Omegalife Hospice of Arizona, Inc.

“Based on interview, review of policy and procedure and review of facility documents, it has been determined the Administrator failed to ensure that high probability hazards were identified on the facility-based hazard vulnerability assessment and subsequently addressed in the facility emergency plan. Failure to address high-risk scenarios can result in the facility being unprepared for emergency events, resulting in injury or death of patients and staff. Findings include: Omegalife Hospice of Arizona Hazard Vulnerability Assessment, found within the Omegalife Hospice of Arizona Emergency Preparedness binder was reviewed. Although values were assigned to impact and preparedness for each potential hazard, no hazards were identified by the facility as being high probability for the community or for the facility. “...Omegalife Hospice of Arizona Emergency Preparedness Plan....” reviewed April 7, 2023 contained no preparedness instructions for specific hazards such as Emerging Infectious Diseases (EIDs) or extreme temperatures. In an interview conducted on September 25, 2024, Employee #1 and #2 acknowledged that specific hazards had not been identified by the facility as being high probability for the facility or the community on the completed hazard vulnerability assessment and therefore no specific hazards had been addressed in the emergency preparedness plan in relation to the hazard vulnerability assessment. “”

“Based on interview, review of policy and procedure and review of facility documentation, it has been determined the Administrator failed to ensure that a method for tracking both staff and patients has been appropriately implemented as outlined in the emergency preparedness plan. Failure to ensure that methods identified for tracking staff and patients in the event of emergency events can result in the facility or emergency responders being unable to assist either patients or staff during an emergency event. Findings include: “...Omegalife Hospice of Arizona Emergency Preparedness Plan....” reviewed April 7, 2023 revealed: “...Each office will keep and maintain a current list of contact information for staff, staff family members...The admitting nurse will obtain a list of contact numbers, and discuss emergency planning options with the patient and family. All information will be kept in the patient’s chart and shall be kept in paper as well as electronic format...Plan Activation-Emergency Call Down Procedure (refer to Calling List)...Office Manager will notify Secretary, and then each will notify persons listed below them on the calling list...The OFfice Manager and Secretary will call the office and list the employees available for assistance then come to the office...Office Manager and Secretary will try those employees not found with the first call attempt and notify the Disaster Supervisor(s) of any other employees found to be on standby...Each month, all Emergency Supervisors will get an updated copy of the emergency list and keep it at home for reference if an emergency occurs after hours, or if the Agency office is damaged or destroyed....” The Omegalife Hospice of Arizona Emergency Preparedness Binder listed both Employee #1 and #2 as Emergency Supervisors. In an interview conducted on September 25, 2024, Compliance Officer asked Employee #1 for a paper copy of the Emergency List or a hard paper copy of a staff contact list. Employee #1 stated that there were no hard copies maintained of staff contacts but staff contact information could be obtained electronically. Employees #1 and #2 were asked if hard copies were maintained of patient contact information and Employee #1 and #2 confirmed that hard copies were not maintained of this information in compliance with the emergency preparedness plan.”

“Based on interview, review of facility policies and procedures and facility documentation, it has been determined the Administrator failed to ensure that alternate means of communication identified by the facility’s emergency preparedness plan have been maintained by the facility. Failure to ensure identified means of alternate communication are maintained can result in facilities being unprepared in an emergency and unable to continue providing services to patients. Findings include: “...Omegalife Hospice of Arizona Emergency Preparedness Plan....” reviewed April 7, 2023 revealed: “...If there is no power, or phone lines, open the emergency kit provided to you by the agency which includes a battery-operated radio and CB radios with frequency 26.965 MHz which will enable you to go to your prearranged meeting if you do not have your own transportation....” In an interview conducted with Employees #1 and #2 on September 25, 2024, Compliance Officer asked to see an example of the emergency kit provided to each employee upon hire. Employees #1 and #2 verified that employees are not provided emergency kits containing a battery-operated radio or a CB radio.”

“Based on interview, review of facility documents and review of facility policies and procedures, it has been determined the Administrator failed to ensure the facility’s emergency preparedness communication plan included the contact information for facility staff, doctors servicing patients, volunteers, other hospices or entities providing services under arrangement. Failure to include vital contact information in the communication plan can result in patients losing contact with vital services through their facility. Findings include: A review of “...Omegalife Hospice of Arizona Emergency Preparedness Plan....” reviewed April 7, 2023 revealed: “...Each office will keep and maintain a current list of contact information for staff, staff family members, vendors...hospitals...A list of vendors who supply each patient’s medical supplies will be obtained and kept in the patient’s chart....” A review of the accompanying Omegalife Hospice Emergency Preparedness binder revealed contact information for key staff members only. No contact information could be found for the remainder of the staff, physicians providing services to patients, contractors providing services under arrangement, volunteers or other hospices. In an interview conducted with Employee #1 and Employee #2 on September 25, 2024, Employee #1 and #2 confirmed that these contact phone numbers were not presently maintained with the emergency preparedness materials.”

“Based on interview, review of facility policy and procedures and review of facility documentation, it has been determined the Administrator failed to ensure that contact phone numbers for emergency officials were maintained in the emergency preparedness communication plan. Failure to ensure that contact phone numbers for emergency officials are maintained in the emergency preparedness communication plan can result in facility staff being unable to access needed assistance in a timely manner. Findings include: A review of “...Omegalife Hospice of Arizona Emergency Preparedness Plan....” reviewed April 7, 2023 which contained the facility communications plan along with the accompanying Omegalife Hospice of Arizona Emergency Preparedness binder revealed no contact information for Federal, state, local or tribal authorities. A Power Point presentation from FEMA was found within the binder that contained an email address for FEMA. No other contact information could be found. In an interview conducted with Employees #1 and #2 on September 25, 2024, Employees #1 and #2 confirmed that no other contact information for emergency officials could be located within the provided emergency preparedness materials.”

“The facility must demonstrate staff knowledge of emergency procedures. This requirement was NOT MET as evidenced by: Based on observation and staff interviews, the facility failed to ensure all personnel are knowledgeable regarding facility evacuation site and secondary meeting location. Two out of two staff members unable to identify facility evacuation site or secondary meeting location. Failure to ensure staff is knowledgeable around emergency procedures has the potential to negatively impact patient safety, increase patient mortality and morbidity, risk the health and welfare of staff, and disrupt facility function leading to a delay or lack in patient care. Findings Include: Facility policy entitled, “... Emergency Preparedness Plan....” revealed “secondary meeting location as 4503 W Bryce Lane, Glendale, Arizona 85301....” Interviews with staff members #16 and #71 revealed they were not aware of secondary meeting location.”

“Based on interview, review of facility policies and procedures and review of facility documents, it has been determined the facility failed to conduct exercises to test the facility’s emergency preparedness plan annually. Failure to test the facility’s emergency preparedness plan can result in a facility not being prepared in the event of an actual emergency event, resulting in preventable harm or fatality to patients or staff. Findings include: “...Omegalife Hospice of Arizona Emergency Preparedness Plan....” reviewed April 7, 2023 revealed: “...Agency staff members will participate in an annual desktop drill to determine the effectiveness and efficiency of the current policy and any forms developed for use in a disaster....” Documentation of drills were requested for calendar years 2024, 2023 and 2022. Documentation of drills conducted in 2023 and 2022 could not be provided. After-Action Report/Improvement Plan from a drill conducted on May 8, 2024 titled, “...Jumanji Too Functional Exercise....” hosted by Arizona Coalition for Healthcare Emergency Response (AZCHER) was provided; however, this report was a general report that did not demonstrate participation. An email accompanying the report dated September 24, 2024 from AZCHER revealed: “...it appears that the deadline to submit the necessary exercise documents has passed. As a result, we are unable to include your facility’s participation in the AAR/IP at this time...Do you have the exercise documents from your facility that you can provide the surveyor? (Sign-in sheet, feedback forms, etc...) Your facility should have completed your own AAR/IP from your own findings in the exercise....” In an interview conducted with Employee #1 and #2 on September 25, 2024, Employee #1 and #2 confirmed that a facility after-action report and sign-in sheet could not be provided for the Jumanji Too Functional Exercise.”

“The facility must demonstrate it maintains an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases including monitoring staff for compliance with hospice policies and procedures related to infection control. This requirement was NOT MET as evidenced by: Based on observation and staff interviews, the facility failed to ensure that procedures outlined in the Influenza Vaccination Program policy are followed. This deficient practice has the potential to increase the risk of infections and outbreaks that lead may lead to unnecessary patient suffering and substandard outcomes. Finding include: Review of facility policy, “Influenza Vaccination Program” revealed, “...1. Omegalife Hospice of Arizona acknowledges that patient care staff, contract staff and LIPs can acquire and transmit influenza from patients or transmit influenza to patients and other staff. Vaccination remains the single most preventive measure...The goals of Omegalife Hospice of Arizona Vaccination Program are to...meet the nationwide target goal of staff vaccination of 90% by 2020. Omegalife will incrementally improve its vaccination rate by 2 percent annually to achieve targeted long-term goal of 100 percent... will collect and review at least annually the reasons given....for declining vaccination...Vaccination rate data will be provided at least annually to key stakeholders, e,g., leaders, managers, and Omegalife Hospice of Arizona Staff....” Review of the facilities infection control binder revealed no data related to Influenza Vaccinations. In interview with the administrator documentation of Influenza Vaccination data collection and analysis activities for the previous year were requested and could not be provided.”