Every finding on record at Trusted Hospice, Inc.

Observed in Tracer Activities. the organization did not review and update the emergency operations plan at least every two years per regulation or annually as stated in their policy. During tracer activities for emergency management, the hospice nurse surveyor noted the plan had not been updated since 2019. This was discussed and reviewed with the Administrator/ Owner.

Observed in Tracer Activities. the organization emergency operations plan did not contain continuity of operations strategies that cover continuity of facilities or alternate sites in case the original site is incapacitated. During review of the emergency operations plan, the hospice nurse surveyor observed the plan did not contain a back up location or plan if the main office was destroyed. This was discussed and reviewed with the Administrator/ Owner.

Observed in Tracer Activities. In 1 of 9 HR files reviewed, the organization failed to provide orientation to staff. During HR record review, the hospice nurse surveyor observed in HR#9 there was no orientation documented, including but not limited to emergency preparedness. This was discussed and reviewed with the Administrator/ Owner. Observed in Tracer Activities. the organization failed to prepare for how it would manage staff during an emergency. During review of the emergency operations plan, the hospice nurse surveyor observed the plan did not mention how it would utilize volunteers during an emergency and the volunteer coordinator was unsure of any education provided to volunteers related to their role in an emergency. This was discussed and reviewed with the Administrator/ Owner.

Observed in Record Review. In 11 of 13 patient records reviewed, the organization failed to assess and reassess its patients. During record review for HV#1, HV#2,RR#1, RR#2, RR#3, RR#4, RR#5, RR#6, RR#8, BR#1 and BR#2, the hospice nurse surveyor observed no initial bereavement assessments had been completed as required by regulation and organizational policy. After discussion with the office manager, it was noted the agency lost their bereavement coordinator last year and their Chaplain took over the role but was not fully trained in all of the obligations related to the role. The organization has begun steps to correct this. This was reviewed and discussed with the Administrator/ Owner.

Observed in Record Review. In 10 of 11 patient records reviewed, the organization failed to assess and reassess its patients. During record review for HV#1, HV#2, HV#3, RR#2, RR#3, RR#4, RR#5, RR#6, RR#7 and RR#8, the hospice nurse surveyor observed multiple late or missed IDG updates. For example: in HV#1 IDG was held on 4/14 then 5/20. In HV#2 IDG was held on 4/14 then 5/20. In RR#4 IDG was held on 3/18 and 4/14. The leadership stated they were unaware of the missed dates. This was discussed and reviewed with the Administrator/ Owner.

Observed in Record Review. In 10 of 11 patient records reviewed, the organization failed to plan the patient's care. During record review for HV#1, HV#2, RR#1, RR#2, RR#3, RR#4, RR#5, RR#6, RR#7 and RR#8, the hospice nurse surveyor observed the patient time frames for achieving goals were all outdated and not resolved or extended. For example: in HV#1 the care plan goals for altered bowel elimination had a target date of 3/29/22 and as of survey date of 6/1/22 had not been addressed. In HV#3 wound care and skin breakdown goals were set for a target date of 5/23/22 but had not been addressed although documentation stated the wound doubled in size at the 5/31/22 visit. This was reviewed and discussed with the Administrator/ Owner.

Observed in Record Review. In 6 of 6 patient records reviewed, the organization failed to plan the patient's care. During record review for RR#5, RR#6, RR#7, RR#8, BR#1 and BR#2 the hospice nurse surveyor observed the IDG did not review the POC at least every 15 days. All charts listed were updated with a bereavement assessment post death but never presented to the IDG. This was discussed and reviewed with the Administrator/ Owner.

Observed in Tracer Activities. the organization failed to analyze data. During tracer activities for data management, the hospice nurse surveyor observed the organization was collecting data but not analysis had been completed or reviewed since 2019. After discussion with the hospice leadership, it was noted the QAPI coordinator had left 9 months earlier and the agency was struggling to manage the program. This was discussed and reviewed with the Administrator/ Owner.

Observed in Tracer Activities. the organization did not have a performance improvement plan. During tracer activities for data management, the hospice nurse surveyor observed the organization did not establish an active performance improvement plan with priorities that included defined processes needing improvement, methods for measuring performance of the processes, analysis methods for identifying causes of poor performance, methods being implemented to address the processes and methods for monitoring and sustaining improved processes. After discussion with the hospice leadership, it was noted the QAPI coordinator had left 9 months earlier and the agency was struggling to manage the program. This was discussed and reviewed with the Administrator/ Owner. Observed in Tracer Activities. the organization failed to establish priorities for performance improvement. During data management tracer activities, the hospice nurse surveyor observed there were no performance improvement activities or documentation of known issues. After discussion with the hospice leadership team it was noted that the team has been tracking and educating but no documentation of activities has been completed. This was discussed and reviewed with the Administrator/ Owner.

Observed in Tracer Activities. During tracer activities for data management, the hospice nurse surveyor observed that the organization had not identified infection risks based on the following: its geographic location, community, and population served the care, treatment, or services it provided the analysis of its surveillance activities and other infection control data This was discussed and reviewed with the Administrator/ Owner.

Observed in Tracer Activities. the organization failed to provide care, treatment, or services in accordance with professional standards of practice, law, and regulation. In the tracer activities and record reviews associated with the volunteer, the hospice nurse surveyor observed notation where the volunteer was routinely giving baths which was outside of her job description and outside of the agency's policy and process of skill level needed to provide this kind of care. This was discussed and reviewed with the Administrator/ Owner.

Observed in Tracer Activities. the organization failed confirm the volunteer understood her defined role. In the Volunteer Program tracer and Record Reviews, the hospice nurse surveyor observed there was a documented defined role for volunteers but the volunteer was not following it as evidenced by multiple notations of giving a bath. In 5/5 records reviewed, the volunteer notated some evidence of participating in bath care or providing the bath herself. This is outside of the defined role. This was discussed and reviewed with the Administrator/ Owner.

Observed in Tracer Activities. the organization failed to document its efforts to recruit and retain volunteers. During tracer activities for data management, the hospice nurse surveyor observed no evidence of efforts to recruit or retain volunteers for 2020, 2021 or 2022 to date. This was discussed and reviewed with the Administrator/ Owner.

Observed in Tracer Activities. the organization failed to document the cost savings achieved through the use of volunteers. During tracer activities, the hospice nurse surveyor observed there was no data observed to support the cost savings of the volunteer program for 2020, 2021, and 2022 to date. After discussion with the hospice leadership it was noted that the volunteer role has been a struggle to fill and that the current volunteer coordinator is new to the role. This was discussed and reviewed with the Administrator/ Owner.

Observed in Tracer Activities. the organization failed to provide services to meet the patient's needs. During tracer activities, the hospice nurse surveyor observed the organization did not document the level of volunteer activity or record any increased care or services achieved through the use of volunteers. Volunteers are providing care but no hours are being tracked. This was discussed and reviewed with the Administrator/ Owner.

Observed in Tracer Activities. Leadership and the governing body failed to understand the degree of risk in §418.100, §418.78, §418.54, §418.60, §418.70, §418.56, §418.58, §418.113. Leadership failed to take full responsibility for the day to day operations as evidenced by the volunteer performing baths outside of her training, defined role and job description. Leadership did not take full responsibility and overall authority for the QAPI and infection control programs as evidenced by lack of data analysis, plan implementation and development of an infection control analysis. This was discussed and reviewed with the Administrator/ Owner.

Observed in Tracer Activities. In 5 of 9 HR files reviewed, the organization failed to provide orientation to staff. During HR record review the hospice nurse surveyor observed in HR#3, HR#5, HR#6, HR#7 and HR#10, there was no documentation of orientation to the relevant policies and procedures, specific job duties, or infection prevention and control activities. This was discussed and reviewed with the Administrator/ Owner.

Observed in Tracer Activities. In 5 of 9 HR files reviewed, the organization failed to document staff competence initially assessed as part of orientation. In HR#3, HR#5, HR#6, HR#7 and HR#9, the hospice nurse surveyor observed there was no competence evaluations documented as required in policy and by regulation. This was discussed and reviewed with the Administrator/ Owner.