Fhp Home Health - Hospice

“Based on a review of the facility’s Emergency Preparedness Plan (EPP) and staff interview, the Hospice agency failed to establish a current comprehensive Emergency Preparedness Program that complies with all applicable Federal Emergency Preparedness requirements that was based off the facility’s all hazard risk assessment and patient population it serves. This deficient practice has the potential to put the current seven patients who are provided care by the facility and facility staff from the agency at risk in the event of an emergent event.Findings include:During a review of the facility Emergency Preparedness plan on 08/01/25 at 1:40 PM, the Home Health and Hospice Manager and the Healthcare Delivery Administrator revealed the all- hazards risk assessment and the EPP, based on that assessment, had not been updated since 2017; in conjunction with other requirements of the EPP that were not included. Cross Reference: E0006, E0013, E0019, E0029, E0030, E0031, E0032, and E0036.”

“Based on record review, interviews, and policy review, it was determined that the Governing Body did not ensure the Quality Assurance program maintained an effective performance improvement program with evidentiary documentation. This failure had the potential to affect the quality of care for the current seven patients receiving services from the agency.Findings include:1. There was no documented evidence that the hospice agency had Governing Body meetings according to agency policy to monitor the Quality Assurance and Performance program. Cross Reference: L562.2. The agency failed to document performance improvement plans being conducted, the reason for the project, and measurable progress. Cros Reference: L573.3. The Governing Body failed to ensure the Quality Assurance Performance Improvement process was defined, implemented, maintained, and evaluated annually. Cross Reference L574.”

“Based on interview and review of the agency’s Emergency Management Plan, also known as the Emergency Preparedness Plan (EPP), the agency failed to ensure the EPP policies were based on a current all hazards-based agency and/or community risk assessment. This failure had the potential to affect the current seven patients receiving care from the agency and employed staff.Findings include:During a review of the agency’s Emergency Preparedness plan on 08/01/25 at 1:40 PM, the Home Health and Hospice Manager and the Healthcare Delivery Administrator revealed the all- hazards risk assessment, the basis for the agency’s EPP, had not been updated since 2017.Review of the all-hazards assessment showed it included “epidemic” and “swine flu” but did not include pandemic/emerging infectious diseases.During an interview on 08/01/25 at 1:59 PM, the Healthcare Delivery Administrator stated, “This is something we have to update since we moved to this building in 2023.””

“Based on interview and review of the agency’s Emergency Preparedness Plan (EPP), the agency failed to develop and implement emergency preparedness policies and procedures based on a current facility and community based all-hazards risk assessment that included emerging infectious diseases and failed to review and update their policies on an annual basis. This failure had the potential to affect the seven patients served by the hospice and hindered the agency’s ability to provide care and services to keep patients and staff safe during an emergency. Findings include: Review of the agency’s EPP on 08/01/25 at 1:40 PM with the Home Health and Hospice Department Manager (HDM) and Healthcare Delivery Administrator (HDA) did not reveal policies and procedures that had been updated every two years. During an interview on 08/01/25 at 1:42 PM stated the last documented update was in 2017.At 1:55 PM, the HDA stated he/she thought there was an update in 2019 but no evidence was provided.”

“Based on interview and review of the agency’s Emergency Management Plan, also known as the Emergency Preparedness Plan (EPP), the agency failed to ensure the EPP addressed a procedure to inform the State and Local Emergency Preparedness Officials of homebound patients in need of evacuation. This failure had the potential to affect any of the seven patients currently receiving care from the agency.Findings include:Review of the agency’s EPP, last updated on 07/11/17, with the Home Health and Hospice Department Manager (HDM) revealed no policy or procedure that identified the procedure the agency would use to notify the local or state emergency officials of homebound patients that required evacuation in an emergency event.During an interview on 08/01/25 at 2:28 PM, the HDM stated, “We don’t have that. It would probably be each case manager, but it’s not written.””

“Based on interview and review of the agency’s Emergency Management Plan, also known as the Emergency Preparedness Plan (EPP), the agency failed to develop and maintain an Emergency Preparedness Communication Plan that was reviewed and updated at least bi-annually (every two years). This failure had the potential to affect the seven current patients receiving care from the agency, potentially hindered the agency’s ability to continue care and services to patients during an emergency event and keep patients and staff safe during an emergency.Findings Include:Review of the agency’s EPP with the Home Health and Hospice Department Manager (HDM) on 08/01/25 at 1:40 PM did not reveal any evidence the Communication Plan had been updated in the last two years.During an interview on 08/01/25 at 2:51 PM, the HDM stated he/she had nothing to show it had been reviewed or updated every two years, stating, “The one in the book is 2017.””

“Based on interview and review of the agency’s Emergency Management Plan, also known as the Emergency Preparedness Plan (EPP), the Hospice failed to maintain a current list of names and contact information in the “Emergency Preparedness Communication Plan” that included other hospice agencies. This failure had the potential to affect the seven patients receiving care from the organization and could delay the agency’s ability to respond to an emergency.Findings include:Review of the agency’s EPP Communication Plan, with a last reviewed date of 07/11/2017, with the Home Health and Hospice Department Manager (HDM), revealed no inclusion of other hospice agencies.During an interview on 08/01/25 at 2:56 PM, the HDM confirmed that other hospices were “not in there.””

“Based on interview and review of the agency’s Emergency Management Plan, also known as the Emergency Preparedness Plan (EPP), the agency failed to maintain a current list of contact information that included the Federal Emergency Preparedness staff and/or agencies in their Emergency Preparedness Communication Plan. This failure had the potential to affect any of the seven patients receiving care from the agency and could delay the agency’s ability to respond to an emergency and had the potential to prevent first responders and other sources of assistance from providing care and services to the agency and its’ patients or staff during an emergency event.Findings include:Review of the agency’s EPP Communication Plan with the Home Health and Hospice Department Manager (HDM) and Healthcare Delivery Administrator (HDA) on 08/01/25 at 1:40 PM revealed no inclusion of emergency contact information for the Federal emergency staff/agency.During an interview on 08/01/25 at 3:01 PM, the HDA confirmed that the Federal Emergency Management Agency (FEMA) was on the island but not included in the EPP Communications Plan.”

“Based on interview and review of the agency’s Emergency Management Plan, also known as the Emergency Preparedness Plan (EPP), the agency failed to ensure the EPP Communication Plan identified a means of primary and/or alternate form of communication with staff, federal and state emergency management agencies. This failure had the potential to affect the current seven patients receiving care from the agency and hinder the agency’s ability to prepare for/respond to potential emergency situations.Findings include:Review of the agency’s EPP Communications Plan on 08/01/25 at 1:40 PM with the Healthcare Delivery Administrator (HDA) did not reveal specified primary and alternate methods of communication with the federal and state emergency management agencies.During an interview on 08/01/25 at 3:05 PM, the HDA stated, “We don’t have that.””

“Based on interview and review of the agency’s documentation, the agency failed to ensure the Emergency Management Plan, also known as the Emergency Preparedness Plan (EPP), documented an updated training program every two years. This failure had the potential to affect the seven current patients receiving care and services from the hospice due to the lack of staff or volunteer preparedness in the case of an emergent event.Findings include:Review of the EPP on 08/01/25 at 1:40 PM with the Home Health and Hospice Department Manager (HDM) revealed no documentation regarding an updated/reviewed training program in the last two years.During an interview on 08/01/25 at 3:32 PM, the HDM confirmed the last training program update was in 2017.”

“Based on record review and interview, the facility failed to ensure the initial Interdisciplinary Group (IDG) assessments were completed within five days of Hospice admission for two of 14 patients (Patient (P) 1 and P2) reviewed out of a total sample of 14. This failure could affect the care the patient and/or family received due to inaccurate assessment of needs.Findings include:1. P1 was admitted to Hospice services on 07/19/25.During P1’s record review, no Social Worker or Spiritual assessments were found.During an interview on 08/01/25 at 4:16 PM, the Billing Associate (BA, operating the electronic medical record) stated, “I don’t think [he/she, Social Worker] completed it before [he/she] left. It’s not completed.”2. P2 was admitted to Hospice services on 07/08/25.During P2’s record review, no Social Worker assessment was found.During an interview on 08/04/25 at 4:37 PM, BA stated “[He/She] hasn’t visited yet.” The Hospice Manager commented that P2 was “Gov.Guam” and they did not cover a Hospice Social Worker.Review of the facility’s policy titled, “Patient Record Content,” revised 06/2018, did not address the requirement of the IDG assessment completion within five days of admission.”

“Based on record review and interview, the facility failed to ensure the Quality Assurance Performance Improvement and/or Governing Body had evidence of at least one measurable improvement in hospice services or palliative outcomes. This failure had the potential to affect the quality of life of any of the seven current hospice patients.Findings include:Review of the facility provided minutes of the last Quality Assurance Performance Improvement meeting, held without the Medical Director in attendance on 05/07/25, revealed the “Attendance Sheet” had a handwritten topic of “Home Health & Hospice Care Conference,” had the following attachments:”PT [Physical Therapy] – RN [Registered Nurse] Case Management Checklist””FHP Hospice Strategic and Improvement Plan for 2024 – 2026,” with”Strategic Goal and Initiatives:1. Quality Improvement and Quality of Care2. Regulatory Compliance and Readiness3. Workforce Development4. Referral Growth and Community Engagement5. Financial Sustainability” and”Activates [sic] and implementation timelines:Q1 [Quarter 1] 2024 5 Day Assessment RulePartnership Building and Education CampaignQ2 2024Partnership BuildingReferral Growth and Community EngagementQ3 2024Build and maintain communicationsWorkforce developmentQ4 2024Financial SustainabilityQ1 2025Revenue enhancement and Cost ManagementQ2 2025Staff Training and educationQ3 2025Staff Training and educationWorkforce developmentRegulatory Compliance and ReadinessQ4 2025Quality Improvement and Quality of CareImplementation of HOPE [Hospice Outcomes & Patient Evaluation] tool.”During an interview on 08/04/25 at 7:50 PM, the Healthcare Delivery Administrator (HDA) stated that the items they had been looking at for improvement were physical therapy / Registered Nurse communication for patient functionality and alleviating pain to increase quality of life. The HDA stated performance improvement issues were not in a written format and were discussed at the Interdisciplinary Group (IDG) meetings every two weeks. The HDA stated QAPI did not meet regularly. The HDA stated, “We met in May and the one before that, the only one was in November of 2024.”The facility provided the last documented Governing Body meeting minutes, and they were dated 09/28/22.No policy regarding Quality Assurance Performance Improvement was provided.”

“Based on interview, policy review, and attempted record review, the agency failed to ensure there was evidence of the Performance Improvement Plans/Projects (PIP) being conducted, the reason for the project undertaking, and/or measurable progress from the improvement plan. This failure had the potential to affect the quality of life for any of the current seven patients or the practices of the Hospice agency staff.Findings include:During an interview on 08/04/25 at 7:50 PM, in response to a request for PIPs in the past year, the Healthcare Delivery Administrator (HDA) stated that the items they had been looking at for improvement were physical therapy / Registered Nurse communication for patient functionality and alleviating pain to increase quality of life. The HDA stated performance improvement issues were not in a written format and were discussed at the Interdisciplinary Group (IDG) meetings every two weeks but QAPI did not meet regularly. The HDA stated, “We met in May and the one before that, the only one was in November of 2024.”Review of the facility policy titled, “Leadership Assessment of Contributions to Quality Assessment/Performance Improvement (QAPI) and Safety Improvement Activities,” revised March 2013, revealed, “. . . 1. At lease annually Hospice leaders and the Governing Body will perform an analysis/assessment of their contributions to Hospice’s QAPI program. 2. Hospice leaders and Governing Body members will establish expectations for using data and information for improving safety and quality of care . . .””

“Based on record review and interview, the agency’s Governing Body failed to ensure the Quality Assurance Performance Improvement activities were evaluated annually. This failure had the potential to affect the quality of life during the palliative care process for any of the current seven patients and the ability of staff to effectively care for those patients.Findings include:In response to a request for the Governing Body meeting minutes, the facility provided a sign-in sheet and agenda from a meeting dated 09/28/22.During an interview on 08/04/25 at 7:50 PM, the Healthcare Delivery Administrator (HDA) stated, “The policy says they are to meet annually. They have not had a meeting since 2022.” The HDA provided an attendance sheet from that meeting dated 09/28/22.Review of the facility policy titled, “Leadership Assessment of Contributions to Quality Assessment/Performance Improvement (QAPI) and Safety Improvement Activities,” revised March 2013, revealed, “. . . 1. At least annually Hospice leaders and the Governing Body will perform an analysis/assessment of their contributions to Hospice’s QAPI program. 2. Hospice leaders and Governing Body members will establish expectations for using data and information for improving safety and quality of care.”Review of the facility policy titled, “Governing Body,” revised 06/2018, revealed, “. . . Responsibilities . . . The Governing Body annually evaluates Hospice’s performance in relation to its vision, mission and goals . . . The Governing Body meets at least annually to review the operation of Hospice and documents all meetings by minutes . . .””

“Based on personnel file review, staff interview, and review of agency policy, the agency failed to offer Hepatitis B vaccines to one of six direct care staff whose personnel files were reviewed. This had the potential for the potential transmission of Hepatitis B to patients and other staff employed by the agency. Findings include: Review of Registered Nurse (RN)3’s personnel file revealed a hire date of 02/22/99. There was no evidence that the hepatitis vaccine had been offered, accepted, or declined by the employee since the date of hire. During an interview on 08/04/25 at 1:20 PM, the Home Health and Hospice Department Manager (HDM) confirmed there was no evidence the Hepatitis B Vaccine (HBV) was offered to or declined by RN3 During an interview on 08/04/25 at 7:03 PM regarding a HBV policy, the Healthcare Delivery Administrator (HDA) stated the agency did not have a policy regarding the HBV, “It’s in our general Human Resources policy that we offer the vaccine for free, but not a Hospice policy.””

“Based on record review, interview, and agency policy review, the facility failed to ensure bereavement services were provided per policy for two of 14 sampled patients (Patient (P) 4 and P5). This failure had the potential to affect the ability of patient family members to process the loss and grief of death.Findings include:1. Review of P4’s record revealed a hospice admission date of 06/12/24 with a terminal diagnosis of brain cancer. P4 passed away on 08/18/24. The record revealed the first bereavement condolence call was on 08/25/24; the first mailing was 08/18/24; the next mailing was at six months on 02/18/25; the next mailing was at 12 months on 08/18/25 During an interview on 08/04/25 at 3:44 PM, the Home Health and Hospice Department Manager (HDM) stated, “The third and ninth months were missed.” 2. Review of P5’s record revealed a hospice admission date 04/16/24 with a terminal diagnosis of prostate cancer. P5 passed away on 07/05/24. The record revealed the first bereavement condolence call was on 07/12/24; the first mailing was a card on 08/05/24; the next contact was at six months on 01/05/25 then at 12 months on 07/05/25, and the record was scheduled to be closed on 08/05/25. During an interview on 08/04/25 at 3:49 PM, the Home Health and Hospice Department Manager (HDM) stated, “The third and ninth months were missed.” Review of the facility policy titled “Bereavement Services,” revised 2014, revealed, “. . . Procedure . . . 3. Within two weeks of the patient death, a condolence card will be mailed to the family. Within a month of death, a twelve-month bereavement mailing program will be initiated for designated family members . . .””

“Based on interview and personnel file review, the facility failed to ensure one of one Certified Nurse Aide / Home Health Aide (CNA/HHA) had twelve hours of annual in-service training. This failure had the potential to affect any of the current seven patients that may require aide services.Findings include:Review of CNA1’s personnel file showed a facility hire date of 01/08/24.During an interview on 08/04/25 at 12:52 PM, the Hospice Manager confirmed CNA1 did not have the twelve in-service hours required. At 2:45 PM, the Hospice Manager provided a few online certificates, two without dates, and the others were dated 07/08/24 and 07/10/24, with a total of eight in-service hours. The Hospice Manager stated the facility year was September to September and confirmed these were outside the past twelve months and the facility did not have a policy regarding in-services.Review of the facility policy titled, “Hospice Aide Services and Training Program,” revised 2014, revealed no reference to the provision of in-service training hours.”

“Based on interview, patient packet review, and policy review, the facility failed to ensure written controlled medication disposal policies were provided to one of three patients/family members (Patient (P) 3) out of a total sample of 14. This failure had the potential for unused or discontinued medications to be mishandled, diverted, or left undestroyed.Findings include:During an interview on 08/04/25 at 11:45 AM, the Responsible Party (RP3) for P3 was asked if he/she had received instruction on medication destruction. RP3 stated, “No.” RP3 confirmed during the interview that the Hospice had provided a comfort pack that included controlled substances. Registered Nurse (RN) 2 reminded RP3 about destroying medications in used coffee grounds or cat litter, RP3 stated, “Oh yes.” The Hospice paper packet provided to P3 and RP3 was reviewed, and there were no documents regarding medication destruction. RN2 confirmed there were no documents related to medication destruction.During an interview on 08/04/25 at 3:06 PM, the Administrator stated the written medication destruction information had not been included in the sample admission packet provided to the surveyor and “probably was not in the packet the patient received.”Review of the facility policy titled “Medication Disposal,” revised 06/2018, revealed, “. . . 1. At the time when controlled drugs are first ordered, Hospice will: Provide a copy of the Hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family . . .””