Coventry Hospice

“Based on interview and record review, the agency failed to ensure an updated patient records were readily available to support continuity of care during an emergency, when the agencys emergency preparedness policy and procedure did not contain the most current patient roster. This failure had the potential for the agency to not be able to adequately assess and address the needs of patient to implement immediate intervention during emergencies, placing 13 patients safety and well-being at risk. Findings: A review of the agency’s “[name of the agency] Emergency Preparedness Plan” binder was conducted for the period from October 1, 2023, to October 31, 2024. The agencys Emergency Preparedness Program Binder did not contain the patient roster, which should be readily available to provide adequate support and maintain continuity of care during an emergency. During an interview on October 31, 2024, at 2:00 PM with the Director of Patient Care Services/Administrator (DPCS/Admin), the DPCS/Admin stated she was the person responsible for the agencys emergency preparedness plan, including updating patient roster. The DPCS/Admin was not able to provide an explanation as to why the patient roster had not been updated. A concurrent interview and record review on October 31, 2024, at 2:30 PM, was conducted with the DPCS/Admin. The DPCS/Admin reviewed of the agency’s policy and procedure (P&P) titled, “Emergency Management Plan”, which indicated “;... Each month, all emergency leaders will get an updated copy of emergency list and copy of patient acuity, staff roster ...for reference if the emergency occurs after hours, or if the agency is damaged or destroyed, so that when the DPCS/Administrator activated the EOP [Emergency Operation Plan] the supervisors are all prepared...”. The DPCS/Admin stated he was aware the patient roster needed to be updated monthly as per the agencys P&P. The DPCS/Admin further stated the agency did not follow the policy.”

“Based on interviews and record reviews, the agency failed to implement the agencys Emergency Operation Plan policy and procedure when staff members were not able to provide information regarding the agency’s Emergency Preparedness Plan for alternate communication methods during emergency events during home visits. This failure had the potential to prevent the agency from adequately communicating patient needs to implement immediate interventions and maintain continuous care during emergencies with staff and with Federal, State, tribal, regional, and local emergency management agencies. This put the safety and well-being of 13 patients at risk during emergency events. Findings: During an interview with a Certified Home Health Aid (CHHA), on October 29, 2024, at 9:10 AM, CHHA stated she was not sure when the agencys Emergency Preparedness Plan in-services was given and stated, “;it might have been two months ago, around August 2024.” CHHA further stated that she was unsure of the alternate communication methods for communicating patient needs during emergency events and only remembered being instructed to report to the office if she was unable to contact anyone. During an interview with a Registered Nurse/Case Manager (RN/CM), on October 29, 2024, at 10:00 AM, RN/CM stated she received the agencys Emergency Preparedness Plan in-services “;two months ago” which is in August 2024. The RN/CM further stated that she was unsure of the alternate communication methods for communicating patient needs during emergency events and only remembered being instructed to report to the office if she was unable to contact anyone. During an interview with Director of Patient Care Services/Administration (DPCS/Admin), on October 31, 2024, at 2:00 PM, the DPCS/Admin stated the last time the agencys Emergency Preparedness Plan in-services was provided to the staff was in April 2024. The DPCS/Admin further stated she did not have documentation to show the alternate communication method had been provided to all staff to maintain essential functions during emergency even. During a concurrent interview and record review, on October 31, 2024, at 2:30 PM, with the DPCS/Admin, the DPCS/Admin reviewed the agencys policy and procedure (P&P) titled, “;Emergency Operation Plan,” indicated, “;... GOALS: To be able to coordinate communications, resources and assets, staff responsibilities, utilities and patient clinical and support activities during an emergency. To be able to handle emergencies effectively and to provide continuum of care to our patients served. To be able to have staff maintain safety and be able to know what to do during and after a disaster.... EMERGENCY COMMUNICATION ...2. The DPCS/Administrator is responsible for all Emergency Management for emergency to call staff and who are responsible for the proper communication to staff and patients during an emergency, DME, etc. 3. A list of all staff members and telephone numbers will be included in the agency’s on-call book as this is always with RN and DPCS daily. 4. All staff and patients will be educated that during a disaster use local radio station to listen for agencies’ updates and announcements by the DPCS for all communication... I. Clinical Staff will communicate with means available. If the primary modes of communication with phone or cell phone fails, other methods may be used: a. Texting. Text if you can, instead of calling, to conserve battery power and minimize congestion on cell networks, the Federal communications Commission commends. b. Satellite phones. c. Internet technologies, email or. d. CB radios or HAM radios, if available ...” The DPCS/Admin stated she was responsible for the agencys Emergency Preparedness Plan and confirmed that she did not have documentation to show the alternate communication methods had been provided to all staff to maintain essential functions during emergency event. Furthermore, she stated the agency did not follow the policy.”

“Based on interview and record review, the agency failed to develop, implement, and evaluate performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) from October 1, 2023, to October 31, 2024. This failure had the potential to cause problems in health outcomes, patient safety, and quality of care to go unaddressed and continue in a universe of 13 patients. Findings: A review of the agencys “;Quality Assessment and Performance Improvement (QAPI)” binder for period of October 1, 2023, to October 31, 2024. There was no documented evidence to show PIPs had been initiated, were in process or had been completed for the actual issue that emerged after quality indicator was identified from the data collection and analysis reviewed. During an interview with the Director Patient Care Services/Administrator (DPCS/Admin) on October 31, 2024, at 3:00 PM, the DPCS/Admin stated she is the person responsible for the QAPI Program. The DPCS/Admin further stated no PIPs had been initiated for the actual issue from the quality indicator identified, and it should had been initiated. The DPCS/Admin further stated that she was unfamiliar with how the PIP are selected and implemented to address specific issues or areas for improvement. During a concurrent interview and record review, with the DPCS/Admin, on October 31, 2024, at 3:10 PM, the DPCS/Admin reviewed the agencys policy and procedure (P&P) titled “;Quality Assessment and Performance Improvement (QAPI) Plan”, the P&P, indicated, “;Mission. All QAPI activities must support and be aligned with the mission of the organization. Purpose. The purpose of The Hospice QAPI Plan is to provide a strategy for the systematic organization wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high-value, effective and efficient services in accordance with its mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations. Objectives... To show measurable improvement in indicators that demonstrate an improvement in palliative outcomes and end-of-life support systems. To measure, analyze and track quality indicators, including adverse events, to enable the assessment of processes of care, hospice services and operations. To collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement. To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that it is sustained ...”. The DPCS/Admin stated the agency did not follow the policy.”

“Based on interview and record review, the agency failed to maintain an effective infection control program when the surveillance data (system of collecting patient records and data to measure changes, and trends) and risk analysis (is an interpretive process that draws conclusions from a set of facts) were not routinely reviewed and monitored to prevent and control infections in a universe of 13 patients. This failure had the potential to cause the spread of the infection to the agencys patients. Findings: A review of the agencys “;Infection Control” electronic record, for the year 2024, was conducted. It contained data collection. There was no documented evidence to show surveillance data and risk analysis had been initiated from the data collected. There was no documented evidence to show that the agency had developed a system to identify the root cause, patterns, or trends in the agencys infection control program from October 1, 2023, through October 31, 2024. During an interview on October 31, 2024, at 1:30 PM with the Director of Patient Care Services/Administrator (DPCS/Admin) stated that she was the person responsible for the Infection Control Program. The DPCS/Admin stated the surveillance and analysis had not been done from the data collected reports from October 1, 2023, through October 31, 2024, because she had been unaware of the requirement. During a concurrent interview and record review, on October 31, 2024, at 1:40 PM, with the DPCS/Admin, the agencys policy and procedure (P&P) titled, “;Infection Control Plan”, was reviewed. The P&P indicated, “;... PURPOSE. To delineate an infection control plan to meet the following goals: 1. Establish the mechanisms by which the organization will address surveillance, prevention, identification, control and reporting of infections.... POLICY. [Name of the agency] is committed to reducing the risk of acquisition and transmission of health care associated infections (HAIs). Recognized prevention and control mechanisms will be implemented for planning, surveillance, identification, prevention/control, and reporting procedures. To determine the effectiveness of the infection control plan, [Name of the agency] will measure, assess, improve, and redesign (as appropriate) the surveillance, identification, prevention, and control function ... Procedure... 4. ... A. The risks of infection will take into consideration the organizations geographic location, the community environment, the programs/services provided, and the characteristics of the population served. B. The risk analysis will include a description of prioritized risks; a description of the strategies to minimize, reduce, or eliminate the prioritized risks; and a description of how strategies will be evaluated. The risk analysis will be reviewed at least annually and whenever significant changes occur in any of these factors. 5. The infection control plan will be monitored and evaluated in the annual program evaluation and in conjunction with the review of the organizations safety and performance improvement activities. Surveillance activities, including data collection and analysis, will be used to identify prevention and control risks. The evaluation of the infection control program includes a review of the plan, goals, and risk analysis across all services/programs.” The DPCS/Admin stated she was aware that surveillance should be routinely reviewed and monitored geographically, along with the characteristics of the population served, in accordance with the agency’s policies and procedures. The DPCS/Admin further stated that the agency did not follow this policy”