Every finding on record at Hospice Care Partners, LLC

Observed in Tracer Activities. The organization did not protect the privacy of health information. During review of contracts it was noted that the pharmacy contract lacked a HIPAA Business Associate Agreement. This was confirmed by the Administrator.

Observed in Record Review. The written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. During review of patient records 1-14 it was noted that goals did not have measurable time frames. For example in record 1 goals for falls, and weight management had no time frame. This was confirmed by the administrator

Observed in Record Review. In 14 of 14 patient records reviewed, The organization did not provide the patient with care, treatment, or services according to the patient's individualized plan of care. During review of the aide plan of care created by the RN in records 1-14 it was noted that there were no frequencies for all of the tasks to be provided such as showers, clothing assist and denture care. This was confirmed by the Administrator.

Observed in Individual Tracer. The organization did not implement infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. During home visit 1 it was observed that the nurse cleaned his vital sign equipment with Sani-Wipes and placed the equipment directly back in the bag. The manufacturer's guidelines for the Sani-Wipes require a 3 minute dry time. This was confirmed by the Administrator. Observed in Individual Tracer. The organization did not reduce the risk of infections associated with medical equipment, devices, and supplies. During home visit 1 it was noted that the nurse initially placed his bag on a barrier which was placed on the floor. During the visit, the nurse removed the barrier from the bag and placed the bag directly on the floor. The nurse did not disinfect the bag before removing it from the home. This was confirmed by the Administrator.

Observed in HR File Review. In 2 of 5 HR files reviewed, Staff did not participate in ongoing education and training to maintain or increase their competency and, as needed, when staff responsibilities change. Staff participation is documented. During review of HR records 1 and 3 it was noted that there was no ongoing education documented for 2023. This was verified by the Administrator. Observed in HR File Review. In 2 of 5 HR files reviewed, Staff competence was not assessed and documented once every three years, or more frequently as required by organization policy or in accordance with law and regulation. During review of HR record 3 it was noted that there was no competency documented within the prior three year period. This was confirmed by the Administrator.

Observed in Emergency Management Session. During the Emergency Management system tracer, the surveyor found that the organization had not reviewed and revised the Emergency Operations Plan, including the communication plan at least every two years. The last review and revision documented was in 2017. This was discussed with the Administrator and Clinical Operations Manager.

Observed in Emergency Management Session. During the Emergency Management system tracer, the surveyor learned that the organization had not re-prioritized since 2017 the potential emergencies that could affect its ability to provide services. This was discussed with the Administrator and Clinical Operations Manager.

Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that the initial comprehensive assessment was not completed by all disciplines within five days of the election of the hospice benefit. In the records of HV#1 and HV#3 both the Spiritual Counselor and Social Worker did not document completion of this requirement within the allotted time frame. The same was true for the Spiritual Counselor in the record of RR#6. This was discussed with the Administrator and Clinical Operations Manager.

Observed in Record Review. In 11 of 11 patient records reviewed, it was noted that most patient goals in the plans of care were generic, and very few included specific, measurable, attainable, relevant, and/or timed outcomes. This was discussed with the Administrator and Clinical Operations Manager.

Observed in Data Session. The organization’s leaders did not have an effective, ongoing, organization-wide, data-driven quality assessment and performance improvement program. Leadership did not ensure that all relevant data was collected, aggregated, analyzed, and prioritized according to identified needs of patients and staff since 2018. This was discussed with the Administrator, Clinical Operations Manager and VP of Business Development.

Observed in Data Session. The organization’s leaders had not maintained organization-wide performance improvement since 2018. This was discussed with the Administrator, Clinical Operations Manager and VP of Business Development.

Observed in Infection Control System Tracer. The organization had not identified infection risks based on its geographic location, community, and population served since 2017. This was discussed with the Administrator and Clinical Operations Manager and VP of Business Development.

Observed in Leadership Session. The Governing Body did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: §418.58 and §418.100. This was discussed with the Administrator, Clinical Operations Manager and VP of Business Development.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization did not follow the process for Pre-Visit COVID-19 Screening outlined in their EMR. At HV#1 and HV#3 these assessments were not completed prior to patient visits. This was discussed with the Administrator and Clinical Operations Manager.