Village in Place Hospice

“Based on review of agency policy, medical records (MR) and staff (EMP) interviews, the agency failed to review all the patient’s medications and update the medication profile for two (2) of fourteen (14) MR reviewed (MR1 and MR2). Findings included: Review of the agency policy and procedures was conducted on 6/27/2024 at approximately 2:00 PM revealed, “;SUBJECT: MEDICATION RECONCILIATION/VERIFICATION (DRUG PROFILE)...POLICY: * (AGENCY) Hospice will implement and maintain a process to obtain and document a completed list of a patients current medications upon admission. * A full reconciliation is not required for those procedures that involve minimal medication use and do not include discharge prescriptions or any other changes in medications that the patient has been taking. A list of patients current medications and allergies/sensitivities must be obtained in order to make an informed decision regarding the use of “;minimal medications”...*Medication reconciliation is a multidisciplinary process between Nursing, the Pharmacist and the Physician with patient/family involvement. *Medication reconciliation/verification will be performed: *upon admission to the (Agency) *When a patient is transferred or referred to another setting, service, practitioner or level of care within or outside of this organization * Any transition of care where new medications are ordered or existing orders are rewritten (as defined by the organization) *At the time of discharge...” A review of MR1 (OBV1) was conducted on 6/25/2024 at approximately 11:40 AM, start of care 12/21/2021 Plan of Care certification period 6/8/2024 to 08/6/2024. Revealed an order under section “;DME” listed “;Oxygen Concentrator, Oxygen Portable Tank.” The Plan of Care Order was compared to the Patient Medication Record, oxygen was not listed on the medication record. A review of MR2 (OBV3) was conducted on 6/25/2024 at approximately 10:55 AM, start of care 6/27/2022 Plan of Care certification period 6/21/2024 to 08/19/2024. Revealed an order under section “;DME” listed “;Oxygen Concentrator, Oxygen Portable Tank.” The Plan of Care Order was compared to the Patient Medication Record, oxygen was not listed on the medication record. Per entry in the Plan of Care Order “;...4/16/24 POX 95% on RA, denies SOB and no distress noted. PRN O2 ordered.” An interview was conducted on 6/27/2024 at approximately 2:45 PM with the administrator, director of home health and hospice, director and assist director of home health and hospice which confirmed the above findings.”

“Based on review of agency policy and procedure and staff (EMP) interview, the agency failed to ensure program quality data was collected and available for review as part of the agency quality assessment and performance improvement program. Findings Included: Review of the agency policy and procedures was conducted on 6/27/2024 at approximately 1:05 PM revealed, “;PERFORMANCE IMPROVEMENT PLAN...POLICY: The Administration of (Agency) is committed to and supports a planned, systematic organization-wide performance improvement plan that encompasses will-designed processes and performance measurement, analysis and improvement...SCOPE OF ACTIVITIES: *The scope of the organizational performance improvement program includes an overall assessment of the efficacy of performance improvement activities with a focus on continually improving care provided, and patient safety practices conducted, throughout the Hospice. The program consists of these focus components: performance improvement, patient safety, quality assessment/improvement and quality control activities...Assessment of the performance of the following patient care and organizational functions may be included: *Environment of Care *Emergency Management *Human Resources *Infection Prevention and Control *Information Management *Leadership *Life Safety *Medication Management * Medical Staff *Nursing *Provision of Care, Treatment and Services *Performance Improvement *Record of Care, Treatment and Services *Rights and Responsibilities of the Individual...COMMUNICATITON/INTERGATION OF INFORMATION: *The findings, conclusions, recommendations, actions taken to improve performance and the results of actions taken are documented and reported through established channels. *results of the outcomes of performance improvement activities and patient safety activities will be reported to the Quality Assurance Committee on a quarterly basis as designated. *The Hospice Coordination Nurse will submit a report an analysis of the quality of patient care, treatment and services to the Director of Hospice on a monthly basis. *The Quality Assurance Committee will provide the Board of Directors with a report of the relevant findings from all performance improvement activities performed throughout the organization at least on a quarterly basis...” Review of QAPI information was conducted on 6/28/2024 at approximately 11:25 AM, a document listed “;HIS Admission Measures Completion” listed the following categories: Opioid Bowel, Pain Screening, Pain Assessment, Dyspnea Screening, Dyspnea Treatment, Treatment Preferences and Beliefs Addressed. Listed was the time frame “;Your Agency-Last 90 Days.” During a phone interview with EMP3 on 6/28/2024 at approximately 11:32 AM the surveyor requested this information for the last two years per “;Hospice Survey Checklist” document. EMP3 confirmed no information was available for this report prior to ninety (90) days. An interview was conducted on 6/27/2024 at approximately 2:45 PM with the administrator, director of home health and hospice, director and assist director of home health and hospice which confirmed the above findings.”

“Based on review of agency policy and procedure, observations (OBV) during home visits and staff (EMP) interview, the agency failed to ensure staff followed infection control standards of practice and agency policy and procedure for two (2) of three observations providing direct care to patients (OBV1 and OBV3). Findings Included: Review of the agency policy and procedures was conducted on 7/2/2024 at approximately 9:00 AM revealed, “;NURSING BAG TECHNIQUES...PURPOSE: To maintain a clean nursing bag and prevent transmission of infection to patients. POLICY: *All nurses and home health aides employed by (Agency), A Home Healthcare Provider...are provided with a fully stocked bag prior to beginning their patient care assignments. The nursing bag should have two “;clean” compartments....PROCEDURE: *The bag should be placed on a barrier, i.e., disposable professional towels, paper towels, in the patients home and in a storage container in staffs car. *In the home, identify a clean and safe area for the healthcare bag...Before setting the bag down, spread an impervious barrier on a safe, clean surface...*When the visit is completed: *Contaminated supplies /equipment are contained/disposed of as necessary. *Reusable equipment is cleaned using alcohol, antiseptic wipes, and/or soap and water as appropriate...” A visit was conducted to MR1 (OBV1) residences on 6/27/2024 at 9:25 AM revealed: EMP7 provided direct patient care. EMP7 removed items from open nursing/supply bag and placed the bag on a clean chuck/barrier. Two (2) additional chuck/barrier was placed on each side adjacent to the chuck/barrier the nursing/supply bag was located. One area was being used for clean supplies. The following equipment was observed being used during treatment: pulse oximeter and thermometer. After patient use EMP7 placed the pulse oximeter and thermometer back to the clean location on the chuck/barrier prior to cleaning the reusable equipment. A visit was conducted to MR2 (OBV3) residences on 6/27/2024 at 11:25 AM revealed: EMP8 provided direct patient care. EMP8 removed items from open nursing/supply bag and placed the bag on a clean chuck/barrier. Two (2) additional chuck/barrier was placed adjacent to the chuck/barrier the nursing/supply bag was located. One area was being used for clean supplies. The following equipment was observed being used during treatment: stethoscope, blood pressure cuff, pulse oximeter and thermometer. After patient use EMP8 placed the stethoscope, blood pressure cuff, pulse oximeter and thermometer back to the clean location on the chuck/barrier prior to cleaning the reusable equipment. Based on a review of Centers for Disease Control and Prevention CDC guidance, agency policy/procedure volunteer files (VF) and staff (EMP) interview it was determined that the agency failed to ensure volunteers were screened for TB (tuberculosis) upon hire for one of two volunteer files (VF) reviewed that provided direct patient/family care role (VF2). Findings Included: Review of the Centers for Disease Control and Prevention CDC guidance was conducted on 7/2/2024 at approximately 11:30 AM revealed, “;Clinical Testing Guidance for Tuberculosis: Health Care Personnel...TB screening programs in health care setting, TB screening programs should include anyone working or volunteering in health care settings, including: *Inpatient settings *Outpatient settings...” Review of the agency policy and procedures was conducted on 6/27/2024 at approximately 2:00 PM revealed, “;Policy: Pre-Employment Health Applicable to: All New Hires...II. Policy: It is the policy of (agency) to comply with the State and Federal regulations...III. Pre-employment Health Requirements 1. Standard Requirements: a. A health examination completed no more than 6 months prior to employment by a licensed physician. b. A two-step Mantoux test must be completed. Step 1 may be done within previous 12 months and Step 2 must be done when hired. c. A chest x-ray if the Mantoux test result is positive. A copy of the chest x-ray report to be submitted prior to employment...” Review of the agency policy and procedures was conducted on 6/27/2024 at approximately 1:20 PM revealed, “;HOSPICE VOLUNTEER TRAINING PROGRAM...PURPOSE: (Agency) Hospice has qualified volunteers to help meet the patient/family/caregiver needs and to follow the Interdisciplinary plan of care. Volunteers will be considered qualified to provide Hospice administrative services or direct care under after successfully completing the (Agency) Hospice Volunteer Training Program. POLICY: *Persons desiring to be (Agency) volunteers will undergo the interview and hiring process as approved for hiring volunteers of the (Agency)...*Hospice volunteers will not provide direct or indirect Hospice services until they have satisfactorily completed the (Agency) Training Program...” A review of VF2 was completed on 6/27/2024 at approximately 12:45 PM. VF2, date of hire 8/13/2023: No documentation was provided by the agency to confirm TB testing at time of hire. An interview was conducted on 6/27/2024 at approximately 2:45 PM with the administrator, director of home health and hospice, director and assist director of home health and hospice which confirmed the above findings.”

“Based on review of hospice bereavement program, clinical records (CR), and staff interviews, the hospice failed to ensure that a bereavement plan of care documented the kind of bereavement services to be offered and the frequency of service delivery for two (2) of two (2) bereavement MR reviewed. (MR4 and MR5). Findings included: A review of the agency policy and procedure was conducted on 6/25/2024 at approximately 11:12 AM revealed, “;BEREAVEMENT SERVICES...PURPOSE: To provide appropriate and coordinated bereavement services to families and caregivers. POLICY: Hospice provides bereavement services for at least one year and six (6) contacts following the death of the patient. PROCEDURE: *The Hospice Social Worker completes an initial bereavement assessment when the patient is admitted. *After the initial bereavement assessment is completed, Hospice IDG develop and implement a plan to address bereavement/grief issues...After the death has occurred, Hospice Social Worker updates the initial bereavement assessment with a follow-up bereavement assessment. The interdisciplinary Team discusses the patients death. The team plans the bereavement services, for the patients family/caregivers, based on the initial bereavement assessment and subsequent assessments during care. *Within two (2) weeks after the death of the patient, Hospice sends a sympathy card to the bereaved. *Within four (4) weeks, Hospice sends a survey satisfaction survey with a stamped return envelope to the bereaved for quality assurance purposes. *Within four (4) weeks after the patients death, Hospice staff completed a bereavement assessment form. The assessment notes and observes the bereaved for symptoms related to grief. Hospice staff will render a professional judgment whether the bereaved(s) is/are experiencing normal grief or severe grief reaction...” A review of MR4 was conducted on 6/25/2024 at approximately 11:22 AM, the start of care was 5/23/2023. The bereavement assessment was conducted on 6/1/2023. The bereavement documentation was review. The surveyor could not confirm what services where to be offered and the frequency of service. A review of MR5 was conducted on 6/25/2024 at approximately 1:20 PM, the start of care was 12/5/2023. The bereavement assessment was conducted on 12/27/2023. The bereavement documentation was review. The surveyor could not confirm what services where to be offered and the frequency of service. An interview was conducted with the Bereavement Coordinator on 6/25/2024, at approximately 11:48 AM the bereavement coordinator was aware no list of services or frequency was available. An interview was conducted on 6/27/2024 at approximately 2:45 PM with the administrator, director of home health and hospice, director and assist director of home health and hospice which confirmed the above findings.”