Crawford County Community Health

“Based on agency staff interviews, governing body chairperson interview, agency policy review, review of the governing body minutes and the Quality Assessment Process Improvement (QAPI) meeting minutes, the hospice failed to: 1.Show measurable improvement in indicators related to improved palliative outcomes and hospice services (L561), 2. 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) 3. Use quality indicator data, including patient care, and other relevant data, in the design of its program (L563), 4. Use the data collected to do the following: (i) Monitor the effectiveness and safety of services and quality of care. (ii) Identify opportunities and priorities for improvement (L564), 5. The frequency and detail of the data collection must be approved by the hospice’s governing body (L565), 6. Identify a quality improvement focus (L566), 7. Consider incidence, prevalence, and severity of problems in those areas (L567), 8. Affect palliative outcomes, patient safety, and quality of care (L568), 9. Track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice (L569), 10. Take actions aimed at performance improvement and, after implementing those actions, the hospice must measure its success and track performance to ensure that improvements are sustained (L570), 11. develop, implement and evaluate performance improvement projects (L571), 12. Develop a performance improvement program annually, based on the needs of the hospice’s population and internal organizational needs, must reflect the scope, complexity, and past performance of the hospice’s services and operations (L572), 13. Document what performance improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects (L573), 14. Ensure the governing body is responsible that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually. (L574) and 15. Ensure the governing body is responsible that the hospice-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness (L575). The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure ongoing means that there is a continuous and periodic collection and assessment of data. Assessment of such data enables areas of potential problems to be identified and indicates additional data that should be collected and assessed in order to identify whether a problem exists to meet the needs of their hospice patients.”

“Based on agency staff interviews, Medical Director interview, contract review, and Interdisciplinary Group (IDG) meeting notes, the hospice failed to ensure the medical director or a physician designated by the hospice has responsibility for the medical director component of the hospice’s patient care program. Failure to ensure the medical director or physician designee has the responsibility for the medical director component of the hospice program, placed patients at risk of not receiving hospice services and/ or inadequate or inappropriate care. Findings Include: According to the contract for the hospice medical director, dated 7/1/16, the agency Medical Director shall attend the Hospice Interdisciplinary Group (IDG) meetings for the purpose of reviewing and planning patient care. The Medical Director shall be available by phone for consultation 24 hours per day, 7 days a week. The Medical Director shall arrange appropriate medical coverage if unavailable subject to prior written approval of the agency. During an interview on 6/3/25, at 1:10 PM, the Medical Director stated in the event he is absent, the Nurse Practitioner (NP) or the patients attending physician would be available for any hospice patient needs, and that the Nurse Practitioner could attend IDG meetings when needed. During review of the IDG meeting notes between 3/1/24 through 3/31/25, the Medical Director was not in attendance for the dates of 9/24/24, 1/28/25, and 3/11/25. The hospice NP was in attendance for those IDG meetings in the Medical Directors absence. During an interview on 6/3/25, at 3:15 PM, the Administrator stated the agency had a alternate Medical Director in place with a signed contract until that physician retired about a year ago. The Administrator acknowledged the agency did not have a designed physician contracted to fulfill the duties of the Medical Director was not available. The hospice failed to ensure the medical director or physician designee has responsibility for the medical director component of the hospice’s patient care program. The above findings were reviewed with the hospice Administrator and the Clinical Manager.”

“Based on review of criminal background checks, child abuse and dependent adult abuse record checks, the agency allowed 1 of 7 sampled employees hired or contracted after 5/25/2022 (the date of the last survey conducted by the Department of Inspections and Appeals) without completing the required evaluation by the Department of Human Services (DHS) with employees who had positive criminal background checks within 30 days prior to hire (Staff L, Volunteer). The systemic practice resulted in the failure to ensure the organizational framework of the agency promoted and supported the adherence to state regulations and coordination of safe and effective delivery of care to the agency’s 11 patients. 481 IAC (Iowa Administrative Code) rule 50.9 requires Hospices complete a criminal background history check, a dependent adult abuse background history check and a child abuse background history check on each prospective employee who will have direct patient contact. The hospice must complete these record checks prior to the date of hire of a prospective employee. If a positive criminal history, dependent adult abuse history or child abuse history is identified, the agency must seek approval to hire from the Department of Human Services. 481 IAC rule 50.9(4) limits the validity of criminal history, dependent adult abuse history, and child abuse history record checks to a period of 30 days from the date the results of the background checks were received by the agency. Should a potential employee have a delayed hire date exceeding the allowed 30 days, the agency is required to run the background checks again to search for changes that may have occurred since the last background checks. Failure to complete the required backgrounds checks according to the State of Iowa requirements placed agency patients at risk for potential harm. Findings include: According to the undated policy titled Policy of Checking the Criminal & Abuse Record Results, upon the employee accepting a position with the hospice, an internet criminal and abuse check will be completed after appropriate signatures are obtained. Background checs will be kept in the employee file and dates documented on the orientation checklist. During an interview on 6/3/25 at 10:25 AM the Administrator stated she had not been aware of the requirement for the positive criminal background check to be evaluated by the Department of Human Services. Staff L, Volunteer, had a hire date of 2/15/24. Staff L’s personnel file included an initial criminal history check, dependent adult abuse history check and child abuse history check, completed on 2/4/24. The history background check, finalized 2/7/24, identified evidence of past criminal history, but found no dependent adult abuse or child abuse history. Staff L’s personnel file lacked documentation of DHS evaluation for approval to work with patients at the hospice. The hospice failed to complete DHS evaluation for approval for Staff L, volunteer. The findings were reviewed with the Administrator and Clinical Manager.”

“Based on review of agency emergency preparedness policies and staff interview, the agency failed to ensure the development of a written policy and procedure to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. Failure to have procedures in place for to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency placed agency patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: Review of the agency policy, titled Emergency Preparedness Policy, dated 4/2024, revealed a process for contacting on duty staff. The policy failed to identify a procedure for informing state an local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. During an interview on 6/3/25 at 3:00 PM, the Administrator stated the policy did not include procedures for the agency to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. The above findings shared with the Administrator and Clinical Manager.”

“Based on hospice staff interview and clinical record review the hospice failed to ensure the documentation and correct identification, in a prominent part of the patient’s record, any advance directives executed by the patient for 1 of 14 sampled patients (Patient #2). Failure to ensure the hospice documented and correctly identified any executed advance directives in a prominent part of the record placed patients at risk for their advance directives not being correctly carried out. Findings include: Patient #2 had a start of care date of 12/19/24 and received hospice services while residing in an assisted living facility. Clinical record review revealed: The Plan of Care, dated 3/19/25 to 6/16/25, identified the patient’s advance directive information as full code and do not resuscitate. The hospice agency failed to include accurate advance directive information on the patient’s plan of care. The above findings were reviewed with the Administrator and Clinical Manager.”

“Based on staff interview, clinical record reviews and hospice policy review, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group (IDG) updated the comprehensive assessment with changes to the patient condition regarding wound descriptions and measurements for 4 of 6 sampled patients with a wound (Patient #5, #10, #11 and #12). Failure by the IDG registered nurses (RN) to update the comprehensive assessment with complete wound descriptions and measurements placed the patients at risk for ineffective staff collaboration and communication regarding patients’ wound status and effectiveness of treatments and interventions. Findings include: 4. Patient #10 had a start of care date of 11/26/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 2/24/25 to 5/24/25, included orders for skilled nursing services. The POC identified the patient had a diagnosis of Unspecified protein calorie malnutrition. b. The skilled nurse visit notes, dated 3/24/25, 3/26/25, 3/31/25, 4/3/25, 4/7/25, 4/11/25, 4/14/25, 4/17/25, 4/21/25, 4/28/25 and 5/1/25 identified the patient had open wounds. The documentation failed to include assessments of wounds and measurements by hospice skilled nurse and/or nursing home staff. The hospice skilled nurse failed to include documentation of wound assessments and measurements of the patient’s wounds. The above findings were reviewed with the Administrator and Clinical Manager. 2. Patient #11 had a hospice admission date of 11/1/24 and a death date of 11/26/24, and received hospice services while residing in a private home. Clinical record review revealed: a. The POC, dated 11/1/24 to 1/29/24, included orders for skilled nursing, social worker services, hospice aide and chaplain. The POC identified the patient had diagnosis of Heart Failure. b. The comprehensive assessment at admission, dated 11/1/24, Staff J, RN, included documentation of three venous stasis ulcers. Wound #1 is documented as a venous stasis ulcer to the right inner leg measured 14 CM length by 3 CM width by 0 cm depth., Wound #2 is documented as a venous stasis ulcer to the right outer leg and measured 14 CM length by 8 CM width and 0 CM depth. Wound #3 was documented as a venous stasis ulcer to the left inner leg and measured 8 CM length by 8 CM width by 0 CM depth. All three wounds were documented as having a beefy red wound bed. The hospice skilled nurse failed to include documentation of complete measurements of the patients wounds. 3. Patient #5 had a hospice admission date of 5/3/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 5/3/25 to 7/31/25, included orders for skilled nursing, social worker services, hospice aide and chaplain. The POC identified the patient had diagnosis cerebral infarction (stroke) with Dysphagia (difficulty swallowing). b. The skilled nurse service note, dated 5/12/25, Staff F, RN, included documentation of three wounds to the left lower extremity. Wound #1 is documented as a venous stasis ulcer to the left lower calf, Wound #2 is documented as a venous stasis ulcer to the inside of the left ankle. Wound #3 was documented to the 3rd great toe but did not have a wound classification. The documentation lacked measurements and assessment of all three wounds. c. The skilled nurse service note dated 5/15/25, Staff E, RN included documentation of three wounds to the left lower extremity. Wound #1 is documented as a venous stasis ulcer to the left lower calf, Wound #2 is documented as a venous stasis ulcer to the inside of the left ankle. Wound #3 is documented as a venous stasis ulcer to the 3rd great toe. The documentation lacked measurements and assessment of all three wounds. d. The skilled nurse service note, dated 5/19/25, Staff H, LPN, included documentation of three wounds to the left lower extremity. Wound #1 is documented as a venous stasis ulcer to the left lower calf, Wound #2 is documented as a venous stasis ulcer to the inside of the left ankle. Wound #3 was documented to the 3rd great toe but did not have a wound classification. The documentation lacked measurements and assessment of all three wounds. e. The skilled nurse service note dated 5/22/25, Staff E, RN included documentation of three wounds to the left lower extremity. Wound #1 is documented as a venous stasis ulcer to the left lower calf, Wound #2 is documented as a venous stasis ulcer to the inside of the left ankle. Wound #3 is documented as a venous stasis ulcer to the 3rd great toe. The documentation lacked measurements and assessment of all three wounds. The hospice skilled nurse failed to include documentation of complete measurements of the patients wounds. According to the policy titled Wound Care Assessment, dated 5/15/23, wound assessment and documentation by the Registered Nurse (RN) will include, but not be limited to: type of wound, location of wound (including laterally), color/description of wound bed, descrption of wound edges, description of surrounding skin and skin color, description of wound drainage and odor, wound measurements (height x length x depth). During an interview on 6/3/25 at 9:25 AM the Clinical Manager stated the expectation of hospice staff to assess and measure wounds weekly and to include length, width and depth. 1. Patient #12 had a hospice admission date of 10/31/24 and date of death of 11/6/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The plan of care (POC), dated 10/31/24 to 1/28/25, included orders for skilled nursing and social worker services. The POC identified the patient had diagnosis of cancer of the vulva. b. The comprehensive assessment at admission, dated 10/31/24, Staff J, RN, included documentation of a cyst with 2 open wounds to the pubis area. Wound #1 measured 2 centimeters (CM) length by 2 cm width by 0 cm depth. Wound #2 measured 2.5 cm by 1 cm by 0 depth. The documentation included wound description of both wound beds beefy red. The documentation failed to included measurement of the depth of either of the wound beds. The hospice skilled nurse failed to include documentation of complete measurements of the patients wounds.”

“Based on clinical record review and hospice policy review, the hospice failed to ensure the provision of care in accordance with the patient’s plan of care for 4 of 14 sampled patients (Patients #2, #7, #11 and #13). Failure to follow the patient’s plan of care as directed by the Interdisciplinary Group (IDG) put the patients at risk for inconsistent care that may not meet the needs of the patients. Findings include: 3. Patient #7 had a start of care date of 3/21/25, and received hospice services while residing at home. a. The POC, dated 3/21/25 to 6/18/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease. The POC included orders for the hospice Chaplain to provide religious support 1-2 times monthly. b. Staff K, Hospice Chaplain, provided services on 4/1/25, 4/8/25, 4/15/25, 4/22/25 and 4/29/25 exceeding the ordered visit frequency for April by two visits three visits. The hospice failed to follow all orders as written on the POC. 4. Patient #11 had a start of care date of 11/1/24, a death date of 11/26/25 and received hospice services while residing at home. a. The POC, dated 11/1/24 to 1/29/25, identified the patient had diagnosis of heart failure. The POC included orders for the hospice Chaplain to provide religious support 2 times monthly. b. Staff K, Hospice Chaplain, provided services on 11/5/24, 11/12/24, 11/19/24, and 11/26/24, exceeding the ordered visit frequency for November by two visits. The hospice failed to follow all orders as written on the POC. The above findings were reviewed with the Administrator and Clinical Manager. According the hospice policy titled Hospice Plan of Care and Interdisciplinary Group (IDG), dated 7/25/22, all hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the (IDG) in collaboration with the attending physician, the patient or their representative and the primary caregiver in accordance with the patient’s needs. 1.Patient #2 had a start of care date of 12/19/24 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 3/19/25 to 6/16/25, identified the patient had a diagnosis of Hypertensive heart disease. The POC included orders for skilled nurse to monitor patient’s weight each visit. b. The skilled nurse visit note, dated 4/24/25, completed by Staff C, Registered Nurse (RN), failed to include documentation of the patient’s weight. The hospice failed to follow orders as written on the POC. 2. Patient #13 had a start of care date of 8/5/22, a discharge date of 5/17/24 and received hospice services while residing in a nursing home. a. The POCs, dated 1/27/24 to 3/26/24 and 3/27/24 to 5/25/24, identified the patient had a diagnosis of Parkinson’s disease. The POCs included orders for the hospice Chaplain to provide religious support two times monthly. b. Staff K, Hospice Chaplain, provided services on 3/5/24, 3/12/24, 3/19/24 and 3/26/24; exceeding the ordered visit frequency for March by two visits. c. Staff K, Hospice Chaplain, provided services on 4/2/24, 4/9/24, 4/17/24, 4/23/24 and 4/30/24; exceeding the ordered visit frequency for April by three visits. The hospice failed to follow all orders as written on the POC.”

“Based on clinical record review, hospice policy review, and hospice staff review, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments and/or a complete order for all medications and treatments to meet the needs of the patient for 5 of 14 sampled patients (Patient #3, #6, #7, #8 and #13). Failure to ensure the plan of care included complete orders for medications and treatments placed patients at risk to receive inappropriate treatment of symptoms and/or not meet the needs of the patients. Findings include: 4. Patient #6 had a start of care date of 2/24/25 and received hospice services while residing in a private residence. Review of the clinical record revealed: a. The POC, dated 2/24/25 to 5/24/25, included orders for nursing visits two times per week. The POC identified the patient had a diagnosis of Ovarian cancer. b. The skilled nurse visit note, dated 3/21/25, completed by Staff E, RN, identified the RN accessed the patient’s port with sterile technique and flushed with four sterile normal saline flushes. c. The skilled nurse visit note, dated 4/7/25, completed by Staff E, RN, identified the RN accessed and flushed the patient’s port without difficulty. d. Review of the electronic medical record lacked physician orders to flush the patient’s port. The hospice failed to obtain orders for the patient’s port flushes. 5. Patient #13 had a start of care date of 8/5/22, a discharge date of 5/17/24 and received hospice services while residing in a nursing home. Review of the clinical record revealed: a. The initial POC, dated 8/5/22 to 11/2/22, included orders for nursing and social worker services. The POC identified the patient had a diagnosis of Parkinson’s disease. b. The initial comprehensive assessment, dated 8/5/22, completed by Staff J, RN identified the patient utilized cold therapy for a pain intervention. c. Review of the electronic medical record lacked physician orders for cold therapy. The hospice failed to obtain orders for the patient’s use of cold therapy as a pain intervention. The above findings were reviewed with the Administrator and Clinical Manager. 3. Patient #7 had a hospice admission date of 3/21/25 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plans of Care POC, dated 3/21/25 to 6/18/25, included an orders for nursing visits 2 times per week. The POC identified the patient had a chronic obstructive pulmonary disease and had dependence on supplemental oxygen. The POC lacked orders for liter flow rate, route or frequency of oxygen. b. The comprehensive assessment at admission, dated 3/21/25, Staff B, RN included documentation the patient utilized continuous oxygen at 3 liters per minute per nasal cannula. c. Review of the electronic medical record lacked physician orders for the oxygen. The hospice failed to obtain orders for the patient’s use of oxygen including rate of flow, route and frequency. According to the hospice policy titled, Hospice Plan of Care and Interdisciplinary Team, dated 7/25/22, The plan of care must include all services necessary for the managemant of the terminal illness and related conditions, including drugs, treatment, medical supplies, and appliances necessary to meet the needs of the patient. During an interview on 6/4/25 at 2:30 PM the Clinical Manager stated staff expected to write orders for medications and treatments and they should roll over to the plan of care in the electronic record. 1. Patient #3 had a hospice admission date of 2/28/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 2/22/25 to 4/22/25 and 4/23/25 to 6/1/25, included an orders for nursing visits 1 time per week. The POCs identified the patient had a diagnosis of congestive heart failure and had dependence on supplemental oxygen. The POCs lacked orders for liter flow rate, route or frequency of oxygen. b. The skilled nurse note, dated 3/25/25, Staff J, Registered Nurse (RN) included documentation the patient utilized continuous oxygen at 3 liters per minute. c. Review of the electronic medical record lacked physician orders for the oxygen. The hospice failed to obtain orders for the patient’s use of oxygen including rate of flow, route and frequency. 2. Patient #8 had a hospice admission date of 2/27/25 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC’s, dated 2/27/25 to 5/27/25 and 5/28/25 to 8/25/25, included an orders for nursing visits 2 times per week. The POCs identified the patient had a diagnosis of acute respiratory failure with hypoxia and had dependence on supplemental oxygen. The POCs included for oxygen per physician orders but lacked liter flow rate, route or frequency. b. The skilled nurse note, dated 4/22/25, Staff J, RN, included documentation the patient utilized continuous oxygen at 3 liters per minute. c. Review of the electronic medical record lacked specific physician orders for the oxygen. The hospice failed to obtain orders for the patient’s use of oxygen including rate of flow, route and frequency.”

“Based on hospice clinical record review and hospice policy review, the hospice failed to ensure the Plans of Care (POC) for 5 of 14 sampled patients (Patient #2, #3, #6, #8 and #10) identified all medical equipment and supplies necessary to meet identified patient needs. Failure to include all needed items of medical equipment and supplies the patient used on the POC placed the patients at risk of unanticipated decline or injury and of needs not met. Findings include: 3. Patient #2 had a start of care date of 12/19/24 and received hospice services while residing in an assisted living facility. Review of the clinical record revealed: a. The POC, dated 3/19/25 to 6/16/25, identified the patient had a diagnosis of Hypertensive heart disease and used the following medical equipment and supplies: hospital bed, shower chair, walker, cane, incontinence products, edema wear, grabber/reacher, handles of the stool, lift chair, medication planner, scale, side rails and continuous positive airway pressure (CPAP) machine. b. During a home observation visit on 5/28/25 at 9:35 AM with Staff C, RN, they surveyor identified the patient utilized a pill cutter and a medical alert button. During the same home visit, the patient stated both devices had been utilized for great than 3 months. c. The interdisciplinary group (IDG) meeting notes, dated 3/25/25, 4/8/25, 4/22/25, 5/6/25 and 5/22/25, failed to identify the medical equipment and supplies, pill cutter and medical alert button. The hospice failed to include all medical equipment and supplies utilized by the patient. 4. Patient #6 had a start of care date of 2/24/25 and received hospice services while residing in a private residence. Review of the clinical record revealed: a. The POC, dated 2/24/25 to 5/24/25, identified the patient had a diagnosis of Ovarian cancer and used the following medical equipment and supplies: shower chair, walker and hospital bed. b. The initial comprehensive visit note, completed by the Clinical Manager, identified the patient utilized incontinence products. c. The IDG note, dated 2/25/25, failed to identify the medical supplies incontinence products. The hospice failed to include all medical equipment and supplies utilized by the patient. 5. Patient #10 had a start of care date of 11/26/24 and received hospice services while residing in a nursing home. Review of the clinical record revealed: a. The POC, dated 2/24/25 to 5/24/25, identified the patient had a diagnosis of Unspecified protein calorie malnutrition and used the following medical equipment and supplies: bedside table, edema wear, walker, wheelchair, sit stand lift, neck pillow, handles over toilet, lift chair and hospital bed. b. The social worker note, dated 4/16/25, completed by Staff D, identified the social worker delivered incontinence products for the patient. c. The IDG note, dated 4/22/25, failed to identify the medical supplies incontinence products. The hospice failed to include all medical equipment and supplies utilized by the patient. The above findings were reviewed with the Administrator and Clinical Manager. According to the hospice policy titled, Hospice Plan of Care and Interdisciplinary Team, dated 7/25/22, The plan of care must include all services necessary for the managemant of the terminal illness and related conditions, including drugs, treatment, medical supplies, and appliances necessary to meet the needs of the patient. 1.Patient #3 had a hospice admission date of 2/28/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 4/23/25 to 6/21/25, identified the patient had a diagnosis of congestive heart failure and used the following medical equipment and supplies: bedside table, commode, depends/incontinent pads, gait belt, glasses, med box/planner, pulse oximeter, stool riser, walker, lift chair, chair cushion and bedside commode. b. During a home observation visit on 5/27/25 at 10:30 AM, Staff J, RN, the surveyor observed the patient utilized a wheelchair, oxygen and supplies, urinal, reacher and gait belt. During the same home visit the patient stated the medical equipment and supplies utilized a long time greater than a year. The oxygen had been restarted in March of 2025. c. The interdisciplinary group meeting notes, dated 3/25/25, 4/8, 4/22/25, 5/6 and 5/20/25, failed to identify the medical equiment and supplies, wheelchair, oxygen and supplies, urinal, reacher and gait belt. The hospice failed to include all medical equipment and supplies utilized by the patient. 2. Patient #8 had a hospice admission date of 2/27/25 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC’s, dated 2/27/25 to 5/27/25 and 5/28/25 to 8/25/25, identified the patient had a diagnosis of acute respiratory failure with hypoxia and used the following medical equipment and supplies: bedside table, dentures, depends/incontinent pads, gait belt, handles for over stool, oxygen, hospital bed, lift chair, shower chair, side rails, walker, wheelchair and heel protectors. d. The social worker note, dated 3/31/25, identified the patient now using a Hoyer lift for transfers. c. The interdisciplinary group meeting notes, dated 4/8, 4/22/25, 5/6 and 5/20/25, failed to identify the medical equiment and supplies Hoyer lift. The hospice failed to include all medical equipment and supplies utilized by the patient.”

“Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to develop a QAPI program which showed measurable improvement in indicators related to palliative outcomes and hospice services. Failure to develop a QAPI program which showed measurable improvements in indicators related to palliative outcomes and hospice services, placed the patients at risk for not having patient care problems and needs identified and addressed. Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency’s performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs). The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually. The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise. Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings. The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation. During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators. During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The agency failed to develop a QAPI program which showed measurable improvements in indicators related to palliative outcomes and hospice services. The above findings were reviewed with the Administrator and the Clinical Manager.”

“Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to 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. Failure to collect and analyze data as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency’s performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs). The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually. The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise. Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings. The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation. During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators. During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review. During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings The agency failed to collect and analyze data for the year of 2024 and for January 2025 through April 2025 as part of a QAPI program. The above findings were reviewed with the Administrator and the Clinical Manager.”

“Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to use quality indicator data, including patient care and other relevant data in in the design of the program. Failure to use quality indicator data, patient care data, and other relevant data as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. Findings Include:According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency’s performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs). The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually. The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise. During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review. During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators. During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings. Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings. The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation. The agency failed to use quality indicator data, patient care data, and other relevant data as part of a developed QAPI program. The above findings were reviewed with the Administrator and the Clinical Manager.”

“Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to use quality indicator data, to monitor the effectiveness and safety of the services and quality care, and to identify opportunities and priorities for improvement. Failure to use quality indicator data, to monitor effectiveness and safety of the services and quality care, and to identify and priorities for improvement, as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency’s performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs). The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually. The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise. During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review. During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators. During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings. The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation. The agency failed to to use quality indicator data, to monitor effectiveness and safety of the services and quality care, and to identify and priorities for improvement, as part of a developed QAPI plan. The above findings were reviewed with the Administrator and the Clinical Manager.”

“Based on review of the governing body minutes, staff interview and policy review, the hospice failed to ensure the governing body approved the frequency and detail of quality assessment and performance impovement data collection for 1 of 2 sampled years. Failure of the governing body to approve the specific areas and frequency of data collection for the quality assessment and performance improvement (QAPI) program placed the hospice at risk of not identifying and tracking appropriate details in order to make improvements or changes as needed to the hospice program. Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency’s performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs). The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually. The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise. During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they are provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or approved during the governing body meetings. Review of the governing body meeting minutes, dated 3/17/24, 9/23/24, 11/4/24, 12/9/24, 1/13/25, lacked documentation the board approved the frequency and details of data collection by the hospice QAPI program. Review of the board of health reports, dated 1/2024, 3/2024, 5/2024, 8/2024, 12/2024 and 5/2024, identified a total of 6 reports. The board of health reports for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation. The agency failed to ensure the board approved the frequency and details of data collection by the hospice QAPI program. The above findings were reviewed with the Administrator and the Clinical Manager.”

“Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to conduct performance improvement activities that focus on high risk, high volume or problem prone areas. Failure to conduct performance improvement activities as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency’s performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs). The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually. The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise. During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review. During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators. During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings. The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation. The agency failed to conduct performance improvement activities. The above findings were reviewed with the Administrator and the clinical manager.”

“Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice performance improvement activities failed to consider incidence, prevalence and severity of problems in those areas as part of a developed QAPI program. Failure to consider incidence, prevalence and severity of problems in those areas as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency’s performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs). The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually. The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise. During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review. During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators. During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings. The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation. The agency failed to consider incidence, prevalence and severity of problems in those areas as part of a developed QAPI program as part of a QAPI program. The above findings were reviewed with the Administrator and the Clinical Manager”

“Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to use performance improvement activities to affect palliative outcomes, patient safety, and quality of care Failure to use performance improvement activities to affect palliative outcomes, patient safety, and quality of care as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency’s performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs). The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually. The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise. During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review. During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators. During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings. The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation. The agency failed to use performance improvement activities to affect palliative outcomes, patient safety, and quality of care as part of a developed QAPI program, The above findings were reviewed with the Administrator and the Clinical Manager.”

“Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to identify how adverse event is defined and failed to track adverse events, analyze the cause, and implement preventive actions. Failure to to identify how adverse event is defined and failure to track adverse events, analyze the cause, and implement preventive actions as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency’s performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs). The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually. The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise. During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review. During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators. During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings. The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation. The agency failed to define and track adverse events and to implement preventative actions as part of a QAPI program. The above findings were reviewed with the Administrator and the Clinical Manager.”

“Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to show any action taken to improve and/or sustain performance improvement. Failure to show action taken to improve and/or sustain performance improvement as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency’s performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs). The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually. The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise. During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review. During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators. During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings. The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation. The agency failed to show any action taken to improve and/or sustain improvement as part of a QAPI program. The above findings were reviewed with the Administrator and the Clinical Manager”

“Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to develop, implement and evaluate performance improvement. Failure to develop, implement and evaluate performance improvement as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency’s performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs). The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually. The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise. During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review. During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators. During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings. The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation. The agency failed to develop, implement and evaluate performance improvement as part of a QAPI program. The above findings were reviewed with the Administrator and the Clinical Manager”

“Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to conduct annually the number and scope of distinct performance improvement projects, based on the needs of the hospice’s population and internal organizational needs, must reflect the scope, complexity, and past performance of the hospice’s services and operations. Failure to ensure implementation of performance improvement projects as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency’s performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs). The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually. The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise. During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review. During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators. During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings. The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation. The agency failed to ensure implementation of performance improvement projects as part of a QAPI program. The above findings were reviewed with the Administrator and the Clinical Manager.”

“Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to document what performance improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. Failure to ensure documentation of performance improvement projects as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency’s performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs). The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually. The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise. During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review. During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators. During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings. The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation. The agency failed to ensure documentation of the performance improvement projects as part of a QAPI program. The above findings were reviewed with the Administrator and the Clinical Manager.”

“Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the governing body failed to ensure that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually. Failure of the governing body to maintain an on-going performance improvement program as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency’s performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs). The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually. The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise. During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review. During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators. During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings. The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation. The governing board failed to maintain an ongoing performance improvement plan as part of a QAPI program. The above findings were reviewed with the Administrator and the Clinical Manager.”

“Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the governing body failed to ensure that the hospice-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. Failure of the governing body to ensure a hospice wide assessment as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency’s performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs). The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually. The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise. During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review. During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators. During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings. The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation. The governing body failed to ensure a hospice-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness, as part of a QAPI program. The above findings were reviewed with the Administrator and the Clinical Manager.”

“Based on clinical record review and policy reviews, the hospice failed to follow a bereavement plan of care to ensure the hospice provided bereavement counseling according to identified needs and risks of the bereaved for 1 of 2 sampled bereavement records (Patient #12). Failure to provide bereavement counseling according to identified needs placed the bereaved at an increased risk for worsening or unresolved issues related to grief. Findings include: According to the policy titled Bereavement Referral/Contact, dated 7/2024, the hospice Bereavement Coordinator is responsible for initiating the bereavement contact form. An assessment of the bereaved will be made by a hospice Registered Nurse (RN), social worker or other Interdisciplinary Group (IDG) member shortly following the death of the hospice patient. The bereavement contact form may be used at IDG meetings to help develop a plan of care for assisting the bereaved family members. According to the hospice policy titled Hospice Plan of Care and Interdisciplinary Team dated 7/25/22, the hospice will ensure that care and services are provided in accordance with the plan of care and based on all assessments of the patinet and family needs. 1.Patient #12 had a start of care date of 10/31/24, a death date of 11/6/24 and received hospice services while residing in a nursing home. Review of the clinical record revealed: a. A bereavement assessment post death form, dated 12/29/24, was completed and identified the daughter of Patient #12 as the bereaved. b. The post death form identified the planned date of next contact on 2/6/25. c. Review of the clinical record lacked further contact with the bereaved. The hospice failed to complete further contact according to the plan/interventions with the bereaved following the death of the patient. The above information was reviewed with the Administrator and Clinical Manager.”

“Based on staff interview, review of employee personnel files, and clinical record reviews, the hospice failed to ensure 1 of 3 hospice aides (Staff I) demonstrated competency in the performance of any skills which exceeded the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient’s bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 3 of 3 sampled patients (Patients #2, #8 and #13) who required an extra skill be performed. Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice skills increased the risk for patients to receive inadequate or inappropriate care. Findings include: The Medicare Conditions of Participation direct the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan. During an interview on 6/3/25 at 2:40 PM, the Clinical Manager identified the registered nurse who assigned the skill(s) beyond basic is required to competency test the hospice aide in the extra skill(s). 1.Patient #2 had a start of care date of 12/19/24 and received hospice services while residing in an assisted living facility. a. The aide care plan included Registered Nurse (RN) instructions to the aide to check weight. b. Review of the clinical record showed Staff I, Hospice Aide, provided aide services independently for Patient #2. c. Staff I, Hospice Aide, had a hire date of 2/28/94. Staff I’s personnel file lacked documentation an RN had observed Staff I competently perform the task of checking weight. 2. Patient #8 had a start of care date of 2/27/25 and received hospice services while residing in a nursing home. a. The aide care plan included RN instructions to the aide to apply lotion to arms, legs and trunk, assist with dressing/undressing, brush/style hair, offer oral cares and sponge bath. b. The hospice aide note, completed by Staff I, dated 5/12/25, identified the hospice aide provided feeding assistance to the patient. c. Review of the clinical record showed Staff I, Hospice Aide, provided services independently for Patient #8. d. Staff I, Hospice Aide, had a hire date of 2/28/94. Staff I’s personnel file lacked documentation an RN had observed Staff I competently perform the task of feeding assistance. 3. Patient #13 had a start of care date of 8/5/22, a discharge date of 5/17/24 and received hospice services while residing in a nursing home. a. The aide care plan included RN instructions to the aide to apply edema wear if not already on. b. Review of the clinical record showed Staff I, Hospice Aide, provided aide services independently for Patient #13. c. Staff I, Hospice Aide, had a hire date of 2/28/94. Staff I’s personnel file lacked documentation an RN had observed Staff I competently perform the task of applying edema wear. The above findings were reviewed with the Administrator and Clinical Manager.”

“Based on hospice staff interview, clinical record review, and hospice policy review the hospice failed to ensure all required components of physician initial certification of the patient’s terminal illness (CTI) signed by both the Medical Director and personal care physician obtained for 3 of 14 sampled patients (Patient #7, #9 and #10). Failure to obtain the physician’s certification of terminal illness puts the patient at risk of receiving hospice care inappropriately and/or without a funding source. Findings include: 3. Patient #10 had a start of care date of 11/26/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Election of Hospice Medicare Benefit form signed by the patient/patient representative for services to being on 11/26/24 included the name of the patient’s attending physician. b. The CTI for benefit period 1, dated 11/26/24 to 2/23/25, included the medical director’s signature. c. The CTI for benefit period 1, dated 11/26/24 to 2/23/25, failed to include the patient’s attending physician’s signature. The hospice failed to ensure the initial CTI included signatures from both the medical director and the patient’s attending physician. The above findings were reviewed with the Administrator and Clinical Manager. 2. Patient #7 had a hospice admission date of 3/21/25, and received hospice services while residing at home. Clinical record revealed: a. The Election of Hospice Care form signed by the patient for services to begin on 3/21/25 included the name of the patient’s attending physician. b. The CTI for benefit period 1, dated 03/21/25 to 6/18/25, included the medical director’s signature. c. The CTI for benefit period 1, dated 03/21/25 to 6/18/25, failed to include the patient’s attending physician’s signature. The hospice failed to ensure the initial CTI completed by both the medical director and patient’s attending physician. During an interview with the Clinical Manager on 6/4/25 at 8:50 AM she stated the physician and Advanced Registered Nurse Practitioner (ARNP) were both documented on the patient’s election form as their personal care provider. She further stated the agency did not send the initial CTI because the ARNP was listed first. 1. Patient #9 had a hospice admission date of 12/20/24 and received hospice services while residing in a nursing home. Clinical record revealed: a. The Election of Hospice Care form signed by the patient for services to begin on 12/20/24 included the name of the patient’s attending physician. b. The CTI for benefit period 1, dated 12/20/24 to 3/19/25, included the medical director’s signature. c. The CTI for benefit period 1, dated 12/20/24 to 3/19/24, failed to include the patient’s attending physician’s signature. The hospice failed to ensure the intial CTI completed by both the medical director and patient’s attending physician.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure all documentation was completed timely and appropriately authenticated in accordance with accepted standards of practice and agency standards for 9 of 14 sampled patients (Patients #1, #5, #6, #7, #8, #9, #10, #11 and #13). Failure to ensure all documentation was completed, dated, and signed in a timely manner decreased the ability of hospice staff to communicate and coordinate patient care effectively and to provide safe, effective hospice services to its patients. Findings include: 8. Patient # 8 had a start of care date of 2/27/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC’s, dated 2/27/25 to 5/27/25 and 5/28/25 to 8/25/25, identified the patient had a diagnosis of acute respiratory failure with hypoxia and included orders for skilled nursing, social worker services and hospice aide services. b. The skilled nurse visit note, dated 4/29/25, not completed and signed 4/18/25 by Staff F, RN, per agency policy. c. The skilled nurse visit note, dated 4/29/25, completed and signed 5/13/25 by Staff E, RN, 14 days after the visit and 12 days late (per agency policy). d. The skilled nurse visit note, dated 5/2/25, completed and signed 5/13/25 by Staff E, RN, 11 days after the visit and 9 days late (per agency policy). e. The hospice aide visit notes, dated 4/14/25, 4/17/25 and 5/12/25, completed by Staff G, Hospice Aide, lacked a signature with title of individual completing the visit notes. The hospice failed to ensure timely completion of all documentation. 9. Patient # 9 had a start of care date of 12/20/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC’s, dated 3/20/25 to 6/17/25, identified the patient had a diagnosis of acute respiratory failure with hypoxia and included orders for skilled nursing and social worker services. b. The skilled nurse visit note, dated 5/3/25, not completed and signed 5/8/25 by Staff F, RN, 5 days after the visit and 3 days late (per agency policy). c. The skilled nurse visit note, dated 5/9/25, completed and signed 5/15/25 by Staff F, RN, 6 days after the visit and 4 days late (per agency policy). The hospice failed to ensure timely completion of all documentation. The above findings reviewed with the Administrator and Clinical Manager. 4. Patient #1 had a start of care date of 12/9/24, and received hospice services while residing in a nursing home. a. The POC, dated 3/9/25 to 6/6/25, identified the patient had a primary diagnosis of Alzheimer’s disease and included orders for skilled nurse, hospice aide, and social worker. b. The chaplain visit notes, dated 3/11/25, 3/18/25, 3/25/25, 4/1/25, 4/8/25, 4/15/25, 4/22/25 and 4/29/25, completed by Staff K, Chaplain, lacked a signature with date, time and title of individual completing visit notes. c. The hospice aide visit notes, dated 3/18/25, 3/28/25 and 4/18/25, completed by Staff G, Hospice Aide, lacked a signature with title of individual completing the visit notes. The hospice failed to ensure appropriate authentication of all documentation. 5. Patient # 5 had a start of care date of 5/3/25, and received hospice services while residing in a nursing home. a. The POC, dated 5/3/25 to 7/31/25, identified the patient had primary diagnosis of dysphagia (difficulty swallowing) as a result of a cerebral infarction (stroke) and included orders for skilled nurse, hospice aide, social worker and chaplain. b. The hospice aide visit notes, dated 5/9/25, 5/13/25, 5/16/25, 5/20/25 and 5/23/25 completed by Staff G, Hospice Aide, lacked a signature with title of individual completing the visit notes. The hospice failed to ensure appropriate authentication of all documentation. 6. Patient #7 had a start of care date of 3/21/25, and received hospice services while residing at home. a. The POC, dated 3/21/25 to 6/18/25, identified the patient had a primary diagnosis of chronic obstructive pulmonary disease and included orders for skilled nurse, social worker, hospice aide and chaplain. b.The hospice aide visit notes, dated 3/24/25, 4/1/25, 4/14/25, 4/28/25, 5/1/25, 5/12/25, 5/15/25 and 5/17/25, completed by Staff G, Hospice Aide, lacked a signature with title of individual completing the visit notes. c.The chaplain visit notes, dated 3/25/25, 4/1/25, 4/8/25, 4/15/25, 4/22/25, and 4/29/25 completed by Staff K, Chaplain, lacked a signature with date, time and title of individual completing visit notes. The hospice failed to ensure appropriate authentication of all documentation. 7. Patient #11 had a start of care date of 11/1/24, a death date of 11/26/24 and received hospice services while residing in a private home. a. The POCs, dated 11/1/24 to 1/29/25, identified the patient had a primary diagnosis of heart failure and included orders for skilled nurse, hospice aide, social worker, chaplain and volunteer services. b. The chaplain visit notes, dated, 11/5/25, 11/12/25, 11/19/25 and 11/26/25 completed by Staff K, Chaplain, lacked a signature with full name and title of individual completing visit notes. The hospice failed to ensure appropriate authentication of all documentation. According to the agency policy titled Documentation, dated 7/19/21, routine visit notes for all disciplines will be completed as part of the visit. If it is impossible to complete the documentation immediately following the visit, it may be completed in the office, preferably on the same day as the visit but within two business days at most. During an interview on 6/3/25 at 9:25 AM, the Clinical Manager identified agency staff are to complete routine visit documentation within 2 business days of the visit. 1.Patient # 6 had a start of care date of 2/24/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 2/24/25 to 5/24/25, identified the patient had a diagnosis of Ovarian Cancer and included orders for skilled nurse and social worker services. b. The skilled nurse visit note, dated 4/4/25, completed and signed 4/18/25 by Staff F, Registered Nurse (RN), 14 days after the visit and 10 days late (per agency policy). c. The skilled nurse visit note, dated 4/21/25, completed and signed 4/24/25 by Staff F, RN, 3 days after the visit and 1 day late (per agency policy). The hospice failed to ensure timely completion of all documentation. 2. Patient #10 had a start of care date of 11/26/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 2/24/25 to 5/24/25, identified the patient had a primary diagnosis of Unspecified protein calorie malnutrition and included orders for skilled nurse, hospice aide and social worker services. b. The hospice aide visit notes, dated 5/5/25, 5/8/25, 5/12/25, 5/15/25, 5/19/25 and 5/22/25, completed by Staff G, Hospice Aide, lacked a signature with title of individual completing the visit notes. The hospice failed to ensure appropriate authentication of all documentation. 3. Patient #13 had a start of care date of 8/5/22, a discharge date of 5/17/24 and received hospice services while residing in a nursing home. a. The POCs, dated 1/27/24 to 3/26/24 and 3/27/24 to 5/25/24 identified the patient had a primary diagnosis of Parkinson’s disease and included orders for skilled nurse, hospice aide, social worker, chaplain and volunteer services. b. The skilled nurse visit notes, dated 3/18/24, 3/25/24, 4/2/24, 4/5/24, 4/12/24 and 4/16/24, completed by Staff J, RN, lacked a signature with full name and title of clinician completing the visit notes. c. The chaplain visit notes, dated 3/19/24, 3/26/24, 4/2/24, 4/9/24, 4/17/24, 4/23/24, 4/30/24, 5/7/24, 5/14/24 and 5/17/24, completed by Staff K, Chaplain, lacked a signature with full name and title of individual completing visit notes. d. The hospice aide visit notes, dated 3/22/24, 3/26/24, 3/29/24, 4/2/24, 4/5/24, 4/10/24 and 4/16/24, completed by Staff G, Hospice Aide, lacked a signature with title of individual completing the visit notes. The hospice failed to ensure appropriate authentication of all documentation.”

“Based on hospice staff interview and clinical record reviews the hospice failed to ensure the hospice staff sent a copy of the patient’s discharge summary to the attending physician for 2 of 2 sampled, live discharged patients (Patients #13 and #14). Failure to ensure the hospice staff included the attending physician in the process of discharge placed the patients at risk for not receiving ongoing medical care and services to meet the needs of the patient. Findings include: 2. Patient #14 had a start of care date of 12/12/24, and revoked services on 12/17/24, and received hospice services while residing in a private residence. a. The POC, dated 12/12/24 to 3/11/25, identified the patient had a primary diagnosis of malignant neoplasm of the exocervix. The POC included orders for skilled nursing and social worker services. b. The discharge summary, dated 12/18/24, included a summary of hospice services and a list of the patient’s current medications. c. Clinical record review lacked documentation the discharge summary was forwarded to the patient’s attending physician. The hospice failed to forward a copy of the discharge summary to the patient’s personal care provider. The above information was reviewed with the Administrator and clinical manager. During an interview on 6/3/25 at 2:30 PM, the Clinical Manager identified she could not see in the electronic medical record if the discharge summary was faxed to the primary care physician. 1. Patient #13 had a start of care date of 8/5/22, a discharge date of 5/17/24 (no longer terminally ill) and received hospice services while residing in a nursing home. a. The Plan of Care (POC), dated 3/27/24 to 5/25/24, identified the patient had a primary diagnosis of Parkinson’s disease. The POC included orders for skilled nursing services. b. The discharge summary, dated 5/17/24, included a summary of hospice services and a list of the patient’s current medications. c. Clinical record review lacked documentation the discharge summary was forwarded to the patient’s attending physician.”

“Based on review of contracts with facilities (hospitals) for short term respite services and interview with hospice staff, the hospice failed to ensure contractual agreements with 2 of 2 sampled facilities (Hospital A and B) providing short term respite level of care services to hospice patients included specifications of the requirement that each patient must receive all nursing services as prescribed and must be kept comfortable, clean, well-groomed and protected from accident, injury and infection. Failure to include these specifications in the contractual agreements placed patients at risk of not having all of their needs adequately met in accordance with the patient’s plan of care. Findings include: During an interview on 6/3/25 at 2:05 PM, the Administrator identified the agency utilizes Hospital A and B for respite services and noted the contractual agreements needed to be updated. 1.The hospice agency had a contractual agreement with Hospital A, dated 10/4/21. The contractual agreement failed to specify each patient receiving respite care must receive all nursing services as prescribed and must be kept comfortable, clean, well-groomed and protected from accident, injury and infection. 2.The hospice agency had a contractual agreement with Hospital B, dated 11/8/21. The contractual agreement failed to specify each patient receiving respite care must receive all nursing services as prescribed and must be kept comfortable, clean, well-groomed and protected from accident, injury and infection. The above findings were reviewed with the Administrator and Clinical Manager.”

“Based on review of the written agreements between the hospice and inpatient facilities (hospitals), the hospice failed to ensure the written agreement identified the hospice’s responsibility to maintain a description of the training and documentation of the names of those giving the training for 2 of 2 sampled written agreements (Hospital A and B). Failure to ensure the written agreements with hospitals specified the hospice’s responsibility to ensure hospital staff caring for hospice patients received training and the hospice maintained appropriate documentation of the training placed hospice patients at risk for receiving inpatient care in conflict with the hospice philosophy. Findings include: 1.The hospice agency had a contractual agreement with Hospital A, dated 10/4/21. The contractual agreement failed to specify the agency responsibility to include a description of the training provided and documentation of the training facilitators. 2.The hospice agency had a contractual agreement with Hospital B, dated 11/8/21. The contractual agreement failed to specify the agency responsibility to include a description of the training provided and documentation of the training facilitators. The above findings were reviewed with the Administrator and Clinical Manager.”