Every finding on record at East Valley Hospice Inc

Upon patient record review, 4 of 5 (Patient #1,2,3,4) 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 #1-RN frequency ordered every 14 days - no RN visits documented since 08/14/24 therefore no RN assessments were completed no less frequently than every 15 days. #2-Comprehensive assessment was only completed by an LPN and no evidence of a comprehensive assessment head-to toe assessment completed by the RN prior to benefit period #2 dated 09/02/24-11/30/24. #3-Comprehensive assessment was only completed by an LPN and no evidence of a comprehensive assessment head-to toe assessment completed by the RN from 08/01/24-08/22/24. #4-RN frequency ordered every 14 days - no RN visits documented since 08/15/24 therefore no RN assessments were completed no less frequently than every 15 days.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. #4-SC frequency ordered 1 x month, frequency not followed with only 2 visits made since SOC.

Upon patient record review 1 of 5 (Patient #2) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training #2-Aide frequency ordered 2 x wk. Frequency not followed week of 08/25/24, only one visit was made and there is no missed visit documentation.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. #2-There is no CTI or narrative statement for recert dated 09/02/24.

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 No evidence of emergency drill tabletop for major earthquake included the care of patients with East Valley Hospice.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #13, Patient is missing page 2 of acknowledgement of informed consent which would identify the Bill of Rights.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #11, No evidence of election of attending documented on acknowledgement of consents.

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

Upon patient record review 9 of 14 (Patient #1,3,5,6,7,9,10,11,12) 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 #1,5,6,9,10, No evidence of SC assessment completed, by SC or RN. Patient #3,7,11,12, No evidence of SC assessment or MSW assessment completed by discipline or RN.

Upon patient record review, 2 of 14 (Patient #3,11) 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 #3, No evidence of bereavement assessment completed. Patient #11, No evidence of bereaved family member identified on bereavement assessment completed on 5/15/24.

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, RN visit completed on 2/2/24 then on 2/27/24. No evidence of continuous assessment of this patient.

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

Upon patient record review, 5 of 14 (Patient #1,3,5,7,13) 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, No evidence of psych social care plan identifying no funeral home and full code status. No evidence of initial care plan addressing wound care. Patient #3, No evidence of psych social care plan addressing full code status. No evidence of care plan addressing hemodialysis, who transports to dialysis, who manages the central line, safety issues related to central line such as bleeding complications. Patient #5, No evidence of psych social care plan for addressing family wanting to be re-evaluated for additional hours through IHSS. Patient #7, No evidence of psych social care plan addressing full code status. Patient #13, No evidence of psych social care plan to addressing no funeral home, stating daughter will provide when information is found. No evidence of spiritual care plan to address pray to support patient faith.

Upon patient record review, 1 of 14 (Patient #1) 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, Wound care order to right posterior forearm wound, cleanse with wound cleanser, pat dry with gauze, apply teracyte to wound, cover with border gauze 3x/week. No evidence identifying who will complete the wound care.

Upon patient record review, 1 of 14 (Patient #4) 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 #4, Initial RN assessment documents patient has overbed table and walker. No evidence of overbed table and walker documented on plan of care under DME.

Upon patient record review, 1 fo 14 (Patient #12) 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, SN note on 3/7/24 documents patient was started on furosemide. No evidence care plan was updated with problems/goals/interventions.

Upon client record review, 13 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,13,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, Frequency RN every 14 days, Visit made on 6/25/24 then 7/5/24. No evidence visits were every 14 days. Patient #2, Frequency RN every 14 days, Visits made on 5/21/24 and 5/23/24. No evidence visits were every 14 days. MSW completed evaluation on 5/23/24 via telephone. No evidence of order for visits to be completed via telephone. Patient #3, Frequency LVN 1x/week, first visit completed by LVN was 2/22/24. No evidence of LVN visit the week of 2/15/24. RN every 14 days, visits completed 3/8/24, 3/13/24. No evidence of visits every 14 days. Patient #4, Frequency RN every 14 days, patient seen on 6/6/24 then 6/19/24. No evidence of visits every 14 days. Frequency SN 1x/week, patient seen by LVN on 6/12/24 and RN on 6/12/24. Patient #5, Frequency SN 1x/week, Patient seen 2x the week of 6/4/24, 6/18/24, 6/25/24, 7/6/21. Patient # 6, Frequency SN 1x/week, patient seen 2x week of 5/29/24, 6/10/24. Patient #7, Frequency SN 1x/week, patient seen 6/12/24 by LVN and 6/12/24 by RN. Patient seen 2x the week of 6/26/24. Patient #8, Frequency SN 2x/week, patient seen 6/5/24 by LVN and 6/5/24 by RN. Patient #9, Frequency MSW every recertification, patient seen 5/26/24 and 6/21/24. No evidence of orders for monthly visits. Patient #10, Frequency SN 1x/week, SN visits on 5/9/24, 5/14/24, 5/15/24, 5/17/24. No evidence visits were completed 1x/week. Patient #11, Frequency RN every 14 days. RN visits on 2/2/24 then 2/27/24. No evidence of visit every 14 days. Patient #13, Frequency MSW every certification. visits made 1/8/24 and 4/1/24. Certification period 1/5/24 to 4/3/24. No evidence of order for extra scheduled visit. RN frequency 2x/week, LVN visit 3/25/24, RN visit 3/25/24 LVN visit 3/27/24. No evidence visit schedule was followed. Patient #14, Frequency SN 3x/week. No evidence of SN visits the week of 10/20/23.

Upon patient record review 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #3, Initial RN assessment documents request hospice to contact local clergy. No evidence local clergy was contacted.

Upon observation, there was no evidence the organization develops, implements, and maintains an effective, on-going, organization wide Quality Assessment and Performance Improvement (QAPI) program.

Upon observation, there was no evidence the program shows measurable improvement in indicators related to improved palliative outcomes and hospice services.

Upon observation, there was no evidence the program must use quality indicator data, including patient care, and other relevant data, in the design of the program.

Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement Agency documents, b/p cuff, hand hygiene, flu vaccines, employees, anticoagulation, comfortable dying, continuous care, DME, pharmacy, medication error, grievance, satisfaction survey, incident report, infection control, oxygen safety. Incident report, infection control, comfortable dying and oxygen safety have collected data. Each of these reports have evaluation and goals. No evidence of how to accomplish these goals.

Upon observation, there was no evidence QAPI activities focus on high risk ,high volume, or problem prone areas.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by considering incidence, prevalence, and the severity of problems.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by understanding how they affect palliative outcomes, patient safety and quality of care.

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 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 in QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's Quality Assessment and Performance Improvement program.

Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases.

Upon patient record review 6 of 14 (Patient #1,2,3,7,8,14) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1, aide care plan identifies under bath hygiene; safety razor. No evidence task was completed on aide sheet. Patient #2, aide frequency 1x/week, aide visits on 5/21/24 and 5/25/24. Patient #3, aide frequency 3x/week. No evidence of aide visits the week of 2/15/24. Aide care plan documents vitals every visit. No evidence task was completed on 6/17/24 or 6/26/24. Patient #7, aide frequency 2x/week effective 5/29/24. No evidence of aide visits the week of 5/29/24. Aide note on 6/3/24 documents as completed; objects within reach and bed in low position. No evidence of aide care plan directing these tasks to be completed. 6/5/24 Aide documents as completed; objects within reach. No evidence of aide care plan directing this task to be completed. Patient #8, aide frequency 2x/week effective 5/22/24. No evidence of aide visits the week of 5/22/24. Patient #14, aide frequency 2x/week. No evidence of visits on 10/20/23, only one visit the week of 10/25/23 and 3 visits provided on 11/20/24, 11/22/24, 11/24/24.

Upon patient record review 1 of 14 (Patient #1) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient #1, Aide care plan states to notify RN is b/p less than 90/60. On 6/22/24, b/p 103/58 documented on aide sheet. No evidence aide reporting b/p to RN. On 6//15/24, b/p 105/55 documented on aide sheet. No evidence of aide reporting b/p to RN.

Upon personnel record review, 1 of 14 (Personnel #1) did not have evidence that the administrator is a hospice employee and possesses the education and experience required by the governing body. No evidence of Administrator meeting the qualifications per the job description. Job description states Administrator must have a Bachelor degree in Business Administrator or Masters in health care field. Administrator has a Bachelor of Science in Marketing.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #3, No evidence of certifying physician narrative includes current status. Narrative states "I certify that patient's condition is terminal and may lead to death in six months or less if the disease continues to run its normal course." " I attest/confirm that I composed this narrative based on my review of patients medical records, team assessment and/or examination of the patient" IDT discussed patient's current condition and all agreed to continue hospice services at this time. Patient documented face to face narrative for certification #2. Certification signed on 5/15/24 stating patient has 3+ pitting edema. SN visit notes on 5/6, 5/7, 5/14, 5/21, all document "none" for assessment of edema.

Upon patient client record review, 3 of 14 (Patient #10,11,13) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #10, Patient acknowledgement of informed consent was completed and signed by staff. No evidence patient signed consent. Signature space left empty. Patient #11, Patient did not complete election date on acknowledgement of informed consent. Patient #13, Patient is missing page 2 of acknowledgement of informed consent which would identify the election date.

Upon patient client record review, 1 of 14 (Patient #5) did not have evidence that each patient record contains Advance Directives. Patient #5, Advance Directive was documented yes on acknowledgement of informed consent. No evidence of copy of Advanced Directive was received.

Upon patient client record review, 1 of 14 (Patient #13) 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 #13, Patient is missing page 6 of acknowledgement of informed consent which would identify the Advance Directive.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence that the hospice assumes responsibility for professional management of the resident's hospice services in accordance with the hospice plan of care. The hospice is responsible for providing all hospice services including: • Ongoing assessment, care planning, monitoring, coordination and provision of care by the Hospice IDG • Assessment, coordination and provision of any needed general inpatient or continuous care • Coordination by the hospice RN for the implementation of the plan of care for the patient • Provision, in a timely manner, of all supplies, medications, and DME needed for the palliation and management of the terminal illness and related conditions • Financial management responsibility for all medical supplies, appliances, medications and biologicals related to the terminal illness and related conditions • Determination of the appropriate level of care to be given to the patient (routine homecare, inpatient, or continuous care) Patient #13, Level of care changed on 4/12/24 to continuous care. No evidence of RN assessment prior to change of level of care or during the time patient was on continuous care which ended due to death on 4/13/24.