Every finding on record at Hospice of Peace

Observed in Document Review. Interview with Leadership and review of the QAPI program/meeting minutes revealed no documented data since fourth quarter of 2023. Leadership shared the QAPI meeting was completed in April for first quarter with all the data and documentation given to the Quality Coordinator and not available to review at the time of this survey. This was reviewed, discussed, and validated with the Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted that the organization did not assess for potential medication related problems including adverse effects, drug reactions, significant side effects, and significant drug interactions, including ineffective drug therapy, duplicate drug therapy, and noncompliance with drug therapy. For example, during HV#3 the hospice nurse failed to conduct a medication assessment. She asked if there had been any changes to medications and discussed medication for pain that the patient used as needed, but did not complete an assessment of patient's medications.

Observed in Record Review. In 1 of 2 patient records reviewed, for bereavement services it was noted an initial bereavement assessment was not completed. For example, in RRBR#1 there was no documentation of an initial bereavement assessment. This was confirmed with the Administrator.

Observed in Record Review. In 2 of 10 patient records reviewed, it was noted that the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. For example, during record review HV#2 it was noted that the fall risk assessment was completed on admission and documented as high risk and the POC did not include related goals and interventions related to the fall risk. This patient record included documentation that the patient fell twice during one month following admission to hospice, was evaluated and there were no changes to the POC to include goals and interventions for falls. For example, during record review HV#3 it was noted that the fall risk assessment completed on admission documented high risk for falls and the POC did not include related goals and intervention for falls.

Observed in Data Session. During the Data session it was noted that the quality assessment and performance improvement program did not demonstrate improvement in the indicators related to improved palliative outcomes and hospice services. This was confirmed with the DPCS and Administrator present.

Observed in Data Session. During the Data session it was noted that the hospice did not use quality indicator data, including patient care and other relevant data, in the design of its quality assessment and improvement program. This was confirmed with the DPCS and Administrator present.

Observed in Data Session. During the Data session it was noted that the hospice did not use the results of data analysis to identify improvement opportunities. This was confirmed with the DPCS and Administrator present. Observed in Data Session. During the Data session it was noted that the hospice did not analyze and compare internal data over time to identify levels of performance, patterns, trends, and variations. This was confirmed with the DPCS and Administrator present.

Observed in Data Session. During the Data session it was noted that the hospice's governing body did not approve the frequency and detail of the data collection. This was confirmed with the DPCS and Administrator present.

Observed in Data Session. During the Data session it was noted that the hospice did not select performance improvement activities that affect palliative outcomes, patient safety, and the quality of care and that were based on the prevalence and severity of the problems in it's high volume, high risk areas. This was confirmed with the DPCS and Administrator present.

Observed in Data Session. During the Data session it was noted that the hospice did not collect data on adverse patient events. This was confirmed with the DPCS and Administrator present.

Observed in Data Session. During the Data session it was noted that the hospice did not act on improvement priorities. This was confirmed with the DPCS and Administrator present.

Observed in Data Session. During the Data session it was noted that performance improvement did not occur organization wide. This was confirmed with the Administrator and DPCS present. Observed in Data Session. During the Data session it was noted that as part of performance improvement, leaders did not delegate the following: - Set priorities for data collection, performance improvement activities, and patient health outcomes - Give priority to high-volume, high-risk, or problem-prone processes for performance improvement activities Note: Examples of areas of risk include blood-borne infections, wound care, undetected urinary tract infections, oxygen-related fires, and patient handoff to or from the home care organization. - Identify the frequency of data collection for performance improvement activities - Reprioritize performance improvement activities in response to changes in the internal or external environment This was confirmed with the Administrator and DPCS present.

Observed in Data Session. During the Data session if was noted that the organization had not maintained a written infection control program for the protection of patients, families, visitors, and staff and included surveillance, identification, prevention, control and investigation of infectious and communicable diseases. This was confirmed with the Administrator and DPCS present.

Observed in Data Session. During the Data session if was noted that the organization's written infection prevention did not include surveillance, to minimize, reduce or eliminate the risk of infection. This was confirmed with the Administrator and DPCS present. Observed in Patient Home. In 3 of 3 home visits conducted, it was noted that the organization did not implement infection prevention as planned. For example, during HV#1, #2 and #3 the nurses failed to perform hand hygiene consistent with the organization's Hand Hygiene policy. During HV#1 and HV#2 the nurse failed to perform hand hygiene after removing gloves greater than 2 times at each visit. During HV#3 the nurse performed hand hygiene at the appropriate times however each opportunity of performing hand hygiene, hand soap and water and sanitizer, was followed by the nurse shaking or waving her hands to completely dry them. Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not implement infection prevention and control activities when performing disinfection of medical supplies. For example, during home visits #1 and #2 the disinfectant manufacturer instructions for use were not followed as evidenced by: the nurse did not follow contact time (wet time) as specified in the Lysol wipe disinfectant manufacturer’s IFUs and packaging. For example, during HV#2 the blood pressure machine fell to the floor. The nurse picked it up placed it on the bed and continued performing vital signs without any cleaning or disinfecting of the machine after it was picked up off the floor.

Observed in Data Session. During the Data session if was noted that the organization did not implement infection prevention and control activities including surveillance, to minimize, reduce, or eliminate the risk of infection. This was confirmed with the Administrator and DPCS present.

Observed in Data Session. During the Data session if was noted that the organization's written infection prevention did not address its prioritized risks. This was confirmed with the Administrator and DPCS present. Observed in Data Session. During the Data session it was noted that the organization's written infection prevention did not include limiting the spread of infections associated with procedures. This was confirmed with the Administrator and DPCS present. Observed in Data Session. During the Data session it was noted that the organization's written infection prevention did not address improving compliance with hand hygiene guidelines. This was confirmed with the Administrator and DPCS present. Observed in Data Session. During the Data session it was noted that the organization's written infection prevention did not address limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was confirmed with the Administrator and DPCS present.

Observed in Tracer Activities. During discussion with the Volunteer Coordinator it was revealed that the organization did not have any active volunteers following the change of ownership 6 months ago and was unable to provide any documentation prior to the change of ownership. The organization was unable to provide documented efforts to recruit volunteers. This was discussed with the Volunteer Coordinator present.

Observed in Tracer Activities. During discussion with the Volunteer Coordinator it was revealed that the organization was not able to provide documented cost savings achieved through the use of volunteers following the change of ownership 6 months ago and was unable to provide any documentation of cost savings prior to the change of ownership. This was discussed with the Volunteer Coordinator present.

Observed in Tracer Activities. During discussion with the Volunteer Coordinator it was revealed that the organization did not have any active volunteers following the change of ownership 6 months ago and was unable to provide any documentation prior to the change of ownership. The organization was unable to provide documentation of an amount that equals 5% of the total patient care hours of all paid hospice employees and contract staff. This was discussed with the Volunteer Coordinator present.

Observed in Data Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by…condition level findings at 418.60, 418.60(b), 418.78, 418.100, 418.100(c)(1)(v), and 418.58.

Observed in HR File Review. During review of Human Resource files it was noted that the organization did not provide hospice aide services. For example, on the first day of survey during discussion the DPCS and Administrator stated that they did not currently have patients being seen by an aide, but they had in the past and had an aide available if needed. However, on the second day of survey during HR file review the DPCS and HR staff member stated they do not have an aide on staff and no contract with any aide service.

Observed in HR File Review. In 2 of 7 HR files reviewed, it was noted that staff competence was not initially assessed and documented as part of orientation. For example, in the Volunteer Coordinator file only 1 page of the 3 page competence document was completed with no signatures. For example, in the Medical Director's file there was no documentation of initial competence. This was discussed with the Office Manager and DPCS present.

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the medication list was inaccurate. For example, during HV#3 the LVN assessed the patient's pain and discussed the patient's pain with the caregiver. The caregiver reported that the patient used Tylenol as needed for pain and the medication list did not include Tylenol.

Observed in Tracer Activities. During contract review it was noted that the contract with a wound care company was not valid. The contract had typed names on the signature line and the organization was unable to provide a copy with signatures. This was confirmed with the Office Manager and DPCS present.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted that the nurse did not follow the organization's bag technique policy.  For example, the organization's policy Bag Technique included that the bag should not be placed on the patient's floor however during home visit #1 the nurse placed the bag on the kitchen floor while performing medication review.  This was discussed with the DPCS.

Observed in Patient Home. In 1 of 1 home visits conducted, During HV# 1's home observation it was noted the nurse did not follow the organization's bag technique policy No. 9-014 that included cleaning the blood pressure cuff in accordance with manufacturer's guideline. For example: The nurse was observed cleaning the automatic blood pressure cuff with an alcohol pad. Review of the manufacturer's guidelines revealed the equipment should be cleaned with a soft dry cloth only. This was reviewed, discussed, and validated with the alternate Administrator/DPCS.

Observed in Record Review. In 1 of 1 patient records reviewed with live discharge, During RR# 1's record review it was noted the organization had not ensured a written discharge summary was completed with a live discharge. For example: Review of RR# 1's record revealed no documentation of a discharge summary. This was reviewed, discussed, and validated with the alternate Administrator/Director of Patient Care Services.