Every finding on record at Sva Hospice

Observed in Emergency Management Session. The Emergency Operations Plan did not include documentation of potential risks in the community that could impact the organization’s ability to provide care for its patients. No assessment was documented prior to July 2021 of these potential risks as confirmed with the QA Coordinator and Care Manager. Observed in Emergency Management Session. The organization had not identified in writing the potential emergencies that could affect its ability to provide services and the likely consequences of those emergencies. There was no documentation of this assessment prior to July 2021 as confirmed with the QA Coordinator and Care Manager.

Observed in Emergency Management Session. The organization had not conducted an exercise to test the emergency plan at least annually. There was no documentation of an annual implementation for calendar year 2019 as confirmed with the QA Coordinator and Care Manager.

Observed in Record Review. In 1 of 11 patient records reviewed, the hospice plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: physician orders for scope and frequency of services. In the chart for RR#1, the orders for SN services were 2/week, the LVN was seeing the patient 2/week, however the plan of care stated SN weekly as confirmed with the Care Manager.

Observed in Record Review. In 2 of 11 patient records reviewed, the hospice plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: treatments necessary to meet the patient’s needs. In the chart for HV#2, during the home visit, it was discussed with the LVN and observed by this surveyor that fall precautions were in place including bed rails, bed in lowest position, fall mat used overnight by the facility staff. These same strategies were in place for HV#1, though also none of these individualized interventions were included on the POC as confirmed with the Care Manager.

Observed in Data Session. The organization did not act when it did not achieve or sustain planned improvements. For CY 2019, the organization had a PIP to improve patient acceptance of volunteer services at admission. The organization did not meet this goal. There was no documentation to indicate this project was continued or modified as confirmed with the QAPI Coordinator.

Observed in Data Session. The hospice QAPI program had not documented an evaluation of the QAPI program annually. The only annual evaluation documentation found during the survey was dated July 2021 as confirmed with the QAPI Coordinator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization had not implemented the infection prevention and control activities it had planned. During HV#2, the LVN washed her hands, however turned off the water tap with her cleaned hand, not using the paper towel as is organizational procedure. This was discussed and acknowledged by the nurse during the visit. Additionally, during both HV#2 and HV#3, the LVN used cleansing cloths which she had purchased herself to clean her equipment that were not Alcohol based cloths as required by organizational policy Bag Technique. This was discussed with the QAPI Coordinator.

Observed in Record Review. In 1 of 11 patient records reviewed, the record did not contain information that reflected the patient's care, treatment and services. In the chart for RR#7, the patient revoked the hospice benefit, however there was no information in the chart regarding how the organization became aware that a revocation was requested. This was discussed with the Care Manager.

Observed in Record Review. In 1 of 2 patient records reviewed, in which a discharge alive occurred, the hospice discharge summary in the chart for RR#7 did not include a summary of the patient's stay including treatments, symptoms, and pain management. This was discussed with the Care Manager.