Every finding on record at Community Hospital of Anaconda

Based on record review and interview, the hospice agency failed to maintain a comprehensive emergency preparedness (EP) program with an annually updated emergency plan, which could affect all hospice patients. The findings include: --- During an interview on 4/10/24 at 1:45 p.m., staff member A stated the hospice EP program was included within the affiliated critical access hospital's plan. Staff member A stated, "The individual plan in each patient's chart is what we look at, so it's individualized. It's not really an overall plan." Staff member A stated the facility risk assessments would be the responsibility of staff member M. Staff member A stated she had not updated the phone call tree and would need to get the list from a staff member at the hospital.Review of the hospice policies and procedures on 4/10/24 showed, the hospice had an Emergency Preparedness program plan from the hospital with a section labeled for the hospice agency. The hospice agency section did not contain a facility and community-based risk assessment. The hospital section of the book had a Hazards/Vulnerability Assessment that had not been updated since 2017. The phone call tree had not been updated since 8/2021, and it contained the names of individuals who were no longer employed by the agency. During an interview on 4/10/24 at 2:10 p.m., staff member M stated the emergency plan for the hospice agency should have been separate from the hospital plan, and each department head was responsible for completing and updating all forms for their department's emergency plan. Staff member M stated the emergency plan presented to surveyors was the hospital plan with some additions for hospice, but the department head had not maintained the book or individual training. Review of the affiliated critical access hospital's EOP (emergency operation plan) on 4/10/24, showed the hospital's EOP did not include the hospice agency as part of their EOP.

Based on record review and interview, the hospice agency failed to develop, establish, and maintain a training program for the hospice emergency preparedness (EP) program, which could affect all hospice patients. The findings include: --- During an interview on 4/10/24 at 1:45 p.m., staff member A stated the hospice EP program was included within the affiliated critical access hospital's plan. Staff member A stated the emergency preparedness training program consisted of the online courses the hospital provided. Staff member A stated the training is general information. Staff member A stated the hospice did not complete a training specific to the hospice agency's EP program. Review of the EP training test on 4/10/24, showed the test contained the hospital EP training and did not include specific training for the hospice emergency plan. During an interview on 4/10/24 at 2:10 p.m., staff member M stated the emergency plan for the hospice agency should have been separate from the hospital plan, and each department head was responsible for completing and updating all forms for their department's emergency plan. Staff member M stated the emergency plan presented to surveyors was the hospital plan with some additions for hospice, but the department head had not maintained the book or individual training for staff.

Based on record review and interview, the hospice agency failed to ensure participation in interdisciplinary group meetings by all required professional groups. This practice had the potential to affect all patients. Findings included: --- During an interview on 4/9/24 at 8:30 a.m., staff member B stated the IDG team would meet and discuss residents that were currently active, then the case manager would write the plan of care after the meeting and have the physician sign at a later date. Staff member B stated the physician quit abruptly the first week of April, and the agency had been having issues with the physician completing administrative duties and attending meetings since February 2024. Staff member B stated face-to-face visits for hospice patients had not been completed, and she had a large stack of documents the physician had not signed which included orders, plans of care, certifications and recertification's. Staff member B stated the agency was continuing to attempt to reach the physician for signatures. Staff member B stated staff member E was on maternity leave and did not attend meetings. Staff member B stated the agency had a hospital employee as the coverage for staff member E's maternity leave, but that coverage was for emergent issues only. Review of the agency's Hospice Interdisciplinary Team Meetings dated 5/10/23 through 3/27/24, showed the following missing required professional attendees: -5/10/23: No pastoral or other counseling and no social worker. -5/24/23: No pastoral or other counseling and no social worker. -6/21/23: No pastoral or other counseling and no social worker. -7/19/23: No pastoral or other counseling and no social worker. -8/02/23: No pastoral or other counseling and no social worker. -8/16/23: No pastoral or other counseling and no social worker. -8/30/23: No pastoral or other counseling and no social worker. -9/13/23: No pastoral or other counseling and no social worker. -10/11/23: No pastoral or other counseling and no social worker. -10/25/23: No pastoral or other counseling and no social worker. -11/8/23: No pastoral or other counseling and no social worker. -11/21/23: No pastoral or other counseling and no social worker. -1/3/24: No pastoral or other counseling and no social worker. -1/31/24: No pastoral or other counseling and no social worker. -2/28/24: No medical director or physician present. -3/27/24: No pastoral or other counseling and no social worker. During an interview on 4/9/24 at 4:17 p.m., staff member E stated she was on maternity leave from July 2023 to October 2023. Staff member E stated the agency chose not to have the pastoral/counseling/social worker visits; nurses covered the assessments, and no one attended IDG for her position while she was on maternity leave. Staff member E stated the agency chose to use a hospital employee to cover any emergency needs of patients receiving hospice services. Review of the agency's policy, "Physician Services and Medical Director Roles and Responsibilities", revised June 2018, reflected the following: - "Participates in and acts as a medical resource to the IDG and Hospice leadership."

Based on record review and interview, the hospice agency failed to provide services for patients residing in the nursing home, in accordance with the patient's established plan of care for 2 (# 's 8 and 15) of 3 patients. Findings include: --- 1. Review of patient # 8's medical record reflected the following missed visits: 3/28/24 HHA patient missed visit reflected, "No HHA this week due to COVID." 4/3/24 HHA patient missed visit reflected, "No HHA this week due to COVID." 4/9/24 HHA patient missed visit reflected, "Patient lives in SNF." 3/28/24: Hospice nursing clinical note reflected, " call to facility due to possible covid outbreak..." 4/1/24: Hospice nursing clinical note reflected, "SN completed phone call with nursing staff at SNF to obtain update on patient..." 4/4/24: Hospice nursing clinical note reflected, "Outbreak of COVID in SNF and residents in quarantine." 4/8/24: Hospice nursing clinical note reflected, "patient on quarantine r/t COVID dx." Review of resident # 8's Plan of Treatment, dated 3/4/24, reflected skilled nursing visit frequency should have occurred two times weekly and HHA visits should have occurred one time weekly. During an interview on 4/10/24 at 11:00 a.m., staff member A stated the agency had two patients in the nursing home. Staff member A stated she made the executive decision to only call on patients to see how they were doing rather than doing a visit because the nursing home had COVID-19. Staff member A stated she made this decision because the nursing home was staffed with nurses, so she knew they were getting the care they needed, and she wanted to prevent any spread of COVID-19 to other patients. 2. Patient #15 had a SOC date of 1/20/23 and resides at a nursing facility. Patient #15's Plan of Treatment showed skilled nursing was to complete two visits per week and aide services were to be completed two times a week. Patient #15 Plan of Treatment showed the Social Worker was to visit one time per month. Review of patient #15's clinical notes, dated 3/15/24 through 4/10/24, showed the following: Skilled Nursing visits were missed on 4/1/24, 4/4/24, 4/8/24, and 4/10/24. Home Health Aide visits were missed on 3/15/24, 3/28/24, 4/3/24, and 4/9/24. Social Services visit was missed on 4/9/24. During an interview on 4/11/24 at 9:36 a.m., staff member A stated she had made the decision to cancel in-person visits due to a COVID-19 outbreak. But instead staff were to call the facility and get a report on the patient. During an interview on 4/9/24 at 4:18 p.m., staff member E stated she made a phone call to the nursing facility instead of an in-person visit due to the COVID-19 outbreak.

Based on record review and interview, the hospice agency failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. This has the potential to affect the quality of care provided for all hospice patients. --- During an interview on 4/11/24 at 8:32 a.m., staff member A stated, "The governing board hasn't given me much guidance on QAPI; no specific data points, and I've been here for five years." During an interview on 4/11/24 at 8:51 a.m., staff member A stated she had not completed an analysis of the infections or looked for trends. Staff member A stated, "We look at each patient on service at the IDG meetings, so if there was a trend we'd see it then." Staff member A stated she chose a project for QAPI and wrote a plan. She stated the projects were based on issues the staff stated they are struggling with. Staff member A stated she did not use quality indicators or objective data to determine the areas of concern for her QAPI meetings. Staff member A stated she would present her PIP to the board at a monthly hospital QAPI meeting, and if accepted, she would present on the status of the PIP quarterly. Staff member A stated the hospice and home health agency participated as part of the hospital QAPI. Staff member A stated, "We have bits and pieces of stuff, but none are really put together." Review of the agency's policy, "Community Hospital of Anaconda Quality Improvement Plan Periodic Evaluation & Quality Assurance Review", revised 4/2017, reflected the following: -..."B. Meetings: Departments or teams are expected to meet as often as necessary. Minutes and data collection regarding QI activities will be reviewed at each meeting and documented."

Based on record review and interview, the hospice agency failed to maintain and document an effective infection control program, including surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. This practice has the potential to affect all hospice patients. Findings include: --- Review of the agency's Infection Control book, no date, reflected the following forms for use with the infection control program: Hand Hygiene Monitoring: last dated monitoring occurred in January 2015 Alcohol Product Usage Compliance: last dated audit occurred in December 2014 Annual Flu Vaccine Program Evaluation: no completed form in the book Infection Control Quarterly Data Aggregation and Analysis: no completed forms in the book Review of the agency's policy, "Infection Prevention and Control Program", revised 10/17, reflected: -" ...There shall be a collaboration between the Infection Preventionist and all departments to identify any HAI trends or patterns that may occur, as well as identification of opportunities to improve outcomes in reduction and control of infections..." -"...The Infection Preventionist (Infection Control Nurse) shall:...Develop and maintain a system for identifying, reporting, investigating and controlling infections and communicable diseases..." During an interview on 4/11/24 at 8:51 a.m., staff member A stated she had not completed an analysis of the infections or looked for trends. Staff member A stated, "We look at each patient on service at the IDG meetings, so if there was a trend we'd see it then." Staff member A stated she puts the names of those with infections in the logbook, but does not analyze the data or investigate the infections to look for trends. Staff member A showed the surveyor the logbook and stated the hospice and home health agency's infections are combined, and it appeared to have twelve infections, including six urinary tract infections. When asked if she would consider this a trend, she stated, "It depends on the circumstances for each patient, that's why we just look at them individually during IDG meetings." Review of the logbook showed the form only required a date, patient ID #, infection type, MD notification, antibiotic treatment, and community-acquired or agency-acquired information. Staff member A stated she was confused on how to determine community-acquired or agency-acquired, so all were marked as community-acquired. Staff member A stated, "We have a program, but it's not fully implemented in many aspects. We have bits and pieces of stuff, but none are really put together." Staff member A stated she had not been using the forms in the infection control program and was not aware of the requirements for investigations of infections. During an interview on 4/11/24 at 8:57 a.m., staff member A stated, "This is the policy the hospital gave me." When asked if the agency had a separate program from the hospital, staff member A stated they are all using one policy, but she was responsible for the infection control program for the hospice and home health agencies.

Based on record review and interview, the hospice agency failed to ensure a recertification order was completed with the face-to-face visit by the physician for 6 (#'s 4, 5, 6, 7, 12 and 15) of 15 sampled patients. Findings include: --- 1. Review of patient # 6's medical record reflected no recertification order had been completed and no face-to-face had been completed for the current benefit period. The face-to-face was due on 2/26/24. 2. Review of patient # 7's medical record reflected no recertification order had been completed and no face-to-face had been completed for the current benefit period. The face-to-face was due on 3/26/24. 3. Review of patient # 5's medical record reflected no recertification order had been completed and no face-to-face had been completed for the current benefit period. The face-to-face was due on 3/31/24. 4. Review of patient # 4's medical record reflected no recertification order had been completed and no face-to-face had been completed for the current benefit period. The face-to-face was due on 3/29/24. 5. Review of patient # 15's medical record reflected no recertification order had been completed and no face-to-face had been completed for the current benefit period. The face-to-face was due on 3/15/24. 6. Review of patient # 12's medical record reflected no recertification order had been completed. Recertification was due on 3/10/24. During an interview on 4/9/24 at 8:30 a.m., staff member A stated the IDG team would meet and discuss patients that were currently active, then the case manager would write the plan of care after the meeting and have the physician sign at a later date. Staff member A stated the physician quit abruptly the first week of April, but the agency had been having issues with physician completing administrative duties and attending meeting since February 2024. Staff member A stated face-to-face visits had not been done for patients, and she had a large stack of documents the physician had not signed, including orders, plans of care, certifications and recertification's. Staff member A stated the agency was continuing to attempt to reach the physician for signatures. Staff member A stated the case managers create the orders, plans of care, and certification/recertification orders in the system. Staff member A stated the orders are in the system but are not signed by a physician.

Based on interview and record review, the agency failed to ensure patient certification/recertification of terminal illnesses, discharge orders, plan of care/treatment plans, and physician orders had a provider's signature for 7 (#s 1, 2, 8, 10, 11, 12 and 15) of 15 sampled patients. Findings include: --- 1. Review of patient # 1's medical record reflected the initial certification of terminal illness order had not been completed by the physician for the current benefit period. The benefit period started on 3/26/24. The plan of care dated 3/26/24 had not been signed by the physician. 2. Review of patient # 2's medical record reflected the discharge order, dated 11/28/23, had not been completed by the physician. 3. Review of patient # 8's medical record reflected the recertification of terminal illness order had not been signed by the physician for the current benefit period. The benefit period started on 3/2/24. The plan of care dated 3/4/24 had not been signed by the physician. 4. Review of patient # 10's medical record reflected two unsigned physician orders, dated 1/31/24, reflected the following: "Haldol 0.5mg i po q6hr prn anxiety/agitation." "ABHR 1 application of 1/2 to 1 teaspoon to inner wrist 2-3 times a day as needed for anxiety/agitation." 5. Review of patient # 11's medical record reflected the initial certification of terminal illness order had not been signed by the physician for the current benefit period. The benefit period started on 3/5/24. The plan of care dated 3/5/24 had not been signed by the physician. During an interview on 4/9/24 at 8:30 a.m., staff member A stated the IDG team would meet and discuss residents that were currently active, then the case manager would write the plan of care after the meeting and had the physician sign at a later date. Staff member A stated the physician quit abruptly the first week of April, but the agency had been having issues with physician completing administrative duties and attending meeting since February 2024. Staff member A stated face-to-face visits had not been done, and she had a large stack of documents the physician had not signed, including orders, plans of care, certifications and recertifications. Staff member A stated the agency was continuing to attempt to reach the physician for signatures. Staff member A stated the case managers create the orders, plans of care and certification/recertification orders in the system. Staff member A stated the orders are in the system but are not signed by a physician. 6. Patient #12 had a SOC (start of care) date of 12/11/23 with a primary diagnosis of congestive heart failure (CHF). During an interview on 4/11/24 at 8:55 a.m., staff member A stated the physician order for patient #12, dated 2/28/24, was not signed and dated. Review of patient #12's physician order, dated 2/28/24, did not show a signature and a date. 7. Patient #15 had a SOC date of 1/20/23 with a primary diagnosis of chronic obstructive pulmonary disease (COPD). During an interview on 4/11/24 at 9:36 a.m., staff member A stated a Certification of Terminal Illness (CTI) was not signed and dated, by the physician, for patient #15. Review of patient #15's Certification of Terminal Illness form, dated 1/23/23, did not show a signature and a date. Review of the agency's policy for Patient Record: Authentication showed, "All patient record entries will be dated and authenticated... All entries in patient records will be legible, clear, complete and appropriately authenticated, dated and timed."