Cherishaven Hospice

“It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program: reflects the complexity of the hospice and services; involves all hospice services, including those provided under contract; addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness; focuses on indicators related to improved palliative outcomes; includes investigation and analysis of sentinel and adverse events; includes defined data detail and frequency of collection, and approves such; has evidence of action taken that results in improvement in hospice performance; and, is evaluated annually. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of Participation was not met as evidenced by document review, Quality Assessment and Performance Improvement (QAPI) documents, and interviews which revealed issues with the organization’s QAPI program in the following areas: Failed to ensure an active QAPI program for the years 2023, 2024, and 2025 and that the governing body approved the frequency and detail of the data collection {HQPI.5.I/L565/418.58(b)(3)}; Failed to ensure performance improvement activity currently or for the years 2023 and 2024, which focused on high-risk, high-volume, or problem-prone areas. {HQPI.6. I./L566/ 418.58(c)(1)(i)}; Failed to ensure to take action to improve performance, assess success, or track results to ensure sustained improvement. There was no documented evidence to show a QAPI program was in place in currently or for the years 2023 and 2024 {HQPI.8. I/L570/418.58(c)(3)}; Failed to ensure the governing body reviewed the active QAPI program for the years 2023 and 2024. The Governing Body minutes for 2023 and 2024 revealed a lack of evidence of the review of the QAPI program {HQPI.1. D/L574/ 418.58(e)(1)}; and Failed to ensure an active QAPI program for the years 2023, 2024, and 2025 {HQPI.1. D/L575/ 418.58(e)(2)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.58: Quality assessment and performance improvement. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure completion of the initial comprehensive assessments within five calendar days after the election of hospice care. DOCUMENT 1: The agency’s policy 4-042, titled Comprehensive Assessment, dated April 2021, stated in part, “A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after election of hospice care.” CLINICAL RECORD 4: The patient’s power of attorney signed the hospice election of care on October 17, 2025, and requested the start of care on October 20, 2025. The nursing assessment took place on October 20, 2025, the psychosocial assessment occurred on October 21, 2025, and the spiritual assessment took place on October 28, 2025 (11 days after the election of the hospice care). CLINICAL RECORD 6: The patient’s power of attorney signed the hospice election of care on April 23, 2025. Nursing assessment occurred on April 23, 2025; the patient declined psychosocial assessment, and spiritual assessment occurred on May 15, 2025 (22 days after the election of the hospice care). An interview with the Director of Clinical Services was conducted on December 10, 2025. She acknowledged that the clinical records do not reflect the reason for the delay in the initial spiritual assessments.”

“It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program includes defined data detail and frequency of collection and approves such; The hospice must maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS. The standard was not met, as evidenced by the document review and interview. The agency’s governing body did not ensure an active QAPI program for the years 2023, 2024, and 2025. Upon reviewing the governing body minutes for 2023, 2024, and 2025, it was revealed that the agency did not ensure defined data detail and frequency of collection. The agency did not provide any evidence of data collection. DOCUMENT 3: The agency’s policy titled Improving Organizational Performance, dated April 2021, stated in part, “ management activities as applicable to the organization’s quality indicators and data collection and analysis (measured and documented in a systematic and retrievable way)”. An interview with the Alternate Administrator/Director of Patient Care Services, conducted on December 11, 2025, revealed that the agency did not ensure QAPI data collection and analysis, as referenced in the sole available QAPI document dated January 5, 2024. This agenda listed the following reports: Quality Tracking Data Report, Facility Focus Report, Infection Control Surveillance Report, Clinical Record Review, Patient Satisfaction Survey, Incident Reports, and Safety. She stated that the reports and data are not available, so she reported the information verbally. She said there are no minutes available for the meeting. The standard was not met, as evidenced by the document review and interview. The agency’s governing body did not ensure an active QAPI program for the years 2023, 2024, and 2025. Upon reviewing the governing body minutes for 2023, 2024, and 2025, it was revealed that the agency did not ensure defined data detail and frequency of collection. The agency did not provide any evidence of data collection.”

“It is required that hospice performance improvement (PI) activities focus on high-risk, high-volume, or problem-prone areas The standard was not met, as evidenced by the document review and interview. The agency did not ensure a performance improvement activity currently or for the years 2023 and 2024, which focused on high-risk, high-volume, or problem-prone areas. The agency was unable to provide documentation to support the performance improvement activities. DOCUMENT 3: The agency’s policy 3-001, titled Improving Organizational Performance, dated April 2021, stated in part, “Senior management with Governing Body oversight will focus on high-risk, high-volume, and problem-prone areas.” An interview with the Alternate Administrator/Director of Patient Care Services, conducted on December 11, 2025, revealed that the agency does not collect data for analysis to determine the focus of performance improvement activities. She acknowledged the lack of data and analysis. She stated that we are small enough; these activities are not necessary. The standard was not met, as evidenced by the document review and interview. The agency did not ensure a performance improvement activity currently or for the years 2023 and 2024, which focused on high-risk, high-volume, or problem-prone areas. The agency was unable to provide documentation to support the performance improvement activities.”

“It is required that the hospice takes action to improve performance, assesses the success of the action after implementing it and tracks ongoing results to ensure improvement is sustained. The standard was not met, as evidenced by the document review and interview. The agency did not take action to improve performance, assess success, or track results to ensure sustained improvement. A review of the QAPI binder revealed that the content consisted of QAPI policies and the Plan-Do-Study-Act (PDSA) model for continuous process improvement. The binder lacked documentation demonstrating the use of the PDSA Model or any supporting documents to justify the actions taken to improve performance. DOCUMENT 3: The agency’s policy 3-001 titled Improving Organizational Performance, dated April 2021, stated in part, “The organization must document the quality improvement projects undertaken, the reason for conducting the projects, and the measurable progress achieved on the projects”. An interview with the Alternate Administrator/Director of Patient Care Services, conducted on December 11, 2025, revealed that the agency does not ensure action to improve performance, assess the effectiveness of implemented actions, and track ongoing results. She acknowledged the lack of documentation for any project and has not used the PDSA model for continuous process improvement. The standard was not met, as evidenced by the document review and interview. The agency did not take action to improve performance, assess success, or track results to ensure sustained improvement. A review of the QAPI binder revealed that the content consisted of QAPI policies and the Plan-Do-Study-Act (PDSA) model for continuous process improvement. The binder lacked documentation demonstrating the use of the PDSA Model or any supporting documents to justify the actions taken to improve performance.”

“It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program The hospice governing body is responsible for ensuring that the program is evaluated annually. The hospice must maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS. The standard was not met, as evidenced by the document review and interview. The agency did not ensure the governing body reviewed the active QAPI program for the years 2023 and 2024. The Governing Body minutes for 2023 and 2024 revealed a lack of evidence of the review of the QAPI program. DOCUMENT 3: The agency’s policy titled Improving Organizational Performance, dated April 2021, stated in part, “ The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, maintained, and evaluated annually. An interview with the Alternate Administrator/Director of Patient Care Services, conducted on December 11, 2025, revealed that the agency’s Governing Body minutes for the years 2023 and 2024 do not address the QAPI program. She acknowledged that the agenda and minutes do not reflect a review of the QAPI program. The standard was not met, as evidenced by the document review and interview. The agency did not ensure the governing body reviewed the active QAPI program for the years 2023 and 2024. The Governing Body minutes for 2023 and 2024 revealed a lack of evidence of the review of the QAPI program.”

“It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program addresses efforts and sets priorities for improved quality of care and patient safety and ensures all improvement actions are evaluated for effectiveness. The hospice must maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS. The standard was not met, as evidenced by the document review and interview. The agency’s governing body did not ensure an active QAPI program for the years 2023, 2024, and 2025. Upon reviewing the governing body minutes for 2023, 2024, and 2025, it was revealed that the governing body did not address the efforts and priorities for improving the quality of care and patient safety. DOCUMENT 2: The agency’s policy 8-003, titled Governing Body, dated April 2021, stated in part, “The governing body will ensure the organization-side quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety.” An interview with the Alternate Administrator/Director of Patient Care Services, conducted on December 11, 2025, confirmed that the governing body minutes provided for review did not include QAPI reports or discussion. The standard was not met, as evidenced by the document review and interview. The agency’s governing body did not ensure an active QAPI program for the years 2023, 2024, and 2025. Upon reviewing the governing body minutes for 2023, 2024, and 2025, it was revealed that the governing body did not address the efforts and priorities for improving the quality of care and patient safety.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The standard was not met, as evidenced by the document review and interview. The agency did not ensure that hospice volunteers were present in an amount equal to five percent of the total patient care hours. Documentation showed that for the year 2025, zero volunteer hours were documented, for 2024, 1.74 hours were reported, and for 2023, 66.1 hours were documented. The agency has one active office volunteer and no patient care volunteer noted at the time of the survey. DOCUMENT 4: The agency’s policy 9-024, titled Volunteer Services, dated April 2021, stated in part, “ The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that hours of volunteer services will exceed 5 % of the total patient care hours of paid and contracted hospice personnel.” An interview with the Alternate Administrator/Director of Patient Care Services, conducted on December 11, 2025, revealed that the Volunteer Coordinator was unavailable for an interview. She stated that we don’t need volunteers because most of our patients live in assisted living facilities. Discussion continued regarding the required percentage of hours, and she acknowledged that the agency has not met the requirement. The standard was not met, as evidenced by the document review and interview. The agency did not ensure that hospice volunteers were present in an amount equal to five percent of the total patient care hours. Documentation showed that for the year 2025, zero volunteer hours were documented, for 2024, 1.74 hours were reported, and for 2023, 66.1 hours were documented. The agency has one active office volunteer and no patient care volunteer noted at the time of the survey.”