Elysian Hospice, Inc.

“Based on document review and interview, it was determined the Hospice failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program since November 1, 2021. Therefore, the Condition of Participation, 42 CFR 418.58, Quality Assessment and Performance Improvement was not met, as evidenced by: Findings include: 1. The Hospice failed to ensure the QAPI program measured improvement in patient outcomes and hospice services. L561. 2. The Hospice failed to ensure the QAPI program measured, tracked, and analyzed quality indicators. L562. 3. The Hospice failed to ensure the QAPI program used quality indicators to design its program. L563. 4. The Hospice failed to ensure the QAPI program collected data to monitor effectiveness and identify opportunities for improvement. L564. 5. The Hospice failed to ensure the QAPI program included performance improvement activities which were based on high-risk areas. L566. 6. The Hospice failed to ensure the QAPI program included performance improvement activities which were based on the incidence, prevalence, and severity of problems. L567. 7. The Hospice failed to ensure the QAPI program included performance improvement activities which were based on patient outcomes safety and quality of care. L568. 8. The Hospice failed to ensure the QAPI program included performance improvement activities that tracked adverse events, analyzed the cause, and implemented preventative actions. L569. 9. The Hospice failed to ensure the QAPI program measured performance improvement actions to ensure success. L570. 10. The Hospice failed to ensure the QAPI program evaluated performance improvement projects. L571. 11. The Hospice failed to ensure the QAPI program performance improvement projects were based on the scope and complexity of its services. L572. 12. The Hospice failed to ensure the QAPI program documented performance improvement projects. L573. 13. The Governing Body failed to ensure the QAPI program was implemented, maintained, and evaluated annually. L574. 14. A review of the Hospice QAPI binder on 10/8/2025, annotated the last QAPI documentation on 11/1/2021 as, “Performance Improvement Project updates”. The binder lacked documentation of ongoing QAPI meetings/activities addressing points 1 through 13 above, as required. 15. A review of the Governing Body binder with meeting minutes was completed on 10/8/2025. The binder lacked documentation of review of the findings of the QAPI committee, as required by policy, from December 13, 2021 through September 19, 2025. 16. The Policy 10.1.1, titled Quality Assessment and Performance Improvement (QAPI) Plan, from Policies and Procedures Manual for Hospice ©2009 MED-PASS, Inc., (Revised 2015), states: “Objectives· To collect and analyze data to improve identified processes and outcomes of care…..· To collect and analyze data to improve identified processes of patient care/services as well as outcomes of patient care, leadership and managerial processes, as indicated…… · To meet federal CMS requirements for QAPI. Responsibility/Accountability 1. The Governing Body is ultimately responsible for QAPI and implementation of the QAPI plan……4. The QAPI committee will meet on a regular basis and will report findings to the Administrator/Director, who, in turn, will report to the Governing Body. Results will also be communicated by the QAPI committee to staff, including contract staff.” 17. An interview with the CEO (Chief Executive Officer), E #1, was completed on 10/8/2025 at approximately 10:05 AM. During discussion regarding lack of QAPI documentation, E #1 agreed the last documentation relating to QAPI was 11/1/2021, stating “Yeah, that needs to be updated.””

“Based on document review and interview, it was determined the Hospice failed to ensure bereavement services were provided as required. Findings include: 1. On 10/7/25 review of the policy titled, “Bereavement Services (policy: 4.26.1, Policies and Procedures Manual for Hospice © 2009 MED-PASS, Inc. (revised 2014) )” was completed. The policy requires, “...Procedure 2. An initial Bereavement Risk Assessment will be performed as part of the Comprehensive Assessment...Procedure 5. Unless Bereavement Services have been refused…A bereavement plan of care will be initiated, which may include…The plan of care will note the kind of bereavement services to be offered and frequency of service delivery…. Procedure 9. Bereavement assessment and clinical notes are documented in the patient’s permanent clinical record.” 2. The following records were reviewed for Bereavement Services on 10/07/25 at approximately 12:00 PM. The following records lacked an initial Bereavement Risk Assessment: a) Pt. #1 Start of Care (SOC) 09/22/25 Date of Death N/A b) Pt. #2 Start of Care (SOC) 03/26/25 Date of Death N/A c) Pt. #3 Start of Care (SOC) 12/03/24 Date of Death N/A d) Pt. #5 Start of Care (SOC) 09/10/25 Date of Death 09/17/25 e) Pt. #6 Start of Care (SOC) 04/15/25 Date of Death 06/09/25 3. The following records were reviewed for Bereavement Services on 10/07/25 at approximately 12:00 PM. The following records lacked documentation of refusal for bereavement services: a) Pt. #1 Start of Care (SOC) 09/22/25 Date of Death N/A b) Pt. #2 Start of Care (SOC) 03/26/25 Date of Death N/A c) Pt. #3 Start of Care (SOC) 12/03/24 Date of Death N/A d) Pt. #4 Start of Care (SOC) 07/18/25 Date of Death 07/21/25 e) Pt. #5 Start of Care (SOC) 09/10/25 Date of Death 09/17/25 f) Pt. #6 Start of Care (SOC) 04/15/25 Date of Death 06/09/25 4. During an interview with the Chief Executive Officer (CEO) (E#1) on 10/08/25 at approximately 10:30 am, E#1 verbally confirmed the lack of the initial Bereavement assessment being completed. E#1 also confirmed that Bereavement refusals are not being documented.”