Every finding on record at Silver Sky Hospice, Inc.

Observed in Individual Tracer. The organization did not reduce the risk of infections associated with medical equipment, devices, and supplies. During home visit 1 it was observed that the nurse dropped several items on the floor such as a pen and a folder and wiped them with baby wipes (non-disinfecting) before returning them to her bag. This was discussed with the Administrator. Observed in Individual Tracer. The organization did not implement the infection prevention and control activities it has planned. During home visit 1 the RN did not cleanse her hands after patient care and before entering the nursing bag per policy. This was discussed with the Administrator. Observed in Individual Tracer. The organization did not reduce the risk of infections associated with medical equipment, devices, and supplies. During home visit 1 the RN cleaned the equipment used for vital signs with baby wipes rather than the disinfecting solutions per policy. The nurse explained that the patient and wife had allergies to the Clorox disinfectant wipes that she normally used and that she planned to disinfect the equipment with the Clorox wipes after she got the equipment to her car. The nurse place the equipment back in the nursing bag after it was wiped with the baby wipes so the equipment was contaminated when being placed in the bag. This was discussed with the Administrator.

Observed in HR File Review. In 2 of 8 HR files reviewed, Staff did not participate in ongoing education and training. During review of HR records 2 and 7 there was no documentation of ongoing training. This was confirmed by the HR manager.

Observed in HR File Review. The organization did not provide orientation to staff. During review of HR record 2 it was noted that the orientation sheet was not signed by a supervisor. This was confirmed by the HR manager.

Observed in Record Review. In 5 of 13 patient records reviewed, The medical director, physician member of the interdisciplinary team, or physician designee did not provide written certification that the patient’s life expectancy is six months or less if the illness runs its normal course. Note: The determination of the patient’s life expectancy considers the following factors: - The primary terminal condition - Related diagnoses, if any - Current subjective and objective medical findings - Current medication and treatment orders - Information about the medical management of the patient’s conditions unrelated to the terminal condition During review of records 2,7,8,10 and 13 it was noted that there was not a certification of terminal illness. This was confirmed by the Case Manager.

Observed in Record Review. In 2 of 13 patient records reviewed, Entries in the record were not authenticated. Entries must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. During review of records 1 and 5 it was noted that aide notes were electronically signed by a nurse rather than by the aide. This was confirmed by the Case Manager.

Observed in Emergency Management Session. The surveyor was unable to review the organization EOP that included the following: Maintaining or expanding services, conserving resources, curtailing resources, helping patients and families develop a home emergency plan, Educating them about self-care and sources of alternative care in the community, coordinating home visits from another agency office or alternative care site in the community, supplementing resources from outside the local community and curtailing admissions of new patients. The organization was not able to produce an EOP that the surveyor could assess or if the plan was reviewed and updated.

Observed in Emergency Management Session. The surveyor could not assess the EOP that described how the organization will obtain and replenish medications and related supplies that will be required in response to an emergency. The organization could not produce the EOP for the surveyor to review.

Observed in Emergency Management Session. The surveyor was unable to assess the EOP that described how staff will be notified that emergency response procedures have been initiated. The organization could not produce the EOP for the surveyor to review.

Observed in Emergency Management Session. The surveyor was unable to assess how the organization prepared for how it will manage resources and assets during emergencies as the EOP was not produced for the surveyor to review..

Observed in Emergency Management Session. The surveyor was unable to assess if the organization conducted tests of its emergency plan as the organization could not provide the surveyor with evidence of documented disaster drills.

Observed in Document Review. During review of the organization admission packet information it was noted the consent form lacked the hospice benefit election date, the choice of attending physician and the notification of possible noncovered medications, supplies and other items.

Observed in Record Review. In 1 of 2 patient records reviewed, During HV#1 record review it was noted documentation in the goal section of the POC were assessment measures. For example: Prevent discomfort due to increasing edema. Goals: Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects, Assess / monitor cardiac status every visit,Assess and monitor effectiveness of medications, Educate Pt/Family/PCG to notify hospice regarding changes, Instruct on sign and symptoms of impending exacerbation and how to manage. Optimal bowel elimination and comfort. Goals: Facilitate optimum bowel movement, Pt/Family/PCG will verbalize having elimination needs met at an acceptable level, Pt/Family/PCG will verbalize understanding that symptom is a part of the disease process and the limitations of treatments, Reduce discomfort with improved bowel elimination status, Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects, Assess / monitor effectiveness of medications, Assess / monitor nutritional needs every visit, Assess bowel status every visit, Assist family in finding ways to re-direct their desire to provide fluids by teaching them mouth care including oral hygiene

Observed in Record Review. In 1 of 2 patient records reviewed, During HV#1 record review it was noted lack of SN, MSW, Chaplain and hospice aide frequency and duration of visits on the POC.

Observed in Record Review. In 2 of 2 patient records reviewed, In HV #1, it was noted on the RN initial assessment oxygen safety assessment form and documentation that the patient uses oxygen at 2L/min PRN SOB. The order for oxygen therapy is not on the POC or the medication profile. During RR#1 it was noted an order for oxygen therapy of 2-5L/min continuous. There are no direction on titration of the liter flow.

Observed in Record Review. In 1 of 2 patient records reviewed, During HV#1 record review there is lack of documentation of IDG meetings/collaboration since April 2022 to date in the medical record.

Observed in Data Session. The organization was unable to provide the surveyor with written documentation of an effective, ongoing, data driven QAPI program that included all hospice services, reflected the complexity of the operation and included indicators related to palliative outcomes and document actions to demonstrate improvement in hospice performance. Observed in Data Session. The organization was unable to provide the surveyor with documentation that it conducted and has an effective, ongoing, organizationwide, data-driven quality assessment and performance improvement program. The surveyor was unable assess documentary evidence of the organization QAPI plan Observed in Data Session. The surveyor was unable to determine if the organization had an effective, ongoing, organizationwide, data-driven quality assessment and performance improvement program in place as the organization could not provide the surveyor with a QAPI plan.

Observed in Data Session. The surveyor was unable to assess the quality assessment and performance improvement program improvement in indicators related to improved palliative outcomes and hospice services as the organization was unable to provide the surveyor with data related to palliative outcomes and could not produce a QAPI plan for the surveyor to review.

Observed in Data Session. The surveyor was unable to assess if the quality assessment and performance improvement program demonstrated improvement in the indicators related to palliative outcomes and hospice services. The organization was unable to produce a QAPI plan for the surveyor to review.

Observed in Infection Control System Tracer. The surveyor could not validate the organization maintained an infection control program for the protection of patients, families, visitors, and staff, and included surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. The infectious and communicable disease program was not described and presented to the surveyor in writing to review.

Observed in Patient Home. In 1 of 1 home visits conducted, During HV#1 it was noted the SN entered her nursing bag multiple times with gloved hands after touching the patient and the patient's environment. The SN did not adhere to the organization bag technique policy. Observed in Patient Home. In 1 of 1 home visits conducted, During HV#1 it was noted the SN did not follow the organization hand hygiene policy. The SN disinfected her hands at the beginning of the visit, donned gloves and disinfected her gloved hands throughout the visit. She did not remove her gloves and disinfect her hands and replace with a new pair of gloves during the visit.

Observed in Infection Control System Tracer. The surveyor could not assess if the organization's written infection prevention and control goals included limiting unprotected exposure to pathogens. The organization could not produce the infection control goals for the surveyor to assess. Observed in Infection Control System Tracer. The surveyor could not assess the organization's written IC goals that included limiting the spread of infections associated with procedures. The organization could not produce the goal for limiting the spread of infection associated with procedures. Observed in Infection Control System Tracer. The surveyor was unable to assess if the organization had set goals for its prioritized risks. The organization was unable to produce it infection control goals for the surveyor to review. Observed in Infection Control System Tracer. The surveyor could not assess the organization's written IC goals that included the following limiting the spread of infections associated with the use of medical equipment, devices, and supplies. The organization could not produce the IC goal limiting the spread of infections associated with the use of medical equipment, devices, and supplies.

Observed in HR File Review. In 1 of 1 HR files reviewed, for hospice aides. During HR#5 file review it was noted lack of documentation that demonstrated compliance with initial home health aide or hospice aide training requirements. The competence assessments was blank.

Observed in HR File Review. In 4 of 7 HR files reviewed, During HR#2, #3, #4 and #5 file review it was noted lack of orientation to the employees specific job duties. In addition HR#3 chaplain's orientation check list was blank. HR#4 Medical Director's orientation check list was blank. HR#5 DPCS orientation check list was blank.

Observed in HR File Review. In 4 of 7 HR files reviewed, During HR#2 review it was noted lack of initial competency assessment as part of the MSW orientation. During HR#3 file review it was noted lack of an initial competency performed with the Chaplain. During HR#4 file review it was noted lack of initial competency performed with the Medical Director. During HR#5 file it was noted lack of initial competency as part of the DPCS orientation. Observed in HR File Review. In 1 of 1 HR files reviewed, for hospice aides. During HR#5 file review it was noted lack of documentation that demonstrated compliance with initial home health aide or hospice aide training requirements. The orientation check list was blank.

Observed in Record Review. In 1 of 2 patient records reviewed, During HV#1 record review it was noted the medications in the home did not match the medication profile. The patient stated she no longer used Robitussin for the past 2 months, does not take Zinc tablets and Bacitracin ointment was discontinued according to the patient. The patient stated she takes Losartan 25 mg daily that was not on the medication profile.

Observed in HR File Review. In 2 of 7 HR files reviewed, During HR#2 and HR#5 review it was noted lack of documentation of a criminal background check completed at hire.