Armstrong Hospice

“Based on interview and record review, it was determined the hospice failed to develop, implement, and maintain an effective, ongoing, hospice-wide data- driven quality assessment and performance improvement program. The hospice’s governing body must ensure that the program: reflects the complexity of its organization and services; involves all hospice services (including those services furnished under contract or arrangement); focuses on indicators related to improved palliative outcomes; and takes actions to demonstrate improvement in hospice performance. The hospice must maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS (L559); failed to show measurable improvement in indicators related to improved palliative outcomes and hospice services (L561); failed to show measure, analyze, and track quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations (L562); failed to provide documentation on how the hospice used quality indicator data, including patient care, and other relevant data, in the design of its program (L563); failed to provide documentation on how the hospice used the data collected to monitor the effectiveness and safety of services and quality of care and identify opportunities and priorities for improvement (L564); failed to provide documentation the frequency and detail of the data collection was approved by the hospice’s governing body (L565); the hospice failed to provide documentation that the hospice’s performance improvement activities focused on high risk, high volume, or problem-prone areas (L566); failed to provide documentation that the hospice’s performance improvement activities considered incidence, prevalence, and severity of problems in those areas (L567); failed to provide documentation that the hospice’s performance improvement activities affected palliative outcomes, patient safety, and quality of care (L568); failed to provide documentation that the performance improvement activities tracked adverse patient events, analyzed their causes, and implemented preventive actions and mechanisms that included feedback and learning throughout the hospice (L569); failed to provide documentation the hospice took actions aimed at performance improvement and, after implementing those actions, measured its success and tracked performance to ensure that improvements were sustained (L570); failed to provide documentation the hospice developed, implemented and evaluated performance improvement projects (L571); failed to provide documentation of the number of scope of distinct performance improvement projects conducted annually, based on the needs of the hospice’s population and internal organizational needs, that reflected the scope complexity, and past performance of the hospice’s services and operations (L572); failed to provide documentation of the performance improvement projects that are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects (L573); failed to provide documentation that the hospice’s governing body ensured the ongoing program for quality improvement and patient safety was defined, implemented, and maintained, and was evaluated annually (L574); failed to provide documentation the hospice-wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety, and that all improvement actions were evaluated for effectiveness (L575); failed to provide documentation that one or more individual(s) who are responsible for operating the quality assessment and performance improvement program were designated and failed to provide documentation that one or more individual(s) who are responsible for operating the quality assessment and performance improvement program are designated (L576). The extent and cumulative effect of these systemic practices resulted in the hospice not developing, implementing, and maintaining an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program.”

“Based on interview and clinical record review, the hospice failed to maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases (L577); the hospice failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases that is an integral part of the Hospice’s quality assessment and performance improvement program (L580); the hospice failed to ensure the hospice’s quality assessment and performance improvement (QAPI) program included a method of identifying infectious and communicable disease problems and a plan for implementing the appropriate actions that are expected to result in improvement and disease prevention (L581); and the hospice failed to ensure the hospice provided infection control education to employees, contracted providers, patients, and family members and other caregivers (L582). The extent and the cumulative effect of these systemic practices resulted in the failure of the agency to deliver statutorily mandated compliance with provision of infection control program to prevent the spread of infections.”

“Based on interview and clinical record review, the hospice failed to use volunteers in defined roles and under the supervision of a designated hospice employee (L641); the hospice failed to maintain, document and provide volunteer orientation and training consistent with hospice industry standards (L643); the hospice failed to use volunteers in day-to-day administration and/or direct patient care roles (L644); the hospice failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers (L645); the hospice failed to document cost savings achieved through the use of volunteers (L646); and the hospice failed to maintain records on use of volunteers including the type of services and time worked and use volunteers to provide day-to-day administrative and/or direct patient care services in an amount, at a minimum, equal to 5 percent of the total patient care hours of all paid hospice employees and contract staff (L647). The cumulative effect of these systemic practices resulted in the hospice not operating and furnishing services in compliance with all applicable federal regulations.During a review of the facility’s Policy and Procedure (P&P) titled, “Volunteer Services,” undated, the P&P indicated, “To ensure that qualified volunteers provide appropriate services in accordance with the plan of care and hospice program needs…[agency] will provide volunteer services...”During a review of the hospice’s undated P&P titled, “Regulatory Compliance,” indicated, “To ensure compliance with local, state, federal, and other regulatory bodies.””

“Based on interview and record review, the hospice failed to organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions for a current census of three out of seven unduplicated admissions (L648) and failed to ensure the governing body (or designated persons so functioning) assumed full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations and continuous quality assessment and performance improvement (L651).This failure negatively impacted the day-to-day operations of the hospice and resulted in the hospice’s inability to remain in compliance with Federal Regulations. Based on interview and record review, the governing body (or designated persons so functioning) failed to provide full legal authority and responsibility for the hospice’s overall management and operation and the provision of all hospice services by having 3 of 20 Condition of Participations (COPs) out and by providing hospice services for a current census of three out of seven unduplicated admissions (Patient 1, Patient 2 and Patient 3) out of the hospice’s approved geographical service area. Review of a hospice document titled “Active Patient List” indicated Patient 1 resided in Pittsburg, CA, Patient 2 resided in Seaside, CA, and Patient 3 resided in Millbrae, CA. Review of the hospice’s CMS (Centers for Medicare & Medicaid Services) 855A form, a Medicare provider/supplier enrollment application used by healthcare providers, did not have the above counties listed in their approved geographical service areas. During a review of the hospice’s undated P&P titled, “Admission Criteria and Process,” indicated, “The patient must reside within the geographical area that the Armstrong Hospice services.””

“Based on interview and record review, the hospice and its staff failed to operate and furnish services in compliance with all applicable federal regulations related to the health and safety of patients.The cumulative effect of these systemic practices resulted in the hospice not operating and furnishing services in compliance with all applicable federal regulations. Based on interview and record review, the governing body (or designated persons so functioning) failed to provide full legal authority and responsibility for the hospice’s overall management and operation and the provision of all hospice services by having three of 20 Condition of Participations (COPs) out and by providing hospice services for a current census of three out of seven unduplicated admissions (Patient 1, Patient 2 and Patient 3) out of the hospice’s approved geographical service area.Review of a hospice document titled “Active Patient List” indicated Patient 1 resided in Pittsburg, CA, Patient 2 resided in Seaside, CA, and Patient 3 resided in Millbrae, CA. Review of the hospice’s CMS (Centers for Medicare & Medicaid Services) 855A form, a Medicare provider/supplier enrollment application used by healthcare providers, did not have the above counties listed in their approved geographical service areas. During a review of the hospice’s undated policy and procedure titled, “Regulatory Compliance,” indicated, “To ensure compliance with local, state, federal, and other regulatory bodies.”During a review of the hospice’s undated P&P titled, “Admission Criteria and Process,” indicated, “The patient must reside within the geographical area that the Armstrong Hospice services.””

“Based on interview and record review, the facility failed to ensure a written policy and procedure was available for Sheltering in Place.This failure had the potential to result in patients, staff and volunteers not knowing if it was safe to evacuate during an emergency. During a concurrent interview and record review on 10/7/25 starting at 11:08 a.m., the Administrator acknowledged there should be a policy for Sheltering in Place. The Administrator stated that he thought the Shelter in Place policy was in the Emergency Preparedness plan but was unable to provide the documentation.”

“Based on interview and document review, the hospice failed to provide the patient or representative with verbal and written notice of the patient’s rights and responsibilities for a current census of three out of seven unduplicated admissions.This failure resulted in the patient and/or their representative being unaware of the patient’s rights and responsibilities. Findings:Review of the hospice’s sample admission packet contained a form titled, “Patient and Family Rights and Responsibilities,” that indicated, “To be informed by the license of the provisions of the law regarding complaints and procedures for registering Complaints confidentiality. Including, but not limited to the address and telephone number of the local district office of the department. For complaint may contact California Department of Public Health. 464 W. 4th St., #529, San Bernardino, CA 92401 Phone number (909) 483-3777.” During a review of the hospice’s undated policy and procedure (P&P) titled, “Patient Bill of Rights/Responsibilities,” indicated, “To encourage awareness of patient rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning… Receive in writing, prior to the start of care, the telephone numbers for the ACHC Hotline, including hours of operation, and the purpose of the hotlines to receive complaints or questions about the organization.”This P&P indicated the patient and/or their representative was to call ACHC (Accreditation Commission for Health Care- an independent third-party organization that provides nationally recognized accreditation for hospice and home health agencies) hotline to file a complaint.During an interview on 10/6/25 at 11:44 a.m. with the Administrator/Director of Patient Care Services (DPCS) he confirmed the listed San Bernadino District Office was an “error” and should have listed Sacramento District Office. The Administrator/DPCS also confirmed they were not currently accredited by ACHC.”

“Based on interview and record review, the Hospice Agency failed to ensure that the care and services were provided in accordance with the plan of care for one out of five sampled patients (Patient 2), when Patient 2’s Health Aide (HA) frequency of visit order was not followed.This failure had the potential for Patient 2 to not receive required services negatively affecting Patient 2’s comfort and well-being. A review of Patient 2’s plan of care dated 10/7/25 indicated, “HA: -2x/week [two times a week] for personal care and assistance starting week of 8/19/25 then 3x [three times] a week starting week of 8/24/25…”A review Patient 2’s visit calendar indicated Patient 2 was missing two visits from the HA during week of 8/31/25 to 9/6/25, missing one visit from the HA during week 9/7/25 to 9/13/25, and missing one visit from the HA during week 9/14/25 to 9/20/25. During a concurrent interview and record review on 10/6/25 at 3:03 p.m., with the Director of Patient Care Services (DPCS), Patient 2’s clinical records were reviewed. The DPCS confirmed that Patient 2’s HA frequency of visit order was not followed and stated the plan of care should have be followed.A review of the facility’s policy and procedure (P&P) titled, “THE PLAN OF CARE”, undated, indicated, “To ensure that an individualized plan of care is completed that complies with accepted standard of care and regulatory issues...The care provided to the patient must be in accordance with the plan of care…The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs.”A review of the P&P titled, “MISSED VISITS”, undated, indicated, “If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequence is maintained…””

“Based on interview and record review, the hospice failed to show measurable improvement in indicators related to improved palliative (relieve of pain and other symptoms) outcomes and hospice services.The failure decreased the hospice’s potential to improve care and services provided to their patients. Findings:During a concurrent record review of the hospice’s Quality Assessment and Performance Improvement (QAPI) binder and interview with the Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:24 a.m. he was unable to provide documentation the hospice showed measurable improvement in indicators related to improved palliative outcomes and hospice services.During a review of hospice’s undated policy and procedure titled “Improving Organizational Performance,” indicated, “Senior management, as designated by the Governing Body, will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations of hospice’s performance improvement activities; and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will-be active participants in the organization’s quality assessment and performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the QAPI program is defined, implemented and maintained, and is evaluated annually.””

“Based on interview and record review, the hospice failed to provide documentation they measured, analyzed, and tracked quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations.The failure decreased the agency’s potential to improve care and services provided to their patients. Findings:During a concurrent record review of the hospice’s Quality Assessment and Performance Improvement (QAPI) binder and interview with the Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:24 a.m. he was unable to provide documentation on how they measured, analyzed, and tracked quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations.During a review of hospice’s undated policy and procedure titled, “Improving Organizational Performance,” indicated, “Senior management, as designated by the Governing Body, will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations of hospice’s performance improvement activities; and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will-be active participants in the organization’s quality assessment and performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the QAPI program is defined, implemented and maintained, and is evaluated annually.””

“Based on interview and record review, the hospice failed to provide documentation on how the hospice used quality indicator data, including patient care, and other relevant data, in the design of its program.The failure decreased the agency’s potential to improve care and services provided to their patients. During a concurrent record review of the hospice’s Quality Assessment and Performance Improvement (QAPI) binder and interview with the Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:24 a.m. he was unable to provide documentation on how the hospice used quality indicator data, including patient care, and other relevant data, in the design of its program.During a review of hospice’s undated policy and procedure titled “Improving Organizational Performance,” indicated, “Senior management, as designated by the Governing Body, will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations of hospice’s performance improvement activities; and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will-be active participants in the organization’s quality assessment and performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the QAPI program is defined, implemented and maintained, and is evaluated annually.””

“Based on interview and record review, the hospice failed to provide documentation it collected data to monitor the effectiveness and safety of services and quality of care and identify opportunities and priorities for improvement.The failure decreased the agency’s potential to improve care and services provided to their patients. Findings:During a concurrent record review of the hospice’s Quality Assessment and Performance Improvement (QAPI) binder and interview with the Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:24 a.m. he was unable to provide documentation the hospice collected data to monitor the effectiveness and safety of services and quality of care and identify opportunities and priorities for improvement.During a review of hospice’s undated policy and procedure titled “Improving Organizational Performance,” indicated, “Senior management, as designated by the Governing Body, will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations of hospice’s performance improvement activities; and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will-be active participants in the organization’s quality assessment and performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the QAPI program is defined, implemented and maintained, and is evaluated annually.””

“Based on interview and record review, the hospice failed to provide documentation the frequency and detail of the data collection was approved by the hospice’s governing body. The failure decreased the hospice’s potential to improve care and services provided to their patients. Findings:During a concurrent record review of the hospice’s Quality Assessment and Performance Improvement (QAPI) binder and interview with the Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:24 a.m. he was unable to provide documentation of the frequency and detail of the data collection was approved by the hospice’s governing body.During a review of hospice’s undated policy and procedure titled “Improving Organizational Performance,” indicated, “Senior management, as designated by the Governing Body, will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations of hospice’s performance improvement activities; and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will-be active participants in the organization’s quality assessment and performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the QAPI program is defined, implemented and maintained, and is evaluated annually.””

“Based on interview and record review, the hospice failed to provide documentation that the hospice’s performance improvement activities focused on high risk, high volume, or problem-prone areas.The failure decreased the hospice’s potential to improve care and services provided to their patients. During a concurrent record review of the hospice’s Quality Assessment and Performance Improvement (QAPI) binder and interview with the Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:24 a.m. he was unable to provide documentation that the hospice’s performance improvement activities focused on high risk, high volume, or problem-prone areas.During a review of hospice’s undated policy and procedure titled “Improving Organizational Performance,” indicated, “Senior management, as designated by the Governing Body, will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations of hospice’s performance improvement activities; and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will-be active participants in the organization’s quality assessment and performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the QAPI program is defined, implemented and maintained, and is evaluated annually.””

“Based on interview and record review, the hospice failed to provide documentation that the hospice’s performance improvement activities considered incidence, prevalence, and severity of problems in those areas.The failure decreased the hospice’s potential to improve care and services provided to their patients. During a concurrent record review of the hospice’s Quality Assessment and Performance Improvement (QAPI) binder and interview with the Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:24 a.m. he was unable to provide documentation that the hospice’s performance improvement activities considered incidence, prevalence, and severity of problems in those areas.During a review of hospice’s undated policy and procedure titled “Improving Organizational Performance,” indicated, “Senior management, as designated by the Governing Body, will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations of hospice’s performance improvement activities; and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will-be active participants in the organization’s quality assessment and performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the QAPI program is defined, implemented and maintained, and is evaluated annually.””

“Based on interview and record review, the hospice failed to provide documentation that the hospice’s performance improvement activities affected palliative outcomes, patient safety, and quality of care.The failure decreased the hospice’s potential to improve care and services provided to their patients. During a concurrent record review of the hospice’s Quality Assessment and Performance Improvement (QAPI) binder and interview with the Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:24 a.m. he was unable to provide documentation that the hospice’s performance improvement activities affected palliative outcomes, patient safety, and quality of care.During a review of hospice’s undated policy and procedure titled “Improving Organizational Performance,” indicated, “Senior management, as designated by the Governing Body, will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations of hospice’s performance improvement activities; and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will-be active participants in the organization’s quality assessment and performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the QAPI program is defined, implemented and maintained, and is evaluated annually.””

“Based on interview and record review, the hospice failed to provide documentation that the performance improvement activities tracked adverse patient events, analyzed their causes, and implemented preventive actions and mechanisms that included feedback and learning throughout the hospice.The failure decreased the hospice’s potential to improve care and services provided to their patients. Findings:During a concurrent record review of the hospice’s Quality Assessment and Performance Improvement (QAPI) binder and interview with the Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:24 a.m. he was unable to provide documentation that the performance improvement activities tracked adverse patient events, analyzed their causes, and implemented preventive actions and mechanisms that included feedback and learning throughout the hospice.During a review of hospice’s undated policy and procedure titled “Improving Organizational Performance,” indicated, “Senior management, as designated by the Governing Body, will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations of hospice’s performance improvement activities; and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will-be active participants in the organization’s quality assessment and performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the QAPI program is defined, implemented and maintained, and is evaluated annually.””

“Based on interview and record review, the hospice failed to provide documentation the hospice took actions aimed at performance improvement and, after implementing those actions, measured its success and tracked performance to ensure that improvements were sustained.The failure decreased the hospice’s potential to improve care and services provided to their patients. Findings:During a concurrent record review of the hospice’s Quality Assessment and Performance Improvement (QAPI) binder and interview with the Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:24 a.m. he was unable to provide documentation the hospice took actions aimed at performance improvement and, after implementing those actions, measured its success and tracked performance to ensure that improvements were sustained. During a review of hospice’s undated policy and procedure titled “Improving Organizational Performance,” indicated, “Senior management, as designated by the Governing Body, will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations of hospice’s performance improvement activities; and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will-be active participants in the organization’s quality assessment and performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the QAPI program is defined, implemented and maintained, and is evaluated annually.””

“Based on interview and record review, the hospice failed to provide documentation the hospice developed, implemented and evaluated performance improvement projects.The failure decreased the hospice’s potential to improve care and services provided to their patients. During a concurrent record review of the hospice’s Quality Assessment and Performance Improvement (QAPI) binder and interview with the Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:24 a.m. he was unable to provide documentation the hospice developed, implemented and evaluated performance improvement projects.During a review of hospice’s undated policy and procedure titled “Improving Organizational Performance,” indicated, “Senior management, as designated by the Governing Body, will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations of hospice’s performance improvement activities; and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will-be active participants in the organization’s quality assessment and performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the QAPI program is defined, implemented and maintained, and is evaluated annually.””

“Based on interview and record review, the hospice failed to provide documentation of the number and scope of distinct performance improvement projects conducted annually, based on the needs of the hospice’s population and internal organizational needs, that reflected the scope complexity, and past performance of the hospice’s services and operations.The failure decreased the hospice’s potential to improve care and services provided to their patients. During a concurrent record review of the hospice’s Quality Assessment and Performance Improvement (QAPI) binder and interview with the Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:24 a.m. he was unable to provide documentation of the number and scope of distinct performance improvement projects conducted annually, based on the needs of the hospice’s population and internal organizational needs, that reflected the scope complexity, and past performance of the hospice’s services and operations.During a review of hospice’s undated policy and procedure titled “Improving Organizational Performance,” indicated, “Senior management, as designated by the Governing Body, will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations of hospice’s performance improvement activities; and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will-be active participants in the organization’s quality assessment and performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the QAPI program is defined, implemented and maintained, and is evaluated annually.””

“Based on interview and record review, the hospice failed to provide documentation of the performance improvement projects that are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.The failure decreased the hospice’s potential to improve care and services provided to their patients. Findings:During a concurrent record review of the hospice’s Quality Assessment and Performance Improvement (QAPI) binder and interview with the Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:24 a.m. he was unable to provide documentation of the performance improvement projects that are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.During a review of hospice’s undated policy and procedure titled “Improving Organizational Performance,” indicated, “Senior management, as designated by the Governing Body, will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations of hospice’s performance improvement activities; and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will-be active participants in the organization’s quality assessment and performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the QAPI program is defined, implemented and maintained, and is evaluated annually.””

“Based on interview and record review, the hospice failed to provide documentation that the hospice’s governing body ensured the ongoing program for quality improvement and patient safety was defined, implemented, and maintained, and was evaluated annually.The failure decreased the hospice’s potential to improve care and services provided to their patients. During a concurrent record review of the hospice’s Quality Assessment and Performance Improvement (QAPI) binder and interview with the Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:24 a.m. he was unable to provide documentation that the hospice’s governing body ensured the ongoing program for quality improvement and patient safety was defined, implemented, and maintained, and was evaluated annually.During a review of hospice’s undated policy and procedure titled “Improving Organizational Performance,” indicated, “Senior management, as designated by the Governing Body, will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations of hospice’s performance improvement activities; and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will-be active participants in the organization’s quality assessment and performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the QAPI program is defined, implemented and maintained, and is evaluated annually.””

“Based on interview and record review, the hospice failed to provide documentation that the governing body ensured the hospice-wide quality assessment and performance improvement (QAPI) efforts addressed priorities for improved quality of care and patient safety, and that all improvement actions were evaluated for effectiveness.The failure decreased the hospice’s potential to improve care and services provided to their patients. During a concurrent record review of the hospice’s QAPI binder and interview with the Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:24 a.m. he was unable to provide documentation the governing body ensured the hospice-wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety, and that all improvement actions were evaluated for effectiveness.During a review of hospice’s undated policy and procedure titled “Improving Organizational Performance,” indicated, “Senior management, as designated by the Governing Body, will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations of hospice’s performance improvement activities; and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will-be active participants in the organization’s quality assessment and performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the QAPI program is defined, implemented and maintained, and is evaluated annually.””

“Based on interview and record review, the hospice failed to provide documentation that one or more individual(s) who are responsible for operating the quality assessment and performance improvement program (QAPI) was designated.The failure decreased the hospice’s potential to improve care and services provided to their patients. Findings:During a concurrent record review of the hospice’s QAPI binder and interview with the Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:24 a.m. he was unable to provide documentation that one or more individual(s) who are responsible for operating the quality assessment and performance improvement program was designated.During a review of hospice’s undated policy and procedure titled “Improving Organizational Performance,” indicated, “Senior management, as designated by the Governing Body, will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations of hospice’s performance improvement activities; and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will-be active participants in the organization’s quality assessment and performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the QAPI program is defined, implemented and maintained, and is evaluated annually.””

“Based on interview and record review, the hospice failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases that is an integral part of the Hospice’s quality assessment and performance improvement (QAPI) program.This failure may cause possible transmission of infections to the patients. During a concurrent review of the hospice’s Infection Control binder and interview with the Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:16 a.m. the Administrator/DPCS was unable to provide documentation on how the hospice maintained a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases that is an integral part of the Hospice’s QAPI program.During a review of the hospice’s undated policy and procedure titled, “Infection Control Plan,” indicated, “Establish the mechanism by which the organization will address surveillance, prevention, identification, control and reporting of infections, utilizing current scientific methods and epidemiologic principles…Provide for surveillance systems to track the occurrence and transmission of infections. Comply with all applicable local, state, federal regulations, and accepted Standards of Practice…””

“Based on interview and record review, the hospice failed to ensure the hospice’s quality assessment and performance improvement (QAPI) program included a method of identifying infectious and communicable disease problems and a plan for implementing the appropriate actions that are expected to result in improvement and disease prevention.This failure may cause possible transmission of infections to the patients. During a concurrent review of the hospice’s Infection Control binder and interview with the Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:16 a.m. the Administrator/DPCS was unable to provide documentation on how they ensured the hospice’s QAPI program included a method of identifying infectious and communicable disease problems and a plan for implementing the appropriate actions that are expected to result in improvement and disease prevention.During a review of the hospice’s undated policy and procedure titled, “Infection Control Plan,” indicated, “Establish the mechanism by which the organization will address surveillance, prevention, identification, control and reporting of infections, utilizing current scientific methods and epidemiologic principles…Provide for surveillance systems to track the occurrence and transmission of infections. Comply with all applicable local, state, federal regulations, and accepted Standards of Practice…””

“Based on interview and record review, the hospice failed to ensure it provided infection control education to employees, contracted providers, patients, and family members and other caregivers. This failure may cause possible transmission of infections to the patients. During a concurrent review of the agency’s Infection Control binder and interview with Administrator/Director of Patient Care Services (DPCS) on 10/7/25 at 9:16 a.m. the Administrator/DPCS was unable to provide documentation on how they ensure the hospice provided infection control education to employees, contracted providers, patients, and family members and other caregivers. During a review of the hospice’s undated policy and procedure titled, “Infection Control Plan,” indicated, “Guide organization personnel in the care and services they provide in relation to infection control practices. Educate organization personnel, patients and family/caregivers, and others in the prevention and control of infections…Comply with all applicable local, state, federal regulations, and accepted Standards of Practice…””

“Based on interview and record review, the hospice failed to provide training and orientation of volunteers for a current census of three out of seven unduplicated admissions. This failure resulted in the hospice’s inability to provide volunteer services for their patients per facility policy and federal regulations. During an interview on 10/6/25, at 1:35 p.m., with Human Resources (HR), HR confirmed there is currently one volunteer who was hired last week. HR stated the volunteer has not had any patient contact or provided any volunteer services and has not completed any training or orientation. HR further stated there were no volunteers employed prior to the current volunteer getting hired. HR confirmed volunteers are needed and are important in hospice care. During a review of the facility’s Policy and Procedure (P&P) titled, “Volunteer Services,” undated, the P&P indicated, “To ensure that qualified volunteers provide appropriate services…[agency] will provide volunteer services…Volunteer Coordinator will develop and implement a specialized volunteer orientation and training program…””

“Based on interview and record review, the agency failed to provide volunteer services for a current census of three out of seven unduplicated admissions. This failure resulted in the hospice’s inability to provide volunteer services for their patients per facility policy and federal regulations. During an interview on 10/6/25, at 1:35 p.m., with Human Resources (HR), HR confirmed there is currently one volunteer who was hired last week. HR stated the volunteer has not had any patient contact or provided any volunteer services and has not completed any training or orientation. HR further stated there were no volunteers employed prior to the current volunteer getting hired. HR confirmed volunteers are needed and are important in hospice care. During a review of the facility’s Policy and Procedure (P&P) titled, “Volunteer Services,” undated, the P&P indicated, “To ensure that qualified volunteers provide appropriate services in accordance with the plan of care and hospice program needs…[agency] will provide volunteer services…Volunteers may work in a variety of capacities, including…Patient care volunteers…Bereavement volunteers…Errands and transportation volunteers…Office volunteers…Volunteer Coordinator will arrange for volunteers to provide volunteer support to patient and family/caregiver…responsibilities consistent with the needs of the patients and families…””

“Based on interview and record review, the agency failed to recruit and provide volunteer services for a current census of three out of seven unduplicated admissions. This failure resulted in the agency’s inability to provide volunteer services for their patients per facility policy and federal regulations. During an interview on 10/6/25, at 1:35 p.m., with Human Resources (HR), HR confirmed there is currently one volunteer who was hired last week. HR stated the volunteer has not had any patient contact or provided any volunteer services and has not completed any training or orientation. HR further stated there were no volunteers employed prior to the current volunteer getting hired. HR stated she was unaware and not able to locate any volunteer recruiting documentation. HR confirmed volunteers are needed and are important in hospice care. During a review of the facility’s Policy and Procedure (P&P) titled, “Volunteer Services,” undated, the P&P indicated, “To ensure that qualified volunteers provide appropriate services in accordance with the plan of care and hospice program needs…[agency] will provide volunteer services…Volunteer Coordinator will document ongoing efforts to recruit, train, and retain volunteers of all ages and ethnic backgrounds…””

“Based on interview and record review, the agency failed to provide volunteer services and document cost savings for a current census of three out of seven unduplicated admissions. This failure resulted in the agency’s inability to provide volunteer services for their patients and analyze potential cost savings per facility policy and federal regulations. During an interview on 10/6/25, at 1:35 p.m., with Human Resources (HR), HR confirmed there is currently one volunteer who was hired last week. HR stated the volunteer has not had any patient contact or provided any volunteer services and has not completed any training or orientation. HR further stated there were no volunteers employed prior to the current volunteer getting hired and there were no records of documented cost savings found. HR confirmed volunteers are needed and are important in hospice care. During a review of the facility’s Policy and Procedure (P&P) titled, “Volunteer Services,” undated, the P&P indicated, “To ensure that qualified volunteers provide appropriate services in accordance with the plan of care and hospice program needs…[agency] will provide volunteer services…Volunteer Coordinator will track the use of volunteers, the cost savings achieved…will provide an annual report to the Governing Body to demonstrate the cost savings of volunteer activities.””

“Based on interview and record review, the agency failed to provide volunteer services and documented volunteer activities for a current census of three out of seven unduplicated admissions. This failure resulted in the agency’s inability to provide volunteer services for their patients per facility policy and federal regulations. During an interview on 10/6/25, at 1:35 p.m., with Human Resources (HR), HR confirmed there is currently one volunteer who was hired last week. HR stated the volunteer has not had any patient contact or provided any volunteer services and has not completed any training or orientation. HR further stated there were no volunteers employed prior to the current volunteer getting hired and there were no records of documented volunteer activities found. HR confirmed volunteers are needed and are important in hospice care. During a review of the facility’s Policy and Procedure (P&P) titled, “Volunteer Services,” undated, the P&P indicated, “To ensure that qualified volunteers provide appropriate services in accordance with the plan of care and hospice program needs…[agency] will provide volunteer services…Volunteers will document their activities/type of service and time worked on volunteer activity/clinical notes and submit this documentation for the patient’s clinical records…Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel.””

“Based on interview and record review, the hospice failed to ensure the governing body (or designated persons so functioning) assumed full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations and continuous quality assessment and performance improvement. This failure negatively impacted the day-to-day operations of the hospice and resulted in the hospice’s inability to remain in compliance with Federal Regulation. Based on interview and record review, the governing body (or designated persons so functioning) failed to provide full legal authority and responsibility for the hospice’s overall management and operation and the provision of all hospice services by having three of 20 Conditions of Participations (COPs) out and by providing hospice services for a census of three (Patient 1, Patient 2 and Patient 3) out of their approved geographical service area. Review of a hospice document titled “Active Patient List” indicated Patient 1 resided in Pittsburg, CA, Patient 2 resided in Seaside, CA, and Patient 3 resided in Millbrae, CA. Review of the hospice’s CMS (Centers for Medicare & Medicaid Services) 855A form, a Medicare provider/supplier enrollment application used by healthcare providers, did not have the above areas listed in their geographical service areas. During a review of the hospice’s undated policy and procedure (P&P) titled, “Admission Criteria and Process,” indicated, “The patient must reside within the geographical area that the Armstrong Hospice services.”During a review of the hospice’s undated P&P titled, “Governing Body,” indicated, “The Governing Body will assume full legal authority, responsibility, decision-making and accountability for the overall management and operations, the provision of services, fiscal operations, human resource management, review of the organization’s budget and operational plans, and its quality assessment and performance improvement (QAPI) program. The Governing Body of Armstrong Hospice will serve as the governing authority for the home care program, which will function according to Armstrong Hospice’s bylaws.”During a review of the hospice’s undated P&P titled, “Regulatory Compliance,” indicated, “To ensure compliance with local, state, federal, and other regulatory bodies.””