checks being obtained in accordance with state requirements. Personnel 7: There was no evidence of a criminal background check.