Alliance Healthcare Hospice

“Based on staff interview, patient medical record reviews, social worker job description, and policy and procedure review, the facility failed to ensure a comprehensive assessment was completed within five (5) days of the admission which included an assessment of the psychosocial and emotional needs related to the terminal illness and that the needs were addressed in the plan of care to support the palliation and management of the patient throughout the dying process for two (2) of 14 patient medical records reviewed: Patient #6 and #8. The facility also failed to ensure the comprehensive assessment was updated by the interdisciplinary group (IDT) in collaboration with the attending physician as frequently as required but no less frequently than every 15 days for five (5) of 14 records reviewed; Patient #2, #7, #8, #9 and #11. Findings Include: Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 from 12:15 p.m. to 12:30 p.m. confirmed the facility’s social worker did not perform a psychosocial and emotional assessment as part of the initial comprehensive assessment of the patient to support development of the plan of care within five (5) days of admission on Patient #6 and Patient #8. The interview also confirmed the facility had no Interdisciplinary Team (IDT) meeting documentation for review and update of the plan of care no less frequently than every 15 days for routine home care in medical record for Patient #2, #7, #8, and #9; and no documentation of an IDT meeting for Patient #11 for review and update the plan of care within seven (7) days for general inpatient care. Review of medical record for Patient #2 revealed no documentation of IDT meetings between dates 04/16/2025 and 05/07/2025 for a routine home care plan update. Review of the medical record for Patient #6 revealed no documentation in the medical record of the social worker performing a psychosocial and emotional assessment for the initial comprehensive assessment within five (5) days of the admission 02/18/2025 and no documented evidence of attempted or missed visits were presented. Review of medical record for Patient #7 revealed no documentation of IDT meetings between dates 11/15/2024 and 12/13/2024 and between dates 04/16/2025 and 05/07/2025 for routine home care plan updates. Review of the medical record for Patient #8 revealed no documentation in the medical record of the social worker performing a psychosocial and emotional assessment for the initial comprehensive assessment within five (5) days of the admission date 11/15/2024, no documented evidence of attempted or missed visits were presented, and no documentation of IDT meetings between dates 04/16/2025 and 05/07/2025 for a routine home care plan update. Review of medical record for Patient #9 revealed no documentation of IDT meetings between dates 04/16/2025 and 05/07/2025 for a routine home care plan update. Review of medical record for Patient #11 revealed no documentation of IDT meetings between dates 04/24/2025 and 05/14/2025 for general inpatient care plan updates. Review of the facility policy and procedure titled, “Subject: Plan of Care,” no date revealed, “…Procedure…3. The psychosocial, spiritual assessment and plan of care will be completed within five (5) days…”. Review of the facility policy and procedure titled, “Subject: Interdisciplinary Team Responsibilities,” number #C-3, effective date 08/05/2022 revealed, “…Policy…Social Worker…initial assessment and POC to be completed and signed within five (5) days of admission…Responsibilities…Attend IDT meetings every 14 days for home-based patients and every 7 days for inpatient…”. Review of the facility policy and procedure titled “Policy and Procedure, #C-2…Subject: Plan of Care,” no date, revealed “…Policy…POC will be reviewed and updated when patient condition changes and a minimum of every 14 days for home care and every 7 days for general inpatient care with the IDT…”.Review of the facility’s social worker job description revealed, “…Responsibilities…Assessment of the social and emotional factors having an impact on the patient’s health status, assist in the formulation of the Plan of Care (POC)…assess each new admission and complete assessment paperwork within five (5) days of patient admission…complete each visit according to POC schedule for Social Worker…”. During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.”

“Based on staff interview, review of the facility Quality Assessment and Performance Improvement (QAPI) documents, review of the facility Governing Body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility failed to have a documented, operational, effective, ongoing, data-driven QAPI program in which the Governing Body assumes oversite an ensures the program reflects the complexity of its services, focuses on indicators to improved palliative outcomes, takes actions to demonstrate improvements in performance and maintains documentation of the program during six (6) of six (6) days of survey. Findings Include: Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the QAPI performance improvement plans were not reassessed and the facility has no documentation of the collection, aggregation., and analysis of data to submit to support the continual assessment of the hospice performance, actions for improvement, outcomes, meetings, or reports to the Governing Body. Review of the facility’s quarterly “QAPI Report Form,” documents areas of focus indicators for improvements. No documentation of monitoring, outcome measurements, updated plans, meetings, or reporting to the Governing Body was presented for review. Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation related to an ongoing QAPI program review and approval for performance improvement plans, measurements, and outcomes. Review of the facility policy and procedure titled “Governance of Hospice,” no date, revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.”

“Based on staff interview, review of the volunteer program documentation provided, review of the volunteer job description, and review of the facility policy and procedures, the facility failed to ensure the hospice has an active Volunteer Program to provide day-to-day administrative and/or direct patient care services which equals five (5) percent of the total patient care hours. Further the hospice does not have documentation of Volunteer Policies and Procedures, a Volunteer Training Program, a Volunteer Recruitment and Retaining program, and Cost Saving documentation with the details required for six (6) of six (6) survey days. Findings Include: Interview with the Administrator/Director of Nursing (DON) and the Office Manager/Volunteer Coordinator on 06/16/2025 from 10:30 a.m. to 11:00 a.m. confirmed the facility does not have an active volunteer program, no volunteers, and no volunteer services are being provided. Interview with the DON on 06/16/2025 at 11:25 a.m. confirmed the facility had no documented Volunteer Policies and Procedures including a policy and procedure for the volunteer cost savings requirement.Review of the volunteer program documentation provided revealed no active volunteers, no training program, no formal recruitment/retaining program, no cost savings report.Review of facility’s document titled, “Provider Summary Report for 01/01/2024 through 12/31/2024,” and review of the facility document titled, “Income Statement,” for the period January through December 31, 2024, revealed no report of cost savings obtained through the use of volunteers. Review of the volunteer job description revealed the facility assigns the Volunteer Coordinator to provide volunteers for patients as needed. Review of the Facility’s Policy and Procedures revealed the facility did present policies and procedures for the volunteer program or required volunteer cost savings. During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.”

“Based on staff interview, patient medical record reviews and facility policy and procedure review, the facility failed to perform and document an initial comprehensive psychosocial and emotional assessment by the social worker within five (5) days of admission on two (2) of 14 patient medical records reviewed: Patient #6 and #8. Findings Include: Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 from 12:15 p.m. to 12:30 p.m. confirmed the social worker did not perform a psychosocial and emotional assessment within five (5) days of admission as part of the initial comprehensive assessment to support development of the plan of care for Patient #6 and Patient #8.Review of medical record for Patient #6 revealed no social worker psychosocial and emotional assessment was documented in the initial comprehensive assessment within five (5) days of the admission 02/18/2025 and no documented evidence of attempted or missed visits was presented for review.Review of medical record for Patient #8 revealed no social worker psychosocial and emotional assessment was documented in the initial comprehensive assessment within five (5) days of the admission date 11/15/2024 and no documented evidence of attempted or missed visits was presented for review.Review of the facility policy and procedure titled, “Subject: Plan of Care” with no date revealed, “…Procedure…3. The psychosocial, spiritual assessment and plan of care will be completed within five (5) days…”. Review of the facility policy and procedure titled, “Subject: Interdisciplinary Team Responsibilities,” numbered #C-3, effective date 08-05-2022, revealed “…Policy…Social Worker…initial assessment and POC to be completed and signed within five (5) days of admission…”.Cross reference to L 520/418.54 for additional information.During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.”

“Based on staff interview, patient medical record reviews, and facility policy and procedure review, the facility failed to perform a comprehensive assessment that identifies the psychosocial and emotional needs related to their terminal illness that must be addressed in the plan of care to promote well-being and comfort throughout the dying process for two (2) of 14 patient medical records reviewed: Patient #6 and #8. Findings Include: Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 from 12:15 p.m. to 12:30 p.m. confirmed the social worker did not perform a psychosocial and emotional assessment to identify and address the needs related to their terminal illness as part of initial comprehensive assessments of the patient to support development of the plan of care for Patient #6 and Patient #8.Review of the medical record for Patient #6 revealed no social worker psychosocial and emotional assessment was documented in the initial comprehensive assessment within five (5) days of the admission 02/18/2025 and no documented evidence of attempted or missed visits was presented for review. Review of the medical record for Patient #8 revealed no social worker psychosocial and emotional assessment was documented in the initial comprehensive assessment within five (5) days of the admission date 11/15/2024 and no documented evidence of attempted or missed visits was presented for review.Review of the facility social worker job description revealed, “…Responsibilities…Assessment of the social and emotional factors having an impact on the patient’s health status, assist in the formulation of the Plan of Care (POC)…assess each new admission and complete assessment paperwork within five (5) days of patient admission…complete each visit according to POC schedule for Social Worker…”. Review of the facility policy and procedure titled, “Subject: Interdisciplinary Team Responsibilities,” number #C-3, effective date 08/05/2022, revealed, “…Policy…Social Worker…initial assessment and POC to be completed and signed within five (5) days of admission…”.Cross reference to L 520/418.54 for additional information.During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.”

“Based on staff interview, patient record reviews, and facility policy and procedures review, the facility failed to ensure the Interdisciplinary Team (IDT) updated the comprehensive assessment in collaboration with the attending physician based on changes in the patient’s condition, progress toward outcomes, and a reassessment of the patient’ response to care as frequently as the patient condition requires and no less frequently than every 15 days for five (5) of 14 records reviewed; patient record #2, #7, #8, #9 and #11. Findings Include: Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 from 12:15 p.m. to 12:30 p.m. confirmed no Interdisciplinary Team (IDT) meeting documentation for review and update of the plan of care no less frequently that every 15 days for routine home care in medical record for Patient #2, #7, #8, and #9; and no documentation of IDT meeting for Patient #11 for review and update the plan of care within 7 days for general inpatient care. Review of medical record for Patient #2 revealed no documentation of IDT meetings between dates 04/16/2025 and 05/07/2025 for a routine home care plan update. Review of medical record for Patient #7 revealed no documentation of IDT meetings between dates 11/15/2024 and 12/13/2024 and between dates 04/16/2025 and 05/07/2025 for routine home care plan updates. Review of medical record for Patient #8 revealed no documentation of IDT meetings between dates 04/16/2025 and 05/07/2025 for a routine home care plan update. Review of medical record for Patient #9 revealed no documentation of IDT meetings between dates 04/16/2025 and 05/07/2025 for a routine home care plan update. Review of medical record for Patient #11 revealed no documentation of IDT meetings between dates 04/24/2025 and 05/14/2025 for general inpatient care plan updates. Review of the facility policy and procedure titled “Policy and Procedure, #C-2…Subject: Plan of Care,” no date, revealed “…Policy…POC will be reviewed and updated when patient condition changes and a minimum of every 14 days for home care and every 7 days for general inpatient care with the IDT…”.Review of the facility policy and procedure titled “Policy and Procedure #C-3…Subject: Interdisciplinary Team Responsibilities,” effective date 08/05/2022, revealed “…Responsibilities…Attend IDT meetings every 14 days for home-based patients and every 7 days for inpatient…”. Cross reference to L 520/418.54 for additional information.During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.”

“Based on staff interview, patient record reviews, the facility policy and procedure review for the plan of care, the facility failed to ensure care and services were provided in accordance with the plan of care for three (3) of 14 patient medical records reviewed: Patient #6, #7, #8. Findings Include: Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 12:15 p.m. to 12:30 p.m. confirmed no nurse visits for Patient # 7 during dates of 02/25/2025 to 03/11/2025 and 05/13/2025 to 06/03/2025 and no nurse visits for Patient #8 from 12/18/2024 to 01/03/2025 and further confirmed no social worker visit for initial assessment on Patient #6 admitted 02/18/2025 and Patient #8 admitted 11/15/2024. Review of the medical record for Patient #6 revealed no social worker initial comprehensive visit within five days of admission 02/18/2025 with no attempted or missed visit documentation presented for review. Review of the medical record for Patient #7 revealed no nurse visit documentation from 02/25/2025 to 03/11/2025 and no nurse visit documentation from 05/13/2025 to 06/03/2025 for a plan of care Skilled Nurse (SN) frequency of one (1) time a week and no documentation of a missed visit presented for review. Review of the medical record for Patient #8 revealed no social worker initial comprehensive visit within five days of admission date 11/15/2024 and revealed no nurse visit from 12/18/2024 to 01/03/2025 with SN frequency one (1) time a week and as needed and no documentation of a missed visit presented for review. Review of the Facility’s Registered Nurse job description revealed, “…3…Implements physician orders in accordance with plan of care…”.Review of the facility social worker job description revealed, “…Responsibilities…Assessment of the social and emotional factors having an impact on the patient’s health status, assist in the formulation of the Plan of Care (POC)…assess each new admission and complete assessment paperwork within 5 days of patient admission…complete each visit according to POC schedule for Social Worker…”. Review of the facility policy and procedure titled “Subject: Plan of Care,” no date, revealed “…Procedure…3. The psychosocial, spiritual assessment and plan of care will be completed within five (5) days…”. Review of the facility policy and procedure titled, “Policy and Procedure #C-2; Subject: Plan of Care,” no date, revealed “…Procedure:…The frequency of services established in the Plan of Care will be sufficient to effectively manage the terminal diagnosis of the patient…”. Review of the facility policy and procedure titled, “Policy and Procedure #C-3; Subject: Interdisciplinary Team Responsibilities,” effective date 08-05-2022, revealed “Responsibilities…Social Worker…Initial assessment and plan of care to be completed and signed within 5 days of admission…”.During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.”

“Based on staff interview, Quality Assessment and Performance Improvement (QAPI) document review, review of the facility governing body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the facility to assess processes of care, hospice services, and operations on six (6) of six (6) survey days. Findings Include: Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility did not have documentation of collection, aggregation, and analysis of any data to submit that supports the ability of the hospice to assess processes of care, services, and operations. Review of the facility’s documents “QAPI Reports,” dated quarterly, reveal the facility does not have data to support reviews or evidence reviews were completed.Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation related to an ongoing QAPI program review and approval for performance improvement plans, measurements, and outcomes. Review of the facility policy and procedure titled “Governance of Hospice,” no date, revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.Cross reference to L 559/418.58 for additional information.During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.”

“Based on staff interview, Quality Assessment and Performance Improvement (QAPI) document review, review of the facility governing body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility failed to monitor the effectiveness and safety of services and quality of care and identify opportunities and priorities for improvement on six (6) of six (6) survey days. Findings Include: Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility did not have documentation of collection, aggregation, and analysis of any data to submit that supports the ability of the hospice to assess processes of care, services, and operations. Review of the facility’s documents titled “QAPI Reports,” dated quarterly, reveal different indicators to assess with monthly chart audits to monitor. No documentation of monthly chart audit data provided to support the facility’s action taken, monitoring of indicators, and assessing compliance to evaluate its effectiveness and safety of services and quality of care.Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation related to an ongoing Facility QAPI program review, identification of indicators for monitoring/measuring outcomes, or approval of performance improvement plans. Review of the facility policy and procedure titled “Governance of Hospice,” no date, revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.Cross reference to L 559/418.58 for additional information.During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.”

“Based on staff interview, Quality Assessment and Performance Improvement (QAPI) document review, review of the facility governing body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility failed to have approval from the governing body for frequency and detail of data collection on six (6) of six (6) survey days. Findings Include: Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility failed to have documentation evidence of the collection, aggregation, and analysis of any data to submit that supports the ability of the hospice to assess processes of care, services, and operations. Review of the facility’s documents titled “QAPI Reports,” dated quarterly, reveal different indicators to assess with monthly chart audits. There is no documented evidence that the facility completed monthly audits, or that the Governing Body reviewed a QAPI Plan indicating the type and frequency detail of the data collection.Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation related to an ongoing facility-wide QAPI program review and approval for performance improvement plans, data collection, measurements, and outcomes. Review of the facility policy and procedure titled “Governance of Hospice,” no date, revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.Cross Reference to L 559/418.58 for additional information During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.”

“Based on staff interview, Quality Assessment and Performance Improvement (QAPI) document review, review of the facility governing body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility failed to track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice on six (6) of six (6) days of survey. Findings Include: Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility did not have any documentation of collection, aggregation, and analysis of adverse patient events or any QAPI data to submit that supports the ability of the hospice to assess processes of care, services, and operations. Review of the facility’s documents titled “QAPI Reports,” dated quarterly, reveal different indicators to assess with monthly chart audits. The facility is unable to provide QAPI data for adverse events, monthly chart audits or other monitoring activities.Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation of adverse events related to an ongoing QAPI program review and approval for performance improvement plans, data collection, measurements, and outcomes. Review of the facility policy and procedure titled “Governance of Hospice,” no date, revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.Cross reference to L 559/ 418.58 for additional informationDuring an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.”

“Based on staff interview, Quality Assessment and Performance Improvement (QAPI) document review, review of the facility governing body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility failed to take actions aimed at performance improvement and failed to measure outcomes and track performance to ensure that improvements are sustained on six (6) of six (6) survey days. Findings Include: Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility does not have documentation of collection, aggregation, and analysis of any QAPI data that supports the ability of the hospice to assess processes of care, services, and operations. Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation related to an ongoing QAPI program review and approval for performance improvement plans, data collection, measurements, and outcomes. Review of the facility’s documents titled “QAPI Reports,” dated quarterly, reveal different indicators to assess with monthly chart audits. The facility is unable to provide QAPI data for the measurement of outcomes and tracking performance for identified area of improvement.Review of the facility policy and procedure titled “Governance of Hospice,” no date, revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.Cross reference to L 559; 418.58 for additional information on the QAPI programDuring an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.”

“Based on staff interview, Quality Assessment and Performance Improvement (QAPI) document review, review of the facility governing body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility failed to develop, implement and evaluate performance improvement projects on six (6) of six (6) survey days. Findings Include: Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility did not have any documentation of collection, aggregation, and analysis of any QAPI data to submit that supports the ability of the hospice to assess processes of care, services, and operations. Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation related to an ongoing QAPI program review and approval for performance improvement plans, data collection, measurements, and outcomes. Review of the facility’s documents titled “QAPI Reports,” dated quarterly, reveal different indicators to assess with monthly chart audits. The facility is unable to provide QAPI data for development, implementation and evaluation performance improvement projects. Review of the facility policy and procedure titled “Governance of Hospice,” no date, revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.Cross reference to L 559; 418.58 for QAPI programDuring an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.”

“Based on staff interview, Quality Assessment and Performance Improvement (QAPI) document review, review of the facility governing body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility failed to document measurable progress achieved on performance improvement projects on six (6) of 6 days of survey. Findings Include: Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility did not have any documentation of collection, aggregation, and analysis of any QAPI data to submit that supports the ability of the hospice to assess processes of care, services, and operations. Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation related to an ongoing QAPI program review and approval for performance improvement plans, data collection, measurements, and outcomes. Review of the facility’s documents titled “QAPI Reports,” dated quarterly, reveal different indicators to assess with monthly chart audits. The facility is unable to provide QAPI data for the collection, aggregation and analysis of data.Review of the facility policy and procedure titled “Governance of Hospice,” no date, revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.Cross reference to L 559; 418.58 for additional information on the QAPI programDuring an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.”

“Based on staff interview, Quality Assessment and Performance Improvement (QAPI) document review, review of the facility governing body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility’s Governing Body failed to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained, and is evaluated annually on six (6) of six (6) survey days. Findings Include: Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility did not have any documentation of collection, aggregation, and analysis of any QAPI data to submit that supports the ability of the hospice to assess processes of care, services, and operations. Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation related to an ongoing QAPI program review and approval for performance improvement plans, data collection, measurements, and outcomes. Review of the facility’s documents titled “QAPI Reports,” dated quarterly, reveal different indicators to assess with monthly chart audits. The facility is unable to provide QAPI data for adverse events, monthly chart audits or other monitoring activities and show documentation of review by the governing body.Review of the facility policy and procedure titled “Governance of Hospice,” no date, revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.Cross reference to L 559; 418.58 for additional information on the QAPI programDuring an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.”

“Based on staff interview, Quality Assessment and Performance Improvement (QAPI) document review, review of the facility governing body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility failed to ensure that all improvement actions were evaluated for effectiveness on six (6) of 6 survey days. Findings Include: Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility did not have any documentation of collection, aggregation, and analysis of any QAPI data to submit that supports the ability of the hospice to assess processes of care, services, and operations. Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation related to an ongoing QAPI program review and approval for performance improvement plans, data collection, measurements, and outcomes. Review of the facility’s documents titled “QAPI Reports,” dated quarterly, reveal different indicators to assess with monthly chart audits. The facility is unable to provide QAPI data for adverse events, monthly chart audits or other monitoring activities.Review of the facility policy and procedure titled “Governance of Hospice,” no date revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.Cross reference to L 559; 418.58 for additional information on the QAPI programDuring an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.”

“Based on staff interview, review of the Quality Assessment and Performance Improvement (QAPI) documents, review of the Governing Body meeting minutes for the past 12 months, and review of the facility policy and procedure for infection control, the facility failed to maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice’s quality assessment and performance improvement program on six (6) of 6 days of surveys. Findings Include: Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility did not have any documentation of collection, aggregation, or analysis of any infection control data that includes monitoring employee illness/infections and analyzing the data in relation to patient infections.Review of the facility policy and procedure titled, “Subject: Infection Control,” dated 11/09/2023, revealed no documentation of a procedure for surveillance, reporting, preventing, and controlling infectious and communicable diseases. Review of the facility’s documents titled “QAPI Reports,” dated quarterly, reveal different indicators to assess with monthly chart audits. The facility is unable to provide QAPI data for infection control, adverse events, monthly chart audits or other monitoring activities.During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.”