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
551766 A. BUILDING __________
B. WING ______________ 		12/06/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
MANOR HOSPICE 9007 ARROW ROUTE SUITE 180, RANCHO CUCAMONGA, CA, 91730
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)
L0500      
35183 The agency failed to ensure that the Condition of Participation: L 500 418.52 Patient's rights was in compliance when: Based on interview and record review, the hospice agency (Agency 1) failed to protect the patients' rights for one of five sampled patients (Patient 1) when two unauthorized Registered Nurses (RN) were given Patient 1's protected health information and sent to Patient 1's home to render care. (Refer to L 501) The cumulative effect of this systemic practice resulted in Patient 1 receiving care from registered nurses whose nursing licenses, nursing care practices and criminal backgrounds had not been checked by Agency 1, opening up a potential for substandard nursing practice and abuse of Patient 1.
L0501      
35183 Based on interview and record review, the hospice agency (Agency 1) failed to protect the patients' rights for one of five sampled patients (Patient 1) when two unauthorized Registered Nurses (RN) were given Patient 1's protected health information and sent to Patient 1's home to render care. This failure caused Patient 1 to receive care from registered nurses whose nursing licenses, nursing care practices and criminal backgrounds had not been checked by Agency 1, opening up a potential for substandard nursing practice and abuse of Patient 1. Findings: A review of Patient 1's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of August 8, 2017, with a recertification period of July 29, 2019 to September 26, 2019. Patient 1 had diagnoses that included Alzheimer's disease (a disease that causes dementia, a general term for memory loss and other cognitive abilities serious enough to interfere with daily life). A review of Patient 1's Skilled Nursing (SN) note dated September 17, 2019 from 7:44 PM to 8:14 PM indicated the following: "Patient/Pcg [primary caregiver] (chief complaint): For IV [intravenous-within a vein] insertion. Is pain controlled? Yes. Pain Level reported at this visit: 0 [zero (0) to 10 pain scale, 0 representing no pain and 10 representing the worst pain]. Vitals and Measurements: Temp: [temperature] 99.1 [degrees Fahrenheit], Pulse: refused, Resp: [respirations-rate of breathing] 18 [number of breaths in one minute], BP: [blood pressure] 144/100 (systolic blood pressure-the top number refers to the amount of pressure the arteries are under when the heart pumps and diastolic blood pressure-the bottom number refers to the amount of pressure the arteries are under when the heart rests between beats). [The SN staff signature line indicated] signed by UNKNOWN STAFF [the signature on the document was "unknown staff"] on 9/17/19" During an interview with the Operations Coordinator (OC) on December 3, 2019 at 11:39 AM, the OC stated he did the scheduling of all clinicians' visits to Agency 1's patients. The OC stated he tried to schedule four different, on-staff, RNs to visit Patient 1 on September 17, 2019, to start an IV for hydration (the process of replacing water in the body). The OC stated they all said "No." The OC stated the Prior Director of Patient Care Services (PDCPS-who left the agency's employ on September 30, 2019) had said she would go if he could not find anyone else. During an interview with the OC on December 3, 2019 at 12:04 PM, the OC stated he received a phone call from the Administrator Designee (AD) on September 17, 2019. The OC stated the AD gave him a name and phone number of a Registered Nurse (RN 2) who was willing to visit Patient 1 and start the IV for hydration. The OC stated he called the phone number provided and RN 2 answered the phone. The OC stated it sounded like RN 2 was driving a car and she was on a speaker phone. The OC stated RN 2 agreed to go start the IV so he gave her Patient 1's information. The OC stated RN 2 told him she had a Registered Nurse (RN 3) with her and that RN 3 worked with her at (name of a home health agency that did not provide care to Patient 1-Agency 2). The OC stated RN 2 told him that she and RN 3 would go see Patient 1 and start the IV. The OC stated he knew RN 2 and RN 3 did not work for Agency 1 but worked for Agency 2 unrelated to Agency 1. The OC stated, "The [AD] told me to do it, so I did." During an interview with the Administrator Designee (AD) on December 3, 2019 at 12:40 PM, the AD stated [name of Agency 2] was owned by RN 2 and she (the AD) did not have ownership interest in [name of Agency 2]. The AD stated she and RN 2 had a business relationship where they would refer patients to each other. The AD stated she and RN 2 had been friends for several years, "off and on." The AD stated, "We couldn't get our nurses to go. I called and begged [name of RN 2] to help me and she agreed." The AD stated, "I told my DPCS [the prior Director of Patient Care Services-PDPCS], who was sick, I had someone else who could help, so she didn't have to go." The AD stated, "[Name of RN 2] mentioned to me about the HIPPA [Health Insurance Portability and Accountability Act-a law designed to protect patient's medical records and other health information] law and I was so worried about getting the IV started I just rolled over her and begged her to do it any way." RN 2 did not respond to requests for an interview. During an interview with a Registered Nurse (RN 3) on December 3, 2019 at 3:07 PM, RN 3 stated he visited Patient 1 because he was told she (Patient 1) was dehydrated (excessive loss of body water) and needed IV hydration. RN 3 stated when they (RN 2 and RN 3) arrived, Patient 1's son refused to allow him (RN 3) to give the IV fluids. RN 3 stated Patient 1 became short of breath so he (RN 3) call 911 and waited until paramedics arrived and then "We [RN 2 and RN 3] left." RN 3 stated he worked for (name of Agency 2) and RN 2 was his boss. RN 3 stated he was in the car with RN 2 when she (RN 2) received the phone call from Agency 1's Operations Coordinator (OC). RN 3 stated RN 2 told him they were going to Patient 1's house to start an IV and give fluids. RN 3 stated they knew Patient 1 was Agency 1's patient and not a patient of Agency 2 where they worked. RN 3 stated, "I didn't question it because [name of RN 2] is my boss." RN 3 stated he did not work for Agency 1 and had not been authorized to see Patient 1 or have access to Patient 1's medical information. A review of Agency 1's policy and procedure titled, "Patient Privacy Rights," dated December 2010 indicated the following: "Policy: [Name of Agency 1] will respect and safeguard all protected health information about the patients it serves. Procedure: The patient will be provided with information about his/her privacy rights in the organization's Notice of Privacy Practices, which will be given to the patient during the admission visit. The patient's privacy rights include: Confidentiality of written, verbal and electronic information including your medical records, information about your health, social and financial circumstance or about what takes place in your home. Be admitted only if we can provide the care you need. A qualified staff member will assess your needs. If you require services that we do not have resources to provide, we will inform you, and refer you to alternative services, if available; or admit you, but only after explaining our limitations and the lack of a suitable alternative. Medical Information: As a patient receiving health services and care, we understand you may be concerned about how your medical and other health-related information may be handled. That is why we, as an organization, are committed to ensuring patient privacy and confidentiality to you and others we serve. General: This notice is drafted to you, consistent with the requirements of the privacy rules ("Privacy Rules") of the Health Insurance Portability and Accountability Act ("HIPPA). As a health care provider, we are committed to meet the requirements of the law to maintain the privacy of our patient's Protected Health Information..."
L0530      
35183 Based on observation, interview, and record review, the agency failed to ensure a review of all medications the patients were taking was conducted for two of five sampled patients (Patients 2 and 3) when: 1. For Patient 2, one medication the patient was taking was not indicated on the medication profile (MP - a current list of all medications prescribed for a specific patient), two medications on the MP the patient was not taking and one medication's administration instructions indicated on the MP did not match the administration instructions indicated on the bottle's pharmacy label. 2. For Patient 3, three medications on the medication profile (MP - a current list of all medications prescribed for a specific patient) the patient was not taking and one medication indicated on the MP the hospice nurse administered wrong, leading to a medication error. This failure had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy. Findings: 1. A review of Patient 2's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of December 12, 2017, with a recertification period of October 3, 2019 to December 1, 2019. Patient 2 had diagnoses that included chronic obstructive pulmonary disease (COPD-a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing). During a home visit on December 4, 2019 with a Registered Nurse (RN 1) and in the presence of Patient 2, an observation of Patient 2's actual medication bottles available in the home were compared with Patient 2's Medication Profile (MP - a current list of all medications prescribed for a specific patient). During an observation and concurrent interview with Patient 2 and RN 1on December 4, 2019 at 9:49 AM, Patient 2 supplied a bottle of famotidine (a medication that reduces heart burn) 40 mg (milligrams-a unit of measure), take one tablet by mouth every evening. Patient 2's MP indicated Zantac (a medication that reduces heart burn) 300 mg, one tablet once daily at night. RN 1 stated on her November 20, 2019 visit to Patient 2's home she was supposed to discontinue the Zantac and add the famotidine to Patient 2's MP and "I didn't." During a continued observation and concurrent interview with Patient 2 and RN 1, Patient 2's MP indicated the following medications: a. Niacin (a B vitamin nutritional supplement), 500 mg (milligrams-a unit of measure), take one tablet once daily. b. Guaifenesin (a medicine that loosens congestion in the chest and throat, making it easier to cough it out) 100 mg in 5 ml (milliliters-a unit of measurement), take 2 teaspoons (10 ml) every 6 hours as needed. Patient 2 stated she did not have these medications and had not taken them for 2 years. During a continued observation and concurrent interview with Patient 2 and RN 1, Patient 2 supplied a bottle of Imodium (a medication that decreases the frequency of diarrhea) where the pharmacy label indicated, 2 mg tablets, take 2 tablets orally after first loose stool, 1 tablet after each subsequent loose stool, no more than 4 tablets in 24 hours. Patient 2's MP indicated, Imodium, 2 mg tablets, take 1 tablet after each subsequent loose stool. RN 1 stated the administration instructions on the MP did not match the administration instructions on the pharmacy's label and it should. RN 1 stated she checked Patient 2's medications against the MP at every visit and did not know why the MP was not current and accurate. 2. A review of Patient 3's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 28, 2018, with a recertification period of October 28, 2019 to December 26, 2019. Patient 3 had diagnoses that included heart disease (dysfunction of the heart due to a disease process) and blindness. During a home visit on December 4, 2019 with the Director of Patient Care Services (DPCS) and in the presence of Patient 3 and Patient 3's private pay caregiver (CG), an observation of Patient 3's actual medication bottles available in the home were compared with Patient 3's Medication Profile (MP - a current list of all medications prescribed for a specific patient). During an observation and concurrent interview with Patient 3, Patient 3's CG and the DPCS on December 4, 2019 at 12:10 PM, Patient 3's CG supplied Patient 3's medication bottles. Patient 3's MP indicated the following medications: a. Albuterol sulfate (a breathing treatment medication to treat wheezing and shortness of breath), 2.5 mg (milligrams-a unit of measure) in 3 ml (milliliters-a unit of measurement), take one-unit dose via handheld nebulizer (a device that changes medication from a liquid to a mist so it can be inhaled into the lungs) every 6 hours as needed. b. Guaifenesin (a medication that loosens congestion in the chest and throat, making it easier to cough it out) 100 mg in 5 ml, take 10 ml every 4 hours as needed. c. Haloperidol (an antipsychotic drug that decreases excitement in the brain) 1 mg tablet, take 1 tablet every 6 hours as needed. The albuterol sulfate, guaifenesin and haloperidol were not with the group of medications Patient 3's CG supplied. Patient 3's CG stated the medications were stored on top of the bureau in the kitchen. Patient 3's CG stated, "I don't know where anymore medications are. I don't touch medications. The hospice nurses fill the pill boxes." Patient 3 stated all the medications were supposed to be stored on top of the bureau in the kitchen. Patient 3 stated she could not see her medications because she was blind but she did know she had not done any breathing treatments. During a continued observation and concurrent interview with Patient 3, Patient 3's CG and the DPCS, the DPCS assessed the contents of Patient 3's pill box and found the hospice nurse had filled each day with 40 mg of furosemide (a medication to reduce extra fluid in the body). Patient 3's MP indicated, furosemide, 20 mg tablet, 1 tablet every other day. The DPCS stated, "There are 2 tablets of 20 mg furosemide in each day of the pill box not 1 tablet. This is a medication error; I'll need to report it the physician." During a phone interview with a Licensed Vocational Nurse (LVN 1) on December 5, 2019 at 9:15 AM, LVN 1 stated she had filled Patient 3's pill boxes on November 25, 2019. LVN 1 stated Patient 3's pill boxes were filled to last Patient 3 for two weeks. LVN 1 stated she had filled Patient 3's pill boxes with 40 mg of furosemide instead of 20 mg, "I made a mistake." During an interview with the DPCS on December 5, 2019 at 1:17 PM, the DPCS stated it was her expectation that the skilled nurse took a copy of the patients' current medication profile with them to the home visit. The DPCS stated the nurses should then use the MP at every visit and compare the medications in the home to it. The DPCS stated, "This would keep all the patients' medications accurate and help to prevent medication errors. I can see I have some work to do with my nurses." A review of the agency's policy and procedure titled, "Medication Profile," dated December 2010, indicated the following: "Purpose: To define the use of the medication profile in evaluating a patient's current medication regimen. Policy: Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Procedure: During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: Using the medication profile to evaluate the use of the drugs in the home setting. Using the medication profile to teach drug purposes, dosages, routes, times, side effects, and contraindications. Using the medication profile as a communication tool for other clinicians involved in care."
L0543      
35183 Based on observation, interview and record review, the agency failed to ensure the plan of care/physician's orders were followed for one of five sampled patients (Patient 3) when Patient 3's medication was not applied two times a day, every day. This failure had the potential to cause Patient 3 to suffer prolonged healing and discomfort. Findings: A review of Patient 3's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 28, 2018, with a recertification period of October 28, 2019 to December 26, 2019. Patient 3 had diagnoses that included heart disease (dysfunction of the heart due to a disease process) and blindness. During a home visit on December 4, 2019 with the Director of Patient Care Services (DPCS) and in the presence of Patient 3 and Patient 3's private pay caregiver (CG), an observation of Patient 3's actual medication bottles available in the home were compared with Patient 3's Medication Profile (MP - a current list of all medications prescribed for a specific patient). During an observation and concurrent interview with Patient 3, Patient 3's CG and the DPCS on December 4, 2019 at 12:10 PM, Patient 3's CG supplied Patient 3's medication bottles. Patient 3's MP indicated the following medication: Nystatin (a medication to treat a fungal infection) 100,000 units in 1 gram, apply an ample amount to the affected area two times a day, for a rash. The nystatin was not with the group of medications Patient 3's CG supplied. Patient 3's CG stated the medications were stored on top of the bureau in the kitchen. Patient 3's CG stated, "I don't know where anymore medications are. I don't touch medications." Patient 3 stated all the medications were supposed to be stored on top of the bureau in the kitchen. Patient 3 stated she could not see her medications because she was blind so if they were not on the bureau she did not know where they were. After a search by Patient 3's CG and the DPCS, with Patient 3's permission, the nystatin powder was found in Patient 3's bathroom. During an interview with Patient 3's CG and the DPCS on December 4, 2019 at 12:53 PM, Patient 3's CG stated she had never applied the nystatin to Patient 3 or helped Patient 3 apply it herself. Patient 3's CG stated Patient 3 would need help with the nystatin because Patient 3 could not see. The DPCS stated the nystatin powder was applied by the hospice nurse and the hospice aide. The DPCS stated a hospice nurse visited one time a week and the hospice aide visited two times a week. The DPCS stated the nystatin would not be applied two times a day, every day, without Patient 3's CG's assistance. A policy and procedure was not provided on the plan of care and teaching of patients' caregivers in the administration of medications.
L0559      
35183 The hospice agency failed to ensure the Condition of Participation L 559 418.58: Quality assessment and performance improvement was in compliance as follows: 1. Based on interview and record review, the agency failed to develop and implement and effective, ongoing, hospice wide Quality Assessment Performance Improvement (QAPI) program for five of five sampled patients (Patients 1, 2, 3, 4, and 5) when: a. The agency did not develop and document a QAPI plan. (Refer to L 560) b. The agency did not form a QAPI committee (a group that meets quarterly to coordinate and evaluate QAPI activities, analyze data, determine problem areas and develop action plans) and QAPI committee meetings were not held. (Refer to L 560) c. The QAPI committee did not choose quality indicators (a measurable element of the agency's practice that can be used to assess the quality of care provided) that reflected the complexity of the organization and its services, involved all hospice services or focused on improved palliative (relieving pain without dealing with the cause of the condition) outcomes (a specific result that can be measured). (Refer to L 560) d. The agency could not demonstrate improvement had been made in any aspect (a particular part or feature) of the agency or the services it offered. (Refer to L 560) 2. Based on interview and record review, the agency failed to select quality indicators (a measurable element of the agency's practice that can be used to assess the quality of care provided) to examine all aspects of the agency's operation for five of five sampled patients (Patients 1, 2, 3, 4 and 5) when all patient services and all activities that may impact patient/family care were not evaluated. (Refer to L 563) 3. Based on interview and record review, the agency's Governing Body (GB) did not approve the frequency and detail of the Quality Assessment and Performance Improvement (QAPI) program's data collection, for five of five sampled patients (Patients 1, 2 ,3 4 and 5). (Refer to 565) 4. 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) for five of five sampled patients (Patients 1, 2, 3, 4, and 5). (Refer to L 571) 5. Based on interview and record review, the agency's Governing Body (GB) failed to ensure the Quality Assessment Performance Improvement (QAPI) program was defined, implemented, maintained and evaluated annually, for five of five sampled patients (Patients 1, 2, 3, 4, and 5). (Refer to L 574) 6. Based on interview and record review, the agency's Governing Body (GB) failed to designate an individual to be responsible to operate the agency's Quality Assessment and Performance Improvement (QAPI) program for five of five sampled patients (Patients 1, 2, 3, 4, and 5). (Refer to L 576) The cumulative effect of these systemic practices had the potential to cause problems in health outcomes, patient safety and quality of care, to go unrecognized and unaddressed and for the mismanagement and underutilization of the agency's QAPI program.
L0560      
35183 Based on interview and record review, the agency failed to develop and implement and effective, ongoing, hospice wide Quality Assessment Performance Improvement (QAPI) program for five of five sampled patients (Patients 1, 2, 3, 4, and 5) when: 1. The agency did not develop and document a QAPI plan 2. The agency did not form a QAPI committee (a group that meets quarterly to coordinate and evaluate QAPI activities, analyze data, determine problem areas and develop action plans) and QAPI committee meetings were not held. 3. The QAPI committee did not choose quality indicators (a measurable element of the agency's practice that can be used to assess the quality of care provided) that reflected the complexity of the organization and its services, involved all hospice services or focused on improved palliative (relieving pain without dealing with the cause of the condition) outcomes (a specific result that can be measured). 4. The agency could not demonstrate improvement had been made in any aspect (a particular part or feature) of the agency or the services it offered. This failure had the potential to cause problems in health outcomes, patient safety and quality of care, to go unrecognized and unaddressed. Findings: During a concurrent interview and record review (of the documented QAPI program) with the Administrator Designee (AD) and Payroll Coordinator (PC) on December 6, 2019 at 10:33 AM, the AD stated she was responsible for the QAPI program, was the Performance Improvement Coordinator and a member of the Governing Body (GB). The PC stated she helped input QAPI information into the agency's computer system and maintained the QAPI program's paper documentation. The PC stated she would retrieve information when needed since the AD attended the interview via phone. The PC stated she could verify what QAPI program documentation existed and what did not. 1. During a continued interview and record review (of the documented QAPI program) with the AD and PC, the AD stated she had not developed and written a QAPI plan that considered: program objectives, all patient care disciplines, how the program would be administered and coordinated, a method for monitoring and evaluating the quality of care, prioritization for resolution of problems, how to monitor for effectiveness, how often to report to the GB or how the agency would document a review of its own QAPI program. The PC verified there was no documented QAPI plan. 2. During a continued interview and record review (of the documented QAPI program) with the AD and PC, the AD stated a QAPI committee had not been formed and QAPI committee meetings had not been conducted. The AD stated patient issues were brought up during Interdisciplinary Group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) meetings and dealt with at that time. The PC verified there was no documentation for the formation of a QAPI committee and there was no documentation that QAPI committee meetings were held. 3. During a continued interview and record review (of the documented QAPI program) with the AD and PC, The AD stated the agency had selected three quality indicators to track: patient infection rates, flu vaccination rates for employees and employee hand hygiene compliance rates. The AD stated no other quality indicators, other than infection control, had been chosen to monitor and track. The PC provided documentation on the patient infection rates, flu vaccination rates for employees and employee hand hygiene compliance rates. The PC verified there was no documentation to show monitoring and tracking of other quality indicators. 4. During a continued interview and record review (of the documented QAPI program) with the AD and PC, The AD stated she could not show the agency improved any aspect of the agency, it's services or patient outcomes. The AD stated no problems in infection control had been identified therefore no actions had been taken. The AD stated no other problems had been identified therefore no actions had been taken. The PC verified there was no documentation to show a problem had been identified, an action had been initiated or improvement made. A review of the agency's policy and procedure titled, "Improving Organizational Performance," dated December 2010, indicated the following: "Purpose: To establish a performance improvement framework which integrates activities to improve organization performance, improve patient safety, reduce the risks for acquisition and transmission of infections and improve palliative care outcomes and services. Policy: Senior management, as designated by the Governing Body, will carry the responsibility: to guide the organization's efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations of hospice's performance improvement activities; and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service."
L0563      
35183 Based on interview and record review, the agency failed to select quality indicators (a measurable element of the agency's practice that can be used to assess the quality of care provided) to examine all aspects of the agency's operation for five of five sampled patients (Patients 1, 2, 3, 4 and 5) when all patient services and all activities that may impact patient/family care were not evaluated. This failure had the potential to cause problems in health outcomes, patient safety and quality of care, to go unrecognized and unaddressed. Findings: During a concurrent interview and record review (of the documented QAPI program) with the Administrator Designee (AD) and Payroll Coordinator (PC) on December 6, 2019 at 10:33 AM, the AD stated she was responsible for the QAPI program, was the Performance Improvement Coordinator and a member of the Governing Body (GB). The PC stated she helped input QAPI information into the agency's computer system and maintained the QAPI program's paper documentation. The PC stated she would retrieve information when needed since the AD attended the interview via phone. The PC stated she could verify what QAPI program documentation existed and what did not. During a continued interview and record review (of the documented QAPI program) with the AD and PC, The AD stated the agency had selected three quality indicators to track: patient infection rates, flu vaccination rates for employees and employee hand hygiene compliance rates. The AD stated no other quality indicators had been chosen to monitor and track in the following areas: a. Physician Services b. Nursing Services c. Medical Social Services d. Counseling Services e. Clinical Records f. Pharmaceutical Services g. Durable Medical Equipment (DME) h. Patients' Rights i. Administrative Services j. Contract Services k. Volunteers l. Hospice Aide The PC provided documentation on the patient infection rates, flu vaccination rates for employees and employee hand hygiene compliance rates. The PC verified there was no documentation to show monitoring and tracking of other quality indicators. A review of the agency's policy and procedure titled, "Improving Organizational Performance," dated December 2010, indicated the following: "Adopt a scientific, problem-solving, data driven approach to quality assessment and performance improvement (QAPI). The scientific approach will include minimally: Planning for performance improvement with integration of information from other relevant activities that focus on high risk, high volume or problem prone areas. These may include: Risk management, such as adverse pain events and medication management Utilization management Quality control Infection control surveillance Patient safety program Palliative outcomes tracking such as pain control Perception of care activities Systematic assessment of performance through comparison of organizational performance."
L0565      
35183 Based on interview and record review, the agency's Governing Body (GB) did not approve the frequency and detail of the Quality Assessment and Performance Improvement (QAPI) program's data collection, for five of five sampled patients (Patients 1, 2 ,3 4 and 5). This failure had the potential to cause problems in health outcomes, patient safety and quality of care, to go unrecognized. Findings: A review of the agency's Governing Body (GB) minutes from January 12, 2016 to September 30, 2019 was conducted. There was no documented evidence to show the GB approved the frequency and detail of the QAPI program's data collection. During a concurrent interview and record review (of the documented QAPI program) with the Administrator Designee (AD) and Payroll Coordinator (PC) on December 6, 2019 at 10:33 AM, the AD stated she was responsible for the QAPI program, was the Performance Improvement Coordinator and a member of the Governing Body (GB). The PC stated she helped input QAPI information into the agency's computer system and maintained the QAPI program's paper documentation. The PC stated she would retrieve information when needed since the AD attended the interview via phone. The PC stated she could verify what QAPI program documentation existed and what did not. During a continued interview and record review (of the documented QAPI program) with the AD and PC, the AD stated the GB was not presented with the frequency and detail of the QAPI program's data collection therefore the GB did not approve it. The PC verified there was no documentation to show the GB approved the frequency and detail of the QAPI program's data collection. A review of the agency's policy and procedure titled, "Improving Organizational Performance," dated December 2010, indicated, "The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, maintained and evaluated annually."
L0571      
35183 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) for five of five sampled patients (Patients 1, 2, 3, 4, and 5). This failure had the potential to cause agency problems to go unresolved. Findings: During a concurrent interview and record review (of the documented QAPI program) with the Administrator Designee (AD) and Payroll Coordinator (PC) on December 6, 2019 at 10:33 AM, the AD stated she was responsible for the QAPI program, was the Performance Improvement Coordinator and a member of the Governing Body (GB). The PC stated she helped input QAPI information into the agency's computer system and maintained the QAPI program's paper documentation. The PC stated she would retrieve information when needed since the AD attended the interview via phone. The PC stated she could verify what QAPI program documentation existed and what did not. During a continued interview and record review (of the documented QAPI program) with the AD and PC, the AD stated a PIP had not been conducted by the agency because she was unaware of the requirement and did not know how to develop a PIP. The PC verified there were no documented PIPs. A review of the agency's policy and procedure titled, "Improving Organizational Performance," dated December 2010, was conducted. There was no documented evidence to show direction on developing, implementing and evaluating PIPs.
L0574      
35183 Based on interview and record review, the agency's Governing Body (GB) failed to ensure the Quality Assessment Performance Improvement (QAPI) program was defined, implemented, maintained and evaluated annually, for five of five sampled patients (Patients 1, 2, 3, 4, and 5) This failure had the potential for mismanagement and underutilization of the agency's QAPI program. Findings: A review of the agency's Governing Body (GB) minutes from January 12, 2016 to December 6, 2019 was conducted. The following four GB meeting minutes documented QAPI program information and indicated: a. Dated January 29, 2016, "Report Goal Result of 2015 QAPI (Infection Risk) program and present QAPI Risk Goal 2016 (Discuss graphs)." b. Dated June 3, 2016, "For the purpose of: Providing training for the Quality Assessment Performance Improvement program." c. Dated January 25, 2017, "This was the purpose of the meeting. The reports were the following: update staff count on Flu Vaccine; QAPI report on the infection control risk, its goals and a result of 2016; identified the priority (see pie diagram) risk for 2017 based result of 2016 and; presentation of goals and action plans including the current preventative programs on medical procedures, equipment and hand hygiene. (See report summary of the Group Leader). Presentation of the 8 [eight] binders in reference to the reports and explain pie diagrams from HMD [HospiceMD-electronic medical record program]." d. Dated May 25, 2017, "Purpose of the Meeting: Report presentation of the analyzed collected data and established conclusions regarding the five Infection Control Goals." There was no documented evidence to show the QAPI program was discussed in 2018 and/or 2019. During a concurrent interview and record review (of the documented QAPI program) with the Administrator Designee (AD) and Payroll Coordinator (PC) on December 6, 2019 at 10:33 AM, the AD stated she was responsible for the QAPI program, was the Performance Improvement Coordinator and a member of the Governing Body (GB). The PC stated she helped input QAPI information into the agency's computer system and maintained the QAPI program's paper documentation. The PC stated she would retrieve information when needed since the AD attended the interview via phone. The PC stated she could verify what QAPI program documentation existed and what did not. During a continued interview and record review (of the documented QAPI program) with the AD and PC, the PC stated she was unable to show the graphs and pie diagrams in the HospiceMD electronic medical record program as indicated in the GB meeting minutes. The PC stated there was no documented evidence on paper of the graphs and pie diagrams indicated in the GB meeting minutes dated January 29, 2016 and January 25, 2017. The PC stated she was unable to show documented evidence of the presentation of goals and action plans including the current preventative programs on medical procedures, equipment indicated in the January 25, 2017 GB meeting minutes. The PC stated she could not locate the 8 (eight) binders indicated in the January 25, 2017 GB meeting minutes. The PC verified the GB meeting minutes did not indicate or discuss the QAPI program past the May 25, 2017 GB meeting minute documentation. During a continued interview and record review (of the documented QAPI program) with the AD and PC, the AD stated, "If the graphs, pie diagrams, goals and action plans for the preventative programs on medical procedures and equipment are not in the QAPI binder provided, I do not know where they are." The AD stated she did not know about the 8 (eight) binders indicated in the January 25, 2017 GB meeting minutes. The AD stated she did not know where QAPI program information could be found on the HospiceMD electronic medical record program. The AD stated she could not identify who the "Group Leader" referenced in the January 25, 2017 GB meeting minutes was. The AD stated she could not show the QAPI program had been discussed in the GB meeting for the years 2018 and 2019. A review of the agency's policy and procedure titled, "Improving Organizational Performance," dated December 2010, indicated, "The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, maintained and evaluated annually."
L0576      
35183 Based on interview and record review, the agency's Governing Body (GB) failed to designate an individual to be responsible to operate the agency's Quality Assessment and Performance Improvement (QAPI) program for five of five sampled patients (Patients 1, 2, 3, 4, and 5). This failure had the potential for mismanagement and underutilization of the agency's QAPI program. Findings: A review of the agency's Governing Body (GB) minutes from January 12, 2016 to December 6, 2019 was conducted. There was no documented evidence to show the GB designated an individual to be responsible to operate the agency's Quality Assessment and Performance Improvement (QAPI) program. During a concurrent interview and record review (of the documented QAPI program) with the Administrator Designee (AD) and Payroll Coordinator (PC) on December 6, 2019 at 10:33 AM, the AD stated she was responsible for the QAPI program, was the Performance Improvement Coordinator and a member of the Governing Body (GB). The PC stated she helped input QAPI information into the agency's computer system and maintained the QAPI program's paper documentation. The PC stated she would retrieve information when needed since the AD attended the interview via phone. The PC stated she could verify what QAPI program documentation existed and what did not. During a continued interview and record review (of the documented QAPI program) with the AD and PC, the PC verified the GB meeting minutes did not indicate an individual had been appointed to be responsible to operate the agency's QAPI program. The AD stated the GB had not appointed her as the individual responsible to operate the agency's QAPI) program. The AD stated the GB did not appoint an individual responsible to operate the agency's QAPI program. A review of the agency's policy and procedure titled, "Job Description: Performance Improvement Coordinator," dated October 2010, indicated, "The Performance Improvement Coordinator is a professional, registered nurse [RN] responsible for all of the quality activities of the organization. The Performance Improvement Coordinator has accountabilities for the monitoring, implementation and evaluation of process and programs to meet regulatory, accreditation and standards of practice." During a continued interview and record review (the agency's policy and procedure titled, "Job Description: Performance Improvement Coordinator,") with the AD and PC, The PC verified the policy and procedure indicated an RN was to fill the position as the Performance Improvement Coordinator. The AD stated, "I am not an RN." A review of the agency's policy and procedure titled, "Improving Organizational Performance," dated December 2010, was conducted. There was no documented evidence to show direction on appointing an individual to be responsible to operate the agency's Quality Assessment and Performance Improvement (QAPI) program.
L0651      
35183 Based on interview and record review, the agency failed to ensure a personnel file was created and maintained for the Administrator and Administrator Designee for five of five sampled patients (Patients 1, 2, 3, 4, and 5) resulting in an inability to show the Administrator and Administrator Designee possessed the education and experience, required by the hospices governing body, to hold the positions. This failure had the potential to cause the agency to be operated and managed by unqualified individuals. Findings: A review of the agency's "Organizational Chart," undated, indicated the position of Administrator was held by the Administrator (Admin) and the position of Administrator Designee was held by the Administrator Designee (AD). During an interview with the Operations Coordinator (OC) on December 5, 2019 at 10:27 AM, the OC stated he was responsible for human resources and personnel files in the absence of Human Resources (HR) who was currently on vacation. The OC stated he could not provide a personnel file for the Admin or the AD because they did not have one. The OC stated the Admin and AD were owners of the agency and therefore did not need to have a personnel file. The Admin was unavailable for interview. During a phone interview with the AD on December 5, 2019 at 4:45 PM, the AD stated that she and the Admin did not have personnel files because they were owners of the agency. The AD stated she would have to gather the information together to show that she and the Admin met the qualifications indicated in the agency's "Administrator Job Description." The AD stated she could not gather the information at this time because she had other obligations and the Admin was out of town. A review of the agency's policy and procedure titled "Job Description: Executive Director/Administrator," dated October 2010, indicated the following: "Job Description Summary: The Executive Director/Administrator is responsible for the overall direction of the hospice services. He/she is responsible for the employment of qualified hospice personnel; is responsible for the provision of hospice services, directly, and the delegation to and coordination of hospice personnel evaluations; is responsible for establishing standards of care to comply with federal and state regulations and guidelines. The Executive Director/Administrator establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy. Position Qualifications: A bachelor's degree in Business Administration, Master's degree in health care of related field preferred. Three to five years' experience in health care management. Demonstrates an ability to supervise and direct professional and administrative personnel. Has an ability to deal tactfully with the community. Has knowledge of corporate business management. Understands hospice care and the services provided to patient and family/caregiver through an interdisciplinary group. Intimate knowledge of Medicare Hospice Certification." A review of the agency's policy and procedure titled "Personnel Record Contents," dated October 2010, indicated, "Policy: [Name of agency] will maintain accurate and complete personnel files on all staff."
L0652      
35183 Based on interview and record review, the agency failed to ensure clinical staff followed accepted standards of practice for one of five sampled patients (Patient 3) when a Hospice Aide (HA) applied a medication to Patient 3. This failure had the potential to cause Patient 3 to suffer prolonged healing and discomfort when medication was applied by untrained staff. Findings: A review of Patient 3's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 28, 2018, with a recertification period of October 28, 2019 to December 26, 2019. Patient 3 had diagnoses that included heart disease (dysfunction of the heart due to a disease process) and blindness. During a home visit on December 4, 2019 with the Director of Patient Care Services (DPCS) and in the presence of Patient 3 and Patient 3's private pay caregiver (CG), an observation of Patient 3's actual medication bottles available in the home were compared with Patient 3's Medication Profile (MP - a current list of all medications prescribed for a specific patient). During an observation and concurrent interview with Patient 3, Patient 3's CG and the DPCS on December 4, 2019 at 12:10 PM, Patient 3's CG supplied Patient 3's medication bottles. Patient 3's MP indicated the following medication: Nystatin (a medication to treat a fungal infection) 100,000 units in 1 gram, apply an ample amount to the affected area two times a day, for a rash. The nystatin was not with the group of medications Patient 3's CG supplied. Patient 3's CG stated the medications were stored on top of the bureau in the kitchen. Patient 3's CG stated, "I don't know where anymore medications are. I don't touch medications." Patient 3 stated all the medications were supposed to be stored on top of the bureau in the kitchen. Patient 3 stated she could not see her medications because she was blind so if they were not on the bureau she did not know where they were. After a search by Patient 3's CG and the DPCS, with Patient 3's permission, the nystatin powder was found in Patient 3's bathroom. During an interview with Patient 3's CG and the DPCS on December 4, 2019 at 12:53 PM, Patient 3's CG stated she had never applied the nystatin to Patient 3 or helped Patient 3 apply it herself. Patient 3's CG stated Patient 3 would need help with the nystatin because Patient 3 could not see. The DPCS stated the nystatin powder was applied by the hospice nurse and the hospice aide. The DPCS stated a hospice nurse visited one time a week and the hospice aide visited two times a week. The DPCS stated the nystatin would not be applied two times a day, every day, without Patient 3's CG's assistance. During a phone interview with a Licensed Vocational Nurse (LVN 1) on December 5, 2019 at 9:15 AM, LVN 1 stated she made nursing visits to Patient 3 once per week every week. LVN 1 stated a Hospice Aide (HA) applied the nystatin powder to Patient 3 after she gave Patient 3 a shower. During a phone interview with a Registered Nurse (RN 1) on December 5, 2019 at 10:04 AM, RN 1 stated she made visits to Patient 3 once every two weeks to conduct a supervisory review of the HA. RN 1 stated a HA applied the nystatin powder to Patient 3 after she gave Patient 3 a shower. During a phone interview with a Hospice Aide (HA 1) on December 5, 2019 at 1:02 PM, HA 1 stated she made visits to Patient 3 two times a week, every week, and gave Patient 3 a shower. HA 1 stated she had not applied the nystatin powder to Patient 3 until today (December 5, 2019). HA 1 stated, "I put the nystatin powder on [Patient 3] today only because the [DPCS] and the [RN 1] told me to. I know I'm not supposed to put medicine on a patient because I am an aide not a nurse but my RN, she told me to do it." During an interview with the DPCS on December 5, 2019 at 1:17 PM, the DPCS stated the nystatin powder was a prescription medication and a hospice aide is not a licensed nurse. The DPCS stated a HA cannot administer or apply a medication. The DPCS stated the HA should not have been instructed to apply the nystatin powder. A review of the agency's policy and procedure titled, "Administration and Documentation of Medications," dated December 2010, indicated the following: "Purpose: To provide guidelines for the safe administration of medications by licensed personnel. Procedure: Non-licensed personnel will not administer medications."