Every finding on record at South Valley Hospice Services, Inc.

Observed in Emergency Management Session. The hospice did not have a comprehensive emergency management program utilizing an all-hazards approach. The current plan was last revised in 2020. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. The hospice did not review and update the plan based on after-action reports or opportunities for improvement every two years or more frequently. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. In the absence of an evaluated and prioritized hazard vulnerability assessment, the hospice was not able to identify and implement mitigation and preparedness activities. This RFI was reviewed with the Administrator and Director of Patient Care Services. Observed in Emergency Management Session. There was no evidence that the hospice evaluated and prioritized the findings of the hazard vulnerability assessment. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. The hospice did not have a continuity plan that identified in writing how and where it would continue to provide essential business functions when the service location had been compromised due to an emergency. This RFI was reviewed with the Administrator and Director of Patient Care Services. Observed in Emergency Management Session. The hospice did not have a written delegation of authority plan to provide the individual with the legal authorization to act on behalf of the organization for specified purposes and to carry out specific duties. This RFI was reviewed with the Administrator and Director of Patient Care Services. Observed in Emergency Management Session. In the absence of an emergency operations plan, the hospice did not identify the patient populations that it would serve and the services it would provide. This RFI was reviewed with the Administrator and Director of Patient Care Services. Observed in Emergency Management Session. The hospice did not have a written continuity of operations plan developed with the participation of leaders. This RFI was reviewed with the Administrator and Director of Patient Care Services. Observed in Emergency Management Session. The hospice did not have a written order of succession that identified who was authorized to assume a particular leadership or management role when that person was unable to perform their duties. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. In the absence of an emergency operations plan, the hospice could not document a process for cooperating and collaborating with other health care organizations. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. The hospice did not have a written all-hazards emergency operations plan with supporting policies and procedures to provide guidance to staff and volunteers on actions to take during emergency or disaster incidents. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. The hospice’s plan for providing patient care and clinical support did not include written procedures for determining what services were needed in the event of an interruption in services during an emergency. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. The hospice did not have a communications plan that identified primary and alternate means for communication with staff and authorities. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. The hospice’s plan for providing patient care and clinical support did not include policies and procedures for informing state and local emergency officials about patients in need of evacuation. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. The hospice did not have a staffing plan to address the management of all staff and volunteers. This RFI was reviewed with the Administrator and Director of Patient Care Services. Observed in Emergency Management Session. The hospice did not develop a staffing plan for managing all staff and volunteers based on the settings and services provided to meet patient care needs during an emergency. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. The hospice’s plan for providing patient care and clinical support did not include written procedures and arrangements with other health care providers for how it would share patient information and documentation and provide transportation. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. In the absence of an emergency operations plan, the hospice did not have a contact list of individuals and entities to be notified in response to an emergency or disaster incident. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. The hospice did not have a communications plan that included a method for sharing location information and medical documentation for patients. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. The hospice did not have a communications plan that described how it would communicate with and report information about its needs, available occupancy, and ability to provide assistance to relevant authorities. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. The hospice did not have a written education and training program in emergency management based on the prioritized risks identified in the hazard vulnerability analysis, the emergency operations plan, communication plans, and policies and procedures. This RFI was reviewed with the Administrator and Director of Patient Care Services. Observed in Emergency Management Session. The hospice did not describe in writing a plan for when and how it will conduct annual testing of its emergency operations plan. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. The hospice did not provide initial education and training in emergency management to all new and existing staff, contract staff, and volunteers consistent with their roles and responsibilities in an emergency. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 2 of 14 patient records reviewed, the hospice did not inform the patient of their rights prior to beginning care. In records RRHV#1, RRHV#2 the payment section was blank on consent forms. This RFI was reviewed with the Administrator and Director of Patient Care Services. the hospice did not inform the patient of their rights prior to beginning care. In records RRHV#1, RRHV#2 the payment section was blank on consent forms. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 10 of 10 active patient records reviewed, interdisciplinary meeting notes did not include comprehensive assessments that documented decline, plan of care revisions, and goals. Nursing, spiritual care and psychosocial notes consistently did not identify changes that had occurred, and most goals were to be completed in two weeks. Only four of 150 goals written in ten records were resolved. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Patient Home. In 3 of 3 home visits conducted, the hospice failed to coordinate care and services. For example, plans of care in hospice binders in assisted living facilities at RRHV#1 and RRHV#2 were dated more than 14 days before this survey date which resulted in facility staff not having current plans of care as required by their policy. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Patient Home. In 2 of 3 home visits conducted, the hospice did not implement infection prevention activities. For example, at patient visit RRHV#1 a home health aide cleaned equipment with disinfecting wipes by applying the solution to all surfaces of each item and placing it on a barrier to dry. A licensed al nurse cleaned equipment the same way at patient visit RRHV#2. The manufacturer’s instructions for use requiring four minutes dwell time for disinfection were not followed. This RFI was reviewed with the Administrator and Director of Patient Care Services. Observed in Patient Home. In 1 of 3 home visits conducted, hospice staff failed to perform hand hygiene according to policy. At visit RRHV#1 a home health aide cleansed her hands several times throughout the visit. During one of those times, she applied hand sanitizer gel but did not continue to rub her hands until dry. Rather, she briefly waved her hands in the air to accelerate drying. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Infection Control System Tracer. In the absence of an infection control plan there were no goals for limiting unprotected exposure to pathogens. This RFI was reviewed with the Administrator and Director of Patient Care Services. Observed in Infection Control System Tracer. In the absence of an infection control plan there were no goals for limiting the spread of infections associated with procedures. This RFI was reviewed with the Administrator and Director of Patient Care Services. Observed in Infection Control System Tracer. In the absence of a prioritized risk assessment there were no goals for improving risks. This RFI was reviewed with the Administrator and Director of Patient Care Services. Observed in Infection Control System Tracer. In the absence of an infection control plan there were no goals for improving compliance with hand hygiene guidelines. Note that hand hygiene practices were observed for all staff in 2023 with one hundred percent compliance. This RFI was reviewed with the Administrator and Director of Patient Care Services. Observed in Infection Control System Tracer. In the absence of an infection control plan there were no goals for limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Tracer Activities. Leaders did not manage implementation of policies and procedures governing the provision of care. Documentation failures were identified in the following: the emergency operations plan; the infection control program; and documentation of certificates of terminal illness in the medical records. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 4 of 10 active patient records reviewed, the hospice did not ensure that all disciplines collaborated in the care of the patient. For example, in record5 RRHV#1, RRNHV#2, RRNHV#4, RRNHV#5 the attending physician did not sign the initial certificate of terminal illness as required in policy 2-026 entitled Certificate of Terminal Illness. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 6 of 10 active patient records reviewed, the hospice did not ensure that the medical director signed subsequent certificates of terminal illness within two days of the new benefit period as required in policy 2-026 entitled Certificate of Terminal Illness. For example, documents were not signed until five to 22 days after the start of the benefit period in records RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#2, and RRNHV#3. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Patient Home. In 10 of 10 active patient records reviewed, the hospice did not provide information on procedures to follow if care, treatment, or services were disrupted by a natural disaster or emergency. No individualized emergency plans providing patient specific information gathered during assessments and re-assessments were found in RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, or RRNHV#7. This RFI was reviewed with the Administrator and Director of Patient Care Services.

Observed in Infection Control System Tracer. The hospice failed to maintain an infection control program for the protection of patients, families, visitors, and staff. The program was not described in writing and was not an integral part of its QAPI program. This RFI was reviewed with the Administrator and Director of Patient Care Services.