Every finding on record at Warm Care Hospice and Palliative Care

Observed in Tracer Activities. The organization had not established priorities for improvement. There were no performance improvement projects documented at the time of survey. Observed in Tracer Activities. The organization had not implemented a QAPI program that reflected the complexities of the organization. The QAPI plan that had been developed did not include services provided under arrangement. There were no indicators related to improved palliative outcomes. There were no identified performance improvement projects, thus the organization had no documentation to demonstrate the operation of the program.

Observed in Tracer Activities. The organization had not documented data analysis over time as discussed with the Case Manager. Observed in Tracer Activities. The organization had not used the results of data analysis to identify improvement opportunities. There were no active PI projects at the time of survey as discussed with the Case Manager.

Observed in Tracer Activities. Review of QAPI plan revealed that the organization had not yet documented any performance improvement projects are being conducted.

Observed in Record Review. IN review of one bereavement file available there was no evidence in the record of an initial or post bereavement assessment, In RRB#1 patient died 9/6/2023. Organization has not had a bereavement Coordinator since 6/2023.

Observed in Record Review. In 3 of 3 patient records reviewed, It was found in review of 3 of 3 patient record, RR#1, RR#2, RR#3s reviewed that there was evidence of Plans of Care.

Observed in Record Review. In 3 of 3 patient records reviewed, It was found on record review for RR#1, RR#2, RR#3 that there were PRN visits for Nursing, MSW and Chaplain as PRN however there was no reason for the visits.

Observed in Tracer Activities. Organization had a Board Meeting on 4/28/2023 however there was no documentation as to frequency or detail of data to be collected. NO QAPI Plan in Place. Observed in Tracer Visit. Organization had a Board Meeting on 4/28/2023 however there was no documentation as to frequency or detail of data to be collected. NO QAPI Plan in Place.

Observed in Tracer Activities. Organization had a Board Meeting on 4/28/2023 however there was no documentation as to frequency or detail of data to be collected. NO QAPI Plan in Place. Observed in Tracer Activities. Organization had a Board Meeting on 4/28/2023 however there was no documentation as to frequency or detail of data to be collected. NO QAPI Plan in Place.

Observed in Tracer Activities. Organization had a Board Meeting on 4/28/2023 however there was no documentation as to frequency or detail of data to be collected.

Observed in Tracer Visit. Organization had a Board Meeting on 4/28/2023 however there was no documentation as to frequency or detail of data to be collected. NO QAPI Plan in Place.

Observed in Tracer Activities. Organization had a Board Meeting on 4/28/2023 however there was no documentation as to frequency or detail of data to be collected. NO QAPI Plan in Place.

Observed in Tracer Activities. Organization had a Board Meeting on 4/28/2023 however there was no documentation as to frequency or detail of data to be collected. NO QAPI Plan in Place.

Observed in Tracer Activities. Organization had a Board Meeting on 4/28/2023 however there was no documentation as to frequency or detail of data to be collected. NO QAPI Plan in Place. No Priorities set.

Observed in Tracer Activities. Organization had a Board Meeting on 4/28/2023 however there was no documentation as to frequency or detail of data to be collected. NO QAPI Plan in Place.

Observed in HR File Review. It was found in review of 2 of 3 HR files that competency at time of hire was not evident in the files. The competency form was in the file however it was blank. Examples: HR#2, HR#3

Observed in Tracer Activities. In review of HME contract it was found that the contract did not include criminal background checks for the employees.

Observed in Data Session. The org had established a QAPI Plan that established priorities, demonstrated improvement for pain measures, and reflected the complexity of the organization, but did not include all services. Bereavement, volunteer, or contracted services was not reflected in the plan reviewed. This observation was reviewed with the DPCS Designee, QAPI Coordinator, and CEO.

Observed in Data Session. During review of the organizations quality program, the organization did not have documentation of ongoing, hospice wide, data driven quality assessment process improvement program. Those present at the Data session stated they have discussed a quality assessment and performance improvement program, but had not documented one. A binder had Quality Improvement Organizations Lake Superior Quality Innovation Network QAPI Written Plan How-To Guide but no written plan. This was reviewed and validated with the Designee DPCS. Observed in Data Session. During review of the organization's quality program, the governing body did not ensure the QAPI program reflected the complexity of its organization and services, focused on indicators related to improved palliative outcome, and did not take action to demonstrate improvement in hospice performance as evidenced by the organization was not able to produce documentation of a QAPI program plan at the time of survey. This was reviewed with the owner and Designee DCPS.

Observed in Data Session. During review of the organization’s quality program, the governing body had not approved the frequency and detail of the data collection associated to QAPI measures for 2023. This was reviewed and validated with the Designee DPCS.

Observed in Data Session. During the Data session the Designee DPCS provided analyzed quality program data, however there was no governing body documentation to determine if improvement was achieved. The most recent governing body minutes (or any governing board documentation) was from Dec 2022, prior to the January 2023 survey.

Observed in Data Session. During review of the organizations quality program, the Hospice QAPI program was not evaluated annually by the organization over the last 3 years. Those present at the Data session stated they had discussed the QAPI program, but had not documented a plan. There were no Governing Boards minutes documented since 12/30/22, prior to the January survey. This was reviewed and validated with the Designee DPCS.

Observed in Data Session. During review of the organizations quality program, it was identified that the organization had not developed a data-based performance improvement program, hence leadership did not set priorities for data collection for the last three years. Those present stated they had discussed a QI plan, but had not documented one. There were no Governing Boards minutes documented since 12/30/22, prior to the January survey. A binder titled QAPI Policy and Plan had Quality Improvement Organizations Lake Superior Quality Innovation Network QAPI Written Plan How-To Guide but no written plan for the organization. This was reviewed and validated with the Deginee DPCS.

Observed in Data Session. During review of the organizations quality program, the organization did not implement the QAPI policy as evidenced by no QAPI plan. Those present at the Data session stated they had discussed the quality program, but had not documented a quality plan. A binder had Quality Improvement Organizations Lake Superior Quality Innovation Network QAPI Written Plan How-To Guide but no written plan. The last documented Governing Board meeting minutes were Dec 30 2022, prior to the January survey and there was no documentation of any other governing board oversight. This was reviewed with the owner and DCPS.

Observed in Emergency Management Session. While reviewing the organization emergency management plan, the surveyor noted that the organization had not modified or updated its Emergency Operations Plan for the past three years

Observed in HR File Review. In 7 of 7 HR files reviewed, upon review of the organization’s emergency management plan and training, there was no documentation to validate staff were provided emergency management training at least every 2years. This was validated in discussion with the DPCS.

Observed in Emergency Management Session. The Hospice Organization did not evaluate the effectiveness of the emergency plan. During review of the organizations Emergency Management plan it was noted there was no documented evaluation of the drills exercises that had been performed for 2020, 2021 and 2022. This was reviewed and validated with the leadership team during the Emergency Management Session. .

Observed in Record Review. In 1 of 2 hospice bereavement records reviewed, the organization did not assess its patients according to its defined scope and content of screening, assessment and reassessment requirements. In Bereavement Record #1, the bereavement follow-up assessment was completed by the nurse, per the organization's Bereavement Policy (2.037-1), the social worker or bereavement coordinator is to complete the post death reassessment, and this was done by the RN. This was reviewed and verified with the DPCS and Owner.

Observed in Record Review. In 11 out of 11 patient records reviewed, the goals established on the plan of care were not measurable. During record review for all 11 records reviewed, the goals for the patient did not have specific and individualized timeframes or measures. Example of goals included: Altered skin will heal to maximum potential, Optimal bowel elimination and comfort, ADL needs are met to an optimal level as evidenced by no pain/discomfort with ADLs as tolerated, Pt will maintain optimum peripheral circulation, Optimal bowel elimination and comfort. These stated goals do not contain specific information that can be accurately measured to assist organizational staff in determining whether the patient is progressing towards achieving their goals. This finding was reviewed with the DPCS.

Observed in Record Review. in 2 of 11 records reviewed the the established frequency for disciplines included PRN visits without discipline specific indications for those unscheduled visits as required by regulation. On review of HSRR #5, both the MSW and Chaplain had PRN visits ordered without a reason or parameters for that visit. On review of HSRR #6, the MSW, Chaplain and RN all had PRN visits ordered without reason for that visit. This was discussed with the DPCS.

Observed in Data Tracer. During review of the organizations quality program, the organization did not have documentation of ongoing, hospice wide, data driven quality assessment process improvement program. This was reviewed and validated with the DPCS. Observed in Data Session. During review of the organization's quality program, the governing body did not ensure the QAPI program reflected the complexity of its organization and services, focused on indicators related to improved palliative outcome, and did not take action to demonstrate improvement in hospice performance as evidenced by the organization was not able to produce documentation of a QAPI program at the time of survey. This was reviewed with the owner and DCPS.

Observed in Data Tracer. During review of the organizations quality program, the organization did not compile and analyze data for improvement opportunities. The organization had been collecting data but it was not being aggregated or analyzed so therefore it was not being utilized to identify areas for process improvement. This was reviewed and validated with the DPCS. Observed in Data Tracer. During review of the organizations quality program, the organization did not compile and analyze data for performance, trends or patterns. While the organization collected data, there was no data analysis performed over time to determine trends in performance. This was reviewed and validated with the DPCS.

Observed in Data Tracer. During review of the organization’s quality program, the governing body had not approved the frequency and detail of the data collection associated to QAPI measures for 2020, 2021 and 2022. This was reviewed and validated with the DPCS.

Observed in Data Tracer. During review of the organizations quality program data was not analyzed to determine if improvement was achieved with the governing body. This was reviewed and validated with the DPCS.

Observed in Data Tracer. During review of the organizations quality program, it was identified that a performance improvement plan had not been documented because a plan for improvement had not been identified. This was reviewed and validated with the DPCS.

Observed in Data Tracer. During review of the organizations quality program, the Hospice QAPI program was not evaluated annually by the organization over the last 3 years. This was reviewed and validated with the DPCS.

Observed in Data Tracer. During review of the organizations quality program, it was identified that the organization had not developed a data-based performance improvement program, hence leadership did not set priorities for data collection for the last three years. This was reviewed and validated with the DPCS.

Observed in Infection Control System Tracer. During review of the infection control plan, the organization did not improve compliance with hand hygiene guidelines because they did not establish any goals or track hand hygiene compliance for the last three years. This was reviewed and validated with the DPCS. Observed in Infection Control System Tracer. During review of the organization's infection control plan, there were no goals set for improving compliance with hand hygiene guidelines. This was reviewed and validated with the DPCS.

Observed in HR File Review. In 1 of 1 HHA HR records reviewed, 12 hours of yearly in-service education was not completed in 2021 and 2020. During review of HR Record #3, the Home Health Aide completed 6 hours of in-service education in 2021 and had no documented in-service education for 2020. This was reviewed and validated with the DPCS.

Observed in Patient Home. In 1 of 1 Home visits with aide services, the home health aide did not provide care according to the patient's plan of care. On HSHV/RR #1, the aide performed care that was not ordered on the Aide Care plan. For example, patient had dentures that were cleaned this was not on the aide delegation, Also, the home health aide applied A & D ointment and Calmoseptine cream to buttock area and this was not on the delegation as well. This was reviewed and validated with the DPCS.

Observed in Record Review. In 1 of 11 patient record reviews that had aide services ordered, the organization did not conduct a hospice aide supervision every 14 days. During record review of HSHV/RR #1, there had not been an aide supervision done on the patient for a span of 26 days in July and another for a span of 21 days in October. This finding was reviewed and validated with the DPCS.

Observed in Leadership Session. During review of the organizations quality program, the organization did not implement the QAPI policy as evidenced by no QAPI plan. In addition, there were Conditions of Participation not met for §415.58. This was reviewed with the owner and DCPS.

Observed in Record Review. On 1 of 11 records reviewed, the hospice nurse surveyor noted that the patient’s record did not contain the pertinent clinical information related to medications. In HSHV/RR #2, the patient had Lactolose and Trimcinolone that had been discontinued and these changes were not reflected on the medication profile. This finding was reviewed with the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not provide care, treatment or services according to the patient's individual plan of care. In HSRR #4, the surveyor noted the plan of care indicated the chaplain was declined and did not have orders for the chaplain, however the chaplain made a visit to the patient without orders for care. This was reviewed with the DPCS.

Observed in Tracer Activities. On review of the agency contracts, it was noted there was no provision in the DME and therapy contracts that the contracted entity obtain a criminal background check on contracted employees who have direct access to patients or access to their medical records. This was reviewed with the DPCS and owner.