Journeys Hospice

“Based on policy review, EP plan review, and staff interview, it was determined the agency failed to ensure the EP plan, including the all hazards risk assessment, was updated on an annual basis. Failure to update the plan on an annual basis had the potential for necessary updates to the EP plan to be missed. Findings include: An agency policy titled, “Emergency Operations Plan” was reviewed. The policy stated, “Hazard Vulnerability Analysis (HVA) will be conducted and evaluated annually in October.” This policy was not followed. An example includes:The facility’s EP plan was reviewed. The last time the all hazards risk assessment was reviewed was August 2023.The HR director was interviewed on 6/16/26 beginning at 12:42 PM. He confirmed the all hazards risk assessment had not been updated since August 2023.The agency failed to ensure the EP plan, including the all hazards risk assessment, was updated on an annual basis.”

“Based on medical record review and staff interview, it was determined the agency failed to maintain responsibility for coordinating care for 1 of 11 current patients (Patient #7) whose medical records were reviewed. Failure to ensure coordination of care created the potential for unmet patient social work needs. Findings include: Patient #7 was an 88 year old male admitted to the agency with a primary diagnosis of atherosclerotic heart disease. He received SN services. Social work services were ordered but he initially refused them. His record for the certification period 3/04/2026 to 6/01/2026 was reviewed.An SN visit note dated 3/22/26 was reviewed. It stated, “I did speak one on one with the daughter and asked about bring out a social worker for a visit/eval. Daughter is ok with this.”An SN visit note dated 3/18/26 was reviewed. It stated, “I did speak one on one with the daughter and asked about bring out a social worker for a visit/eval. Daughter is ok with this.”An SN visit note dated 6/03/26 was reviewed. It stated, “Daughter [name] states she needs to talk to someone about possibly getting guardianship over her dad. Referred to HSW [hospice social worker].”The medical record was reviewed for social work visits or notes and did not include any at the time of record review.The Social Worker was interviewed on 6/16/26 beginning at 11:04 AM and Patient #7’s record was reviewed with her. She stated she had reached out to the daughter about social work visits but had not been able to contact her. She confirmed there were no notes regarding the attempted contact.The agency failed to maintain responsibility for coordinating care for Patient #7.”

“Based on QAPI plan review and staff interview, it was determined the agency failed to ensure performance improvement projects (PIPs) included the reason for conducting the project and measurable progress toward the PIP’s goals. The agency failed to ensure the PIP had clear direction and showed progress. Findings include: QAPI meeting minutes from 2025 to 2026 were reviewed and included the following: The QAPI meeting minutes from 10/15/25 stated, “QAPI team has decided to perform a PIP for our Volunteer Program. By the next QAPI meeting we will form a PIP team and create a plan to grow our Volunteer program, this PIP will also include retention.”The QAPI meeting minutes from 2/04/26 stated, “QAPI team has decided to form a PIP for our Volunteer Program. By the next QAPI meeting we will form a PIP team and create a plan to grow our Volunteer Program.”The QAPI meeting minutes from 4/15/26 stated, “Presented the Volunteer Cost savings, QAPI team decided to do a PIP for our Volunteer Program. [Name], [Name] and [Name] will be the PIP team. They will meet on 4/29/26 11 am to create a plan and present the PIP at the next QAPI meeting.”Minutes were requested from the PIP team meeting that was said to occur on 4/29/26 in the QAPI meeting minutes, but were unable to be located.A document titled, “Performance Improvement Plan (PIP): Hospice Volunteer Program” was provided. The document did not have a date. It stated “The purpose of this Performance Improvement Plan is to stabilize and strengthen the hospice volunteer program by increasing active volunteer utilization, and ensuring reliable support for patient care needs.” It included the following: “Goal…increase the number of active hospice volunteers from 2 to 8 within 90 days, ensuring volunteers are consistently engaged and contributing to patient support.”“Launch targeted recruitment through community outreach, local organizations, and partnerships”“Track recruitment activity weekly to ensure steady progress toward goal.”“Track active volunteer status weekly … monitor volunteer hours and participation consistency … conduct biweekly reviews to assess progress toward 8 active volunteers within 90 days”A document titled “Volunteer Recruitment and Retention Tracking for 2026” was provided. It stated the following: “Activity … PIP volunteer program recruitment strategies” dated 4/29/26. It did not include what recruitment strategies included“Ad at American Legion Society” dated 5/08/26. It did not include what the advertisement included.It was unclear if the PIP had been started yet. There was no documentation of tracking of volunteers or volunteer hours. There was no documentation of progress toward the goal of 8 volunteers. At the time of survey the agency did not have any active volunteers.The DON was interviewed on 6/16/26 beginning at 12:42 PM and the QAPI plan was reviewed in her presence. She confirmed the QAPI plan was missing information on the progress toward the goal.The agency failed to ensure the PIP had clear direction and showed progress.”