Survey Report for 231677

DEPARTMENT OF HEALTH AND HUMAN SERVICES		FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES		OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER	(X2) MULTIPLE CONSTRUCTION	(X3) DATE SURVEY COMPLETED
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	231677	A. BUILDING __________ B. WING ______________	03/24/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
FIRSTHEALTH HOSPICE	717 S ETON ST, BIRMINGHAM, MI, 48009
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE		TITLE	(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
E0001
E0001	20987 This Condition of Participation has NOT been met. Based on record review and interview, the hospice agency failed to develop an emergency preparedness plan based on the COVID-19 virus for the years of 2020 and 2021, and for any other pandemic disease to give guidance to the staff during a pandemic emergency (Refer to L0004), failed to develop and implement emergency preparedness policies and procedures for the COVID-19 virus (Refer to L 0013), failed to maintain a coordinated agency-wide program for the tracking of employees and patients, and failed to develop a screening method for the agency's employees and visits during the COVID-19 pandemic (Refer to L0018), and failed to develop and maintain documented evidence of emergency preparedness training and testing for all employees, on the COVID-19 virus for the years of 2020 and 2021 (Refer to L 0036). The cumulative effects of these deficient practices resulted in a potential for patients and staff being unprepared to respond effectively and with a lack of directions during an actual pandemic emergency. This deficient practice could negatively affect the health and safety of all employees and patients serviced by the agency in the event of a pandemic emergency. The agency was found to be out of compliance with 42 CFR §484.113 Emergency Preparedness Program Conditions of Participation for Hospice Agencies.
E0004
E0004	20987 Based on interview and record review, the hospice agency failed to develop an emergency preparedness plan based on the COVID-19 virus for the years of 2020 and 2021, and for any other pandemic disease to give guidance to the staff during a pandemic emergency. Resulting in no directions for the hospice personnel during an actual pandemic emergency, which could have negatively affected the health and safety of the staff and the patients serviced by the agency employees during the 2020 and 2021 pandemic. Findings included: During an interview on 3/23/2021 at 1:30 PM a request was submitted to review the agency's emergency preparedness plan that included any revisions with the COVID-19 virus, the Administrator #1 replied, "We don't have it here, it was in the other binder that the other Clinical Manager took." There was no documented evidence the agency developed policies and procedures that were based on the COVID-19 disease and any other pandemic diseases. The agency failed to develop and establish written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan for the COVID-19 disease and any other pandemic disease.
E0013
E0013	20987 Based on interview and record review, the hospice agency failed to develop and implement emergency preparedness policies and procedures for the COVID-19 virus for the years of 2020 and 2021, and for any other pandemic diseases to give guidance to the staff during a pandemic emergency. Resulting in no directions for the hospice personnel during an actual pandemic emergency, which could have negatively affected the health and safety of the staff and the patients serviced by the agency employees during the 2020 and 2021 pandemic. Findings included: During an interview on 3/23/2021 at 1:30 PM a request was submitted to review the agency's emergency preparedness plan that included any revisions with the COVID-19 virus, the Administrator #1 replied, "We don't have it here, it was in the other binder that the other Clinical Manager took." There was no documented evidence the agency developed policies and procedures that were based on the COVID-19 disease and any other pandemic diseases. The agency failed to develop and establish written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan for the COVID-19 disease and any other pandemic disease.
E0018
E0018	20987 Based on observation, record review, and interview the hospice agency failed to maintain a coordinated agency-wide program for the tracking of employees and patients, and failed to develop a screening method for the agency's employees and visits during the COVID-19 pandemic for the years 2020 and 2021, resulting in the potential for spreading the COVID-19 infection between staff and the agency's patients currently serviced by the agency, for a potential to negatively affect all current patients being serviced by this agency. Findings include: Upon arrival to the agency on 3/23/21 at 9:30 AM, it was observed that there was no signage posted on the agency's main entrance door or the door to the agency's suite, that directed visitors and staff of the protocol for entering the agency. Upon entering the suite, the writer was greeted by the Intake Coordinator (IC #1) and escorted to a conference room without first being screened for COVID-19. There was no protocol in place for the screening of visitors. On 3/23/21 at 11:36 a.m., an interview was conducted with the Care Manager (LPN #1). When queried about the agency's screening process, LPN #1 reported, "We would usually temp (temperature) you (persons entering facility) upon entering, although we didn't temp you (writer). We don't have any signs posted at the front door. There is only a sign directing where to leave packages. We screen all of our staff here in the office." When asked if there was documented evidence of the screening, LPN #1 reported, "No." There was no evidence that the agency conducted screening of office staff, visitors, or field staff prior to the provision of care. These findings were reviewed and acknowledged by Administrator #1 during an interview on 3/23/21 at 1:35 PM.
E0036
E0036	20987 Based on interview and record review, the hospice agency failed to develop and maintain documented evidence of emergency preparedness training and testing for all employees, on the COVID-19 virus for the years of 2020 and 2021. Resulting in the hospice employees not prepared to properly function during an actual pandemic emergency, which could have negatively affected the health and safety of the staff, and the patients serviced by the agency employees. Findings included: During an interview on 3/23/2021 at 1:30 PM a request was submitted to review the agency's emergency preparedness plan, and any in-service trainings and testings on the COVID-19 virus, the Administrator #1 replied, "We don't have it here, all of that information was in the other binder that the other Clinical Manager took." There was no documented evidence the agency developed policies and procedures that were based on the COVID-19 disease and any other pandemic diseases. The agency failed to develop and maintain documented evidence of emergency preparedness training and testing, for all employees on the COVID-19 virus for the years of 2020 and 2021.
L0540
L0540	27712 Based on record review and interview, it was determined the agency failed to ensure a Registered Nurse that was a member of the interdisciplinary group provided coordination of care and services to ensure continuous assessment of each patient/family needs, resulting in uncoordinated care and the potential for unmet care needs. Findings include: Agency Policy: "Interdisciplinary Group Meeting" undated, stated, "The meeting will be facilitated by the hospice clinical Supervisor or designee..., Members at the meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor." An anonymous complaint received alleged, "The agency is allowing the Licensed Practical Nurse (LPN) to conduct/facilitate the IDG (Interdisciplinary Group) meetings and legally it has to be ran by an RN (Registered Nurse)." On 3/23/21 at 3:40 p.m., during a review of the agency's "IDG Meeting" notes in the patient's clinical records, it was noted that the documents were all signed by LPN #1. There was no indication that the IDG meetings were held/facilitated by an RN. When queried as to who conducts/facilitates the IDG meetings, LPN #1's response was vague, yet reported, "We all kind of do it, but there is an RN in the meeting as well as the Medical Director." When asked why the IDG Meeting notes were all signed by her, LPN #1 reported, "I always thought anyone could sign them." The agency failed to ensure a Registered Nurse that was a member of the interdisciplinary group provided coordination of care and services.
L0559
L0559	27712 This Condition of Participation has NOT been met. Based on record review and interview, it was determined that the hospice failed to ensure the Quality Assessment Performance Improvement (QAPI) program included measuring, analyzing and tracking of quality indicator data elements to assess processes of care, hospice services and operations affecting all 37 patients currently serviced by this agency, resulting in the potential for poor patient outcomes and missed opportunities for improvement (L562); failed to utilize QAPI indicator data that included all patient services that may impact patient/family care as part of the QAPI program, resulting in the potential for unidentified opportunities for improvement and unmet care needs (L563); failed to ensure its QAPI performance improvement activities focused on high risk, high volume, or problem-prone areas, resulting in the potential for unidentified opportunities for improvement and unmet care needs (L566); failed to ensure the Quality Assessment Performance Improvement program documented actions taken to improve performance and track performance measures to ensure improvements are sustained affecting all 37 patients serviced by this agency, resulting in the potential for poor patient outcomes (L570); and, the agency's Governing body failed to ensure that an ongoing program for quality improvement was defined, implemented, and evaluated annually, resulting in the potential for poor patient outcomes and unmet care needs (L574). The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation of 42 CFR§418.58, Quality Assessment and Performance Improvement.
L0562
L0562	27712 Based on record review and interview, it was determined that the hospice failed to ensure the Quality Assessment Performance Improvement program included measuring, analyzing and tracking of quality indicator data elements to assess processes of care, hospice services and operations affecting all 37 patients currently serviced by this agency, resulting in the potential for poor patient outcomes and missed opportunities for improvement. Findings include: During a review of the Quality Assessment Performance Improvement (QAPI) documents for the calendar years 2019 and 2020, it was noted that there was no data that had been collected as part of the review, and no documentation of data elements that were measured, analyzed or tracked as part of the QAPI program. These findings were reviewed with the Administrator (Adm #1) during an interview on 3/23/21 at 1:35 p.m., who reported, "We've been working on QAPI."
L0563
L0563	27712 Based on record review and interview, it was determined the Hospice failed to utilize QAPI indicator data that included all patient services that may impact patient/family care as part of the QAPI program, resulting in the potential for unidentified opportunities for improvement and unmet care needs. Findings include: On 3/23/21 at 10:15 a.m., the agency's QAPI (Quality Assessment Program Improvement) documentation for calendar years 2019 and 2020 was reviewed. During the review, it was noted that there was no documented evidence that the QAPI data included all patient services and how they impact patient/family care as part of the QAPI program. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 3/23/21 at 1:35 p.m., who reported, "We've been working on QAPI."
L0566
L0566	27712 Based on record review and interview, it was determined that The Hospice failed to ensure its QAPI performance improvement activities focused on high risk, high volume, or problem-prone areas, resulting in the potential for unidentified opportunities for improvement and unmet care needs. Findings include: On 3/23/21 at 10:15 a.m., during a review of the agency's QAPI (Quality Assessment Performance Improvement) data, it was noted that the agency had no Performance Improvement Projects available for review that would include a focus on high risk, high volume, or problem-prone areas. These findings were reviewed with the Administrator (Adm #1) during an interview on 3/23/21 at 1:35 p.m. who reported, "We were relying on our previous Clinical Manager to do this but it didn't workout. We've been working on QAPI."
L0570
L0570	27712 Based on record review and interview, it was determined that the Hospice failed to ensure the Quality Assessment Performance Improvement program documented actions taken to improve performance and track performance measures to ensure improvements are sustained affecting all 37 patients serviced by this agency, resulting in the potential for poor patient outcomes. Findings include: During a review of the agency's Quality Assessment Performance Improvement (QAPI) documents on 3/23/21 at 10:15 a.m., it was noted that the agency had no Performance Improvement Projects in place to review. There was no measurable data collected that demonstrated improvements in hospice performance. These findings were reviewed with the Administrator (Adm #1) during an interview on 3/23/21 at 1:35 p.m. who reported, "We're working on QAPI."
L0574
L0574	27712 Based on record review and interview, it was determined that the agency's Governing body failed to ensure that an ongoing program for quality improvement was defined, implemented, and evaluated annually, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: On 3/23/21 at 10:15 a.m., during a review of the agency's QAPI (Quality Assessment Performance Improvement) data, it was noted that no quality improvement program implementation data had been collected. It was further noted that there was no annual evaluation of any quality improvement program results. The Governing Body failed to ensure that an ongoing program for quality improvement was defined, implemented, and evaluated annually. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 3/23/21 at 1:35 p.m. who reported, "Our previous Clinical Manager was assigned to QAPI but didn't do it. We've been working on it." When queried about the Governing Body's provision of oversight of the agency's QAPI program, Adm #1 offered no response.
L0577
L0577	20987 This Condition of Participation has NOT been met. Based on record review and interview, the hospice agency failed to maintain and document an effective infection control program that protects employees, patients, families and visitors against the spread of infection and provide education on the COVID-19 virus for the year of 2020 and 2021 (Refer to L 0578); failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control of infectious and communicable diseases including Covid-19 as an integral part of the agency's Quality Assessment and Performance Improvement program, and failed to develop a method of screening visitors and staff employed by the agency (Refer to L 0580); failed to provide infection control education and education on the COVID-19 Pandemic virus for the year of 2020 and 2021 (Refer to L0582); and failed to maintain written documentation of the in-service training on infection control and the COVID-19 Pandemic virus for the years of 2020 and 2021 (Refer to L0663). The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the safety of all employees, patients, and caregivers against the spread of communicable infectious diseases during a pandemic for the condition of participation of 42 CFR§418.60.
L0578
L0578	20987 Based on record review and interview, the hospice agency failed to maintain and document an effective infection control program that protects employees, patients, families and visitors against the spread of infection and provide education on the COVID-19 virus for the year of 2020 and 2021 to all 17 active employees, patients, families and visitors for a potential to spread infection of employees not able to function during an emergency situation, for a potential to not be adequatelly able to function during a pandemic and emergency situation, which could negatively affect all employees, patients, families and visitors receiving services and care from the hospice agency. Findings include: Agency Policy: "Infection Control Policy: INF.10/HSP7-1A, revised 3-17-2009" stated, "All personnel will be oriented to infection control procedures including standard precautions for hand hygiene, blood borne organisms and the appropriate use of personnel protective equipment, the cleaning and maintenance of medical equipment and devices and proper disposal of infectious or hazardous waste. Annual update on exposure and post-exposure communicable disease and infection control will be provided to the direct care staff through in-service education. Education: The hospice must provide infection control education to employees, contracted providers, patients, and family members and other caregivers." During the Entrance Conference on 3/23/2021 at 10:15 AM, during an onsite Focused Infection Control survey and a Complaint Investigation survey, a request was submitted to review an active employee roster, the employees' Infection Control in-service training logs and the COVID-19 in-service training logs for the years 2020 and 2021 the LPN #1 (licensed practical nurse) replied, "I will check in the administrator's office and see if I can find them." The employee roster documented 17 employee names. The LPN #1 submitted a binder with the employees' in-services for 2019 and 2020. There were four infection control 2019 in-services: 10/20/19 (one employee signature), 10/22/19 (one employee signature), 10/23/19 (seven employee signatures) and 11/22/19 (one employee signature) all of the in-services were on "hand hygiene." And, there was one employee in-service on 6/17/20 (four registered nurses signatures) this in-service was on "hand-washing." There was no documented evidence the agency provided infection control in-service to all 14 employees during the years 2020 and 2021. During an interview with Administrator #1 on 3/23/2021 at 1:30 PM when queried if there were any other employee infection control in-services and any documented employee in-service trainings on the COVID-19 Virus for 2020 or 2021 he replied, "They might be in the other binder, that the Clinical Manager took when she left." The agency failed to provide documented in-service education for all 17 employees on infection control and the COVID-19 Virus for the years 2020 and 2021.
L0580
L0580	27712 Based on observation, record review, and interview the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control of infectious and communicable diseases including Covid-19 as an integral part of the agency's Quality Assessment and Performance Improvement program, and failed to develop a method of screening visitors and staff employed by the agency, resulting in the potential development and spread of the Covid-19 infection between staff and the agency's 37 active patients currently serviced by this agency. Findings include: Upon arrival to the agency on 3/23/21 at 9:05 a.m., it was observed that there was no signage posted on the agency's main entrance door or the door to the agency's suite, that directed visitors and staff of the protocol for entering the agency. Upon entering the suite, the writer was greeted by the Intake Coordinator (IC #1) and escorted to a conference room without first being screened for Covid-19. There was no protocol in place for the screening of visitors. On 3/23/21 at 11:36 a.m., an interview was conducted with the Care Manager (LPN #1). When queried about the agency's screening process, LPN #1 reported, "We would usually temp (temperature) you (persons entering facility) upon entering, although we didn't temp you (writer). We don't have any signs posted at the front door. There is only a sign directing where to leave packages. We screen all of our staff here in the office." When asked if there was documented evidence of the screening, LPN #1 reported, "No." There was no evidence that the agency conducted screening of office staff, visitors or field staff prior to the provision of care. On 3/23/21 at 10:15 a.m., the agency's QAPI (Quality Assessment and Performance Improvement) program documentation was reviewed for calendar years 2019 and 2020. There was no documented evidence that the agency's QAPI program included the surveillance, identification, prevention, or control of Covid-19 or any other infectious and communicable diseases. These findings were reviewed with and acknowledged by the Administrator (Adm#1) during an interview on 3/23/21 at 1:35 p.m. who reported, "We've been working on QAPI."
L0582
L0582	20987 Based on record review and interview, the hospice agency failed to provide infection control education and education on the COVID-19 Pandemic virus for the year of 2020 and 2021 to all 17 of 17 active employees, for a potential of employees not able to function during an emergency situation, for a potential to negatively affect all patients receiving services and care from the hospice agency. Findings include: During the Entrance Conference on 3/23/2021 at 10:15 AM, during an onsite Focused Infection Control survey and a Complaint Investigation survey, a request was submitted to review an active employee roster, the employees' Infection Control in-service training logs and the COVID-19 in-service training logs for the years 2020 and 2021 the LPN #1 (licensed practical nurse) replied, "I will check in the administrator's office and see if I can find them." The employee roster documented 17 employee names. The LPN #1 submitted a binder with the employees' in-services for 2019 and 2020. There were four infection control 2019 in-services: 10/20/19 (one employee signature), 10/22/19 (one employee signature), 10/23/19 (seven employee signatures) and 11/22/19 (one employee signature) all of the in-services were on "hand hygiene." And, there was one employee in-service on 6/17/20 (four registered nurses signatures) this in-service was on "hand-washing." There was no documented evidence the agency provided infection control in-service to all 14 employees during the years 2020 and 2021. During an interview with Administrator #1 on 3/23/2021 at 1:30 PM when queried if there were any other employee infection control in-services and any documented employee in-service trainings on the COVID-19 Virus for 2020 or 2021 he replied, "They might be in the other binder, that the Clinical Manager took when she left." The agency failed to provide documented in-service education for all 17 employees on infection control and the COVID-19 Virus in 2020 or in 2021.
L0663
L0663	20987 Based on record review and interview, the hospice agency failed to maintain written documentation of the in-service training on infection control and the COVID-19 Pandemic virus for the years of 2020 and 2021 to all 17 of 17 active employees to prevent the spread of a communicable disease, for a potential of employees not properly educated and equipped to function during a pandemic, which can negatively affect all employees and patients of the agency. Findings include: Agency Policy: "Infection Control Policy: INF.10/HSP7-1A, revised 3-17-2009" stated, "All personnel will be oriented to infection control procedures including standard precautions for hand hygiene, blood borne organisms and the appropriate use of personnel protective equipment, the cleaning and maintenance of medical equipment and devices and proper disposal of infectious or hazardous waste. Annual update on exposure and post-exposure communicable disease and infection control will be provided to the direct care staff through in-service education. Education: The hospice must provide infection control education to employees, contracted providers, patients, and family members and other caregivers." During the Entrance Conference on 3/23/2021 at 10:15 AM, during an onsite Focused Infection Control survey and a Complaint Investigation survey, a request was submitted to review an active employee roster, the employees' Infection Control in-service training logs and the COVID-19 in-service training logs for the years 2020 and 2021 the LPN #1 (licensed practical nurse) replied, "I will check in the administrator's office and see if I can find them." The employee roster documented 17 employee names. The LPN #1 submitted a binder with the employees' in-services for 2019 and 2020. There were four infection control 2019 in-services: 10/20/19 (one employee signature), 10/22/19 (one employee signature), 10/23/19 (seven employee signatures) and 11/22/19 (one employee signature) all the in-services were on "hand hygiene." And there was one employee in-service on 6/17/20 (four registered nurses' signatures) this in-service was on "hand-washing." There was no documented evidence the agency provided infection control in-service to all 14 employees during the years 2020 and 2021. During an interview with Administrator #1 on 3/23/2021 at 1:30 PM when queried if there were any other employee infection control in-services and any documented employee in-service trainings on the COVID-19 Virus for 2020 or 2021 he replied, "They might be in the other binder, that the Clinical Manager took when she left." At the time of the Exit Conference on 3/23/2021 at 3 PM, no other documented employee in-service training records were submitted for review on infection control and the COVID-19 virus for 2020 and 2021.
L0668
L0668	27712 Based on record review and interview, the Hospice failed to ensure the Medical Director composed and signed the narrative for Hospice Re-Certification for 1 (MR#1) of 1 records reviewed in which the patient had more than one benefit period, from a total sample of 4 records reviewed, resulting in no Physician review of the patient's clinical information and the potential for unmet end of life needs. Findings include: Agency Policy: "Certification of Terminal Illness" undated, stated, "At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patient's medical record or, if applicable, examinaiton of the patient." MR #1: The patient was admitted to hospice on 12/22/20 with a terminal diagnosis of Parkinson's Disease. The patient was on hospice service from 12/22/20 through 3/21/21. During the clinical record review on 3/23/21 at 2:00 p.m., it was noted that the 3/22/21 to 6/19/21 recertification of terminal illness dated 3/10/21, had not signed by the Medical Director or the attending physician. The Medical Director failed to follow agency policy and ensure to compose and sign the narrative. These findings were reviewed with the Adminisrator (Adm #1) and Executive Director (ED #1) during an interview on 3/23/21 at 1:35 p.m.