Every finding on record at Sunrise Healthcare Inc

Based on review of hospice documents, observations and interviews, it was determined the hospice failed to comply with regulations required for an Emergency Preparedness Plan. This deficient practice poses a risk to patients and staff members health and safety if staff are not able to provide patients a safe environment during an emergency situation. --- Findings include: A request was made for the hospice Emergency Preparedness Plan, not provided. Interview with Administrator and DON confirmed that no Emergency Preparedness Plan existed for the hospice.

Based on review of documents, observations and interviews, it was determined that the hospice: Failed to involve the patient in the development of the patients plan of care Failed to update the patient care plan regarding missed visits and calendar changes. This deficient practice poses a risk to the health and safety of patients if patients are not provided consistent care and services. --- Findings include: Review of patient records for Patients #1 through #12 revealed no documentation of communication regarding missed visits. Review of patient records for Patients #1 through #12 revealed no documented updates or any subsequent changes in the plan of care regarding missed visits. Interview with Administrator and DON confirmed that no missed visit communication was made with patients and no updates were made to the plan of care.

Based on hospice documents, observations and interviews, it was determined the hospice failed to develop and maintain a system of communication and integration to provide for and ensure the ongoing sharing of information between all disciplines. This deficient practice poses a risk to the health and safety of patients if patients are not provided consistent care and services. --- Findings include: Review of patient records for Patients #1 through #12 revealed no documentation of communication regarding missed visits. Review of patient records for Patients #1 through #12 revealed no documented updates or changes in the plan of care regarding missed visits. Interview with Administrator and DON confirmed that no missed visit communication was made with patients or physicians, and no updates were made to the plan of care.

Based on review of documents and interview, it was determined that the Hospice facility failed to assess quality in all areas of operations that might be adversely affecting patient care or core hospice services. This deficient practice poses a risk to patients if the Hospice facility does not monitor services provided to ensure quality care and services are being provided to patients. Cross reference: L0559, L0561, L0563, L0579 --- Findings include: Request was made for the Hospice facilitys Quality Assurance and Performance Improvement (QAPI) Plan. The Hospice could not provide one. QAPI plan was requested, not received. Interview with Administrator on 08/15/2024 confirmed that the Hospice did not have a QAPI Plan in place and was not conducting or monitoring QAPI indicators.

Based on interviews, record review and observation it was determined that the governing body failed to ensure the quality assessment and performance improvement program (QAPI) was in compliance or appoint an individual to administer a QAPI program for the hospice. This deficiency poses a risk to the identification and reduction of adverse events for patients. --- Request made for the Governing Body minutes regarding the Quality assessment and performance improvement program (QAPI) for the past 12 months, none was provided. Interview with Administrator on 08/15/2024 confirmed that no governing body minutes were documented, no information was presented at the time of survey.

Based on review of documents and interview, it was determined that the hospice failed to designate an individual(s) to operate the QAPI program. This deficient practice poses a risk to patients if the Hospice facility does not monitor services provided to ensure quality care and services are being provided to patients. --- Findings include: Request was made to speak to the individual in charge of the Hospice facilitys QAPI program. The Hospice facility has no designated individual. Request was made for the Hospice facilitys Quality Assurance and Performance Improvement (QAPI) Plan. The Hospice could not provide one. Interview with Administrator on 08/15/2024 confirmed that The Hospice did not have a designated person in charge of the QAPI program.Administratot confirmed that the Hospice did not have a QAPI Plan in place and was not conducting or monitoring QAPI indicators.

Based on record review and interview, it was determined that the hospice failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases. This deficient practice poses the potential risk to health and safety of patients when infections and communicable diseases are spread amongst patients and staff of the hospice. --- Findings include: A copy of the facility's policy regarding infection control was requested. None was provided. Review of personnel files revealed that TB testing was only documented in two (2) out of five (5) employees in the personnel files Interview with Administrator and DON on 08/15/2024 confirmed that personnel files revealed that TB testing was only documented in two (2) out of five (5) employees in the personnel files. Interview with DON on 08/15/2024 confirmed that there was no documentation of TB testing or surveillance survey for the other three (3) staff members

Based on review of facility policy, record review, and interview it was determined that the hospice failed to provide supervised assessment and competency based orientation to personnel. This deficiency poses a risk to the patients if unqualified staff are providing patient care. Cross reference: L0583 --- Findings include: Hospice Policy No. 4A.10.1, and 4A.14.1 titled, ";Initial" and "Competency Based Orientation", respectively, revealed, ";... Policy Hospice ensures that the competency of all personnel is assessed on hire, prior to providing care to hospice patients. A review of Clinical Employees files #2, #4, #5, #8, #9, and #10 revealed that no skills verification had been performed or documented by the DON or a supervisory clinical member. Interview with Administrator and DON on 08/15/2024 confirmed that no skills verification was being conducted with employees.

Based on review of documents, personnel files and interviews, it was determined that the Hospice facility failed to ensure volunteers were being utilized to assist in providing services to patients. This deficient practice poses a risk to patients when volunteers are not utilized to assist in meeting the needs of patients. --- Findings include: Review of all personnel files for Select Home Hospice revealed no designated Volunteer Coordinator or volunteers being used in the hospice facility. Interview with Administrator on 0815/2024 confirmed the Hospice does not utilize volunteers or have a designated Volunteer coordinator.

Based on record review, observation and interviews it has been determined the governing body has failed to ensure responsibility for hospice services and continuous quality assessment and performance improvement. This standard deficiency poses a risk to patients and family members health and safety. --- Findings include: Request made for the documentation of individuals designated to implement and manage the hospice quality assessment and performance improvement (QAPI) program. None were provided. A request was made for the Governing Body minutes for 2023 and 2024 to review Governing Body approval of QAPI information, none were provided. Interview with Administrator on August 15, 2024 confirmed that there was no QAPI program at the facility and no QAPI coordinator or designee who had been assigned to operate a QAPI program for the hospice. Governing Body minutes for 2023 or 2024 were requested, not received.

Based on record review and interview it was determined that the hospice facility failed to ensure responsibility and oversight of services provided under arrangement. This standard deficiency poses a risk to the health and safety of patients. --- Findings include: Request was made for the hospice facilities current contracts with other agencies, individuals, or organizations to furnish any services under arrangement. None were provided. Interview with Administrator and DON on 08/15/2024 confirmed that no hospice services contracts were available for review.

Based on interview and observation it was determined that the hospice facility failed to make clinical records readily available upon request by an appropriate authority. This standard deficiency poses a risk in determining the hospices compliance with patient health and safety requirements. --- Findings include: A review of Select Home Hospice Patient Record Retention No. 11.8.1 titled "RECORD RETENTION" revealed the process and timeframes of retention of clinical, administrative, financial and personnel records. Select Home Hospice's policy is that the clinical record shall be retained for six (6) years... Request for five (5) patient medical records for discharged patients was requested. None were provided. Interview on August 16, 2024 with Administrator confirmed that the five (5) of 5 of patient files were missing and could not be located at the facility. Administrator stated, "I can't find the records. I have no idea where they are."

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Upon home visits, did not observe LVN perform handwashing prior to visit with patient # 1 and #2 per policy #6-006.1, under procedure #3A-before having direct contact with patients and #3C -after contact with patient's intact skin (when taking a pulse, blood pressure or lifting a patient).