Every finding on record at Delaware Hospice Central Division

Based on staff interviews, and policy and procedure review, the Hospice Agency failed to ensure that orientation and training regarding emergency preparedness had been completed for all employees of the agency. Findings include: Agency policy titled, ";Emergency Preparedness and Response (EPRP) Plan" stated, ";Hospice ensures that all employees...are trained and oriented about their responsibilities in the agencys EPRP upon initial implementation, upon hire and with any updates to the plan..." No evidence of a sign-in sheet for emergency preparedness training for all the agency employees. This finding was confirmed by Employee #2 on 10/12/2023 at 12:37PM.

Based on staff interviews, documentation, and policy review, the Hospice Agency failed to conduct a full-scale exercise that was a comprehensive test of the emergency plan. Findings include: Agency policy titled, ";Emergency Preparedness and Response (EPRP) Plan" stated, ";Hospice ...conducts at least one (1) community-wide mock drill.... or review an actual event that documents and demonstrates that employees have practiced their specific duties and assignments, as outlined in the emergency preparedness plan..." Agency provided surveyors with documentation of a ";Winter Storm" event in January 2022. Summary stated, ";The Hospice staff was notified at 6:15am on Monday January 3, 2022, by our automative notification system that due to the weather all homecare offices would be closed except for inpatient unit staff who would be reporting as normal." Above document was reviewed with Employee #3 on 10/11/2023 at 11:50AM by on-site surveyor who explained that it was incomplete and did not implement and address the components of the comprehensive emergency plan to qualify as a full-scale exercise. No documentation addressing how clients would be notified of the plan activation along with how the care of priority clients would be addressed along with where clinical staff should report and what duties would they be assigned was provided. This finding was confirmed with Employee #2 on 10/12/2023 at 11:24AM.

Based on policy review, record review, patient interview and staff interview, it was determined that for 1 out of 1 patient in the sample the agency failed to ensure further evaluation by appropriate health professionals. --- Agency policy titled "Unusual Occurrence Reporting W/Safety Zone Portal" stated, "...A patient safety event is an event, incident, or condition that could have resulted or did result in harm to a patient...provide care, support and follow-up as appropriate with patient/family/caregiver and/or attending physician as indicated...". Record review of patient # 20 revealed: "Care Coordination Note" date 10/5/23 at 4:00 PM stated, "Telephone call received from pt. She reports she is in more pain as a transport person fell on her. Reports her PRN pain meds only get her pain down to a 7/10..." "Routine Nurse Visit" dated 10/05/2023 at 5:32 PM stated, "...patient stated that there was an incident on 10/2 when she was getting transferred from the ambulance staff. She stated that the man on her left slipped and fell on her right rib cage and her left arm hit the O2 tank...RN visited due to patient having 10/10 pain...complained of 10/10 pain in her right upper torso and lower back pain. She stated it was aching, felt bruised and sore...RN paged NP...she stated that due to an acute injury, she would not be changing patient's medication..." During a patient observation visit on 10/12/23 at approximately 1:30PM with Employee #'s 3 and 4, it was noted that the patient appeared to be in pain upon our arrival. The patient was unable to reposition self, was grimacing, and was saying "ow" frequently. A follow-up interview was conducted with the patient who described that they were having a lot of pain "since that transport guy fell on me". The patient described the event that occurred on 10/2/23 and stated that she was still having significant pain to her left rib area. She stated that she had asked multiple nurses for an x-ray because she thought her rib may have been broken. During an interview on 10/12/23 at 3:30PM with Employee # 's 1 and 3, it was confirmed that an incident report had not been submitted regarding the patient reported injury, an investigation had not been performed, and an x-ray or assessment by a physician or medical provider from hospice had not been performed. It was also stated that the patient had a primary diagnosis of cancer and has metastasis to the bones. It was stated that the patient was unreliable with her pain ratings as "she is all over the place". add

Based on policy review, document review, record review, and staff interview, it was determined that for 1 out of 1 patient in the sample, the agency failed to track and analyze findings and implement preventive actions related to a patient injury. --- Agency policy titled, " Unusual Occurrence Reporting W/Safety Zone Portal" stated, "...maintains a system or generating unusual occurrence reports with follow-up corrective action as applicable...an unusual occurrence is defined as an unusual event involving...patient/family/caregiver. The event is considered unusual if the result was unintended, undesirable, and/or unexpected...All events or occurrences...must be reported. Review of "Unusual Occurrence Log" showed no evidence of an event on 10/02/2023 involving an injury to patient #20. Review of Patient # 20's chart revealed: "Routine Nurse Visit" dated 10/05/23 indicated that patient reported an incident on 10/2/23 in which a transport employee slipped and fell on the patient's right rib cage area during a transport. Patient reported pain 10/10. No evidence found of an unusual occurrence report found. During an interview with Employee # 3 on 10/12/23, it was confirmed that an incident report had not been submitted and an investigation was not completed regarding the event. add

Based on staff interviews, and policy and procedure review, the Hospice Agency failed to ensure that orientation and training regarding hospice philosophy including methods of comfort, pain control, and symptom management were performed for all staff providing care to the patients residing at four of ten facilities (skilled nursing facility (SNF) and nursing facility (NF)). This deficient practice has the potential to affect all patients receiving hospice care while residing in the SNF or NF. Findings include: Agency policy titled, ";Education of Contracted and Agency Employees" stated, ";.... Hospices is responsible for providing orientation to staff furnishing care to hospice patients in the hospice philosophy..." Contract titled, "Nursing Facility Services Agreement" stated, "...The Hospice retains responsibility for ensuring that the required training of personnel who will be providing Hospice Patient care in the Facility has been provided and that a description of the training and the names of those giving the training are documented..." No evidence of a sign-in sheet for training at the four facilities (SNF or NF). This finding was confirmed with Employee #3 on 10/10/2023 at 11:10AM.