Every finding on record at Reflections Hospice of Arizona North, LLC

Based on interview, review of policy and procedure and review of facility documents, the Department has determined the Administrator failed to ensure that each hazard identified as a high risk in the facility risk assessment was addressed in the facility emergency plan. Failure to address high-risk scenarios can result in the facility being unprepared for emergency events, resulting in injury or death of patients and staff. Findings include: --- Facility policy titled, "...Emergency Preparedness Policy...." revised 4/28/2022 revealed: "...Centrix will be prepared to address all hazards that may occur weather [sic] caused by humans or natural phenomenon that would require action by home care and emergency service personnel...." A review of the facility all-hazards risk assessment completed on May 23, 2023 revealed: "...Environmental/altered air quality/pollution....3...." Although Environmental/altered air quality/pollution was rated 3 on a scale of 1 to 3 with 3 being the highest rating for dangerousness, a review of the Centrix/Anthem Emergency Preparedness plan indicated no plan for Environmental/altered air quality/pollution. A subsequent interview with Employees #1 and #2 conducted on April 24, 2024 acknowledged that all highly rated hazards should be addressed by the facility emergency preparedness plan.

Based on interview and review of facility records, the Department has determined the Administrator failed to ensure the facility's emergency preparedness communication plan included the contact information for doctors servicing patients, and for entities providing services under arrangements to the patients and other hospices. Failure to include contact information for physicians, other hospices and entities providing services under arrangement to patients can result in patients losing contact with vital services through their facility. --- A review of the facility Emergency Preparedness Plan and Communication Plan revealed that the Plans did not include the contact phone numbers for any patient physicians other than the contact phone number for the facility medical director. No other hospice phone numbers were included. The phone numbers for entities providing services under arrangement were missing. A request was made for this information and could not be provided. A subsequent interview was conducted with Employees #1 and #2 on April 24, 2024 who indicated that, although many patients choose to have the medical director as their physician of choice, some patients continue to choose their own physician, but these physician phone numbers have not been included in the emergency preparedness plan. No other hospice phone numbers have been included in the plan; however, Employee #1 and #2 did state that, although there were no phone numbers for entities providing services under arrangement contained within the plans, there may be lists with some of these phone numbers contained within them provided to staff in the event of an emergency.

Based on interview and review of facility documents, the Department has determined the Administrator failed to ensure that a full-scale exercise or a tabletop exercise were completed at least annually that included documentation of participation of staff with an accompanying analysis. Failure to include an analysis, or an after-action report, can result in staff not engaging with the exercise and learning what they could have done differently or what they could be missing from the tabletop or full-scale exercise scenario, resulting in lack of preparedness in the event of a real emergency situation. Findings include: --- A review of tabletop exercises completed by Anthem staff on January 25, 2024, May 23, 2023 and April 28, 2022 revealed no after action report or analysis for any of the three exercises. The exercise completed on April 28, 2022 also had no scenario accompanying it. A request was made for after action reports or analyses for these three exercise events but they could not be provided. In a subsequent interview conducted with Employee #1 and #2, it was acknowledged that these after action reports had not been completed and could not be provided.