Every finding on record at Azi Hospice Inc

Based on observation, interview, and record review the hospice agency failed to review and update the current medications for two of 11 sampled patients (Patient 6 and 7). This deficient practice had the potential to place patients at risk for drug interactions, adverse actions, and medication errors that could affect the patient's already compromised health status. --- a. A review of Patient 6's clinical record indicated a start of care date (SOC) of 04/24/2021, with a diagnosis of Alzheimer's disease (progressive disease that destroys memory and other important mental functions). A review of Patient 6's Plan of Care for the certification period of 8/17/2022 to 10/15/2022, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and is to receive routine care. On 09/22/2022, at 11:15 a.m., a joint home visit with the Director of Patient Care Services (DPCS) was conducted at Patient 6's residence. A review of Patient 6's Medication Profile provided by the agency, indicated Patient 6 had an order to take Miralax (used for constipation) 17 grams (unit of measurement) by mouth once daily as directed. During an interview with Patient 6's caregiver on 9/22/2022 at 11:35 a.m., he stated Patient 6 does not take Miralax. b. A review of Patient 7's clinical record indicated a start of care date (SOC) of 12/11/2020, with a diagnosis of Alzheimer's disease. A review of Patient 7's Plan of Care for the certification period of 8/3/2021 to 10/01/2021, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and Patient 7 was to receive routine care. On 09/22/2022, at 12:01 p.m., a joint home visit with the Director of Patient Care Services (DPCS) was conducted at Patient 7's residence. A review of Patient 7's Medication Profile provided by the agency, indicated Patient 7 had the following medication orders: 1. Claritin (used to treat allergy symptoms and hives) 10 milligram (mg-unit of measurement) one tablet by mouth daily as needed for seasonal allergies.2. Morphine Sulfate 5 mg per 0.25 milliliter (ml - unit of measurement) by mouth or sublingually every four hours as needed for mild pain/shortness of breath (SOB).3. Morphine Sulfate 10 mg per 0.5 ml by mouth or sublingually every four hours as needed for moderate pain/ SOB. 4. Prenatal vitamins one tablet by mouth daily. 5. Lexapro (used to treat depression and anxiety) 10 mg by mouth daily. 6. Amlodipine (used to treat high blood pressure and chest pain) five mg by mouth daily,7. Aspirin 81 mg by mouth daily. 8. Singulair (used to treat allergies and prevent asthma attacks) 10 mg by mouth daily.9. Melatonin (used to help with insomnia and improving sleep) three mg by mouth daily at bedtime. 10. Simvastatin (used to treat to treat high cholesterol) 20 mg by mouth daily at bedtime. A review of Patient 7's Claritin medication indicated that it expired on 6/2022. Further review of Patient 7's medications indicated that she did not have Morphine. Additionally, Patient 7's prenatal vitamins, Lexapro, Amlodipine, Aspirin, Singulair, Melatonin and Simvastatin medications were all out and the bubble packs where empty. During an interview with the Director of Patient Care Services (DPCS) on 9/12/2022, at 2:16 p.m., he stated the medication reconciliation is done during every Interdisciplinary team (IDT) meeting. DPCS further stated the SN checks the medications every visit. A review of the agency's undated policy and procedure titled "Medication Profile," indicated the medication profile will be updated for each change to reflect current medications and new and/or discontinued medications.

Based on interview and record review, the hospice agency failed to conduct an initial bereavement assessment for six of 11 sampled patients (Patient 6, 7, 8, 9, 10 and 11). This deficient practice resulted in patients not receiving bereavement assessments. --- a. A review of Patient 6's clinical record indicated a start of care date (SOC) of 4/24/2021, with a diagnosis of Alzheimer's disease (progressive disease that destroys memory and other important mental functions). A review of Patient 6's Plan of Care for the certification period of 8/17/2022 to 10/15/2022, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 6's clinical record indicated there was no initial bereavement assessment conducted. b. A review of Patient 7's clinical record indicated a start of care date (SOC) of 12/11/2020, with a diagnosis of Alzheimer's disease. A review of Patient 7's Plan of Care for the certification period of 8/3/2021 to 10/1/2021, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 7's clinical record indicated there was no initial bereavement assessment conducted. c. A review of Patient 8's clinical record indicated a start of care date (SOC) of 4/14/2021, with a diagnosis of Alzheimer's disease. A review of Patient 8's Plan of Care for the certification period of 8/7/2022 to 10/5/2022, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 8's clinical record indicated there was no initial bereavement assessment conducted. d. A review of Patient 9's clinical record indicated a start of care date (SOC) of 10/19/2021, with a diagnosis of Alzheimer's disease. A review of Patient 9's Plan of Care for the certification period of 8/15/2022 to 10/13/2022, indicated a Skilled Nurse (SN) is scheduled to visit the patient one time a week and Certified Home Health Aide (CHHA) is scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 9's clinical record indicated there was no initial bereavement assessment conducted. e. A review of Patient 10's clinical record indicated a start of care date (SOC) of 10/22/2021, with a diagnosis of Alzheimer's disease. A review of Patient 10's Plan of Care for the certification period of 8/18/2022 to 10/06/2022, indicated a Skilled Nurse (SN) is scheduled to visit patient one time a week and Certified Home Health Aide (CHHA) is scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 10's clinical record indicated there was no initial bereavement assessment conducted. f. A review of Patient 11's clinical record indicated a start of care date (SOC) of 3/21/2022, with a diagnosis of chronic atrial fibrillation (an irregular and often very rapid heart rhythm). A review of Patient 11's Plan of Care for the certification period of 3/21/2022 to 6/18/2022, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 11's clinical record indicated there was no initial bereavement assessment conducted. During an interview with the Administrator (ADM) on 9/12/2022, at 2:15 p.m., he stated the social worker does not complete an initial bereavement assessment and only does a post death assessment. A review of the agency's undated policy and procedure titled "Bereavement Assessment," indicated the purpose of the policy and procedure is to provide guidance for the assessment and reassessment of the bereavement needs of the family/caregivers. The policy and procedure further indicated that on admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that will be given to the Bereavement Coordinator.

Based on interview and record review, the hospice agency failed to update the comprehensive assessment for five of 11 sample patients (Patient 6, 7, 8, 9 and 10). This deficient practice had the potential to result in the hospice agency's lack of identifying signifcicant changes which would require services. --- a. A review of Patient 6's clinical record indicated a start of care date (SOC) of 4/24/2021, with a diagnosis of Allzheimer's disease (progressive disease that destroys memory and other important mental functions). A review of Patient 6's Plan of Care for the certification period of 8/17/2022 to 10/15/2022, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and was to receive routine care. A review of Patient 6's clinical record indicated the only comprehensive assessment in the clinical record was dated 4/27/2021 and nothing more recent. b. A review of Patient 7's clinical record indicated a start of care date (SOC) of 12/11/2020, with a diagnosis of Alzheimer's disease. A review of Patient 7's Plan of Care for the certification period of 8/3/2021 to 10/01/2021, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 7's clinical record indicated that the only comprehensive assessment in the clinical record was dated 12/13/2020 and nothing more recent. c. A review of Patient 8's clinical record indicated a start of care date (SOC) of 04/14/2021, with diagnosis of alzheimer's disease. A review of Patient 8's Plan of Care for the certification period of 08/07/2022 to 10/05/2022, indicated that a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 8's clinical record indicated the only comprehensive assessment in the clinical record was dated 4/15/2021 and nothing more recent. d. A review of Patient 9's clinical record indicated a start of care date (SOC) of 10/19/2021, with a diagnosis of Alzheimer's disease. A review of Patient 9's Plan of Care for the certification period of 8/15/2022 to 10/13/2022, indicated a Skilled Nurse (SN) is scheduled to visit the patient one time a week and a Certified Home Health Aide (CHHA) is scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 9's clinical record indicated the only comprehensive assessment in the clinical record was dated 10/19/2021 and nothing more recent. e. A review of Patient 10's clinical record indicated a start of care date (SOC) of 10/22/2021, with a diagnosis of Alzheimer's disease. A review of Patient 10's Plan of Care for the certification period of 8/18/2022 to 10/06/2022, indicated a Skilled Nurse (SN) is scheduled to visit the patient one time a week and Certified Home Health Aide (CHHA) is scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 10's clinical record indicated the only comprehensive assessment in the clinical record was dated 10/23/2021 and nothing more recent. During an interview with the Director of Patient Care Services (DPCS) on 9/12/2022, at 2:12 p.m., DPCS stated the comprehensive assessment is only done during the initial admission and when a patient revokes services and comes back again. The DPCS further stated that a comprehensive assessment is not done during the recertification period. A review of the agency's undated policy and procedure titled "Comprehensive Assessment," , indicated the comprehensive assessment is done by the interdisciplinary group as frequently as the patient's condition requires but at a minimum of every 15 days.

Based on interview and record review, the hospice agency failed to ensure every member of the interdisciplinary group (IDG) participated in the interdisciplinary group meeting and ensure the documentation for the IDG meetings were complete and comprehensive for 11 of 11 sampled patients (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11) by failing to ensure: 1. The Attending physician signed the POC/IDT notes and the CIT for Patient 1, 2, 7, 8, 9, 10 and 11 to demonstrate they were involved in their care. 2. The medical director and the MSW signed the POC/IDT notes for Patient 2, 3 and 4 to demonstrate their involvement in Patient 2, 3 and 4's care. 3. The chaplains signature was signed on the POC/IDT for Patient 4, 5, 6, 7, 8 , 9 and 10 to demonstrate involvement in their care. 4. The Social Workers signature was signed on the POC/IDT for Patient 6 to demonstrate involvement in Patient 6's care. These deficient practices had the potential to result in a lack of coordination of care for the patients that the agency serves and had the potential for members of the IDG not to contribute to the patient's comprehensive and ongoing assessments and participate in the care planning process. --- a. A review of Patient 1's face sheet indicated an admission to hospice on 5/2/22, with a primary diagnoses of abdominal aortic aneurysm without rupture (enlargement of the abdominal aorta causing thinning of lumen walls leading to possible rupture). A review of Patient 1's "Plan of Care/IDT Review" dated 8/25/22, indicated the Skilled Nurse (SN) visit was to take place once a week and the hospice aide (HA) service was to be done twice a week for selfcare needs. A review of Patient 1's Certificate of Terminal Illness (CTI), with an effective date of certification from 7-31-22 to 10-28-22, indicated Benefit period #2 indicated the Medical Director signed the attending physician referral section and Patient 1 was noted to have a life expectancy of six months or less if the terminal illness runs its normal course. On 9-12-22 at 1:45 p.m., during an interview with DPCS in the conference room, DPCS stated the signature of the medical director was not on the POC/IDT notes for Patient 1 on the following dates: 6/30/22, 7/14/22, 7/28/22, and 8/11/22. b. A review of Patient 2's face sheet indicated an admission to hospice on 1/6/21, with a primary diagnoses of Alzheimer's disease (progressive mental deterioration due to generalized degeneration of the brain). A review of Patient 2's "Plan of Care/IDT Review" dated 8/25/22, indicated the Skilled Nurse (SN) visit was to take place once a week and the hospice aide (HA) service was to be done twice a week for selfcare needs. A review of Patient 2 's Certificate of Terminal Illness (CTI), effective date of certification 8/12/22 to 10/10/22, Benefit period #12 indicated the Medical Director signed the attending physician referral section and Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. On 9/12/22 at 1:45 p.m., during an interview with DPCS in the conference room, DPCS stated the medical director's signature was not on the POC/IDT notes for the following dates: 6-30-22, 7-14-22. In addition to missing the medical director's signature, the signature from the MSW was missing on the following dates:7/28/22, 8/11-22, and 8/26/22. DPCS stated that signatures on the IDT review indicated that all disciplines were actively involved in the meetings. DPCS acknowledged without signatures, it was never done. c. A review of Patient 3's face sheet indicated an admission to hospice on 3/11/22, with a primary diagnoses of cerebral Infarction (disrupted blood supply, resulting in reduced oxygenation to brain tissue). A review of Patient 3's "Plan of Care/IDT Review" dated 8/11/22, indicated the Skilled Nurse (SN) visit was to be done twice a week and the hospice aide (HA) service was three times per week for selfcare needs. A review of Patient 3 's Certificate of Terminal Illness (CTI), effective date of certification 8/8/22 to 10/6/22 , Benefit period #4 indicated the Medical Director signed the attending physician referral section and Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. On 9/12/22 at 1:45pm, during an interview conducted with DPCS in the conference room, DPCS stated the medical director's signature was not on the POC/IDT notes for the following dates: 6-29-22, 7-13-22, 7-27-22, 8-10-22. In addition to missing medical director's signature, the signature from MSW and chaplin was missing for the following date: 8/25/22. DPCS stated that signatures on the IDT review indicated that all disciplines were actively involved in the meetings. DPCS acknowledged without signatures, it was never done d. A review of Patient 4's face sheet indicated an admission to hospice on 5-24-22, with a primary diagnoses of heart failure (failure of the heart to provide sufficient blood flow). A review of Patient 4's "Plan of Care/IDT Review" dated 8/11/22, indicated the Skilled Nurse (SN) visit was to take place twice a week and the hospice aide (HA) service was to be done twice a week for selfcare needs. A review of Patient 4 's Certificate of Terminal Illness (CTI), effective date of certification 8/22/22 to 11/19/22, Benefit period #2 indicated the Medical Director signed the attending physician referral section and Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. On 9/12/22 at 1:45pm, during an interview with DPCS in the conference room, DPCS stated the medical director and Chaplin's signature was not on the POC/IDT notes for the following dates: 6/30/22, 7/14/22, 7/28/22, 8/11/22. In addition to missing medical director and Chaplin's signature, the signature from MSW was missing for the following date: 8/25/22. DPCS stated signatures on the IDT review indicated that all disciplines were actively involved in the meetings. DPCS acknowledged without signatures, it was never done e. A review of Patient 5's face sheet indicated an admission to hospice on 9/3/21, with primary diagnoses of Alzheimer's Disease (progressive mental deterioration due to generalized degeneration of the brain). A review of Patient 5's "Plan of Care/IDT Review" dated 1/12/22, indicated the Skilled Nurse (SN) visit was to take place once a week and the hospice aide (HA) service was twice a week for selfcare needs. A review of Patient 5 's Certificate of Terminal Illness (CTI), effective date of certification 12/2/21 to 3/1/22, Benefit period #2 indicated the Medical Director signed the attending physician referral section and Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. On 9/12/22 at 1:45 p.m., during an interview with DPCS in the conference room, DPCS stated the medical director's signature was not on the POC/IDT notes for the following dates: 11/17/21, 12/1/21, 12/15/21. In addition to missing medical director's signature, the signature from chaplin was missing for the following dates: 12/29/22, and 1/12/22. DPCS stated that signatures on the IDT review indicated that all disciplines were actively involved in the meetings. DPCS acknowledged without signatures, it was never done A review of the agency's undated policy and procedure entitled "Interdisciplinary Group Membership and responsibilities" Policy No. 4-005.1, , indicated the interdisciplinary team/group will collaborate with the patients attending physician to develop a patient-directed plan of care and will participate in the periodic review and updating of the plan of care for each patient and family receiving hospice care. In addition, the interdisciplinary group will supervise hospice care and services including participation in quality assessment performance improvement activities. f. A review of Patient 6's clinical record indicated a start of care date (SOC) of 4/24/2021, with a diagnosis of Alzheimer's disease (progressive disease that destroys memory and other important mental functions). A review of Patient 6's Plan of Care for the certification period of 8/17/2022 to 10/15/2022, indicated a Skilled Nurse (SN) and a Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and provide routine care. A review of Patient 6's Interdisciplinary Group Meeting dated 6/30/22, 7/14/2022, 7/28/2022, 8/11/2022 and 8/25/2022 indicated the physician and pastor's/chaplain signatures were blank. The Interdisciplinary Group Meeting further indicated on 7/14/2022, 7/28/2022, 8/11/2022 and 8/25/2022 the social worker's signatures were blank. g. A review of Patient 7's clinical record indicated a start of care date (SOC) of 12/11/2020, with a diagnosis of Alzheimer's disease. A review of Patient 7's Plan of Care for the certification period of 8/3/2021 to 10/01/2021, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and was to receive routine care. A review of Patient 7's Interdisciplinary Group Meeting dated 7/13/2022, 7/27/2022, 8/10/2022, 8/24/2022 and 9/07/2022 indicated the physician and pastor's/chaplains signatures were blank. h. A review of Patient 8's clinical record indicated a start of care date (SOC) of 4/14/2021, with a diagnosis of Alzheimer's disease. A review of Patient 8's Plan of Care for the certification period of 8/7/2022 to 10/5/2022, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and was to receive routine care. A review of Patient 8's Interdisciplinary Group Meeting dated 6/30/2022, 7/14/2022, 7/28/2022, 8/11/2022 and 8/25/2022 indicated the physician and pastor's/chaplains signatures were blank. i. A review of Patient 9's clinical record indicated a start of care date (SOC) of 10/19/2021, with a diagnosis of Alzheimer's disease. A review of Patient 9's Plan of Care for the certification period of 8/15/2022 to 10/13/2022, indicated a Skilled Nurse (SN) is scheduled to visit the patient one time a week and a Certified Home Health Aide (CHHA) is scheduled to visit the patient two times a week and was to receive routine care. A review of Patient 9's Interdisciplinary Group Meeting dated 6/30/22, 7/14/2022, 7/28/2022, 8/11/2022 and 8/25/2022 indicated the physician signatures were blank. The Interdisciplinary Group Meeting further indicated on 8/25/2022 the pastor's/chaplains signature was blank. j. A review of Patient 10's clinical record indicated a start of care date (SOC) of 10/22/2021, with diagnosis of Alzheimer's disease. A review of Patient 10's Plan of Care for the certification period of 8/18/2022 to 10/06/2022, indicated a Skilled Nurse (SN) is scheduled to visit the patient one time a week and a Certified Home Health Aide (CHHA) is scheduled to visit the patient two times a week and was to receive routine care. A review of Patient 10's Interdisciplinary Group Meeting dated 6/30/2022, 7/14/2022, 7/28/2022, 8/11/2022 and 8/25/2022 indicated the physician and pastor's/chaplains signatures were blank. k. A review of Patient 11's clinical record indicated a start of care date (SOC) of 3/21/2022, with a diagnosis of chronic atrial fibrillation (an irregular and often very rapid heart rhythm). A review of Patient 11's Plan of Care for the certification period of 3/21/2022 to 6/18/2022, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and was to receive routine care. A review of Patient 11's Interdisciplinary Group Meeting dated 3/23/2022, 4/06/2022 and 4/18/2022 indicated the physician's signatures were blank. During an interview with the Director of Patient Care Services (DPCS) on 9/12/2022, at 2:12 p.m., DPCS stated the IDG members include the Medical Director, Social Worker, Pastor and Registered Nurse. DPCS further stated a signature of the individual is the verification of attendance. A review of the agency's undated policy and procedure titled "Interdisciplinary Group Membership and Responsibilities," indicated the hospice interdisciplinary team/group members will include, at a minimum a physician, registered nurse, social worker and pastoral or other counselor.

Based on interview and record review, the hospice agency failed to conduct a performance improvement projects (PIP) every year. This failure had the potential to affect the quality of care provided to patients. --- During a record review of the documentation of performance improvement projects was not on-going and data driven. The agency could not provide sufficient evidence to track, analyze, and implement a (PIP). During a concurrent interview, on 9/12/2022 at 1:45 p.m., with the Administrator (ADM) and the Director of Patient Care Services (DPCS), the ADM stated we currently do not have a QAPI project. DPCS is aware of the QAPI requirements, but could not provide any evidence of past projects during the time of survey. The Hospice's undated policy and procedure entitled, "Improving Organizational Performance" policy No. 4-015.1, , indicated Senior Management with Governing Body oversight will participate in educational activities to increase their level of understanding and ability to implement quality assessment and performance improvement activities. The agency's policy further indicated that senior management will ensure that an integrated patient safety program is implemented throughout the organization and will report the results of QAPI activities to the Governing Body on a quarterly basis.

Based on interview and record review, the hospice agency failed to provide volunteer training to the volunteer coordinator. This deficient practice resulted in the volunteer coordinators not having training. --- On 9/8/2022, a review of the Administrator Designee (ADMD) employee records indicated that the ADMD was also the Volunteer Coordinator. However, there was no certificate of training on file. During an interview with the Administrator Designee (ADMD) on 09/12/2022, at 2:31 p.m., she stated the only training she received regarding being a volunteer coordinator was what was taught to her by the Administrator. The Administrator Designee further stated that she does not have a certificates or proof of documentation regarding the training. A review of the agency undated policy and procedure titled "Volunteer Services," indicated the purpose of the policy and procedure is to ensure that qualified volunteers provide appropriate services in accordance with the plan of care and hospice program needs.

Based on interview and record review, the hospice agency failed to update and implement their coronavirus (COVID-19 - highly contagious respiratory disease caused by a virus that can spread from person to person) employee vaccination policies and procedures to ensure a process of documenting an employee's approval for medical or religious exemption for two of 20 agency employees (Licensed Vocational Nurse [LVN 1] and Certified Home Health Aide [CHHA 1]). This deficient practice resulted in the agency not having an updated policy and procedure for COVID-19 employee vaccination and two employees not having proof that religious exemption was approved. --- On 09/08/2022 and 09/12/2022, a review of the agency's COVID-19 policy and procedure and COVID-19 employee vaccination list was conducted. The COVID-19 vaccination list indicated that there were two (LVN 1 and CHHA 1) out of 20 employees who did not receive the COVID-19 vaccine and that they each submitted a COVID-19 Vaccine Exemption/Declination Form. During an interview with the Administrator Designee (ADMD) on 09/12/2022, at 12:55 p.m. and 2:03 p.m., she stated all employees were fully vaccinated except for LVN 1 and CHHA 1. Administrator Designee (ADMD) further stated that both LVN 1 and CHHA 1 submitted declination forms but no other document regarding the approval of the religious exemption. A review of the agency's undated policy and procedure titled "COVID-19 Policy and Procedure," indicated that the organization will comply with all applicable CMS (Centers for Medicare and Medicaid Services) and CDC (Centers for Disease Control and Prevention) recommendations for SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2).