Every finding on record at Hospice De La Luz

Based on record review and interviews the facility failed to report money stolen from 1 (P[patient] 22) out of 1 (P22) patient reviewed for complaints. This failure to report is legally noncompliant with NMAC 8.370.9.8 Incident Management System Reporting Requirements for Licensed Health Care Facilities and may result in a loss of public trust. --- The findings are:A. Record review of the facility’s complaint log dated 11/20/2024, showed an entry stating P22 had accused S (staff)8, clinical, of using a debit card belonging to P22 to pay S8’s rent.B. During an interview on 07/14/2025 at 2:20 PM with S (staff)1, clinical, she stated she was advised by the facility’s human resources department not to report the incident involving P22 and S8 to the authorities or licensing agency for misappropriation of funds to law enforcement or the state.C. Record review of a legal document dated 09/29/2022 found in S8’s employee file showed an approved garnishment of wages (legal process that allows a creditor to collect money directly from a debtor’s wages). The creditor of the garnishment was an assisted living facility where S8 had previously been employed.  D. During an interview with S1 on 07/15/2025 at 4:30PM, S1 confirmed she was aware of the garnishment on S8 from the ALF. The legal paperwork was in S8’s personnel file. This incident was documented prior to the incident with P22 that occurred at the hospice agency. S1did not report this information to law enforcement or to the state.

Based on record reviews and interviews, the facility failed to ensure patient rights were protected. This failure resulted in money being stolen from 1 (P[patient] 22) out of 1 (P22) patients reviewed for complaints. --- The findings are:A Record review of the facility’s complaint log dated 11/20/2024, showed an entry stating P22 had accused S (staff) 8, clinical, of using a debit card belonging to P22 to pay S8’s rent.B. During an interview on 07/14/2025 at 2:20PM with S1, clinical, S1 was asked about the complaint involving S8 and P22. S1 stated the S22 reported a discrepancy on her bank account statement. S1 confirmed the patient alerted her after checking her bank statement and realizing there was money missing. S1 consulted with the human resources department and S8 was terminated. S1 stated she was advised by the human resources department not to notify the police or the state agency.C. Record review of a statement provided by S1, clinical, on 07/17/2025 it revealed that S8 confirmed, P22 paid her rent.

Based on record review and interview the facility failed to develop an individualized plan of care for 14 patients (P[patient]3, P4, P5, P9, P12, P14, P15, P16, P17, P18, P19, P20, P21, P23) out of 23 (P1-P23) patients reviewed for plan of care. This deficient practice could lead to patient’s not receiving the services they need based on patient’s goals at the end-of-life. --- The findings are:A. Refer to tag L546.B. Refer to tag L548.C. Record review of the patient’s plan of care for P3, P4, P5, P9, P12, P14, P15, P16, P17, P18, P19, P20, P21, and P23 revealed that all patients had the same interventions and goals for identified problems. The plan of care did not reflect the patient’s personal or stated goals.

Based on record review and interview the facility failed to develop a plan of care that included interventions to manage pain and symptoms for 14 (P[patient]3, P4, P5, P9, P12, P14, P15, P16, P17, P18, P19, P20, P21, P23) out of 23 (P1-P23) patients reviewed for plan of care. This deficient practice could lead to patient’s pain being uncontrolled at the end of life. --- The findings are:A. Record review of P3’s plan of care for start of care date 01/31/2025 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The interventions used for pain control were not included in the plan of care.B. Record review of P4’s plan of care for start of care date 12/05/2024 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The interventions used for pain control were not included in the plan of care.C. Record review of P5’s plan of care for start of care date 10/18/2024 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The interventions used for pain control were not included in the plan of care.D. Record review of P9’s plan of care for start of care date 09/15/2023 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The interventions used for pain control were not included in the plan of care.E. Record review of P14’s plan of care for start of care date 03/04/2025 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The interventions used for pain control were not included in the plan of care.F. Record review of P12’s plan of care for start of care date 08/24/2021 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The interventions used for pain control were not included in the plan of care.G. Record review of P15’s plan of care for start of care date 08/10/2023 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The interventions used for pain control were not included in the plan of care.H. Record review of P16’s plan of care for start of care date 05/21/2025 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The interventions used for pain control were not included in the plan of care.I. Record review of P17’s plan of care for start of care date 12/19/2024 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The interventions used for pain control were not included in the plan of care.J. Record review of P18’s plan of care for start of care date 01/15/2025 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The interventions used for pain control were not included in the plan of care.K. Record review of P19’s plan of care for start of care date 07/12/2024 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The interventions used for pain control were not included in the plan of care.L. Record review of P20’s plan of care for start of care date 07/30/2024 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The interventions used for pain control were not included in the plan of care.M. Record review of P21’s plan of care for start of care date 01/30/2025 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The interventions used for pain control were not included in the plan of care.N. Record review of P23’s plan of care for start of care date 12/14/2023 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The interventions used for pain control were not included in the plan of care.O. During an interview with S(staff)1, clinical, on 07/17/2025 at 12:34 PM it was explained that due to limitations in the charting system they are unable to add specifics to the plan of care.

Based on record review and interview the facility failed to develop a plan of care that was measurable for 14 (P[patient]3, P4, P5, P9, P12, P14, P15, P16, P17, P18, P19, P20, P21 and P23) out of 23 (P1-P23) patients reviewed for plan of care. This deficient practice could lead to unmet needs without goals being established, monitored and adjusted as needed. --- The findings are:A. Record review of P3’s plan of care for start of care date 01/31/2025 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”.  The goal stated, “Pain is currently managed at a level acceptable to patient.” There was no specific pain level goal or anticipated date that goal would be met for measuring/tracking patient’s pain. Reviewing the plan of care revealed that none of the problems or goals included a way to measure whether the patient was meeting the intended outcome.B. Record review of P4’s plan of care for start of care date 12/05/2024 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The goal stated, “Pain is currently managed at a level acceptable to patient.” There was no specific pain level goal or anticipated date that goal would be met for measuring/tracking patient’s pain. Reviewing the plan of care revealed that none of the problems or goals included a way to measure whether the patient was meeting the intended outcome.C. Record review of P5’s plan of care for start of care date 10/18/2024 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The goal stated, “Pain is currently managed at a level acceptable to patient.” There was no specific pain level goal or anticipated date that goal would be met for measuring/tracking patient’s pain. Reviewing the plan of care revealed that none of the problems or goals included a way to measure whether the patient was meeting the intended outcome.D. Record review of P9’s plan of care for start of care date 09/15/2023 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”.  The goal stated, “Pain is currently managed at a level acceptable to patient.” There was no specific pain level goal or anticipated date that goal would be met for measuring/tracking patient’s pain. Reviewing the plan of care revealed that none of the problems or goals included a way to measure whether the patient was meeting the intended outcome.E. Record review of P12’s plan of care for start of care date 08/24/2021 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The goal stated, “Pain is currently managed at a level acceptable to patient.” There was no specific pain level goal or anticipated date that goal would be met for measuring/tracking patient’s pain. Reviewing the plan of care revealed that none of the problems or goals included a way to measure whether the patient was meeting the intended outcome.F. Record review of P14’s plan of care for start of care date 03/04/2025 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”.  The goal stated, “Pain is currently managed at a level acceptable to patient.” There was no specific pain level goal or anticipated date that goal would be met for measuring/tracking patient’s pain. Reviewing the plan of care revealed that none of the problems or goals included a way to measure whether the patient was meeting the intended outcome.G. Record review of P15’s plan of care for start of care date 08/10/2023 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The goal stated, “Pain is currently managed at a level acceptable to patient.” There was no specific pain level goal or anticipated date that goal would be met for measuring/tracking patient’s pain. Reviewing the plan of care revealed that none of the problems or goals included a way to measure whether the patient was meeting the intended outcome.H. Record review of P16’s plan of care for start of care date 05/21/2025 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”.  The goal stated, “Pain is currently managed at a level acceptable to patient.” There was no specific pain level goal or anticipated date that goal would be met for measuring/tracking patient’s pain. Reviewing the plan of care revealed that none of the problems or goals included a way to measure whether the patient was meeting the intended outcome.I. Record review of P17’s plan of care for start of care date 12/19/2024 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The goal stated, “Pain is currently managed at a level acceptable to patient.” There was no specific pain level goal or anticipated date that goal would be met for measuring/tracking patient’s pain. Reviewing the plan of care revealed that none of the problems or goals included a way to measure whether the patient was meeting the intended outcome.J. Record review of P18’s plan of care for start of care date 01/15/2025 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The goal stated, “Pain is currently managed at a level acceptable to patient.” There was no specific pain level goal or anticipated date that goal would be met for measuring/tracking patient’s pain. Reviewing the plan of care revealed that none of the problems or goals included a way to measure whether the patient was meeting the intended outcome.K. Record review of P19’s plan of care for start of care date 07/12/2024 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The goal stated, “Pain is currently managed at a level acceptable to patient.” There was no specific pain level goal or anticipated date that goal would be met for measuring/tracking patient’s pain. Reviewing the plan of care revealed that none of the problems or goals included a way to measure whether the patient was meeting the intended outcome.L. Record review of P20’s plan of care for start of care date 07/30/2024 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The goal stated, “Pain is currently managed at a level acceptable to patient.” There was no specific pain level goal or anticipated date that goal would be met for measuring/tracking patient’s pain. Reviewing the plan of care revealed that none of the problems or goals included a way to measure whether the patient was meeting the intended outcome.M. Record review of P21’s plan of care for start of care date 01/30/2025 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”. The goal stated, “Pain is currently managed at a level acceptable to patient.” There was no specific pain level goal or anticipated date that goal would be met for measuring/tracking patient’s pain. Reviewing the plan of care revealed that none of the problems or goals included a way to measure whether the patient was meeting the intended outcome.N. Record review of P23’s plan of care for start of care date 12/14/2023 revealed the interventions for the problem of “Pain/Altered Comfort” stated, “Evaluated effectiveness of pain control measures”.  The goal stated, “Pain is currently managed at a level acceptable to patient.” There was no specific pain level goal or anticipated date that goal would be met for measuring/tracking patient’s pain. Reviewing the plan of care revealed that none of the problems or goals included a way to measure whether the patient was meeting the intended outcome..O. During an interview with S(staff)1, clinical, on 07/17/2025 at 12:34 PM it was explained that due to limitations in the charting system they are unable to add specifics such as pain level goals or anticipated dates to the plan of care.

Based on record review and observations during patient visits the hospice agency failed to follow accepted standards of practice to prevent the transmission of infection in 3 (P[patient] P3, P9, and P18) out of 4 (P3, P9, P12, P18)  patients observed during home visits. This failure could result in the transmission of disease-causing bacteria resulting in an infection in the patient. --- The Findings are:A. Record review of “Indwelling Urinary Catheter Insertion and Maintenance, (2024),” found at cdc.gov a recommendation to keep indwelling Foley drainage bag off the floor to maintain unobstructed urine flow.B. Record review of “Strategies to prevent catheter-associated urinary tract infections in acute care hospitals 2022 update, (2023)” found at nih.gov under heading “Management of indwelling catheters”, the following statement was found: “…b. “Do not place bag on floor.” c. “Keep the catheter and collecting tube free from kinking, which can impair urinary flow and increase stasis within the bladder, increasing infection risk…”C. Record review of Clinical Safety: “Hand Hygiene for Healthcare Workers (2024)” found at cdc.gov performing hand hygiene immediately before touching a patient was important in preventing the transmission of disease-causing bacteria.D. Record review of “Why should I clean my mobile device (2021)” found at gamahealthcare.com it stated mobile devices can become contaminated with pathogens and should be cleaned with disinfectant wipes after use.E. Record review of “Glove Usage Guideline: From the Joint Commission, CDC, and World Health Organization (2025)” found at infectioncontroltoday.com it stated gloves must be changed when moving from contaminated to clean tasks for the same patient because gloves can become contaminated and are not a substitute for hand hygiene.F. During an observation of home visit, 07/15/2025 at 10:00AM, S (Staff) 2, clinical, placed the indwelling urinary catheter drainage bag for P9 on the floor. S2 instructed caregiver staff to place the drainage bag on the floor.G. During an observation of home visit,07/16/2025 at 09:30AM, S (Staff) 9, clinical, did not perform hand hygiene before contact with P3. S9 used her tablet to document information during the home visit and then handed the tablet to P3 to sign without cleaning the device.H. During an observation of home visit, 07/16/2025 at 3:30PM, S2, clinical, removed a soiled dressing from P18 and did not change gloves before cleaning, packing the wound (the process of filling an open wound with a dressing), and applying a clean dressing.

Based on record review and interview the facility failed to have a policy in place and failed to educate patients on disposal of controlled drugs (substances that are regulated by law due to their potential for harm and abuse) for 14 (P[patient]3, P4, P5, P9, P12, P14, P15, P16, P17, P18, P19, P20, P21 and P23) out of 14 (P3 through P23) patients reviewed for education of drug disposal. This deficient practice could lead to improper disposal or mishandling of controlled drugs. --- The findings are:A. Record review of P3’s plan of care and start of care dated 01/31/2025 did not reveal education regarding the disposal of controlled substances.B. Record review of P4’s plan of care and start of care dated 12/05/2024 did not reveal education regarding the disposal of controlled substances.   C. Record review of P5’s plan of care and start of care dated 10/18/2024 did not reveal education regarding the disposal of controlled substances.D. Record review of P9’s plan of care and start of care dated 09/15/2023 did not reveal education regarding the disposal of controlled substances.  E. Record review of P14’s plan of care and start of care dated 03/04/2025 did not reveal education regarding the disposal of controlled substances.  F. Record review of P12’s plan of care and start of care dated 08/24/2021 did not reveal education regarding the disposal of controlled substances.G. Record review of P15’s plan of care and start of care dated 08/10/2023 did not reveal education regarding the disposal of controlled substances.H. Record review of P16’s plan of care and start of care dated 05/21/2025 did not reveal education regarding the disposal of controlled substances.I. Record review of P17’s plan of care and start of care dated 12/19/2024 did not reveal education regarding the disposal of controlled substances.J. Record review of P18’s plan of care and start of care dated 01/15/2025 did not reveal education regarding the disposal of controlled substances.K. Record review of P19’s plan of care and start of care dated 07/12/2024 did not reveal education regarding the disposal of controlled substances.  L. Record review of P20’s plan of care and start of care dated 07/30/2024 did not reveal education regarding the disposal of controlled substances.  M. Record review of P21’s plan of care and start of care dated 01/30/2025 did not reveal education regarding the disposal of controlled substances.  N. Record review of P23’s plan of care and start of care dated 12/14/2023 did not reveal education regarding the disposal of controlled substances.   O. During an interview on 07/15/2025 at 1:15 PM with S(staff)1, clinical, it was confirmed that staff do not provide education to patients or their families regarding medication disposal.

Based on record review and interview the facility failed to meet the Condition of Participation to ensure nursing personnel were licensed by the New Mexico Nursing Practice Act 61-3-5. This deficient practice led to patient’s receiving skilled nursing services from an individual that did not hold a valid nursing license. --- The findings are:A. Refer to tag L784.

Based on record review and interview the facility failed to ensure personnel were licensed as required by the New Mexico Nursing Practice Act 61-3-5 for 1 (S[staff] 10) out of 3 (S2, S3, and S10) staff members reviewed for nursing licensure. This deficient practice led to patient’s receiving skilled nursing services from an individual that did not hold a valid nursing license. --- The findings are:A. Record review of the “New Mexico Nursing Practice Act” under “61-3-5 License Required” it stated, “Except as otherwise provided in the Nursing Practice Act, no person shall use the title ‘nurse’ unless the person is licensed or has been licensed in the past as a registered nurse or licensed practical nurse under the Nursing Practice Act.”B. Record review of S10’s employee file, revealed the following:C. Review of resume for S10 revealed she has been employed in New Mexico since 2014 and has worked as a nurse in New Mexico since 2020. S10 started at the facility on 06/23/2025.D. Record review of S’10’s personnel file revealed a license verification report dated 06/19/2025 that showed an active license for Texas. The active license for Texas indicated that it was a compact license (type of nursing license that allows nurses to work in various states right away without having to wait for a license in one of the allowed states). It was revealed this license did not belong to S10.E. Record review of P21’s visit dated 07/10/2025 revealed that S10 conducted a “SN [skilled nursing] Hospice Subsequent Visit” and performed an assessment and provided education to caregiver regarding medication, pain management and patient care.1. On 07/14/2025 conducted a “RN [registered nurse] Subsequent Visit” and performed an assessment, foley catheter care and flushed the foley catheter, and provided education to facility staff regarding medication, pain management and patient care.F. Record review of P24’s visit dated 07/15/2025 revealed that S10 conducted a “RN Hospice Subsequent Visit” and performed an assessment, adjusted oxygen prescription, provided education to facility staff regarding medication and patient care.G. Record review of P25’s visit dated 07/09/2025 revealed that S10 conducted a “RN Hospice Subsequent Visit” and performed an assessment, provided education to patient regarding medication, and called in medication refills to the pharmacy.H. Record review of P26’s visits dated 07/08/2025, 07/11/2025, and 07/15/2025 revealed that S10 conducted a “RN Hospice Subsequent Visit” and performed an assessment and provided education to facility staff regarding medication and patient care.I. Record review of P28’s visit dated 07/09/2025 revealed that S10 conducted a “SN Hospice Subsequent Visit” and performed an assessment, called in medication refills to the pharmacy, and provided education to caregiver regarding patient care.J. Record review of P28’s visit dated 07/08/2025 revealed that S10 conducted a “SN Hospice Subsequent Visit” and performed an assessment, provided provider with medication adjustment recommendations and took the verbal order from the provider, and provided education to facility staff regarding medication and patient care.1. Review of a coordination note dated 07/10/2025 revealed that S10 was involved in a care planning meeting at the patient’s place of residence with patient, patient’s sister, house manager, volunteer coordinator, and physician. At this care planning meeting S10 discussed medication changes and received medication orders from the physician.2. On visit dated 07/11/2025 S10 conducted a “RN Hospice Subsequent Visit” and performed an assessment, received new orders from provider, performed medication reconciliation at the facility and provided education to facility staff.K. Record review of P29’s visit dated 07/08/2025 revealed that S10 conducted a “RN Hospice Subsequent Visit” and performed an assessment, provided recommendations on medication adjustments and received orders from the provider, called in medication refills to the pharmacy, and provided education to caregiver regarding medication education patient care.1. Review of a coordination note dated 07/09/2025 revealed that S10 contacted the provider regarding medication interactions.2. Review of a coordination note dated 07/10/2025 revealed that S10 was involved a care planning meeting at the patient’s place of residence with patient, patient’s daughter, house manager, volunteer, hospice licensed practical nurse, and volunteer coordinator. At this care planning meeting S10 discussed medication changes, pain management and received medication orders from the physician.3. On 07/10/2025 S10 conducted an “RN Hospice Subsequent Visit” and performed an assessment, placed an order for an oxygen concentrator, and called in medication refills to the pharmacy.4. On 07/15/2025 S10 conducted a “RN Hospice Subsequent Visit” and performed an assessment and provided education to facility staff regarding patient care.K. Record review of P30’s visit dated 07/08/2025, 07/14/2025 revealed that S10 conducted a “RN Hospice Subsequent Visit” and performed an assessment and provided education to facility staff regarding pain management and patient care.1. On visit dated 07/14/2025 S10 conducted a “RN Hospice Subsequent Visit” and performed an assessment, called in medication refills to the pharmacy, contacted the provider regarding medication management, medication interactions and pain management. S10 also provided education to facility staff regarding medication, pain management, and patient care.2. Review of coordination note date 07/15/2025 S10 placed an additional call the provider regarding medication interactions.L. During an interview with S1, clinical, on 07/17/2025 at 2:00 PM it was explained that initially they did have trouble verifying S10’s license but were able to verify that there was an active license in Texas and S10 had told the facility that her license was under that name. S10 told the facility it was a maiden name. The facility failed to verify the information provided by S10. M. During an interview with S12, staff of licensing authority, on 07/17/2025 at 2:15 PM it was confirmed that the individual that held the nursing license had a different date of birth than S10.

Based on observation, record review, and interview the facility failed to ensure all patient care was provided in accordance with the patients Hospice Plan of Care for 1 (P[patient]5) out of 3 (P3-P6) patients being reviewed. This deficient practice could possibly lead to patients hospice needs being unmet. --- The findings are: A. Record review of the facilitys policy titled ";Plan of Care Process" dated 09/01/24 stated ";All hospice care and services furnished to patients and their families will follow an individualized written POC (plan of care) . . . B. Record review of P5s medical record under the section plan of care with the date of 09/25/2024 through 11/23/2024 revealed a care plan that stated ";Hospice Skilled Nurse to insert/maintain indwelling catheter (a tube that is inserted in the bladder). Skilled Nurse to change foley every 30 days and may irrigate (push normal saline into the foley to clear blockage) the foley with 60 milliliters of normal saline as needed. C. During an observation of P5s home visit on 10/29/2024 at 10:15 am to 10:50 am S [staff] 5 (clinical) emptied the indwelling foley bag (a bag at the end of the indwelling foley to collect the urine) of urine. S5 did not change the indwelling foley at this time. D. During an interview on 10/29/2024 at 10:55 am, S2 (clinical) was asked when the indwelling foley catheter was going to be changed, S2 stated ";I dont change it the patient is taken to a urologist (a medical doctor who specializes in diagnosing and treating conditions that affect the urinary tract and reproductive system) for the indwelling foley to be changed. S2 was asked to look at the care plan and S2 confirmed that the care for P5 stated the skilled nurse was to change the foley. E. During an interview on 10/29/2024 at 1:00 pm S1 (non-clinical) confirmed the care plan printed was the current plan of care and should be followed as written.

Based on document review and interview, the hospice agency did not establish a comprehensive emergency prepared program (EPP.) The hospice did not have 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: 1. The hospice agency has no documentation of any of the components of an EPP (See E0004). 2. 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). 3. 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). 4. The hospice agency did not have documentation of emergency preparedness training ever being completed (See E0037)

Based on record review and interview, the hospice agency failed to develop an Emergency Preparedness Program (EPP). Failure to create an EPP has 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: A. Record Review of the hospice agency's Emergency Preparedness Binder finds their plan is a generic emergency plan that was printed and placed in the binder. It is not site/community specific. B. During an interview on 07/21/22 at 10:24 am, the Administrator stated the documentation the agency had related to emergency preparedness was in the Emergency Preparedness Binder, The Administrator agreed that the plan was not site/community specific.

Based on document review and interview, the hospice facility failed to develop a communication plan that included names and contact information for hospice employees, entities providing services under arrangement, patients' physicians, and other hospices. The failure to not have a communication procedure in place could delay needed assistance for all the agency hospice patients. Findings include: A. During the entrance meeting on 07/20/22, the hospice emergency preparedness program (EPP) documentation was requested. By the time of the exit conference on 07/21/22 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. B. During an interview on 07/21/22 at 10:24 am, the Administrator stated she had a list of staff members that would be the "emergency phone tree". The Administrator further stated that she would email me the list. The list has not been emailed to the state surveyors.

Based on document review and interview, the hospice facility failed to develop a communication plan that included names and contact information federal, state, tribal, regional, and local emergency preparedness staff. The failure to not 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: A. During the entrance meeting on 07/20/22, the hospice emergency preparedness program (EPP) documentation was requested. By the time of the exit conference on 07/21/22 no documentation was presented that included a list of the names and contact information for federal, state, tribal, regional, and local emergency officials. B. During an interview on 07/21/22 at 10:24 am, the Administrator stated the hospice agency did not have a list of the names and contact information for federal, state, tribal, regional, and local emergency officials.

Based on policy record 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 not train staff on emergency procedures has 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: A. Record Review of the undated hospice agency emergency preparedness plan states that all new and existing staff, individuals providing services and volunteers will have emergency preparedness training at least annually. B. During an interview on 07/21/22 at 10:24 am, the Administrator confirmed there was no documentation of staff training.

Based on record review and interview, the hospice failed to meet the Condition of Participation for Quality Assessment & Performance Improvement (A data driven proactive approach to quality improvement). The findings are: 1. Hospice failed to develop, implement and maintain an effective, ongoing (continuous and periodic collection and analysis of data) Quality Assessment Performance Improvement (QAPI) program. (See L560) 2. The hospice failed to measure, analyze and track quality indicators including adverse patient events and other aspects of performance. (See L562) 3. The hospice failed to use data to monitor effectiveness, safety and quality of care and identify opportunities for improvement. (See L 564) 4. The hospice failed to take actions aimed at performance improvement and track to ensure improvements are sustained (See L 570) 5. The hospice must document what Performance Improvement Projects (PIPs) are being done, the reason for the PIP and progress toward achieving PIP goals. (See L 573) 6. The hospice failed to include a quality surveillance, identification, prevention, control, and investigation of infectious and communicable diseases as an integral part of the hospice's QAPI program. (See L580)

Based on record review and interview, the agency failed to ensure that a hospice-wide Quality Assessment and Performance Improvement (QAPI) program was comprehensive. The hospice did not incorporate the core services (physician services, medical social services, counseling services, bereavement and spiritual services) or the non-core services (physical and occupational therapy) into the agency's quality assessment and performance improvement program. The program further failed to include evaluation of hospice aides and volunteer services. The findings are: A. Record review of the provided minutes of the facility QAPI meeting was undated and labeled as: "NEW CQI [Continuous Quality Improvement] WE ARE FOLLOWING FOR 2022" The following items were listed "In 2022-we will focus on obtaining 100% compliance with the new format/requirements for Volunteer personnel files" "In 2022-we will focus on obtaining 100% compliance with the new format/requirements for Employee personnel files" "In 2022-we will focus on maintain our Bereavement program...we will focus on maintain our Bereavement program with monthly audits. We will ensure compliance with pre and post Bereavement assessments" "In 2022-we will focus on providing our staff with the required 12 hours of education...." "In 2022 we will utilize a new tool when looking to discharge patient's due to ineligibility" "In 2022 we will be focusing on increasing our Hospice Level Quality measures. All patients will have pain POC open" "In 2022 we will continue to monitor 23, 38 and 72 hour pain assessments" "In 2022 we will continue to track complaints, incidents, falls, infections and wounds" "in 2022 will be tracking to ensure all physician orders are signed due to the new process with HCHB" "In 2022 we will continue to Volunteer calls to new admissions" "In 2022 we will discuss verbiage used by staff to ensure we are meeting pt/families needs...i.e. 'what is your greatest need today'." "In 2022 we continue to track team effective communication and easiest most efficient ways to communicate with staff members without overlapping and/or being redundant" "In 2022 we will utilize the information and graphs in the new 3rd party survey program. Information will be shared with the staff and we will use the information to formulate CQI measures to enhance patient care and patient and family satisfaction" B. On 07/20/24 at 10:24 am during interview with Administrator (ADM) she provided the CQI document. She stated the Hospice had a general board meeting in early January 2022 during which QAPI was discussed. She stated this document was the minutes of that meeting. She stated she had no specific notes of the QAPI concerns. She stated since the January meeting she has accumulated incident reports and other data but she has not compiled any notes or numbers to analyze this data. She stated she had no specific written plans for the QAPI concerns. C. On 07/21/22 at 8:58 am during interview with ADM stated "we aren't into meetings just yet." She stated there were no minutes specific to the QAPI team. She stated the CQI document contained both board concerns and QAPI concerns. She stated the document did not specifically identify those items that were discussed as QAPI concerns.

Based on record review and interview, the agency failed to measure, analyze, and track quality indicators and other aspects of performance as part of their performance improvement program. This failed practice has the potential to affect all patients currently being served by not ensuring improved hospice performance and improved palliative outcomes. The findings are: A. Record review of the provided minutes of the facility Quality Assessment and Performance Improvement (QAPI) meeting was undated and labeled as: "NEW CQI [Continuous Quality Improvement] MEASURES WE ARE FOLLOWING FOR 2022" The following items were listed "In 2022-we will focus on obtaining 100% compliance with the new format/requirements for Volunteer personnel files" "In 2022-we will focus on obtaining 100% compliance with the new format/requirements for Employee personnel files" "In 2022-we will focus on maintain our Bereavement program...we will focus on maintain our Bereavement program with monthly audits. We will ensure compliance with pre and post Bereavement assessments" "In 2022-we will focus on providing our staff with the required 12 hours of education...." "In 2022 we will utilize a new tool when looking to discharge patient's due to ineligibility" "In 2022 we will be focusing on increasing our Hospice Level Quality measures. All patients will have pain POC open" "In 2022 we will continue to monitor 23, 38 and 72 hour pain assessments" "In 2022 we will continue to track complaints, incidents, falls, infections and wounds" "in 2022 will be tracking to ensure all physician orders are signed due to the new process with HCHB" "In 2022 we will continue to Volunteer calls to new admissions" "In 2022 we will discuss verbiage used by staff to ensure we are meeting pt/families needs...i.e. 'what is your greatest need today'." "In 2022 we continue to track team effective communication and easiest most efficient ways to communicate with staff members without overlapping and/or being redundant" "In 2022 we will utilize the information and graphs in the new 3rd party survey program. Information will be shared with the staff and we will use the information to formulate CQI measures to enhance patient care and patient and family satisfaction" B. On 07/21/22 at 11:38 am during interview with Administrator (ADM) she stated that the Hospice executive board had met in early January 2022 and during this meeting a review of the QAPI committee had occurred. She stated that since this meeting she had begun to gather data from various sources. She stated she had no current measure, analysis or tracking of data to review.

Based on record review and interview, the agency failed to identify opportunities and priorities for improvement. This failed practice could result in the hospice's inability to effectively meet its patients' palliative needs. The findings are: A. Record review of the provided minutes of the facility QAPI meeting was undated and labeled as: "NEW CQI [Continuous Quality Improvement] MEASURES WE ARE FOLLOWING FOR 2022" The following items were listed "In 2022-we will focus on obtaining 100% compliance with the new format/requirements for Volunteer personnel files" "In 2022-we will focus on obtaining 100% compliance with the new format/requirements for Employee personnel files" "In 2022-we will focus on maintain our Bereavement program...we will focus on maintain our Bereavement program with monthly audits. We will ensure compliance with pre and post Bereavement assessments" "In 2022-we will focus on providing our staff with the required 12 hours of education...." "In 2022 we will utilize a new tool when looking to discharge patient's due to ineligibility" "In 2022 we will be focusing on increasing our Hospice Level Quality measures. All patients will have pain POC open" "In 2022 we will continue to monitor 23, 38 and 72 hour pain assessments" "In 2022 we will continue to track complaints, incidents, falls, infections and wounds" "in 2022 will be tracking to ensure all physician orders are signed due to the new process with HCHB" "In 2022 we will continue to Volunteer calls to new admissions" "In 2022 we will discuss verbiage used by staff to ensure we ar meeting pt/families needs...i.e. 'what is your greatest need today'." "In 2022 we continue to track team effective communication and easiest most efficient ways to communicate with staff members without overlapping and/or being redundant" "In 2022 we will utilize the information and graphs in the new 3rd party survey program. Information will be shared with the staff and we will use the information to formulate CQI measures to enhance patient care and patient and family satisfaction" B. Record review of the document labeled CQI does not identify those items that are to be reviewed by the QAPI program and it does not prioritize any items that might be considered as QAPI topics. C. On 07/20/22 at 10:24 am during interview with Administrator (ADM) she provided the document labeled as CQI and stated the document was a minute of a board meeting completed in early January 2022. She stated the document contained QAPI items.

Based on record review and interview, the agency failed to take actions aimed at performance by not measuring and tracking performance improvements to determine that improvments are sustained throughout the Quality Assessment and Performance Improvement (QAPI) program. This failed systemic practice could result in the agency's inability to ensure patients' safety. The findings are: A. Record review of the provided minutes of the facility QAPI meeting was undated and labeled as: "NEW CQI [Continuous Quality Improvement] MEASURES WE ARE FOLLOWING FOR 2022" The following items were listed "In 2022-we will focus on obtaining 100% compliance with the new format/requirements for Volunteer personnel files" "In 2022-we will focus on obtaining 100% compliance with the new format/requirements for Employee personnel files" "In 2022-we will focus on maintain our Bereavement program...we will focus on maintain our Bereavement program with monthly audits. We will ensure compliance with pre and post Bereavement assessments" "In 2022-we will focus on providing our staff with the required 12 hours of education...." "In 2022 we will utilize a new tool when looking to discharge patient's due to ineligibility" "In 2022 we will be focusing on increasing our Hospice Level Quality measures. All patients will have pain POC open" "In 2022 we will continue to monitor 23, 38 and 72 hour pain assessments" "In 2022 we will continue to track complaints, incidents, falls, infections and wounds" "in 2022 will be tracking to ensure all physician orders are signed due to the new process with HCHB" "In 2022 we will continue to Volunteer calls to new admissions" "In 2022 we will discuss verbiage used by staff to ensure we are meeting pt/families needs...i.e. 'what is your greatest need today'." "In 2022 we continue to track team effective communication and easiest most efficient ways to communicate with staff members without overlapping and/or being redundant" "In 2022 we will utilize the information and graphs in the new 3rd party survey program. Information will be shared with the staff and we will use the information to formulate CQI measures to enhance patient care and patient and family satisfaction" B. On 07/20/22 at 10:24 am during interview with Administrator (ADM) she stated she had several items she was reviewing for QAPI and that she had gathered incident reports and other data. She stated she had not gathered this data into any measurable format to indicate that the QAPI items were being monitored or where showing improvement.

Based on record review and interview, the agency failed to document any performance improvement projects being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects for the quality assessment and performance improvement (QAPI) program. This failed systemic practice could result in the agency's inability to ensure patients' safety. The findings are: A. Record review of the provided minutes of the facility QAPI meeting was undated and labeled as: "NEW CQI [Continuous Quality Improvement] MEASURES WE ARE FOLLOWING FOR 2022" The following items were listed "In 2022-we will focus on obtaining 100% compliance with the new format/requirements for Volunteer personnel files" "In 2022-we will focus on obtaining 100% compliance with the new format/requirements for Employee personnel files" "In 2022-we will focus on maintain our Bereavement program...we will focus on maintain our Bereavement program with monthly audits. We will ensure compliance with pre and post Bereavement assessments" "In 2022-we will focus on providing our staff with the required 12 hours of education...." "In 2022 we will utilize a new tool when looking to discharge patient's due to ineligibility" "In 2022 we will be focusing on increasing our Hospice Level Quality measures. All patients will have pain POC open" "In 2022 we will continue to monitor 23, 38 and 72 hour pain assessments" "In 2022 we will continue to track complaints, incidents, falls, infections and wounds" "in 2022 will be tracking to ensure all physician orders are signed due to the new process with HCHB" "In 2022 we will continue to Volunteer calls to new admissions" "In 2022 we will discuss verbiage used by staff to ensure we are meeting pt/families needs...i.e. 'what is your greatest need today'." "In 2022 we continue to track team effective communication and easiest most efficient ways to communicate with staff members without overlapping and/or being redundant" "In 2022 we will utilize the information and graphs in the new 3rd party survey program. Information will be shared with the staff and we will use the information to formulate CQI measures to enhance patient care and patient and family satisfaction" B. On 07/21/22 at 11:38 am during interview with the Administrator (ADM) she was asked to provide any written plans in progress (PIP). She stated she had no such written plans to provide. She stated that the Hospice was planning an upcoming meeting in late July 2022 at which the QAPI program would be discussed. She stated she was uncertain what this meeting would discuss. She stated they would probably discuss bereavement, falls, infections. She stated that these items were not PIPs.

Based on record review and interview, the Hospice failed to incorporate their infection control program with the quality assessment and performance improvement (QAPI) program. This failed practice could likely result in infections and communicable diseases to go unnoticed, causing unnecessary illness for patients, families/friends and staff. The findings are: A. Record review of the provided minutes of the facility QAPI meeting was undated and labeled as: "NEW CQI [Continuous Quality Improvement] MEASURES WE ARE FOLLOWING FOR 2022" The following items were listed "In 2022-we will focus on obtaining 100% compliance with the new format/requirements for Volunteer personnel files" "In 2022-we will focus on obtaining 100% compliance with the new format/requirements for Employee personnel files" "In 2022-we will focus on maintain our Bereavement program...we will focus on maintain our Bereavement program with monthly audits. We will ensure compliance with pre and post Bereavement assessments" "In 2022-we will focus on providing our staff with the required 12 hours of education...." "In 2022 we will utilize a new tool when looking to discharge patient's due to ineligibility" "In 2022 we will be focusing on increasing our Hospice Level Quality measures. All patients will have pain POC open" "In 2022 we will continue to monitor 23, 38 and 72 hour pain assessments" "In 2022 we will continue to track complaints, incidents, falls, infections and wounds" "In 2022 will be tracking to ensure all physician orders are signed due to the new process with HCHB" "In 2022 we will continue to Volunteer calls to new admissions" "In 2022 we will discuss verbiage used by staff to ensure we are meeting pt/families needs...i.e. 'what is your greatest need today'." "In 2022 we continue to track team effective communication and easiest most efficient ways to communicate with staff members without overlapping and/or being redundant" "In 2022 we will utilize the information and graphs in the new 3rd party survey program. Information will be shared with the staff and we will use the information to formulate CQI measures to enhance patient care and patient and family satisfaction" B. Record review of the document labeled CQI measures failed to reveal any documentation or indication of any review of an infection control program that was being reviewed by QAPI. C. On 07/20/22 at 10:24 am during interview with administrator ADM she provided the document labeled CQI measures and stated this was minutes from a board meeting conducted in early January 2022. She stated this document contained the Hospice minutes of their last QAPI meeting.