Every finding on record at VNA & Hospice of Southwest Region, Inc.

Based on staff interview and record review, the Hospice failed to update the Agency and community-based risk assessment every 2 years to include the management of the consequences of power failures, natural disasters and other emergencies that would affect the Hospice's ability to provide care. Findings include: --- Per interview on 1/15/25 at 9:50 AM the Director of Operations, Safety & Security and the Director of Clinical Operations demonstrated a comprehensive Emergency Preparedness Plan which has been developed. However, per review of the Agency Vulnerability Analysis noted the areas of concern related to weather, communication failures and/or active shooter had not been updated since 2017. Both Directors confirmed the Vulnerability Analysis required updating, but commented the list of potential hazards would probably remain the same. Presently the Hospice Agency has 36 areas of vulnerability identified to include weather problems, disruptions in communications caused by multiple source failures and active shooter, bomb threats, hazmat exposure, and/or civil disturbance as part of the overall analysis.

Based on interview and record review the Hospice failed to designate a physician to initially certify 1 of 19 patients (Patient #2) for Hospice. Findings include: --- Per record review Patient #2 with a history of diabetes, high blood pressure, and breast cancer was referred to Hospice on 2/23/24. Per review of a ";Hospice Attending Physician Certification" order the providers signature on 2/27/24 was noted to be from a Physicians Assistant (PA), not a Doctor of Medicine (MD). Per the Hospices policy, "Physician Services-Attending Physician's Role"-revised in November of 2023, ";The medical care of each patient...will be the responsibility of the patients attending physician. Communication between the attending physician and other members of the interdisciplinary group will be ongoing and documented in the hospice clinical record. When the attending physician is absent, the attending physician must designate another physician to oversee care for the hospice patient according to his/her medical groups departmental procedure...Attending Physician is: 2. A Doctor of Medicine or osteopathy authorized to practice medicine by the State in which s/he performs that function; or 3. A Nurse Practitioner (NP) who meets the training, education, and experience requirements as described in section 410.75 (b) of 42 CFR 410". Per interview on 1/14/25 at 2:11 PM with the Clinical Operations Officer, s/he confirmed that Physicians Assistants do not have the authority to certify patients for Hospice.