Every finding on record at Hope Hospice and Palliative Care Inc

Based on record review and interview the agency failed to document a risk assessment based on all-hazards approach in 1 of 1 Emergency Preparedness programs reviewed. --- Findings include: Review of agency policy/procedure titled "Emergency / Disaster Management, Policy Number: AD.E10" last reviewed on 01/30/2024 revealed no documentation of a completed facility or community based all-hazards risk assessment. During an interview with Director A on 12/04/2024 at 9:30 AM, Director A stated, "We don't have that" and was unaware that they (Agency) needed a risk assessment. Director A stated that the agency works with the community to determine risks and participates in community exercises. Director A was unable to provide documentation of a community based risk assessment.

Based on record review and interview the Hospice agency failed to maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases in 1 of 1 Infection Control Programs reviewed. Findings include: The agency staff failed to properly disinfect reusable equipment. See Tag L579 The agency failed to include the Infection Control program as an integral part of QAPI program and document methods to survey, identify and screen employees for clinically apparent communicable diseases. See Tag L580.

Based on observation, record review, and interview agency staff failed to properly disinfect reusable equipment prior to returning it to the nursing bag in 1 of 1 RN (Registered Nurse) observation visit out of a total of 3 observation visits (RN B). --- Findings include: Review of policy ";Infection Control-Bag Technique" policy number: PC.I10, last revised 12/2020 revealed in part, ";5. All items that might be used with other patients (for example, stethoscopes) are cleaned with the appropriate disinfectant after each use and before being returned to the bag. 7. Disinfect reusable items before returning them to the bag: c. Allow items to dry before putting back in the bag." Review of disinfectant wipes label for use revealed ";1. Wipe surface with enough wipes for treated surface to remain visibly wet for 4 minutes. 2. Let the surface dry." An observation visit was performed with RN B at the residence of Patient #2 on 12/3/2024 at 1:15 p.m. At the conclusion of the visit, RN B used a disinfectant wipe to wipe down equipment that was used during the visit. RN B placed the equipment directly into a plastic bag and returned it to the nursing bag, without allowing the items to remain wet for 4 minutes. During an interview on 12/4/2024 at 12:30 p.m. with Director A, Director A was asked what the expectation is for staff disinfecting equipment. Director A stated that staff should follow the instructions on the label.

Based on record review and interview the Hospice agency failed follow agency policies and procedures and to maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases in 1 of 1 Infection Control Programs reviewed. Findings include: Review of agency policy and procedure tilted, "Infection Control - Program Policy Number: PC.I40" Last reviewed on 12/2020 revealed, "Procedures: 2. As an integral component of the hospice's quality assessment and performance improvement program (QAPI), infection control data is collected and analyzed to determine trends and areas in need of improvement to minimize the risk of infections. Data collected may include, but not limited to; a. identification of targeted infections; b. identification of unusual/undesirable trends and factors contributing to those trends; c. monitoring staff compliance with infection control policies and procedures; and d. reportable employee or patient illnesses and infections. 3. A summary of all infection control activities performed as well as results of aggregated surveillance data analysis is provided by the QAPI committee and included in reports to the hospice's leaders." Review of the agency's Infection Control program revealed no documentation of identifying infectious and communicable disease or any surveillance data that was reviewed or monitored. Review of the agency's QAPI program revealed no documentation of an integrated infection control program. No infection control data was found. During an interview with Director A on 12/04/2024 at 9:40 AM, Director A stated the agency does not track specific patient / employee infection control data. She stated that she does monitor the CDC website for disease trends. When asked if the agency had a policy related to screening employees for communicable disease, Director A stated, "We don't have a policy related to employees and communicable diseases."

Based on record review and interview, agency staff failed to ensure that the hospice plan of care identified which provider was responsible for performing their respective functions in 7 of 7 patients residing in an SNF (Skilled Nursing Facility) or an ALF (Assisted Living Facility) out of a total of 13 records reviewed (Patients #1, #2, #3, #5, #9, #10, and #13). --- Findings include: Review of policy ";Plan of Care (POC)" policy number PC.P40, last revised 12/2020 revealed in part, ";6. For hospice patients who reside in a skilled nursing facility, community based residential setting, or other contracted residential facility (referred to as facility): c. The hospice plan of care identifies the care and services that are needed and specifically identifies which provider (hospice, facility staff) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care." Review of Patients #1, #2, #3, #5, #9, #10, and #13 medical records revealed that these patients resided in a SNF or ALF. Review of the Plans of Care for these patients revealed no identification of which provider was responsible for performing their respective functions. During an interview conducted on 12/4/2024 at 1:00 p.m. with Director A, Director A was asked what the expectation is for plans of care of patients who reside in a facility. Director A stated that the plan of care should identify who is responsible for doing what.

Based on record review and interview, agency staff failed to review and update the agency's emergency preparedness plan at least every two years in 1 of 1 plan reviewed. Findings include: Review of the agency's "Emergency Preparedness Plan" dated 3/2020 on 2/21/2022 at 11:006 AM revealed in part, "The Emergency Preparedness Plan was last reviewed and updated 3/2019." An interview was conducted on 2/21/2022 at 11:46 AM with Administrator A. When asked if the emergency plan had been reviewed since 3/2019 Administrator A stated "I am feeling I do not have that, but I will look." An interview was conducted on 2/22/2022 at 10:06 AM with Administrator A. When asked if Administrator A found the updated Emergency Preparedness Plan Administrator A stated "I did not find the documentation."

Based on record review and interview, the agency staff failed to develop plans of care that were individualized with measurable outcomes in 9 of 9 open patient records reviewed. (Patients #1-9) out of a total of 11 records reviewed. Findings include: 1. Agency staff failed to develop plans of care that were individualized to meet the needs of the patient. See tag L 545. 2. Agency staff failed to develop goals with measurable outcomes. See L 548 This systemic failure has the potential to affect all patients admitted and cared for by this agency.

Based on observation, record review and interview, this agency staff failed to develop plans of care that were individualized to meet the needs of the patient in 9 of 9 open records reviewed (Patients #1-#9.) Findings Include: Review of policy titled "Plan of Care" dated 12/2020, revealed in part, "Procedure 4. Revisions to the plan of care are based on information from the patient's updated comprehensive assessment and the patient's progress towards outcomes specified in the plan. 11. The plan of care includes, but is not limited to: c. measurable outcomes anticipated from implementing and coordinating the plan of care." A home visit observation conducted on 2/22/2022 at 9:05 AM for Patient #1 revealed a start of care 12/8/2021 and primary diagnosis of chronic obstructive pulmonary disease. Observation of Registered Nurse E Assessment on 2/22/2022 revealed Cardiopulmonary Assessment: Respiratory assessment for bilateral lower leg edema. Nutrition Assessment: Reports from daughter not eating much. Pain assessment: denies pain at this time, was give morphine this AM. Urinary Assessment: scant amount of urine measured from this AM void. Patient #1's "Hospice Plan of Care dated 12/8/2021-2/5/2022 revealed no individualized goals or interventions related to Edema, Pain, Nutrition, or Urinary. A home visit observation conducted on 2/22/2022 at 7:45 AM for Patient #2 revealed a start of care 12/13/2021 and primary diagnosis of Nonrheumatic tricuspid valve insufficiency. Observation of Certified Nurse Aide J bath/shower cares on 2/22/2022 revealed Skin Assessment during shower, Activity assistance with a wheeled walker, Weight obtained. Patient #2's "Hospice Plan of Care dated 12/13/2021 - 3/12/2022 revealed no individualized goals or interventions related to Activity assist with a wheeled walker; Skin Assessment, or Weight. A record review was conducted on 2/21/2022 on Patient #3's open medical record. Patient #3 was admitted to hospice on 2/11/2022 with a diagnosis of Rectal Cancer. The following goals: Patient/caregiver will be independent with ostomy care; Patient/caregiver will demonstrate ability to effectively manage ostomy care; Patient free of any signs/symptoms of infection; Patient/caregiver will verbalize understanding of pain management regimen; Patient will express decrease of nausea/vomiting symptoms. The goals are not individualized to meet the patient's specific needs. A record review was conducted on 2/21/2022 on Patient #4's open medical record. Patient #4 was admitted to hospice on 2/13/2022 with a diagnosis of Myelodysplastic Syndrome. The following goals: Patient's personal care needs will be met; Maintain clean, safe environment. The goals are not individualized to meet the patient's specific needs. A record review was conducted on 2/21/2022 on Patient #5's open medical record. Patient #5 was admitted to hospice on 2/8/2022 with a diagnosis of Small Cell B-Cell Lymphoma. The following goals: Promote skin integrity; Patient's personal care need will be met; Family/Caregiver will acknowledge support from hospice team; Family/caregiver will consult with staff as needed for support; Patient will maintain optimum bowel functioning; Patient's nutritional needs will be met as patient's condition/comfort allows; Caregiver will use a calm approach to avoid overstimulation throughout lifespan. The goals are not individualized to meet the patient's specific needs. A record review was conducted on 2/21/2022 on Patient #6's open medical record. Patient #6 was admitted to hospice on 2/6/2019 with a diagnosis of Alzheimer's. The following goals: Patient's symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow throughout life span; Anxiety/agitation controlled through course of care. The goals are not individualized to meet the patient's specific needs. A record review was conducted on 2/21/2022 on Patient #7's open medical record. Patient #7 was admitted to hospice on 1/10/2022 with a diagnosis of Parkinson's Disease with Dementia. The following goals: Patient will maintain optimum level of functioning and physical mobility appropriate for stage of disease process; Patient will remain safe at home. The goals are not individualized to meet the patient's specific needs. A record review was conducted on 2/21/2022 on Patient #8's open medical record. Patient #8 was admitted to hospice on 2/8/2022 with a diagnosis of Chronic Kidney Disease Stage 4. The following goals: Patient can identify risk factors; Patient's symptoms will be consistent with state of disease process and problems managed as well as disease process will allow; Mobility and self-care in activity of daily living achieved for optimal level of functioning within limitations imposed by illness. The goals are not individualized to meet the patient's specific needs. A record review was conducted on 2/21/2022 of Patient #9's open medical record. Patient #9 was admitted to hospice on 1/4/2022 with a diagnosis of Congestive Heart Failure. The following goals: Patient's personal care needs will be met; Promote safe personal care and hygiene, promote skin integrity; Patient will maintain optimum level of functioning appropriate for stage of disease process; Patient's symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow. The goals are not individualized to meet the patient's specific needs. In interview with Administrator A on 2/22/2022 at 10:29 AM. Administrator A states "I can see were we are not individualizing the goals, some of the nurses do not know they can be individualized/customized in the new computer system."

Based on record review and interview, staff failed to develop goals with measurable outcomes in 9 of 9 open records reviewed ( Patient's #1 - #9) out of a total of 11 records reviewed. Findings Include: Review of policy titled "Plan of Care" dated 12/2020, revealed in part, "Procedure 4. Revisions to the plan of care are based on information from the patient's updated comprehensive assessment and the patient's progress towards outcomes specified in the plan. 11. The plan of care includes, but is not limited to: c. measurable outcomes anticipated from implementing and coordinating the plan of care." Patient #1 was admitted to hospice on 12/8/202 with a primary diagnosis of chronic obstructive pulmonary disease. Patient #2 was admitted to hospice on 12/13/2021 with a primary diagnosis of Nonrheumatic tricuspid valve insufficiency. Patient #3 was admitted to hospice on 2/11/2022 with a diagnosis of Rectal Cancer. Patient #4 was admitted to hospice on 2/13/2022 with a diagnosis of Myelodysplastic Syndrome. Patient #5 was admitted to hospice on 2/8/2022 with a diagnosis of Small Cell B-Cell Lymphoma. Patient #6 was admitted to hospice on 2/6/2019 with a diagnosis of Alzheimer's. Patient #7 was admitted to hospice on 1/10/2022 with a diagnosis of Parkinson's Disease with Dementia. Patient #8 was admitted to hospice on 2/8/2022 with a diagnosis of Chronic Kidney Disease Stage 4. Patient #9 was admitted to hospice on 1/4/2022 with a diagnosis of Congestive Heart Failure. Review of Patients #1 - 9's goals revealed the following unmeasurable goals: "Promote Skin Integrity" (Patient #1, #2, #5, 9) There is no objective criteria to evaluate progress toward the goal. "Patient's Personal care needs will be met" (Patient #1, #2, #4, #5, #9) There is no objective criteria to evaluate progress toward the goal. "Patient recognized energy limitations and understands/uses energy conservation techniques" (Patient #2) There is no objective criteria to evaluate progress toward the goal. "Patient/caregiver will be independent with ostomy care" (Patient #3) There is no objective criteria to evaluate progress toward the goal. "Patient free of any signs/symptoms of infection" (Patient #3) There is no objective criteria to evaluate progress toward the goal. "Patient's symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow" (Patient #4, #6, #7, #8, #9) There is no objective criteria to evaluate progress toward the goal. "Anxiety/agitation controlled through course of care" (Patient 6) There is no objective criteria to evaluate progress toward the goal. "Patient will remain safe at home" (Patient 7) There is no objective criteria to evaluate progress toward the goal. In interview with Administrator A on 2/22/2022 at 10:29 AM when asked how nurses document progress towards a goal "Patient will remain safe" Administrator A stated "I see what your saying, that when a goal is charted the staff needs to state how its being met."

Based on record review, observation, and interview, the agency staff failed to ensure that Centers for Disease Control (CDC) guidelines were followed to prevent the spread of COVID-19 in 1 of 1 infection programs reviewed. The agency also failed to maintain an environment free from potential contamination in 2 of 2 home visits observed (Patient #1 & #2.) The staff failed to ensure that a documentation system is in place to monitor the contingency plan for exempted/unvaccinated staff for COVID-19 for all staff who filed an exemption status at the facility in 10 of 10 (CNA (certified nursing assistant) B, Registered Nurse C, Registered Nurse D, Registered Nurse E, CNA F, Registered Nurse G, Nurse Practitioner H, Social Worker I, and, CNA J) staff who filed exemption for the COVID-19 Vaccine in a total of 15 staff. staff who filed exemption for the COVID-19 Vaccine in a total of 15 staff. Findings include: 1. The agency failed to ensure a method is in place for identifying and documenting that required exempted/unvaccinated staff are appropriately screened for COVID-19 per the agency policy. See tag L 900 2. Agency has no policies and procedures for tracking of staff COVID vaccination. Elements missing: See Tag L900. 1. A process for tracking COVID vaccine status and a process for receiving and approving exemptions or delays. 2. A contingency plan to mitigate risk of transmission by exempted staff. 3. The agency failed to follow CDC nationally recognized infection prevention and control guidelines for Covid-19. See tag L 900. 4. The facility failed to maintain an environment free from potential contamination in 2 of 2 home visits observed (Patient #1 & #2) . See tag L 900. The cumulative effects of the systematic failures has the potential to affect all patients receiving care at this Hospice.

Based on record review, observation, and interview, the agency staff failed to ensure that Centers for Disease Control (CDC) guidelines were followed to prevent the spread of COVID-19 in 1 of 1 infection programs reviewed. The agency also failed to maintain an environment free from potential contamination in 2 of 2 home visits observed (Patient #1 & #2.) The staff failed to ensure that a documentation system is in place to monitor the contingency plan for exempted/unvaccinated staff for COVID-19 for 10 of 10 (CNA (certified nursing assistant) B, Registered Nurse C, Registered Nurse D, Registered Nurse E, CNA F, Registered Nurse G, Nurse Practitioner H, Social Worker I, and, CNA J) staff who filed exemption for the COVID-19 Vaccine in a total of 15 staff. Findings Include: CDC COVID-19 Guidelines, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" last updated February 2, 20222, reviewed 2/23/2022 3:37 PM. It states in part "Ensure everyone is aware of recommended Infection Prevention and Control (IPC) practices in the facility. Post visual alerts (e.g., signs posters) at the entrance with instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Establish a process to identify anyone entering the facility, regardless of their vaccination status. Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any symptoms of COVID-19. Implement Source Control Measures. Source control refers to use of respirators or well-fitting facemask's or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status." Centers for Medicare & Medicaid Services, "Guidance for the Interim Final rule - Medicare and Medicaid Programs, Omnibus COVID-19 Health Care Staff Vaccination #QSO-22-07-ALL" last updated 12/28/2021, states in part "Regulatory Requirements, all staff are fully vaccinated for COVID-19 regardless of clinical role or patient contact. Exemptions, Process for staff to request vaccine exemptions. Contingency Plans, Interventions implemented to mitigate spread of COVID-19 infection, additional source control requirements (N95, physical distancing, restricted areas) regular testing, active recruitment of vaccinated staff. Policy and Procedures process for ensuring all staff are fully vaccinated, and/or have received a minimum of 1 vaccine done (new hires), process for tracking and documenting vaccination status for all staff, exemption requests and status, contingency plans for non-fully vaccinated staff. Staff list with vaccination status, Position/role of each staff member, newly hired staff, Staff unvaccinated due to exemption. Percentage of unvaccinated staff, excluding approved exemptions." CDC Interim Guidance for "Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2" updated Jan. 21, 2022, states in part "Cloth mask: Textile (cloth) covers that are intended primarily for source control in the community. They are not personal protective equipment (PPE) appropriate for use by healthcare personnel." Facility policy entitled, "COVID-19 Emergency Preparedness, 4/2/2020, revealed in part "Every Patient Visit, a. Employees of this agency will wear the following. cloth gown, gloves, cloth mask with filter in place, and shoe covers." Facility Addendum titled "COVID Policy", dated 2/19/2021, revealed in part "Effective 2/19/2021, due to a decrease in COVID cases, we will begin utilizing the following PPE (personal protective equipment) for patient visits, a. Cloth or disposable masks and gloves. b. Wearing appropriate PPE as requested by facility." Addendum dated 4/29/2021 revealed in part, "1. Effective as of 4/29/2021, due to update from the health department, we will begin using the following PPE for patient visits: a. Home patients: wear cloth mask or disposable mask into the home as desired by patient and/or family. Masks may be removed if/when requested by family and/or patient. b. Facility patients: Continue to use appropriate PPE as requested." Review of facility document titled, "COVID 19 Policy and Procedure" dated 11/9/2021 revealed, "1. Unvaccinated employees shall test every other week or meet the required set forth by the facility that they are entering to take care of their patients. 2. All testing results shall be kept with the employee file starting December 6, 2021. 3. If any employee tests positive for COVID 19 or diagnosed by a healthcare provider, with symptoms or fever 100.4 or above, and new unexplained cough with shortness of breath, loss of taste or smell with no other explanation, the employee shall not work until symptoms are resolved or 10 days. 4. If an employee has been exposed to COVID 19 without the correct PPE will not be removed from the workplace if they are a-symptomatic, and who have had COVID 19 in the last 3 months, or fully vaccinated. 5. Employees of this agency shall wear protective gear in the home if the patient requests and/or based upon facility requirements." During an interview with Administrator A on 2/21/2022 at 2:49 PM, Administrator A was asked to provide the policy and procedures, tracking of Vaccination Status for employees, and tracking of the precautions implemented for exempted/unvaccinated staff. Administrator A stated "I called area hospitals and nursing homes to see how they are handling the staff who refused the COVID 19 Vaccine, they informed me they were using exemptions for unvaccinated staff." Administrator A provided document titled "Board of Directors Meeting" dated 1/17/2022 revealed in part "Old Business: COVID regulations were reviewed as it related to employee's exemptions brought forth by employees will be approved for employment. Administrator A stated "This is the best I can produce." During an interview with Administrator A on 2/21/2022 at 3:09 PM. Administrator A was asked what the requirement was for tracking of Exempted/unvaccinated staff. Administrator A stated "they are required to provide a negative COVID 19 test bi-weekly." Administrator A was asked to provide documentation of exempted/unvaccinated staff agency required negative testing. Administrator A provided paper copies of testing done for exempted/unvaccinated staff." During a review of agency documentation of exempted/unvaccinated staff, there were 10 employees that filed an exemption, of the 10 exempted employees, 6 had a documented negative COVID 19 test, however the testing provided was not in the last two-week period. Testing provided showed: CNA B last negative test was 11/1/2021, Registered Nurse C last negative test was 9/7/2021, Registered Nurse D no testing on file, Registered Nurse E- last negative test 1/8/2022, CNA F last negative test 1/10/2022, Registered Nurse G no testing on file, Nurse Practitioner H no testing on file, Social Worker I last negative test 10/11/2021, CNA J no testing on file, Social Worker K is exempt from testing for 90 days for a positive COVID 19 tested on 1/13/2022." Interview with Administrator A on 2/22/2022 at 9:52 AM, Administrator A asked what Infection Control guidelines the agency follows, Administrator A stated "the Visiting Nurse Association of America and for COVID 19 we use the CDC guidelines." During an observation on home visit for Patient #1 on 2/22/2022 at 9:05 AM with Registered Nurse E, Registered Nurse E who is documented as exempted from COVID 19 vaccine with the last documented negative COVID 19 test on file from 1/8/2022, entered and performed cares for Patient 1 without wearing a mask. During an observation on home visit for Patient #2 on 2/22/2022 at 7:45 AM with CNA J, CNA J who is documented as exempted from COVID 19 vaccine with no negative COVID 19 test on file, entered and performed cares for Patient 2 without wearing a mask. Interview with Administrator A on 2/22/2022 at 10:29 AM. Administrator A stated "I know we are doing COVID 19 testing at certain nursing home facilities, but you won't find further documentation of tracking or documentation of policy and procedures related to COVID 19 Vaccine."