WINGS OF HOPE HOSPICE AND PALLIATIVE CARE, INC.

R9-10-113.B.2.a-b. Tuberculosis Screening B. A health care institution's chief administrative officer shall: 2. As part of the annual assessment of the health care institution ' s risk of exposure to infectious tuberculosis according to subsection (A)(2)(d), ensure that documentation is obtained for each individual required to be screened for infectious tuberculosis that: a. indicates the individual's freedom from symptoms of infectious tuberculosis; and b. Is signed by a medical practitioner, occupational health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101.

Based on a review of the agency's employee handbook, agency documentation within personnel files, and staff interviews, the Department determined that the Administrator failed to ensure that a medical practitioner, an occupational health provider, or a local health agency signed off on the agency’s employee tuberculosis exposure risk assessments. This deficient practice has the potential to result in inaccurate risk determinations, failure to identify employees who require further TB testing or follow-up, and increased risk of disease transmission. Findings include: A review of the agency's employee handbook, dated 09/09/2021, revealed: "...5-14 Health and Safety...The Company intends to comply with all health and safety laws applicable to our business...." A review of Employee #1’s personnel file revealed a document titled “TB TARGETED MEDICAL QUESTIONNAIRE FORM” that did not include a designated signature line or prompt for a medical practitioner, an occupational health provider, or a local health agency, and thereby was missing the required signatures to authenticate Employee #1’s freedom from symptoms of infectious tuberculosis. A review of Employee #2’s personnel file revealed a document titled “TB TARGETED MEDICAL QUESTIONNAIRE FORM” that did not include a designated signature line or prompt for a medical practitioner, an occupational health provider, or a local health agency, and thereby was missing the required signatures to authenticate Employee #2’s freedom from symptoms of infectious tuberculosis. A review of Employee #4’s personnel file revealed a document titled “TB TARGETED MEDICAL QUESTIONNAIRE FORM” that did not include a designated signature line or prompt for a medical practitioner, an occupational health provider, or a local health agency, and thereby was missing the required signatures to authenticate Employee #4’s freedom from symptoms of infectious tuberculosis. A review of Employee #5’s personnel file revealed a document titled “TB TARGETED MEDICAL QUESTIONNAIRE FORM” that did not include a designated signature line or prompt for a medical practitioner, an occupational health provider, or a local health agency, and thereby was missing the required signatures to authenticate Employee #5’s freedom from symptoms of infectious tuberculosis. In an interview conducted on Feb 12, 2026, Employee #3 confirmed that Employees 1, 2, 4, and 5 had missing medical practitioner, occupational health provider, or local health agency signatures on their tuberculosis risk assessment forms. Employee #3 stated they were not aware that this needed to be done.

R9-10-604.1.a-e. Quality Management An administrator shall ensure that: 1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes: a. A method to identify, document, and evaluate incidents; b. A method to collect data to evaluate services provided to patients; c. A method to evaluate the data collected to identify a concern about the delivery of services related to patient care; d. A method to make changes or take action as a result of the identification of a concern about the delivery of services related to patient care; and e. The frequency of submitting a documented report required in subsection (2) to the governing authority;

Based on a review of agency polices and procedures, patient medical records, and staff interviews, the Department determined that the Administrator failed to ensure that staff implemented the agency’s policy for incident reporting after their involvement with a reportable event. This deficient practice resulted in two staff members witnessing a patient fall and sustain injuries without creating an incident report and without documenting the fall in the patient’s medical record. Findings include: A review of the agency’s policy titled: “Fall Risk Assessment and Prevention, Policy #840,” revised 08/2025, revealed: “...4. Post Fall Response…if a fall occurs, staff will document the circumstances, findings, and actions taken… A review of the agency’s policy titled: “QAPI, Adverse Event Reporting, Policy #401,” revised 7/2025, revealed: “...POLICY: Hospice documents and investigates adverse events as part of the Hospice’s QAPI program…Reportable events include…interventions resulting in injury…harm or death to a patient…patient falls…It can also be any event that is not consistent with the routine operation of hospice or the routine care of a patient, including not following policy…PROCEDURE: When an adverse event occurs, the employee involved or discovers the event shall promptly document the event on an occurrence/incident report….” A review of Patient #1’s medical record revealed: “...Skilled Nursing Visit Note…Date of Visit 6/6/2024…Time In 10:28 MST…Time Out 11:08 MST…NARRATIVE NOTES...Patient assessed in bed, pt is bed bound…In better spirits today considering fall yesterday, pt presented with confusion yesterday but appeared less today…weakness present…pt presents with bottom wound…new wound of right forearm from fall on 6/5…Pt is unable to use legs at all…able to assist sightly (sic) with arms when turning but very weak and episodes of dizziness at times… A review of the agency documentation titled “Fall Occurrence form,” revealed: “...Describe the fall event…Pt is non weight bearing pt, CNAs had Boyer (sic) lift available and they told pt dtr they did not need it…They attempted to stand him up and they were unable to hold him, pt has no feeling in his legs and per pt he told them that and they decided to go ahead with it…Describe the immediate outcomes of the fall event…Severe skin tear to right forearm, top…Pt appeared confused….” The document further revealed that this fall occurrence form was written by Employee #4, after they were notified of the fall by Patient #1’s daughter, the day after the fall occurred. Employee #4 was not present at Patient #1’s home during the fall occurrence. A review of agency documentation titled “Employee Counseling Report,” dated 6/10/2024, revealed that Employee #1 was one of the staff members involved in lifting Patient #1 without the use of the Hoyer lift on June 5, 2024, which resulted in a fall with injury. Employee #1 revealed that the assignment to Patient #1 on the day of the fall was last-minute and that they did not review the patient’s plan of care before administering care to the patient that day. A review of agency documentation titled “Employee Counseling Report,” dated 6/11/2024, revealed that Employee #2 was the other staff member involved in lifting the patient without the use of the Hoyer lift on June 5, 2024, which resulted in a fall with injury. Employee #2 revealed that they decided to forego the care plan because they felt able to hold the patient without the use of the Hoyer lift. In an interview conducted on February 23, 2026, Employee #3 confirmed that Patient #1 experienced a fall with injuries on June 5, 2024, in the presence of two staff: Employee #1 and Employee #2. Employee #3 confirmed that neither staff member created incident reports about Patient #1’s fall. In addition, Employee #3 confirmed that neither Employee #1 nor Employee #2 documented the fall event in the patient's chart. Employee #3 further confirmed that the agency was made aware of the fall because Patient #1’s daughter notified the agency about the adverse event.

Based on a review of the agency’s policy and procedures, patient medical records, and staff interviews, the Department determined that the Administrator failed to ensure that agency staff implemented the agency's developed fall prevention and fall recovery program after a patient suffered a fall while in the agency’s care. This deficient practice resulted in a patient not receiving a post-fall assessment by a Registered Nurse until a week after they suffered a fall that resulted in sustained injuries. Findings include: A review of the agency’s policy titled: “Fall Risk Assessment and Prevention, Policy #840,” revised 08/2025, revealed: “...2. Post-Fall Injury Assessment and Documentation…1. Following any patient fall or suspected injury, the RN completes an initial assessment immediately…5. All post-fall findings, interventions, physician notifications (if applicable), Plan or Care updates, and follow-up actions must be documented in the patient’s clinical record as soon as possible, but no later than 24 hours.…” A review of Patient #1’s medical record revealed that the patient suffered a fall on 06/05/2024. There is no documentation of an assessment being performed by a registered nurse, nor a registered nurse visit, until 06/10/2024. A request was made for a post-fall assessment that was performed by a registered nurse. None were provided. In an interview conducted on February 13, 2026, Employee #3 and #6 both confirmed that the agency had an LPN (licensed practical nurse) assess the patient post-fall on 06/05/2024, and not a registered nurse. Both Employee #1 and Employee#3 also confirmed that a registered nurse did not assess the patient nor their injuries that they sustained on June 5, 2024, until seven (7) days later, on June 10, 2024.

Based on a review of the agency’s policies and procedures, patient records, agency documentation, and staff interviews, the Department determined that the Administrator failed to ensure that services were provided to a patient according to their care plan. This deficient practice resulted in a patient experiencing an avertible fall and sustaining injuries when two staff members did not follow the patient’s established plan of care. Findings include: A review of the agency’s policy titled “Plan of Care- Revised, Policy #829”, revised on 01/2024, revealed: “...POLICY…All hospice care and services furnished to patients and their families must follow an individualized written plan of care….” A review of the agency’s policy titled “Nursing Services, Policy #824”, last revised on 08/2025, revealed: “...PURPOSE: To ensure nursing services are provided to hospice patients as determined in the Plan of Care (POC)...Nursing services ensure that the nursing needs of the patient are met as identified in the patient's initial assessment, comprehensive assessment, and updated assessments…." A review of Patient #1’s medical record revealed: “...Aide Care Plan…2. Activity- Assist with Transfers- pt is non-weight bearing for transfers…Resolved Date- 06/05/2024…5. Activity- Transfer to bed/chair with assistance- Use Hoyer Lift with 2 person assist… Start Date- 06/05/2024….” A review of Patient #1’s medical record revealed: “...Skilled Nursing Visit Note…Date of Visit 6/6/2024…Time In 10:28 MST…Time Out 11:08 MST…NARRATIVE NOTES...Patient assessed in bed, pt is bed bound…In better spirits today considering fall yesterday, pt presented with confusion yesterday but appeared less today…weakness present…pt presents with bottom wound…new wound of right forearm from fall on 6/5…Pt is unable to use legs at all…able to assist sightly (sic) with arms when turning but very weak and episodes of dizziness at times… A review of the agency documentation titled “Fall Occurrence form,” revealed: “...Describe the fall event…Pt is non weight bearing pt, CNAs had Boyer (sic) lift available and they told pt dtr they did not need it…They attempted to stand [Patient #1] up and they were unable to hold [Patient #1], pt has no feeling in [Patient #1] legs and per pt he told them that and they decided to go ahead with it…Describe the immediate outcomes of the fall event…Severe skin tear to right forearm, top…Pt appeared confused….” A review of agency documentation titled “Employee Counseling Report,” dated 6/10/2024, revealed that Employee #1 was one of the staff members involved in lifting Patient #1 without the use of the Hoyer lift on June 5, 2024, which resulted in a fall with injury. Employee #1 revealed that the assignment to Patient #1 on the day of the fall was last-minute and that they did not review the patient’s plan of care before administering care to the patient that day. A review of agency documentation titled “Employee Counseling Report,” dated 6/11/2024, revealed that Employee #2 was the other staff member involved in lifting the patient without the use of the Hoyer lift on June 5, 2024, which resulted in a fall with injury. Employee #2 revealed that they decided to forego the care plan because they felt able to hold the patient without the use of the Hoyer lift. In an interview conducted on Feb 13, 2026, Employee #3 confirmed that Patient #1’s care plan changed the morning of June 5, 2024, when the patient became a two-person assist, due to the need of using a Hoyer lift to move the patient. Employee #3 confirmed that the patient fell because the two staff members assigned to give care to the patient did not follow the care plan update, which instructed them to use the Hoyer lift, and instead, attempted to manually lift the patient, despite a documented history of weakness. Employee #3 confirmed that the patient sustained injuries from the fall that occurred on June 5, 2024.