Inspection Report
Complaint Investigation
Deficiencies: 18
Aug 20, 2024
Visit Reason
State-compiled facility profile showing 1 complaint inspection from August 2024 with deficiency history
Findings
The complaint investigation conducted on August 19-20, 2024 found multiple deficiencies related to administration, quality management, patient rights, personnel competency, and infection control. A total of 18 deficiencies were identified indicating failures in policy implementation and documentation.
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.
Deficiencies (18)
| Description |
|---|
| R9-10-603. Administration A. A governing authority shall: 5. Review and evaluate the effectiveness of the quality management program at least once every 12 months; |
| R9-10-603. Administration C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health and safety of a patient that: g. Cover specific steps for: ii. The hospice service agency or hospice inpatient facility to respond to a patient ' s complaint; |
| R9-10-603. Administration C. An administrator shall ensure that: 2. Policies and procedures for hospice services are established, documented, and implemented to protect the health and safety of a patient that: e. Cover dispensing, administering, and disposing of medication; |
| R9-10-603. Administration C. An administrator shall ensure that: 6. Unless otherwise stated: a. Documentation required by this Article is provided to the Department within two hours after a Department request; and |
| R9-10-604. 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: 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 |
| R9-10-604. Quality Management An administrator shall ensure that: 3. The report required in subsection (2) and the supporting documentation for the report are maintained for at least 12 months after the date the report is submitted to the governing authority. |
| R9-10-610. Patient Rights B. An administrator shall ensure that: 2. A patient is not subjected to: j. Retaliation for submitting a complaint to the Department or another entity; or |
| R9-10-612. Hospice Services E. A director of nursing shall ensure that: 4. A personnel member is only assigned to provide services the personnel member can competently perform; |
| R9-10-614. Infection Control An administrator shall ensure that: 1. An infection control program is established, under the direction of an individual qualified according to policies and procedures, to prevent the development and transmission of infections and communicable diseases including: a. A method to identify and document infections; d. Documenting infection control activities including: ii. The actions taken relating to infections and communicable diseases, and |
| R9-10-603. Administration A. A governing authority shall: 5. Review and evaluate the effectiveness of the quality management program at least once every 12 months; |
| R9-10-603. Administration C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health and safety of a patient that: g. Cover specific steps for: ii. The hospice service agency or hospice inpatient facility to respond to a patient ' s complaint; |
| R9-10-603. Administration C. An administrator shall ensure that: 2. Policies and procedures for hospice services are established, documented, and implemented to protect the health and safety of a patient that: e. Cover dispensing, administering, and disposing of medication; |
| R9-10-603. Administration C. An administrator shall ensure that: 6. Unless otherwise stated: a. Documentation required by this Article is provided to the Department within two hours after a Department request; and |
| R9-10-604. 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: 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 |
| R9-10-604. Quality Management An administrator shall ensure that: 3. The report required in subsection (2) and the supporting documentation for the report are maintained for at least 12 months after the date the report is submitted to the governing authority. |
| R9-10-610. Patient Rights B. An administrator shall ensure that: 2. A patient is not subjected to: j. Retaliation for submitting a complaint to the Department or another entity; or |
| R9-10-612. Hospice Services E. A director of nursing shall ensure that: 4. A personnel member is only assigned to provide services the personnel member can competently perform; |
| R9-10-614. Infection Control An administrator shall ensure that: 1. An infection control program is established, under the direction of an individual qualified according to policies and procedures, to prevent the development and transmission of infections and communicable diseases including: a. A method to identify and document infections; d. Documenting infection control activities including: ii. The actions taken relating to infections and communicable diseases, and |
Report Facts
Inspections on page: 1
Total Deficiencies: 18
Complaint Inspections: 1
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