Every finding on record at Keck Enterprises LLC

Based on document review and interview, the hospice agency failed to conduct exercises to test the emergency preparedness plan annually. Failure to conduct a community-based exercise, mock disaster drill, tabletop, or facility-based functional exercise has the potential to delay the agency's ability to respond effectively to meet the needs of the 100 hospice patients in an emergency. Findings include: Review of the "Emergency Preparedness" binder revealed the agency failed to document any testing of the emergency preparedness plan. During an interview on 04/12/22 at 3:00 PM, the Executive Director confirmed the agency did not have documentation of a community-based exercise, mock disaster drill, tabletop, or functional exercise having been completed at any time.

Based on review of Quality Assessment and Performance Improvement (QAPI) documentation, policy review, and interview, the hospice agency failed to analyze patient infection data and fall data. The failure to analyze the data had the potential to miss opportunities to improve patient outcomes for the 100 patients receiving hospice care. Findings include: Review of the hospice agency's "Hospice QAPI Meeting Minutes," for the review time period including 10/01/21 to 12/31/21, showed the agency did track the number of patient infections and aggregated the data according to location of infection and known COVID-19 infections. The QAPI meeting minutes did not include staff reported infections or an analysis of the infection data which would identify trends and potential opportunities for improvement. The hospice meeting minutes also included the number of patient falls occurring in October, November, and December. There was no analysis of the patient fall data to identify possible contributing factors. Review of the hospice agency policy titled, "Quality Assessment and Performance Improvement (QAPI) Plan," revised November 2020, revealed, "Objectives ... To measure, analyze and track quality indicators including adverse events, to enable the assessment of processes of care, hospice services and operations ... The QAPI Coordinator chairs the QAPI Committee and is responsible for coordinating and facilitating all quality improvement activities. This includes, but is not limited to: ... Aggregating, trending, and analyzing data using appropriate statistical techniques ..." During an interview on 04/14/22 at 10:15 AM, the QAPI/Complaints staff person, who was designated as responsible for the QAPI program, confirmed that the "Hospice QAPI Meeting Minutes" included tracking of patient data and that no analysis of the data was present.