Starlight Hospice Inc.

“Upon patient record review, 11 of 14 (Patients # 1, 2, 3, 5, 6, 7, 9, 10, 11, 12, 14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1) Upon review of the aide plan of care dated 3/8/25, the task of record bowel movement did not have a frequency. Patient #2) Upon review of the aide plan of care dated 3/3/25, the tasks of record bowel movement and change bed linens did not have a frequency. Patient #3) Upon review of the aide plan of care dated 2/28/25, the task of record bowel movement did not have a frequency. Patient #5) Upon review of the aide plan of care dated 5/23/25, the task of record bowel movement did not have a frequency. Patient #6) Upon review of the aide plan of care dated 2/2/25, the task of record bowel movement did not have a frequency. Patient #7) Upon review of the aide plan of care dated 1/22/25, the tasks of record bowel movement and change bed linens did not have a frequency.. Patient #9) Upon review of the aide plan of care dated 12/21/25, the task of change bed linens did not have a frequency. Patient #10) Upon review of the aide plan of care dated 1/16/25, the task of record bowel movement did not have a frequency. Patient #11) Upon review of the aide plan of care dated 1/9/25, the tasks of record bowel movement and change bed linens did not have a frequency. Patient #12) Upon review of the aide plan of care dated 12/27/24, the tasks of record bowel movement and change bed linens did not have a frequency. Patient #14) Upon review of the aide plan of care dated 3/28/25, the tasks of record bowel movement and change bed linens did not have a frequency.”

“Upon patient record review 2 of 14 (Patients # 3, 11) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #3) Patient declined to have hospice aide services as of 5/31/25 and no further visits where made, the patient record did not have evidence of an order to discontinue hospice aide. Patient #11) Upon review of hospice aide’s notes dated 1/3, 1/6, 1/8, 1/10, 1/13, 1/15/25, the documentation included the completion of tasks that where not ordered on the hospice aide plan of care. These tasks are bedrails up, objects within reach, bed in low position, assist with toileting, assist with dressing, and aspiration precautions,”

“Based on record review, document review, policy review, and interview, the facility failed to ensure Plans of Care contained measurable goals for 13 of 14 (Patients (P)1, P2, P3, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14) records reviewed. This had the potential for the staff to be unable to assess progress or lack of progress in a patient’s status related to improvement in health status. Findings include: Review of the Care Plans for 13 of 14 patients revealed there was no documentation to indicate goals included on their Care Plans were measurable. Refer to L548.”

“Based on interview, record review, and policy review, the hospice agency failed to ensure that Physician Orders received by telephone at the Hospice, were received by licensed staff only per Hospice policy and in compliance with applicable laws and regulations related to the health and safety of patients for nine of 14 patients (Patient (P)1, P2, P4, P5, P7 P10, P11, P12, P14). Failure to ensure that only licensed personnel received Physician Orders by telephone had the potential to affect the health and welfare of patients receiving care from the Hospice. Findings include: A review of P1, P2, P4, P5, P7, P10, P11, P12, P14) Physician tab in the electronic medical record (EMR) revealed that an unlicensed staff person received was receiving Physician Orders by telephone. Refer to L678.”

“Based on observation, interview, and policy review, the agency failed to ensure that Emergency Preparedness drills and exercises were conducted according to regulations. Failure to follow the guidelines for conducting these drills had the potential for staff to be unaware of what their responsibilities are during an emergency, which could lead to injuries and had the potential to affect eight of eight current patients. Findings include: A review of the agencys Emergency Preparedness Plan indicated a fire drill was completed on 11/15/24 and on 01/15/25. The Emergency Preparedness Plan indicated that an earthquake drill was held on 11/20/23, 03/20/24, and 01/21/25. A review of the Emergency Drill Report Minutes of Disaster Drill and Critique, located within the Emergency Preparedness binder and completed after both fire drills and earthquake drills, indicated the comments, critiques, and analysis were the same after each drill, both years. Further review of the Emergency Preparedness Plan revealed there was no indication the agency had participated in any community-based drills or documented evidence that the agency attempted to collaborate with any community entity for emergency drills or exercises. A review of the handwritten, undated “Hazard Vulnerability Analysis,” located within the Emergency Preparedness binder, recorded all hazards were rated “four” cumulatively, apart from “Biologic (Epidemic),” which was rated “eight.” Despite this type of event scoring the highest severity classification of all other events, there was no evidence that this type of event drill, planning, or education was conducted. During an interview on 02/26/25 at 2:30 PM, the Administrator Designee confirmed that the staff participated in an online class called “;Shake Out,” which was also related to earthquake training and preparedness. The Administrator Designee was not active in the planning of Emergency Drills and, as a recently hired employee, was not able to speak to the history or logic behind why the drill and preparedness exercises were conducted only for earthquake and fire nor to the lack of community involvement. The Administrator Designee agreed that there was duplication of the drills in previous years and the Hospice needed to widen the variety of drills and exercises completed and make efforts to be more active with the community. A review of the policy titled, “Emergency Operations Plan and Policies,” revised June 2017 and located within the Emergency Preparedness binder under “Procedure,” revealed, “. . . Hospice has developed and maintains an emergency preparedness plan and policies that are reviewed and updated at least annually. The plan:Is based on and includes a documented, facility-based (Hospice) and community-based risk assessment, utilizing an all-hazards approach.Includes strategies for addressing emergency events identified by the risk assessment . . .Hospice will coordinate efforts with area emergency management agencies, to mitigate, prepare, respond and recover from high priority emergencies that impact the community, e.g., local health department, law enforcement and office of emergency management . . . Working closely with other agencies and hospitals in referral areas to plan fordisasters and emergency situations . . .””

“Based on interview, record review, and policy review, the hospice agency failed to ensure complete and accurate drug profiles were maintained on 2 of 14 patients (Patient (P) P2 and P7) whose records were reviewed out of a total sample of 14. This deficient practice had the potential to affect health and safety through adverse events such as increased drug side effects, actual or potential drug reactions, and duplicate drug therapy for the agency’s patients. Findings include: A review of the policy No.4-050.1 “Medication Profile” revealed, a drug regimen review will be performed by a registered nurse at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. An interview conducted with the Administrator Designee on 02/25/25 at 12:15 PM revealed that the procedure for medication reconciliation in the home should be conducted at each patient visit. The Administrator Designee further explained that clarification and new orders should be obtained from the physician when discrepancies are found. When new orders are obtained, the Plan of Care and Current Treatment/Medication/DME List should be updated at that time. 1. A home visit was conducted with P2, who was admitted to hospice service on 10/24/24 with a terminal diagnosis of chronic kidney disease and with a comorbid diagnosis of hypertension, with the Registered Nurse (RN1) on 02/26/25 at 3:30 PM. Discrepancies between the medications listed on the undated, printed “Current Treatment/Medication/DME List” provided by the hospice agency and the medications were found in the patient’s home. A. Hydralazine 25 milligram (mg) tablets, one by mouth every eight hours as needed for systolic blood pressure greater than 160 [millimeters of Mercury (mmHg)] was present in the patient’s medication box, but this was not included on the undated, printed “Current Treatment/Medication/DME List provided by the agency. The printed Plan of Care Summary with an effective date of 02/24/25 provided by the agency did not list this medication. An interview with RN1 revealed that this medication should not be present and was an old prescription. An interview conducted during the visit with the facility caregiver and a review of the facility medication record revealed that this medication was not listed as active and had not been administered this calendar year. No other older records were available to review. No explanation was given as to why the medication had not been discarded. 2. A home visit was conducted for P7, who was admitted to hospice service on 09/09/24 with a terminal diagnosis of chronic obstructive pulmonary disease, with the Hospice Aide on 02/25/24 at 10:00 AM. Discrepancies between the medications listed on the undated, printed “Current Treatment/Medication/DME List,” provided by the hospice agency, and the medications found in the patient’s home were noted. The Plan of Care Summary (POC Summary), a printed document with the effective date of 02/24/25 that was provided by the hospice agency prior to the home visit, mirrored the findings on the Current Treatment/Medication/DME List. The medication reconciliation in the home revealed: a. Albuterol 2.5 mg/3 Milliliters (ml) for nebulizer. This was a single packet and not contained in a box with further dosing instructions. During the interview, the patient confirmed that this medication was currently utilized and provided by the hospice. This medication was not listed on the undated, printed “Current Treatment/Medication/DME List” provided by the hospice agency, nor was it listed on the undated, printed “Current Treatment/Medication/DME List” located within the patient binder in the home. b. Hydralazine hydrochloride 10 mg, three tablets orally three times daily, was recorded on the undated, printed “Current Treatment/Medication/DME List.” The medication bottle in the home recorded, Hydralazine hydrochloride 10 mg, three tablets orally daily. During the interview, the patient’s family member confirmed that he/she administered the patient’s tablet medications, and the Hydralazine Hydrochloride 10 mg was given once daily, as indicated on the medication bottle found in the home. c. The undated, printed “Current Treatment/Medication/DME List” provided by the hospice recorded, Metformin 500 mg, two tablets oral twice daily. The bottle found in the home recorded. Metformin 1000 mg, one tablet twice daily. During the interview, the family member confirmed that the patient was administered one 1000 mg tablet twice daily per the bottle instructions. The potential existed for the patient to be administered two 1000 mg tablets if the written instructions for the incorrectly listed 500 mg Metformin were to be confused with the correct instructions for one 1000 mg tablet. d. Methocarbamol 500 mg tablet, three tablets orally twice daily, was recorded on the undated, printed “Current Treatment/Medication/DME List” provided by the hospice agency. The bottle found in the home recorded, Methocarbamol 500 mg tablet three tablets orally daily. It was confirmed per the patient’s family member that this medication was only administered on an as needed basis, although the medication was ordered routinely on the bottle instructions and the undated, printed “Current Treatment/Medication/DME List,” both provided by the agency and a second copy found in the patient’s home “Patient Information” binder.”

“Based on record review, interview and facility policy review, the facility failed to ensure that patient Plans of Care (POCs) included measurable goals to assess if progress toward expected outcomes were being met for 13 of 14 sampled patients (Patient (P) 1, P2, P3, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14) reviewed for care plan development. This deficient practice had the potential to affect all patients receiving services from the facility. Findings include: Review of the facility policy titled, Plan of Care, revised in November 2020, indicated the written Plan of Care includes, but is not limited to “. . . measurable outcomes anticipated from implementing and coordination of the plan of care . . .” 1. Review of P1’s electronic medical record (EMR) revealed a Care Plan developed to address P1s spiritual needs relative to a fear of the unknown, dated 11/28/24, included a goal of healing road to peace 2 weeks. An additional Care Plan developed to address P1s anxiety and depression, dated 01/30/25, included a goal of minimize episodes of anxiety and depression 2 weeks. An additional Care Plan developed to address P1s deficit in activities of daily living (ADLs), dated 11/28/24, included the goal of ADL needs are met 2 weeks, The POC did not include measurable data elements to monitor progress toward the expected outcomes and goals. 2. Review of P2’s EMR revealed a Care Plan, developed to address P2s spiritual needs relative to a low risk related to bereavement, dated 10/24/24, included a goal of coping and acceptance of death by Patient/PCG 2 weeks. An additional Care Plan developed to address P2s ambulatory with fall risk status, dated 10/24/24, included the goal of maintain mobility and independence 2 weeks. The POC did not include measurable data elements to monitor progress toward the expected outcomes and goals. 3. Review of P3’s EMR revealed a Care Plan, located under the POC tab, developed to address P3s contractures and weakness, dated 02/02/25, included a goal of increase strength and energy for functional activities. An additional Care Plan developed to address P3s potential for altered cardiac status due to arrythmias and poor cardiac output, dated 12/26/24, included the goal of Pt will have adequate cardiac output and no arrythmias 2 weeks. The POC did not include measurable data elements to monitor progress toward the expected outcomes and goals. 4.Review of P5’s EMR revealed a “;Care Plan,” located under the “;POC” tab, developed to address P5s potential for harm related to lower extremity weakness, dated 11/04/24, included a goal of “;minimize injury during ambulation 2 weeks.” An additional “;Care Plan” developed to address P5s use of Trazodone (antidepressant medication), dated 11/04/24, included a goal of “;Patient will have adequate period of rest and sleep.” The “;POC” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 5. Review of P6s EMR revealed a Care Plan, developed to address P6s potential for altered nutritional status due to poor PO (oral intake), dated 08/12/24, included a goal of patient will meet nutritional needs 2 weeks. The POC did not include measurable data elements to monitor progress toward the expected outcomes and goals. 6. Review of P7’s EMR revealed a Care Plan, developed to address P7’s potential for neurologic/mental alteration secondary to anxiety and depression, dated 07/09/24, included a goal of minimize episodes of anxiety and depression in 2 weeks. An additional Care Plan developed to address P7s chronic pain, dated 12/29/24, included a goal of relieve pain to increase rest and comfort 2 weeks. The POC did not include measurable data elements to monitor progress toward the expected outcomes and goals. 7. Review of P8s EMR revealed a Care Plan, developed to address P8s anxiety, dated 01/09/25, included a goal of minimize episodes of anxiety and depression 2 weeks. An additional Care Plan developed to address P8s potential for harm related to impaired balance, dated 01/09/25, included a goal of minimize injury during ambulation 2 weeks. The POC did not include measurable data elements to monitor progress toward the expected outcomes and goals. 8. Review of P 9s EMR revealed a Care Plan, developed to address P9s potential for altered nutritional status related to loss of appetite, dated 08/19/24, included a goal of patient will have adequate food and fluids as tolerated 2 weeks. An additional Care Plan developed to address P9s hypothyroidism, dated 08/19/24, included a goal of maintain normal thyroid hormone level in 2 weeks. The POC did not include measurable data elements to monitor progress toward the expected outcomes and goals. 9. Review of P10s EMR revealed a Care Plan,” located under the “;POC” tab developed to address P10s use of Morphine (opioid pain medication) for pain, dated 08/06/24, included a goal of “;relieve pain to promote rest and comfort in 2 weeks.” The “;POC” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 10. Review of P11s EMR revealed a Care Plan, developed to address P11s use of oxygen as needed for shortness of breath, dated 05/29/24, included a goal of minimize episodes of shortness of breath during activities of daily living (ADLs) in 2 weeks. An additional Care Plan developed to address P11s altered sleep patterns, dated 05/29/24, included a goal of patient will have adequate period of rest and sleep in 2 weeks. The POC did not include measurable data elements to monitor progress toward the expected outcomes and goals. 11. Review of P12s EMR revealed a Care Plan, developed to address P12s grieving family, dated 03/18/24, included a goal of be able to cope with changes in 2 weeks. An additional Care Plan developed to address P12s potential for harm, dated 03/18/24, included a goal of minimize injury during ambulation in 2 weeks. The POC did not include measurable data elements to monitor progress toward the expected outcomes and goals. 12. Review of P13s EMR revealed a Care Plan, developed to address P13s chest pain, dated 10/25/23, included a goal of manage pain to promote rest and comfort. An additional Care Plan, developed to address P13s altered cardiac status secondary to high blood pressure, dated 12/04/23 included a goal of patient will have adequate cardiac output and no arrhythmias 2 Weeks. The POC did not include measurable data elements to monitor progress toward the expected outcomes and goals. 13. Review of P14s EMR revealed a Care Plan, developed to address P14s incontinence, dated 05/04/24, included a goal of improve urinary flow and reduce symptoms and preventing serious complications and improve of quality of life. two weeks. An additional Care Plan developed to address P14s potential for fall/injury, dated 08/07/24, included a goal of no fall/injury will happen. The POC did not include measurable data elements to monitor progress toward the expected outcomes and goals. During an interview with the Administrator Designee on 02/27/25 at 2:00 PM, the Administrator Designee reviewed the care plans with the surveyor and confirmed the goals on patient care plans were not measurable. She stated the software used contains a drop-down menu for goals and she stated staff was not tailoring them to hospice care and having a way to measure the progress.”

“Based on interview, policy review, and observation, the agency failed to ensure the Quality Assessment Performance Improvement (QAPI) program was maintained according to regulations. Failure to follow the guidelines for the development, implementation, and maintenance of this program has the potential to negatively impact eight of eight current patients. Findings include: A review of all four of the quarterly reports, located within the Quality Assessment Performance Improvement binder, for quarters one through four for the year 2024, indicated there was no documented evidence of measurable improvement in outcomes either as compared month to month, quarter to quarter, or any progress or improvements made within the calendar year. The surveyor completed all analyses shown in this citation for demonstration purposes. In the year 2024, quarter one, undated printed reports recorded a total of 17 live discharges from the agency. Upon request, this quarter’s printed Average Daily Census (ADC) report was provided. Analysis showed 38% of the agency’s ADC for the first quarter of 2024 were live discharges. No documented evidence was found to show any analysis or measurement of improvement or decline in each live discharge type or aggregate discharge trends over previous months, quarters, or years. In the year 2024, quarter two, undated printed reports recorded a total of 31 live discharges from the agency. Upon request, the printed Average Daily Census (ADC) report was provided for this quarter. Analysis showed 79% of the agency’s ADC for the second quarter of 2024 were live discharges. No documented evidence was found to show any analysis or measurement of improvement or decline in each live discharge type or aggregate discharge trends over previous months, quarters, or years. In the year 2024, quarter three, undated printed reports recorded a total of 7 live discharges from the agency. Upon request, this quarter’s printed Average Daily Census (ADC) report was provided. Analysis showed 39% of the agency’s ADC for the third quarter of 2024 were live discharges. No documented evidence was found to show any analysis or measurement of improvement or decline in each live discharge type or aggregate discharge trends over previous months, quarters, or years. In the year 2024, quarter four, undated printed reports recorded a total of 9 live discharges from the agency. Upon request, this quarter’s printed Average Daily Census (ADC) report was provided. Analysis showed 50% of the agency’s ADC for the third quarter of 2024 were live discharges. No documented evidence was found to show any analysis or measurement of improvement or decline in each live discharge type or aggregate discharge trends over previous months, quarters, or years. A review of the QAPI Summary Report and Professional Advisory Committee Meeting minutes dated 03/31/24, 06/29/24, 09/29/24, and 12/30/24 did not address the above reports or their findings. The sections contained within the minutes titled Scope of Services, Admission/Discharge, Care Planning Process, Clinical Records Review Summary, Personnel Management, Management/Supervision/Administration, Customer Satisfaction, Financial Performance, Contract Management Process, Infection Control/Safety/Risk Management Process, Emergency Care Processes, Policies, Procedures and Administrative Practice, Performance Improvement Process, and Strategic Planning Process, all record ongoing as the plan to the improve. There was no evidence found that any of the reports were analyzed or compiled to measure improvement or decline. A review of the undated policy titled Quality of Services and Products located within the Quality Assessment Performance Improvement binder under the heading Responsibilities of the QAPI Coordinator records, the QAPI Coordinator chairs the QAPI Committee and is responsible for coordinating and facilitating all quality improvement activities. This includes but is not limited to: Bullet point number four under this heading indicated, evaluating the effectiveness of planned and implemented actions. During an interview with the Administrator Designee on 02/26/25 at 9:00 AM, it was clarified all 2024 QAPI Program materials, documents, and reports were contained within the QAPI Program” binder. The Administrator Designee further clarified that no aggregate reports were compiled to show measurable improvement each month, quarter, or year over year.”

“Based on interview, policy review, and observation, the agency failed to ensure the Quality Assessment Performance Improvement (QAPI) program was maintained according to regulations. Failure to follow the guidelines for the development, implementation, and maintenance of this program has the potential to negatively impact eight of eight of the agency’s current patients. Findings include: A review of all four of the quarterly reports, located within the Quality Assessment Performance Improvement binder, for quarters one through four for the year 2024, indicated there was no documented evidence of analysis, tracking, or trending of quality indicators. The surveyor completed all analyses shown in this citation for demonstration purposes. The agency failed to aggregate any of the data found on quarterly reports into any documented evidence of analysis or interpretation of the data, and no evidence was found of documented tracking or trending of this data to determine the needed performance improvement, education, or necessary process changes. Quarter one 2024 findings included printed reports with only the total number of patients. The undated Discharge reports located in the QAPI Program binder with the handwritten titles of Prognosis Extended, Status Improved, and Symptoms Managed, indicated a total of 11 patients discharged for these reasons in the first quarter of 2024. Upon request, the Average Daily Census (ADC) printed report provided to the surveyor was 45 for the first quarter of 2024. The percentage of the agency ADC discharged for these reasons was 24%. Further, the undated Discharge report located in the QAPI Program binder with the handwritten title of Revocations revealed six patients choosing to revoke hospice services in the first quarter of 2024. The percentage of the agency ADC discharged for this reason was 13%. This equaled 17 live discharges from this agency in the first quarter, 38% of their ADC. The report, located in the QAPI Program binder with the title Unwanted Hospitalization Measure Report, recorded 42.86% of patients were hospitalized in the first quarter, even after preference not to be hospitalized. No documented evidence was found of the analysis, tracking, trending, or actions needed to address these findings. Quarter two 2024 findings included printed reports with only the total number of patients. The undated Discharge reports located in the QAPI Program binder with the handwritten titles of Prognosis Extended, Status Improved, and Symptoms Managed, indicated a total of 24 patients discharged for these reasons in the second quarter of 2024. The Average Daily Census (ADC) for this quarter was 39. The percentage of the agency ADC discharged for these reasons was 62%. Further, the undated Discharge report located in the QAPI Program binder with the handwritten title of Revocations revealed seven patients choosing to revoke hospice services in the second quarter of 2024. The percentage of the agency ADC discharged for this reason was 18%. This equaled 31 live discharges from this agency in the second quarter, 79% of their ADC. The report located in the QAPI Program binder with the title of Unwanted Hospitalization Measure Report, records 16.67% of patients were hospitalized in the second quarter even after preference not to be hospitalized. No documented evidence was found of the analysis, tracking, trending, or actions needed to address these findings. Quarter three 2024 findings included printed reports with only the total number of patients. The undated Discharge reports located in the QAPI Program binder with the handwritten titles of Prognosis Extended and Symptoms Managed, indicated a total of seven patients discharged for these reasons in the third quarter of 2024. No report was found titled Status Improved as in previous quarters. The Average Daily Census (ADC) for this quarter was 18. The percentage of the agency ADC discharged for these reasons was 39%. Further, the undated Discharge report located in the QAPI Program binder with the handwritten title of Revocations, revealed two patients choosing to revoke hospice services in the third quarter of 2024. The percentage of the agency ADC discharged for this reason was 11%. This equaled nine live discharges from this agency in the third quarter, 50% of their ADC. The report located in the QAPI Program binder with the title of Unwanted Hospitalization Measure Report, records that 0% of patients were hospitalized in the third quarter even after preference not to be hospitalized. No documented evidence was found of the analysis, tracking, trending, or actions needed to address these findings. The report located in the QAPI Program” binder with the title of Comfortable Dying Measure records that 50% of patients responded no to the question, Was your pain brought to a comfortable level within 48 hours of the start of hospice care? There was no documented evidence found of this data measure being further analyzed for needed process change, improvement plan, or staff education. Quarter four 2024 findings included printed reports with only the total number of patients. The undated Discharge reports located in the QAPI Program binder with the handwritten titles Prognosis Extended, Status Improved, and Symptoms Managed, indicated a total of 9 patients discharged for these reasons in the fourth quarter of 2024. The Average Daily Census (ADC) for this quarter was 13. The percentage of the agency ADC discharged for these reasons was 69%. There is no Discharge report located in the QAPI Program binder with the handwritten title of Revocations, found for the fourth quarter of 2024. The report located in the QAPI Program binder with the title of Unwanted Hospitalization Measure Report, records that 9.09% of patients were hospitalized in the fourth quarter even after preference not to be hospitalized. A review of the QAPI Summary Report and Professional Advisory Committee Meeting minutes dated 03/31/24, 06/29/24, 09/29/24, and 12/30/24, did not address the above reports or their findings. The sections contained within the minutes titled Scope of Services, Admission/Discharge, Care Planning Process, Clinical Records Review Summary, Personnel Management, Management/Supervision/Administration, Customer Satisfaction, Financial Performance, Contract Management Process, Infection Control/Safety/Risk Management Process, Emergency Care Processes, Policies, Procedures and Administrative Practice, Performance Improvement Process, and Strategic Planning Process, all record ongoing as the plan to the improve. There was no evidence found that any of the reports were aggregated, trended, or analyzed. There was no documented evidence of any discussion by the QAPI Committee during these meetings to track, trend, or analyze each quarter’s data in any way. A review of the undated policy titled Quality of Services and Products located within the Quality Assessment Performance Improvement binder under the heading Responsibilities of the QAPI Coordinator recorded, The QAPI Coordinator chairs the QAPI Committee and is responsible for coordinating and facilitating all quality improvement activities. This includes but is not limited to: Bullet point number six under this heading indicated, Aggregating, trending and analyzing data using appropriate statistical techniques. During an interview with the Administrator Designee on 02/26/25 at 9:00 AM, it was clarified that all 2024 QAPI Program materials, documents, and reports were contained within the QAPI Program binder. The Administrator Designee further clarified that no reports were compiled to aggregate each month, quarter, or year for analysis, tracking, or trending.”

“Based on documentation review, interview, and policy review, the agency failed to demonstrate viable and ongoing efforts that they were actively attempting to recruit volunteers. This had the potential to cause eight of eight agency patients to have unmet needs. Findings include: A review of the Volunteers binder indicated the method used for recruitment was a flyer. There was no evidence of any other methods being used. A review of the Volunteer Activity schedules dated for 2023 and 2024 indicated all the schedules and plans were the same, containing the same recruitment plans every year as follows: January- ACHC Volunteer Program Training and Inservice for Roles and Responsibilities. Flyers went out and posted at church, grocery store and Restaurant. February- Meeting with Clinical staff regarding recruitment plan (volunteer requirement) March- Flyers went out and posted at church, grocery store, laundromat, and Restaurant. April- Meeting follow-up regarding recruitment plan. May- Training and Services Hospice MD volunteer documentation June- Training and Inservice Hospice MD to get report. July- Flyers went out posted to churches. August- Training and Inservice for different types of volunteers September- Flyers went out posted at restaurant and laundromat. October- Training and In-services Facility November- Flyers went out and posted at grocery store. December- Re-evaluation of recruitment plan and training and in-service A review of the Volunteer Activity plan dated for 2025 indicated the months of January and February were the same as January and February 2023 and 2024. The months of March 2025 through December 2025 were blank, with no documented evidence of volunteer recruitment activities planned. During an interview with the Volunteer Coordinator (VC) on 02/25/25 at 2:30 PM, the VC acknowledged that the 2025 plan needed to be completed to include more proactive, varied recruitment strategies. The VC could not address the rationale behind recruitment strategies from previous years as this role was recently acquired. However, the Volunteer Coordinator did express understanding of the intent and importance of a robust and varied recruitment plan. The undated policy titled “Volunteer Staff” number “H:3-012.1” located within the “Volunteer” binder recorded as Procedure number one documented, “there will be active and ongoing efforts to recruit, train, and retain volunteers . . .””

“Based on interview, record review, and policy review, the hospice agency failed to ensure that telephone or verbal physician orders were received by licensed Hospice staff per Hospice policy and regulation for nine of 14 patients (Patient (P)1, P2, P4, P5, P7, P11, P12, P13, P14) whose records were reviewed out of a total sample of 14. This deficient practice had the potential to cause adverse effects on the quality of care, quality of life, health, and safety of the agency’s patients. Findings include: Review of the Hospice policy titled, “Verification of Physician Orders,” dated November 2020, revealed, “. . . To ensure that accurate physician . . . orders are obtained in accordance with applicable law and regulation . . . Orders will be obtained from a licensed physician ... for care and services to be provided to hospice patients . . . Verbal orders will be taken and documented only by professional, licensed hospice personnel . . .” 1. Review of P1’s Demographics, revealed P1 was admitted to Hospice services on 11/28/24 with diagnoses that included metabolic encephalopathy. A review of P1’s EMR revealed Physicians Orders, dated 11/28/24, indicated the admission orders included medications such as Tramadol (opioid pain medication) and were documented to be a phone order/read back with a digital signature attached, belonged to an administrative employee who was not a licensed clinician. 2. Review of P2’s Demographics, revealed P2 was admitted to Hospice services on 10/24/24 with diagnoses that included chronic kidney disease. A review of P2’s EMR revealed Physicians Orders, dated 11/13/24 indicated an order for oxygen and an oxygen concentrator and was documented to be a phone order/read back with a digital signature attached, belonged to an administrative employee who was not a licensed clinician. 3. Review of P’4s Demographics, revealed P4 was admitted to Hospice services on 12/03/24 with diagnoses that included respiratory failure with hypoxia. A review of P4’s EMR revealed admission Physician Orders, dated 12/03/24, which included orders for medications such as Tramadol (opioid pain medication) and was documented as phone order/read back with a digital signature attached, belonged to an administrative employee who was not a licensed clinician. 4. Review of P5s Demographics, revealed P5 was admitted to Hospice services on 11/04/24 with diagnoses which included cerebral infarction. Review of P5s EMR revealed admission Physician Orders, dated 11/04/24, which included orders for medications such as Carbidopa (Parkinsons medication) and was documented as phone order/read back with a digital signature attached, belonged to an administrative employee who was not a licensed clinician. 5. Review of P7s Demographics, revealed P7 was admitted to Hospice services on 07/09/24 with diagnoses which included chronic obstructive pulmonary disease (COPD). Review of P7s EMR revealed Physician Orders, dated 07/11/24, which included an order for oxygen and was documented as phone order/read back with a digital signature attached, belonged to an administrative employee who was not a licensed clinician. 6. Review of P11s Demographics, revealed P11 was admitted to Hospice services on 05/29/24 with diagnoses which included arteriosclerotic heart disease. Review of P11s EMR revealed Physician Orders, dated 05/29/24, which included an order for medications such as Norco (opioid pain medication) and was documented as phone order/read back with a digital signature attached, belonged to an administrative employee who was not a licensed clinician. 7. Review of P12s Demographics, revealed P12 was admitted to Hospice services on 03/18/24 with diagnoses which included arteriosclerotic heart disease. Review of P12s EMR revealed Physician Orders, dated 03/18/24, which included an order for Nitroglycerin 0.4 milligrams (vasodilator medication) and was documented as phone order/read back with a digital signature attached, belonged to an administrative employee who was not a licensed clinician. 8. Review of P13s Demographics, located in the EMR, revealed P13 was admitted to Hospice services on 10/25/23 with diagnoses which included chronic pain. Review of P13s EMR revealed Physician Orders, dated 10/25/23, which included an order for Tramadol and was documented as phone order/read back with a digital signature attached, belonged to an administrative employee who was not a licensed clinician. 9. Review of P14s Demographics, revealed P14 was admitted to Hospice services on 05/04/24 with diagnoses which included senile degeneration of the brain. Review of P14s EMR revealed Physician Orders, dated 05/04/24, which included an order for Percocet (opioid pain medication) and was documented as phone order/read back with a digital signature attached, belonged to an administrative employee who was not a licensed clinician. During an interview with the Designee Administrator on 02/27/25 at 10:30 AM, the Designee Administrator reviewed the Physician Orders in question and agreed that the employee taking these orders was an administrative employee and not a licensed clinician. The Administrator stated that the administrative employee creates the Physician Orders and the Medical Director signs them. When the Designee Administrator was shown orders documented as phone order/read back that were received by the unlicensed employee, there was no further explanation.”