Star Hospice Care Inc.

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, and document review which revealed the hospice: Failed to ensure the registered nurse member of the IDG provided coordination of care, ensured continuous assess of each patient’s and family needs and ensured the implementation of the IDG{HCPC.19.I/L540/ 418.56(a)}; Failed to ensure the patient’s individualized written plan of care contained measurable outcomes anticipated from implementing and coordinating the plan of care {HCPC.21.I /L548/ 418.56(c)(3)}; and Failed to ensure that the plan of care included drugs and treatment necessary to meet the needs of the patient {HCPC.21.I/L549/ 418.56(c)(4)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.56: IDG, Care Planning, Coordination of Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program: reflects the complexity of the hospice and services; involves all hospice services, including those provided under contract; addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness; focuses on indicators related to improved palliative outcomes; includes investigation and analysis of sentinel and adverse events; includes defined data detail and frequency of collection, and approves such; has evidence of action taken that results in improvement in hospice performance; and, is evaluated annually. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of Participation was not met as evidenced by document review, Quality Assessment and Performance Improvement (QAPI) documents, and interviews which revealed issues with the organization’s QAPI program in the following areas: Failed to ensure that the governing body appointed an individual as responsible for operating the QAPI program {HQPI.2.I/L576/418.58(e)(3)}; Failed to ensure that the QAPI program demonstrated measurable improvement among indicators related to improved palliative outcomes and hospice services in 2022 and 2023{HQPI.3.I/L561/418.58(a)(1)}; Failed to ensure the hospice tracked, measured and analyzed quality indicators of performance that enabled the assessment of processes of care, hospice services, operations, and adverse patient events{HQPI.4. I/L562/418.58(a)(2)}; Failed to ensure the collection of data to monitor the effectiveness and safety of services and quality of care or identify {HQPI 5.I/L564/418.58(b)(2)(ii)}; Failed to ensure that the governing body approved the frequency and detail of the data collection {HQPI.5.I/L565/418.58(b)(3)}; Failed to ensure that hospice performance improvement (PI) activities involved licensed professionals as participants {HQPI.6.I/L586/418.62(c)}; Failed to ensure that performance improvement activities: Analyze the causes; Implement preventive action and mechanisms that include feedback and learning throughout the hospice{HQPI.7.I/L569/418.58(c)(2)}; Failed to ensure that the hospice took action to improve performance, assess the success of the action after implementing it and track ongoing results to ensure improvement was sustained. There was no documented evidence to show a QAPI program was in place in 2022 and 2023 {HQPI.8.I/L570/418.58(c)(3)}; and Failed to ensure that the hospice documented what performance improvement projects were being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects {HQPI.9.I/L573/418.58(d)(2)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.58: Quality assessment and performance improvement. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice must use volunteers to the extent specified in paragraph (e) of this section. These volunteers must be used in defined roles and under the supervision of a designated hospice employee. Volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care and documented in the patient record, including the time spent. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition of Participation was not met as evidenced by a review of clinical records, document review, and interview which revealed the hospice: Failed to ensure that volunteers were used in day-to-day administrative and/or direct patient care roles in 2024 {HCDT.21.I/L644/ 418.78(b)}; Failed to ensure that agency had ongoing efforts to recruit and retain volunteers for 2022, 2023 and 2024 {HSRM.30.I/L645/ 418.78(c)}; and Failed to ensure that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff for 2024 {HSLG.7.I/L647/ 418.78(e)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.78: Volunteers. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by document review, personnel record reviews, clinical record reviews, and interviews which revealed issues with the organization’s compliance with local, state, and federal law and regulation related to the health and safety of patients: and as a licensed entity if state or local law provides for hospice licensing in the following areas: Failed to ensure the Hospice Administrator was an employee of the organization {HSLG.3.I/L651/ 418.100(b)}; Failed to ensure an orientation was provided to all employees and contracted staff who have patient and family contact that included the hospice philosophy{HSRM.15.I/L661/ 418.100(g)(1)}; Failed to ensure to an orientation was provided that addressed the employee’s specific job duties {HSRM.15.I/L662/ 418.100(g)(2)}; and Failed to assess the skills and competency of the individuals providing care{HSRM.14.I/L663/ 418.100(g)(3)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation CFR 418.100: Organization and administration of services. The impact of this deficiencies could negatively impact the agency’s provision of safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and service from the agency.”

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: For all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; Demonstration of staff knowledge of emergency procedures; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; More frequent training occurs if there is a significant update of EP policies and procedures; A periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and Documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by interview and personnel record review. In 2 of 11 (18%) personnel records reviewed revealed the agency did not ensure that all new hospice employees and those providing services under arrangement received initial training in EP policies and procedures consistent with their expected roles. Personnel Record 4: The Nurse Practitioner was hired on 01/09/2024. There was no documented evidence of initial training in EP policies and procedures consistent with their expected role. Personnel Record 11: The Hospice Administrator was hired on 06/12/2023 as an independent contractor and termed the last week of December 2023. There was no documented evidence of initial training in EP policies and procedures consistent with their expected role. During an interview on 12/06/2024, the Director of Patient Care Services agreed there was no evidence the training was provided. The Director of Patient Care Services stated, “these two staff do not have much at all for a personnel file.””

“It is required that the hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include, but is not limited to: A second full-scale exercise that is community-based or a facility-based functional exercise; or A mock disaster drill; or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. A review of the Emergency Preparedness Binder revealed the hospice providing care in the patient’s home did not conduct exercises to test the emergency preparedness plan annually including participation in a full-scale exercise that was community-based every two (2) years Document 2: The Emergency Preparedness Binder documented a fire drill on 02/15/2024. There was no documented evidence of a full-scale exercise that was community-based every two (2) years. There was no documented evidence that the hospice tested the emergency preparedness plan annually in 2022 or 2023. During an interview on 12/06/2024, the Director of Patient Care Services stated, “There is nothing documented for Emergency Preparedness for 2022 or 2023. A review of the Emergency Preparedness Binder revealed the agency did not ensure to test the Emergency Preparedness every year.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 3 (33%) home visit observations revealed the agency did not ensure the drug profile was updated at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. Home Visit 2: During the home visit with the Registered Nurse Case Manager (Personnel Record 5) and Director of Patient Care Services (Personnel Record 2) on 12/05/2024, a medication review was completed by comparing the hospice medication profile to the patient’s current medications with the daughter. The daughter presented Diclofenac Sodium 1% gel apply to affected area topically every 6 hours as needed for pain, Ventolin HFA Albuterol Inhaler 108 90 base/act inhale one puff by mouth every 6 hours as needed for shortness of breath, and Colace 100mg capsule, take one every day as needed for constipation. The daughter stated that the patient uses the Diclofenac Sodium gel almost every day, the Ventolin Inhaler about once a month, and the Colace about twice a week. The Diclofenac Sodium gel, Ventolin inhaler and Colace were not listed on the hospice medication profile printed on 12/04/2024. During the home visit the Registered Nurse Case Manager (Personnel Record 5), stated “I need to get these updated on the profile.” During a joint record review and interview on 12/05/2024, the Director of Patient Care Services agreed that the patient’s medication profile was not updated with the current medications.”

“It is required that the hospice designates a registered nurse member of the interdisciplinary group (IDG) to provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed the hospice did not ensure the registered nurse member of the IDG provided coordination of care, ensured continuous assess of each patient’s and family needs and ensured the implementation of the IDG. Clinical Record 1: The patient elected the hospice benefit on 10/17/2024 for the diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. The plan of care updated on 10/29/2024 identified a cardiovascular problem - potential for alteration in cardiovascular system related to heart disease with the goal, “optimal cardiovascular function” and a respiratory problem - potential for altered respiratory status related to shortness of breath on exertion with the goal, “optimal respiratory status.” The plan of care did not include measurable goals for the patient’s cardiovascular and respiratory problems. Clinical Record 3: The patient elected the hospice benefit on 06/14/2024 for the diagnosis Atherosclerotic heart disease of native coronary artery with unstable angina pectoris. The plan of care updated on 06/14/2024 identified a cardiovascular problem - potential for alteration in cardiovascular system related to heart disease with the goal, “optimal cardiovascular function.” The plan of care did not include a measurable goal for the cardiovascular problem. Clinical Record 4: The patient elected the hospice benefit on 03/27/2024 for the diagnosis of Senile degeneration of brain. During the home visit 2 with the Registered Nurse Case Manager (Personnel Record 5) on 12/05/2024, a medication review was completed by comparing the hospice medication profile to the patient’s current medications with the daughter. The daughter presented Diclofenac Sodium 1% gel apply to affected area topically every 6 hours as needed for pain, Ventolin HFA Albuterol Inhaler 108 90 base/act inhale one puff by mouth every 6 hours as needed for shortness of breath, and Colace 100mg capsule take one every day as needed for constipation. The daughter stated that the patient uses the Diclofenac Sodium gel almost every day, the Ventolin Inhaler about once a month, and the Colace about twice a week. The Diclofenac Sodium gel, Ventolin inhaler and Colace were not listed on the hospice medication profile printed on 12/04/2024 and the plan of care reviewed on 12/05/2024 did not include the Diclofenac Sodium gel, Ventolin Inhaler, and Colace. There was no documented evidence that the medication list and the plan of care was updated by the registered nurse. During a joint record review and interview on 12/05/2024, the Director of Patient Care Services agreed that the goals were not defined and measurable and that the plan of care did not include the drugs and treatment necessary to meet the needs of the patient.”

“It is required that each patient’s individualized written plan of care contains measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure the patient’s individualized written plan of care contained measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 1: The patient elected the hospice benefit on 10/17/2024 for the diagnosis Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. The plan of care updated on 10/29/2024 identified a cardiovascular problem - potential for alteration in cardiovascular system related to heart disease with the goal, “optimal cardiovascular function” and a respiratory problem - potential for altered respiratory status related to shortness of breath on exertion with the goal, “optimal respiratory status.” The plan of care did not define “optimal” nor include measurable goals for the cardiovascular and respiratory problems. Clinical Record 3: The patient elected the hospice benefit on 06/14/2024 for the diagnosis Atherosclerotic heart disease of native coronary artery with unstable angina pectoris. The plan of care updated on 06/14/2024 identified a cardiovascular problem - potential for alteration in cardiovascular system related to heart disease with the goal, “optimal cardiovascular function.” The plan of care did not define “optimal” nor include a measurable goal for the cardiovascular problem. During a joint record review and interview on 12/05/2024, the Director of Patient Care Services agreed that “optimal” goals were not defined and measurable.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals; Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; Includes all services necessary for the palliation and management of the terminal illness, including the following drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that the plan of care included drugs and treatment necessary to meet the needs of the patient. Clinical Record 4: The patient elected the hospice benefit on 03/27/2024 for the diagnosis of Senile degeneration of brain. During the home visit 2 with the Registered Nurse Case Manager (Personnel Record 5) on 12/05/2024, a medication review was completed by comparing the hospice medication profile to the patient’s current medications with the daughter. The daughter presented Diclofenac Sodium 1% gel apply to affected area topically every 6 hours as needed for pain, Ventolin HFA Albuterol Inhaler 108 90 base/act inhale one puff by mouth every 6 hours as needed for shortness of breath, and Colace 100mg capsule take one every day as needed for constipation. The daughter stated that the patient uses the Diclofenac Sodium gel almost every day, the Ventolin Inhaler about once a month, and the Colace about twice a week. The Diclofenac Sodium gel, Ventolin inhaler and Colace were not listed on the hospice medication profile printed on 12/04/2024. The plan of care reviewed on 12/05/2024 did not include the Diclofenac Sodium gel, Ventolin Inhaler, and Colace. During a joint record review and interview on 12/05/2024, the Director of Patient Care Services agreed that the plan of care did not include the drugs and treatment necessary to meet the needs of the patient.”

“It is required that the QAPI program demonstrates measurable improvement among indicators related to improved palliative outcomes and hospice services. This standard was not met as evidenced by document review and interview. A review of the QAPI binder revealed the agency did not ensure that the QAPI program demonstrated measurable improvement among indicators related to improved palliative outcomes and hospice services in 2022 and 2023. Document 5: The QAPI Binder was reviewed. There was no documented evidence to show a QAPI program was in place in 2022 and 2023. During an interview on 12/06/2024, the Director of Patient Care Services stated, “We do not have anything documented for QAPI in 2022 or 2023. When I started in January 2024, I noticed 2022 and 2023 had nothing documented so I began implementing the program at that point.” During an interview on 12/06/2024, the Office Manager stated, “I told the previous Administrator that nothing was documented in 2022 and 2023, and she said we weren’t due for survey until the beginning of the year, so we didn’t need to do it yet.” A review of the QAPI binder revealed the agency did not ensure that the QAPI program demonstrated measurable improvement among indicators related to improved palliative outcomes and hospice services in 2022 and 2023.”

“It is required that the hospice measures, analyzes, and tracks quality indicators of performance that enable the assessment of: Processes of care; Hospice services; Operations; Adverse patient events. This standard was not met as evidenced by document review and interview. A review of the QAPI binder revealed the agency did not ensure the hospice tracked, measured and analyzed quality indicators of performance that enabled the assessment of processes of care, hospice services, operations, and adverse patient events. Document 5: The QAPI Binder was reviewed. There was no documented evidence to show a QAPI program was in place in 2022 and 2023. During an interview on 12/06/2024, the Director of Patient Care Services stated, “We do not have anything documented for QAPI in 2022 or 2023. When I started in January 2024, I noticed 2022 and 2023 had nothing documented so I began implementing the program at that point.” During an interview on 12/06/2024, the Office Manager stated, “I told the previous Administrator that nothing was documented in 2022 and 2023, and she said we weren’t due for survey until the beginning of the year, so we didn’t need to do it yet.” A review of the QAPI binder revealed the agency did not ensure to track, measure and analyze quality indicators of performance that enable the assessment of: Processes of care; Hospice services; Operations; Adverse patient events.”

“It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the QAPI program. Data elements abstracted and aggregated from comprehensive patient assessments are used in quality assessment and improvement. Data collected is used to: Monitor the effectiveness and safety of services and quality of care; Identify opportunities and priorities for improvement. This standard was not met as evidenced by document review and interview. A review of the QAPI binder revealed the agency did not ensure the collection of data to monitor the effectiveness and safety of services and quality of care or identify opportunities and priorities for improvement. Document 5: The QAPI Binder was reviewed. There was no documented evidence to show a QAPI program was in place in 2022 and 2023. During an interview on 12/06/2024, the Director of Patient Care Services stated, “We do not have anything documented for QAPI in 2022 or 2023. When I started in January 2024, I noticed 2022 and 2023 had nothing documented so I began implementing the program at that point.” During an interview on 12/06/2024, the Office Manager stated, “I told the previous Administrator that nothing was documented in 2022 and 2023, and she said we weren’t due for survey until the beginning of the year, so we didn’t need to do it yet.” A review of the QAPI binder revealed the agency did not ensure to collect data to monitor the effectiveness and safety of services and quality of care; Identify opportunities and priorities for improvement.”

“It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the QAPI program. Data elements abstracted and aggregated from comprehensive patient assessments are used in quality assessment and improvement. Data collected is used to: Monitor the effectiveness and safety of services and quality of care; Identify opportunities and priorities for improvement. The frequency and detail of the data collection is approved by the hospice’s governing body. This standard was not met as evidenced by document review and interview. A review of the QAPI Binder and Governing Body Binder revealed the agency did not ensure that the governing body approved the frequency and detail of the data collection. Document 4: The Governing Body Binder was reviewed. There was no documented evidence that the frequency and detail of the data collection was approved by the hospice’s governing body. Document 5: The QAPI Binder was reviewed. There was no documented evidence that the frequency and detail of the data collection was approved by the hospice’s governing body. During an interview on 12/06/2024, the Director of Patient Care Services stated, “We do not have anything documented for QAPI in 2022 or 2023. When I started in January 2024, I noticed 2022 and 2023 had nothing documented so I began implementing the program at that point.” A review of the QAPI Binder and Governing Body Binder revealed the agency did not ensure that the governing body approved the frequency and detail of the data collection.”

“It is required that performance improvement activities: Analyze the causes; Implement preventive action and mechanisms that include feedback and learning throughout the hospice. This standard was not met as evidenced by document review and interview. A review of the QAPI binder revealed the agency did not ensure that performance improvement activities: Analyze the causes; Implement preventive action and mechanisms that include feedback and learning throughout the hospice. Document 5: The QAPI Binder was reviewed. There was no documented evidence to show a QAPI program was in place in 2022 and 2023. During an interview on 12/06/2024, the Director of Patient Care Services stated, “We do not have anything documented for QAPI in 2022 or 2023. There were no QAPI meetings documented in 2022 or 2023. During an interview on 12/06/2024, the Office Manager stated, “I told the previous Administrator that nothing was documented in 2022 and 2023, and she said we weren’t due for survey until the beginning of the year, so we didn’t need to do it yet.” A review of the QAPI binder revealed the agency did not ensure that performance improvement activities: Analyze the causes; Implement preventive action and mechanisms that include feedback and learning throughout the hospice.”

“It is required that the hospice takes action to improve performance, assesses the success of the action after implementing it and tracks ongoing results to ensure HQPI.8.I/L570/improvement is sustained. This standard was not met as evidenced by document review and interview. A review of the QAPI binder revealed the agency did not ensure that the hospice took action to improve performance, assess the success of the action after implementing it and track ongoing results to ensure improvement was sustained. There was no documented evidence to show a QAPI program was in place in 2022 and 2023. During an interview on 12/06/2024, the Director of Patient Care Services stated, “We do not have anything documented for QAPI in 2022 or 2023. A review of the QAPI binder revealed the agency did not ensure that the hospice took action to improve performance, assessed the success of the action after implementing it and tracked ongoing results to ensure improvement is sustained.”

“It is required that the documented number and scope of performance improvement projects conducted annually: Represent the needs of the hospice population served; Represent the internal needs of the organization; Reflect the scope, complexity,HQPI.9.I/L and past performance of the hospice’s services and operations. Documentation of selected PI projects include: The reason for conducting the projects; Measurable progress achieved. This standard was not met as evidenced by document review and interview. A review of the QAPI binder revealed the agency did not ensure that the hospice documented what performance improvement projects were being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. Document 5: The QAPI Binder was reviewed. There was no documented evidence to show a QAPI program was in place in 2022 and 2023. During an interview on 12/06/2024, the Director of Patient Care Services stated, “We do not have anything documented for QAPI in 2022 or 2023. A review of the QAPI binder revealed the agency did not ensure that the hospice documented what performance improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.”

“It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program: Reflects the complexity of the hospice and services; Involves all hospice services, including those provided under contract or arrangement; Addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness; Focuses on indicators related to improved palliative outcomes; Includes investigation and analysis of sentinel and adverse events; Includes defined data detail and frequency of collection, and approves such; Has evidence of action taken that results in improvement in hospice performance; Is evaluated annually. The hospice must maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS. This standard was not met as evidenced by document review and interview. A review of the QAPI Binder and Governing Body Binder revealed the hospice did not ensure that the governing body defined, implemented, maintained, and evaluated the performance improvement program (QAPI) annually. Document 4: The Governing Body Binder was reviewed. There was no documented evidence that the Governing Body evaluated performance improvement program (QAPI) annually in 2022 and 2023. Document 5: The QAPI Binder was reviewed. There was no documented evidence that the agency maintained an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program in 2022 and 2023. During an interview on 12/06/2024, the Director of Patient Care Services stated, “We do not have anything documented for QAPI in 2022 or 2023. When I started in January 2024, I noticed 2022 and 2023 had nothing documented so I began implementing the program at that point.” During an interview on 12/06/2024, the Office Manager stated, “I told the previous Administrator that nothing was documented in 2022 and 2023, and she said we weren’t due for survey until the beginning of the year, so we didn’t need to do it yet.” A review of the QAPI Binder and Governing Body Binder revealed the hospice did not ensure that the governing body defined, implemented, maintained, and evaluated the performance improvement program (QAPI) annually.”

“It is required that one or more individual(s) is appointed by the governing body as responsible for operating the QAPI program. This standard was not met as evidenced by document review and interview. A review of the QAPI Binder and Governing Body Binder revealed the agency did not ensure that the governing body appointed an individual as responsible for operating the QAPI program. Document 4: The Governing Body Binder was reviewed. There was no documented evidence that the governing body appointed an individual as responsible for operating the QAPI program in 2022 and 2023. Document 5: The QAPI Binder was reviewed. There was no documented evidence that the governing body appointed an individual as responsible for operating the QAPI program in 2022 and 2023. During an interview on 12/06/2024, the Director of Patient Care Services stated, “We do not have anything documented for QAPI in 2022 or 2023. I do not see anyone appointed to operate the QAPI program. I was appointed in January 2024.” A review of the QAPI Binder and Governing Body Binder revealed the agency did not ensure that the governing body appointed an individual as responsible for operating the QAPI program.”

“It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by interview and personnel record review. In 2 of 11 (18%) personnel records reviewed revealed the agency did not ensure infection control education was provided to employees and contracted providers. Personnel Record 4: The Nurse Practitioner was hired on 01/09/2024. The Nurse Practitioner began providing care to patients on 01/20/2024. There was no documented evidence that the hospice provided infection control education. Personnel Record 11: The Hospice Administrator was hired on 06/12/2023 as an independent contractor and terminated the last week of December 2023. There was no documented evidence that the hospice provided infection control education. During a joint review of the employee’s file, and interview on 12/4/2024, the Director of Patient Care Services agreed there was no documented evidence that the infection control education was completed.”

“Hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. The hospice may contract for physician services. This standard was not met as evidenced by interview and personnel record review. In 2 of 2 (100%) personnel records reviewed of core services staff that are contracted revealed the agency did not ensure that core services were provided by hospice employees. Personnel Record 4: The Nurse Practitioner was hired as a contractor on 01/09/2024. The Nurse Practitioner began providing care to patients on 01/20/2024. A W9 was in the personnel record. There was no documented evidence that the hospice had the Nurse Practitioner sign a contract before providing services. Personnel Record 7: The Medical Social Worker was hired as a contractor for 03/25/2022-08/31/2024 before becoming a direct staff Social Worker for the agency on 09/01/2024. During a joint record review and interview on 12/06/2024, the Director of Patient Care Services stated, “We did realize it later and changed the Social Worker to direct staff in September but still need to talk to the Nurse Practitioner.””

“It is required that hospice performance improvement (PI) activities involve licensed professionals as participants. This standard was not met as evidenced by document review and interview. A review of the QAPI binder revealed the agency did not ensure hospice performance improvement (PI) activities involved licensed professionals as participants. Document 5: The QAPI Binder was reviewed. There was no documented evidence to show hospice performance improvement (PI) activities involved licensed professionals as participants or that a QAPI program was in place in 2022 and 2023. During an interview on 12/06/2024, the Director of Patient Care Services stated, “We do not have anything documented for QAPI in 2022 or 2023. When I started in January 2024, I noticed 2022 and 2023 had nothing documented so I began implementing the program at that point.” During an interview on 12/06/2024, the Office Manager stated, “I told the previous Administrator that nothing was documented in 2022 and 2023, and she said we weren’t due for survey until the beginning of the year, so we didn’t need to do it yet.” A review of the QAPI binder revealed the agency did not ensure hospice performance improvement (PI) activities involve licensed professionals as participants.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed of patients that accepted hospice aide services revealed the agency did not ensure the hospice aide provided services as ordered and included on the plan of care. Clinical Record 2: The hospice aide plan of care dated 07/22/2024 ordered a shower every visit. The hospice aide visit documentation on 11/01/2024 revealed the hospice aide completed a bed bath. There was no documented evidence that the hospice aide provided a shower as ordered or reason the plan of care was not followed. Clinical Record 3: The hospice aide plan of care dated 06/14/2024 did not order bathing. The hospice aide visit documentation on 11/29, 11/27, 11/25, 11/22, 11/20, 11/18, 11/15, 11/13, 11/11, 11/08, 10/28, 09/25, 06/26 revealed the hospice aide completed a bed bath. There was no documented reason the plan of care was not followed. Clinical Record 6: The hospice aide plan of care dated 10/30/2023 ordered a shower with shower chair every visit. The hospice aide visit documentation on 03/29/2024 and 04/10/2024 revealed the hospice aide completed a bed bath. There was no documented evidence that the hospice aide provided a shower with shower chair as ordered or reason the plan of care was not followed. During a joint record review and interview on 12/04/2024, the Director of Patient Care Services stated, “They should only be providing services ordered on the plan of care which these did not do. We need to provide more education with the hospice aides.””

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed of patients that accepted hospice aide services revealed the agency did not ensure the hospice aide reported changes in the patient’s needs a registered nurse (RN). Clinical Record 2: The hospice aide plan of care dated 07/22/2024 ordered a shower every visit. The hospice aide visit documentation on 11/01/2024 revealed the hospice aide completed a bed bath. There was no documented evidence that the hospice aide notified the RN of the change in the patient’s bathing needs. Clinical Record 3: The hospice aide plan of care dated 06/14/2024 did not order bathing. The hospice aide visit documentation on 11/29, 11/27, 11/25, 11/22, 11/20, 11/18, 11/15, 11/13, 11/11, 11/08, 10/28, 09/25, 06/26 revealed the hospice aide completed a bed bath. There was no documented reason the plan of care was not followed or that the RN was notified of the change in the patient’s bathing needs. Clinical Record 6: The hospice aide plan of care dated 10/30/2023 ordered a shower with shower chair every visit. The hospice aide visit documentation on 03/29/2024 and 04/10/2024 revealed the hospice aide completed a bed bath. There was no documented evidence that the hospice aide provided a shower with shower chair as ordered or the reason the plan of care was not followed or that the RN was notified of the change in the patient’s bathing needs. During a joint record review and interview on 12/04/2024, the Director of Patient Care Services stated, “They should only be providing services ordered on the plan of care which these did not do. We need to provide more education with the hospice aides.””

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. This standard was not met as evidenced by document review and interview. A review of the Volunteer Binder revealed the agency did not ensure that volunteers were used in day-to-day administrative and/or direct patient care roles in 2024. During an interview on 12/04/2024, the Director of Patient Care Services/Volunteer Coordinator stated, “We do not have a volunteer right now. We are looking to hire one as soon as possible. I do not have any documentation of volunteer hours. I am not sure when we last had a volunteer.” A review of the Volunteer Binder revealed the agency did not ensure that volunteers were used in day-to-day administrative and/or direct patient care roles in 2024.”

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. In 1 of 1 (100%) Volunteer Binder reviewed revealed the agency did not ensure that ongoing efforts to recruit and retain volunteers were documented for 2022, 2023 and 2024. Document 3: A review of the Volunteer Binder on 12/05/2024 revealed the agency did not ensure that ongoing efforts to recruit and retain volunteers were documented for 2022, 2023 and 2024. During a joint review of the Volunteer Binder, and interview on 12/05/2024, the Director of Patient Care Services/Volunteer Coordinator agreed there was no documented evidence of recruitment or retention efforts in 2022, 2023, or 2024. Additionally, the Director of Patient Care Services stated, “I am updating the volunteer program and will be sure we start to document our efforts.””

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions and the durations. This standard was not met as evidenced by document review and interview. In 1 of 1 (100%) Hospice Volunteer Requirement Report reviewed revealed the agency did not ensure that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. Document 6: A review of the Hospice Volunteer Requirement Report on 12/05/2024 revealed the agency did not ensure to provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff in 2024. There were no documented volunteer hours in 2024. During a joint review of the Hospice Volunteer Requirement Report, and interview on 12/05/2024, the Director of Patient Care Services/Volunteer Coordinator agreed the hospice agency did not meet the minimum five percent cost savings requirement for 2024. Additionally, the Director of Patient Care Services stated, “We have no documentation of volunteer hours for 2022, 2023 or 2024.””

“It is required that a qualified administrator is appointed by and reports to the governing body and is responsible for day-to-day hospice operation. The hospice administrator: Is an employee of the organization; Informs the governing body about ongoing operations, including patient care delivery issues and QAPI activities; Has the education and experience as required by the governing body. If the administrator is not available, another individual is assigned the administrator’s duties and responsibilities as defined in policy and procedure. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 1 (100%) contract for Administrator services reviewed revealed the agency did not ensure the Hospice Administrator was an employee of the organization. Contract 7: The Independent Contractor Agreement, dated and signed by the hospice CEO and the Administrator on 06/12/2023 revealed the Administrator of the Company shall be responsible for the overall direction of the hospice services. Personnel Record 11: The Hospice Administrator was hired on 06/12/2023 as an independent contractor. The Hospice Administrator (independent contractor) was terminated the last week of December 2023. During an interview on 12/06/2024, the CEO/Owner/Administrator (current) stated, “We didn’t realize the Administrator couldn’t be contracted.””

“It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties: The needs and concerns of patients and families coping with a terminal illness; Education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by interview and personnel record review. In 2 of 11 (18%) personnel records reviewed revealed the agency did not ensure an orientation was provided to all employees and contracted staff who have patient and family contact that included the hospice philosophy Personnel Record 4: The Nurse Practitioner was hired on 01/09/2024. The Nurse Practitioner began providing care to patients on 01/20/2024. There was no documented evidence that the hospice provided orientation about the hospice philosophy. Personnel Record 11: The Hospice Administrator was hired on 06/12/2023 as an independent contractor and termed the last week of December 2023. There was no documented evidence that the hospice provided orientation about the hospice philosophy. During a joint review of the employee’s file, and interview on 12/6/2024, the Director of Patient Care Services agreed there was no documented evidence that hospice provided orientation about the hospice philosophy.”

“It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties: The needs and concerns of patients and families coping with a terminal illness; Education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by interview and personnel record review. In 2 of 11 (18%) personnel records reviewed revealed the agency did not ensure to an orientation was provided that addressed the employee’s specific job duties. Personnel Record 4: The Nurse Practitioner was hired on 01/09/2024. The Nurse Practitioner began providing care to patients on 01/20/2024. There was no documented evidence that the hospice provided an orientation that addressed the employee’s specific job duties. Personnel Record 11: The Hospice Administrator was hired on 06/12/2023 as an independent contractor. The Hospice Administrator (independent contractor) was terminated the last week of December 2023. There was no documented evidence that the hospice provided orientation that addressed the employee’s specific job duties. During a joint review of the employee’s file, and interview on 12/6/2024, the Director of Patient Care Services agreed there was no documented evidence that the hospice provided an orientation that addressed the employee’s specific job duties.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by interview and personnel record review. In 1 of 11 (9%) personnel records reviewed revealed the agency did not ensure to assess the skills and competency of the individuals providing care. Personnel Record 4: The Nurse Practitioner was hired on 01/09/2024. The Nurse Practitioner began providing care to patients on 01/20/2024. There was no documented evidence that the hospice assessed the competency of the Nurse Practitioner. During a joint record review and interview on 12/05/2024, the Director of Patient Care Services agreed there was no documented evidence that hospice assessed the competency of the Nurse Practitioner.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: A copy of the hospice discharge summary; The patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review and interview. In 8 of 8 (100%) clinical records reviewed in which the patient was discharged due to moving out of the service area or was no longer terminally ill revealed that the agency did not ensure that the discharge summary was forwarded to the patient’s attending physician. Document 7: Agency Policy, Discharge Summary, No. H:2-086.1 Revised April 2018, stated in part, “All patients discharged from hospice will have a discharge summary completed. A copy of the discharge summary will be provided to the patient’s attending physician.” Clinical Record 6: The patient elected the hospice benefit on 10/30/2023 and discharged on 04/21/2024 (hospitalized). There was no documented evidence that the discharge summary was provided to the patient’s attending physician. Clinical Record 7: The patient elected the hospice benefit on 07/28/2023 and discharged on 04/06/2024 (hospitalized). There was no documented evidence that the discharge summary was provided to the patient’s attending physician. Clinical Record 8: The patient elected the hospice benefit on 12/22/2022 and discharged on 08/07/2024 (prognosis extended). There was no documented evidence that the discharge summary was provided to the patient’s attending physician. Clinical Record 10: The patient elected the hospice benefit on 05/10/2023 and discharged on 02/27/2024 (status improved). There was no documented evidence that the discharge summary was provided to the patient’s attending physician. Clinical Record 11: The patient elected the hospice benefit on 05/03/2024 and discharged on 05/09/2024 (hospitalization). There was no documented evidence that the discharge summary was provided to the patient’s attending physician. Clinical Record 12: The patient elected the hospice benefit on 06/16/2023 and discharged on 04/10/2024 (status improved). There was no documented evidence that the discharge summary was provided to the patient’s attending physician. Clinical Record 13: The patient elected the hospice benefit on 06/13/2024 and discharged on 09/16/2024 (moved out of area). There was no documented evidence that the discharge summary was provided to the patient’s attending physician. Clinical Record 14: The patient elected the hospice benefit on 04/05/2024 and discharged on 11/30/2024 (symptoms managed). There was no documented evidence that the discharge summary was provided to the patient’s attending physician. During a joint record review and interview on 12/05/2024, the Director of Patient Care Services agreed there was no documented evidence that the discharge summary was sent to the patient’s attending physician.”

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. Criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by interview and personnel record review. In 3 of 11 (27%) personnel records reviewed revealed the agency did not ensure to obtain a background check on all hospice employees who have direct patient contact or access to patient records. Personnel Record 2: The Administrator Designee/Human Resources Director/Director of Patient Care Services was hired on 01/05/2024. The background check was completed 09/15/2024. There was no documented evidence that the hospice obtained a criminal background check upon hire. Personnel Record 4: The Nurse Practitioner was hired on 01/09/2024. The Nurse Practitioner began providing care to patients on 01/20/2024. There was no documented evidence that the hospice obtained a criminal background check. Personnel Record 11: The Hospice Administrator was hired on 06/12/2023 as an independent contractor and termed the last week of December 2023. On 11/27/2023, the Nevada Automated Background Check System (NABS) printout documented “This applicant has not been previously determined eligible for employment and must be fingerprinted by 12/07/2023.” As of 12/04/2024, there was no documented evidence that the hospice obtained a criminal background check. During a joint record review and interview on 12/04/2024, the Director of Patient Care Services agreed there was no documented evidence that the criminal background checks were completed upon hire.”