Every finding on record at Quest Hospice, Inc.

Observed in Leadership Session. When contracting for medical director services, the contract must specify the physician who assumes the medical director responsibilities and obligations. During leadership review the surveyor noted the organization has a contracted medical director. The organization contracted with a medical group for an alternate, but a specific physician was not identified. This was validated with the administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the patient record is complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval. For RRNHV#2 the documentation showed wound care was completed, but did not indicate the treatment provided to the wound. For RRHV#2, the surveyor noted during the medication reconciliation the medication profile listed the same medication for Vitamin D3 but a different dose. This was discussed with the administrator.

Observed in Record Review. In 3 of 14 patient records reviewed, the organization did not ensure the patient record is complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval. For example in RRHV#2, NHV#1 and NHV#2, the clinical documentation was not completed for three nursing visit for at least fourteen days after the visit was completed. This was reviewed with the administrator.

Observed in Record Review. In 1 of 6 patient records reviewed, During RR#3 Live Discharge, it was noted the Notice of Non Medicare Coverage (NOMNC) was signed and dated the date of the hospice discharge. This was discussed with the organization leadership.

Observed in Record Review. In 2 of 6 patient records reviewed, During RR#4 and RR#5 it was noted the frequency of SN visits was 1x/week plus 1 PRN. The order lacked the reason for the PRN visit. This was discussed with the organization leaders.

Observed in Record Review. In 1 of 5 patient records reviewed, During RR#2 it was noted during the IDG meeting the end of March 2023 the RN documented the fall risk assessment was high risk with a score of 18. The POC was not updated to include interventions and goals related to fall risk reduction education to the patient and caregivers. This was discussed with the DPCS and Administrator.

Observed in Record Review. In 2 of 5 patient records reviewed, During RR#1 it was noted an order for oxygen therapy 2-5L/min via NC without parameters on the administration of different liter flows. This was discussed with the DPCS and Administrator. This was discussed with the DPCS and the Administrator. During RR#2 it was noted the hospice aide assignment form completed by the RN was not accurate. The order on the aide assignment stated 02 at 3-5L/min. The POC listed an oxygen concentrator but lacked an order for oxygen therapy use. The RN note the end of March 2023 stated the patient was not using oxygen therapy. This was discussed with the DPCS and Administrator.

Observed in Record Review. In 1 of 3 patient records reviewed, During RR#3 it was noted frequency orders for the MSW and chaplain were not followed. The frequency order was once a month for both disciplines. There was lack of documentation of MSW and chaplain visits in March 2023 without documentation of a reason for the missed visits. This was discussed with the DPCS and Administrator.

Observed in Record Review. In 1 of 5 patient records reviewed, During RR#2 it was noted on the hospice aide assignment, vital signs every visit. Upon review of aide notes with a frequency of 3x per week from the middle of March 2023 to present, vital signs were recorded by the aide during 1 visit. This was discussed with the DPCS and Administrator.

Observed in Record Review. In 1 of 1 closed patient record review, During D/C# 1's patient record review it was noted the organization failed to provide interdisciplinary, collaborative services. For example: review of D/C#1's patient record revealed the bereavement assessment and plan of care was updated at death but was not presented to the IDG for collaboration. This was reviewed, discussed and validated with the DPCS and Administrator.

Observed in Record Review. In 2 of 4 active patient records reviewed, During RR# 3 and RR# 4's patient record review it was noted the organization failed to provide interdisciplinary, collaborative care, treatment, or services For example: review of RR# 3 and RR# 4's patient records revealed the Social Worker was seeing the patients but had not documented goals and interventions on the Plan of Care. Further review of RR# 4's patient record revealed the Chaplain was seeing the patient but had not documented goals and interventions on the plan of care. This was reviewed, discussed, and validated with the DPCS.

Observed in Tracer Activities. The organization failed to engage in planning activities related to a written Emergency Operations Plan. The hospice nurse surveyor noted the Emergency Operation’s Plan was not reviewed and updated as evidenced by the organization was not able to produce documentation at the time of survey. There was documentation that it was reviewed and updated but the current plan was outdated, did not include the pandemic and contained many names of employees who no longer worked at the agency. It did not include the name of the DPCS designee who was currently acting as the DPCS with a role to play in the Emergency Operations Plan. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. The organization failed to engage in planning activities related to a written Emergency Operations Plan.The hospice nurse surveyor noted the organization did not prioritize the potential emergencies as evidenced by an outdated HVA that was provided to the surveyor. The HVA appeared to be from the previous survey and did not contain any risks factors related to the pandemic although they kept a separate binder with Covid related education and tracking. The organization was not able to produce written documentation of its updated prioritized emergencies. This was discussed and reviewed with the Administrator. Observed in Tracer Activities. The organization failed to engage in planning activities related to a written Emergency Operations Plan. The surveyor noted the organization did not use its prioritized emergencies as a basis for defining mitigation activities as evidenced by the organization did not identify its current prioritized emergencies and therefore were not able to define mitigation activities. This was discussed and reviewed with the Administrator. Observed in Tracer Activities. The organization failed to engage in planning activities related to a written Emergency Operations Plan. The hospice nurse surveyor noted the organization did not use its prioritized emergencies as a basis for defining preparedness activities as evidenced by the organization did not identify current prioritized emergencies and therefore could not base its preparedness activities on the prioritized emergencies. The organization provided an out of date HVA from the previous survey. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. The organization failed to engage in planning activities related to a written Emergency Operations Plan. The hospice nurse surveyor observed the Emergency Operation’s Plan did not include a continuity of operations strategy that covered all required elements as evidenced by the organization was not able to produce this documentation at the time of survey. The organization did not include succession plan that lists the current employee who replaces the key leader(s) during an emergency if the leader is not available to carry out his or her duties. The list was outdated and the employees were no longer employed by this hospice. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. The organization failed to engage in planning activities related to a written Emergency Operations Plan. The hospice nurse surveyor observed the Emergency Operations Plan did not identify the individual(s) to whom the staff reported in an emergency as evidenced by the organization was not able to produce this documentation at the time of survey. The Emergency Plan given to the surveyor contained outdated names. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. The organization failed to engage in planning activities related to a written Emergency Operations Plan. The hospice nurse surveyor observed as part of its communication plan, the organization did not maintain the names and contact information of staff, physician volunteers, and other response partners contracted entities, and relevant federal, state, tribal, regional, and local emergency preparedness staff as evidenced by the list included in the outdated plan had employees who were no longer at the organization. This was discussed and reviewed with the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to train staff for their assigned emergency response roles. During interviews for HV#1 and HV#2 with visit staff, the hospice nurse surveyor observed the HHA and the LVN could not explain their response or role if the organization declared an emergency. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. The organization failed to assess and reassess its patient's. During tracer activities for the volunteer program, the hospice nurse surveyor observed there was no active volunteer program and therefore the organization was not assessing the need for volunteer services. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 11 of 11 resident records reviewed, the organization failed to provide interdisciplinary, collaborative care, treatment, or services. During record review for all records, the hospice nurse surveyor observed no documentation of collaboration between the IDG and the RN/ LVN seeing the patient. The IDG was held and documented by the DPCS who had not seen the patient's and there was no documentation of conversation with staff seeing the patients. Conversation with 3 staff members also resulted in them stating the DPCS no longer worked there. The record reviews noted the IDG notes were being copy/ pasted from visit notes. This was confirmed by the Administrator and DPCS designee. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to plan the patient's care. During record review for HV#1, RR#1 and RR#3, the hospice nurse surveyor observed missing items from the Plan of Care. For example: in HV#1, the patient had anxiety but no goals or interventions were noted. In RR#1, the patient had notes stating agitation but no goals or interventions were noted and for RR#3, the patient had a goal of maintaining skin integrity but when the patient developed a sacral wound nothing was updated or added to the Plan of Care. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to provide interdisciplinary, collaborative services. During record review for RR#4, RR#5, RR#6, RR#7 and RR#8, the hospice nurse surveyor observed the bereavement assessment and plan of care was updated at death but was not presented to the IDG for collaboration. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 4 of 11 patient records reviewed, the organization failed to provide interdisciplinary, collaborative care, treatment, or services. During record review for HV#3, RR#4, RR#6, and RR#7, the hospice nurse surveyor observed the Social Worker was seeing the patients but had not documented goals and interventions on the Plan of Care. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. The organization failed to establish priorities for performance improvement. During tracer activities for the volunteer program, the hospice nurse surveyor observed the hospice QAPI program failed to address bereavement or volunteer services. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. The organization failed to improve performance. The hospice nurse surveyor observed the organization had a PIP in place for infections due to a high number but their Process Improvement did not include actions to be taken to improve the rate of infection. The actions listed consisted on monitoring. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. The organization failed to have an effective, on-going, organizational wide, data driven quality assessment and performance program. During tracer activities for Data Management, the hospice nurse surveyor observed the organization did not have an established QAPI program in place for 2023 and the 2022 and 2021 plans had data collection time points with no actionable goals. There was no evidence that the organization had a systemic approach to change and performance improvement. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. The organization failed to plan for prevention and control of infections. During tracer activities for infection control, the hospice nurse surveyor observed the organization had no infection prevention and control plan since 2017. They were collecting data on some items but not implemented a written plan. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. The organization failed to identify risks for acquiring and spreading infection, and therefore did not set goals which included limiting the spread of infection associated with procedures. During tracer activities for infection control, the hospice nurse surveyor observed the organization had no infection prevention and control plan since 2017. This was discussed and reviewed with the Administrator. Observed in Tracer Activities. The organization failed to identify risks for acquiring and spreading infection, and therefore did not set goals to minimize the spread of infection. During tracer activities for infection control, the hospice nurse surveyor observed the organization had no infection prevention and control plan since 2017. This was discussed and reviewed with the Administrator. Observed in Tracer Activities. The organization failed to implement a program that follows categories IA, IB, and IC of either the current Centers for Disease Control and Prevention (CDC) and/or the current World Health Organization (WHO) hand hygiene guidelines. The organization was able to provide a plan from 2019 but nothing newer and had not aggregated data to assess their goal of 90%. This was discussed and reviewed with the Administrator. Observed in Tracer Activities. The organization failed to document a written infection prevention and control goal to include improving compliance with hand hygiene guidelines. They had no documented infection control plan but were using a hand hygiene check off from 2019 which stated a goal of 90%. No implementation or data tracking had taken place. This was discussed and reviewed with the Administrator. Observed in Tracer Activities. The organization failed to identify risks for acquiring and spreading infection, and therefore did not set goals which included limiting the spread of infection associated with the use of medical equipment, devices and supplies. During tracer activities for infection control, the hospice nurse surveyor observed the organization had no infection prevention and control plan since 2017. This was discussed and reviewed with the Administrator. Observed in Tracer Activities. The organization failed to identify risks for acquiring and spreading infection, and therefore did not set goals which included limiting unprotected exposure to pathogens. During tracer activities for infection control, the hospice nurse surveyor observed the organization had no infection prevention and control plan since 2017. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization failed to plan the patient's care. During record review for RR#4, RR#5, RR#6, RR#7 and RR#8, the hospice nurse surveyor observed an updated bereavement assessment and plan of care at death but it was not presented to the IDG for team involvement. This was discussed and reviewed with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to supervise staff effectively. During HV#2, the hospice nurse surveyor observed no documentation of an aide supervisory visit since 12/26 which was 22 days earlier. And also noted after discussion with the caregiver at the board and care, he suggested an RN had not visited, only the LVN and HHA. The Administrator added to the conversation reminding him that he must have forgotten. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. The organization failed to provide services that met the patient needs. During tracer activities for the volunteer program, the hospice nurse surveyor observed the hospice did not have an active volunteer program or volunteer coordinator. The Administrator was unaware of the requirement to recruit and retain active volunteers. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. The organization failed to provide services that met their patient needs. During tracer activities for the hospice volunteer program, the hospice nurse surveyor observed the hospice failed to document the cost savings achieved through the use of volunteers. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. The organization failed to provide services that met the patient needs. During tracer activities for the volunteer program, the hospice nurse surveyor observed the hospice did not have an active volunteer program or volunteer coordinator. The Administrator was unaware of this requirement, but hired a Volunteer Coordinator to begin the process while the surveyor was on-site. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. Leadership and the governing body failed to understand the degree of risk in 418.100, 418.113, 418.56, 418.58, 418.78 and 418.60. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to maintain compete and accurate patient records. During RR#4, the hospice nurse surveyor observed the SW notes on 8/7 and 8/9 stated final arrangements were completed but the nursing notes on 8/3 for IDG and the communication note with son on 8/18 stated arrangements not completed. This was discussed and reviewed with the Administrator.

Observed in Patient Home. In 1 of 1 home visits conducted, the organization failed to provide education and training based on the patient's needs. During HV#1, the hospice nurse surveyor observed the LVN assist the caregiver at the board and care to turn on the oxygen concentrator and place the NC in the patient's nose. The nurse surveyor observed a portable heater 6 inches away from the concentrator. Once the on-site administrator was made aware, she instructed them to move the concentrator but the patient with NC was still 6 inches away from the heater. The LVN did not educate the caregiver on the associated fire risks with this procedure. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. The organization failed to maintain an infection control program for the protection of patients, families, visitors, and staff, and includes surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. During tracer activities for infection control, the hospice nurse surveyor observed the organization had no infection prevention and control plan since 2017. They were collecting data on some items but not implemented a written plan. This was discussed and reviewed with the Administrator.

Observed in HR File Review. In 1 of 10 HR files reviewed, the organization failed to verify staff qualifications. During HR file review, the hospice nurse surveyor observed HR#6 ( LVN) did not have primary source verification upon hire. This was discussed and reviewed with the Administrator.