Americade Palliative Health Services, Inc.

Quality assessment & performance improvement (42 CFR 418.58)

“Observed in Data Session. During review of the QAPI program and discussion with the staff present it was noted that the hospice QAPI program was not evaluated annually. The documentation provided stated that the program was last evaluated 3/2023. This was confirmed and discussed with the nurse and office assistant present.”

Rule L0559. Condition-level.

Governing body and administrator (42 CFR 418.100(b))

“Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by a condition level finding at 418.60, 418.78, 418.100 and 418.58.”

Rule L0651. Condition-level.

Services (42 CFR 418.100(c)(2))

Rule L0653. Condition-level.

EP Training Program (42 CFR 418.113(d)(1)(iii))

“Observed in HR File Review. In 4 of 10 HR files reviewed, it was noted that ongoing emergency management training was not completed every 2 years. For example in the Medical Director, MSW, Spiritual Counselor, and Volunteer files there was no documentation of emergency management training after orientation. This was confirmed and discussed with the Office Assistant present.”

Rule E0037. Standard-level.

EP Testing Requirements (42 CFR 418.113(d)(2)(ii)(B))

“Observed in Emergency Management Session. During review of the Emergency Operations plan and discussion with the nurse and office assistant present it was noted that for 2 years in a row the organization did a tabletop exercise and had no actual activations, either in response to an actual emergency or an organization based. This was confirmed and discussed with the nurse and office assistant present.”

Rule E0039. Standard-level.

Content of plan of care (42 CFR 418.56(c))

Rule L0545. Standard-level.

Content of plan of care (42 CFR 418.56(c)(2))

Rule L0547. Standard-level.

Program data (42 CFR 418.58(b)(3))

“Observed in Data Session. During the Data system tracer it was noted that there was no evidence of the organization’s governing body had approved the frequency and detail of data collection. This was confirmed with the nurse present.”

Rule L0565. Standard-level.

Performance improvement projects (42 CFR 418.58(d)(2))

“Observed in Data Session. During a review of the QAPI program and discussion with the staff present, it was noted that the organization did not have any performance improvement projects being conducted. The documentation showed 2 PIPs that ended in 2025 and nothing since that time. Discussion with the staff present revealed they were unable to speak to any current PIPs being conducted. This was confirmed by the nurse and office assistant present.”

Rule L0573. Standard-level.

Prevention (42 CFR 418.60(a))

Rule L0579. Standard-level.

Control (42 CFR 418.60(b)(2)(ii))

“Observed in Data Session. During the review of the Infection Control plan and discussion with the staff present it was noted that the data collected in 2025 stated 96% compliance hand hygiene compliance. However, there was no documentation that the data was analyzed for possible improvement. The data that was collected did not include all disciplines such as volunteers and therapists. This was confirmed and discussed with the nurse and office assistant present.”

Rule L0581. Standard-level.

Education (42 CFR 418.60(c))

“Observed in HR File Review. In 4 of 10 HR files reviewed, During review of HR files it was noted that the organization had not provided infection control education to staff. For example, the Medical Director, Volunteer, MSW and Spiritual Counselors files did not include infection control education. This was confirmed and discussed with the Office Assistant present.”

Rule L0582. Standard-level.

Counseling services (42 CFR 418.64(d)(1)(iv))

“Observed in Record Review. In 3 of 3 patient records reviewed, in bereavement care it was noted that the organization had not provided care or services according to the individualized POC. For example in records RRBR#1, #2, and #3 there was no bereavement plan of care documented and no documentation of services after the post death assessment. This was confirmed and discussed with the nurse and office assistant present.”

Rule L0596. Standard-level.

Competency evaluation (42 CFR 418.76(c)(5))

“Observed in HR File Review. In 1 of 10 HR files reviewed, staff competence was not assessed and documented once every year as required by organization policy. For example, a volunteer did not have a competency since their initial competency over six years ago. This was confirmed with the Office Assistant present.”

Rule L0619. Standard-level.

Recruiting and retaining (42 CFR 418.78(c))

“Observed in Tracer Activities. During review of the Volunteer program documentation and discussion with the Volunteer Coordinator it was noted that the hospice had not documented efforts to recruit or retain volunteers. The Volunteer Coordinator stated that he talked with people at church, but he was unable to discuss any other recruitment activities and no retention activities. There was no documentation of any efforts. This was confirmed and discussed with the Volunteer Coordinator.”

Rule L0645. Standard-level.

Cost saving (42 CFR 418.78(d)(3))

“Observed in Tracer Activities. During review of the Volunteer program documentation and discussion with the Volunteer Coordinator it was noted that the organization did not have documentation of cost savings achieved through use of volunteers for 2025 and 1st quarter 2026.”

Rule L0646. Standard-level.

Level of activity (42 CFR 418.78(e))

“Observed in Tracer Activities. During review of the Volunteer program documentation and discussion with the Volunteer Coordinator it was noted that volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff. For example the organization documented 2.06% for the year 2025 and 1.52% for 1st quarter 2026. The was confirmed and discussed with the Volunteer Coordinator.”

Rule L0647. Standard-level.

Use and mintenance of equipment and supplies (42 CFR 418.106(f)(2))

“Observed in Patient Home. In 1 of 1 home visits conducted, that included oxygen therapy it was noted that the staff did not provide education on the safe storage of oxygen cylinders in the home. For example during visit RRHV#1 the backup oxygen e-tank was stored in a enclosed closest without air flow. The RN did not provide education related to oxygen storage. This was confirmed and discussed with the nurse present.”

Rule L0702. Standard-level.