Every finding on record at Family Care Home Health & Hospice, LLC

Observed in Record Review. In 4 of 4 hospice patient records reviewed of patients admitted since the triannual survey it was noted that the organization had not addressed and documented the need for volunteer services. During discussion with the Hospice DON she stated that she had not been aware of the need for the volunteer service assessment. In 1 of 4 patient records reviewed the organization did not document the completion of an initial comprehensive assessment. For example, in record HOSRR#2 the psychosocial assessment was documented on day 28 after admission. This was discussed with the Hospice DON.

Observed in Record Review. In 1 of 4 patient records reviewed, the organization did not document the completion of an initial comprehensive assessment in 5 calendar days. For example, in record HOSRR#2 the psychosocial assessment was documented on day 28 after admission. This was discussed with the Hospice DON.

Observed in Record Review. In 4 of 4 patient records reviewed, the plan of care goals were not specific, measurable or individualized to the patient and family. For example in record HOSRR#2 Patient and Caregiver follow company policy regarding tubing changes, filter changes (up to manufacturer recommendations) and how to add water to humidifier. There is no description of what the company policy or the manufacturer recommendations are. Patient and/or CG will verbalize & demonstrate understanding a Foley cath management as evidence by being able to empty foley cath bag, demonstrate foley care, irrigate foley cath, and foley bag etiquette. In record HOSRR#3 Pain will be well controlled. There is no description of what well controlled pain would be for this patient. Record HOSRR#4 Pt will have easy breathing.Pt to have minimal edema. There is no description of what easy breathing or minimal edema would be for this patient. This was discussed with the Hospice DON.

Observed in Tracer Activities. Leaders did not manage implementation of patient care policies and procedures governing the provision of care as evidenced by condition level findings at:418.102. This was discussed with the Administrator, Administrative Assistant and Hospice DON.

Observed in Record Review. In 4 of 4 patient records reviewed, certificates of terminal illness (CTI) did not consistently support patient life expectancies of six months or less if the illness was to run its normal course. For example upon patient records reviewed certificates of terminal illness (CTI) did not consistently support patient life expectancies of six months or less if the illness was to run its normal course. For example, documentation was repeated verbatim from the nurse's comprehensive note documentation and examples of decline were ambiguous. lacked metrics, or did not support on-going appropriateness for the hospice benefit. This was discussed with the Hospice DON.

Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization had not had a written comprehensive emergency management program that utilizes an all-hazards approach. The program includes, but is not limited to, the following: - Leadership structure and program accountability - Hazard vulnerability analysis - Mitigation and preparedness activities - Emergency operations plan and policies and procedures - Education and training - Exercises and testing - Continuity of operations plan - Disaster recovery - Program evaluation. This finding was discussed with and verified by the Administrator.

Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization had not had a hazard vulnerability analysis included the following: - Natural hazards (such as flooding, wildfires) - Human-caused hazards (such as active shooter or cyber/information technology crimes) - Technological hazards (such as utility or information technology outages) - Hazardous materials (such as radiological, nuclear, chemical) - Emerging infectious diseases (such as Ebola, Zika Virus, SARS-CoV-2). This finding was verified by the Administrator. Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization had not conducted a hazard vulnerability analysis (HVA) using an all-hazards approach that includes the following: - Hazards that are likely to impact the organization’s geographical region, community, facility, and patient population - A community-based risk assessment (such as those developed by external emergency management agencies) - Separate HVAs for its other accredited organizations if they significantly differ from the main site The findings are documented. This finding was verified by the Administrator.

Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization had not had a continuity of operations plan that identified in writing how and where it will continue to provide its essential business functions when the location of the essential or critical service has been compromised due to an emergency or disaster incident. This finding was verified by the Administrator. Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization's emergency operations plan had not identified the patient population(s) that it will serve and the types of services it would have the ability to provide in an emergency or disaster event. This finding was verified by the Administrator. Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization had not had a written continuity of operations plan (COOP) that is developed with the participation of key executive leaders, business and finance leaders, and other department leaders as determined by the organization. These key leaders identify and prioritize the services and functions that are considered essential or critical for maintaining operations. This finding was verified by the Administrator. Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization had not had a written delegation of authority plan that provides the individual(s) with the legal authorization to act on behalf of the organization for specified purposes and to carry out specific duties. This finding was verified by the Administrator.

Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization's emergency operations plan had not included a process for cooperating and collaborating with other health care organizations, relevant community partners (such as fire, police, local incident command, public health departments), and relevant authorities (such as federal, state, tribal, regional, and local emergency preparedness staff). This finding was verified by the Administrator.

Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization had not had a plan for providing patient care and clinical support includes policies and procedures that describe how it will inform state and local emergency preparedness officials about its patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This finding was verified by the Administrator.

Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization had not had a plan for providing patient care and clinical support includes written procedures and arrangements with other health care providers for how it will share patient care information and medical documentation and how it will provide transportation to other health care facilities to maintain continuity of care. This finding was verified by the Administrator.

Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization's communications plan identifies its primary and alternate means for communicating with staff and relevant authorities (such as federal, state, tribal, regional, and local emergency preparedness staff). The plan includes procedures for the following: - How and when alternate/backup communication methods are used - Testing the functionality of the organization’s alternate/backup communication systems or equipment. This finding was verified by the Administrator.

Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization had not had a plan for providing patient care and clinical support includes written procedures and arrangements with other health care providers for how it will share patient care information and medical documentation and how it will provide transportation to other health care facilities to maintain continuity of care. This finding was verified by the Administrator. Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization's communications plan had not included a method for sharing and/or releasing location information and medical documentation for patients under the organization’s care to the following individuals or entities, in accordance with law and regulation: - Patient’s family, representative, or others involved in the care of the patient - Disaster relief organizations and relevant authorities - Other health care providers. This finding was verified by the Administrator.

Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization's communications plan had not described how the organization will communicate with and report information about its needs, available occupancy, and ability to provide assistance to relevant authorities. Note: Examples of what an organization may need to report to relevant authorities include, but are not limited to, shortages in personal protective equipment, staffing shortages, evacuation or transfer of patients, and temporary loss of part or all of the organization’s function. This finding was verified by the Administrator.

Observed in Emergency Management Session. During review and discussion of the Emergency Management plan for Home Health and Hospice, the Surveyor noted that the organization had not had a committee that oversees the emergency management program reviews and evaluates all exercises and actual emergency or disaster incidents. The committee reviews after-action reports (AARs), identifies opportunities for improvement, and recommends actions to take to improve the emergency management program. The AARs and improvement plans are documented. This finding was verified by the Administrator.

Observed in Patient Home. In 4 of 4 home visits conducted, the hospice’s advance directive policy and information from the state of Arizona was not found in the handbook in patients' homes, nor was there documentation in the record that the information was provided and reviewed. This RFI was reviewed with the Administrators and the Hospice Director of Nursing.

Observed in Record Review. In 1 of 2 discharge records reviewed, a Notice of Medicare Non-Coverage was not signed by the patient’s guardian a minimum of 48 hours prior to discharge as required by law. In RRDC#2 there was no documentation of the document having been signed. This was confirmed by an Administrator.

Observed in Record Review. In 14 of 14 active patient records reviewed, the organization did not assess and document the need for volunteer services because there were no volunteers available. This RFI was reviewed with the Administrators and the Hospice Director of Nursing. Observed in Record Review. In 2 of 14 active patient records reviewed, .the organization did not document the completion of an initial comprehensive assessment. In record RRHV#1, and RRNHV#1there was no psychosocial, spiritual, or bereavement assessment documented. This RFI was reviewed with the Administrators and the Hospice Director of Nursing

Observed in Record Review. In 2 of 14 active patient records reviewed, the organization did not document the completion of an initial comprehensive assessment. In record RRHV#1, and RRNHV#1there was no psychosocial, spiritual, or bereavement assessment documented. This RFI was reviewed with the Administrators and the Hospice Director of Nursing

Observed in Record Review. In 11 of 14 active patient records reviewed, where the interdisciplinary group met two or more times the organization failed to update the comprehensive assessment based on changes occurring since the initial assessment. Interdisciplinary group meeting notes did not document patient decline, progress towards desired outcomes and goals, and plans for the following two weeks. This RFI was reviewed with the Administrators and the Hospice Director of Nursing.

Observed in Record Review. In 1 of 2 discharge records reviewed, where the patient was leaving hospice for an extended prognosis there was no order written in record RRDC#2. This RFI was reviewed with the Administrators and the Hospice Director of Nursing.

Observed in Record Review. In 14 of 14 active patient records reviewed, plan of care goals were not specific or measurable. Here are some examples: the patient and/or caregiver will verbalize and demonstrate proper safe use of oxygen concentrator and back up tanks; understanding of indication and storage of comfort medications; understanding of indications and proper administration of comfort medication; safe use of nebulizer. Additional goals included: shortness of breath to be controlled while on hospice; pain will be controlled while on hospice; anxiety to be managed while on hospice; and will verbalize a decrease in symptoms of depression. More than 90% of interventions were directed toward staff, not the patient or caregiver. This RFI was reviewed with the Administrators and the Hospice Director of Nursing.

Observed in Patient Home. In 1 of 4 fire barrier wall checks, an order was not obtained to change a medication. At the home visit for RRHV#1 the RN stated that Atropine sulfate ophthalmic ointment 1% was discontinued because it was no longer available from the contracted pharmacy. The list provided to the surveyor for the visit still included the medication because the physician was not contacted for an order to discontinue it. This RFI was reviewed with and confirmed by the Hospice Director of Nursing.

Observed in Infection Control Tracer. During review and discussion of the Infection Prevention and Control program for Home Health and Hospice, the surveyor noted that the organization had not had current written policies and procedures to guide its activities and methods for preventing and controlling the transmission of infections and communicable diseases. The policies and procedures are in accordance with applicable law and regulation and nationally recognized evidence-based guidelines, and standards of practice. This finding was verified by the Administrator.

Observed in Tracer Activities. During a discussion with the volunteer coordinator and review of available volunteer recruitment initiatives, the pharmacy Hospice surveyor noted that current documentation of this requirement was not available for 2024. .The validation of this missing information was reviewed with the volunteer coordinator at thew time of the survey

Observed in Tracer Activities. During a discussion with the volunteer coordinator and review of any available records prepared in 2024, the pharmacy Hospice surveyor noted that current documentation of this requirement was not available for 2024--no estimates of the dollar amount saved by volunteers providing services and care rather than employees providing care was available. The validation of this missing information was reviewed with the volunteer coordinator at thew time of the survey

Observed in Tracer Activities. During a discussion with the volunteer coordinator and review of available records prepared in 2024, the pharmacy Hospice surveyor noted that current documentation of direct patient care and administrative to equal 5% was not available for 2024--no estimates of the amount saved by volunteers providing services and care rather than employees providing care was now ongoing. The validation of this missing information was reviewed with the volunteer coordinator at thew time of the survey

Observed in Tracer Activities. Leaders did not manage implementation of patient care policies and procedures governing the provision of care as evidenced by condition level findings at §418.52, §418.56, §418.78, §484.102, and §484.110. This RFI was reviewed with the Administrators and Directors of Nursing.

Observed in Record Review. In 14 of 14 active patient records reviewed, certificates of terminal illness (CTI) did not consistently support patient life expectancies of six months or less if the illness was to run its normal course. For example, documentation was repeated verbatim in consecutive CTIs, examples of decline were ambiguous, lacked metrics, or did not support on-going appropriateness for the hospice benefit. In several records the CTI included a statement that a patient’s mid arm circumferences had decreased 3 centimeters since the last certification, however there was no documentation in nursing assessments, updates to the comprehensive assessments, or interdisciplinary group meeting notes to support this statement. This RFI was reviewed with the Administrators and the Hospice Director of Nursing.

Observed in Record Review. In 2 of 2 patient records reviewed, discharge summaries were not written and attending physicians were not notified of the availability of the summaries in records RRDC#1 and RRDC#2. This RFI was reviewed with the Administrators and the Hospice Director of Nursing.

Observed in Record Review. In 1 of 3 patient records reviewed, the surveyor noted that the organization failed to provide medication and treatment to meet the patient and family's needs. For example: In HOSRR#1, the record included Diclofenac Sodium cream PRN pain. There was no indication beyond PRN pain to indicate when the patient should use this medication. This was confirmed with the hospice DON present.

Observed in Document Review. In 3 of 3 home visits conducted, the organization failed to inform the patient or representative with written notice of the patient's rights and responsibilities in a language and manner that the patient understands. For example: upon review of the hospice admission packet, it was noted that the organization failed to inform the patient in writing their financial liability. In the hospice consent process there is an indication to see fee schedule. A fee scheduled is included in the admission packet, yet this fee schedule does not indicate what financial liability is specific to the patient. This finding of no written indication of financial liability was also noted the home packets for HVHOS#1, HVHOS#2, and HVHOS#3. This observation was reviewed with the Assistant Administrator.

Observed in Record Review. In 1 of 13 patient records reviewed, The organization failed to ensure the patient and primary caregiver were given education and training as appropriate. For example in RRHOS#10 the patient was prescribed morphine for pain control. The nursing documentation noted caregiver will give patient 0.25 ml Q 6 hours for her pain and monitor her There is no indication in the record that the patient or caregiver received any education and training on the medication and its administration. This observation was reviewed with the Assistant Administrator.

Observed in Record Review. For example: in review of HVHOS#1 it was noted that the goals vague and not measurable. For pain the goals stated pain will be managed, for Bowel the goals states patient to have optimal bowel evacuation, for a nutritional goal it states encourage small frequent meals. Similar findings of goals that fail to be specific and measurable can be seen throughout the records of RRHOS#1, HVHOS#2, RRHOS#5, RRHOS#9, RRHOS#6. This observation was reviewed with the Assistant Administrator. Observed in Record Review. In 10 of 13 patient records reviewed, the organization did not ensure that the individualized plan of care reflected goals based on the patient's needs, nor that the plan of care goals were individualized, specific, and measurable. For example: in review of RRHOS#2 there was no care plan to address O2 safety even though risks were identified on the O2 safety checklist. In RRHOS#4 the O2 safety care plan has interventions that addressed pain control. In RRHOS#3 the patient experienced a fall, yet there was no plan of care open to address fall safety. In HVHOS#3 there was a care plan requesting volunteer services, yet no follow up from volunteer services. Further the patient is being seen by the chaplain yet there are no spiritual care plan noted. These observation were reviewed with the Assistant Administrator.

Observed in Record Review. In 1 of 13 patient records reviewed, The organization failed to provide a statement of the scope and frequency of the services necessary to meet the patient and family's needs. For example: In RRHOS#4, the hospice aide was visiting the patient and aide assignment was documented, yet no frequency was established in the plan of care. This observation was reviewed with the Assistant Administrator.

Observed in Record Review. For example: in RRHOS#8 the SN documentation noted that the patient was started on morphine and lorazepam on the day prior to death. There is no order for these medications noted in the clinical record. Further the SN documentation noted that a dressing was applied to the wound yet there are no orders in the record for a dressing. Example 2: in RRHOS#7 the patient was discharged no longer terminally ill, there was no discharge order noted on the clinical record. These observations were reviewed with the Assistant Administrator. Observed in Record Review. For example: in RRHOS#7 record review the oxygen on the medication profile stated Oxygen Inhalation gas continuous 12-16 lpm. There is no route, nor specific instruction for when to use which liter flow noted. Example 2: In RRHOS#1, RRHOS#2, RRHOS#4, and RRHOS#5 the patient was prescribed morphine sulfate (concentrate) oral solution 20mg/ml, dose 0.25 to 1 ml by mouth every hour as needed. There is no specific instructions for the patient/caregiver to know which dose to give for what specified pain level. These observations were reviewed with the Assistant Administrator. Observed in Record Review. In 7 of 13 patient records reviewed, the organization failed to ensure that medications and treatments necessary to meet the patient's needs had orders, indications and/or route of administration. For example: upon review of the medication profile for RRHOS#2, the patient was noted to be prescribed multiple PRN pain medication to include morphine concentrate, oxycodone, and ibuprofen. There is no indication beyond PRN for pain to guide the patient to know which pain medication to take related to the type or severity of the pain experienced. Similar observations of multiple PRN pain medications were noted in RRHOS#4, and HVHOS#3. This observation was reviewed with the Assistant Administrator.

Observed in Record Review. In 8 of 13 patient records reviewed, The organization failed to ensure care and services were provided in accordance with the plan of care. For example: in review of HVHOS#2 the MSW was scheduled a frequency of 1-2 times per quarter, yet in the first quarter since admission the patient received 4 home and 2 telehealth visits, exceeding the established frequency. Similar findings of were noted in RRHOS#5 were the chaplain and MSW were planned for 2-3 month yet did not meet the frequency, in RRHOS#10 the chaplain failed to meet established frequency, and RRHOS#9 the chaplain was declined on admission yet the chaplain had a scheduled frequency on the plan of care and was visiting the patient per the plan of care. These observations was reviewed with the Assistant Administrator. Observed in Record Review. For example: in review of RRHOS#1 the patient had a wound with dressing change order to cleanse with wound cleanser, pat dry, apply calcium alginate, and secure with bordered gauze on 12/30/21 the SN documented aquacel was placed over wound and dressing applied, further the dressing orders were not included as part of the individualized plan of care. Similar finding for not following wound care orders and wound care orders not included on the plan of care were noted in RRHOS#9. These observations was reviewed with the Assistant Administrator. Observed in Record Review. For example: Upon review of HVHOS#1 the vital signs on 12/7/21 only BP was recorded, on 11/21/21 no vital signs were recorded and on 12/28/21 no temp or O2 sat was recorded. There was no documentation as to why the vital signs were omitted and no indication that the RN was notified. Similar findings were noted throughout the record and also noted in VHHOS#2, RRHOS#3, RRHOS#4. In RRHOS#1 on 11/16/21 the patients BP was recorded outside of listed parameter yet there is no indication the RN was notified. Example 2: In HVHOS#2 the LVN documented that BP was 156/101, there is no indication in the record that the increased BP was reported to the RN or the MD. These observation was reviewed with the Assistant Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, staff failed to perform hand hygiene consistent with organization policy. For example: during HVHOS#1 the SN failed to cleanse hands between glove changes while providing patient care. This observation was reviewed with the Director of Nursing.

Observed in Data Tracer. The hospice surveyor noted the organization's written infection prevention and control goals did not include limiting the spread of infections associated with the use of medical equipment, devices and supplies as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the assistant administrator.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization failed to ensure the RN supervise the hospice aide to no less frequently that every 14 days. For example: in RRHOS#4 there was a 28 day gap in aide supervisory visits by the RN in the 1st benefit period. This observation was reviewed with the Assistant Administrator.

Observed in Tracer Activities. Document observation as follows for Deemed HOS: “The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100 and 418.56, 418.60.

Observed in Record Review. In 4 of 13 patient records reviewed, the organization failed to ensure the medical director reviewed the clinical information for the patient and provide written certification that considered all of the required elements. For example: in RRHOS#5 the physicians narrative did not include current subjective and objective findings, nor current medication and treatment orders. Similar findings were noted in the certification narratives for RRHOS#9, RRHOS#10, RRHOS#6. This observation was reviewed with the Assistant Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed, the organization failed to ensure the patient record contained pertinent clinical information related to wound care treatments. For example: Upon review of RRHOS#1 on multiple occasions the SN documented wound care completed per wound care order. This statement did not specify what treatment was provided to the patient nor the patient's response to the treatment. This observation was reviewed with the Assistant Administrator.

Observed in Record Review. In 1 of 13 patient records reviewed, There was no documentation in the patient record that written policies and procedures for management and disposal of controlled drugs was provided to the patient. For example in HVHOS#1 the patient was prescribed morphine on admission yet there is no documentation that the policy for medication destruction was provided. This observation was reviewed with the Assistant Administrator.

Observed in Record Review. In 1 of 13 patient records reviewed, There was no documentation in the patient record that written policies and procedures for managing controlled drugs was provided and discussed as outlined in organization policy 11.2.1. For example in HVHOS#1 the patient was prescribed morphine on admission yet there is no documentation that the policy for medication destruction was received by the patient as per policy. This observation was reviewed with the Assistant Administrator.

Observed in Competency Session. In 3 of 7 contracts reviewed, In review of contract with High Desert Respiratory, Sunrise Pharmacy, Nutritionist it was noted that the contracts did not contain a stipulation that all contracted entities obtain criminal background checks on contracted employees who have direct patient contact or access to patient records. This observation was reviewed with the Assistant Administrator.