Every finding on record at Helping Hands Hospice

Based on record review and interviews, the facility failed to ensure that data is collected and analyzed for performance and quality improvement. This deficient practice can lead to poor operational performance and poor quality of care for all patients. --- The findings are: A. Record review of the facility's policy titled ";Quality Assessment and Performance Improvement (QAPI) Plan, Data Collection, from Policies and Procedures Manual for Hospice 2009 MED-PASS. Inc (Revised June 2018) page 10.1.5" 3. ";Data collection will be ongoing and frequency will be determined by the process improvement activity and approved by the Governing Body." B. During an interview with the administrative assistant on 12/03/2024 at 3:36 pm stated the facility is currently not reviewing QAPI (Quality Assessment and Program Improvement) and performance improve projects

Based on record review and interview, the facility failed to ensure that performance improvement projects are conducted annually addressing the scope, complexity and past performance of hospice operations and services. This deficient practice can result in poor operational performance and poor quality of care for all patients. --- The findings are: A. Record review of the facility's policy titled ";Quality Assessment and Performance Improvement (QAPI) Plan, Performance Expectations, Policies and Procedures Manual for Hospice© 2009 MED-PASS, Inc. (Revised June 2018) page 10.1.7 PERFORMANCE EXPECTATION 1. For each process identified to be improved, mechanisms to identify levels, patterns or trends in that process that will trigger further evaluation of the process will be identified. Performance expectations may include, but are not limited to: • Thresholds. • Setting upper and lower control limits. • Percentages. • Ratios. • Setting performance goals for further evaluation. • Identification of patterns/trends. 2. Sample size will be determined for each process improvement activity to adequately represent the process and will be randomly selected. For each established process to be improved, the performance expectation will be determined. The frequency of data collection and analysis will be specified for each process. The QAPI committee, and/or those involved in patient care, will analyze the data collected to pursue opportunities for improvement and identify important problems. 3. A summary of data collection, analysis, recommendations for improvement and report of cumulative findings will be prepared by the QAPI committee. The reports are forwarded to the Governing Body. Failure to achieve expected levels of performance will be documented and an explanation delineated to identify opportunities for improvement. B. During an interview with the administrative assistant on 12/03/2024 at 3:36 pm stated the facility is currently not reviewing QAPI (Quality Assessment and Program Improvement) and performance improve projects.

Based on record review and observation the facility failed to monitor, manage and maintain expired patient care supplies. This deficient practice could lead to infection for all patients receiving care. The findings are: --- A. Record review of the facilitys policy titled ";Supply Maintenance, Procedure, At the Hospice Site(s), page 5.14.1" states: 1. All medical supplies, especially sterile items, will be properly stored in a clean, dry area and handled in a sanitary manner protected from potential contamination as indicated by the manufacturer. 2. Supply packaging will remain intact while stored. If outer package is damaged or opened, supply will be removed and discarded. 3. Supplies will be checked for expiration date prior to use. If outdated, the supplies will be immediately removed from stock and discarded. 4. New medical supplies will be stored behind older supplies to assist in a timely rotation of supplies. 5. Staff will inspect packages of sterile items for evidence of interruption or exposure to liquid prior to use. 6. Staff using sterile medical supplies will handle items in a manner to protect sterility and prevent contamination. If supplies are taken from Hospice to the patient's environment, staff assures appropriate and safe delivery of supplies. Supplies will be placed in a plastic or paper bag and placed in a clean area of the car for transport. B. During observation on 12/03/2024 at 2:30pm, of supply room the following was revealed: 1. ReadyBath Cap, Conditioning shampoo cap. One use package. Expired 04/2023 2. PeriGuard Ointment Skin Protectant, DermaRite. Soiled and ointment oozing from cap. 3. Derma Klenz, wound cleaner. Bottle half full-on shelf with new full bottles (for single patient use only). Open bottle breaks sterility and can cause cross-contamination. 4. Integrity, wound cleaner. Bottle ¼ full on shelf with new full bottles.(for single patient use only). Open bottle breaks sterility and can cause cross-contamination.

Based on record review and interview the facility failed to have an initial Certification of Terminal Illness that specified if a patient (P) had an anticipated 6 months or less to live for 3 (P4, P6, and P10) of 14 (P1-P14) patients being reviewed for initial certification of terminal illness. This deficient practice could possibly lead to a delay in patient care. The findings are: --- A. Record review of the facilitys policy titled ";Certification/Recertification of Terminal Illness" under section 1 stated ";In order to be eligible to elect Hospice care under Medicare, a patient much be certified as being terminally ill" under section 5 stated ";The written certification must specify that it is anticipated that the patients life expectancy is 6 months or less, if the illness runs its normal course." B. Record review of P4s medical record revealed a form titled ";Hospice Plan of Care and Certification", but it did not certify that P4 was terminally ill and did not certify that P4 had a life expectancy of 6 months or less to live. C. Record review of P6s medical record revealed a form titled ";Hospice Plan of Care and Certification", but it did not certify that P6 was terminally ill and did not certify that P6 had a life expectancy of 6 months or less to live. D. Record review of P10s medical record revealed a titled ";Hospice Plan of Care and Certification", but it did not certify that P10 was terminally ill and did not certify that P10 had a life expectancy of 6 months or less to live. E. During an Interview on 12/03/24 at 3:15 PM with S1, Clinical Staff Member, S1 confirmed that P4, P6, and P10 did not have a certification that certified that all three patients are terminally ill and have a life expectancy of 6 months or less to live.

Based on record review and interview the facility failed to provide a symptom management related to the patients terminal illness by not responding to the patients needs in a timely manner. This deficient practice is likely to lead to all patient needs not being met. --- The findings are: A. Record review of the facilitys policy titled On-Call Services (services to address the patients immediate needs) Not Dated, Reference number 5016 stated, ";Hospice provides on-call coverage 24 hours a day." Procedure stated, ";The patient may reach the on-call number provided on the admission to the Hospice program." B. Record review of the facilitys policy titled Hospice Nursing Care Reference number 3011, Not Dated, stated under Procedure; ";The Hospice nurse is available 24 hours to meet the physical, psychosocial, spiritual and practical needs of patients, families or caregivers." C. During an interview on 05/01/2024 at 3:00 pm, P3 stated he knows the on-call number and has called it a few times. When called, P3 just got a voicemail and gets a return call a few hours later or the next day. When asked if calling the on-call were emergent calls, P3 stated ";yes."

Based on record reviews and interviews the facility failed to meet the Condition of Participation by failing to ensure that 1 (P [patient] 2) of 9 patients (P1-P9) being reviewed had a complete care plan. This deficient practice is likely to lead to patients end of life hospice needs not being met resulting in pain and suffering. The findings are: --- A. The facility failed to ensure P2 had a complete plan of care. Refer to tag L-0545.

Based on record reviews and interviews the facility failed to ensure that 1 (P [patient] 2) of 9 (P1-P9) patients reviewed had an Interdisciplinary group meeting with all qualified personnel. This deficient practice is likely to lead to a patients hospice needs remaining unmet and the Interdisciplinary Group being unaware of the patients hospice needs. The findings are: --- . A. Record review of the facilitys policy titled ";Interdisciplinary Team Coordination of Care" Policy #5003 not dated, stated ";Hospice uses a comprehensive, coordinated healthcare process and an interdisciplinary team to provide services and aid patients, families or caregivers" and ";The interdisciplinary team consists of physicians, nurses, social workers, certified home hospice aids, clergy, counselors, volunteers, and therapists" B. Record review of the facilitys policy titled ";Interdisciplinary Team Meeting" Policy #5004, not dated, stated ";The team meets bi-weekly [every other week]." C. Record review of P2s Medical Record , under the ";Admission Profile" revealed P2 was admitted to the hospice service on 12/04/23 and discharged from service on 12/24/23. P2s medical record did not contain any documentation of Interdisciplinary Team Meetings. D D. During an interview on 04/30/24 at 12:56 PM, with Staff (S)3, Director of Nursing, S3 confirmed that there was no documented Interdisciplinary Group Meetings for P2.

Based on record review and interviews the facility failed to develop a written Plan of Care for 1 (P[patient] 2) of 9 (P1-P9) patients reviewed for a Plan of Care. This deficient practice is likely to result in the patients care needs being unmet. The findings are: --- The findings are: A. Record review of facilitys policy titled ";Interdisciplinary Team Plan of Care" Not dated, stated ";Hospice establishes an individualized plan of care with patient, family or caregiver on the day of admission. The interdisciplinary team reviews the plan within 3 days of the admission to Hospice." B. Record review of P2s medical record under ";Admission Profile" revealed that P2 was admitted on 12/04/23 and discharged on 12/24/23. P2s medical record did not have a written Plan of Care . C. During an interview on 05/01/24 at 8:31 AM, with Staff (S)4, facility administrator, S4 confirmed that P2 did not have a Plan of Care.

Based on record review, observation and interview the facility failed to monitor, manage and maintain expired patient care supplies. This deficient practice could lead to infections and ineffective treatment for all patients receiving care. The findings are: --- A. Record review of the facilitys policy titled ";Supply Maintenance number 5.14.1."; Revised 2014, stated ";At the Hospice Site: 1. Hospice maintains and delivers supplies according to applicable federal/state laws and regulations. 2. Supplies will be checked for expiration date prior to use. If outdated, the supplies will be immediately removed from stock and discarded. B. During an observation on 04/30/2024 at 10:00 AM, of the supply room, the following was revealed: 1. Eight (8) boxes of insulin syringes (syringe used to administer diabetic medication) with the label from an (Name of Pharmacy) with a patients name on them. These insulin syringes had an expiration date of 06/2014. 2. Central Line (tube going into heart for administration of medications) dressing change kit (Sterile Dressing) with an expiration date of 09/2014. 3. Box of Mepilex Border dressings (dressing to cover a wound) with an expiration date of 10/28/2023. 4. Adaptec Rope (dressing used for wound) with an expiration date 02/2022. C. During an interview on 04/30/24 at 10:00 AM, with Staff (S)3, Director of Nursing (DON), DON confirmed there is no system in place to monitor supplies for expiration dates and that the patients syringes should not have been in the storage room and have such an expired date. S3 stated ";Staff could have pulled the expired items and taken them to a patient for use." S3 stated ";I had no idea that there were so many expired supplies."

Based on record review and interviews the facility failed to ensure medical social services are provided to the patients by a qualified social worker. This deficient practice is likely to lead to patients and their families having unmet social service needs. The findings are: --- A. Record review of the facilitys policy titled ";Psychosocial Services" Policy #3015, not dated, stated ";Hospice provides psychosocial services by a qualified social worker" and ";These services are provided according to the interdisciplinary team plan of care." B. Record review of the facilitys staff list revealed the facility did not have a qualified social worker on staff. C. During an interview on 05/03/24 at 8:31 AM, with Staff(S)4, Facility Administrator, S4 confirmed that there is no social worker on service, and they have not had a qualified social worker since December of 2023.

Based on record review and interview the facility failed to meet the Condition of Participation by failing to have a qualified home hospice aide providing care. This deficient practice is likely to lead to inadequate patient care for all patients that could result in patient harm. The findings are --- A. The facility failed to have a qualified home health aide. Refer to tag L0609.

Based on record reviews and interviews the facility failed to ensure there was a qualified Hospice Aid to provide patient care to all patients. This deficient practice is likely to lead to all patient's showers, hygiene and personal needs not getting met. The findings are: --- A. Record review of the facilitys document titled ";Home Hospice Aide" not dated, under ";Job Summary" stated ";Successful completion of an approved practical training program with a total of at least 75 hours of combined classroom and supervised clinical training with demonstrated knowledge of necessary skills." B. Record review of the Personnel File for Staff (S)5, home hospice aide, revealed S5 did not have any training to be a Home Hospice Aide. C. During an interview on 05/03/24 at 8:31 AM, with S4, Facility Administrator, when asked if S5 had completed a training program, S4 stated ";She [S5] had not previously done HHA [home hospice aid] training." When asked about the amount of training provided, S3 stated, ";about 60 hours of training." S4 confirmed that the facility could not provide documentation of the training provided to S5. D. During an interview with S5 on 05/02/24 at 9:55 AM, S5 confirmed she had not completed the training program.

Based on document review, policy review, and interview, the hospice agency did not establish a comprehensive emergency prepared program (EPP.) The hospice could not produce any documentation of an EPP which included the agency's emergency plan, based on a community-based risk assessment, updated every two years, and included a process for cooperation with local, tribal, regional, state, and federal emergency preparedness officials. The lack of an EPP could delay the agency ability to respond in the event of a disaster. Findings include: The hospice agency has no documentation of any of the components of an EPP (See E0004). The hospice agency did not have evidence of a communication plan that included the names and contact information for employees, entities providing services under arrangement (See E0030). The hospice agency did not have evidence of a communication plan that included contact information for federal, state, tribal, regional, and local emergency officials (See E0031). The hospice agency did not have documentation of emergency preparedness training ever being completed (See E0037) The hospice agency did not have documentation of emergency preparedness testing. There was no documentation of participation in a full-scale exercise, tabletop, or individual facility-based exercise (See E0039)

Based on policy review and interview, the hospice agency failed to develop an emergency preparedness program (EPP). Failure to create an EPP had the potential for the agency to be unable to successfully navigate a natural, man-made, or facility-based disaster which could impact the safety of all patients receiving hospice services. Findings include: Review of a hospice agency policy titled, "Emergency Operations Plan and Policies," revised June 2018, revealed, "Hospice has established and maintains an emergency preparedness program that meets all requirements." During an interview on 01/18/22 at 8:30 AM, the Administrator stated the only documentation the agency had related to emergency preparedness was a copy of the official plan developed by the county for emergency response. The Administrator stated there was no additional documentation to demonstrate the hospice agency developed its own EPP.

Based on policy review and interview, the hospice agency failed to develop an Emergency Preparedness Program (EPP) which included policies and procedures that are reviewed and update at least every two years. Review of the provided hospice policy titled, "Emergency Operations Plan and Polices," revised June 2018 did not include policies or procedures which addressed the following standards. This deficient practice had the potential to affect all patients who receive care from this hospice agency. Findings include: 1. A procedure to inform emergency officials about homebound hospice patients in need of evacuation from their residence. (See E0019) 2. Development of arrangements with other hospice agencies or healthcare facilities to transfer patient care services in the event of an emergency if the hospice is unable to continue to provide services. (See E0025) 3. Development of a written emergency preparedness communication plan. (See E0029)

Based on policy review and interview, the hospice agency failed to develop a policy which included the procedure to inform state and local emergency officials about hospice patients in need of assistance to evacuate their home in a disaster. The failure to have a procedure in place could delay needed assistance for all the agency hospice patients. Findings include: Review of a hospice policy titled, "Emergency Operations Plan and Policies," revised June 2018 revealed this document guides the process to develop emergency preparedness policies. The policy does not identify the procedure to inform emergency officials of a patient who is homebound and in need of evacuation from their residence during a disaster. The policy is dated more than two years ago and there is no documentation to show the policy has been reviewed and updated. During an interview on 01/18/22 at 8:30 AM, the Administrator confirmed the policy has not been reviewed or revised since June 2018 and the policy does not include a procedure for notifying emergency officials of patient's needing assistance to evacuate during an emergency. The Administrator stated there was no additional documentation.

Based on policy review and interview, the hospice agency failed to develop a policy and procedure that addressed arranging with other hospice providers and healthcare facilities to transfer patients in the event the hospice agency is unable to provided services during an emergency. The failure to have a procedure in place could delay needed assistance for all the agency hospice patients. Findings include: Review of a hospice agency policy titled, "Emergency Operations Plan and Policies," revised June 2018 revealed the document did not include the development of arrangements with other providers or healthcare facilities in the event the agency would need to transfer patients to another provider in a disaster or emergency. During an interview on 01/18/22 at 8:30 AM, the Administrator stated the agency does not have any agreements with other agencies or healthcare facility in the event of needing to transfer patients due to an emergency. The Administrator stated there was no additional documentation.

Based on policy review and interview, the hospice facility failed to develop an emergency preparedness program (EPP) that included a policy and procedure communication plan or update polices every two years. The failure to have a communication procedure in place could delay needed assistance for all the agency hospice patients. Findings include: Review of a hospice agency policy titled, "Emergency Operations Plan and Policies," revised June 2018 revealed the policy did not include an emergency preparedness communication procedure and the policy has not bee reviewed or update within the past 2 years. During an interview on 01/18/22 at 8:30 AM, the Administrator stated there was no additional documentation to demonstrate the hospice agency developed its own EPP.

Based on policy review and interview, the hospice facility failed to develop a communication plan the included names and contact information for hospice employees, entities providing services under arrangement, patients' physicians, and other hospices. The failure to have a communication procedure in place could delay needed assistance for all the agency hospice patients. Findings include: During the entrance meeting on 01/17/22 at 8:40 AM, the hospice emergency preparedness program (EPP) documentation was requested. By the time of the exit conference on 01/19/22 at 10:50 AM no documentation was presented that included a list of the names and contact information for hospice staff, entities providing services under arrangement, or patients' physicians was presented. During an interview on 01/18/22 at 8:30 AM, the Administrator stated the hospice agency did not develop its own EPP. The Administrator stated there was no addition documentation or a list with contact information that staff can reference during a disaster.

Based on policy review and interview, the hospice facility failed to develop a communication plan the included names and contact information federal, state, tribal, regional, and local emergency preparedness staff. The failure to have a communication procedure in place that included how to contact emergency officials could delay needed assistance for all the agency hospice patients. Findings include: During the entrance meeting on 01/17/22 at 8:40 AM, the hospice emergency preparedness program (EPP) documentation was requested. By the time of the exit conference on 01/19/22 at 10:50 AM no documentation was presented that included a list of the names and contact information for federal, state, tribal, regional, and local emergency officials. During an interview on 01/18/22 at 8:30 AM, the Administrator stated the hospice agency did not develop its own EPP. The Administrator stated there was no addition documentation or a list with contact information that staff can reference during a disaster.

Based on policy review and interview, the hospice did not provide staff training on the agency emergency preparedness program (EPP) and emergency policies and procedures. The failure to train staff on emergency procedures had the potential to delay the agency's ability to respond during a disaster. This deficient practice affects all patients and staff of the agency. Findings include: Review of a hospice agency policy titled, "Emergency Operations Plan (EOP) Training Program," revised June 2018, revealed, "Hospice will do the following: Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement and volunteers ... Provide emergency preparedness training at least annually. Maintain documentation of the training." During an interview on 01/19/22 at 9:45 AM, the Administrator confirmed there was no documentation of staff training.

Based on policy review and interview, the hospice agency failed to conduct exercises to test the emergency plan annually. The failure to test the emergency preparedness procedures by participating in a community-based exercise, a facility based functional exercise, a mock disaster drill, or a tabletop exercise had the potential to delay the agency's ability to respond during a disaster. Findings include: Review of a hospice agency policy titled, "Testing Program for Emergency Operations Plan (EOP)," revised June 2018, revealed, "Hospice will conduct exercises to test the EOP at least annually ... Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based excise ... Analyze Hospice's response to and maintain documentation of all drills, tabletop exercises and emergency events ... Revise EOP as needed." During an interview on 01/19/22 at 9:45 AM, the Administrator confirmed there was no documentation of staff participating in any activity designed to test the hospice agency ability to perform in a disaster and the agency has not participated in any community-based test full-scale exercise, facility-based exercise, mock disaster drill, or tabletop exercise.

Based on document review, policy review, and interview, the hospice failed to measure, analyze, and track indicators as a component of the Quality Assessment and Performance Improvement (QAPI) program. Adverse event tracking data was not documented or included in QAPI. The failure to assess quality indicators had the potential to impact core hospice services, impact the ability of the hospice to demonstrate improvement based on data analysis, and directly impact all patient receiving hospice services safety. Findings include: Review of a hospice agency policy titled, "Quality Assessment and Performance Improvement (QAPI) Plan," revised June 2018, revealed, "Data collection will include established priorities for improvement ... Data collection will include: High risk processes: patients are placed at risk of serious consequences or deprived of care ...High volume processes: .... Problem prone processes ... Hospice will also collect data about: Infection control surveillance system ... Incident reporting ... Medication errors ... Adverse drug reactions ... Patient falls." Review of the QAPI documentation presented did not include any quality indicators or data elements that could be measured, analyzed, or tracked. The QAPI did not include data related to adverse patient events. During an interview on 01/18/22 at 8:30 AM, the Administrator confirmed the agency did not have documentation of measurable quality indicators to include in its QAPI program such as infection control surveillance, adverse event, or patient complaint/concern tracking and trending data to include in its QAPI program.

Based observation, policy review, document review, and interview, the hospice agency failed to implement an infection control and prevention program. The hospice did not develop protocols for infection surveillance, provide staff education on a routine basis or specifically related to the COVID-19 pandemic, did not monitor that staff were following standard precautions or agency infection control policies, and did not ensure infection prevention data trends were reported in Quality Assessment Performance Improvement (QAPI) meetings. The hospice did not have any documentation of infection tracking or trending or surveillance for COVID-19. Findings include: The hospice: 1. Failed to ensure nursing staff cleaned equipment after use and failed to follow bag technique in a patient's home. (See L579) 2. Failed to document infection surveillance, tracking, trending, identification, and investigation. (See L580) 3. Failed to include infection prevention data in the hospices quality assessment and performance improvement (QAPI) program. (See L580) 4. Failed to provide infection control education and failed to document training specific to COVID-19. (See L580)

Based on observation, policy review, and interview the hospice agency failed to ensure nursing staff clean equipment used to check patient vital signs after use or followed the agency policy for bag technique during one of one patient (Patient (P)1) home visit observations. This had the potential to allow for the transmission of microorganisms that could cause the spread of infection for all patients receiving hospice services from the agency. Findings include: A home visit observation at the home of P1 on 01/16/22 from 9:30 AM to 10:30 AM revealed the following: 1.Certified Nurse Aide (CNA) placed the bag containing equipment used by staff during the visit on the coffee table without placing a barrier down. 2. The CNA and Licensed Practical Nurse (LPN)1 each placed hard plastic clipboards used to support paper notes directly on the coffee table without a barrier. 3. The CNA checked the patient's blood pressure using a stethoscope and sphygmomanometer. The CNA also used applied an oximeter to the patients finger to check oximetry and pulse. The CNA then placed each item back into the bag without cleaning the equipment. 4. LPN1 used a stethoscope that had been around his/her neck to auscultate (listen to) P1's lung sounds and then placed the stethoscope back around his/her neck without cleaning it. 5. The CNA used a tape measure to check the circumference of P1's forearm and thigh. After measuring the CNA placed the tape measure back into the bag without cleaning it. Review of the undated hospice agency policy titled, "'Cleaning and Disinfection Vital Sign Equipment," revealed after checking the patient's blood pressure (BP) staff are to "Remove the sphygmomanometer from the extremity and wipe the sphygmomanometer with a disinfectant wipe (s) and allow it to air dry ... Wipe the stethoscope's surfaces with a disinfectant wipe and allow it to dry ... wipe the pulse oximeter, including the interior portion that had direct contact with the patient's finger, as directed by the manufacturer with a 70% isopropyl alcohol prep pad or other low-level disinfectant wipe, and allow it to air dry." Review of the undated hospice agency policy titled, "Bag Technique: Rolling and Hand-carried," revealed "Use a surface barrier of a water-resistant material under the bag and/or equipment used in patient care ... Clean the equipment and supplies that had direct patient or environmental contact." During an interview on 01/17/22 at 3:00 PM, the Administrator confirmed it was the policy of the hospice agency that a barrier should be placed first before staff set down nursing bags or other equipment on surfaces in the patient home. The Administrator also confirmed all equipment is expected to be cleaned after use and before placing the equipment back into the bag.

Based on observation, policy review, document review, and interview, the hospice agency failed to document ongoing infection prevention surveillance and include the collected information in the hospice's Quality Assessment Performance Improvement (QAPI) program. This failure had the potential to miss opportunities to identify potential infection trends and respond appropriately based on analysis of the data which could affect the ability to prevent and control infections for all patients of the agency receiving hospice care. Findings include: Review of a hospice agency policy titled, "Infection Control Plan," revised June 2018, revealed, "These policies/procedures include: ... Establishes a surveillance program for infections acquired while receiving Hospice care ... Reviews the program's effectiveness annually and revise, as necessary." Review of a hospice agency policy titled, "Quality Assessment and Performance (QAPI) Plan," revised June 2018, revealed, "Hospice will also collect data about ... Infection control surveillance system." Observation during a home visit for patient (P)1 on 01/17/22 between 9:30 AM and 10:30 AM, revealed an 8-inch by 10-inch paper posted on the refrigerator which said, "Started ABX (antibiotic) on 01/07/22 for Pee/dark." P1's daughter stated that family caregivers post signs on the refrigerator for other family caregivers can see to notify them of changes. P1's daughter confirmed P1 was treated for a urinary tract infection earlier this month. The Licensed Practical Nurse (LPN)1, who was present at the time of the visit, confirmed P1 had been treated for signs and symptoms of a urinary tract infection. Review of "Quarterly Quality Improvement Board IDG [Interdisciplinary Group] Report" dated 01/01/21 to 03/31/21, 04/01/21 to 06/30/21, 07/01/21 to 09/30/21, 10/02/21 to 12/31/221, revealed there was no information about infection prevention surveillance data included in QAPI. During an interview on 01/18/22 at 8:30 AM, the Administrator stated the hospice agency did not have any infection prevention and surveillance documentation to present because no patients or staff were diagnosed with an infection, including COVID-19, during the past year. When asked, the Administrator confirmed there was no infection surveillance documentation at all including for this year to date or the prior 3 years. When asked about P1's urinary tract infection, the Administrator confirmed there was no documentation of P1's urinary track infection noted during the home visit.

Based on policy review, and interview, the hospice failed to provide education to staff on COVID-19 and the agency's infection prevention program. The failure to provide staff education had the potential to result in an increase in infections for all patients receiving hospice services from the agency. Findings include: Review of a hospice agency policy titled, "Infection Control Plan," revised June 2018, revealed, "These policies/procedures include ...Establishes a training program upon employment which: Educates employees in the infection control program. Advises employees of any revision or when changes occur." During an interview on 01/19/22 at 9:45 AM, the Administrator stated the agency did not have any documentation of staff training and confirmed there was no documentation of staff training completed specific to COVID-19, infection prevention, infection documentation, tracking infections, cleaning of equipment, or standard precautions.

Based on personnel record review and interview, the hospice agency failed to routinely provide substantially all core services directly by hospice employees. The hospice medical social worker was not an employee of the agency. This failure had the potential to result in all hospice patients and family members not receiving services to which they are entitled or would benefit from. Findings include: Review of the personnel file for the Social Worker (SW) revealed a contract for services on a per visit basis. During an interview on 01/18/22 at 11:30 AM, the Administrator confirmed the SW is a contract staff person and does not receive a W-2 from the agency. The Administrator also stated the SW had been performing in roles as medical social services, counselling, and bereavement supervision.

Based on observation, policy review, record review, and interview, the hospice agency failed to monitor, manage, and maintain the equipment used to access the web-based medical record system. This had the potential to result in unauthorized access to patient information for all patients receiving care from the hospice. Findings include: During an interview on 01/17/22 at 8:40 AM, the Administrator stated the agency uses a web-based electronic medical record (EMR) system called Healthcare First and that staff can access the program with their personal computers, laptops, and cellphones. Surveyor was provided with a log-in and password to access the patient records in the web-based EMR. During review of patient information, the surveyor identified that patient information could be save to the computer desktop which would allow for access to patient information when not logged into the web based EMR. During a home visit observation on 01/17/22 from 9:30 AM to 10:30 AM, licensed practical nurse (LPN)1 used his/her personal cellphone to access the patient's medical record. The login information and password required to access the EMR was saved to LPN1's cellphone. Therefore, if LPN1's phone was not locked anyone who picked up the phone could access patient medical records. Review of a hospice agency policy titled, "Information Management Plan," revised June 2018, revealed, "Data encryption, passwords and firewalls are utilized for electronic patient information ... All patient information and personnel information is strictly confidential." During an interview on 01/18/22 at 8:30 AM, the Administrator confirmed that patient information could be saved to staff personal devices and the agency does not monitor or maintain the personal devices the staff use. The Administrator also confirmed that the agency would not be aware if a staff person lost a laptop or cell phone which could provide unauthorized access or if staff allowed other people to use their personal devices capable of accessing patient information.

Based on personnel file review and interview, the hospice agency failed to ensure the Social Worker (SW) had the required qualifications which included having a Master of Social Work (MSW) degree or a baccalaureate degree and be supervised by an MSW. This failure had the potential to result in all patients and family members not receiving all services to which they are entitled. Findings include: Review of the personnel file for the SW revealed it contained a copy of a baccalaureate degree in SW. The file included a blank resume. There was no documentation to indicate the SW's prior experience or training with bereavement. During an interview on 01/19/22, the Administrator confirmed the SW does not have a master's degree and is not supervised by a social worker with a master's degree.

Based on policy review and interview, the hospice agency failed to obtain a Clinical Laboratory Improvement Amendments (CLIA) of 1988 waiver for blood glucose monitoring using an agency owned glucometer. This failure could impact testing results if staff members were not trained to the specific procedure, demonstrated competency with the device, and conduct quality control analysis as required under the CLIA waiver. Findings include: During the entrance interview on 01/17/22 at 8:40 AM, the Administrator stated the agency does own a glucometer and at times nursing staff have used it to check patient blood sugar via finger stick. The Administrator stated the hospice agency does not have a CLIA waiver. Review of a hospice agency policy titled, "Waived Testing: Blood Glucose Monitors and/or Coagulation Testing," revised June 2018, revealed, "Hospice will obtain a CLIA waiver for analysis of blood glucose levels and/or coagulation testing via finger stick."