Every finding on record at Elim Wellcare Hospice, LLC

Observed in Emergency Management Session. The organization did not review and make updates based on after-action reports or opportunities for improvement to the following items every two years, or more frequently if necessary: - Hazard vulnerability analysis - Emergency management program - Emergency operations plan - Communications plan - Continuity of operations plan - Testing program. Example: The agency had not reviewed their HVA, emergency management program, emergency operations plan, communications plan and continuity of operations plan since 2022. The agency had also not implemented a testing program for its Emergency Management Program since 2022. This was confirmed with the Agency Administrator.

Observed in Emergency Management Session. The organization did not conduct exercises to test the emergency plan at least annually. Example: Since 2022, the organization has not conducted an operations based testing exercise or a full-scale community based exercise to test the emergency plan. This was confirmed by the agency Administrator.

Observed in Data Session. The organization did not analyze and compare internal data over time to identify levels of performance, patterns, trends, and variations. Example: In reviewing QAPI/PI data, it was noted by the surveyor that data was identified, collected and reported quarterly. However the data was not aggregated over time to assist the agency in identifying opportunities and priorities for improvement. This was validated by the agency Administrator and QAPI RN.

Observed in Tracer Activities. The agency did not perform an annual evaluation of their QAPI program to demonstrate that an ongoing program for quality improvement and patient safety is maintained. This was confirmed by the QAPI RN and Administrator.

Observed in HR File Review. In 1 out of 8 HR files reviewed, the agency did not have documentation of staff participation in ongoing education and training specific to Infection control. Example: HR#3 did not participate in the annual staff training related to Infection control. This was confirmed with the agency Administrator

Observed in Tracer Activities. The hospice did not have documentation related to the cost savings achieved through the use of volunteers. Example: The hospice was unable to provide the Surveyor estimated dollar costs that the hospice would have incurred if paid employees occupied the identified positions for the same amount of time that volunteers spent working in those positions. This was confirmed by the agency Administrator.

Observed in Tracer Activities. The hospice was unable to provide documentation demonstrating evidence that volunteer staff provided day-to-day administrative or direct patient care in an amount that equaled 5% of the total patient care hours of all paid hospice employees and contract staff. Example: The Agency Administrator reported to the Surveyor that they had not engaged in tracking the percentage of total patient care hours over the last year.

Observed in Infection Control Tracer. On review of the written Infection Control Plan and on interview with the Administrator it was found that although the hospice had identified prioritized risks in writing, the plan had not identified goals for each of the risks. This was validated by the Administrator.

Observed in Emergency Management Session. The organization did not identify in writing the potential emergencies that could affect its ability to provide services and the likely consequences of those emergencies. During the Emergency Management Session, it was identified the organization had a template for a hazard vulnerability analysis (HVA) risk assessment, but had not completed and documented the HVA process according to its Emergency Management Plan Policy/Procedure. This was reveiwed and confirmed with the Administrator.

Observed in Emergency Management Session. The organization's Emergency Operations Plan did not include a continuity of operations strategy that covered - Continuity of facilities and communications, - A succession plan if the leaders are not able/available to carry out their duties, - A delegation of authority plan. During the Emergency Management Session, it was note the organization had templates for a delegation of authority plan and succession plan, but the plans had not been completed/documented on the template. This was reveiwed and confirmed with the Administrator.

Observed in Emergency Management Session. The organization did not identify deficiencies and opportunities for improvement in the evaluation of all emergency response exercises and responses to actual emergencies. Since the organization had not tested/implemented/evaluated its Emergency Operations Plan (EOP), deficiencies and opportunities for improvement were not identified and documented. This was reveiwed and confirmed with the Administrator. Observed in Emergency Management Session. The organization's management and staff did not evaluate all emergency response exercises and responses to actual emergencies. Since the organization had not conducted any emergency response exercises, or implemented its Emergency Operations Plan (EOP) in response to an actual emergency, an evaluation of the EOP was not completed. This was reveiwed and confirmed with the Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not ensure the hospice plan of care was based on the patient's goals, and the time frames, settings, and services required to meet those goals. In RR#2, it was noted the single goal for the patient's multiple pressure wounds was to be free of infection. In review of the wound care consultant/NP assessment notes, the interventions and recommendations included mechanical debridement and nutritional/dietary consultation. The patient's single wound care goal was not based on the actual plan of care. This was reveiwed and confirmed with the Administrator.

Observed in Record Review. In 7 of 11 patient records reviewed, the organization did not plan the patient's care by including all services needed for the palliation and management of the terminal illness and related conditions in the plan of care. In RR#1, RR#2, RR#3, RR#4, RR#5, RR#7, and RR#8, the plan of care did not include interventions to manage the patient's assessed/documented pain and symptoms, including pain/comfort, weakness, constipation, incontinence, integumentary risks, insomnia, and/or agitation. This was reveiwed and confirmed with the Administrator.

Observed in Data Session. The organization did not maintain documentation of the quality assessment and performance improvement (QAPI) program, and demonstrate its operation. This was reveiwed and confirmed with the Administrator. Observed in Data Session. Since the organization did not develop/implement a quality assessment and performance improvement (QAPI) program, the governing body did not ensure the QAPI program reflected the following criteria: - Reflected the complexity of the organization and its services, - Involved all services provided, - Actions to demonstrate improvement in the organization's performance, - Focused on indicators that were related to improved palliative outcomes. This was reveiwed and confirmed with the Administrator. Observed in Data Session. Leaders did not establish priorities for performance improvement by developing, implementing, and annually evaluating an effective, ongoing, organization-wide, data-driven quality assessment and performance improvement program. This was reveiwed and confirmed with the Administrator.

Observed in Data Session. The organization's quality assessment performance improvement (QAPI) program did not demonstrate improvement in the indicators related to improved palliative outcomes and hospice services. This was reveiwed and confirmed with the Administrator.

Observed in Data Session. The hospice organization did not use quality indicator data, including patient care and other relevant data, in the design of its quality assessment and improvement program. This was reveiwed and confirmed with the Administrator.

Observed in Data Session. Since the organization did not develop/implement a quality assessment and performance improvement (QAPI) program, the governing body did not approve the frequency and detail of the data collection. This was reveiwed and verified with the Administrator.

Observed in Data Tracer. The organization did not developed a data-based performance improvement program, hence leadership did not set priorities and frequency for data collection. This was reveiwed and verified with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not implement its planned infection prevention and control activities to minimize, reduce and eliminate the risk of infection. In HV#3, the RN did not follow the organization's bag technique policy. The nurse placed the barrier, field bag, and care equipment on the floor of the patient's home. This was reviewed and confirmed with the Administrator.

Observed in Infection Control System Tracer. The organization did not implement the infection prevention and control activities it had planned. During the Infection Control System Tracer discussion it was noted the organization's infection prevention and control activities did not include any surveillance or documentation of patient infections. This was reveiwed and verified with the Administrator.

Observed in Infection Control System Tracer. The organization did not identify risks for acquiring and spreading infections. During the Infection Control System Tracer discussion, it was noted the organization did not completed and documented an annual infection control risk assessment/analysis according to its established policy. This was reveiwed and confirmed with the Administrator.

Observed in HR File Review. In 1 of 8 HR files reviewed, the organization did not ensure staff were competent to perform their responsibilities. In HR#4. it was noted the initial competency of the hospice aide was completed by a LVN via verbal assessment. There was no documentation of the direct/actual evaluation of skills and competency by the Registered Nurse before the hospice aide provided patient care. This was reviewed and confirmed with the Administrator.

Observed in Record Review. In 3 of 6 hospice aide patient records reviewed, the organization did not ensure the hospice aide provided care, treatment, or services ordered in the plan of care. In RR#3 and HV#3, the plan of care for the hospice aide included reporting/documenting the patient's last bowel movement (BM) each visit. It was noted the aide did check this task as completed on the visit notes, but did not report/document the date of the patient's last BM. In HV#2, the aide plan of care included: assist with feeding, document intake food/fluids, and encourage fluids every visit. These tasks were not completed/documented on several hospice aide visit notes, with no explanation indicated as to why. This was reveiwed and confirmed with the Administrator.

Observed in Data Session. The governing body/leadership did not ensure the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100, 418.58, and 418.60. This was reveiwed and confirmed with the Administrator.

Observed in HR File Review. In 3 of 8 HR files reviewed, the organization did not assess and document staff competence as required by organizational policy. In review of HR#4, HR#7, and HR#8, annual staff competency assessments of the Hospice Aide, contracted Medical Director, and MSW were not completed/documented as required by organizational policy. This was reveiwed and confirmed with the Administrator.