Dynamic Hospice

“Based on record reviews, and staff interviews, it was determined that the agency failed to cover medications related to admission diagnoses for three patients (P) (P6, P7, P8) of 14 sampled patients. Findings included: 1. Review of the clinical records for P6 revealed that the start of care was completed by a skilled nurse on 12/22/2025. The admission diagnoses were Parkinson’s disease (a progressive, incurable neurodegenerative disorder that impacts the nervous system and motor control), and dementia disease (a decline in mental ability severe enough to interfere with daily life, caused by physical changes in the brain), comorbidity of mixed hyperlipidemia [it is commonly referred to as high cholesterol]. The agency failed to cover the following medication:• Atorvastatin Calcium (Lipitor), [use to prevent heart attacks and strokes] 40 milligrams (mg), take one tablet by mouth daily at bedtime. On 04/29/2026 at 1:30 PM, a phone interview was conducted with Registered Nurse (RN) CC, who said that she did not know why the diagnosed medication for P6 was not covered. RN CC also said that she was training with RN BB at that time. RN BB was not available for interview because she was on vacation and travelled out of country. 2. Review of the clinical records for P7 revealed that the start of care was completed by a skilled nurse on 09/05/2025. The admission diagnoses were (a hypertensive heart disease with heart failure [a chronic condition where the heart muscle is too weak to pump blood efficiently and causing fluid backup], comorbidity hyperlipidemia [it is commonly referred to as high cholesterol]. The agency failed to cover the following medication:•Atorvastatin Calcium (Lipitor), [use to prevent heart attacks and strokes] 20mg take one tablet by mouth daily at bedtime. 3. Review of the clinical records for P8 revealed that the start of care was completed by skilled nurse on 12/30/2025. The admission diagnosed was Alzheimer’s disease (a decline in mental ability severe enough to interfere with daily life, causing the brain to shrink). The hospice agency failed to cover the following medication for P8:• Donepezil HCI [it works by increasing acetylcholine in the brain, which can help improve memory] 10mg taking one tablet by mouth daily at bedtime. On 04/29/2026 at 1:49 PM, an interview was conducted with the Director of Nursing (DON) in the conference room. She confirmed that RN BB and RN CC did not cover the diagnosed medications for P6, P7 and P8. DON also said that they were audited by the pharmacist who confirmed that the hospice was paid to cover the diagnoses and comorbidities medications. DON said that RN AA and RN DD resigned. Policy was requested but was not available upon exit.”

“Based on review of policy titled “Quality Assessment and Performance Improvement,” record reviews, and staff interview, it was determined the agency failed to maintain a Quality Improvement Plan (QAPI) program with indicators that are measured, analyzed and tracked for improvement and quality of care. Findings included: Review of agency’s policy titled “Quality Assessment and Performance Improvement,” revised June 2019 revealed the following:“Objectives:• To collect and analyze data to improve identified processes and outcomes of care• To collect and analyze date to improve identified processes of patient care/services as well as outcomes of patient care, leadership and managerial process, as indicatedResponsibility/Accountability:The Administrator/Director is responsible for assigning staff to the Quality Assessment Performance Improvement (QAPI) committee. The QAPI committee will be responsible for coordination of all QAPI activities, reviewing collection of data, analyzing data, assisting staff in developing design or improvement activities, planning actions, collection data, analyzing the effectiveness of action and implementing effective actions.” Review of document titled “Hospice QAPI KPI Dashboard,” with no date indicates the agency has three active/ongoing performance projects (PIPs) however, the PIPs failed to contain data collection, audits, or relevant data collection from identified quality indicators for improving hospice services. On 04/27/2026 at 1:15 PM, during an office interview, the Director of Nursing (DON) confirmed the Quality Improvement Plan (QAPI) program did not contain Performance Improvement Projects (PIP) with indicators that are measured, analyzed and tracked for improvement and quality of care. Furthermore, when PIP documentation for the last two quarters was requested the DON stated she did not have any data for the PIPs because the nurse who was over QAPI resigned and she is not able to locate any data for the PIPs.”

“Based on review of policy titled “Infection Control Surveillance System: Prioritized Ricks Defined,” record reviews, and staff interview, it was determined the agency failed to maintain an Infection Control Surveillance System program with indicators that are measured, analyzed and coordinated with quality assessment performance improvement (QAPI) team to be tracked for improvement and quality of care. Findings included: Review of agency’s policy titled “Infection Control Surveillance System: Prioritized Ricks Defined,” revised June 2019 ,” revealed the following:“Purpose: To define infection control surveillance identification and reporting for patients and staff.Procedure:3. At least quarterly, the Director and infection control and QAPI committees will review and assess the infection control logs. Data will be aggregated and analyzed on the Infection Control Quarterly Data Aggregation and Analysis: Patients and Employees form.5. The committees will make recommendations for and implement improvement activities” Review of documents titled “30-Minute Hospice QAPI Meeting Agenda,” dated 11/17/25 and 2/9/26 indicates the agency has had two QAPI meetings however, the QAPI agenda failed to discuss Infection control surveillance and tracking. On 04/27/2026 at 2:00 PM, during an office interview, the Director of Nursing confirmed that infection control logs have not been discussed during the QAPI meeting and they should as she has noted a trend of urinary infections. She also states that she understands infection control is a part of QAPI and should be discussed during the meetings.”

“Based on the review of policies and procedures, records review, and staff interviews, it was determined the facility failed to ensure that a governing body (or designated persons so functioning) assumes full legal authority and responsibility for the management of the hospice, and the provision of all hospice services to include the following:1. failure to measure, analyze, and track Quality Improvement Plan (QAPI) program indicators.2. failure to maintain an infection control program that measures, analyzes, and coordinates with the QAPI team to be tracked.3. failure to provide medications related to the palliation and management of the terminal illness and related conditions for three patients (P) (P6, P7, P8) of 14 sampled patients. Findings included: Review of policy titled “Governing Body,” revised June 2019, revealed the following:“POLICYThe Governing Body assumes full legal authority and responsibility for the management of hospice, the provision of all hospice services, its fiscal operations and assumes responsibility for the safety and quality of care provided including QAPI.RESPONSIBILITIES2. All Governing Body members fulfill their responsibilities (including attending meetings, budget oversight and evaluating senior management).” Cross reference to L0562 relating to the hospice’s failure to maintain a Quality Improvement Plan (QAPI) program with indicators that are measured, analyzed and tracked. Cross reference to L0580 relating to the hospice’s failure to maintain an Infection Control Surveillance System program with indicators that are measured, analyzed and coordinated with quality assessment performance improvement (QAPI) team to be tracked. Cross reference to L0686 relating to the hospice’s failure to cover drugs, biologicals, and medical supplies.”