Every finding on record at Free Spirit Hospice, Inc.

Observed in Record Review. In 2 of 3 patient records reviewed, the POLSTs indicated that CPR was to be attempted. However, the RN documented in both initial comprehensive assessments that the patient had chosen not to be resuscitated in records RRNHV#2 and RRNHV#3. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Tracer Activities. The organization was not able to show that data analyses and comparison over time to identify levels of performance, patterns, trends, and variations had occurred since the survey seven weeks ago. This was because not enough time had passed to evaluate improvement. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Tracer Activities. Review of QAPI documents and governing board meeting minutes completed since the survey seven weeks ago could not provide proof of improved quality care, patient safety, and evaluation of actions for effectiveness. This was because not enough time had passed to evaluate improvement. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. The Surveyor noted the organization’s Emergency Operations Plan did not describe the response procedures to follow when emergencies occur as evidenced by the HCO was unable to produce documentation of an emergency management plan at time of survey. This was discussed with the DON and Owner/RN/Designee Administrator. Observed in Emergency Management Session. The Surveyor noted the Emergency Operation’s Plan was not reviewed and updated every 2 years as evidenced by the organization was not able to produce documentation at the time of survey. This was discussed with the DON and Owner/RN/Designee Administrator.

Observed in Emergency Management Session. During the Emergency Management session the Surveyor noted the organization did not use its prioritized emergencies as a basis for defining mitigation activities as evidenced by the organization did not have a documented emergency management plan and therefore were not able to define mitigation activities. This was confirmed with Owner and DON present.

Observed in Emergency Management Session. The Surveyor noted the Emergency Operation’s Plan did not describe the patient population served by the organization or the extent to which additional populations may be cared for during an emergency. This was evidenced by the organization was not able to produce documentation at the time of survey. This was discussed with the DON and Owner/RN/Designee Administrator. Observed in Emergency Management Session. The Surveyor noted the organization’s written Emergency Operations Plan did not describe the recovery strategies, actions and individual responsibilities necessary to restore the organization’s care, treatment and services after an emergency. Observed in Emergency Management Session. The Surveyor noted the Emergency Operation’s Plan did not include a continuity of operations strategy that covered all required elements as evidenced by the organization was not able to produce this documentation at the time of survey. The organization did not include Continuity of facilities and communications to support organizational functions at the original site or alternate site(s), in case the original site is incapacitated - A succession plan that lists who replaces the key leader(s) during an emergency if the leader is not available to carry out their duties - A delegation of authority plan that describes the decisions and policies that can be implemented by authorized successors during an emergency and criteria or triggers that initiate this delegation. This was discussed with the DON and Owner/RN/Designee Administrator.

Observed in Emergency Management Session. The Surveyor noted the organization did not have a process for cooperation and collaboration with the local, state, tribal, regional and federal emergency preparedness officials to maintain and integrated response during a disaster or emergency situation as evidenced by the organization was not able to produce this documentation at the time of survey. This was discussed with the DON and Owner/RN/Designee Administrator.

Observed in Emergency Management Session. The Surveyor noted the Emergency Operations Plan did not describe how the organization would manage staff support needs as evidenced by the organization was not able to produce this documentation at the time of survey. This was discussed with the DON and Owner/RN/Designee Administrator. Observed in Emergency Management Session. The Emergency Operations Plan did not describe how the organization would obtain and replenish nonmedical supplies during an emergency as evidenced by the organization was not able to produce this documentation at the time of survey. This was discussed with the DON and Owner/RN/Designee Administrator.

Observed in Emergency Management Session. The Surveyor noted the organization’s Emergency Operations Plan did not describe how the organization was to manage staff during emergencies as evidenced by the organization was not able to produce this documentation at the time of survey. This was discussed with the DON and Owner/RN/Designee Administrator. Observed in Emergency Management Session. The Surveyor noted the Emergency Operation’s Plan did not describe how staff would be notified that emergency response procedures had been initiated as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the DON and Owner/RN/Designee Administrator present. Observed in Emergency Management Session. The Surveyor noted the Emergency Operations Plan did not describe how the organization would manage activities related to care, treatment or services during an emergency as evidenced by the organization was not able to produce this documentation. The HCO was unable to produce documentation of an emergency management plan at time of survey. This was discussed with the DON and Owner/RN/Designee Administrator. Observed in Emergency Management Session. The Surveyor noted the Emergency Operations Plan did not describe how the organization would identify staff and authorized volunteers during an emergency. The HCO was unable to produce documentation of an emergency management plan at time of survey. This was discussed with the DON and Owner/RN/Designee Administrator. Observed in Emergency Management Session. The Surveyor noted the Emergency Operation’s Plan did not describe how the organization would inform state and local officials of any on-duty staff they were not able to contact as evidenced by the organization was not able to produce this documentation during the survey. This was discussed with the DON and Owner/RN/Designee Administrator. Observed in Emergency Management Session. The Surveyor noted the Emergency Operation’s Plan did not describe how the organization would inform local emergency preparedness officials before, during and after emergencies regarding patient for whom the organization was not able to contact or patients in need of evacuation due to their medical or behavioral health condition or home environment. This was evidenced by the organization was not able to produce this documentation during survey. This was discussed with the DON and Owner/RN/Designee Administrator. Observed in Emergency Management Session. The Surveyor noted the Emergency Operations Plan did not describe how the agency would communicate with patients during an emergency as evidenced by the organization was not able to produce this documentation at the time of survey. This was discussed with the DON and Owner/RN/Designee Administrator. Observed in Emergency Management Session. The Surveyor noted the organization did not establish back-up procedures in the event that communications failed during an emergency as evidenced by the organization was not able to produce this documentation at the time of survey. This was discussed with the DON and Owner/RN/Designee Administrator.

Observed in Emergency Management Session. The Emergency Operations Plan did not describe how the organization would obtain and replenish medications and supplies that would be needed in response to an emergency. The HCO was unable to produce documentation of an emergency management plan at time of survey. This was discussed with the DON and Owner/RN/Designee Administrator.

Observed in Emergency Management Session. The Surveyor noted the Emergency Operations Plan did not describe the process for assigning staff to all essential staff functions as evidenced by the organization was not able to produce this documentation at the time of survey. This was discussed with the DON and Owner/RN/Designee Administrator. Observed in Emergency Management Session. The Surveyor noted the Emergency Operation’s Plan did not describe how state and federally designated health care professionals would be incorporated into the staffing strategy for addressing a surge in needs during an emergency as evidenced by the organization was not able to produce this documentation. This was discussed with the DON and Owner/RN/Designee Administrator.

Observed in Emergency Management Session. The Surveyor noted the emergency plan did not include the organization’s arrangements with other organizations in the event that it cannot serve it own customers as a result of an emergency as evidenced by the organization was not able to produce this documentation at the time of survey. This was discussed with the DON and Owner/RN/Designee Administrator.

Observed in Emergency Management Session. The Surveyor noted the organization’s leaders did not participate in the development of the Emergency Operations Plan as evidenced by the HCO was unable to produce documentation of an emergency management plan at time of survey. This was discussed with the DON and Owner/RN/Designee Administrator.

Observed in Emergency Management Session. The Surveyor noted the Emergency Operations Plan did not describe The organization’s primary and alternate means of communicating with staff and federal, state, tribal, and local emergency management agencies - The organization's arrangements for communicating information and medical documentation on patients under the organization’s care, as necessary, with other health care providers in order to maintain continuity of care - Process for communicating information about the general condition and location of patients under the organization’s care to public and private entities assisting with disaster relief - How the organization will communicate information about its needs (including for inpatient hospices, its inpatient hospice occupancy needs) and ability to provide assistance to the authority having jurisdiction, the incident command center, or designee. The HCO was unable to produce documentation of an emergency management plan at time of survey. This was discussed with the DON and Owner/RN/Designee Administrator.

Observed in Emergency Management Session. The surveyor noted the organization’s emergency preparedness training program was not based on their emergency management plan as evidenced by the HCO was unable to produce documentation of an emergency management plan at time of survey. This was discussed with the DON and Owner/RN/Designee Administrator.

Observed in Emergency Management Session. During the Emergency Management session the Surveyor noted the organization did not determine what its role would be in the community response plan as evidenced by the organization did not have written documentation of its role in the community response plan. This was confirmed with the Owner and DON present.

Observed in Record Review. In 2 of 10 patient records reviewed, it was noted that the comprehensive assessment was not completed no later than 5 calendar days after the election of hospice care. For example, in record HV#2 the spiritual counselor completed the bereavement assessment on day 6. For example, in RR#5 there was no initial bereavement assessment documented and the MSW completed the initial assessment on day 18.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization did not document a patient specific comprehensive assessment. For example, in record RR#4 and RR#5 there was no initial bereavement assessment documented. For example, in RR#4 there was no initial spiritual assessment documented. Also in RR#5 the initial comprehensive spiritual assessment was incomplete with no documentation of spiritual concerns or needs of the patient and family or documentation of their desire for the involvement of a religious group. In fact, in RR#5, the spiritual counselor documentation of the initial assessment was incomplete; section #1 and #2 were complete, section #3 was incomplete and section #4, #5, and #6 were blank and there was no signature. This was discussed with the DON.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted that the patient record in the home was inaccurate or contained errors (i.e. conflicts with other documentation). For example, the POLST document clearly stated that the patient requested to be a full code status. However, the Consent Form for the Comfort Kit stated the patient was a DNR. This was discussed with the Owner/RN/Designee Administrator present and she stated the DNR was in error.

Observed in Record Review. In 10 of 10 patient records reviewed, it was noted that the written plan of care was not individualized for the patient and based on the patient's goals and the time frames, settings and services required to meet the goals. For example, in record HV#1 4 of 13 goals within 14 days reviewed at next IDG and 9 of 13 goals had no time frames. Also in record HV#1, HV#2 and RR#5 the patients were receiving monthly spiritual counselor visits and there was no goals or interventions related to spiritual care documented in either record. For example, HV#3 all 7 goals with no time frames and general, such as Healing road to peace. For example, in RR#1 the goals were general with no time frames, Minimize complications due to impaired mobility. For example, in HV#1, HV#3, RR#1, RR#2, RR#3,and RR#4 the MSW indicated at the first visit a psychosocial goal, however when the goal area is opened the goal and interventions are blank. For example, in RR#5 the documented goals were generalized, optimal blood sugar management. This was discussed with the DON.

Observed in Data Session. During the Data session it was noted that while the HCO collected data, there was no data analysis performed over time to determine trends in performance. Observed in Data Session. During the Data session it was noted that the HCO had been collecting some data and there was documentation that some of that data was aggregated. However there was no documentation that data was trended or analyzed so therefore it was not being utilized to identify areas for process improvement. This was confirmed with the owner/RN/Designee Administrator and DON.

Observed in Data Session. It was noted that although the organization was collecting data the frequency was not documented and was not approved by the governing body. This was confirmed with the DON and Owner/RN/Designee Administrator.

Observed in Data Session. During the Data session it was noted that the hospice identified specific performance improvement projects that were being conducted but did not document the reasons for conducting the projects or the measurables. This was confirmed with the DON present.

Observed in Data Session. During the Data session it was noted that the HCO did not have a quality assessment and improvement program in place for the current year. the hospice QAPI program was not evaluated annually and there was no documentation that the governing body had not been involved or informed of the HCO’s QAPI program or projects. This was confirmed with the QAPI staff present.

Observed in Data Session. During the Data session it was noted that the organization's performance improvement did not occur organizantionwide. For example, at the time of survey the organization was not able to provide documentation of improved quality of care and patient safety or evaluation of actions for effectiveness. For example there was documentation of data for 2 performance improvement projects, however there was no documentation or data for how the decision was made to pursue these 2 PI projects. The Governing Body minutes for the past 18 months (all the documented minutes provided) did not include documentation of performance improvement. This was confirmed with the QAPI staff who provided the minutes.

Observed in Data Session. During the Data session it was noted that the organization did not have written infection prevention and control goals that included Limiting the spread of infections associated with procedures. The HCO was unable to provide documentation at the time of survey. This was confirmed with the Owner/RN/Designee Administrator present. Observed in Data Session. During the Data session it was noted that the organization did not have written infection prevention and control goals that included; Limiting the spread of infections associated with the use of medical equipment, devices, and supplies. The HCO was unable to provide documentation at the time of survey. This was confirmed with the Owner/RN/Designee Administrator present. Observed in Data Session. During the Data session it was noted that the HCO could not provide evidence that the required infection prevention goals were documented as evidenced by: The HCO was collecting hand hygiene data but there was no written infection prevention and control goal to improve compliance with hand hygiene guidelines.  This was confirmed with the DON. Observed in Data Session. During the Data session it was noted that the organization did not have written infection prevention and control goals that included Improving compliance with hand hygiene guidelines. The HCO was unable to provide documentation at the time of survey. This was confirmed with the Owner/RN/Designee Administrator present. Observed in Data Session. During the Data session it was noted that the organization did not have written infection prevention and control goals that included Limiting unprotected exposure to pathogens. The HCO was unable to provide documentation at the time of survey. This was confirmed with the Owner/RN/Designee Administrator present.

Observed in Record Review. In 1 of 1 bereavement record, it was noted that the hospice had not developed a bereavement plan of care that was specified the type of bereavement services to be offered or the frequency of service delivery. For example, in record BR#1 the bereavement care plan did not include any interventions, it did include 3 free text goals that were general and not specific or individualized to the grieved. The goals did not include time frames or frequency of service delivery. This was discussed with the DON.

Observed in Tracer Activities. During discussion with the Volunteer Coordinator it was found that while the organization had documentation of efforts to recruit additional volunteers there was no documentation of retention efforts. This was confirmed with the Volunteer Coordinator, Owner/Designee Administrator and DON present.

Observed in Tracer Activities. During tracer activities it was noted that the HCO failed to implement the policies. For example, the emergency preparedness policy, data policy and infection control policy referenced the Emergency Management plan, QAPI/Performance Improvement plan and Infection Control plan however the HCO was unable to provide documentation of these plans at time of survey.

Observed in Record Review. In 1 of 10 patient records reviewed, In RR#5, the spiritual counselor documentation of the initial assessment was incomplete; section #1 and #2 were complete, section #3 was incomplete and section #4, #5, and #6 were blank and there was no signature

Observed in Patient Home. In 1 of 2 home visits conducted, that included oxygen therapy it was noted that information on the storage, handling, and access to medical gases and supplies was not provided. For example, during HV#3 the E-tank was stored in the patient's bedroom closest. The nurse did not re-educate patient regarding safe storage of the E-tank. The record indicated that safe storage was included in the initial nurse assessment, no re-education was documented. This was discussed with the DON.