There are  13 surveys for this facility. Please select a date to view the survey results.

1. Upon notification of areas of deficiencies, the Administrator/Director of Operations with the assistance of the Area Vice President of Operations and Area Vice President of Clinical implemented comprehensive and systematic changes to ensure ALL current patients and future patients' plan of care is individualized to meet specific needs/goals, established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patients' needs if any of them so desire. Plan of Care will include individualized visit frequencies for all core team members necessary for the palliation and management of the terminal illness and related conditions and visit frequencies will be updated to reflect changes in patient condition.

a. Education/Training -

- On 10/28/2024 Comprehensive re-education and remediation for ALL staff on appropriate agency policies related to deficient areas. Review of Agency Policies and Procedures included the following policies:

AA-005 Hospice Plan of Care

IM-001 Clinical Records Maintenance and Confidentiality


b.Identification/Implementation -

- Initiated immediately all active patients plan of care will be reviewed at IDG to ensure plan of care reflects patients' needs/goals and includes a review of all missed visits, medications and treatments necessary for the palliation and management of the terminal illness and related conditions.
- All staff will follow the missed visit process, provide documentation of attempts to reschedule missed visits, and clearly document why a visit was missed.
- With each IDG and order changes, the patient plan of care will be revised and visit frequencies adjusted to ensure the plan of care reflected goals are based on the current patient assessment and current patient services that are necessary for the palliation and management of the terminal illness and related conditions. The scribe will enter all missed visits with the reason for the missed visit and any attempts at scheduling the missed visit during IDG.

c Auditing and Monitoring -

- Initiated immediately, 100% of current patients' plan of care will be audited to ensure plan of care is individualized, reflects goals based on current patient assessment and current patient services necessary for the palliation and management of the terminal illness and related conditions.

Including visit frequencies to align with patient goals and symptom management in coordination/oversight of patients' physician (if any), Hospice Medical Director and Interdisciplinary team.
Missed visit report will be run daily to ensure all missed visits are reviewed by the Clinical Manager and/or Director and a missed visit note is entered into the patient's medical record.
The missed visits will be reviewed at IDG with the interdisciplinary team and Hospice Medical Director. The scribe will document in IDG all missed visits and review.

- Auditing to continue monthly for a period of 2 months or until 100% compliance is met. If compliance is not met after 2 months, the audits will continue for the next 2 months, and staff remediation will be done as needed to assure compliance.
- Audits will be added to QAPI plan.
- All findings will be reported at the quarterly QAPI committee meeting and Governing Body as appropriate, but at minimum annually.

d.Ongoing adherence – The Administrator/Director of Operations will ensure ongoing adherence and monitoring of all aspects of the plan of corrections for cited deficiencies.
e.Completion date 12/13/2024

1.Upon notification of areas of deficiencies, the Administrator/Director of Operations with the assistance of the Area Vice President of Operations and Area Vice President of Clinical implemented comprehensive and systematic changes to ensure ALL current patients and future patients' will have an RN supervisory visit made at minimum every 14 calendar days to ensure adequate supervision is provided for all home health aides providing patient care, assess the quality of care, and ensure the current aide care plan meets the patients current goals and needs.

a.Education/Training –

- On 10/28/2024 Comprehensive re-education and remediation for ALL staff on appropriate agency policies related to deficient areas. Review of Agency Policies and Procedures included the following policies:

AA-005 Hospice Plan of Care

AA-015(b) Supervision of Discipline HHA


b.Identification/Implementation –

- Initiated immediately all active patients' calendars will be reviewed to ensure an RN supervisory visit is scheduled at minimum every 14 calendar days and the hospice aide care plan is individualized to meet the patient's needs/goals.
- The RN will document in the supervisory visit note the discipline for whom supervision is occurring.
- With each IDG the visit frequencies will be reviewed to ensure adequate visits are ordered to meet the individualized needs/goals of the patients.

c.Auditing and Monitoring –

- Initiated immediately, 100% of current patients' calendars will be audited to ensure a RN supervisory visit is scheduled and completed at minimum every 14 calendar days.

The nurse will review the hospice aide care plan during the supervisory visit to ensure it meets the patients' current needs/goals and revised as needed.

- Auditing to continue monthly for a period of 2 months or until 100% compliance is met. If compliance is not met after 2 months, the audits will continue for the next 2 months, and staff remediation will be done as needed to assure compliance.
- Audits will be added to QAPI plan.
- All findings will be reported at the quarterly QAPI committee meeting and Governing Body as appropriate, but at minimum annually.

d.Ongoing adherence – The Administrator/Director of Operations will ensure ongoing adherence and monitoring of all aspects of the plan of corrections for cited deficiencies.
e.Completion date 12/13/2024