Every finding on record at Red Rock Hospice

Observed in HR File Review. In 2 of 8 HR files reviewed, it was noted that emergency management education and training was not completed every 2 years. For example HHA1 and the MSW HR files had no EM training documented. This was confirmed and discussed with the HR staff and Team Coordinator present.

Observed in Emergency Management Session. During the Emergency Management session it was noted that the organization did not test its plan in any of the last 3 years. This was confirmed and discussed with the VP of Clinical Services and the Team Coordinator.

Observed in Record Review. In 2 of 10 patient records reviewed, it was noted that the comprehensive assessment was not completed. For example in record RRHV#3 and RRNHV#5 there was no documentation of an initial bereavement or initial spiritual counselor assessment. This was confirmed and discussed with the Team Coordinator present.

Observed in Record Review. In 1 of 12 patient records reviewed, it was noted that the interdisciplinary group updates were incomplete. For example, in record RRDC#1 the nurse's IDG documentation prior to discharge for extended prognosis stated Pt due to be discharged for extended prognosis and MD's area was left blank. This was confirmed and discussed with the VP of Clinical Services and the Team Coordinator.

Observed in Record Review. In 3 of 4 patient records reviewed, it was noted that not all required core disciplines attended interdisciplinary meetings. The organization's process to document attendance at the IDGs was to sign into the IDG note in the EHR and on multiple records core disciplines signatures were missing. For example in records RRBR#1, RRBR#2 and RRDC#1 there was no RN signature on the IDG and record RRDC#1 there was no MD signature. This was confirmed and discussed the VP of Clinical Services and Team Coordinator present. Observed in Record Review. During record review it was noted that the organization failed to discuss the patient's condition for potential extended prognosis and documented at the IDG meeting. For example in record RRDC#1 the patient was discharged for extended prognosis however there was no documentation of discussion at IDG and no discharge order in the record. This was confirmed and discussed with the VP of Clinical Services and the Team Coordinator.

Observed in Data Session. During Data session it was noted that the QAPI program did not involve all services provided as evidenced by the HCO was not able to produce this documentation at the time of survey, such as contracted staff. The hospice surveyor noted the QAPI program did not include indicators that were related to improved palliative outcomes as evidenced by the HCO was not able to produce this documentation at the time of survey. This was confirmed with the VP of Clinical Services and Team Coordinator present. Observed in Data Session. During the Data session it was noted that the HCO was not able to demonstrate the operation of its QAPI program as evidenced by the HCO was not able to produce the documentation of the program or speak to the program at the time of survey. This was confirmed with the VP of Patient Services and Team Coordinator present.

Observed in Data Session. During the Data session it was noted that the QAPI program did not demonstrate improvement in its palliative outcomes and hospice services as evidenced by the HCO was not able to provide documentation at the time of survey. This was confirmed and discussed with the VP of Clinical Operations and Team Coordinator present.

Observed in Data Session. During the Data session it was noted that the hospice did not use patient care indicator data in the design of its quality assessment and improvement program as evidenced by the HCO was not able to produce this documentation at the time of survey. This was confirmed and discussed with the VP of Clinical Operations and Team Coordinator present.

Observed in Data Session. During the Data session it was noted that the HCO did not analyze and compare data over time to identify levels of performance, patterns, trends and variations as evidenced by lack of documentation. This was confimed and discussed with the VP of Clinical Operations and Team Coordinator present. Observed in Data Session. During the Data session it was noted that the HCO did not use the results of data analysis to identify improvement opportunities as evidenced by no records or documentation. This was confirmed and discussed with the VP of Clinical Operations and Team Coordinator present.

Observed in Data Session. During the Data session it was noted that the hospice did not effectively evaluate its QAPI program annually as evidenced by the Governing board minutes mentioning the QAPI plan and data however the HCO was not able to produce this documentation at the time of survey. This was confirmed with the VP of Clinical Services and Team Coordinator present.

Observed in Data Session. During the Data session it was noted that performance improvement was not organization wide as evidenced by limited data provided and QAPI meeting minutes with verbal discussion of items from greater than 6 months prior with no data support. This was confirmed and discussed with the VP of Clinical Operations and Team Coordinator present. Observed in Tracer Activities. During review of the Volunteer program and discussion with leadership it was noted that leaders failed to identify priorities for performance improvement. For example, the volunteer coordinator left the organization 13 months prior to survey and the only volunteer left the organization 10 months prior to survey. Leadership via the governing board minutes or QAPI committee minutes did not address the volunteer program, the interim plan or ongoing plan for the program. Also during the Data session it was noted that the HCO leadership did not establish priorities for data collection/PI activities as evidenced by review of the Governing board minutes, QAPI committee minutes and review of data. Only 2 items of data were available. This was confirmed and discussed with the VP of Clinical Services and Team Coordinator present.

Observed in Infection Control System Tracer. During the Infection Control/Data system tracer it was noted that the organization's infection prevention and control activities did not include any surveillance or recording of patient infections. This was confirmed and discussed with the VP of Clinical Services and the Team Coordinator present.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement services it was noted that the Bereavement care plans did not include specific, individualized interventions, and 3 care plans were identical. This was confirmed and discussed with the VP of Clinical Services and the Team Coordinator.

Observed in HR File Review. In 2 of 2 HR files reviewed, for hospice aides it was noted that there were no in-service education hours documented. For example HHA1 and HHA2's HR files did not have any documentation of education hours. This was confirmed and discussed with the HR staff and Team Coordinator present.

Observed in Tracer Activities. During discussion with the Vice President of Clinical Operations it was noted that the organization did not have any active volunteers in the last 10 months and had not documented efforts to recruit them.

Observed in Tracer Activities. During review of the Volunteer program it was noted that the organization had not had any volunteers for 10 months and prior to 10 months it was reported that they had 1 volunteer. The organization did not have any documentation of the cost saving achieved through the use of the volunteer, the position occupied by the volunteer, the work time spent by the volunteer occupying the position or the dollar costs that the hospice would have incurred if paid employees occupied the position identified. This was confirmed and discussed with the VP of Clinical Operations.

Observed in Tracer Activities. During review of the Volunteer program it was noted that volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff. The organization has had no volunteer for 10 months and 1 volunteer prior to that with no documentation of the percentage of hours. This was confirmed and discussed with the VP of Clinical Operations.

Observed in Data Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by…condition level findings at 418.58, 418.78 and 418.102

Observed in HR File Review. In 2 of 8 HR files reviewed, it was noted that staff competency was not assessed as part of orientation. For example the RN file initial competency was completed after 13 months of employment and the Bereavement Coordinator did not have any documented competency. This was confirmed and discussed with the Team Coordinator and HR staff present. Observed in HR File Review. In 1 of 8 HR files reviewed, During HR file review it was noted that the organization's policy required annual competences and the Medical Director did not have competencies documented per policy for the last three years. The Medical Directors most recent competency was in 2021. This was confirmed and discussed with the HR staff and Team Coordinator present.

Observed in Record Review. In 4 of 10 patient records reviewed, it was noted that the certification of terminal illness was not completed. For example, in records RRNHV#1, #2 and #4 and RRHV#3 the Medical Director had not documented a review of the clinical information or signed the initial certificate of terminal illness. This was confirmed and discussed with the VP of Clinical Services and Team Coordinator.

Observed in Record Review. In 3 of 4 patient records reviewed, that included patients on service for more than 1 certification period it was noted that the Medical Director failed to review the clinical information and sign the CTI prior to recertification. For example in record RRHV#2 the patient's 6th recertification period began 19 days ago. The CTI area for the RN was completed, but the physician area was blank with no signature. In record RRHV#1 the patient's 3rd recertification period began 8 days ago. The CTI area for the RN was completed, but the physician area was blank with no signature. In record RRNHV#7 the patient's 17th recertification period began 5 days ago and the CTI area for the RN was complete but the physician area was blank with no signature. The was confirmed and discussed with the VP of Clinical Operations and Team Coordinator present.

Observed in Record Review. In 1 of 2 patient records reviewed, post patient death, it was noted that the death visit document was missing. This was confirmed and discussed with the VP of Clinical Services and the Team Coordinator present.

Observed in Record Review. In 11 of 11 patient records reviewed, the Hospice Surveyor noted patient goals had been generic, non-specific and without an appropriate time frame. examples include: for pain: The patient will remain at a comfortable level during care'; for constipation: 'Patient will have optimal bowel elimination and comfort'. For musculoskeletal: 'Pt will have optimal functional activities.' All were to be achieved by the end of the plan of care. This was validated with the DOPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the Hospice Surveyor noted patient care orders had been incomplete. HOS HV #2, the foley catheter order was: Foley catheter-16F- May irrigate PRN with 20-50cc Normal saline.-May replace as needed for dislodgment. The order had been missing the balloon size of the catheter, and the indications for the prn irrigation. This was validated with the DOPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the Hospice Surveyor noted Hospice Aide supervisory visits had not been completed every 14 days. This was found in HOS RR # 9, where the patient had not had a HA supervisory visit from June until October. Validated with the DOPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, The Hospice Surveyor noted the Medical Director failed to review the clinical information and sign the CTI prior to recertification. This was noted in HOS RR #4. The same patient was transferred from a different hospice and the Medical Director had not completed a CTI upon transfer. This was validated with the DOPCS.

Observed in Record Review. In 2 of 4 patient records reviewed, where the patient had an open wound requiring intervention, the Hospice Surveyor had been unable to validate that wound care had been completed as ordered as the steps had not been described. For example, in HOS HV #1, the documentation was: 'Wound care was given this visit', and 'Current treatment applied'. HOS HV # 3 wound care had been documented as 'wound care done per orders', 'Dressing changed as per orders', and 'Wound care given to left buttock'. This was validated with the DOPCS