Hospice of the Valley, Inc.

“Based on review of the emergency preparedness (EP) program and interview, it was determined the agency failed to perform and document a facility-based and community-based risk assessment, utilizing an all-hazards approach, to identify all risks or emergencies that the agency would reasonably expect to encounter. This had the potential to affect all persons served by the hospice agency. Findings include: A review of the agency’s EP program conducted on 4/11/24 revealed there was no documentation of an all hazards risk assessment identifying natural, man-made and other emergencies the agency was likely to encounter. An interview conducted on 4/11/24 at 4:45 PM with Employee Identifier # 1, Compliance, Quality and Education Director, confirmed the agency had no documentation an all hazards risk assessment had been performed.”

“Based on review of the emergency preparedness (EP) program and interview, it was determined the agency failed to review and/or update EP policies and procedures at least every two years. This had the potential to affect all persons served by the hospice agency. Findings include: A review of the agency’s EP policies and procedures on 4/11/24 revealed the last revision date was October 2021, which was greater than two years. An interview conducted on 4/11/24 at 4:45 PM with Employee Identifier # 1, Compliance, Quality and Education Director, confirmed the agency had not reviewed or updated their EP policies and procedures since October 2021, which was greater than two years.”

“Based on review of the emergency preparedness (EP) program and interview, it was determined the agency failed to conduct exercises to test their emergency plan at least annually. This had the potential to affect all persons served by the hospice agency. Findings include: A review on 4/11/24 of the agency’s EP program exercise/testing documentation for 2021, 2022, 2023 and 2024, revealed there was no documentation the agency had conducted a full-scale community or individual facility based exercise every two years, nor a mock disaster drill, or tabletop exercise/workshop in the opposite year. The agency failed to test their emergency plan at least annually as required. An interview conducted on 4/11/24 at 4:45 PM with Employee Identifier # 1, Compliance, Quality and Education Director, confirmed their was no documentation the agency had conducted training exercises in 2021, 2022, 2023, or 2024.”

“Based on a review of medical records (MR), policy and procedure and staff interviews, it was determined the agency failed to ensure all core members of the Interdisciplinary Team (IDT) were present to communicate updates to the Plan of Care (POC). This deficient practice affected 14 of 14 active records reviewed and had the potential to affect all patients admitted to the agency. Findings include: Agency Policy: Interdisciplinary Team Meeting Policy Number: 2-007.1 Date Reviewed: September 2021 Policy: The Interdisciplinary Team will meet at least every fifteen days to communicate updates to the Interdisciplinary Team Plan of Care. Procedure: ...Core members of the team include physician, nurse, social worker and chaplain. All team members in attendance will be signed in electronically to the meeting. In the event of mechanical or electronic failure, team members will be signed in on an attendance form. 1. Review of the MRs for 14 active patients revealed no signatures, electronic or physical, to verify attendance by all core members, for all IDT meetings. An interview conducted on 4/11/23 at 4:04 PM with Employee Identifier # 2, Patient Services Director, confirmed all IDT meetings conducted did not have electronic signatures or physical signatures indicating attendance for all core members.”

“Based on review of medical records, observations, agency policy and procedure, and staff interview, it was determined the facility failed to ensure services were coordinated between the facility and the hospice agency. This affected Home Visit (HV) # 1, one of one HVs in a facility, and had the potential to affect all of the agency’s patients residing in facilities. Findings Include: Agency Policy: Coordination of Care/Services with Contracts/Agreements Policy Number: 2-013.1 Date Reviewed: September 2021 Purpose: To ensure the coordination of care/services provided by the Hospice and by outside providers. Policy: ... All services provided, whether directly or under contractual agreement, will be guided by Hospice of the Valley policies and procedures. Procedure: ...When care is provided at a care facility: ...4. The Hospice program retains responsibility for evaluating services, maintaining professional management responsibility and ensuring continuity of care in all settings ... and case management collaboration. HV # 1 was admitted to the agency on 3/14/24 with diagnoses including: Senile Degeneration of Brain, Not Elsewhere Classified. HV # 1 resides in a Skilled Nursing Facility (SNF). A home visit was conducted on 4/9/24, to observe care provided by Employee Identifier (EI) # 4, Medical Social Worker. During the HV, the surveyor observed in HV # 1’s MR orders written by the hospice nurse on facility letterhead. The orders were to discontinue aspirin, pantoprazole, acetaminophen, donepezil, and meloxicam, effective 3/25/24. Review of Interdisciplinary Team (IDT) notes dated 4/2/24 revealed aspirin, pantoprazole, acetaminophen, donepezil and meloxicam had a start date of 3/14/24 with no end date or physician order to discontinue. An interview conducted on 4/11/24 at 4:14 PM with EI # 2, Patient Services Director, confirmed there was no documentation that medication changes were updated in the IDT notes or by a physician order.”

“Based on review of the Quality Assurance Performance Improvement (QAPI) program and staff interview, it was determined the agency failed to demonstrate an effective, hospice-wide, data driven QAPI program that documents measurable improvements in quality indicators. This had the potential to negatively affect all patients served by the hospice agency. Findings include: A review of the agency’s QAPI program conducted on 4/11/24 revealed there was no documentation indicating measurable improvement in indicators related to improved palliative outcomes and hospice services. An interview was conducted on 4/11/24 at 10:05 AM with Employee Identifier (EI) # 1, Compliance, Quality, and Education Director, and EI # 2, Patient Services Director. The agency’s current Performance Improvement Projects (PIPs) that included data elements to reflect ongoing monitoring and quality indicators were requested. The requested data was not provided. EI # 1 stated there were no PIPs currently. When asked who was on the QAPI Team, EI # 1 replied, “I am working on getting one together.” EI # 1 failed to provide documentation with quality indicators that data was being measured to improve palliative outcomes and hospice services.”

“Based on review of the Quality Assurance Performance Improvement (QAPI) program and staff interview, it was determined the agency failed to ensure staff accurately measured, analyzed, and tracked all adverse events for patient outcome and care improvement processes. This had the potential to negatively affect all patients served by the hospice agency. A review of the agency’s QAPI program conducted on 4/11/24 revealed no documentation the hospice measured, analyzed, and tracked quality indicators, including adverse patient events, and other aspects of performance that enabled the hospice to assess processes of care, hospice services, and operations. An interview was conducted on 4/11/24 at 10:05 AM with Employee Identifier (EI) # 1, Compliance, Quality, and Education Director, and EI # 2, Patient Services Director. The Adverse Event and Incident Report Log was requested. No documentation was provided. When asked how adverse events were evaluated, tracked, and analyzed, EI # 1 replied that adverse events including falls and medication errors are documented in KanTime (a computer system used for documentation). EI # 1 stated staff must input the information for it to alert him/her to an incident requiring follow-up. No documentation was provided for adverse events reported in the last 12 months.”

“Based on review of the Quality Assurance Performance Improvement (QAPI) program, agency policy and procedure, and staff interview, it was determined the agency failed to ensure the QAPI program was approved by the Governing Body. This had the potential to negatively affect all patients served by the hospice agency. Findings include: Agency Policy: Governing Body Policy No: 6-003.1 Revised: 10/2023 Purpose: To outline the roles and responsibilities of the governing body. Policy: The governing body assumes full legal authority and responsibility for the operation of Hospice of the Valley... Procedure: ...4. B. Relevant findings of performance improvement activities are provided to the governing body on a monthly and quarterly basis. C. Information relevant to the quality of patient care is communicated effectively. 5. The governing body authorizes adequate resources and support to establish and maintain an organization-wide performance improvement program. Information related to the performance improvement program is provided to the governing body. A review of the agency’s QAPI program conducted on 4/11/24 revealed no documentation of approval of the QAPI plan by the Governing Body (GB). An interview was conducted on 4/11/24 at 10:05 AM with Employee Identifier (EI) # 1, Compliance, Quality, and Education Director. EI # 1 was asked “Who is on the QAPI Team with title?” and replied “I am working on getting one together.” When asked if the agency QAPI program frequency and program objectives had been approved by the GB, EI # 1 verified there was no documentation of the GB approval of the agency’s QAPI program.”

“Based on review of the Quality Assurance Performance Improvement (QAPI) program and staff interview, it was determined the agency failed to ensure a QAPI plan which focused on high risk, high volume, or problem-prone areas. This had the potential to negatively affect all patients served by the hospice agency. Findings include: A review of the agency’s QAPI program conducted on 4/11/24 revealed no documentation of Performance Improvement (PI) activities focused on high risk, high volume, or problem-prone areas. An interview was conducted on 4/11/24 at 10:05 AM with Employee Identifier (EI) # 1, Compliance, Quality, and Education Director. The agency’s policy and procedure related to the QAPI program was requested. No policy was provided. EI # 1 confirmed there were no PI activities which focused on high risk, high volume, or problem-prone areas.”

“Based on review of the Quality Assurance Performance Improvement (QAPI) program and staff interview, it was determined the agency failed to develop, implement, and evaluate performance improvement projects (PIPs). This had the potential to negatively affect all patients served by the hospice agency. A review of the agency’s QAPI program conducted on 4/11/24 revealed no documentation the hospice had developed, implemented and evaluated PIPs. An interview was conducted on 4/11/24 at 10:05 AM with Employee Identifier (EI) # 1, Compliance, Quality, and Education Director and EI # 2, Patient Services Director. When asked what current PIPs were being tracked, EI # 1 stated “none.””

“Based on review of the Quality Assurance Performance Improvement (QAPI) program and staff interview, it was determined the agency failed to ensure Performance Improvement Projects (PIPs) were conducted reflecting the scope, complexity, and past performance of the hospice’s services and operations. This had the potential to negatively affect all patients served by the hospice agency. Findings include: A review of the agency’s QAPI program conducted on 4/11/24 revealed no documentation of any current PIPs and no documentation for any PIPs in the last 12 months. An interview was conducted on 4/11/24 at 10:05 AM with Employee Identifier (EI) # 1, Compliance, Quality, and Education Director and EI # 2, Patient Services Director. During the interview, EI # 1 revealed there were no PIPs since he/she became employed by the agency in October 2023. No additional documentation of previous PIPs was provided.”

“Based on review of the agency volunteer program, personnel records, policies and procedures, and staff interviews, it was determined the agency failed to complete and obtain the results of background checks for 69 of 69 volunteers and 25 of 45 employees. This deficient practice had the potential to affect all patients, employees, volunteers, and visitors. Findings include: Agency Policy: Selection/Hiring of Personnel Policy Number: 0-004.1 Revised Date: October 2023 Policy: All employees will undergo personal background checks and meet all health requirements prior to employment. Procedure: Hiring: 5. Other information obtained during the application process will include, but will not be limited to...national criminal background check. Policy: Volunteer Services Policy Number: 4-016.1 Policy: Volunteers may work in a variety of capacities, including: Patient Care Volunteers...Bereavement Volunteers...Errands and Transportation Volunteers...Office Volunteers... and Special Project Volunteers... Procedure: 7. Volunteers must meet the same criteria as paid employees about screening... 1. A review of the Volunteer Program was conducted on 4/10/24 at 2:50 PM with Employee Identifier (EI) # 3, Volunteer Coordinator. The review revealed background checks were filed in the volunteer’s personnel records indicating “completed” but no documentation of the results of the background checks or if the volunteer was eligible to be a volunteer. EI # 3 stated he/she had never obtained the results from a background check for any volunteer and always thought the documentation received once the background check was submitted indicating, “completed” was all that was necessary. 2. Review of employee personnel files on 4/11/24 revealed 25 of 45 background checks were incomplete and there was no documentation the results of the background checks were obtained prior to hire. An interview was conducted on 4/11/24 at 10:05 AM with EI # 1, Compliance Quality and Education Director who confirmed the results from the background checks were not obtained prior to hire.”