Family Hospice

“Based on record reviews and staff interviews it was determined the agency failed to ensure patients’ care and services were provided according to the plan of care (POC) for one patient (P) (P#9) of nine sampled patients. Findings include: Review of the clinical record for P#9 reveals a start of care on 4/16/24 with Certified Nursing Assistant (CNA) services three times a week. During the week of 4/22/2024 through 4/28/2024, CNA services failed to be provided. During the week of 4/29/2024 through 5/5/2024, CNA services failed to be provided. Record review failed to reveal documentation of missed CNA visits. On 5/7/2024 at 12:00 p.m., during an interview with the Director of Nursing (DON), it was confirmed the POC for P#9 has CNA services ordered for three times a week for the certification period of 4/16/2024 through 7/14/2024. The DON stated the agency received a call from the family on 4/19/2024 stating that CNA services were no longer needed. The DON confirmed P#9s medical records did not have documentation of a phone call from the family that reflected declined CNA services nor was there documentation of missed CNA visits.”

“Based on record reviews and staff interviews, it was determined the agency failed to develop and implement a Performance Improvement Project (PIP) as a part of the agencys Quality Assurance and Performance Improvement (QAPI) program. Findings include: Record reviews revealed the agencys Quality Assurance and Performance Improvement (QAPI) data did not include a Performance Improvement Project (PIP) ensuring services are meeting quality standards. On 5/6/2024 at 10:00 a.m., an interview with the Director of Nursing (DON) confirmed the agencys QAPI data did not include a current PIP. The DON stated she did not know the process for completing a PIP but revealed she had a template for documenting a PIP.”

“Based on record reviews, policy reviews, and staff interviews, it was determined the governing body failed to ensure the agencys Quality Assurance and Performance Improvement (QAPI) program included a Performance Improvement Project (PIP) and failed to ensure that patients entering the third or later benefit period received a face-to-face assessment for two patients (P) (P#12, P#13) of 13 patients reviewed. Findings include: Review of the policy titled “;2023 Quality Assurance & Performance Improvement (QAPI) Plan for Community Hospice”, dated 2023 reveals the following: Performance Improvement Projects The QAPI team at Community Hospice will review our sources of information to determine if gaps or patterns exist in our systems of care that could result in quality problems; or if there are opportunities to make improvements....The QAPI team will determine which problems will become the focus for a performance improvement project (PIP). Depending on the PIP, the QAPI team will charter a PIP Team who is entrusted with a mission to look into a problem area and come up with plans for correction and/or improvement to be implemented. Review of the policy titled, “;Certification of Terminal Illness and Face-To-Face Encounter”, policy #9005, effective 9/7/2017 reveals the following: Face-to-Face Encounter: • For recertifications (sic) on or after January 1, 2011, a Hospice physician or Hospice nurse practitioner must have a face-to-face encounter with each Hospice patient prior to the beginning of the patients third benefit period, and prior to each subsequent benefit period. • The face-to-face encounter must occur prior to the recertification for the third benefit period and each subsequent benefit period. 1. Record review reveals P#12 was admitted to hospice on 4/29/2021. The clinical record failed to reveal documentation of a face-to-face assessment by the certifying physician before the beginning of benefit period number 17, (beginning 2/13/2024 and ending 4/12/2024). 2. Record review reveals P#13 was admitted to hospice on 6/29/2023. The clinical record failed to reveal documentation of a face-to-face assessment by the certifying physician before the beginning of benefit periods number four and five, (dates of 2/24/2024 through 4/23/2024 and 4/24/2024 through 6/22/2024). On 5/6/2024 at 10:00 a.m., during an interview with the Director of Nursing (DON) and Administrator, it was confirmed the agencys QAPI data did not include a current PIP. The DON and Administrator confirmed understanding of the agencys QAPI policy outlining the governing bodys responsibility for overseeing the QAPI content to include a PIP for prioritizing opportunities for improvement. On 5/7/2024 at 12:00 p.m., an interview with the Administrator and Director of Nursing (DON) confirmed that clinical records for P#12 and P#13 lacked the required face-to-face documentation.”