Every finding on record at Pleasant Day Hospice, Inc.

Based on interview and record review, the hospice agency (HA) failed to ensure the emergency preparedness plan/drill for all healthcare workers were completed in an annual basis. This failure had the potential for the staffs to have lack the knowledge on how to respond effectively during an emergency situation. Findings: During a review of the Emergency Preparedness Plan of the hospice agency (HA) on 8/29/2022 at 1:10 p.m., the HA did not have evidence of Emergency Preparedness training/disaster drill for all field staffs. During an interview on 8/29/2022 at 1:10 p.m., with the HA's Administrator (Admin), Admin stated they do emergency inservice early 2021 but could not provide evidence of the field staff receiving Emergency Preparedness training/disaster drill training. A review of the HA's policy and procedure titled "Emergency Preparedness Plan(EPP)" indicated that agency administration and staff will educate and assist patients on emergency preparedness to the greatest extent possible (at the minimum upon admission and in the event of an actual emergency). This agency does an annual all hazard vulnerability assessment(HVA). The EPP is written based on ther risk assessment. Changes otr additions will bve made based on the annual risk assessment, gaps identified during exercises or real events or changes in CMS or licensing requirements.The current staff will be trainbed on the new or updated EPP at the time of its publication. All new staff will be trained on the EPP in orientation. Volunteers must be trained on the EPP. EP training will be con ducted annually. Documenattion of the training on the EPP and annual emergency preparedness training will be maintained by Human Resources. Knowledge of EPP and emergency preparedn ess will be shown by return demonstration, if applicable and participation in the facility testing program. The agency will participate in a full scale exercise that is community-based or when a community-based exercise is not available, an individual, facility based exercise annually.

Based on observation, interview and record review, the hospice agency failed to review all medications the patients were taking and update the medication profiles with the currently used medications for one of 11 sample selected patients, (Patients 3). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. Findings: a. A review of Patient 3's admission record indicated the patient was admitted to the hospice agency on 2/6/2022, with primary diagnosis of Alzheimer's disease (affects memory, thinking and behavior). A review of the "Initial orders and Plan of Care," dated 2/6/2022, indicated the skilled nurse (SN) visit frequency for Patient 3 was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). The space for administration and education on medication was not check marked. On 8/24/2022, at 10:45 a.m., during a joint home visit with License Vocational Nurse 1 (LVN), Patient 3 was observed sitting by the dinning room table in the living room with Family member 2 was next to the Patient 3. During Patient 3's medication review comparing the medication profile, with Family member 2, the following discrepancies were verified: 1. Patient 3 had a container labeled to take Seroquel one tablet in the A.M., day, while the medication profile indicated Patient 3 to take Seroquel 50 mg at bedtime. The medication profile did not list the A.M. dose of Seroquel During an interview with the Administrator on 8/29/2022, at around 1:120 p.m.., he stated the medication profile should be updated every visit. A review of the agency's policy titled " Medication profile, " with a revised date of 4/2020, indicated the patients' receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the interdisciplinary (IDG) group members have attended the meetings held for 4 of 11 patients, (Patients 4, 5, 6 and 7). This deficient practice violated the HA's policies and had the potential for the patients' needed care and services to not be provided timely and/or supervised and had the potential for patient's not to receive the appropriate comfort nursing care and symptom management for their terminal illnesses. Findings: 1. A review of Patient 4's admission record indicated the patient was admitted to the hospice agency on 3/8/22, with a primary diagnosis of heart disease unspecified (a common heart condition that affects the major blood vessels that supply the heart muscle) and diabetes (abnormal blood sugar levels) due to underlying condition with diabetic polyneuropathy (a condition that affects the multiple peripheral sensory and motor nerves that branch out from the spinal cord into the arms, hands, legs and feet). A review of Patient 4's medical record titled, "POC/IDG Review", did not indicate the Spiritual Counselor (SC) attended IDG on 3/15/22, 4/13/22, 4/27/22, 5/24/22, 6/8/22, 6/29/22, 7/9/22, 7/17/22, 8/10/22, 8/24/22, 9/7/22. The Registered nurse (RN) did not attend on 4/27/22 and 7/17/22 and Social worker (SW) did not attend on 3/15/22,4/13/22, 4/27/22, 7/17/22 and 9/7/22. 2. A review of Patient 5's admission record indicated the patient was admitted to the HA on 5/28/22, with a primary diagnosis of acute systolic and diastolic congestive heart failure (the inability of the heart muscles to pump enough blood to meet your body's demands). A review of Patient 5's medical record titled "POC/IDG Review", did not indicate the Hospice RN attended IDG on 6/8/22, 7/13/22, 8/24/22, 9/7/22, SC did not attend on 6/8/22, 7/13/22, 7/27/22, 8/10/22, 8/24/22, SW did not attend on 9/7/22. 3. A review of Patient 6's admission record indicated the patient was admitted to the HA on 4/26/22, with a primary diagnosis of left ventricular failure (left heart failure occurs when there is dysfunction of the left ventricle, resulting insufficient delivery of blood to vital organs). A review of Patient 6's medical record titled "POC/IDG Review", did not indicate the Hospice SW attended the IDG on 6/8/22, SW did not attend the IDG meeting on 6/8/22 and SC on 5/17/22 and 6/8/22. 4. A review of Patient 7's admission record indicated the patient was admitted to the HA on 9/3/21, with a primary diagnosis of Alzheimer's disease (a general term for memory loss and other cognitive abilities serious enough to interfere with daily life). A review of Patient 7's medical record titled "POC/IDG Review", did not indicate the Hospice SC did not attend the IDG meetings on 9/4/21, 9/29/21, 10/3/21, 10/26/21, 11/10/21, 11/23/21, 2/1/22, 2/15/22, 3/2/22, 3/15/22, 3/30/22, 4/27/22, 5/25/22, 6/8/22, 6/29/22, 7/13/22, 7/27/22. RN did not attend on 11/23/21, 6/8/22, 7/27/22. SW did not attend the IDG meetings on 9/4/21 and 9/29/21. During an interview on 9/7/2022 at 12:30 p.m., with the RN2, RN2 admitted that the members of the IDG should sign at the end of each patient review. RN 2 further added that if it is not signed, the member did not show attendance for the meeting. A review of the HA's policy titled, "Interdisciplinary Group Meeting", revised April 2018 indicated that the interdisciplinary group (IDG) will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care (POC), deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certifications and recertifications of patients on the hospice program. Each patient's POC will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires. The meeting will be facilitated by the hospice clinical supervisor/nursing supervisor or designee. The hospice medical director and all hospice interdisciplinary group members (IDG members) will be present including volunteers and attending physicians, as available. The patient/family caregiver will be informed of the schedule for this meeting, its purpose and that the discussion is confidential. Members of the IDG meeting will sign an attendance form that will be kept by the hospice clinical supervisor/nursing supervisor. A review of the HA's policy titled, "Interdisciplinary Group Membership and Responsibilities", revised April 2018, indicated the hospice interdisciplinary team/group (IDT/IDG) members will include Physician, Registered Nurse, Social worker and Pastoral or other counselor. Additional members may include Physical therapist, speech therapist, Occupational therapist, Registered Dietitian, Pharmacist, Home care aide/home maker and volunteer.

Based on interview and record review, the Hospice agency (HA) failed to provide evidence the QAPI (Quality Assurance and Performance Improvement system- a data driven and proactive approach to quality improvement. All members of an organization, including residents, are involved in continuously identifying opportunities for improvement) had been implemented and is functioning effectively by ensuring its structure includes program objectives, all patient care disciplines, description of how the program will be administered and coordinated, methodology for monitoring and evaluating the quality of care, priorities for resolution of problems, monitoring to determine effectiveness of action, oversight responsibility reports to governing body, and documentation of the review of its own QAPI program. This deficient practice resulted in the inability of the agency to identify issues, improve health outcomes, patient safety, and quality of care. Findings: On 8/29/2022, at 1:20 p.m., during a review of the QAPI , only the Administrator (Admin) facilitates all meetings and no written documentation who were the attendees of the QAPI. On a concurrent interview, the Admin stated that at that time meeting was held, Admin is the only governing body for the agency. The Admin stated he was aware that a QAPI program was needed and the QAPI program was supposed to meet at least quarterly. Admin stated that if QAPI is not done will result to no review if the HA's meets professional standards of quality of care. A review of the HA's document titled " Sample Quality Assessment and Performance Improvement (QAPI) Plan" revised april 2019, indicated the purpose of the hospice QAPI plan is to provide the strategy for the systematic organization-wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high value, effective and efficient services in accordance with its mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations. A review of the HA's policy no. 4-015.1 titled " Improving Organization Performance", revised April 2019, indicated all personnel will be active participants in hospice's quality assessment performance improvement (QAPI) activities.

Based on interview and record review the hospice agency (HA) failed to ensure a process of tracking, documenting, implementing their policies and procedures regarding Coronavirus disease (COVID 19, a severe respiratory illness caused by virus and spread from person to person) and providing education of infection control all HA staff, patients and their families. This deficient practice had the potential to result in placing employees, patients and their families at risk for spreading and/or contracting COVID-19 infection, that could lead to severe respiratory illness, hospitalization and/or death. Findings: On 8/29/2022 at 12:50 p.m., during an interview with the Administrator (Admin), Admin stated that during the pandemic the hospice agency (HA) conducts infection control in-service once a month. Admin stated that attendees are both office and field staff. Admin stated that field staff answers a Covid-19 screening questionnaire first prior to daily visits and staff get their own antigen self-tests when they have symptoms and report to the office. Admin also claimed field staff had their N95 fit testing annually. Admin could not show written documentation for their Covid-19 screening tracking log and N95 fit testing for staff. During a review of the HA's infection control "In-service sheets" provided by the Admin., In-service sheets are dated but there is no time and no specific in-service topic was listed. There was no facilitator documented on the in-service sign in sheets and Admin could not provide copies of the lesson plan for each "in-service." A review of the HA's policy no. 2-081.1 titled "Infection Control Precautions", revised April 2019, indicated the patient and family/caregiver will receive, when appropriate, information and instruction regarding infection control precautions, in accordance with applicable PLEASANT DAY HOSPICE, INC policies. A review of the HA's document titled, "Covid-19 Preparedness and Response Plan", has designated the Adminsitrator to stay up to date on federal, state and local guidance, incoprporating those recommendations into our workplace, training our workforce on control practices, proper use of personal protective equipment (PPE) and the steps employees must take to notify our business of any Covid-19 symptom and suspected cases of Covid-19, reviewing HR policies and practices to ensure they are consistent with this plan and existing local, state and federal requirements. Pleasant Day Hospice will require and keep a record of all self-screening protocols for all employees or contractors entering the worksite, including at a minimum, a questionaire covering symptoms and suspected or confirmed cases of Covid-19. Conduct a daily self creening protocol for all employees or contractors entering the workplace. including at a minimum, a questionaire covering symptoms and suspected or confirmed exposure to people with possible Covid-19.

Based on interview and record review, the hospice agency failed to ensure volunteer services were offered to 11 of 11 sample patients on a continuous basis. The deficient practice failed to facilitate compliance with the core services requirement. Findings: During the recertification entrance conference with the administrator on 8/23/2022, he stated due to COVID-19, the hospice had no volunteer to provide services and their volunteer coordinator had not done any patient visits due to COVID 19. There was no documentation volunteer services were offered. During the recertification survey, the volunteer coordinator was unavailable. A review of the Hospice Agency's policy and procedures titled, "Volunteer Services", dated November 2017, indicated ", the volunteer coordinator will arrange for volunteers to provide volunteer support to patient and family/caregiver, in accordance with the plan of care. Volunteers will document their activities on volunteer activity/clinical notes and submit this documentation for the patient's clinical records".

Based on record review and interview, the hospice agency failed to ensure to appoint designated persons in the governing body to assume full legal authority, responsibility and management of the hospice agency and failed to ensure an appointed, qualified administrator to run the day to day operation of the hospice. Findings: On 8/29/2022, at 1:45 p.m., during an interview and concurrent employee file review with the Administrator, he stated he was the only governing body of the hospice and had not designated persons to assist with the responsibilities of the hospice agency. The administrator also stated, he has not updated his Administration license in years and dose not have a current administrator license. A review of the hospice agency's job description of Executive Director/Administrator dated 11/2017, indicated, "The Executive Director/Administrator is responsible for the overall direction of the day to day operations of the hospice services. He/she is responsible for the employment of qualified hospice personnel; is responsible for the provision of hospice services, directly, and the delegation to and coordination of hospice personnel evaluations; is responsible for establishing standards of care to comply with federal and state regulations and guidelines. The Executive Director/Administrator establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy."

Based on record review and interview, the hospice agency failed to ensure an appointed designated persons in the governing body to assume full legal authority, responsibility and management of the hospice agency and failed to ensure appointed a qualified administrator to run the day to day operation of the hospice. Findings: On 8/29/2022, at 1:45 p.m., during an interview and concurrent employee file review with the Administrator/CEO, he stated he was the only governing body of the hospice and had not designated persons to assist with the responsibilities of the hospice agency. The administrator also stated, he has not updated his Administration license in years and dose not have a current administrator license. Review of the hospice agency's job description of Executive Director/Administrator dated 11/2017, inidcated, "The Executive Director/Administrator is responsible for the overall direction of the day to day operations of the hospice services. He/she is responsible for the employment of qualified hospice personnel; is responsible for the provision of hospice services, directly, and the delegation to and coordination of hospice personnel evaluations; is responsible for establishing standards of care to comply with federal and state regulations and guidelines. The Executive Director/Administrator establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy."

Based on record review and interview, the hospice agency failed to ensure their social worker met the qualifications of Master of Social Work (MSW) degree from a school of social work accredited by the Council on social work. This deficient practice failed to be in compliance with the state requirements provided for the hospice agency. Findings: During a review of the hospice agency's Social Workers employee file on 8/24/2022, indicated the social worker had an Associate clinical license in social work. There was no documentation the agency had a Master of Social Work employed by the hospice agency. During an interview with the Administrator/CEO on 8/29/2022, at 1: 45 p.m., he stated he was sure she met the qualification, however, the administrator was unable to provide documentation that the hospice agency had a qualified social worker.