Every finding on record at Nevaeh Hospice Inc

Upon patient record review, 3 of 14 (Patient #2, 5, 6) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #2, 5: There is no documented signature confirming the patient received copy of Patient Rights and Responsibilities. There is an outdated consent form utilized on these patients according to interview. There is evidence of updated form including signature for validation. Patient #6: Boxes are not manually checked on manual form that contains signature to confirm patient received copy of Patient Rights and Responsibilities.

Upon patient record review, 3 of 14 (Patient #9, 10, 11) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #9, 10, 11: MD choice not clear. Form has blank for "my choice is..." and it is not checked or completed. There is not space for "I do not choose."

Upon patient record review, 1 of 14 (Patient #6) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #6: No documented evidence of initial bereavement assessment was completed within 5 days of election.

Upon patient record review, 2 of 14 (Patient #3, 10) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #3: Documented 5/18/24 PRN SN visit note related to coccyx wound. SN initiated Optifoam dressing. There was no update to IDG POC related to new findings/treatment. Patient #10: MD order for 3/15/24 ear wax removal and 3/19/24 order for Cephalexin PO for ear infection. There was no update to IDG POC.

Upon client record review, 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: There was a documented PRN SN Visit 6/7/24 for leaking Foley reported by ALF staff. “16 Fr Foley replaced with an 18 Fr. Foley catheter...10 cc balloon”. Still there was no order documented for catheter maintenance or changes. The catheter change was performed without physician order. There was a 5/18/24 SN PRN Visit Note r/t coccyx/mid/lower back pressure injury. Nurse initiated Optifoam. There was no documented order for the treatment. 5/28/24 IDG Meeting note references need for suture removal from Rt BKA amputation site. Although there was documentation of planned suture removal for 5/30/24, there was no follow up documentation that plan/intervention was completed. Upon interview, it was confirmed that the sutures removed by nurse 5/30/24. However, the nurse received verbal order, but failed to document the order in medical record, prior to performing suture removal.

Upon personnel record review, 1 of 14 (Personnel #6 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·(C) Shampoo, sink, tub, and bed Personnel #6: There is no documented evidence of personnel's competence of shampoo, sink, tub, bed. The agency presented an updated competency form that they are currently using.

Upon patient record review 2 of 14 (Patient #1, 6) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1: Missed Visit Report documenting hospice aide out sick 5/23/24. . There is no evidence that replacement aide or a different date for visit was offered. Patient #6: Missed Visit Report related to HA had sick time 5/24/24. There is no evidence that replacement aide or a different date for visit was offered.

Upon patient client record review, 10 of 14 (Patient #2, 3, 4, 5, 7, 8, 9, 10, 11, 12) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #2, 3, 4, 7, 8, 10, 11: The name of agency is not written in allocated space to identify agency. Patient #5,12: Medical Director and Medical Director alternate names written in space for hospice care provider name, rather than agency name. Patient #9, 10, 11: MD choice not clear. Form has blank for "my choice is..." and it is not checked or completed. There is not space for "I do not choose."

Upon patient client record review, 1 of 14 (Patient #7) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #7: Patient Visit Date 5/29/24 by SC. The electronic signature date for SC, however is 5/13/24 1:13 pm. Upon interview, the staff states a drop down box is utilized to choose date and SC inadvertently chose wrong date.

Upon client record review, 2 of 14 (Patient #11,12) did not have evidence that the discharge summary includes all required information. Patients #11, 12: Records include discharge visit notes, but there are no DC Summaries.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Patient #6: The agency patient admission handbook includes a copy of the policies, but there is no documented evidence that discussion occurred. This was an outdated form that did not include acknowledgement of discussion and the form has since been updated.

Upon personnel record review, 1 of 14 (Personnel #11 ) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #11: Recently contracted individual O.T. has no evidence of criminal background check.

Based on record review and interview, the facility failed to develop and maintain an emergency preparedness plan, an emergency preparedness manual (binder.) This deficient practice can delay the ability to offer patient care by not being prepared in case of an emergent (unpredictable or unforeseen) situation that can lead to inappropriate patient treatment. The findings are: A. Record review of the Emergency Preparedness documentation revealed the following: 1. No written emergency preparedness plan that comprehensively describes its approach to a natural, man-made and facility-based disasters based upon the facility and community-based risk assessment and communication plan utilizing an all-hazards approach 2. No emergency preparedness manual (binder) that coordinates with Federal, state, tribal, regional and local emergency preparedness systems to prepare to meet needs, in a consistent manner, of patients and staff during disasters and emergency situations. To maintain operations, respond to any emergency and have priority patients identified and their needs met as expediently as possible B. Record review of [name of facility] Policy and Procedure, Safety, dated 2Q(quarter)/2020, Emergency Preparedness for Hospices, revealed: 1. Under Policy section: "The hospice has a written emergency preparedness program that comprehensively describes its approach to a natural, man-made and facility-based disasters based upon the facility- and community-based risk assessment and communication plan utilizing an all-hazards approach." 2. Under Purpose section: "To coordinate with Federal, state, tribal, regional and local emergency preparedness systems to prepare to meet needs, in a consistent manner, of patients and staff during disasters and emergency situations. To maintain operations, respond to any emergency and have priority patients identified and their needs met as expediently as possible." 3. Under Procedure section: "The hospice must comply with all applicable Federal, State, local emergency preparedness, and accredited organization requirements. The hospice must establish and maintain an emergency preparedness program that meets the requirements of this section." 4. Under Emergency Plan section: "The hospice must develop and maintain an emergency preparedness program that is reviewed and updated at least every two years. The plan must do the following: Be based on and include a documented, facility-based and community based risk assessment, utilizing an all-hazards approach. The approach is specific to the location and will consider hazards most likely to occur in the surrounding area. 5. Under Policies and Procedures section: "The hospice must develop and implement emergency preparedness policies and procedures, based on the emergency plan, risk assessment, and the communication plan established in federal law. The policies and procedures must be reviewed and updated at least annually (as a component of the annual review and update." 6. Under Communication Plan section: "The hospice will develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and must be reviewed and updated at least annually per New Mexico law." 7. Under Training and Testing section: "The hospice must develop and maintain an emergency preparedness training and testing program that is based on New Mexico and Federal regulations regarding the emergency plan, risk assessment, policies and procedures, and the communication plan. The training and testing program must be reviewed and updated at least annually per New Mexico law. The hospice training program must do all of the following: Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. Demonstrate staff knowledge of emergency procedures. A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan." C. On 09/08/2022 at 9:00 am, during survey requested from Staff (S)#3 (Office Manager) a copy of the Emergency Preparedness policy, Emergency Preparedness manual (binder.) S#3 confirmed not sure if the facility has an Emergency Preparedness manual but would confirm with S#5 (Chief Executive Officer.) D. On 09/08/2022 at 11:30 am, during an interview, S#5 (Chief Executive Officer) confirmed the facility does not have an emergency plan binder available to view.

Based on record review and interview, the facility failed to document a comprehensive and measurable wound assessment by the Registered Nurse (RN) on a weekly basis for 1 [P(patient)2] of 11 [P1-P11] patients reviewed. This failed practice could lead to worsening of patient wounds, infection, and increased patient discomfort. The findings are A. Record review of Facility's Policy titled, "Wound Care" (no date present), revealed: a. "Wound assessment, except for measurement of the wound, will be done at each scheduled nursing visit and on PRN (as needed) visits as changes in the wound indicate. Assessment and treatment/dressing change will be documented on the wound management form and included as part of the visit note. Measurement will be once a week." b. "Wound measurement will be done once each week or as appropriate to the type of wound, type of dressing and status of the patient." B. Record review of P2, RN Initial/Comprehensive Assessment, dated 04/14/2022 revealed: a. "Wound name: Pressure Ulcer; b. Location: sacrum; c. Wound type: Pressure Injury; d. Pressure Ulcer Stage: III; (Full thickness tissue loss, exposing subcutaneous (skin) adipose (fat) tissue as caused by prolonged contact with an object or surface) e. Length (cm(centimeters)): 2; f. Width (cm): 2; g. Depth (cm): 1.8." C. Record review of P2, Skilled Nursing Visit, revealed no documentation of wound assessment by the RN for the following skilled nursing visits: a. 04/17, 04/25, 04/27, 04/30, 05/03, 05/10, 05/14, 05/18, 05/21, 05/24, 05/31, 06/08, 06/11, 06/17, 06/22, 06/25, 06/28, 07/02, 07/07, 07/10, 07/13, 07/19, 07/27, 08/03, 08/24, 08/30, and 09/06/2022. D. On 09/06/2022 at 4:35 pm, during an interview with S (staff)2, Administrator, S2 states, "As far as I know, we (trained hospice personnel) do all of our own wound care. We don't teach caregivers here, but I'd have to check what [alternate location's] policy is." When asked if [alternate location] has separate policy's, S2 states, "no, they are the same." E. On 09/06/2022 at 4:35 pm, during an interview, with S2, Administrator, when asked if there is a note regarding the RN performing wound care and assessment for P2, S2 confirmed that there is no note present that shows the RN is performing wound care and assessment. F. Record review of P2, Skilled Nursing Visit, dated 04/12/2022-09/06/2022, revealed no documentation of measurements or trending of measurements taken of a Stage III pressure ulcer or of a new stage II pressure ulcer (localized partial thickness skin loss involving the epidermis, dermis, or both as caused by prolonged contact with an object or surface).

Based on record review and interview the facility failed to meet the Condition of Participation (COP) for Hospice to maintain an effective, ongoing, hospice-wide data-driven (QAPI) Quality Assessment and Performance Improvement program by failing to comply with the requirements as evidenced by the following: A. The facility failed to provide documentary evidence quarterly (every three months) meetings for the last twelve months and a plan on how information is gathered to identify patient care issues or patient safety concerns and what was done to improve performance. Refer to tag 0560.

Based on record review and interview, the facility failed to maintain an effective, ongoing, hospice-wide data-driven (QAPI) Quality Assessment and Performance Improvement program to ensure adequate and effective operation in the areas of clinical care, provide documentary evidence quarterly (every three months) meetings, and a plan on how information is gathered to identify patient care issues or concerns and what was done to improve performance. This deficient practice increases the likelihood of the facility not having a process for improving and identifying areas in quality and performance of patient care practices. The findings are: A. Record review of [name of facility] Policy and Procedure, Section Five Quality, QA (Quality Assessment) 11, Quality Assessment Performance Improvement (QAPI), dated 1Q(quarter)/2019: 1. Under Policy section: "The hospice will develop, implement, evaluate and maintain an effective, ongoing, hospice-wide, data-driven QAPI program which adheres to Federal regulations 418.58." 2. Under Purpose section: "To systematically measure, analyze, and track measurable indicators for improved health outcomes, including adverse patient events (an unexpected medical problem that happens during treatment with a drug or other therapy) and other aspects of performance that enable the agency to assess processes of care, services and operations. The QAPI efforts address priorities for improved quality of care and patient safety." 3. Under QAPI Program section: a. "The hospice will develop, implement, evaluate, and maintain an effective, ongoing hospice-wide, data-driven QAPI program. This program will measure, analyze, and track quality indicators, including adverse patient events and other aspects of performance that enables assessing processes of care, hospice services and operations. The program well be capable of showing measurable improvement in performance indicators related to improved palliative outcomes and hospice services. The program must have a written plan of implementation. b. The hospice will establish and implement procedures to identify, monitor, report, investigate and document all adverse events, incidents, accidents, variances, or unusual occurrences that involve patient care. c. The hospice will investigate all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care. A plan of correction will be developed to prevent the same or similar event from occurring again, this plan will include preventative actions and mechanisms that include feedback and learning throughout the hospice. All events will be documented. d. The governing body must ensure: i. The ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually. ii. The hospice-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. iii. One or more individual(s) who are responsible for operating the quality assessment and performance improvement program are designated. Duties and responsibilities relative to the QAPI coordinator include: Assisting with the overall development and implementation of the QAPI program Assisting in the identification of goals and related patient outcomes Coordinating, participating and reporting of activities and outcomes." 4. Under Program Scope section: "The hospice's QAPI program must be able to show measurable improvement in indicators related to improved palliative outcomes and hospice services." 5. Under Program Data section: "The QAPI program will utilize quality indicator data, including patient care, and other relevant data, in the design of its program. The data collected will be used to monitor the effectiveness and safety of services and quality of care and to identify opportunities and priorities for improvement. All patient services and all activities that have impact on the patient/family care should be evaluated as part of the QAPI program." 6. Under Program Activities section: a. "The hospice's performance improvement activities must: Focus on high risk, high volume, or problem-prone areas. High risk includes all factors associated with significant risk to the health or safety of patients such as types of services, geographic concerns, or specific patient care services. High volume refers to care or service areas that are frequently provided by the Agency to a large patient population which may increase the scope of the problem. Problem-prone areas refer to care or service areas that have the potential for negative outcomes and are associated with a diagnosis or condition for a particular patient group or component of the Agency's operation or historical problem areas. Consider incidence, prevalence, and severity of problems in those areas; and affect palliative outcomes, patient safety, and quality of care. Review all variances is conducted at least quarterly to detect trends and create action plan(s) to decrease occurrences. Variances may include, but are not limited to: Infections, Communicable diseases, Incidents, Accidents, Complaints/grievances. b. The program activities must track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice. c. The hospice will determine its definition of an adverse event and adhere to the definition when tracking and analyzing these events and implementing preventative actions. New processes must be implemented hospice-side and assure it is effective in reducing the adverse event. d. The hospice must take actions aimed at performance improvement, and, after implementation of actions, must measure its success and track performance to ensure sustainment of the improvements." 7. Under Executive Responsibilities section: a. "The Administer is responsible to allocate resources for implementation of the QAPI program. b. The governing body has the responsibility for ensuring the following: i. QAPI program reflects the complexity of the hospice and services ii. QAPI program involves all hospice services (including those services furnished under contract or arrangement) iii. QAPI program focuses on indicators related to improved palliative outcomes iv. QAPI program takes actions to demonstrate improvement in hospice performance v. Program is ongoing, defined, implemented, and maintained; vi. Hospice-wide and addresses the priorities for improved quality of care and patient safety." B. Record review of QAPI records from 09/01/2021- 08/31/2022 revealed no documentation of tracking and trending of important indicators for improving outcomes in patient care for (i. e. infection control, wound care, and grievance resolution.) And no indication as to when the agency had its last QAPI meeting. C. Record review of Incident Events (records to improve patient safety and care quality) from 01/01/2022 thru 09/07/2022 revealed the Hospice Agency had information in patient charts with no outcome data (resolution of how the incident event for patient safety/quality of care was solved.) However, no QAPI plan within the QAPI program to collect and analysis the data to improve patient care services. D. On 09/07/2022 at 10:30 am, during an interview, Staff (S)#1 (Director of Nursing) confirmed the facility has not had a specific meeting for QAPI in the last 12 months, the facility has monthly meetings and discusses concerns but does not discuss what measures to take or minimize concerns for patient care or safety. S#1 and S#2 (Executive Director Administrator) have taken the responsibility to oversee QAPI. S#1 confirmed the facility does not have an Adverse Event Log, if there are concerns with any patient it is noted in the patient chart. E. On 09/07/2022 at 1:20 pm, during an interview, S#2 (Executive Director Administrator) confirmed in the monthly staff meetings they discuss patient care concerns but currently do not have a consistent QAPI program in place. S#2 confirmed will refer to the facilities QAPI policy to incorporate structured processes for the QAPI program. F. On 09/07/2022 at 4:20 pm, during an interview, S#5 (Chief Executive Officer) confirmed there has not been a specific meeting for QAPI to track and trend measurable indicators in patient care and safety for improved health outcomes. G. On 09/07/2022 at 4:30 pm, during an interview, S#7 (Co-Owner of the facility) confirmed understanding the importance of having a QAPI program and confirmed the facility has not had a QAPI specific meeting to measure and track quality indicators with outcomes in patient care and safety in the last twelve months.

Based on record review and interviews the agency failed to maintain and document an effective Infection Control Program. This failed practice has the potential to affect all patients, families, and personnel by not being able to identify risk factors in all settings of patient care. The findings are: A. Record review of facility policy titled; "Monitoring Infections" dated 2018 states under "Procedure: IV. Infection control tracking will be used to collect data and trend data on infections both personnel and patients. Surveillance data will be analyzed for trends and related factors that may contribute to correlations between personnel, patients, and infection control practices. a. Data is utilized to assess the effectiveness of the infection control program. Corrective action plans and steps for improvement as needed." B. On 09/07/2022 at 10:15 am, during an interview with S1, Director of Nursing when asked to provide infection control data analysis and trending information, no documentation could be provided. S1 said "- I don't see any records from the previous time frame. I have looked and haven't come across anything." C. On 09/07/22 at 4:00 pm, during an interview with S2, Administrator, when asked about system in place for infection control tracking and trending information could not be provided. S2 said "I don't' think we have anything month to month."

Based on record review and interview the hospice agency failed to maintain documentation of governing body oversight of the hospice program and failed to appoint an administrator. The failed practice can result in the agency not having oversight and resulting in poor quality of care for all hospice patients. The findings are: A. No Governing Body meeting was held after previous administrator resigned in May 2022. The facility failed to provide documentation of governing body meeting minutes showing appointment of a new administrator. B. On 09/07/22 at 12:29 pm during an interview with S5, Chief Execute Officer, when asked if governing body met to appoint a new administrator, S5 answered "No, we did not."