Wings of Hope Hospice

“Based on record review and interview, the agency failed to ensure the comprehensive assessment included a review of the patient’s prescription and over the counter drugs to determine medication interactions or any adverse effects for 5 (P-14, P-15, P-17, P-18, P-19) of 19 records reviewed, resulting in the potential for harmful medication effects for the current 75 patients. Findings include: P-14: This patient elected hospice on 3/5/24 with a terminal diagnosis of a leaking abdominal aortic aneurysm. The comprehensive assessment completed by the nurse on 3/5/24, documents in the area for medication profile review that the patient has a new or changed medication described as Morphine 20 mg/ml oral concentrate. During review of the clinical record on 2/4/25, a medication interaction report was generated utilizing the agency’s software. The report indicates there are severe interactions between the patient’s following medications: Haloperidol and Morphine. There was no documentation to indicate the nurse was aware of the severe interactions and no documentation to indicate the physician was informed of the severe interactions. The findings were reviewed with RN-K (registered nurse/quality assurance/education) during an interview on 2/7/25 at 10:30 a.m. RN-K explained that the pharmacy gives notice of interactions to the medical director who has to approve the medications. There was no documented evidence the pharmacy notified the medical director of the severe interactions. The agency’s current policy titled, Comprehensive Assessment No. 1-014 (approved 8/31/23) states, there is a review of current medications, over-the-counter medications, supplements, and herbal remedies to identify actual or potential drug interactions. The policy failed to detail the review by the pharmacy and notification of the physician. P-15: This patient elected hospice on 1/1/25 with terminal diagnoses of lung and brain cancer. The comprehensive assessment completed by the nurse on 1/1/25, documents in the area for medication profile review that new/changed medications were identified and the medication profile updated. During review of the clinical record on 2/4/25, a medication interaction report was generated utilizing the agency’s software. The report indicates there are 13 severe interactions between the patient’s medications. There was no documentation to indicate the nurse was aware of the severe interactions and no documentation to indicate the physician was informed of the severe interactions. P-17: This patient elected hospice on 6/19/24 with a terminal diagnosis of liver cancer with ascites (excess fluid in abdominal cavity). The comprehensive assessment completed by the nurse on 6/19/24, documents in the area for medication profile review that no issues were identified. During review of the clinical record on 2/6/25, a medication interaction report was generated utilizing the agency’s software. The report indicates there are 2 severe interactions between the patient’s medications. There was no documentation to indicate the nurse was aware of the severe interactions and no documentation to indicate the physician was informed of the severe interactions. P-18: This patient elected hospice on 1/19/25 with a terminal diagnosis of leukemia. The comprehensive assessment completed by the nurse on 1/19/25, documents in the area for medication profile review there was no evidence of change since last review. During review of the clinical record on 2/6/25, a medication interaction report was generated utilizing the agency’s software. The report indicates there are 3 severe interactions between the patient’s medications. There was no documentation to indicate the nurse was aware of the severe interactions and no documentation to indicate the physician was informed of the severe interactions. P-19: This patient elected hospice on 12/27/24 with a terminal diagnosis of encephalopathy (change in brain function). The comprehensive assessment completed by the nurse on 12/27/24, documents in the area for medication profile review there was no evidence of change since last review. During review of the clinical record on 2/6/25, a medication interaction report was generated utilizing the agency’s software. The report indicates there are 2 severe interactions between the patient’s medications. There was no documentation to indicate the nurse was aware of the severe interactions and no documentation to indicate the physician was informed of the severe interactions.”

“Based on record review and interview, the Hospice failed to ensure the comprehensive assessment included an initial bereavement assessment that identified all who would be affected by the patient’s death in 8 (P-1, P-2, P-3, P-4, P-9, P-10, P-17, P-18) records, from a total of 19 records reviewed resulting in the potential for unmet bereavement care needs. Findings included: **Policy No. 1-021 titled “;Bereavement Assessment” (approved 8/31/2023) stated, “;The hospice bereavement plan of care will be developed based on an initial assessment of the patient and family/caregiver needs, during the course of care, and at the time of the patients death as part of the comprehensive assessment.” P-1: This 83-year-old patient was admitted to this hospice agency on 4/13/24 with the terminal diagnosis of a malignant neoplasm of the left breast (breast cancer) and an unspecified intestinal obstruction. During record review on 2/5/25, it was noted the initial bereavement assessment in the social work evaluation dated 4/15/24 included the patients daughter who was present during the assessment. However, the social work evaluation also identified the patient was married and had 3 other children that would help care for her and her husband as needed. The agency failed to assess the initial bereavement needs of the additional identified individuals. P-2: This 88-year-old patient was admitted to this hospice facility on 1/6/25 with the terminal diagnosis of chronic obstructive pulmonary disease. During record review on 2/5/25, it was noted the initial bereavement assessment in the social work evaluation dated 1/8/25 included the patients daughter. However, the social work evaluation also stated the patients daughter and granddaughter shared medial and financial power of attorney for the patient. The agency failed to assess the initial bereavement needs of the patients granddaughter. Findings were reviewed with and acknowledged by the Director of Clinical Services and Finance (Director-B) during an interview on 2/6/25 at 9:00 AM. P-9: The referral was dated 8/7/2024. The Start of Care was dated 8/8/2024. The Plan of Care for the certification period 8/8/2024 to 11/5/2024 identified diagnoses of Nonrheumatic aortic valve disorder, Dependence on supplemental oxygen, Dyspnea, Chronic Kidney Disease, ST elevation (STEMI) myocardial infarction. The patient was receiving Skilled Nursing, and Medical Social Worker Services. Upon review of the record, it was noted that the Medical Social Worker failed to include all family members in the family contact document and the bereavement assessment. The patient had two living children, a daughter and son, however, the daughter was only family member whose contact information was included in the patient record. There was no further information, contact information or interviews with the patient’s son by the MSW to determine if the patient’s son was involved or had any bereavement needs. P-10: The referral was dated 10/25/2024. The Start of Care was dated 10/25/2024. The Plan of Care for the certification period 10/25/24 to 1/22/2025 identified diagnoses of Chronic Congestive Heart Failure, Coronary Artery Disease, Hypertension, Cardiomyopathy, Non-ST Elevation Myocardial Infarction, Hypothyroidism, Diabetes type 2, Chronic Kidney Disease. Upon review of the record, it was noted that the Medical Social Worker failed to document all Family Members in the bereavement assessment. The patient was residing with her daughter who was the primary caregiver for this patient. However, there were also 5 grandchildren living in the home. There was no evidence found in the record that the Social Worker had performed a bereavement risk assessment on the 5 children living with the patient. The Medical Social Worker failed to include all family members in the bereavement risk assessment. These findings were reviewed with and acknowledged by the Director of Clinical Services and Finance (Director-B) during an interview on 2/8/25 at 1:00 PM. P-3: The patient was admitted to Hospice services on 1/7/25 with a terminal diagnosis of Cardiomyopathy. The clinical record review conducted on 2/4/25 at 2:00 p.m. revealed a document titled “Family contact/HIPAA Approval” which documented the patient the patient had a spouse, 2 daughters and 1 son. The document was for all person’s staff would communicate with regarding care. The Initial Bereavement Assessment dated 1/31/25 completed by the Medical Social Worker (MSW) only included the patient’s wife. The assessment failed to include all parties (2 daughters and 1 son) who would be affected by the patient’s death. These findings were reviewed with and acknowledged by the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:15 a.m. P-4: The patient was admitted to Hospice services on 12/13/24 with a terminal diagnosis of Congestive Heart Failure. The clinical record was review on 2/5/25 at 8:20 a.m. and revealed the patient had a daughter. The Family Contact form documented that the patient had 3 sons and 1 sister. The Initial Bereavement Assessment dated 12/18/24, completed by the MSW only included one of the patient’s sons. The assessment failed to include all parties who would be affected by the patient’s death. These findings were reviewed with and acknowledged by the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:35 a.m. P-17: This patient elected hospice on 6/19/24 with a terminal diagnosis of liver cancer with ascites (extra fluid in abdomen). During record review on 2/6/25, it was noted the hospice had a Family Contact HIPAA Approval form that listed the name of one son as primary care giver, then listed “others” which included two sons, a daughter-in-law, and a sister-in-law. The initial bereavement assessment conducted by the MSW on 6/24/24 included only the one son who was the primary caregiver. The initial bereavement assessment failed to include the other four family members. P-18: This patient elected hospice on 1/19/25 with a terminal diagnosis of leukemia. During record review on 2/6/25, it was noted that the patient’s face sheet (information) listed one daughter as the emergency contact and another daughter as the primary care giver. The initial bereavement assessment conducted by the MSW on 1/24/25 included the daughter who was the primary caregiver. The initial bereavement assessment failed to include the other daughter identified as the emergency contact. P-3: The patient was admitted to Hospice services on 1/7/25 with a terminal diagnosis of Cardiomyopathy. The clinical record review conducted on 2/4/25 at 2:00 p.m. revealed a document titled “Family contact/HIPAA Approval” which documented the patient the patient had a spouse, 2 daughters and 1 son. The document was for all person’s staff would communicate with regarding care. The Initial Bereavement Assessment dated 1/31/25 completed by the Medical Social Worker (MSW) only included the patient’s wife. The assessment failed to include all parties (2 daughters and 1 son) who would be affected by the patient’s death. These findings were reviewed with and acknowledged by the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:15 a.m. P-4: The patient was admitted to Hospice services on 12/13/24 with a terminal diagnosis of Congestive Heart Failure. The clinical record was review on 2/5/25 at 8:20 a.m. and revealed the patient had a daughter. The Family Contact form documented that the patient had 3 sons and 1 sister. The Initial Bereavement Assessment dated 12/18/24, completed by the MSW only included one of the patient’s sons. The assessment failed to include all parties who would be affected by the patient’s death. These findings were reviewed with and acknowledged by the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:35 a.m. P-9: The referral was dated 8/7/2024. The Start of Care was dated 8/8/2024. The Plan of Care for the certification period 8/8/2024 to 11/5/2024 identified diagnoses of Nonrheumatic aortic valve disorder, Dependence on supplemental oxygen, Dyspnea, Chronic Kidney Disease, ST elevation (STEMI) myocardial infarction. The patient was receiving Skilled Nursing, and Medical Social Worker Services. Upon review of the record, it was noted that the Medical Social Worker failed to include all family members in the family contact document and the bereavement assessment. The patient had two living children, a daughter and son, however, the daughter was only family member whose contact information was included in the patient record. There was no further information, contact information or interviews with the patient’s son by the MSW to determine if the patient’s son was involved or had any bereavement needs. P-10: The referral was dated 10/25/2024. The Start of Care was dated 10/25/2024. The Plan of Care for the certification period 10/25/24 to 1/22/2025 identified diagnoses of Chronic Congestive Heart Failure, Coronary Artery Disease, Hypertension, Cardiomyopathy, Non-ST Elevation Myocardial Infarction, Hypothyroidism, Diabetes type 2, Chronic Kidney Disease. Upon review of the record, it was noted that the Medical Social Worker failed to document all Family Members in the bereavement assessment. The patient was residing with her daughter who was the primary caregiver for this patient. However, there were also 5 grandchildren living in the home. There was no evidence found in the record that the Social Worker had performed a bereavement risk assessment on the 5 children living with the patient. The Medical Social Worker failed to include all family members in the bereavement risk assessment. These findings were reviewed with and acknowledged by the Director of Clinical Services and Finance (Director-B) during an interview on 2/8/25 at 1:00 PM. **Policy No. 1-021 titled “;Bereavement Assessment” (approved 8/31/2023) stated, “;The hospice bereavement plan of care will be developed based on an initial assessment of the patient and family/caregiver needs, during the course of care, and at the time of the patients death as part of the comprehensive assessment.” P-1: This 83-year-old patient was admitted to this hospice agency on 4/13/24 with the terminal diagnosis of a malignant neoplasm of the left breast (breast cancer) and an unspecified intestinal obstruction. During record review on 2/5/25, it was noted the initial bereavement assessment in the social work evaluation dated 4/15/24 included the patients daughter who was present during the assessment. However, the social work evaluation also identified the patient was married and had 3 other children that would help care for her and her husband as needed. The agency failed to assess the initial bereavement needs of the additional identified individuals. P-2: This 88-year-old patient was admitted to this hospice facility on 1/6/25 with the terminal diagnosis of chronic obstructive pulmonary disease. During record review on 2/5/25, it was noted the initial bereavement assessment in the social work evaluation dated 1/8/25 included the patients daughter. However, the social work evaluation also stated the patients daughter and granddaughter shared medial and financial power of attorney for the patient. The agency failed to assess the initial bereavement needs of the patients granddaughter. Findings were reviewed with and acknowledged by the Director of Clinical Services and Finance (Director-B) during an interview on 2/6/25 at 9:00 AM. P-17: This patient elected hospice on 6/19/24 with a terminal diagnosis of liver cancer with ascites (extra fluid in abdomen). During record review on 2/6/25, it was noted the hospice had a Family Contact HIPAA Approval form that listed the name of one son as primary care giver, then listed “others” which included two sons, a daughter-in-law, and a sister-in-law. The initial bereavement assessment conducted by the MSW on 6/24/24 included only the one son who was the primary caregiver. The initial bereavement assessment failed to include the other four family members. P-18: This patient elected hospice on 1/19/25 with a terminal diagnosis of leukemia. During record review on 2/6/25, it was noted that the patient’s face sheet (information) listed one daughter as the emergency contact and another daughter as the primary care giver. The initial bereavement assessment conducted by the MSW on 1/24/25 included the daughter who was the primary caregiver. The initial bereavement assessment failed to include the other daughter identified as the emergency contact.”

“Based on record review and interview, the agency failed to ensure the goals on the Plan of Care were measurable to determine progress towards meeting the goals implemented on the plan of care in 9 of 13 records (P-1, 2, 9, 10, 11, 12, 13, 15, 17) reviewed. Findings included: P-15: This patient elected hospice on 1/1/25 with terminal diagnoses of lung and brain cancer. During record review on 2/4/25, it was noted that the 1/1/25 plan of care failed to include measurable goals and outcomes pertinent to the needs of the patient or family. The plan includes a spiritual goal that states the patient/family will review life for meaning and acceptance. There was no indication as to how this goal would be measured by the spiritual care provider. A skilled nursing goal states the patient/caregiver will demonstrate techniques to promote wound healing. There was no indication how this goal would be measured by the nurse to ensure wound healing. P-17: This patient elected hospice on 6/19/24 with a terminal diagnosis of liver cancer with ascites (excess fluid in abdominal cavity). During record review on 2/6/25, it was noted that the 6/19/24 plan of care failed to include measurable goals and outcomes pertinent to the needs of the patient. A nursing goal states that the patient will be pain free or verbalize an acceptable pain level with current pain management regimen level. There was no indication what level of pain is acceptable to this patient. The findings were reviewed with and acknowledged by RN-K (quality assurance/educator) during an interview on 2/7/25 at 10:30 a.m. P-9: The referral was dated 8/7/2024. The Start of Care was dated 8/8/2024. The Plan of Care for the certification period 8/8/2024 to 11/5/2024 identified diagnoses of Nonrheumatic aortic valve disorder, Dependence on supplemental oxygen, Dyspnea, Chronic Kidney Disease, ST elevation (STEMI) myocardial infarction. The patient was receiving Skilled Nursing, and Medical Social Worker Services. Upon review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included: “Patient/Caregiver administers medications appropriately with understanding of side effects and states implications and expected results; Maintenance of respiratory baselines as evidenced by breathing at optimal level within disease parameters; Patient will maintain optimum bowel functioning consistent with food intake and stage of disease process. These goals are not objectively measure to determine the patient’s progress towards obtaining the goals. P-10: The referral was dated 10/25/2024. The Start of Care was dated 10/25/2024. The Plan of Care for the Certification Period 10/25/2024 to 1/22/2025 identified diagnoses of Chronic combined systolic and diastolic heart failure (CHF), Atherosclerotic heart disease, Hypertension, Non-ST elevation MI, ischemic cardiomyopathy, obesity, hypothyroidism, and Insulin Dependent Diabetes Mellites. The patient was receiving Skilled Nursing, Aide, Chaplain, and Medical Social Work Services. Upon review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient’s progress towards goals. Examples included: “Patient’s personal care needs will be met; Maintenance of respiratory baselines as evidenced by breathing at optimal level with disease parameters.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. P-11: The referral was dated 1/5/24. The Start of Care was dated 1/7/2024. The Plan of Care for the certification period 1/7/24 to 1/27/2024 identified diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Unspecified Chronic Kidney Disease. The patient was receiving Skilled Nursing 1xday for 40 days with 5 PRN visits; Aide services 5x week for 4 weeks with 4 PRN visits; Medical Social Work 1 visit; and Chaplain services for 3 PRN (as needed) visits. Upon review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient’s progress towards goals. Examples included: “Patient will be pain free or verbalize an acceptable pain level with current pain management regimen; Maintenance of respiratory baselines as evidenced by breathing at optimal level within disease, cough, and breathing patterns.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. P-12: The referral was dated 12/16/2024. The Start of Care was dated 12/17/24. The Plan of Care for the certification period 12/17/24 to 3/16/2025. The Plan of Care identified diagnoses of Malignant neoplasm of lower-outer quadrant of right female breast, Vitamin D deficiency, Hypokalemia, Insomnia, Hypercholesterolemia, Congestive Heart Failure, and Vascular dementia without behavioral disturbance. The patient was receiving Skilled Nursing 1xweekx14 weeks with 5 prn visits; Aide services 2xweekx11 weeks with 5 prn visits; Medical Social Work services 1xmonthx4months with 4 prn visits; and Chaplain services for 4 prn visits. Upon review of the record, it was noted the goals were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included: Patient will maintain optimal coping through hospice care; Patient’s personal care needs will be met; Pt/CG can describe/demonstrate measures to improve/maintain skin integrity; Patient/Caregiver/family will be able to identify potential complications, actions to take, and when to call Hospice. These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. P-13: The Start of Care was dated 3/5/2024. The Plan of Care for the certification period 1/29/25 to 3/29/2025 identified diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Acute respiratory failure with hypoxia, and pneumonia. The patient was receiving Skilled Nursing and Hospice Aid services 1xweekx9 weeks + 5 PRN visits; Chaplain services 1-2 per month for 3 months with 3 PRN visits; Medical Social Work visits 1-2 visits per month for 2 months with 4 prn visits. Upon review of the record, it was noted the goals were not measurable to determine the patient’s progress towards obtaining the goals. Examples included: “Patient/family will review life for meaning and joy; Patient and family spiritual needs met; Maintain clean, safe environment; Assist with necessary arrangements, planning; Maintain safe clean environment.” These goals are not objectively measurable to determine the patient’s progress towards attaining the goals. These findings were reviewed with and acknowledged by the Director of Clinical Services and Finance (Director-B) during an interview on 2/8/25 at 1:00 PM. **Policy No. 3-002 titled “;Patient Focused Performance Improvement” (revised 4/2021) stated, “;1. At the time of admission and on and ongoing basis, an individualized plan of care/service including specific and measurable goals will be developed for each patient.” P-1: This 83-year-old patient was admitted to this hospice agency on 4/13/24 with the terminal diagnosis of a malignant neoplasm of the left breast (breast cancer) and an unspecified intestinal obstruction. During record review on 2/5/25, it was noted the goals on the plan of care dated 4/13/24 were not objectively measurable to allow patient progress to be tracked and the need for revisions in treatment to be identified. For example, a skilled nursing goal stated, “;Maintenance of respiratory baselines as evidenced by breathing at optimal level within disease parameters.” [sic] A social work goal stated, “;Continuity of care will be maintained as appropriate to patient/primary caregiver needs.” P-2: This 88-year-old patient was admitted to this hospice facility on 1/6/25 with the terminal diagnosis of chronic obstructive pulmonary disease. During record review on 2/5/25, it was noted the goals on the plan of care dated 1/6/25 were not objectively measurable to allow patient progress to be tracked and the need for revisions in treatment to be identified. For example, a skilled nursing goal stated, “;CG (caregiver) can maintain usual bowel patterns.” A hospice aide goal stated, “;CG can perform ADL with optimal ability.” Findings were reviewed with and acknowledged by the Director of Clinical Services and Finance (Director-B) during an interview on 2/6/25 at 9:00 AM.”

“Based on record review and interview, the Hospice failed to maintain an effective system of communication and an ongoing sharing of information between the Physician and ordered disciplines in 1 (P-3) record in which the patient experienced a significant change in condition, from a total of 19 sampled patients reviewed, resulting in lack of coordinated care, the potential for unidentified/untreated health concerns and unmet patient care needs. Findings include: P-3: The patient was admitted to hospice on 1/7/25 with a terminal diagnosis of Cardiomyopathy, and additional diagnoses that included Parkinson’s Dementia and Hypertension. During the record review on 2/4/25 at 2:00 p.m., it was noted that the plan of care ordered the patient to receive Skilled Nursing (SN) services at a frequency of 2x/wk. x 13 wks. and 5 prn (as needed) visits. A “Communication Note” dated 2/1/25 at 1:09 a.m., documented by the Triage Nurse read, “Received call at 02/01/2025 01:01 form [sic] daughter reporting ingoing [sic] anxiousness and delirium. Caller reports patient had HS (nighttime) routine medications and Seroquel tonight, caller reports patient has not slept the last 3 nights. Caller states patient is not speaking of sound mind, is restless and has not has [sic] sleep in several days. Caller states “he may have a fever”. Writer reviews chart and recommends use of PRN Haldol, caller refuses to administer stating she gave it 3 nights ago and it was not effective. Caller requesting nurse visit for evaluation. 24/7 availability reinforced. Writer placed on DL (Dispatch Log) for dispatch.” At the time of this review, there was no documented evidence that the SN had performed a follow-up visit to assess the health needs of the patient. Additionally, there was no documented evidence that the Physician or Interdisciplinary Team had been made aware of the patient’s change in condition. These findings were reviewed with the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:15 a.m. who reported, “Let me check the Dispatch Log; I don’t have an explanation as to why there was no follow-up. That’s a problem.””

“Based on record review and interview, it was determined the hospice failed to ensure its Quality Assessment Performance Improvement (QAPI) program included all patient services that impact patient/family care as part of the QAPI program. Findings include: On 2/7/25 at 10:06 a.m., during an interview with the QAPI Coordinator, a request was made to review the QAPI data for calendar years 2023 and 2024. Upon review, there was no documented evidence the 2023/2024 QAPI reports included all patient services and how they impact patient/family care as part of the QAPI program. These findings were reviewed with and acknowledged by the QAPI Coordinator at the time of discovery.”

“Based on documents reviewed and interview, the hospice failed to ensure the QAPI performance improvement activities focus on high risk, high volume, or problem-prone areas. Findings include: On 2/7/25 at 10:06 a.m., during an interview with the QAPI Coordinator, a request was made to review the QAPI data for calendar years 2023 and 2024. Upon review, there was no documented evidence the 2023/2024 QAPI reports focused on high volume problem prone areas. During a review of the agency’s incident reports for calendar years 2023/2024, it was noted that there were a significant number of reported and unwitnessed falls. However, the agency focused on Performance Improvement topics such as “Improving GSS (grief support) survey scores, Compliance Committee and Orientation Program.” These were the chosen projects for both calendar years 2023 and 2024. There was no documented evidence that the Performance Improvement Projects included all patient services and how they impacted patient/family care as part of the QAPI program. These findings were reviewed with and acknowledged by the QAPI Coordinator at the time of discovery.”

“Based on record review and interview, the agency failed to ensure its Performance Improvement Projects tracked adverse patient events, analyzed causative factors and implemented preventive measures to prevent reoccurrence. Findings include: On 2/7/25 at 10:06 a.m., during an interview with the QAPI Coordinator, a request was made to review the QAPI data for calendar years 2023 and 2024. Upon review, there was no documented evidence the 2023/2024 QAPI reports tracked adverse patient events, analyzed causative factors and developed improvements. During a review of the agency’s incident reports for calendar years 2023/2024, it was noted that there were a significant number of reported and unwitnessed falls. However, the agency’s Performance Improvement Projects consisted of topics such as “Improving GSS (grief support) survey scores, Compliance Committee and Orientation Program.” These were the chosen projects for both calendar years 2023 and 2024. There was no documented evidence that the Performance Improvement Projects tracked adverse events, analyzed causative factors and developed preventative measures to prevent reoccurrence. These findings were reviewed with and acknowledged by the QAPI Coordinator at the time of discovery.”

“Based on record review and interview, the governing body failed to ensure responsibility and annually evaluate the hospice’s quality assurance and performance improvement program in 2024, resulting in a lack of oversight for the hospice quality improvement program. Findings include: The monthly Board of Director Meeting minutes for 2024 were reviewed on 2/6/25 at 10:45 a.m. During review of the meeting minutes, it was noted that there was no documentation to indicate the Board of Directors had discussed or reviewed matters related to the hospice’s quality assurance and performance improvement program. The findings were reviewed with and acknowledged by Admin-A (executive director) during an interview on 2/7/25 at 1:30 p.m.”

“Based on record review and interview, it was determined that the Agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the Hospice’s Quality Assessment Performance Improvement program, resulting in the potential for increased, untreated infections among the Agency’s active patients, and staff population. Findings include: On 2/7/25 at 10:06 a.m., during an interview with the QAPI Coordinator, a request was made to review the QAPI data for calendar years 2023 and 2024. Upon review, there was no documented evidence the 2023/2024 QAPI data included any discussions on infection Control. Upon review of the Governing board meeting minutes for calendar year 2024, there was no inclusion of the topic of infection control. Additionally, there were no projects that addressed the agency’s infections as identified in the surveillance report provided for review. The agency failed to ensure its infection control program was included in the QAPI program. These findings were reviewed with and acknowledged by the QAPI Coordinator at the time of discovery.”

“Based on record review and interview, it was determined that the hospice failed to ensure follow-up nursing assessments were conducted to ensure the needs of the patient were met for 1 (P-3) patient who experienced a significant change in condition, from a total of 19 sampled records reviewed, resulting in the potential for unidentified/untreated health concerns and progression towards end of life. Findings include: P-3: The patient was admitted to hospice on 1/7/25 with a terminal diagnosis of Cardiomyopathy, and additional diagnoses that included Parkinson’s Dementia and Hypertension. During the record review on 2/4/25 at 2:00 p.m., it was noted that the plan of care ordered the patient to receive Skilled Nursing (SN) services at a frequency of 2x/wk. x 13 wks. and 5 prn (as needed) visits. A “Communication Note” dated 2/1/25 at 1:09 a.m., documented by the Triage Nurse read, “Received call at 02/01/2025 01:01 form [sic] daughter reporting ingoing [sic] anxiousness and delirium. Caller reports patient had HS (nighttime) routine medications and Seroquel tonight, caller reports patient has not slept the last 3 nights. Caller states patient is not speaking of sound mind, is restless and has not has [sic] sleep in several days. Caller states “he may have a fever”. Writer reviews chart and recommends use of PRN Haldol, caller refuses to administer stating she gave it 3 nights ago and it was not effective. Caller requesting nurse visit for evaluation. 24/7 availability reinforced. Writer placed on DL (Dispatch Log) for dispatch.” At the time of this review, the SN had not performed a follow-up visit to assess the urgent needs of the patient. Additionally, there was no further documentation of the status of the patient. These findings were reviewed with the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:15 a.m. who reported, “Let me check the Dispatch Log; I don’t have an explanation as to why there was no follow-up. That’s a problem.””

“Based on the record review and interview, it was determined the Hospice failed to make bereavement/grief support services available to the bereaved family member up to 1 year following the death of the patient in 3 (P-6, P-7, P-8) of 3 bereavement records, and failed to complete a bereavement plan of care that listed the bereaved family members, resulting in the potential for ineffective coping/grieving, lack of grief support and unmet bereavement needs. Findings include: P-6: The patient was admitted to Hospice on 12/27/24 with a terminal diagnosis of Malignant Neoplasm Right Lung and Brain Cancer. During the record review on 2/6/25 at 9:30 a.m., it was noted that the patient passed away on 1/9/25. The Initial Bereavement Risk Assessment dated 12/31/24, completed by the Medical social Worker (MSW) identified the patient’s wife as the bereaved. A Celebration of Life document stated the patient was survived by his wife, 2 sisters, 2 brothers, 2 sons and a daughter. The section of the “Grief & Loss Risk Assessment” dated 1/15/25, completed by the Bereavement Coordinator, documented, “Primary Caregiver, Family and Significant Others Involved in Care:” only listed the patient’s wife. Upon further review, the Bereavement POC was void of persons who would be affected by the patients death and receive grief support services. Additionally, there were no frequencies in which contact would be made or when services would be provided. The Hospice failed to make bereavement/grief support services available to the bereaved family members. These findings were reviewed with and acknowledged by the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:50 a.m. P-7: The patient was admitted to Hospice on 12/8/23 with a terminal diagnosis of Left Ventricular Failure. During the record review on 2/6/25 at 10:50 a.m., it was noted that the patient passed away on 12/25/23. The Initial Bereavement Risk Assessment dated 12/11/23, completed by the MSW, only identified the patient’s wife as the bereaved. A Celebration of Life document stated the patient was survived by his wife, son and grandson and read, “The patient loved his grandson very much...” The document further stated that the patient was also survived by 5 siblings. The Grief & Loss Risk Assessment dated 12/27/23, completed by the Bereavement Coordinator, only listed the patient’s wife as the person to receive grief support. Upon further review, the Bereavement POC revealed that none of the above-mentioned family members were included in the POC, and there were no frequencies in which contact would be made or when services would be provided. The Hospice failed to make bereavement/grief support services available to the bereaved family members. These findings were reviewed with and acknowledged by the Educator/QAPI Coordinator during an interview on 2/7/25 at 10:00 a.m. P-8: The patient was admitted to Hospice on 8/5/24 with a terminal diagnosis of ST Elevation Myocardial Infarction. During the record review on 2/6/25 at 12:40 p.m., it was noted that the patient passed away on 8/17/24. The Initial Bereavement Risk Assessment dated 8/6/24, completed by the MSW, only identified the patient’s wife as the bereaved. A Celebration of Life document stated the patient was survived by his wife, 2 sons and 4 grandchildren. The Grief & Loss Risk Assessment dated 8/21/24, completed by the Bereavement Coordinator, only listed the patient’s wife as the person to receive grief support. Upon further review, the Bereavement POC revealed that none of the bereaved family members were listed and there were no frequencies in which contact would be made or when services would be provided. The Hospice failed to make bereavement/grief support services available to the bereaved family members. These findings were reviewed with and acknowledged by the Educator/QAPI Coordinator during an interview on 2/7/25 at 10:05 a.m. BC #1 at the time of discovery.”

“Based on record review and interview the hospice failed to ensure hospice aides received at least 12 hours of in-service training annually for 3 (Aide-E, Aide-F, and Aide-G) of 3 aide personnel files reviewed of aides employed for more than 12 months, resulting in a lack of educational development and training opportunities for these 3 aides. Findings include: The personnel files for three aides were reviewed on 2/6/25 and the following was noted: Aide-E: Date of hire 5/8/23. No in-service education for 2023 was provided for review. The 2024 in-service education totaled 11.45 hours. Aide-F: Date of hire 9/23/22. The 2023 in-service education totaled 9.2 hours. The 2024 in-service education totaled 10 hours. Aide-G: Date of hire 8/1/22. No in-service education for 2023 was provided for review. The 2024 in-service education totaled 11 hours. The hospice failed to follow its own policy titled, Training/Inservice Education No.1-033 (revised April 2021), which states aides must receive at least 12 hours of in-service training per calendar year. The findings were reviewed with and acknowledged by Manager-H (human resources) during an interview on 2/6/25 at 11:35 p.m.”

“Based on record review and interview, the hospice failed to ensure the registered nurse prepared written patient specific care instructions that included safety precautions and the frequency in which ordered tasks were to be performed for 7 (P-1, P-2, P-3, P-4, P-15, P-16, P-19) of 8 records in which aide services were provided, from a total of 19 sampled records reviewed, resulting in the potential for injury and overlooked care needs. Findings include: P-15: This patient elected hospice on 1/1/25 with terminal diagnoses of lung and brain cancer. During record review on 2/4/25, it was noted that the aide was ordered to provide services 3 times a week for 14 weeks. The aide care plan instructed the aide to provide assistance with personal care/hygiene and activities of daily living. The aide care plan failed to indicate the frequency of the assistance with personal care/hygiene and activities of daily living. It was unclear if the aide was to provide bathing and all care/services 3 times per week, twice a week, or once a week. The hospice plan of care included the following safety measures: safe transfers, skin breakdown prevention, transfer precautions, and ambulation precautions. The aide care plan failed to include these safety measures to alert the aide to the specific care required for this patient. P-16: This patient elected hospice on 1/31/25 with terminal diagnoses of congestive heart failure and diabetes. During record review on 2/5/25, it was noted that the aide was ordered to provide services 3 times a week for 9 weeks. The aide care plan instructed the aide to provide assistance with personal care/hygiene and activities of daily living. The aide care plan failed to indicate the frequency of the assistance with personal care/hygiene and activities of daily living. It was unclear if the aide was to provide bathing and shampoo hair 3 times per week, twice a week, or once a week. P-19: This patient elected hospice on 12/27/24 with a terminal diagnosis of encephalopathy (a change in brain function). During record review on 2/6/25, it was noted that the aide was ordered to provide services 2 times a week for 1 week and then 3 times a week for 12 weeks. The aide care plan instructed the aide to provide assistance with personal care/hygiene and activities of daily living. The aide care plan failed to indicate the frequency of the assistance with personal care/hygiene and activities of daily living. It was unclear if the aide was to provide bathing and all care/services 3 times per week, twice a week, or once a week. The hospice plan of care included the following safety measures: fall precautions and seizure precautions. The aide care plan failed to include these safety measures to alert the aide to the specific care required for this patient. P-3: The patient was admitted to hospice on 1/7/25 with a terminal diagnosis of Cardiomyopathy. During the clinical record review on 2/4/25 at 2:00 p.m., it was noted that the patient was ordered to receive Hospice Aide services at a frequency of 1x/wk. x 12 wks. and 5 prn (as needed) visits. The Hospice plan of care revealed the patient had dyspnea (shortness of breath) with minimal exertion and had fall/ambulation precautions. The Aide Care Plan failed to include any safety precautions. Additionally, there was no specified frequency in which the ordered tasks were to be performed. These findings were reviewed with and acknowledged by the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:15 a.m. P-4: The patient was admitted to hospice on 12/13/24 with a terminal diagnosis of Congestive Heart Failure. During the record review on 2/5/25 at 8:20 a.m., it was noted that the patient was ordered to receive Hospice Aide services at a frequency of 3x/wk. x 13 wks. and 5 prn visits. The Hospice plan of care revealed the patient had dyspnea with minimal exertion, ambulation/fall precautions and received oxygen. Upon review, the Aide Care Plan was void of any of the above-mentioned safety precautions. Additionally, there was no specified frequency in which the ordered tasks were to be performed. These findings were reviewed with and acknowledged by the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:35 a.m. P-1: This 83-year-old patient was admitted to this hospice agency on 4/13/24 with the terminal diagnosis of a malignant neoplasm of the left breast (breast cancer) and an unspecified intestinal obstruction. Hospice aide services were ordered for 2-3 times per week for 13 weeks with 5 PRN (as needed) visits. The hospice plan of care dated 4/13/24 indicated the patient had fall precautions and standard precautions. The aide care plan failed to include these safety precautions. Additionally, the aide care plan failed to include the frequency for each intervention/task on the care plan to be performed by the aide. P-2: This 88-year-old patient was admitted to this hospice facility on 1/6/25 with the terminal diagnosis of chronic obstructive pulmonary disease. Hospice aide services were ordered for 3 times a week for 13 weeks. The hospice plan of care dated and skilled nursing evaluation (both dated 1/6/25) indicated the patient had dyspnea with exertion and was on up to 6 liters of oxygen. The aide care plan failed to include safety and oxygen precautions. Additionally, the aide care plan failed to include the frequency for each intervention/task to be performed by the aide. During an interview with hospice aide (Aide-J) on 2/5/25 at 1:15 PM, Aide-J was asked how she knows how often to perform the interventions in the aide care plan. Aide-J stated it “;is assumed” it is every visit unless otherwise specified. During an interview with the Director of Clinical Services and Finance (Director-B) on 2/6/25 at 9:00 AM, Director-B agreed with the statement above, however, he agreed how this could be unclear and should be documented better to avoid confusion. Director-B acknowledged the findings.”

“Based on record review and interview, the hospice failed to ensure the aide provided care in accordance with the plan of care in 1 (P-1) of 8 records reviewed with hospice aide services, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-1: This 83-year-old patient was admitted to this hospice agency on 4/13/24 with the terminal diagnosis of a malignant neoplasm of the left breast (breast cancer) and an unspecified intestinal obstruction. During record review on 2/5/25, it was noted the aide care plan dated 4/13/24 stated, “;3. Elimination – Document bowel movements (Varianced).” [sic] During review of 10 hospice aide visits between 4/15/24 and 5/17/24, it was determined 10 of 10 aide visits stated “;Unable to Document: Not applicable this visit” or “;Done” after this intervention, however, failed to include a date of when a bowel movement occurred. Findings were reviewed with and acknowledged by the Director of Clinical Services and Finance (Director-B) during an interview on 2/6/25 at 9:00 AM.”

“Based on record review and interview, the Hospice failed to ensure a Discharge Summary was completed that detailed the course of care provided, including symptom and pain management, responses to treatment, Physician’s orders and the patient’s health status at the time of discharge for 1 P-4) of 2 patients who were discharged to the community or revoked Hospice services, from a total of 19 sampled records reviewed, resulting in the potential for unmet care needs and interruption in post-discharge continuity of care. Findings include: Policy: Discharge Summary 1-026, 82023 stated, “All patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record; A copy of the discharge summary will be provided to the patient’s attending physician.” P-4: The patient was admitted to Hospice on 12/13/24 with a terminal diagnosis of Congestive Heart Failure. During the clinical record review on 2/5/25 at 8:20 a.m., it was noted that the plan of care ordered Skilled Nursing (SN), Spiritual Care (SC), Medical social Work (MSW) and Hospice Aide services to be provided. A document titled “Live Discharge Notification” documented, “I hereby give notice on 12/21/24 that I no longer wish to receive hospice services..., I am choosing revocation of hospice services for the following reason: Seeking curative treatment.” There was no summary of care available for review. The Hospice failed to complete a Discharge Summary that detailed the course of care provided and the patient’s health status at the time of discharge/revocation. Further, there was no documented evidence that the Physician was provided a copy of the summary as per this requirement. These findings were reviewed with the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:35 a.m.”

“Based on observation, record review, and interview, the agency failed to ensure coordination of hospice care with the skilled nursing facility in 1 (P-2) of 5 records reviewed of patients residing in skilled nursing facilities, resulting in the potential for unmet care needs due to a lack of communication between the agency and the facility. Findings include: **Policy No. 1-027 titled “;Missed Visits” (approved 8/31/2023) stated, “;B. Document in the patients medical record the following information:....6. Other person(s) that were notified of the missed visit.” P-2: This 88-year-old patient was admitted to this hospice facility on 1/6/25 with the terminal diagnosis of chronic obstructive pulmonary disease. During a joint home visit with the hospice aide (Aide-J) on 2/5/25 at 1:00 PM, the patient declined the hospice aide visit because she had already gotten dressed for the day and did not want to get undressed again to shower. Aide-J was observed verbally telling a staff member in the hall of the facility that the patient declined, and the aide would be back later in the week. After the attempted visit, Aide-J was asked how missed visits are typically handled for patients living in a skilled facility. Aide-J stated she typically lets a staff member at the facility know, however, admitted that the communication is not documented in the patient’s record. Additionally, it was noted the patient had missed visits on 1/13/25, 1/20/25, and 1/27/25 per patient request. The reasons for the missed visits were documented, however, there was no evidence it was communicated with the staff at the nursing facility. Findings were reviewed with and acknowledged by the Director of Clinical Services and Finance (Director-B) during an interview on 2/6/25 at 9:00 AM.”