Every finding on record at Valley Hospice of Arizona, Inc.

Based on agency policies and procedures, and 29 patient medical record reviews, it was determined that the agency failed to ensure that the patients or representatives were inadequately informed and in agreement with the IDG's plan of care (dated 10/26/21 and 11/04/21) which was to discharge, or transfer the 29 patients to other healthcare providers. This posed a high risk to patients that could potentially leave them without a healthcare provider and violates patient rights by not being provided with the information they need to select the options that involve the provision of their healthcare services. Findings Include: The hospice policy entitled "Discharge Criteria" contained "...Patients are discharged by a hospice based on specifically defined criteria...Purpose: To establish guidelines for discharge of patients from hospice...1. Patient will be discharged from services as follows: Patient moves out of Hospice's service area...Patient transfer to another hospice...Hospice determines that the patient is no longer terminally ill...2. The patient is informed of discharge plan in a timely manner and acknowledges understanding of the reason...4. Prior to a discharge for any reason listed in #1, the IDG will obtain a written order form (from) Medical Director...Hospice must notify its Medicare Administrative Contractor (MAC) and State Agency of the circumstances surrounding the impending discharge. Hospice will consider referral to other appropriate and/or relevant state community agencies...or other health care facilities before discharge...7. Hospice has in place a discharge planning process that takes into account that a patient's condition might stabilize or otherwise change such that the patient cannot continue to be certified as terminally ill. The process includes planning for any necessary family counseling, patient education or other services before the patient is discharged...Staff will be knowledgeable about the discharge procedures including instructions and follow up responsibilities...." The review of 29 patient medical records found that discharge notices were either not provided to the patients/caregiver/family, or that the patients/caregiver/family understood that their care and services would either be discontinued by discharge or transferred to another healthcare provider effective 10/26/21 and 11/04/21 as per email sent to IDG from the Director of Nursing (DON). The email was observed to have an attachment that was not provided to for review. There were a total of 8 out of 29 patients that did not have documented evidence of discharge. Two patients #4 and #23 reportedly refused to sign the discharge forms, per interview information obtained by the PCO (Patient Care Ombudsman). Six of the 8 patients ( #1, #5, #19, #22, #24 and #27) that did not have documented evidence of discharge failed to respond or sign the discharge notice. Seven of the 8 lived in group homes or assisted living facilities, 1 patient (#5) lived in an apartment. The Department attempted to call patient #5 and received a recording that the call could not be completed as dialed. The phone number was verified. The medical record of patient #5 revealed documentation that the patient was being evaluated by the "SAIL" program for housing and resources. Patient #27 was contacted by phone on 12/17/21. The patient disclosed that he/she thought that hospice aide (HA) had not come for approximately 2 weeks. Patient #27 further stated that he/she has a "man" that helps him/her out and that his/her son and daughter in law were always helping him/her with any needs, but he/she stated that he/she did not know why the hospice was discharging him/her and had not signed the documents. The hospice failed to coordinate, and involve the patients, caregiver and family with the discharge plans involving their care.

Based on review of facility policies and procedures medical records, Interdisciplinary Group (IDG) Care Plans, and interviews, it was determined the facility failed to ensure: L 541: that a Social Worker (SW) was part of the core services Interdisciplinary Group (IDG) provided by the Hospice, which poses the potential risk that all needs of the Hospice patients are not being met by the SW/Counselor, a core member of the IDG, document support that the development of the plan of care was a collaborative effort involving all members of the IDG, for 29 of 29 patients, which poses the potential risk that patient's and their families will not receive assistance with all services needed for them and their loved ones. L 551: [The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following:] (6) The IDG's documentation of the patient's or representative's level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's own policies, in the clinical record. The 29 medical records reviewed revealed that the discharge forms provided to the patients/caregiver/family failed to contain the signature of the clinician obtaining the discharge notification for patients. Further, there was no evidence that the explanation of benefits related to discharge, transfer and revocation was understood by 25 of 29 patients L 555: Home visits by the Skilled Nurse (SN) Social Worker (SW)/Counselor (CLG), and Hospice Aide were not documented to have been performed, in accordance with the plan of care, in 29 of 29 patient for a total of 63 missed visits; and The above poses the potential risk that the patients are not receiving adequate hospice and comfort care through their final days. The cumulative effect of this systemic practice resulted in: 1. The Hospice's inability to provide hospice services as ordered, 2. The Hospice's failure to effectively coordinate the care of its patients during the discharge, transfer and revocation of hospice benefit for a total of 24 out of 29 medical records reviewed, 3.The Medical Records failed to contain the requirements of an informed discharge consent for patients which resulted in the hospice being out of compliance with the federal regulations for Interdisciplinary Group (care planning collaboration), Core Services (SN, and MSW) and Medical Records.

Based on review of 29 patient medical records, the hospice policy and procedure, and interviews, it was determined the facility failed to: Provide the care and supervision of services offered by the hospice, resulting in missed nursing (SN) visits for symptom management, missed social worker (MSW)SN visits assessment visits for patient's #1-29. Findings Include: Twenty nine patient medical records were reviewed. Twenty nine of 29 failed to contain documentation that clinican visits were conducted as ordered on the plan of care (POC) as evidenced by missed visits. Twenty nine of 29 patient medical records failed to contain documentation that MSW assessment visits were conducted as ordered on the POC. There was no evidence that the MSW had participated in the IDG meetings to develop the POC for the month of October 2021 for the 29 patient medical records reviewed. The policy and procedure entitled "IDG Care Planning Process" contained "...In order to assure that care provided is appropriately planned to meet each patient's specific needs and problems, Hospice will utilize data/information gathered during the comprehensive assessment, updates to the comprehensive and reassessments, in the care planning process to provide care that is consistent with the patient and family needs, with the patient's needs and goals as a priority...the POC (Plan of Care) includes all services necessary for the palliation and management of the terminal illness and related conditions including: Interventions to manage pain and other symptoms...Effective pain and symptom management includes the ongoing assessment of the patient's physical, psychosocial, emotional and spiritual needs and reassessing the effectiveness of the current POC to address those needs...Coordination of Hospice's internal resources includes:... Notifying the patient in a timely manner about schedule changes...Care will be coordinated with other involved external organizations...Staff will: Share relevant information to facilitate continuity and care coordination...." The hospice IDG members failed to provide and supervise the hospice care and services resulting in missed visits without providing notification to the patient, caregiver or family. The Administrator stated during interview conducted on 12/06/21 that the DON (Director of Nursing) had provided the notification to the patients. The Department was provided with a copy of the email. The email had an attachment which was not provided to the Department. It could not be confirmed that the patients, caregivers and family were notified of schedule changes. The hospice IDG failed to supervise the care and services to ensure that patients received care and services as ordered in the IDG POC.

Based on review of policies/procedures, facility documentation and interview, it was determined that the facility failed to ensure that a Medical Social Worker (MSW) was part of the core Interdisciplinary Group (IDG) services provided by the Hospice, which poses the potential risk that the social, emotional, and access to resource needs of the Hospice patients were not met. Findings include: Facility policy entitled " IDG " revealed: "Hospice has designated IDG which, in consultation with the patient's attending physician, prepares a written plan of care (POC) for each patient. The group consists of a Physician...Registered Nurse (RN)...Social Worker (MSW)...Pastoral ... ...The core ID members include...Social Worker...." The IDG meetings were documented to have regularly occurred every 2 weeks. There was no evidence in the medical records that the IDG made changes to the POC to reflect that the agency did not have a MSW during the month of October 2021. The IDG POC for all 29 patient medical records showed an MSW frequency of 1-2 times weekly. The Administrator verified, in an interview conducted on 12/03/21 that there was no MSW from 09/17/21 until present. The Administrator stated that an applicant was extended a job offer, however the candidate declined the offer in November (exact date unknown), The hospice failed to have an MSW on it's IDG. No notification was provided to the Department of the inability to provide MSW (Core) services prior to the unnanounced onsite complaint investigations. The failure of the agency to provide MSW services as ordered increases the likelihood that patients in need of social, emotional and access to resources would experience distress during their physical decline.

Based on 29 of 29 patient medical record reviews, and agency policies and procedures, it was determined that the agency failed to ensure that the patients or representatives were adequately informed and in agreement with the IDG's plan of care (dated 10/26/21 and 11/04/21) which was to discharge, or transfer the patients to other healthcare providers. This poses a high risk to patients that could potentially leave them without a healthcare provider and violates patient rights by not being provided with the information they need to select the options that involve the provision of their healthcare. Findings Include: The hospice policy entitled "Discharge Criteria" contained "...Patients are discharged by a hospice based on specifically defined criteria...Purpose: To establish guidelines for discharge of patients from hospice...1. Patient will be discharged from services as follows: Patient moves out of Hospice's service area...Patient transfer to another hospice...Hospice determines that the patient is no longer terminally ill...2. The patient is informed of discharge plan in a timely manner and acknowledges understanding of the reason...4. Prior to a discharge for any reason listed in #1, the IDG will obtain a written order form (from) Medical Director...Hospice must notify its Medicare Administrative Contractor (MAC) and State Agency of the circumstances surrounding the impending discharge. Hospice will consider referral to other appropriate and/or relevant state community agencies...or other health care facilities before discharge...7. Hospice has in place a discharge planning process that takes into account that a patient's condition might stabilize or otherwise change such that the patient cannot continue to be certified as terminally ill. The process includes planning for any necessary family counseling, patient education or other services before the patient is discharged...Staff will be knowledgeable about the discharge procedures including instructions and follow up responsibilities...." The Administrator provided emails from the Director of Nursing (DON) on 12/03/21 dated 10 /26/21. The email contained the following "...I have attached the list with the discharging patients. It will only leave us a couple of patients. Are we discharging outright or transferring to some other hospice?...." The email had an attachment entitled "Patients to be discharged by episode. pdf 462 K". The Department was not provided with the attachment. An email dated 11/04/21 sent by the DON, in reference to the IDG meeting that was to be conducted that day, contained "...#8, #21, #29 and the name of one additional patient (not reviewed by the Department) ...Everyone else has an extended prognosis except #4, whom the family will need to start helping, the office manager is in agreement. These patients should take no more than 15 minutes to review. I will email time and call in info...." Again on 11/04/21 the DON sent an email revealing "...On a prior email I attached a discharge form. I have also call the Group home's family members and will fax over the same forms to them I have informed all parties on the discharges - Group Homes/families/patients...(Employee's) #8 and #10 please let me know once you receive all or any of the signed discharge forms back..." The IDG agenda dated 11/04/21 revealed "...New business All patients to be discharged for extended prognosis other than #8, #21, #29 and (name of patient, record was not included as part of the 29 reviews). The medical records for patients #1-#29 were reviewed. The 29 medical records failed to contain documentation by the clinicians that the patients were being notified of being discharged to another healthcare provider or for discharged from service for extended prognosis. The Department reviewed 29 patient medical records. Reviews were conducted 12/02/21-12/08/21. Additional information, previously requested and pertinent to the survey was emailed to the Department was by the provider on 12/10/21 that resulted in the following analysis of the discharged patients: a total of 12 patients were verified to have been transferred to another hospice agency or healthcare agency, 2 patients (#3, and #14) were discharged for extended prognosis, 1 patient (#6) was discharged to death, 5 patients (#9, #10, #18, and #26) were discharged for unknown reasons (no reason was documented on the discharge form), 2 patients (#21 and #25) signed revocations equaling 21 patients, leaving 8 patients (#1, #4 (refused to sign discharge), #5, #19, #22, #23 (refused to sign discharge), #24, and #27) which the Department did not a receive verification of discharge/transfer or revocation documentation signed by the patient. The Department verified that patient's #1, #4, #19, #22, #23, #24, #27 were residing in group homes and assisted living facilities and had resources available to seek care outside of the hospice. The Department placed telephone calls to patient's #5 (phone number not in service) in attempt to verify that the patient was able to access care. The Department requested the additional information of the Transfer of Care Summary/Discharge Summary documentation. There was no documentation of a Discharge Summary found in the patient's medical records or submitted to the Department for the 29 patients.. The interview with the Administrator conducted on 12/10/21 revealed that the agency was unable to provide additional documents as they were still waiting for the return of additional documentation to be returned from various individuals.

Based on review of policies/procedures, medical records, facility documents and interview, it was determined that the facility failed to ensure that Clinician's were communicating to ensure that the visits ordered in the Plan of Care (POC) for Skilled Nursing (SN), Medical Social Worker (MSW) and Hospice Aide (HA) were performed in accordance with the POC for 29 of 29 patients for a total of 63 missed visits. The failure to provide patients and caregivers with communication that care and services would be missed due to agency hardships poses the risk of increased likelihood that patients could suffer poor outcomes related to symptom management. Findings include: The policy and procedure entitled "IDG Care Planning Process" contained ...Coordination of Hospice's internal resources includes:... Notifying the patient in a timely manner about schedule changes...Care will be coordinated with other involved external organizations...Staff will: Share relevant information to facilitate continuity and care coordination...." The Department reviewed 29 patient medical records. The review revealed that 29 visits were missed by the MSW, 27 visits were missed by the SN, and 7 visits were missed by the HA (total 63 visits not made) (cross reference tags L591 and L594 for specific details). The Administrator stated that she was aware of the missed MSW visits on 12/03/21. The hospice failed to maintain a method of communication sharing and adhere to its policy to ensure that care and services were provided.

Based on the hospice policies and procedures, medical record reviews and interviews, it was determined the hospice failed to: L 591, Provide Nursing Services at the frequency contained in the Plan Of Care. Nursing visits were missed at a high frequency from 10/15/21-10/26/21, L 594. Provide social services. There were no social services being provided by the hospice during the time of the Medicare complaint investigation surveys . The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with the provisions of Core Services for social services and nursing services places the patients, caregivers, and family. The failure to provide patients with core services creates an increased and substantial risk for poor symptom management related to unmet physical, medical, psychosocial and emotional needs.

Based on review of 29 medical records and agency policy and procedure, it was determined that the hospice failed to provide the care and services at the frequency ordered in the plan of care. The failure to provide care and services to the patients results in a high potential for poor outcomes related to symptom management of the patients condition, Findings Include: The medical records for 29 patients were reviewed for the time period of 10/01/21-10/26/21 as it was reportedly the date of discharge per IDG (Interdisciplinary Group) email sent by Director of Nursing (DON) dated 10/26/21. The skilled nurse (SN) frequency for all 29 records was for 1-2 visits per week for 9 weeks. The record reviews revealed that 22 of the 29 records had missing documentation that SN visits were conducted at the frequency ordered in the plan of care (POC) for the following patients #2 (no SN 10/01/21-10/14/21), #3 (no SN 10/11/21, 10/20/21) , #4 (no SN 10/18/21), #6 (no SN 10/21/21-10/29/21) , #7 (no SN 10/22/21), #10 (no SN after 10/18/21, pt. admitted to hospital), #11 (no SN on 10/22/21)) , #12 (no SN 10/01/21-10/14/21), #13 (no SN 10/20/21), #15 (no SN 10/19/21-10/26/21), #16 (no SN 10/07/21-10/21/21), #17 (no SN 10/21/21-10/30/21/21), #19 (10/14/21-10/26/21), #20 (no SN 10/18-10/26/21), #21 (no SN 10/20/21), #22 (no SN 10/19/21), #23 (no SN 10/18/21), #24 (no SN 10/19/21-10/26/21), #25 (no SN 10/13/21), #26 (no SN 10/15/21), #27 (no 10/18/21), #28 (no SN 10/20/21), and #29 (no SN 10/22/21). The total number of missed SN visits by record review equaled 27, Documents obtained by the Department from the "Biller" revealed 15 missed SN visits equaling a discrepancy of 12 visits when compared to the documentation that was provided to the Department for review.. The record reviews failed to contain documentation of the 12 visits recorded as not being missed by the "Biller". There was no documentation provided to the Department that Medical Director, patients or caregivers were notified of missed visits or attempts to make up the frequency. The agency policy and procedure entitled " Staff Nurse" contained"...Performs specific nursing procedures as ordered (e.g. treatments, management of symptoms) following doctor's orders...attends team conferences...Always communicates to the supervisor if unable to meet a patient's need or perform a procedure...participates in an on-call system and is responsible for providing on-call coverage when unavailable for assigned duties...." The Department requested the answering service call logs for the time period of 10/01/21-12/03/21..The Department was provided the answering service call logs for 11/01/2021-11/30/2021 (November only). There were 3 calls received from 3 patients (#3, #21, and #24), documented by the answering service, that indicated the need for a nurse to provide a return call to assess the patients. Documentation of the response from the on-call nurse was not provided to the Department for review. The interviews conducted, with the current Administrator, failed to confirm that nursing care was conducted as ordered in the POC or that a response to the patient's request to receive a call from the SN was performed..

Based on review of 29 patient medical records, the hospice policies and procedures and interview, it was determined the hospice failed to provide social work services to 29 of 29 patients that had orders for MSW services to be provided at the frequency of 1-2 times monthly. The failure to ensure that the patients received the MSW services puts the patients at high risk for outcomes related psychosocial, emotional distress and lack of resources during their final phase of life. Findings include: The hospice policy "Interdisciplinary Team" contained: "...Hospice will assign interdisciplinary teams to provide care and services. The following disciplines are a direct part of the hospice team:..social workers...."...Hospice provides the following services...Social Worker...."" The medical records reviewed for 29 patient revealed that the Medical Social Worker (MSW) visits were not conducted for 29 of 29 patients. There was no documented evidence provided to the Department that MSW had conducted visits with any of the patients during the month of October 2021 (the time frame reviewed). At the minimum, based on the frequency ordered by the Interdisciplinary Group (IDG) of 1-2 visit per month 29 visits were missed and at a maximum there would be 58 visits that could have been made. The IDG met every 15 days as required. There were no changes made to the Plans of Care (POC), nor documented orders or evidence that MSW services had been discontinued by the Medical Director(MD) or the Interdisciplinary Group (IDG) and there was no evidence of sign in to the IDG by the MSW for the month of October 2021. The surveyors requested the medical social worker (MSW) personnel file, on 12/03/21. The Administrator stated in an interview on 12/03/21, that the MSW had been terminated on 09/17/21 and no longer worked for the hospice. The Administrator revealed during the interview that the MSW had allegedly not been conducting visits with the patients and reported this was discovered through an agency audit of "sign in" logs that were maintained in the homes. The Administrator stated that an offer had been extended to a candidate in November (exact date not disclosed) however, the MSW applicant declined the job offer. The owner administrator confirmed, on 12/03/21, that the hospice had no MSW services available from 09/17/21-present.

Based on observation of office environment, the absence of documentation onsite and readily available to the surveyors for review, and interview with the administrator, it was determined that the agency's governing authority and/or designated leadership for the facility failed to responsibly manage this hospice agency, as evidenced by the failure to provide all hospice services as ordered to patients that directly correlates to an insufficient number of staff to provide care and services, These combined factors have the effect of producing and increasing the likelihood of potential high risks to patients for poor outcomes. Findings Include: Two separate complaints were submitted to the Department alleging that patients were not receiving the care and services as ordered. Additionally, the Department received a call from a Patient Care Ombudsman (PCO) that was investigating the agency's ability to remain solvent. The Department entered the facility on 12/02/21 and exited the survey on 12/10/21. The provider/Administrator/Governing Body was given a document upon entrance that listed the documents that would be necessary to conduct the complaint investigations. The Department reviewed 29 patient medical records. Cross reference tags contained in the Statement of Deficiencies (SOD). The record reviews revealed that visits were not conducted or missed by the following: Medical Social Worker (MSW), Skilled Nurse (SN) and Hospice Aide (HA) during the month of October 2021. (the time frame selected for review based on complaint intakes). The PCO conducted an interview with Employee #13 on 12/03/21 for which the Department was present. The interview revealed that the staff did not receive their salary and began to resign, due to not being paid for their services. The Administrator resigned on 10/29/21. The Alternate Administrator (also the governing Body) then became the Administrator. Two people (Administrator and assistant) were observed to be onsite at the agency during the survey. The Administrator disclosed during interview on 12/02/21, that the Director of Nursing (DON) died on 11/12/21, and that Administrator did not have access to the DON's computer or password and that most of the information requested was on the DON's computer. The Administrator further that the DON worked from home spending only 1 day a week in the office, since the pandemic. The Administrator additionally stated on 12/02/21 that the office assistant did not have the same privileges (on the electronic medical records) as the DON, and that this would require some coordination between the electronic medical records company and the biller in order to obtain the information on the list. The Department was informed that the agency planned to discharge all patients on 10/26/21 and 11/04/21 during the IDG meeting per an email sent by the DON. The Department received documented evidence that 21 out of 29 patient records, selected for review, contained a signed and completed form of discharge, transfer, or revocation as of 12/10/21. The governing body failed to responsibly manage the hospices provision of care and its fiscal operations.

Based on review of hospice policies and procedures, review of 29 patient's records, additional internal agency documents and interview, it was determined that the hospice failed to complete a discharge/ transfer of care summary for Patient 1-29 , which poses a high potential risk for inconsistent quality and effective care to be provided to the patients and includes a possible delay of medical care from another provider which the patient would be entitled to seek. Findings include: The hospice policy entitled "Discharge Criteria" contained "...Patients are discharged by a hospice based on specifically defined criteria...Purpose: To establish guidelines for discharge of patients from hospice...1. Patient will be discharged from services as follows: Patient moves out of Hospice's service area...Patient transfer to another hospice...Hospice determines that the patient is no longer terminally ill...2. The patient is informed of discharge plan in a timely manner and acknowledges understanding of the reason...4. Prior to a discharge for any reason listed in #1, the IDG will obtain a written order form (from) Medical Director...Hospice must notify its Medicare Administrative Contractor (MAC) and State Agency of the circumstances surrounding the impending discharge. Hospice will consider referral to other appropriate and/or relevant state community agencies...or other health care facilities before discharge...7. Hospice has in place a discharge planning process that takes into account that a patient's condition might stabilize or otherwise change such that the patient cannot continue to be certified as terminally ill. The process includes planning for any necessary family counseling, patient education or other services before the patient is discharged...Staff will be knowledgeable about the discharge procedures including instructions and follow up responsibilities...." The Administrator provided emails from the Director of Nursing (DON) on 12/03/21 dated 10 /26/21. The email contained the following "...I have attached the list with the discharging patients. It will only leave us a couple of patients. Are we discharging outright or transferring to some other hospice?...." The email had an attachment entitled "Patients to be discharged by episode. pdf 462 K". The Department was not provided with the attachment. An email dated 11/04/21 sent by the DON, in reference to the IDG meeting that was to be conducted that day, contained "...#8, #21, #29 and the name of one additional patient (not reviewed by the Department) ...Everyone else has an extended prognosis except #4, whom the family will need to start helping, the office manager is in agreement. These patients should take no more than 15 minutes to review. I will email time and call in info...." Again on 11/04/21 the DON sent an email revealing "...On a prior email I attached a discharge form. I have also called the Group Homes, family members and will fax over the same forms to them I have informed all parties on the discharges - Group homes/families/patients...(Employee's) #8 and #10 please let me know once you receive all or any of the signed discharge forms back..." The IDG agenda dated 11/04/21 revealed "...New business All patients to be discharged for extended prognosis other than #8, #21, #29 and (name of patient, record was not included as part of the 29 reviews). The Department reviewed 29 patient medical records. Reviews were conducted 12/02/21-12/08/21. Additional information, previously requested and pertinent to the survey was emailed to the Department was by the provider on 12/10/21 that resulted in the following analysis of the discharged patients: a total of 12 patients were verified to have been transferred to another hospice agency or healthcare agency, 2 patients (#3, and #14) were discharged for extended prognosis, 1 patient (#6) was discharged to death, 5 patients (#9, #10, #18, and #26) were discharged for unknown reasons (no reason was documented on the discharge form), 2 patients (#21 and #25) signed revocations equaling 21 patients, leaving 8 patients (#1, #4 (refused to sign discharge), #5, #19, #22, #23 (refused to sign discharge), #24, and #27) which the Department did not a receive verification of discharge/transfer or revocation documentation signed by the patient. The Department verified that patient's #1, #4, #19, #22, #23, #24, #27 were residing in group homes and assisted living facilities and had resources available to seek care outside of the hospice. The Department placed telephone calls to patient's #5 (phone number not in service) to verify that they were able to access care. The Department requested the additional information of the Transfer of Care Summary/Discharge Summary documentation. There was no documentation of a Discharge Summary found in the patient's medical records or submitted to the Department for the 12 patients that transferred care. The interview with the Administrator conducted on 12/10/21 revealed that the agency was unable to provide additional documents as they were still waiting for the return of additional documentation to be returned from various individuals.