3 Reports
Inspection Report — Sep 24, 2024
Enforcement State
Date: Sep 24, 2024
Visit Reason
Civil monetary penalty, action 00120984 (invoice INV-263744), assessed 24 September 2024.
Findings
A $4,500.00 penalty was assessed and paid in full on 20 December 2024.
Report Facts
Penalty amount: 4500
Amount paid: 4500
Amount remaining: 0
Inspection Report — Aug 20, 2024
Complaint Investigation State
Date: Aug 20, 2024
Visit Reason
On-site complaint investigation at Hospice of the West, a Hospice Service Agency, conducted August 19-20, 2024.
Complaint Details
Deficiencies were found during the unannounced on-site State Complaint survey conducted on August 19-20, 2024. Based on the rules found at R9 A.A.C. 10, Article 6 Hospices, the Department has authorized the facility to continue to provide the following Scope of Service: Outpatient Hospice Services.
Findings
The inspection found 18 deficiencies related to administration, patient rights, quality management, and infection control. The facility failed to adequately review and evaluate its quality management program, implement grievance procedures, ensure competent personnel assignments, and document infection control activities.
Deficiencies (18)
R9-10-603 — The Governing Body failed to ensure the QAPI program was reviewed and evaluated for effectiveness at least every 12 months, risking unaddressed patient care deficits.
R9-10-603 — The administrator failed to implement grievance procedures for patients as outlined in facility policies for 11 of 12 patients reviewed, risking unaddressed patient grievances.
R9-10-603 — The administrator failed to ensure medications were dispensed and administered according to facility policies and procedures, risking patient harm from side effects or adverse events.
R9-10-603 — The administrator failed to provide required documentation to the Department within two hours after a request, hindering urgent investigations and compromising material integrity.
R9-10-604 — The administrator failed to implement a quality improvement plan that included methods to make changes or take action based on identified concerns about patient care delivery.
R9-10-604 — The governing body failed to maintain documentation for at least 12 months of reports submitted regarding QAPI, limiting oversight and trend assessment.
R9-10-610 — The administrator failed to ensure patients and caregivers were not subjected to retaliation for submitting complaints to the Department in 2 of 12 patients reviewed.
R9-10-612 — The facility failed to ensure personnel were assigned only to provide services they could competently perform, risking substandard patient care.
R9-10-614 — The administrator failed to document actions taken relating to infections and communicable diseases according to facility policies for Patient #12, risking exposure to infections.
R9-10-603 — No evidence text provided.
R9-10-603 — No evidence text provided.
R9-10-603 — No evidence text provided.
R9-10-603 — No evidence text provided.
R9-10-604 — No evidence text provided.
R9-10-604 — No evidence text provided.
R9-10-610 — No evidence text provided.
R9-10-612 — No evidence text provided.
R9-10-614 — No evidence text provided.
Report Facts
Deficiencies cited: 18
Report
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