Every finding on record at Saint Verena Hospice Care, Inc

Observed in Emergency Management Session. During document review and discussion, the surveyor noted that the HCO did not conduct a test of it's emergency plan for 2023, 2024 or 2025. This was validated in an observation by the Administrator and the DPCS.

Observed in Emergency Management Session. During document review and discussion, the surveyor noted that the HCO did not complete a Hazardous Vulnerability analysis for 2025 and 2026. This was validated in an observation by the Administrator and the DPCS.

Observed in Medical Management Session. - Leaders failed to identify priorities for performance improvement During document review and discussion, the surveyor noted that the HCO did not identify in writing High-Alert/Hazardous Meds. The area in the policy and procedure manual was blank and the organization could not produce a written document. This was validated in an observation by the Administrator and the DPCS.

Observed in Record Review. During document review and discussion, the surveyor noted that the HCO did not document the efforts to recruit and retain volunteers for the past 3 years. This was validated in an observation by the Administrator and the DPCS.

Observed in Data Tracer. During review of the Volunteer program for the past 3 years, there was no documentation to validate cost savings had been achieved using volunteers. In discussion with the Volunteer Coordinator, information regarding cost savings is not being tracked nor documented. This was validated in a discussion with and observation by the Administrator and DCPS.

Observed in HR File Review. In 8 of 8 HR files reviewed, During HR document review and discussion, the surveyor noted that in 8 of 8 files the HCO had not provided workplace violence education as required. This was validated in an observation by the Administrator and the DPCS.

Observed in HR File Review. During document review and discussion, the surveyor noted that the HCO did not verify the education of the Chaplain. This was validated in an observation by the Administrator and the DPCS.

Observed in HR File Review. In 2 of 10 Personnel records reviewed, there was no evidence that the organization had trained staff for their assigned emergency response roles. It was identified during the review of HR3 Licensed Vocational Nurse, and HR6 Certified Hospice Aide, that these staff had not received training for their assigned emergency response roles. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 1 records reviewed where the patient revoked hospice services, the organization did not respect the patient's right to elect and revoke hospice care. Identified during the review of RR#9, there was no documentation of a Revocation Form being signed. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 5 of 10 active patient records reviewed, the hospice's interdisciplinary group, did not complete the initial comprehensive assessment withing five (5) calendar days after the election of hospice care. For example, identified in the review of HV#3, the Medical Social Worker did not complete the initial comprehensive psychosocial assessment or the initial bereavement risk assessment until day 12 following the start of care date. In RR#2, the initial bereavement risk assessment was not completed until approximately 5 months following the start of care date. In RR#3, the initial bereavement risk assessment was not completed until approximately 3 months following the start of care date. In RR#5, the Medical Social Worker did not complete the comprehensive psychosocial assessment or the initial bereavement risk assessment until day 6 following the start of care date. In RR#11, it was identified that the initial bereavement risk assessment was not completed prior to the patient's death 7 1/2 months following the start of care date. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 3 of 10 active patient records reviewed, the organization did not ensure that the hospice's interdisciplinary group updated the comprehensive assessment every 15 days in accordance with Policy No. 2-049.1,2 (8) The interdisciplinary group will conduct assessments . . . a minimum of every two weeks. For example in the review of the record for HV#1, the Registered Nurse (RN) completed the ongoing comprehensive assessment on day 18 during the fourth month following the start of care date, and as of the survey date, is 4 days late in completing the ongoing comprehensive assessment approximately 7 months following the start of care date. In the review of HV#2, the RN completed the ongoing comprehensive assessment on day 19 approximately 3 weeks following the start of care date, and as of the survey date is 7 days late in completing the ongoing comprehensive assessment approximately 2 months following the start of care date. In the review of RR#6, it was identified that the RN ongoing comprehensive assessment was 15 days late approximately 2 months following the start of care date. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 10 active patient records reviewed, the organization did not provide care according to the patient's individualized plan of care. For example in HV#1, the hospice aide visit frequency was 3 times per week but was seen only twice during weeks 4, 11, and 24 following the start of care date. This was reviewed and validated with the Director of Patient Care Services.

Observed in Patient Home. In 1 of 1 home visits conducted where the clinician used reusable medical equipment, the organization did not ensure the risk of infections was reduced in accordance with Policy 9-014.2 - 5) When the visit is completed, reusable equipment will be cleaned using alcohol and/or soap and water as appropriate . . .. Observed in HV#3, the Registered Nurse used a Lysol disinfecting wipe to clean the stethoscope, blood pressure manual cuff, and infrared thermometer. This was reviewed and validated with the Director of Patient Care Services.

Observed in HR File Review. In 1 of 3 Certified Hospice Aide Personnel Records reviewed, there was no evidence that the 12-hours of in-service training was completed during 2022. It was identified in the review of HR6 that the Certified Hospice Aide had no documented attendance to in-services provided in 2022. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 4 of 10 active patient records reviewed, the Registered Nurse (RN) did not conduct a supervisory visit to the patient's home every 14 days. For example, in HV#1, the supervisory visit was 5 days late during the fourth month following the start of care date, and as of the survey date, was 5 days late approximately 7 months following the start of care date. In HV#2, the supervisory visit was 6 days late approximately 3 weeks following the start of care date, and as of the survey date was 8 days late approximately 2 months following the start of care date. In the review of RR#6 the supervisory visit was 16 days late approximately 2 months following the start of care date. In the review of RR#7, it was identified that the supervisory visit was 17 days late approximately 3 months following the start of care date. This was reviewed and validated with the Director of Patient Care Services.

Observed in HR File Review. In 2 of 10 Personnel Records reviewed, the organization's education and training did not comply with law and regulation. It was identified in the review of HR3 Licensed Vocational Nurse, and HR 6 Certified Hospice Aide, that these staff did not complete the annual OSHA Blood Borne Pathogens training. This was reviewed and validated with the Director of Patient Care Services.