Every finding on record at Los Alamos Visiting Nurse Service Hospice

Based on record review and interview the hospice failed to meet the Condition of Participation by not maintaining an emergency preparedness program. This deficient practice could cause delays in the hospices response to emergency and disaster situations for all patients. --- The findings are: A. The hospice failed to develop an emergency response to include all risks identified in the ";Hazard Vulnerability Analysis"(identify potential emergencies, for locations within the organization/facility and the community). Refer to Tag E-0006. B. The hospice failed to develop a process for collaboration with local, tribal, regional, state, and federal emergency preparedness officials to maintain an integrated response during a disaster or emergency. Refer to Tag E-0009. C. The hospice failed to have an emergency preparedness communication plan. Refer to Tag E-0029. D. The hospice failed to provide education and instruction in emergency preparedness for staff and failed to fulfill testing and training requirements for the emergency preparedness program. Refer to Tag E-0036.

Based on interview and record review the hospice agency failed to review and update their emergency preparedness plan every two years. This deficient practice could affect all patients of the hospice during an emergency due to delays in emergency management response and outdated information. --- The findings are: A. Record review of the agencys emergency preparedness policies and procedures titled ";Disaster Plan," revealed the there was no date of updates or review of the plan. B. During an interview on 06/05/24 at 4:00 pm with Staff (S)1 Administrator, S1 confirmed that the ";Disaster Plan" has not been reviewed or updated every two years.

Based on interview and record review the hospice agency failed to address risks identified on the ";Hazard Vulnerability Analysis." (identify potential emergencies, for locations within the organization/facility and the community) This deficient practice could cause delays in the emergency response for all patients of the hospice. --- The findings are: A. Record review of the emergency preparedness document ";Hazard Vulnerability Analysis", dated 01/04/2022, revealed the identified risk: ";nuclear [a nuclear threat is related to a nuclear reaction that causes the nuclei to be split or combined and causes an explosion or exposure to deadly radiation] /biohazard [a threat related to bacteria, viruses, parasites, molds or fungi that pose a threat to human health]-[name of outside entity] The risk of a nuclear or biohazard emergency event related to the nearby entity a local government research facility, was not addressed. B. Record review of the agencys undated emergency preparedness policies and procedures titled ";Disaster Plan", revealed it did not address a response to the identified ";nuclear/biohazard-[name of outside entity]" as a risk. C. During an interview on 06/05/24 at 4:00 pm with Staff (S)1 Administrator, S1 confirmed that the ";Disaster Plan" did not address all the identified risks on the ";Hazard Vulnerability Analysis."

Based on an interview the hospice agency failed to include a process for collaboration with local, tribal, regional, state, and federal emergency preparedness officials to maintain an integrated (Consisting of different groups or people) response during a disaster or emergency. This deficient practice could cause delays in the emergency response for all patients of the hospice agency. --- The findings are:A. During an interview on 06/06/24, at 11:53 am with Staff (S)1 Administrator, S1 confirmed that there was no documented process for collaboration with local, tribal, regional, state, and federal emergency preparedness officials to maintain an integrated disaster or emergency response in the emergency preparedness plan.

Based on interview and record review the hospice agency failed to have a procedure to follow up with on-duty staff and patients in the event of an emergency or interruption of utility services (electricity, gas, water); the agency failed to have a procedure to inform state and local officials of any on-duty staff or patients that they are unable to contact. This deficient practice could likely cause a delay in the emergency response for all patients of the hospice agency. --- The findings are: A. Record review of the agencys undated emergency preparedness policies and procedures titled ";Disaster Plan," revealed no procedures to follow up with on duty staff and patients in the event of an emergency or interruption of services; and to inform state and local officials of any on-duty staff or patients that they are unable to contact. B. During an interview on 06/06/24, at 11:53 am with Staff (S)1 Administrator, S1 confirmed that there are no documented procedures to follow up with on duty staff and patients in the event of an emergency or interruption of services; and to inform state and local officials of any on-duty staff or patients that they are unable to contact.

Based on interview and record review the hospice agency failed to have a policy and procedure that provides for a means to shelter in place for patients, staff, and volunteers who remain in the facility. This deficient practice could likely cause patients, staff and volunteers to have preventable exposure to emergency situations that requires shelter --- The findings are: A. Record review of the agencys undated emergency preparedness policies and procedures titled ";Disaster Plan," revealed no means for a shelter in place for patients, staff, and volunteers who remain in the facility. B. During an interview on 06/05/24, at 4:00 pm with Staff (S)1 Administrator, S1 confirmed that there is no policy and procedure for a shelter in place for patients, staff, and volunteers who remain in the facility.

Based on interview and record review the hospice agency failed to have a policy and procedure that addresses the use of employees in an emergency, including the process and rule for integration of state and federally designated health care professionals to address needs during an emergency. This deficient practice could cause a delay in emergency response for all patients of the hospice agency. --- The findings are: A. Record review of the agencys undated emergency preparedness policies and procedures titled ";Disaster Plan," revealed no policy or procedure that addresses the use of employees in an emergency or to address surge needs during an emergency. B. During an interview on 06/05/24 at 4:00 pm with Staff (S)1 Administrator, S1 confirmed that there is no policy or procedure that addresses the use of employees in an emergency or to address surge needs during an emergency.

Based on interview and record review the hospice agency failed to have a policy and procedure that addresses the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act. This deficient practice could lead to delays in emergency response for all patients of the hospice agency. --- The findings are: A. Record review of the agencys undated emergency preparedness policies and procedures titled ";Disaster Plan," revealed no policy and procedure that addresses the facilitys role under a waiver declared by the Secretary, in accordance with section 1135 of the Act. B. During an interview on 06/05/24, at 4:00 pm with Staff (S)1 Administrator, S1 confirmed that the agency did not have a policy and procedure that addresses the facilitys role under a waiver declared by the Secretary, in accordance with section 1135 of the Act.

Based on record review and interview the facility failed meet the condition for participation by failing to have an accurate emergency preparedness communication plan in place. This deficient practice is likely to lead to miscommunication or no communication in the event of an emergency. --- The findings are: A. Record review of the agencys undated emergency preparedness policies and procedures titled ";Disaster Plan," revealed no communication plan; and a document titled ";Emergency Phone Numbers" listed phone numbers for (Name of outside state) and federal offices, (Name of outside State) and (Name of outside City) Federal Bureau of Investigation Offices. There were no State of New Mexico, (Name of County) (name of town) emergency telephone numbers. B. During an interview on 06/05/24 at 4:00 pm with Staff (S)1 Administrator, S1 confirmed that there is no emergency preparedness communication plan.

Based on interview and record review the hospice agency failed to have an emergency preparedness communication plan that included the names and contact information for hospice employees, patients physicians, or volunteers. This deficient practice could likely lead to a delay in the emergency response for all patients of the hospice agency. --- The findings are: A. Refer to Tag E-0029

Based on interview and record review the hospice agency failed to maintain an emergency preparedness communication plan that included contact information for federal, state, tribal, regional, and local emergency preparedness staff, and other sources of assistance. This deficient practice could likely lead to a delay in the emergency response for all patients of the hospice agency. --- The findings are: A. Refer to Tag E-0029

Based on record review and interview the hospice agency failed to provide education and instruction in the emergency preparedness program for staff; and failed to fulfill testing and training requirements for the emergency preparedness program. This deficient practice could lead to staff being uninformed about the processes and procedures to follow to assist all patients of the hospice agency in the case of an emergency. --- The findings are: A. Record review of the agencys undated emergency preparedness policies and procedures titled "Disaster Plan" and the individual personnel files of the staff, revealed the records did not contain any documentation of testing or training in emergency preparedness topics since the year 2020. B. During an interview on 06/05/24, at 4:00 pm with Staff (S)1 Administrator, S1 confirmed that the agency has not had any training or testing with the hospice emergency preparedness plan for the years 2021, 2022, and 2023.

Based on record review and interview the hospice agency failed to perform staff training in emergency procedures at least every 2 years and to maintain documentation of the emergency preparedness training. This deficient practice could lead to staff being uninformed about the processes and procedures to follow to assist all patients of the hospice agency in the case of an emergency. --- The findings are: A. Refer to Tag E-0036

Based on record review and interview, the hospice agency failed to participate in a full-scale exercise, or a facility based functional exercise every two (2) years. This deficient practice could lead to staff being uninformed about the processes and procedures to follow to assist all patients of the hospice agency in the case of an emergency. --- The findings are: A. Refer to Tag E-0036

Based on record reviews and interviews the facility failed to ensure that 5 patients (P[patient]1, P5, P7, P8, and P12) of 14 (P1-P14) patients reviewed, had a comprehensive assessment completed from all of the interdisciplinary team members, including the social worker and chaplain, within a 5 day period from the Hospice Election date. This deficient practice is likely to lead to the patients end of life psychosocial, emotional and spiritual needs being unmet. --- The findings are: A. Record review of P1s medical record revealed the document titled ";Patient Face Sheet" that P1 was admitted on 05/22/24. Under the document titled ";Election of Hospice Benefit and Patient Authorization" revealed P1 elected hospice on 05/22/24. Under the section ";Narrative Notes" dated 06/03/24, revealed that the social worker completed an initial assessment on 06/03/24. B. During an interview on 06/05/24, at 2:28 PM with Staff (S)4, Social worker, S4 confirmed she did not complete the social work aspect of the comprehensive assessment for P1 within the 5 day period. C. Record review of P5s medical record under ";Patient Face Sheet" revealed that P5 was admitted on 04/04/24. In the document titled ";Election of Hospice Benefit and Patient Authorization" revealed that P5 elected hospice on 04/04/24. Under the section ";Medical Social Worker Visit Note" revealed that social work completed the initial assessment on 04/15/24. D D. During an interview with S4, on 06/05/24 at 2:28 PM, S4 confirmed that she did not complete the initial assessment within the first 5 days of the patients hospice election for P5. E. Record review of P7s medical record Under ";Patient Face Sheet" revealed that P7 was admitted on 03/12/24. The form titled ";Election of Hospice Benefit and Patient Authorization" revealed the P7 elected hospice on 03/12/24. Under the section ";Narrative Notes" dated 04/01/24 revealed that the social work initial assessment was completed on 04/01/24. F. During an interview on 06/05/24 at 2:28 PM, S4 confirmed that P7 was not seen by a social worker to assess the needs of the patient within the 5-day period of the election of hospice. G. Record review of P8s Medical Record under ";Patient Face Sheet" revealed that P8 was admitted on 05/16/24. The form titled ";Election of Hospice Benefit and Patient Authorization" revealed that P8 elected hospice on 05/16/24. Under the section ";Medical Social Worker Visit Note" stated that the initial social work assessment was completed on 5/22/24. H. During an interview on 06/05/24 at 2:28 PM with S4, when asked if P8 was seen within a 5 day period of the hospice election, S4 stated ";I missed the mark by one day." When asked when the social work aspect of the comprehensive initial assessment should be completed S4 stated ";It is to be done within the first 5 days of admission, I am supposed to see the patient within the first 5 days." I. Record review of P12s medical record under the section ";Patient Face Sheet" revealed that P12 was admitted on 09/12/22. The Chaplain did not complete the Chaplain aspect of the comprehensive assessment within 5 days and completed it on 09/24/22. J J. During an interview on 06/06/24 at 11:53 AM with S1, Facility administrator, S1 confirmed that the P12 did not have a chaplain visit within the first 5 days of admission.

Based on record review and interview the facility failed to meet the Conditions of Participation to provide an effective ongoing Quality Assessment and Performance Improvement (QAPI) program. This deficient practice can result in poor operational performance and poor quality of care for all patients. --- The findings are: A. The facility failed to maintain a QAPI program. Refer to tag L-561

Based on record review and interview the facility failed to provide a program that shows evidence of improvement in indicators related to the palliative outcomes of hospice care. This deficient practice can lead to ineffective assessments of care for all patients. --- The findings are: A. Record review of facilitys undated policy titled, ";Program Improvement Program/QAPI [Quality Assessment and Performance Improvement]" stated ";Overview: The agency has implemented a data driven QAPI program that reflects the scope and complexity of the agency and the care, and services provided." ";The program has been developed to implement, evaluate, and maintain an effective ongoing, Agency wide and data driven improvement program. The program focuses on indicators related to the improved outcomes, including the use of emergent care service hospital admissions and re-admissions; and takes action that address the Agency performance across the spectrum of care, including the prevention and reduction of medical errors." B. On 06/04/2024, requested facilitys QAPI meeting minutes and data, facility could not provide any QAPI meeting minutes and data. C. During an interview on 06/04/2024 at 3:00 pm with Staff (S)2, Clinical Manager, S2 confirmed that the meetings are not being conducted and data is not being collected.

Based on interview the facility failed to develop a system that evaluates, analyzes and tracks adverse patient events and other aspects of performance. This deficient practice can result in ineffective assessments of care for all patients. --- The finding is: A. During an interview on 06/04/2024 at 3:00 pm with Staff(S)2, Clinical Manager, S2 confirmed that the meetings are not being conducted and data is not being collected. (Refer to tag L-561)

Based on interview the facility failed to ensure that data is collected and analyzed for performance and quality improvement. This deficient practice can lead to poor operational performance and poor quality of care for all patients. --- The findings are: A. During an interview on 06/04/2024 at 3:00 pm with Staff(S)2, Clinical Manager, S2 confirmed that the meetings are not being conducted and data is not being collected. (Refer to tag L-561)

Based on interview the facility failed to collect data to monitor the effectiveness of quality of care and safety of services and identify opportunities for improvement. This deficient practice can lead to a decrease in quality of care for all patients. --- The findings are: A. During an interview on 06/04/2024 at 3:00 pm with Staff(S)2, Clinical Manager, S2 confirmed that the meetings are not being conducted and data is not being collected. (Refer to tag L-561)

Based on the interview, the facility failed to develop an analysis for the frequency of when data is collected and approved by the governing body. This deficient practice can result in a breakdown of structure in administration that can diminish quality of care for all patients. --- The findings are: A. During an interview on 06/04/2024 at 3:00pm with Staff(S)2, Clinical Manager, S2 confirmed that the meetings are not being conducted and data is not being collected. (Refer to tag L-561)

Based on the interview the facility failed to develop performance activities that focus on the volume, high risk and problem-prone areas of data collection. This deficient practice can lead to poor operational performance and poor quality of care for all patients. --- The findings are: A. During an interview on 06/04/2024 at 3:00 pm with Staff(S)2, Clinical Manager, S2 confirmed that the meetings are not being conducted and data is not being collected. (Refer to tag L-561)

Based on interview, the facility failed to create an incident tracking system that analyzes causes and adverse events and the severity of events. This deficient practice can result in ineffective assessments of care for all patients. --- The findings are: A. During an interview on 06/04/2024 at 3:00 pm with Staff(S)2, Clinical Manager, S2 confirmed that the meetings are not being conducted and data is not being collected. (Refer to tag L-561)

Based on interview, the facility failed to develop a system that monitors the outcomes of palliative care, patient safety and quality of care provided. This deficient practice can lead to a decrease in quality of care for all patients. --- The findings are: A. During an interview on 06/04/2024 at 3:00 pm with Staff(S)2, Clinical Manager, S2 confirmed that the meetings are not being conducted and data is not being collected. (Refer to tag L-561)

Based on interview, the facility failed to develop a system to track adverse events, analyze the cause and implement preventive actions. This deficient practice can result in ineffective assessments of care for all patients. --- The findings are: A. During an interview on 06/04/2024 at 3:00 pm with Staff(S)2, Clinical Manager, S2 confirmed that the meetings are not being conducted and data is not being collected. (Refer to tag L-561)

Based on interview, the facility failed to create a system to assess the issues that arise with the hospice and track performance to ensure that improvements are sustained. This deficient practice can result in a breakdown of structure in administration that can diminish quality of care for all patients. --- The findings are: A. During an interview on 06/04/2024 at 3:00 pm with Staff(S)2, Clinical Manager, S2 confirmed that the meetings are not being conducted and data is not being collected. (Refer to tag L-561)

Based on interview, the facility failed to develop a performance improvement project that implements and evaluates the hospice. This deficient practice can result in a breakdown of structure in administration that can diminish quality of care for all patients. --- The findings are: A. During an interview on 06/04/2024 at 3:00p m with Staff(S)2, Clinical Manager, S2 confirmed that the meetings are not being conducted and data is not being collected. (Refer to tag L-561)

Based on interview, the facility failed to ensure that performance improvement projects are conducted annually addressing the scope, complexity and past performance of hospice operations and services. This deficient practice can result in poor operational performance and poor quality of care for all patients. --- The findings are: A. During an interview on 06/04/2024 at 3:00 pm with Staff(S)2, Clinical Manager, S2 confirmed that the meetings are not being conducted and data is not being collected. (Refer to tag L-561)

Based on interview, the facility failed to create a performance improvement document that covers what projects are being conducted, the quality measures and the reason for conducting performance improvement projects. This deficient practice can result in poor operational performance and poor quality of care for all patients. --- The findings are: A. During an interview on 06/04/2024 at 3:00 pm with Staff(S)2, Clinical Manager, S2 confirmed that performance improvement programs are not being conducted. (Refer to tag L-561)

Based on interview, the facility failed to ensure that an ongoing program for patient safety and quality is defined, implemented and maintained annually by the governing body. This deficient practice can result in poor operational performance and poor quality of care for all patients. --- The findings are: A. During an interview on 06/06/2024 at 8:00 am with Staff(S)1, Executive Director, S1 confirmed that there is no updated information on Quality Assessment and Performance Improvement (QAPI) and the hospice is not keeping track of trends for quality improvement. (Refer to tag L-561)

Based on interview, the facility failed to develop a Quality Assessment and Performance Improvement system that evaluates the quality of care and effectiveness of patient safety. This deficient practice can result in a breakdown of structure in administration that can diminish quality of care for all patients. --- The findings are: A. During an interview on 06/04/2024 at 3:00 pm with Staff(S)2, Clinical Manager, S2 confirmed that the meetings are not being conducted and data is not being collected. (Refer to tag L-561)

Based on interview the facility failed to designate one or more individuals to operate the Quality Assessment and Performance Improvement (QAPI) program. This deficient practice can result in a breakdown of structure in administration that can diminish quality of care for all patients. --- The findings are: A. During an interview on 06/06/2024 at 11:53 am with Staff(S)1, Administrator, S1 confirmed that no one is operating the QAPI program. (Refer to tag L-561)

Based on record review and interview, the hospice failed to ensure that 1 (S (Staff) 6 Hospice Aide) of 1 (S6) hospice aide being reviewed completed 12 hours of in-service training during the year 2023. This deficient practice could lead to decreased quality of care for all patients of the facility. --- The findings are: A. Record review of S6s personnel file, revealed the form "In-Service Participation" for the year 2023 revealed S6 only completed 8 hours of training. B. During an interview on 06/05/24 at 10:00 am with S2 Registered Nurse Clinical Manager, S2 confirmed that S6 did not complete the required 12 hours of training for the year 2023.

Based on the interview, the facility failed to have a governing body that assumes responsibility for all areas of hospice including continuous quality assessment and performance improvement, management responsibilities and daily operation of the hospice. This deficient practice can result in the breakdown of structure in administration that can diminish quality of care for all patients. --- The findings are: A. During an interview on 06/06/2024, at 11:53 am with Staff(S)1, Administrator, S1 confirmed that no one is operating the QAPI program. (Refer to tag L-561)