HOSPICE OF THE WEST

Based on interview, review of facility documentation and review of facility policies and procedures, the Department has determined the Governing Body failed to ensure the QAPI (Quality Assessment and Performance Improvement) program was reviewed and evaluated for effectiveness at least every 12 (twelve) months.  Failure to ensure QAPI programs are addressing established priorities and are being effectively evaluated can result in patient care deficits not being addressed. Findings include:

Based on interview, facility policy and procedures and facility documentation, the Department has determined the administrator failed to implement grievance procedures for patients as outlined in the facility policies and procedures for 11 out of 12 patients reviewed, Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12.  Failure to implement and document grievance procedures as outlined in facility policies and procedures can result in patient grievances and complaints not being comprehensively addressed. Findings include:

Based on review of patient medical records, review of facility documents, and review of facility policies and procedures, the Department has determined the Administrator failed to ensure that medications were dispensed and administered according to facility policies and procedures.  Failure to ensure that medications are dispensed and administered according to facility policies and procedures can result in patients suffering side effects, adverse events or unnecessary pain. Findings include:

Based on interview, review of facility policies and procedures, review of facility documents and review of medical records, the Department has determined the Administrator failed to provide documentation to the Department as required by this Article within two hours after a Department request.  Failure to provide documentation to the Department within two hours after a Department request can hinder urgent investigation into patient care matters and can compromise the integrity of materials provided resulting from an investigative request. Findings include:

Based on interview, review of facility policies and procedures and facility documentation, the Department has determined the Administrator failed to ensure that a quality improvement plan was implemented that included, at minimum, a method to make changes or take action as a result of identifying concerns about the delivery of a service relating to patient care.  Failure to implement methods to make changes or take action stemming from the identification of concerns regarding the delivery of service relating to patient care can result in negative trends in patient care continuing unabated, resulting in entrenched substandard patient care. Findings include:

Based on interview, review of facility policies and procedures and review of facility documentation, the Department has determined that the governing body has failed to maintain documentation for at least 12 months of reports submitted to the governing body regarding QAPI (quality and performance improvement).  Failure to maintain documentation of QAPI reports can result in the governing body having no documentation of participation or oversight into the QAPI process and inability to adequately assess trends affecting the facility. Findings include:

Based on interview, review of facility policies and procedures and review of facility documentation, the Department has determined the Administrator failed to ensure that patients and their caregivers were not subject to retaliation for submitting a complaint to the Arizona Department of Health Services in two (2) out of 12 (twelve) patients reviewed, patients #8 and #12.  Failure to ensure patients are not subjected to retaliation for filing a report with the Department or another entity can result in patients hesitating to report service issues for fear of losing access to care. Findings include:

Based on interview and review of facility policies and procedures, the Department has determined the facility failed to ensure that personnel providing hospice services were assigned only to provide services they could competently perform.  Failure to ensure that personnel are able to competently perform the tasks they are assigned can result in patients receiving substandard care. Findings include:

Based on review of facility documents, review of patient medical records and review of facility policies and procedures, the Department has determined the Administrator failed to ensure that an established infection control program failed to document actions taken relating to infections and communicable diseases according to facility policies and procedures for Patient #12.  Failure to engage in and document actions taken to prevent infections and communicable diseases according to facility policies and procedures can result in patients and staff being needlessly exposed to infectious and communicable diseases. Findings include: