Every finding on record at Everest Hospice

Based on record review and staff interviews it was determined the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency. This deficient practice has the potential that the facility is not educated and prepared in the event of an emergency leaving a vulnerable population at risk leading to negative outcomes. --- Findings include: A review of Everest Policy, titled, "Everest Hospice Patient Emergency Plan Policy", revealed, "...4. Please refer to the Emergency Preparedness Plan Manual...." A review of the presented Everest Hospice Emergency Preparedness (EP) binder revealed no documentation of policies or procedures relating to collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. In an interview conducted on June 25, 2024, with Employee #1, he/she confirmed he/she was unaware of the collaboration process with the aforementioned agencies or where the contact information was not located. No additional documentation was provided.

Based on record review and staff interviews it was determined the facility failed to conduct exercises to test the emergency plan at least annually. This deficient practice has the potential that staff are not educated and lack the knowledge of the emergency plan posing the risk of poor outcomes to both staff and the vulnerable population being served. --- Findings include: A review of Everest Hospice Policy titled, "Training and Testing", revealed, "... 3. All Everest Team Members must participate in Emergency Preparedness Plan Training at least once a year. a. All Everest Hospice Team Members must participate in Emergency Preparedness drills-sign the paperwork of participation-whenever drills are performed...6. The Everest Hospice Agency must conduct ONE FULL-SCALE EMERGENCY PREPAREDNESS TRAINING ANNUALLY. This annual training must include both a community drill and a table-top[sic] drill. (When a community drill is not feasible an individual full-scale test can be submitted in its place)...." A document titled,"... JUMANJI TOO FUNCTIONAL/FULL-SCALE EXERCISE VIRTUALLY DELIVERED TO YOUR FACILITY...", dated May 8, 2024, revealed, "... PLEASE EMAIL THIS SIGN-IN SHEET TO [NAME REDACTED]@AZHHA.ORG SUBMIT ALL COMPLETED DOCUMENTS BY MAY 17, 2024...." Page(s) 7-9 titled, " HOTWASH FORM was not completed. Page 10 titled, "AZCHER HOT WASH PORTION" was not completed. A request was made for the certificate of participation was asked for. No documentation could be provided. A request was made for the 2023 Emergency Preparedness drill(s). No documentation could be provided. In an interview conducted on June 25, 2024, with Employee #1, he/she stated the facility participated in the aforementioned drill. He/she was unable to provide the sign-in sheet for the Everest Team Members who participated in the aforementioned drill. An email chain was presented on June 26, 2024 to the survey team that revealed; on Wednesday, June 26, 2024, at 10:58 AM from Employee #2, to AzCHER, stating"... We participated in the Jumanaji exercise-[name redacted] RN is no longer with Everest Hospice I believe she submitted documentation that we completed the exercise. We are in the middle of Survey- I'm needing a copy of the certificate or any information stating we completed the exercise. If you could please send that to me ASAP!... Wed, Jun 26, 2024 at 12:02 PM... Hi [name redacted], Unfortunately, we did not receive any exercise documentation for your facility. If you can provide a sign-in sheet or attendance list of all those that particiapated, we can email you today to confirm your exercise participation. Please note, we will not provide certificate but we will mention your facility in the After-Action report. Thank You!... Wed, June 26, 2024, at 12:28 PM... Here is the sign in sheet... Wed, Jun 26 at 12:32 PM... Thank you for providing the sign-in sheet for AzCHER's 2024 Jumanji Too Functional/Full Scale Exercise. This email confirms exercise participation for Everest Hospice...." A document titled, " Everest Hospice Jumanji AzCHER 5/8/2024, was presented on June 26, 2024, with the above-mentioned email chain. This was not present in the Emergency Preparedness binder presented on June 25, 2024. Not all team members' signatures were present on the document. The Administrator, chaplain, medical director, volunteer, and office manager were absent from the drill.

Based on record review, observation, and staff interviews it was determined the facility failed to inform patient's of his or her rights, and the hospice must protect and promote the exercise of these rights. This negligent and deficient practice has the potential that patients and patient caregivers are not being educated and provided with copies of consent posing the risk of patient rights violations. --- Findings include: A review of the Everest Hospice admission packet revealed a document titled, " Patient Admission Checklist", revealed, "... Consents to be completed for Admission... 1. DNR/DNI Consent... MD Signature 2. Advance Directives 3. DNR (Orange)... RN Signature 4. Patient Contact List 5. Consent for Primary Caregiver Updated 2/26/2024...." a document titled, " RECEIPT OF HOSPICE PATIENT BOOKLET", revealed, " The following patient booklet contents have been reviewed with me: History and Philosophy of Hospice Frequently asked questions Roles of the interdisciplinary team Patient Rights and Responsibilities HIPAA (Privacy Act) Notice Home Safety Tips Infection control t home Emergency Preparedness Pain Management Nutrition Bowel Management instructions Primary Caregiver Guidelines Preparing for the Dying Process Grief Patient or Patient Representative Signature Date...." No documentation of consent for hospice election, release of information, choice of physician, or medication reconciliation form was present in the admission packet. In an interview conducted on June 26, 2024, with Employee #1, he/she stated that the patients sign consent for treatment, the election of the hospice benefit, preferred physician, psychotropic medication consent, the release of information, and services to be provided all via the clinician(s) tablet/computer. The patient is then provided copies at the next scheduled visit. The patient or patient caregiver are not given information on how they can revoke hospice benefits or a copy of any completed paperwork upon admission.

Based on record review, and staff interviews it was determined the hospice failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program. This deficient practice has the potential to cause issues regarding agency insufficiencies, and patient care and services are not being recognized, addressed, and corrected posing the risk of poor outcomes, --- Findings include: A review of Everest Hospice policy titled, "Everest Hospice Quality Assurance/Performance Improvement (QAPI) Policy", revealed, "...8. The following QAPI quality indicator measures are being monitored: a. Adverse Events b. Infections c. Chart Audits... 11...b. Determine problem areas. c. Develop a Performance Improvement Plan for improvement based on the review findings. d. Ensure that the Performance Improvement Plan is implemented as directed...." A review of Everest Hospice policy titled, " Everest Hospice Governing Body Policy", revealed "... Ensures the Everest Hospice Agency has an ongoing program to promote Quality Assessment and Performance Improvement. (QAPI)...." A review of Everest Hospice policy titled, "Everest Hospice Quality Assurance/Performance Improvement (QAPI) Director", revealed, "... is responsible for coordinating and implementing the collection of quality and compliance-related data which includes, but is not limited to: a. Review of Patient Records b. Review of Other Sources of Clinical Data c. Identification and Trending of Deficiencies d. Analysis of Trended Data...2. Assists in monitoring performance improvement activities of Everest Hospice Team Members...Supervision...2. Supervises: QAPI Audits b. QAPI Research... 11. Attends pertinent continuing education programs other than routine in-services...12, Assists in the development of QAPI activities according to Everest Hospice Agency's QAPI plan with appropriate data; a. Collection b. Aggregation c. Analysis d. Action e. Reporting of Results... 14. Chairs QAPI committee 15. Prepares QAPI reports/minutes of meetings...17. Assists in the identification of goals and related patient outcomes...." A review of seven(7) Employee files revealed no evidence that a QAPI Director Job Description was present in any of the seven(7) personnel records. A review of the Everest Hospice organizational chart revealed no identification of a QAPI Director or QAPI Auditor. A review of the Everest Hospice QAPI binder revealed no documented evidence that reflected changes or actions taken as a result of the identification of concern(s) about the delivery of services related to patient care. A review of the 2023 and 2024 QAPI Reports and the January 4, 2023, and January 8, 2024, Governing Body Meetings revealed no documentation of any change made or action(s) taken as a result of concerns regarding patient care or delivery of services. A request was made for additional QAPI meeting minutes for 2023 and 2024. No additional documentation was received. A request was made for the infection control log for 2023 and 2024. Documentation was not updated as of the date of this writing. A request was made for the documentation of Chart Audits. No documentation was received or could be provided. A request was made to speak with the QAPI Director. No interview was conducted as there was no one identified in the personnel files with the job description of the QAPI Director. In an interview conducted on June 25, 2024, with Employee #1, he/she confirmed that no documentation of changes made from the identification of care delivery was present in any documentation. No additional documentation could be provided as the hospice is "...ran from Utah..." per Employee #1

Based on record review and staff interview it was determined the hospice failed to include Performance Improvement Projects (PIP) that focused on high risk, high volume, and problem-prone areas. This deficient practice has the potential that issues regarding patient care and services, agency weaknesses, and areas of concern are not recognized, addressed, and corrected posing the risk of negative and poor patient outcomes. --- A review of Everest Hospice policy titled, " Everest Hospice Governing Body Policy", revealed "... Ensures the Everest Hospice Agency has an ongoing program to promote Quality Assessment and Performance Improvement. (QAPI)...." A review of Everest Hospice policy titled, "Everest Hospice Quality Assurance/Performance Improvement (QAPI) Director", revealed, "... is responsible for coordinating and implementing the collection of quality and compliance-related data which includes, but is not limited to: a. Review of Patient Records b. Review of Other Sources of Clinical Data c. Identification and Trending of Deficiencies d. Analysis of Trended Data...2. Assists in monitoring performance improvement activities of Everest Hospice Team Members...Supervision...2. Supervises: QAPI Audits b. QAPI Research... 11. Attends pertinent continuing education programs other than routine in-services...12, Assists in the development of QAPI activities according to Everest Hospice Agency's QAPI plan with appropriate data; a. Collection b. Aggregation c. Analysis d. Action e. Reporting of Results... 14. Chairs QAPI committee 15. Prepares QAPI reports/minutes of meetings...17. Assists in the identification of goals and related patient outcomes...." A review of a document titled, "2023 Governing Body Meetings", dated, January 04, 2023, revealed, "... A. Review of Agenda:... Comprehensive Chart Audit Summary Report ...Quality Assurance & Performance Improvement (QAPI) Plan...Policies for Governing Body Approval: QAPI Annual Written Plan... Project Improvement Plan...." No evidence of the plan or a Project Improvement Plan (PIP) was present. A request was made for documentation of the comprehensive chart audits and the PIP. No documentation could be provided. A review of a document titled, " 2024 Governing Body Meetings", dated, January 08, 2024, revealed, "... A. Review of Agenda:... Comprehensive Chart Audit Summary Report ...Quality Assurance & Performance Improvement (QAPI) Plan...Policies for Governing Body Approval: QAPI Annual Written Plan... Project Improvement Plan...." No evidence of the plan or a Project Improvement Plan (PIP) was present. A request was made for documentation of the comprehensive chart audits and the PIP. No documentation could be provided. A review of seven(7) Employee files revealed no evidence that a QAPI Director Job Description was present in any of the seven(7) personnel records. A review of the Everest Hospice organizational chart revealed no identification of a QAPI Director or QAPI Auditor. A review of the Everest Hospice QAPI binder revealed no documented evidence that reflected changes or actions taken as a result of the identification of concern(s) about the delivery of services related to patient care. A request for additional documentation was asked for. No additional documentation was received. In an interview conducted on June 27, 2024, with Employee #1, he/she confirmed he/she was the QAPI Director and QAPI Auditor. He/she stated the role has not "... officially appointed... everything is done from Utah with no control from Arizona...."

Based on record review and staff interview it was determined the hospice failed to implement performance improvement projects. This deficient practice has the potential issues of risk involving patient care, services, and agency deficiencies that are not being evaluated, addressed, and implemented to improve the areas above posing the risk for poor outcomes. --- Findings include: A review of Everest Hospice policy titled, "Everest Hospice Quality Assurance/Performance Improvement (QAPI) Policy", revealed, "...8. The following QAPI quality indicator measures are being monitored: a. Adverse Events b. Infections c. Chart Audits... 11...b. Determine problem areas. c. Develop a Performance Improvement Plan for improvement based on the review findings. d. Ensure that the Performance Improvement Plan is implemented as directed...." A review of the 2023 and 2024 QAPI Reports and the January 4, 2023, and January 8, 2024, Governing Body Meetings revealed no documentation of any change made or action(s) taken as a result of concerns regarding patient care or delivery of services. A request was made for additional QAPI meeting minutes for 2023 and 2024. No additional documentation was received. A request was made for the infection control log for 2023 and 2024. Documentation was not updated as of the date of this writing. A request was made for the documentation of Chart Audits. No documentation was received or could be provided. A request was made to speak with the QAPI Director. No interview was conducted as there was no one identified in the personnel files with the job description of the QAPI Director. In an interview conducted on June 26, 2024, with Employee #1, he/she confirmed that no documentation of changes made from the identification of care delivery was present in any documentation. No additional documentation could be provided as the hospice is "...ran from Utah..." per Employee #1

Based on record review and staff interviews it was determined the hospice failed to document what performance improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved. This deficient practice has the potential that issues regarding patient care and services, and agency needs are not being recognized, addressed, and change implemented posing the risk of poor outcomes, --- Findings include: A review of Everest Hospice policy titled, " Quality Assurance/Performance Improvement", revealed, "... Program Activities: ...b. Performance improvement activities will track complaints, infections, medication error[sic] and other adverse patient events, analyze their causes....' A review of Everest Hospice policy titled, "Quality Assurance/Performance Improvement (QAPI)", revealed, "... 2. The Everest Hospice Agency QAPI program will consist of ...b. Performance Improvement Projects (PIPs) that address issues or concerns identified within the organization... 12. The Performance Improvement Plan will assure that: a. Activities occur in a formal, organized manner b. The Everest Hospice Agency is providing quality care and meeting all regulations. c. Quality is defined and measured in terms of patient/service outcomes...." A review of Everest Hospice 2023 Governing Body Meetings dated, January 04, 2023, revealed, "...I. Quality Assurance & Performance Improvement Program... 2023 Annual QAPI Plan Project Improvement Summary Report... Policies for Governing Body Approval:... Project Improvement Plan...." A request was made for the Project Improvement Plan policy. No documentation was received. A review of Everest Hospice 2024 Governing Body Minutes dated January 08, 2024, revealed, "... I. Quality Assurance & Performance Improvement Program...Project Improvement Summary Report Comprehensive Audit Tool... Policies for Governing Body Approval: QAPI Annual Written Plan Project Improvement Plan...." A request was made for the PIP. No documentation was received. A review of the 2023 and 2024 QAPI reports were reviewed. No documentation of a PIP was present in the QAPI information presented. In an interview conducted on June 25, 2024, with Employee #1, he/she confirmed no PIPs were present for 2023 or 2024. No additional documentation was provided. In a follow-up interview on June 26, 2024, with Employee #1, he/she again confirmed there was no documentation PIPs had been performed in 2023 or 2024 and no additional documentation was provided. He/she confirmed they were the QAPI Auditor and the QAPI Director.

Based on interview, review of policies and procedures it was determined the facility failed to ensure an active infection control program was in place that includes monitoring for staff infections control practices as well as tracking, investigation, and follow up of communicable diseases and active infections for patients and staff. Inadequate infection control programs have the potential to lead to increased rates and severity of infections, increase the likelihood of multidrug-resistant bacteria, and increases the risk of outbreaks that have the potential to disseminate to the community. Severe infections have the potential to lead to sepsis as well as unnecessary patient suffering and substandard outcomes. --- Findings include: Review of facility policy, ";...Infection Control Policies and Procedures - Revised September 09, 2021... revealed,"...G. The Everest Hospice Agency identifies infection risks for the acquisition of, and spreading of, infectious agents based on the following: a. Analysis of infection control data through surveillance activities, b. Surveillance activities to address processes and/or outcomes for better infection prevention and/or control. c. The Everest Hospice Agency will prioritize identified risks of acquiring and spreading infectious agents. d. The Everest Hospice Agency will document all identified risks of acquiring and spreading infectious agents...." Review of Infection Control Binder did not reveal documentation to support infection control analysis and surveillance activities per facility policies. During interview with employee #1, documentation to support infection control analysis and surveillance activities per facility policies was requested. Employee # 1 confirmed documentation was unable to be provided. Employee #1 stated they were in the process of reviewing and updating Infection Control policies and procedures. Review of facility policy, ";... Infection Control Policies and Procedures - Revised September 09, 2021... revealed, "... Everest Hospice Infection Control Plan Procedures...H. The Everest Hospice Agency will evaluate the EVEREST HOSPICE INFECTION CONTROL PLAN PROCEDURES by review of its: i. Infection Rates ii. Infection Trends iii. Wound Care iv. Hand Hygiene v. Foley Catheter Insertion.... " Review of Infection Control Binder did not reveal documentation to support review of Infection Rates, Infection Trends, Wound Care, Hand Hygiene, Foley Catheter Insertion was requested. During interview with employee #1, documentation to support review of Infection Rates, Infection Trends, Wound Care, Hand Hygiene, Foley Catheter Insertion. Employee # 1 confirmed documentation was unable to be provided. Employee #1 stated they were in the process of reviewing and updating Infection Control policies and procedures. Review of facility policy, ";... Infection Control Policies and Procedures - Revised September 09, 2021... revealed, "... Everest Hospice Infection Control Plan Procedures...Infection reporting and Tracking...a. all Infections among patients and Everest Hospice Team members (including volunteers) will be reported and analyzed to identify patters of infection occurrence(s)...d. The Everest Hospice Agency will track, report, and prioritize patients at risk for infections in order to identify patterns of infections and proactive measures for infection prevention of infections...." Review of Infection Control Binder did not reveal documentation to support tracking, reporting, and prioritizing of patients at risk for infections in order to identify patterns of infections and proactive measures for infection prevention of infections. During interview with employee#1, documentation to support tracking, reporting, and prioritizing of patients at risk for infections in order to identify patterns of infections and proactive measures for infection prevention of infections was requested. Employee # 1 confirmed documentation was unable to be provided. Employee #1 stated they were in the process of reviewing and updating Infection Control policies and procedures. Review of facility policy, ";... Infection Control Policies and Procedures - Revised September 09, 2021...revealed, "...Infection Reporting and Tracking...S. Infection Control activities will be reported to the Everest Hospice Performance Improvement Team each meeting...." Review of Infection Control Binder did not reveal documentation to support reporting of Infection Control activities to the Everest Performance Improvement Team meetings. During interview with employee #1 documentation to support reporting of Infection Control activities to the Everest Performance Improvement Team meetings was request. Not provided. Employee #1 stated they were in the process of reviewing and updating Infection Control policies and procedures. Review of facility policy, ";... Infection Control Policies and Procedures - Revised September 09, 2021... revealed, "...Tuberculosis Risk Assessment. a, Using the TUBERCULOSIS (TB) RISK ASSESSMENT WORKSHEET, pages 126-139 the Everest Hospice Agency will determine its TB risk level..." Review of Infection Control Binder did not reveal documentation to support the Tuberculosis Risk Assessment Worksheet per facility policy was completed. During interview with employee#1, documentation to support completion of the Tuberculosis Risk Assessment Worksheet. Employee # 1 confirmed documentation was unable to be provided. Employee # 1, later completed the TB assessment on-site. Review of facility policy, ";... Infection Control Policies and Procedures - Revised September 09, 2021...revealed, "...p 17, Everest Hospice Infection Control Procedures...2. The proper cleaning and handling of Equipment bags, Equipment Bag supplies and cleaning of Equipment Bags and supplies to prevent and/or control the spread of infectious diseases of Everest Hospice patients...e. The Equipment Bag should...a barrier should be used ...." Observation of staff during home visits with patients # 7(seven) and # 8 (eight) revealed 2 (two) out of 3 (three) staff members (Staff members #9 and #13) did not follow facility policy and procedure for bag technique. Staff #12, provided the link https://www.youtube.com/watch?v=GZxdSZK6dHI to video used demonstrate proper bag technique to staff members. Interviews with Staff #1 and #12, confirmed equipment/bags should be placed on barriers. Review of facility policy, ";... Infection Control Policies and Procedures - Revised September 09, 2021...revealed, "...Hand Hygiene. A. ...Onsite competency assessments will be carried out at least annually to address hand hygiene compliance" Review of Infection Control Binder did not reveal documentation to support documentation of on-site competency assessments carried out at least annually to address hand hygiene compliance. During interview with employee #1 documentation to support annual hand hygiene competency assessments where conduct per facility policy was requested. Employee # 1 confirmed documentation was unable to be provided. Employee #1 stated they were in the process of reviewing and updating Infection Control policies and procedures.

Based on record review and staff interview it was determined the hospice failed to maintain 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. This deficient practice has the potential that infection monitoring and prevention is not being monitored, evaluated, and addressed, posing the risk of negative outcomes to a vulnerable patient population. --- Findings include: A review of Everest Policy revealed, "... 10. Infection monitoring is an ongoing Quality Assurance/Performance Improvement (QAPI) measure and should be discussed at: a. Quarterly QAPI meetings b. Interdisciplinary Team (IDT) meetings...." A request was made for the IDT meeting minutes. The IDT binder contained no evidence of IDT meetings being recorded or documentation that infection measures were discussed. No additional documentation was provided. A review of the QAPI binder revealed no evidence of infection monitoring or evaluation. A review of the 2023 and 2024 Governing Body Meeting minutes revealed no documentation of infection surveillance, identification, prevention, or control was discussed. In an interview conducted on June 26, 2024, with Employee #1, he/she confirmed the infection control program has not been implemented, ongoing, or maintained per policy. He/she further confirmed no additional documentation was available.

Based on record review and staff interview it was determined the hospice failed to include licensed professionals participate in the hospice's quality assessment and performance improvement program and hospice-sponsored in-service training. This deficient practice has the potential that issues regarding quality are not being recognized, addressed, and corrected posing negative risks to a vulnerable patient population and staff. --- Findings include: A review of policy titled, "EVEREST HOSPICE QUALITY ASSURANCE/PERFORMANCE IMPROVEMENT (QAPI) POLICY". revealed, "... 6. The Everest Hospice Agency QAPI Team consists of: a. Director of Professional Practice b. Assistant Director of Professional Practice c. Other Everest Team Members as appointed...." A review of the 2023 and 2024 Everest Hospice Governing Body Meetings revealed no appointments of the aforementioned QAPI Team per policy. A review of seven (7) OF SEVEN (7) personnel files revealed no documentation of job descriptions for the QAPI Team positions. A review of the Everest QAPI binder revealed no documentation of the licensed professionals participating as QAPI committee/members. A request was made for in-service training that QAPI members participate in. No documentation could be provided. In an interview conducted on June 27, 2024, with Employee #1, he/she confirmed no documentation of licensed professionals participating in the hospice's quality assessment and performance improvement program and hospice-sponsored in-service training was available. He/she further confirmed no documentation of the QAPI-appointed team was available.

Based on record review and staff interviews the Department determined the Administrator failed to ensure that Bereavement counseling for a patient's family for at least one year after the death of the patient is included in the hospice services provided by the hospice. This deficient practice has the potential that the patient's family members are not receiving the full benefits of the hospice services posing the risk of bereavement not being followed up on and for patient rights violations. --- Findings include: A review of Everest Hospice Policy titled, "Everest Hospice Bereavement Services Policy", revealed, "...B. The Everest Hospice Agency will provide Bereavement Services to the survivor or family member(s) of patient in need of bereavement for up to 13 months, additional time may be added if needed...." A review of the Everest Hospice Bereavement Services Manual binder, dated September 19, 2029, revealed,"... 11/18/2019..." was the last date bereavement services were documented. Patient #1 listed in the aforementioned Bereavement Services binder expired on 6/15/2019. The last documented contact with the bereaved was a mailing on 09/15/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #2 listed in the Bereavement Services binder expired on 7/6/2019. The last documented contact was a mailing on 10/6/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #3 in the Bereavement Services binder expired on 11/8/2019. No documentation the bereaved were contacted in person, via phone, or mailing. There was no documentation that the bereaved refused services. Patient #4 listed in the Bereavement Services binder expired on 6/5/2019. The last documented contact was a mailing on 9/5/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #5 listed in the Bereavement Services binder expired on 4/12/2019. The last documented contact was a mailing on 10/122019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #6 listed in the Bereavement Services binder expired on 8/4/2019. The last documented contact was a mailing on 11/4/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #7 listed in the Bereavement Services binder expired on 8/6/2019. The last documented contact was a mailing on 11/6/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #8 listed in the Bereavement Services binder expired on 8/4/2019. The last documented contact was a mailing on 11/4/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #9 listed in the Bereavement Services binder expired on 11/19/2019. There was no documentation any bereavement services had been attempted. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #10 listed in the Bereavement Services binder expired on 2/21/2019. The last documented contact was a mailing on 8/21/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #11 listed in the Bereavement Services binder expired on 11/5/2019. The last documented contact was a mailing on 11/11/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #12 listed in the Bereavement Services binder expired on 5/29/2019. The last documented contact was a mailing on 8/29/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #13 listed in the Bereavement Services binder expired on 11/1/2019. The last documented contact was a mailing on 11/1/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #14 listed in the Bereavement Services binder expired on 10/23/2019. The last documented contact was a mailing on 11/4/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #15 listed in the Bereavement Services binder expired on 6/18/2019. The last documented contact was a mailing on 9/18/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #16 listed in the Bereavement Services binder expired on 5/12/2019. The last documented contact was a mailing on 11/12/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #17 listed in the Bereavement Services binder expired on 5/12/2019. The last documented contact was a mailing on 11/12/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #18 listed in the Bereavement Services binder expired on 7/6/2019. The last documented contact was a mailing on 10/6/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #19 listed in the Bereavement Services binder expired on 7/6/2019. The last documented contact was a mailing on 10/6/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #20 listed in the Bereavement Services binder expired on 12/23/2018. The last documented contact was a mailing on 6/21/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #21 listed in the Bereavement Services binder expired on 8/8/2019. The last documented contact was a mailing on 11/8/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #22 listed in the Bereavement Services binder expired on 5/18/2019. The last documented contact was a mailing on 11/18/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #23 listed in the Bereavement Services binder expired on 3/4/2019. The last documented contact was a mailing on 9/4/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #24 listed in the Bereavement Services binder expired on 10/25/2019. The last documented contact was a mailing on 11/11/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #25 listed in the Bereavement Services binder expired on 4/30/2019. The last documented contact was a mailing on 10/30/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #26 listed in the Bereavement Services binder expired on 5/8/2019. The last documented contact was a mailing on 11/8/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #27 listed in the Bereavement Services binder expired on 3/1/2019. The last documented contact was a mailing on 8/1/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #28 listed in the Bereavement Services binder expired on 4/4/2019. The last documented contact was a mailing on 10/4/2019. No documentation was made the bereaved refused any further bereavement services/counseling. A request was made for the bereavement/bereaved receiving services for the years; 2020, 2021, 2022, and 2023. No documentation could be provided. A census for June 2023-June 2024 revealed 26 patients had expired and six(6) were listed on the "Bereavement Activity Report" printed from the Electronic Medical Record(EMR) system Homecare Homebase. No documentation that the remaining twenty patient family members had declined bereavement services. In an interview conducted on July 26, 2024, with Employee #1, he/she confirmed that no additional information that could be provided for the years 2020-2023. In a document titled. " Bereavement Protocols And Follow Up Timelines", revealed, " The Everest Hospice Program adheres to the CHAP/COPS and State Regulations... The Bereavement program continues for 13 months post death for the family and loved ones....' A review of Everest Hospice "Job Description: Bereavement Coordinator", revealed, "... Qualifications: Bachelor's Degree in Social Work or Counseling or equivalent theological degree from college or university, or certification of special training in bereavement....Job Responsibilities:...1) Initiate bereavement services within one week of death. 6. The needs of the family are reflected in the bereavement care plan and updates and revisions are conducted on an ongoing basis... Re-evaluation of the family/significant others needs will be provided for a minimum of 12 months... I have received, read, and understand the Job Descriptions above...." A review of Employee #1's personnel file revealed no job description for the Bereavement Coordinator. In an interview conducted on June 26, 2024, with Employee #1, he/she confirmed that he/she was the Bereavement Coordinator. He/she was unaware of the qualifications needed and confirmed he/she did not qualify for the job per the Everest Hospice Bereavement Coordinator job description.

Based on record review, and staff interview it was determined the hospice failed to appoint a designated employee for volunteers to report to. This deficient practice has the potential that volunteers are not being educated, trained, and aware of whom to report to posing the risk of negative volunteer and patient outcomes. --- Findings include: A review of the Everest Hospice Policy and Procedure Manual with a revised date of May 30, 2024t, revealed no job description for a Volunteer Coordinator. A review of the Everest Organizational Chart revealed no evidence of a volunteer coordinator. In an interview conducted on June 26, 2024, with Employee #1, he/she confirmed he/she was the volunteer coordinator. A review of Employee #1's personnel file on June 25, 2024, revealed no documentation he/she was the volunteer coordinator.

Based on record review and staff interview it was determined the hospice failed to document the cost savings achieved through the use of volunteers. This deficient practice has the potential that volunteer services are not being utilized posing the risk of patients not receiving hospice services. --- Findings include: A review of the Everest Hospice Volunteer Services Manual revealed, "...VOLUNTEER SERVICES' POLICIES AND PROCEDURES The Hospice Medicare benefit requires that volunteers provide five percent (5%) of total patient care... Volunteer Assignments and Reporting Responsibility...4. Volunteers must document patient/caregiver contact on a Volunteer Service Report (page 29) and submit to the Director of Volunteer Services...." A request was made for the volunteer cost savings documentation. No documentation could be provided. In an interview conducted on June 25, 2024, with Employee #1, he/she confirmed no documentation of a volunteer cost-savings report. In an interview conducted on June 27, 2024, with Employee #2, he/she confirmed limited access to financial information is released from the corporate office located in Utah.

Based on record review and staff interview it was determined the hospice failed to provide care and services in a manner consistent with accepted standards of practice. This deficient practice has the potential that patient and patient caregivers are not receiving the services posing the risk of poor outcomes. --- Findings include: A review of Everest Hospice Policy titled, "Everest Hospice Bereavement Services Policy", revealed, "...B. The Everest Hospice Agency will provide Bereavement Services to the survivor or family member(s) of patient in need of bereavement for up to 13 months, additional time may be added if needed...." A review of the Everest Hospice Bereavement Services Manual binder, dated September 19, 2029, revealed,"... 11/18/2019..." was the last date bereavement services were documented. Patient #1 listed in the aforementioned Bereavement Services binder expired on 6/15/2019. The last documented contact with the bereaved was a mailing on 09/15/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #2 listed in the Bereavement Services binder expired on 7/6/2019. The last documented contact was a mailing on 10/6/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #3 in the Bereavement Services binder expired on 11/8/2019. No documentation the bereaved were contacted in person, via phone, or mailing. There was no documentation that the bereaved refused services. Patient #4 listed in the Bereavement Services binder expired on 6/5/2019. The last documented contact was a mailing on 9/5/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #5 listed in the Bereavement Services binder expired on 4/12/2019. The last documented contact was a mailing on 10/122019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #6 listed in the Bereavement Services binder expired on 8/4/2019. The last documented contact was a mailing on 11/4/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #7 listed in the Bereavement Services binder expired on 8/6/2019. The last documented contact was a mailing on 11/6/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #8 listed in the Bereavement Services binder expired on 8/4/2019. The last documented contact was a mailing on 11/4/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #9 listed in the Bereavement Services binder expired on 11/19/2019. There was no documentation any bereavement services had been attempted. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #10 listed in the Bereavement Services binder expired on 2/21/2019. The last documented contact was a mailing on 8/21/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #11 listed in the Bereavement Services binder expired on 11/5/2019. The last documented contact was a mailing on 11/11/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #12 listed in the Bereavement Services binder expired on 5/29/2019. The last documented contact was a mailing on 8/29/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #13 listed in the Bereavement Services binder expired on 11/1/2019. The last documented contact was a mailing on 11/1/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #14 listed in the Bereavement Services binder expired on 10/23/2019. The last documented contact was a mailing on 11/4/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #15 listed in the Bereavement Services binder expired on 6/18/2019. The last documented contact was a mailing on 9/18/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #16 listed in the Bereavement Services binder expired on 5/12/2019. The last documented contact was a mailing on 11/12/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #17 listed in the Bereavement Services binder expired on 5/12/2019. The last documented contact was a mailing on 11/12/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #18 listed in the Bereavement Services binder expired on 7/6/2019. The last documented contact was a mailing on 10/6/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #19 listed in the Bereavement Services binder expired on 7/6/2019. The last documented contact was a mailing on 10/6/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #20 listed in the Bereavement Services binder expired on 12/23/2018. The last documented contact was a mailing on 6/21/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #21 listed in the Bereavement Services binder expired on 8/8/2019. The last documented contact was a mailing on 11/8/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #22 listed in the Bereavement Services binder expired on 5/18/2019. The last documented contact was a mailing on 11/18/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #23 listed in the Bereavement Services binder expired on 3/4/2019. The last documented contact was a mailing on 9/4/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #24 listed in the Bereavement Services binder expired on 10/25/2019. The last documented contact was a mailing on 11/11/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #25 listed in the Bereavement Services binder expired on 4/30/2019. The last documented contact was a mailing on 10/30/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #26 listed in the Bereavement Services binder expired on 5/8/2019. The last documented contact was a mailing on 11/8/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #27 listed in the Bereavement Services binder expired on 3/1/2019. The last documented contact was a mailing on 8/1/2019. No documentation was made the bereaved refused any further bereavement services/counseling. Patient #28 listed in the Bereavement Services binder expired on 4/4/2019. The last documented contact was a mailing on 10/4/2019. No documentation was made the bereaved refused any further bereavement services/counseling. A request was made for the bereavement/bereaved receiving services for the years; 2020, 2021, 2022, and 2023. No documentation could be provided. A census for June 2023-June 2024 revealed 26 patients had expired and six(6) were listed on the "Bereavement Activity Report" printed from the Electronic Medical Record(EMR) system Homecare Homebase. No documentation that the remaining twenty patient family members had declined bereavement services. In an interview conducted on June 26, 2024, with Employee #1, he/she confirmed that no additional information that could be provided for the years 2020-2023. In a document titled. " Bereavement Protocols And Follow Up Timelines", revealed, " The Everest Hospice Program adheres to the CHAP/COPS and State Regulations... The Bereavement program continues for 13 months post death for the family and loved ones....' A review of Everest Hospice "Job Description: Bereavement Coordinator", revealed, "... Qualifications: Bachelor's Degree in Social Work or Counseling or equivalent theological degree from college or university, or certification of special training in bereavement....Job Responsibilities:...1) Initiate bereavement services within one week of death. 6. The needs of the family are reflected in the bereavement care plan and updates and revisions are conducted on an ongoing basis... Re-evaluation of the family/significant others needs will be provided for a minimum of 12 months... I have received, read, and understand the Job Descriptions above...." A review of Employee #1's personnel file revealed no job description for the Bereavement Coordinator.

Based on record review and staff interviews it was determined the hospice failed to ensure entries must be legible, clear, complete, appropriately authenticated, and dated following hospice policy and currently accepted standards of practice. This deficient practice has the potential that the hospice is not following State laws regarding the authentication of clinical records posing the risk of regulation violations. --- Findings include: A review of Everest Hospice policy titled" Everest Hospice Clinical Record Policy", revealed, " A. The Everest Hospice Agency will maintain an Electronic Medical Record and a Paper Chart for each patient that contains: A. Forms that Require Signatures b. Other Documentation...D. All entries must be: a. Legible b. Clear c. Complete d. Appropriately Authenticated e. Dated...." A review of Everest Hospice Policy titled, " Everest Hospice Electronic Medical Records Policy", revealed, "1. It is the goal and policy of the Everest Hospice Agency to ensure complete, accurate, and timely documentation of all patient medical issues and records...2. Electronic Medical Record content: a. Shall be in compliance with all applicable Federal, Arizona State, and local laws...." A review of 19 of 19 patient medical records revealed no time stamp was present on clinical records, orders, or entries into the Electronic Medical Record (EMR) system being used by the hospice. A request for paper charts on 19 of 19 complete patient records could not be provided with the date and time on orders. In an interview conducted on June 27, 2024, with Employee #1, he/she confirmed the aforementioned Everest polices failed to have time stamp or time signature in the requirements. In an interview conducted on June 27, 2024, with Employee #2, he/she confirmed the Electronic Medical Record (EMR) system was unable to provide a report of time entries. He/she attempted to contact the EMR company and run a report.

Based on record review and staff interviews it was determined the hospice failed to assure orientation of such staff furnishing care to hospice patients in the hospice philosophy. This deficient practice has the potential that at the contracted skilled nursing facility providing care for the hospice patient is unaware of the procedures regarding methods of comfort, pain control, symptom management, as well as principles about death and dying posing the risk of poor outcomes and negative patient care. --- Findings include: A review of Everest Hospice Policy titled, " Everest Hospice Nursing Facility In-Services and Reference Manual Policy", revealed, "... 2. The Everest Hospice Agency will conduct an annual in-service on hospice care for the facility. 3. In-service records will be kept in the Contracted Facility In-Service Binder in the Everest Hospice Agency office...." A review of a contract for Diamondback Healthcare Center revealed no documentation of the staff being provided hospice philosophy/orientation or annual in-services. A review of a contract between La Loma Village revealed no documentation of the staff being provided hospice philosophy/orientation or annual in-services. A request was made for the orientation provided to the above-mentioned facilities. No documentation of hospice philosophy training/orientation, or annual in-services that it was provided. In an interview conducted on June 26, 2024, with Employee #1, he/she confirmed there was no documentation the aforementioned facilities were orientated to hospice or given any annual in-service training by the hospice.

Based on record review and staff interview it was determined the hospice failed to meet the licensing requirements set forth by State Law. This deficient practice has the potential that patient and patient caregivers are not at risk for harm and negative outcomes. --- Findings include: A review of 19 of 19 patient medical records revealed Interdisciplinary Meetings are not being held or recorded. A review of the current admission packet revealed patients and patient representatives are not being provided with education and consent to treatment upon admission. These documents are being taken back to the hospice office and provided "... at the next opportunity or visit because there are no printers with the clinicians...." A review of 19 medical records revealed the EMR system being utilized by the hospice is not recording the time on the orders, certificate of terminal illness, and medication orders. A review of contracts revealed the hospice failed to educate the Skilled Nursing Facilities (SNF) on the hospice philosophy and provide basic hospice orientation to the SNF's providing patient care. A review of the Quality Assurance Performance Improvement (QAPI) program is not being maintained and Performance Improvement Project (PIP) are not being done. Infection control issues are not being reviewed, assessed, and changes implemented. In interviews conducted on June 25, 2024, through June 27, 2024, Employee #1 confirmed the hospice is "....controlled from Utah...."

Based on the review of policy and procedures, staff interviews, and medical records, it was determined the hospice failed to ensure that patient rights regarding neglect were established and communicated to the appropriate channels. This poses a potential risk for patient harm resulting in negative patient outcomes. --- Findings include: A review of facility documentation revealed a document titled ";Everest Hospice Employee Handbook" dated 3/2019. The document stated ";...Abuse, Neglect, & Exploitation: All company employees are to report suspected abuse, neglect, or exploitation. This is required by law. If employees should suspect any of these activities, they are to immediately notify their supervisor... 2. Employees are to immediately notify their supervisor if they suspect signs of abuse, neglect, or exploitation... 3. When necessary, Medical Social Workers may be asked to assist in determining if the client is at risk for abuse, neglect or exploitation and to help develop the most effective plan of action. 4. The supervisor is responsible for taking any actions necessary, such as contacting the most appropriate agency (Law enforcement Agencies, Arizona Department of Health, Adult Protective Services,..." In a document titled "Patient Missed Visits". The policy states "... B. Missing a patient visit could potentially endanger a patient and is never acceptable...E. If an Everest Hospice Team Member goes to a patient home and no one answers the door it is the Everest Hospice Team Member's responsibility to investigate. F. It is the Everest Team Member's responsibility to determine that the patient is truly not home and that no incident has occurred. G. The Everest Hospice team Member will follow the following procedure: a. ... attempt to reach the patient by phone. b. If the patient does not answer: i...call the secondary number listed in the patient's file. ii. If the Everest Hospice Team Member cannot reach the Clinical Care Coordinator he/she will call the RN Case Manager to see if any additional instructions are available for an alternate means of entry. iii. The Everest Hospice Team Member is to call the Everest Hospice Clinical Coordinator to see if any additional instructions are available for an alternate means of entry..." A review of the medical record for patients #6 and #13 revealed that the patient(s) had last been seen for a skilled nursing(SN) visit on 10/13/2022 and were discharged for cause on 10/19/2022. Medical Social Worker(MSW) attempted a visit on 10/19/2022 with no answer to the door, and no answer to phone calls made to the patients. MSW reported this to the supervisor (nurse case manager). However, no documentation of the event was recorded in the facility report log, no further action was documented to ensure the aforementioned patients were safe. Review of Patient #6s medical records revealed a document titled "Missed Visit Form (MSW Visit)" dated 10/19/2022. The document stated "... Travel to patient: Yes, Attempt made: 13:01; Reason: No Answer to Locked Door; Comments: This missed visit may put the patient's health in jeopardy in the following ways no way to ensure that the pts needs are being met. I therefore recommend the following actions occur immediately: report this information to the nurse case manager... Supervisor Notified: Yes, by Phone... " Clinician signature 10/19/2022.Review of Patient #6s medical records revealed a document titled "Discharge-Live" dated 10/27/2022. The document stated "...Discharge Date: 10/19/2022 ... Comments: Discharge patient from Hospice services. Patient's have not been available for NP to complete a qualifying face to face visit for continued hospice services. The patient has not answered the door pr(sic) phone the last two weeks for RN visits.Referring MD has been notified. Final attempt was 10/27/2022..." Digitally signed by Employee #9 on 10/19/2022. Review of Patient #13s medical records revealed a document titled "Missed Visit Form (MSW Visit)" dated 10/19/2022. The document stated "... Travel to patient: Yes, Attempt made: 13:01; Reason: No Answer to Locked Door; Comments: This missed visit may put the patient's health in jeopardy in the following ways needs may not be met . I therefore recommend the following actions occur immediately: Call to the nurse case manager.... Supervisor Notified: Yes, by Other - tiger text... ". Digitally signed by: [Employee #12] on 10/19/2022. Review of Patient #13s medical records revealed a document titled "Discharge-Live" dated 10/27/2022. The document stated "...Discharge Date: 10/19/2022 ... Comments: Discharge patient from Hospice services. [Patient #13] have not been available for NP to complete a qualifying face to face visit for continued hospice services. The patient has not answered the door pr(sic) phone the last two weeks for RN visits. Referring MD has been notified. Final attempt was 10/27/2022". Digitally signed by Employee #9 on 10/19/2022. During the interview with Employee #1 on 12/8/2022, it was acknowledged that there was no follow-through or investigation conducted per facility policy and procedure on the condition of Patients #6 and #13 prior to being discharged from services. In a joint interview with Employees #1, #2, and #3 On 12/08/2022, the employees acknowledged the Clinical Care Coordinator (CCC) position outlined in the aforementioned Policy & Procedure (P&P) did not reflect any job roles within the facility structure. They acknowledged an opportunity to correct the identified job role within the P&P to accurately represent a current role within the facility. Findings include: A review of facility documentation revealed a document titled ";Everest Hospice Employee Handbook" dated 3/2019. The document stated ";...Abuse, Neglect, & Exploitation: All company employees are to report suspected abuse, neglect, or exploitation. This is required by law. If employees should suspect any of these activities, they are to immediately notify their supervisor... 2. Employees are to immediately notify their supervisor if they suspect signs of abuse, neglect, or exploitation... 3. When necessary, Medical Social Workers may be asked to assist in determining if the client is at risk for abuse, neglect or exploitation and to help develop the most effective plan of action. 4. The supervisor is responsible for taking any actions necessary, such as contacting the most appropriate agency (Law enforcement Agencies, Arizona Department of Health, Adult Protective Services,..." A review of facility documentation revealed a document titled "Patient Missed Visits". The policy states "... B. Missing a patient visit could potentially endanger a patient and is never acceptable...E. If an Everest Hospice Team Member goes to a patient home and no one answers the door it is the Everest Hospice Team Member's responsibility to investigate. F. It is the Everest Team Member's responsibility to determine that the patient is truly not home and that no incident has occurred. G. The Everest Hospice team Member will follow the following procedure: a. ... attempt to reach the patient by phone. b. If the patient does not answer: i. Call the secondary number listed in the patient's file.; ii. If the Everest Hospice Team Member cannot reach the Clinical Care Coordinator he/she will call the RN Case Manager to see if any additional instructions are available for an alternate means of entry.; iii. The Everest Hospice Team Member is to call the Everest Hospice Clinical Coordinator to see if any additional instructions are available for an alternate means of entry..." A review of the medical record for patients #6 and #13 revealed the patient(s) had last been seen for a skilled nursing (SN) visit on 10/13/2022. The patients were discharged for cause on 10/19/2022. Medical Social Worker (MSW) attempted a visit on 10/19/2022 with no answer to the door, and no answer to phone calls made to the patients. MSW reported this to the supervisor (nurse case manager). However, no documentation of the event was recorded in the facility report log, no further action was documented to ensure the aforementioned patients were safe. A review of Patient #6s medical records revealed a document titled "Missed Visit Form (MSW Visit)" dated 10/19/2022. The document stated "... Travel to patient: Yes, Attempt made: 13:01; Reason: No Answer to Locked Door; Comments: This missed visit may put the patient's health in jeopardy in the following ways no way to ensure that the pts needs are being met. I therefore recommend the following actions occur immediately: report this information to the nurse case manager... Supervisor Notified: Yes, by Phone... " Clinician signature 10/19/2022. Further review of Patient #6s medical records revealed a document titled "Discharge-Live" dated 10/27/2022. The document stated "...Discharge Date: 10/19/2022 ... Comments: Discharge patient from Hospice services. Patient's have not been available for NP to complete a qualifying face to face visit for continued hospice services. The patient has not answered the door pr (sic) phone the last two weeks for RN visits. Referring MD has been notified. Final attempt was 10/27/2022..." Digitally signed by Employee #9 on 10/19/2022. Review of Patient #13s medical records revealed a document titled "Missed Visit Form (MSW Visit)" dated 10/19/2022. The document stated "... Travel to patient: Yes, Attempt made: 13:01; Reason: No Answer to Locked Door; Comments: This missed visit may put the patient's health in jeopardy in the following ways needs may not be met . I therefore recommend the following actions occur immediately: Call to the nurse case manager.... Supervisor Notified: Yes, by Other - tiger text... ". Digitally signed by: [Employee #12] on 10/19/2022. Review of Patient #13s medical records revealed a document titled "Discharge-Live" dated 10/27/2022. The document stated "...Discharge Date: 10/19/2022 ... Comments: Discharge patient from Hospice services. [Patient #13] have not been available for NP to complete a qualifying face to face visit for continued hospice services. The patient has not answered the door pr(sic) phone the last two weeks for RN visits. Referring MD has been notified. Final attempt was 10/27/2022". Digitally signed by Employee #9 on 10/19/2022. During the interview with Employee #1 on 12/8/2022, it was acknowledged that there was no follow-through or investigation conducted per facility policy and procedure on the condition of Patients #6 and #13 prior to being discharged from services. In a joint interview with Employees #1, #2, and #3 On 12/08/2022, the employees acknowledged the Clinical Care Coordinator (CCC) position outlined in the aforementioned Policy & Procedure (P&P) did not reflect any job roles within the facility structure. They acknowledged an opportunity to correct the identified job role within the P&P to accurately represent a current role within the facility.

Based on record review and interview, it was determined the hospice failed to organize, manage, and administer its resources to provide the hospice care and services to patients. The deficient practice poses a potential for patient harm resulting in negative patient outcomes by not facilitating the patients and families' needs and goals. --- Findings include: A review of facility documentation revealed a document titled ";2022 Governing Body Meetings" dated 6/29/2022. The document stated ";...Items discussed: Various DON Interviews, Potential SLC DON to cover and bridge during staffing shortage?; AZ office have too much on plate? Off load things to UT?..." A review of facility documentation revealed a document titled ";Grievance Log 2022 Employee Complaints:". The document stated ";Q3 9/12/2022; Employee complaint: Concerns about staffing; Description of complaint: worried about being spread too thin with nursing;...Regulatory Bodies Notified? Which?: Yes;Administration". A review of Patient #15s medical record revealed a document titled ";Plan of Care" dated 10/12/2022. The document stated ";Service Type: Skilled Nursing 2/week..." However, further review of patient #15s medical record revealed the frequency of skilled nursing visits did not match the frequency outlined in Patient #15s plan of care. Additionally, no visit occurred between 10/19/2022 to 10/27/2022. A review of Patient #15s medical record revealed a document titled ";Missed Visit Form (RN-Skilled Nursing Visit)" dated 11/02/2022. The document stated "; Travel to patient: No, Reason no answer to phone call... Comments: No answer, attempted to schedule, message... MD Notified: Yes, by Phone; Physician: [Employee #10]". In a Telephonic interview conducted on December 13, 2022 with Patient #15s representative, the representative reported when the DON was out, the facility did not have an alternate RN to perform nursing visits, due to being short staffed. The representative reported requesting supplies and never receiving them. The representative reported a nurse never showed up for any visits on

Based on record review and interview, it was determined the hospice failed to ensure nursing services were made routinely available on a 24-hour basis 7 days a week. The deficient practice poses a potential for patient harm resulting in negative patient outcomes by failing to provide sufficient staffing to provide nursing services as outlined in the patients plan of care. --- Findings include: A review of facility documentation revealed a document titled ";2022 Governing Body Meetings" dated 6/29/22. The document stated ";...Items discussed:Various DON Interviews, Potential SLC DON to cover and bridge during staffing shortage?; AZ office have too much on plate? Off load things to UT?..." A review of facility documentation revealed a document titled ";Grievance Log 2022 Employee Complaints:". The document stated ";Q3 9/12/2022; Employee complaint: Concerns about staffing; Description of complaint: worried about being spread too thin with nursing;...Regulatory Bodies Notified? Which?: Yes;Administration". A review of Patient #15s medical record revealed a document titled ";Plan of Care" dated 10/12/2022. The document stated ";Service Type: Skilled Nursing 2/week..." However, further review of patient #15s medical record revealed the frequency of skilled nursing visits did not match the frequency outlined in Patient #15s plan of care. Additionally, no visit occurred between 10/19/2022 to 10/27/2022. A review of Patient #15s medical record revealed a document titled ";Missed Visit Form (RN-Skilled Nursing Visit)" dated 11/02/2022. The document stated "; Travel to patient: No, Reason no answer to phone call... Comments: No answer, attempted to schedule, message... MD Notified: Yes, by Phone; Physician: [Employee #10]". In a Telephonic interview conducted on December 13, 2022 with Patient #15s representative, the representative reported when the DON was out, the facility did not have an alternate RN to perform nursing visits, due to being short staffed. The representative reported requesting supplies and never receiving them. The representative reported a nurse never showed up for any visits on the week of 10/31 and the patients representative was advised to go to the emergency room, when calls were made to request a nurse visit.

Based on record review and interview, it was determined the hospice failed to ensure that staffing for all services reflects its volume of patients, their acuity, and level of intensity of services needed. The deficient practice poses a potential for patient harm resulting in negative patient outcomes by not ensuring that the plan of care outcomes are achieved. --- Findings include: A review of facility documentation revealed a document titled ";2022 Governing Body Meetings" dated 6/29/22. The document stated ";...Items discussed: Various DON Interviews, Potential SLC DON to cover and bridge during staffing shortage?; AZ office have too much on plate? Off load things to UT?..." A review of facility documentation revealed a document titled ";Grievance Log 2022 Employee Complaints:". The document stated ";Q3 9/12/2022; Employee complaint: Concerns about staffing; Description of complaint: worried about being spread too thin with nursing;...Regulatory Bodies Notified? Which?: Yes; Administration". A review of Patient #15s medical record revealed a document titled ";Plan of Care" dated 10/12/2022. The document stated ";Service Type: Skilled Nursing 2/week..." However, further review of patient #15s medical record revealed the frequency of skilled nursing visits did not match the frequency outlined in Patient #15s plan of care. Additionally, no visit occurred between 10/19/2022 to 10/27/2022. A review of Patient #15s medical record revealed a document titled ";Missed Visit Form (RN-Skilled Nursing Visit)" dated 11/02/2022. The document stated "; Travel to patient: No, Reason no answer to phone call... Comments: No answer, attempted to schedule, message... MD Notified: Yes, by Phone; Physician: [Employee #10]". In a Telephonic interview conducted on December 13, 2022 with Patient #15s representative, the representative reported when the DON was out, the facility did not have an alternate RN to perform nursing visits, due to being short staffed. The representative reported requesting supplies and never receiving them. The representative reported a nurse never showed up for any visits on the week of 10/31/2022 and the patients representative was advised to go to the emergency room, when calls were made to request a nurse visit.