Willow Hospice and Palliative Care LLC

“Based on the review of the hospice documents and Staff interview, it was determined the hospice failed to implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program. This has the potential to affect all Pts. receiving hospice care services. Findings include: 1.The hospice failed to maintain/track/analyze the quality assessment in all areas of the operations. (L562) 2. The hospice failed to ensure the frequency and details of the quality assessment and performance improvement program were approved. (L565) 3. The hospice failed to ensure the ongoing maintenance and annual evaluation of the QAPI program. (L574) The cumulative effect of these systemic practices resulted in the Hospices inability to ensure an effective QAPI Program.”

“Based on Staff list review, clinical record review and Staff interview, it was determined that the hospice failed to use volunteers in day to day administrative roles or direct patient care roles, failed to maintain documentation and demonstrate ongoing efforts to recruit and maintain volunteers and failed to document any positions held by volunteers, amount of time spent by volunteers in those positions and estimate the cost savings related to use of volunteers. This has the potential to affect services provided to patients Findings include: 1. The hospice failed to use volunteer services in day to day administrative or direct patient care roles. (L644) 2. The hospice failed to maintain documentation and demonstrate ongoing efforts to recruit and maintain volunteers. (L645) 3. The hospice failed to ensure it documented any positions held by volunteers, amount of time spent by volunteers in those positions and estimate the cost savings related to use of volunteers. (L646) The cumulative effect of these systemic practices resulted in the hospices inability to ensure that the hospice volunteer services were provided to patients.”

“Based on Staff interview, it was determined that the hospice failed to ensure the hospice has an agreement with a facility to provide pain control, symptom management, and respite purpose. This has the potential to affect services provided to patients Findings include: 1. The hospice failed to have a facility agreement for inpatient care of symptom management and pain control. (L706) 2. The hospice failed to have a facility agreement for respite purpose. (L708) 3. The hospice failed to have an inpatient care under arrangement. (L711) The cumulative effect of these systemic practices resulted in the hospices inability to ensure that the hospice patients receive services in an inpatient facility for pain control and respite care.”

“Based on a review of the Hospice Emergency Preparedness Plan and staff interview, it was determined the Hospice failed to ensure the Emergency Preparedness Plan was based on a facility and community risk assessment, utilizing an all-hazards approach. Findings include: 1. The Hospice Emergency Preparedness Plan was reviewed on 12/18/24 at 11:00 AM. The plan lacked documentation that the Emergency Preparedness Plan was based on a facility-based and or community-based risk assessment, utilizing an all-hazards approach. 2. Findings of the Hospice Emergency Preparedness Plan lacking the risk assessment was confirmed during an interview with the Administrator on 12/19/24 at 12:30PM.”

“Based on a review of the Hospice Emergency Preparedness Plan, and Staff interview, it was determined that the Agency failed to ensure that the Hospice conducted / participated in a full-scale Community Based Exercise or Facility Based Exercise to ensure the effectiveness of the Agency’s Emergency Preparedness Plan. Findings Include: 1. The Hospice Emergency Preparedness Plan was reviewed on 02/18/24 at 11:00 AM. The Emergency Preparedness Plan failed to include documentation indicating that the Agency conducted / participated in any testing of the Emergency Preparedness Plan. 2. During an interview with the Administrator on 12/19/24, the Administrator confirmed that the Agency failed to conduct / participate in a community and/or facility-based testing or drill. Findings Include: 1. The Hospice Emergency Preparedness Plan was reviewed on 12/18/24 at 11:00 AM. The Emergency Preparedness Plan failed to include documentation indicating that the Agency conducted / participated in any testing of the Emergency Preparedness Plan. 2. During an interview with the Administrator on 12/19/24, the Administrator confirmed that the Agency failed to conduct / participate in a community and/or facility-based testing or drill.”

“Based on the clinical records review and Staff interview, it was determined in 1 of 2 (Pts. # 3) clinical records reviewed, the IDG failed to meet every 15 days to review the POC. Findings include: 1. Pt. #3 was admitted to the hospice services on 12/12/23 with diagnosis of Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 12/17/24. The clinical record included IDG meetings dated 12/15/23 and 01/11/24 (more than 15 days). 2. The findings were confirmed during the interview on 12/18/24 at 11:30 AM, with the Agency Supervisor.”

“Based on the review of the Governing Board minutes, QAPI documents and Staff interview, it was determined the hospice failed to maintain/track/analyze the quality assessment in all areas of the operations. Findings include: 1. The Governing Board minutes for 2023 and 2024 were reviewed on 12/18/24 at 11:00 AM and lacked the measurements/tracking for QAPI indicators. 2. The QAPI documents were reviewed on 12/18/24 at 11:00 AM, and lacked the measurements/tracking. The hospices quality assessment and performance improvement program was last documented as: “;01/2021 4th quarter”. 3. The findings were confirmed during the interview on 12/18/24 at 11:30 AM, with the QA Director.”

“Based on the review of the Governing Board minutes and Staff interview, it was determined the hospice failed to ensure the frequency and details of the quality assessment and performance improvement program were approved. Findings include: 1. The Governing Board minutes for 2023 and 2024 were reviewed on 12/18/24 at 11:00 AM, and lacked documentation of the Governing Body approval for QAPI projects and QAPI indicators. 2. The hospice quality assessment and performance improvement program was reviewed on 12/18/24 at 11:00 AM and lacked documentation that the Governing body met to approve the data collection frequency and details of the quality assessment and performance improvement program. 3. The findings were confirmed during the interview on 12/18/24 at 11:30 AM, with the QA Director.”

“Based on the review of the Governing Board minutes and Staff interview, it was determined the hospice failed to ensure the ongoing maintenance and annual evaluation of the QAPI program. Findings include: 1. The Governing Board minutes for 2023 and 2024 were reviewed on 12/18/24 at 11:00 AM and lacked the annual QAPI evaluation, for 2023 and 2024. 2. The hospice quality assessment and performance improvement program was reviewed on 12/18/24 at 11:00 AM and lacked the annual QAPI evaluation for 2023 and 2024. 3.The findings were confirmed during the interview on 12/18/24 at 11:30 AM, with the QA Director.”

“Based on Staff interviews, Staff list review and clinical record review, it was determined that the hospice failed to use volunteer services in day to day administrative or direct patient care roles. . Findings include: 1. During entrance interview with the Agency Supervisor on 12/17/24 at 11:32 AM and with the Social Worker on 12/18/24 at 9:30 AM, both stated that there are no volunteers for the hospice. 2. The Staff list was reviewed on 12/18/24 and lacked hospice volunteers. 3. The clinical records for Pts. # 1, 2, 3 and 4 were reviewed from 12/17/24 to 12/18/24. The clinical records lacked the use of volunteers. 4. During an interview with the Agency Supervisor on 12/18/24 at 9:48 AM, the Agency Supervisor confirmed that the hospice did not provide or use volunteer services in day to day administrative or direct patient care roles.”

“Based on a review of the hospice volunteer program and Staff interview, it was determined that the hospice failed to ensure it documented any positions held by volunteers, amount of time spent by volunteers in those positions and estimate the cost savings related to us of volunteers. Findings include: 1. The hospice volunteer program was reviewed on 12/18/24. There was no documentation that the hospice identified volunteers, positions held, amount of time spent and estimated cost savings related to use of volunteers. 2. During an interview with the Agency Supervisor on 12/18/24 at 11:45 AM, the Agency Supervisor confirmed that the hospice did not have any volunteers and therefore have no documentation of cost savings related to use of volunteers.”

“Based on review of the hospice patient admission folder and staff interview, it was determined the hospice Administrator failed to ensure the patient admission folder contained the correct hospice name and hospice contact information. Findings include: 1. The hospice patient admission folder was reviewed on 12/18/24. The admission folder contained “1st Choice Total Senior Care” as the name of the hospice and not Willow Hospice and Palliative Care. 2. On 12/17/24 the telephone number displayed on the patient admission folder was called by surveyor, the telephone number corresponds to “1st Choice Senior Care”. 3. During an interview with the Administrator, on 12/18/24 at 2:00 PM, the Administrator confirmed the admission folder contains incorrect hospice name and contact information.”

“Based on clinical record review and Staff interview, it was determined that in 1 of 1 (Pts. #3 ) live discharge records reviewed, the hospice failed to ensure that a hospice discharge summary was completed. 2. Pt. #3 was admitted to the hospice services on 12/12/23 with diagnosis of Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 12/17/24. The clinical record included a live-discharge note dated 01/19/24 and lacked the discharge summary. 3. Pt. #4 was admitted to the hospice services on 04/15/23 with diagnosis of Unspecified Chronic Systolic (Congestive) and Diastolic Heart Failure. The clinical record was reviewed on 12/17/24. The clinical record included a live-discharge note dated 05/25/23 and lacked the discharge summary. 4. The findings were confirmed during the interview on 12/18/24 between 11:30 AM and 1:00 PM, with the Agency Supervisor. Findings include: 1. Pt. #2 was admitted to hospice services on 09/19/22 with the diagnosis of: Chronic combined systolic (congestive) and diastolic (congestive) heart failure. The clinical record was reviewed on 12/17/24. The clinical record included a live discharge note dated 05/14/23, indicating Pt. was discharged to home. There was no hospice discharge summary.”

“Based on document request and Staff interview it was determined that the hospice failed to have an arrangement agreement with a facility to provide inpatient care for pain control and symptom management. Findings include: 1. On 12/18/24 a request was made to the Agency Supervisor for hospice agreement document for inpatient care facility. 2. During an interview with the Agency Supervisor on 12/18/24 at 12:00 PM. The Agency Supervisor stated that the hospice does not have an agreement with any facility to provide inpatient care for pain control and symptom management. 3. During an interview with the Administrator on 12/19/24 at 12:30 PM, the Administrator confirmed that the hospice does not have an agreement with any facility for inpatient care.”

“Based on document request and staff interview it was determined that the hospice failed to have an arrangement agreement with a facility to provide respite care. Findings include: 1. On 12/18/24 a request was made to the Agency Supervisor for hospice agreement document for inpatient respite care facility. 2. During an interview with the Agency Supervisor on 12/18/24 at 12:00 PM. The Agency Supervisor stated that the hospice does not have an agreement with any facility to provide respite care. 3. During an interview with the Administrator on 12/19/24 at 12:30 PM, the Administrator confirmed that the hospice does not have an agreement with any facility for respite care.”

“Based on document request and staff interview it was determined that the hospice failed to have an arrangement agreement with a facility to provide short-term inpatient care. Findings include: 1. On 12/18/24 a request was made to the Agency Supervisor for hospice agreement document for short term inpatient care facility. 2. During an interview with the Agency Supervisor on 12/18/24 at 12:00 PM. The Agency Supervisor stated that the hospice does not have an agreement with any facility to provide short term inpatient care. 3. During an interview with the Administrator on 12/19/24 at 12:30 PM, the Administrator confirmed that the hospice does not have an agreement with any facility for short term inpatient care.”