Care360 Hospice, LLC

“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 review of documents, personnel records, clinical records, and interviews, which revealed problems with the governing body’s oversight regarding the organization, management, and administration of resources necessary to provide hospice care and services in the following areas: Failure to ensure that the governing body employed safeguards that care and services provided were consistent with the accepted standards of practice. {HCDT.1. I/L652/ 418.100(c)(1)};and failure to ensure that the skills and competencies of all individuals providing care were assessed {HSRM.14. I/L663/ 418.100(g)(3)}; The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.100: Organization and Administration of Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. IDG members must provide the care and services offered by the hospice, and the group, its entity, must supervise the care and services provided to the patient and family. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure that the IDG supervise the care and services provided to the patient and family. DOCUMENT 1: Agency Policy, Standards of Practice, PC.S30, stated in part, “All employees of [Hospice Name] provide care and services according to accepted standards of practice and State and Federal laws and regulations. All employees of [Hospice Name] provide care to patients and families according to the accepted standards of practice and code of ethics of their respected discipline. Each hospice program shall utilize personnel that have appropriate training and qualifications for the services that they provide. Any staff member who functions in a professional capacity shall meet the standards acceptable to that profession, including but not limited to possessing current (state) licensure, registration, or certification, if required by law, and practicing within the applicable scope of practice.” DOCUMENT 3: The ([state name) Board of Nursing website defined scope of practice and regulatory requirements specified in the Nurse Practice Act, Chapter 4723, ORC, and administrative rules, Chapters 4723-1 - 4723-27, OAC, including, but is not limited to, a registered nurse shall provide nursing care within the scope of practice of nursing for a registered nurse as set forth in division (B) of section 4723.01 of the Revised Code and the rules of the board. A registered nurse shall maintain current knowledge of the duties, responsibilities, and accountabilities for safe nursing practice. A registered nurse shall demonstrate competence and accountability in all areas of practice in which the nurse is engaged. A registered nurse may provide nursing care that is beyond basic nursing preparation for a registered nurse, provided: (D)(1)The nurse obtains education that emanates from a recognized body of knowledge relative to the nursing care to be provided; (D)(2)The nurse demonstrates knowledge, skills, and abilities necessary to provide the nursing care; The nurse maintains documentation satisfactory to the board of meeting the requirements set forth in paragraphs (D)(1) and (D)(2) of this rule. Implementing Health Care Provider Orders: An authorized health care provider’s order does not expand the licensed nurse’s scope. CLINICAL RECORD 2: A review of the clinical record revealed the registered nurse (RN) documented on the RN visit note dated 08/31/2025, that the patient was inconsolable and her left lung was not moving any air. Reported a knocking/sucking sound in the left lung. The RN contacted the physician (Personnel Record 3) and the physician asked for percussion to be performed and that resulted in a resounding drum sound like a tom-tom on the left side of chest per physician(Personnel Record 3), “Patient appears to have a spontaneous pneumothorax”. This RN called the POA (power of attorney)(daughter), who stated she preferred the option of a bedside needle decompression....(daughter) request that ‘procedure be done at bedside....Via live HIPPA compliant video instruction from physician (Personnel Record 3), RN (Personnel Record 1) Inserted a 14 G catheter into the mid clavicular second intercostal space of the left side of the patient’s chest; 14 G needle was inserted straight and then upward at a 90 degree angle....procedure complete.” This was outside the scope of the Registered Nurse. There was no documented evidence that the IDG supervised the care and services provided to the patient. During a joint record review and interview on 11/05/2025, the Executive Director stated, “She was not authorized to complete that skill so she should not have performed it.””

“It is required that the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice: Nursing services. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 5 (20%) clinical records reviewed revealed that the hospice did not ensure that nursing services were provided consistent with accepted standards of practice. DOCUMENT 1: Agency Policy, Standards of Practice, PC.S30, stated in part, “All employees of (Hospice Name) provide care and services according to accepted standards of practice and State and Federal laws and regulations. All employees of (Hospice Name) provide care to patients and families according to the accepted standards of practice and code of ethics of their respected discipline. Each hospice program shall utilize personnel that have appropriate training and qualifications for the services that they provide. Any staff member who functions in a professional capacity shall meet the standards acceptable to that profession, including but not limited to possessing current (state) licensure, registration, or certification, if required by law, and practicing within the applicable scope of practice.” DOCUMENT 3: The (state) Board of Nursing website defined scope of practice and regulatory requirements specified in the Nurse Practice Act, Chapter 4723, ORC, and administrative rules, Chapters 4723-1 - 4723-27, OAC, including, but is not limited to, a registered nurse shall provide nursing care within the scope of practice of nursing for a registered nurse as set forth in division (B) of section 4723.01 of the Revised Code and the rules of the board. A registered nurse shall maintain current knowledge of the duties, responsibilities, and accountabilities for safe nursing practice. A registered nurse shall demonstrate competence and accountability in all areas of practice in which the nurse is engaged. A registered nurse may provide nursing care that is beyond basic nursing preparation for a registered nurse, provided: (D)(1)The nurse obtains education that emanates from a recognized body of knowledge relative to the nursing care to be provided; (D)(2)The nurse demonstrates knowledge, skills, and abilities necessary to provide the nursing care; The nurse maintains documentation satisfactory to the board of meeting the requirements set forth in paragraphs (D)(1) and (D)(2) of this rule. Implementing Health Care Provider Orders: An authorized health care provider’s order does not expand the licensed nurse’s scope. CLINICAL RECORD 2: The patient elected the hospice benefit on 08/28/2025 with a diagnosis of Senile degeneration of brain. The registered nurse (Personnel Record 1) documented on the skilled nurse visit note dated 08/31/2025 that the patient was in severe respiratory distress. She reported this to the physician (Personnel Record 3). The physician asked for percussion to be performed which resulted in a resounding drum sound like tom-tom on the left side of chest per physician (Personnel Record 3), Via live HIPPA compliant video instruction from physician (Personnel Record 3), the RN (Personnel Record 1) Inserted a 14 Gauge catheter into the mid clavicular second intercostal space of the left side of the patient’s chest; 14 Gauge needle was inserted straight and then upward at a 90-degree angle.... procedure complete.” During a joint record review and interview on 11/05/2025, the Executive Director agreed that the after-hours nurse did not follow the Agency’s Policy on Standards of Practice. In addition, the Director of Clinical Services agreed that the nursing care provided by the after-hours nurse was not provided in a manner consistent with the accepted standards of practice.”

“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. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 1 (100%) personnel record of the After Hours Registered Nurse (RN) reviewed revealed the hospice did not ensure to assess the skills and competencies of the RN before she performed a bedside needle decompression. DOCUMENT 4: Agency Policy, Competency Assessment, HR.C10, stated in part, “The hospice’s governing body is ultimately responsible for assuring the competency of all individuals who provide patient and family care and services on the hospice’s behalf. The hospice’s governing body is ultimately responsible for assuring the competency of all individuals who provide patient and family care and services on the hospice’s behalf.” PERSONNEL RECORD 1: The After Hours Registered Nurse (AHRN) was hired on 05/19/2025 and terminated on 09/03/2025. On 08/31/2025 the employee suspension report documented, “performed a procedure (chest needle decompression) at the bedside of a hospice patient that was out of the RN scope of practice, as she had no training or evaluation of competence to perform.” There was no documented evidence that the AHRN had the required training to complete a bedside needle decompression. There was no documented evidence that the hospice completed a competency evaluation of the RN’s ability to complete a bedside needle decompression. During a joint record review and interview on 11/05/2025, the Executive Director stated, “She was not authorized to complete that skill so she should not have performed it.” The Director of Clinical Services agreed there was no evidence that the hospice evaluated the competency of the After Hours Registered Nurse to perform a chest needle decompression. Additionally, the Director of Clinical Services stated, “We would not have completed a competency on that skill because they are not allowed to do it.””

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed where the physician provided live video instruction for the care provided to the patient, it was revealed that the hospice did not ensure that the Hospice Medical Director documented the care and services provided. CLINICAL RECORD 2: The patient elected the hospice benefit on 08/28/2025 with a diagnosis of Senile degeneration of brain. The RN visit documentation on 08/31/2025 stated, “patient is uncomfortable and gasping for air.... She is in severe respiratory distress. Reported to the physician (Personnel Record 3) that (patient’s name) is unconsolable and her left lung was not moving any air. Reported a knocking/sucking sound in left lung. Physician (Personnel Record 3) who asked for percussion to be performed and that resulted in a resounding drum sound like tom-tom on the left side of chest per physician (Personnel Record 3) the patient appears to have a spontaneous pneumothorax....This RN called POA(power of attorney)(daughter)..prefers option of bedside needle decompression....(daughter) request that ‘procedure be done at bedside....Via live HIPPA compliant video instruction from the physician (Personnel Record 3), the RN (Personnel Record 1) Inserted a 14 Gauge catheter into the mid clavicular second intercostal space of the left side of patient’s chest. The 14 Gauge needle was inserted straight and then upward at a 90 degree angle....procedure complete.” Continued review of the clinical record revealed, documentation, “1539 (Personnel Record 3) checking on patient status and asked for updated vital signs. 1617 (Personnel Record 3) assessing patient status. 1842 (Personnel Record 3) checked on patient status. 2021 Personnel Record 3 was notified of the patient’s death.” There was no documentation of the physician’s communication or orders documenting the physician’s involvement in the care related to the chest needle decompression . During a joint record review and interview on 11/05/2025, the Director of Clinical Services agreed there was no documented evidence that the Hospice Medical Director documented any clinical notes including the care and services provided related to the chest needle decompression and his instructions and coordination with the Registered Nurse. During an interview on 11/05/2025, the Hospice Medical Director stated, “I thought I put it somewhere.””

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed revealed the hospice did not ensure to include a written physician order. CLINICAL RECORD 2: The patient elected the hospice benefit on 08/28/2025 with a diagnosis of Senile degeneration of brain. The Registered Nurse visit documentation on 08/31/2025 revealed that, “patient is uncomfortable and gasping for air.... She is in severe respiratory distress. Reported to physician (Personnel Record 3), that [patient] is inconsolable and her left lung was not moving any air. Reported a knocking/sucking sound in left lung. Physician (Personnel Record 3) asked for percussion to be performed and that resulted in a resounding drum sound like tom-tom on the left side of chest per physician (Personnel Record 3) patient appears to have a spontaneous pneumothorax. Via live HIPPA compliant video instruction from physician (Personnel Record 3), the RN (Personnel Record 1) Inserted a 14 Gauge catheter into the mid clavicular second intercostal space of the left side of the patient’s chest. 14 Guage needle was inserted straight and then upward at a 90 degree angle....procedure complete.” There was no documented evidence of a physician’s order for the chest needle decompression. During a joint record review and interview on 11/05/2025, the Director Clinical Services agreed there was no documented evidence of a physician’s order for the chest needle decompression. Additionally, the Director Clinical Services agreed this would require a signed physician order. During an interview on 11/05/2025, the Hospice Medical Director stated, “If the nurse would have put in an order, I would have signed it.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care, drugs, and treatment necessary to meet the needs of the patient, and medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 10 (20%) clinical records reviewed revealed the agency did not ensure that the Plan of Care included interventions that included oxygen use and safety. CLINICAL RECORD 3: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 08/11/2025. The Plan of Care (POC) dated 08/11/2025 included an order for “Oxygen gas for inhalation, 2L via NC PRN, Reason: Dyspnea”. The POC did not include interventions or measurable goals related to oxygen use and safety. CLINICAL RECORD 8: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice on 09/16/2025. The Plan of Care (POC) dated 09/16/2025 included “Oxygen Gas for Inhalation, 2-5 Liter as needed/prn, Reason: Shortness of Breath (SOB), Instructions: Start supplemental oxygen as needed for comfort via nasal cannula/face mask at 2-5 liters per minute. May titrate as tolerated/needed.” The initial nursing comprehensive nursing assessment dated 09/16/2025, documented by the Registered Nurse (RN), included education on the purpose, directions for use, and side effects/interactions for “Oxygen Gas for Inhalation 2-5 Liters.” The POC did not include interventions, measurable goals related to oxygen use and safety, or oxygen supplies. The Alternate Administrator (Personnel Record 4) was interviewed on 10/23/2025 and stated, “There should be interventions and goals for oxygen on the plan of care when the patient is on oxygen.””

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview and observation. In 2 of 6 (33%) home visit observations performed, the agency did not ensure that clinical staff followed the agency’s policy on hand hygiene. POLICY: The agency’s “Infection Control-Hand Washing and Bag Technique” policy, (Dated 07/24/2025) stated in part, “Use of alcohol-based hand sanitizer is preferred (until dry) ...a. Before and after caring for patients, or when coming in contact with inanimate objects/equipment in the immediate vicinity of the patient...c. After removing gloves.” and “ 5. The most effective form if infection control is good hand washing. Employees must cleanse hands before entering/removing supplies from bag, before examination, and after patient care. 7. ...hands are to be cleansed before re-entering the bag.” HOME VISIT 5: A home visit observation was conducted with the Registered Nurse (RN) (Personnel Record 5) on 10/22/2025. During the visit, the RN entered the clinical bag to return clean equipment to the bag. The RN did not disinfect her hands before returning the clean equipment to the bag. The RN did not follow the agency’s hand hygiene policy. HOME VISIT 6: A home visit observation was conducted with the Registered Nurse (RN) (Personnel Record 3) on 10/23/2025. During the visit, the RN removed her gloves after disinfecting the equipment used during the visit and returned the equipment to the clinical bag without disinfecting her hands after removing the gloves and before returning the clean equipment to the bag. The RN did not follow the agency’s hand hygiene policy. The Administrator (Personnel Record 1) was interviewed on 10/23/2025 and stated, “The nurse should have cleaned her hands before going into the bag.””

“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, and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. A review of the agency’s volunteer program and cost savings reports revealed that the agency did not provide volunteer 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 the year 2024 (0.59%) The Administrator provided cost savings data as follows: Y 2024 = 0.59% and CY 2025 (YTD) = 0.59%. The agency has not provided volunteer 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 Volunteer Coordinator (Personnel Record 12) was interviewed on 10/21/2025 and stated, “There is a PIP in place, started in January 2024 to increase utilization of volunteer services. We are continuing to work on increasing the use of volunteers.” A review of the agency’s volunteer program and cost savings reports revealed that the agency did not provide volunteer 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.”

“It is required that performance improvement activities track adverse patient events, analyze the causes, and 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. In review of QAPI data for the two quarters of the year 2025, it was revealed that the agency did not ensure that data from the Alternate Delivery Site (ADS) (site 2) was included in the agency QAPI reports. QAPI Plan: Reviewed the QAPI Plan at the parent location which was complete with performance improvement plans, analysis, and action plans for parent and one of three alternate delivery sites. No data available for ads two for quarters one and two 2025. Reviewed ADS 2 data on site on 09/05/2025 which included a form that read, “QAPI meeting agenda” with no branch data or branch performance improvement projects. There were no ADS 2 QAPI minutes presented to site visitor upon request. Clinical Director of ADS 2 stated in an interview on 09/05/2025, “We do QAPI with (the parent) but it doesn’t apply to us. They had problems with wounds, we don’t. We don’t have any current performance improvement projects.” Stated that the occurrence reports are for the ADS only but there is no specific QAPI plan for the branch. “Everything I have is in this binder.” No data available for quarter one or two 2025. Interview with ADS Clinical supervisor on 09/05/2025. Clinical supervisor stated “We haven’t had a QAPI meeting since I have been here, I was hired in April 2025. After showing her a QAPI meeting sign in sheet for 05/22/2025 with her signature she stated, “Well, we met in here but it was education not really a QAPI meeting.” Compliance and education officer stated in an interview on 09/04/2025, “In about January, (the alternate site) really quit participating with us in the QAPI plan. They don’t provide me with any data anymore.” The agency did not ensure that analysis of the causes for adverse patient events and the implementation of preventative action and feedback and learning occur at all alternative delivery sites. The agency did not ensure that analysis of the causes for adverse patient events and the implementation of preventative action and feedback and learning occur at all alternative delivery sites.”

“it is required that the hospice must designate a physician to serve as medical director. The medical director must be a Doctor of Medicine or osteopathy who is an employee or is under contract with the hospice. When the medical director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the medical director. All physician employees, and those under contract, must function under the supervision of the hospice medical director. Hospice physician employees, and those physicians under contract, meet the requirement by either providing the services directly or through coordinating patient care with the attending physician. This standard was not met as evidenced by interview and personnel record review. In 2 of 2 (100%) personnel files reviewed of employees identified as hospice physicians, it was revealed that the agency did not ensure that one physician was identified as the one and only medical director with a clear job description and defined responsibilities and obligations. Personnel #4: The physician was hired 07/22/2022 with the job description of Alternate Medical Director. There were no other job descriptions in the personnel file or found. During an interview on 09/04/2025 it was stated that he (Personnel #4) was the medical director and covered the parent location and alternate delivery site 1. When asked how oversight was provided to the physician who covered the alternate delivery sites, for site 2 and site 3, he stated, “She knows almost as much as me. She works for several hospice agencies. Sometimes her patients pop up on my computer for IDG, and it looks fine.” Personnel #5: The physician was hired on 02/05/2025 with a job description of Alternate Medical Director and responsibility for supporting the alternate delivery sites 2 and3. During an interview on 09/05/2025, she was asked, “How does the medical director provide oversight, and how often do you speak with him?” Personnel #5 replied,” We probably talk every 2 months.” In a joint review of personnel records and an interview on 09/04/2025, the Human Resources Manager confirmed that the organization had directly hired two physicians and both physicians had the job description of alternate medical director and there was no employee with a job description titled, “Medical Director.” In an interview and review on 09/05/2025 with the Owner, Administrator and Corporate Compliance and Education Officer, the Administrator stated, “I don’t think (Personnel #4) really does provide any oversight of Personnel #5”. The Corporate Compliance Officer and Educator agreed, and the Owner stated, “We will have to create a structure for that oversight.””

“It is required that a hospice operating multiple locations, also known as alternative delivery sites (ADS) shares administration, supervision, and services with the hospice issued the certification number. This standard was not met as evidenced by document review, observation, personnel record review, and interview. Review of a communication memo to all staff and interviews revealed the agency did not ensure that the alternate delivery sites shared administration and supervision with the parent hospice location that was issued the certification number. Documentation: Review of a “Memo to Staff” dated May 28, 2025, read in part, “Today I want to share an update about our leadership structure, not as a reflection of any individual, but as a natural next step in building the most supportive, servant driven culture in hospice care. Moving forward I (owner) will be directly overseeing our Alternate Delivery Site (ADS) 2 and 3 markets to ensure we remain deeply connected to our teams and communities. The Administrator will focus her leadership on the parent and ADS 1, where she will continue to guide operations and support excellence in care delivery. To support this transition: ADS 2 leadership will report directly to our Executive Director, of ADS 2 who will keep a direct line to me for all support and oversight. Our SW in ADS 2 will take on responsibility for ADS 2 and 3 as we start that region. Ancillary and spiritual care services will remain under current leadership. Our compliance officer will oversee Parent and ADS 1.” Signed by the “owner” who wis not reflected on the organization structure chart. Personnel #10 stated in an interview on 09/05/2025, “If there were a compliance concern, I would notify my manager or executive director. Although the employee was asked repeated if there was any other corporate employee that would be contacted, she replied no, she would allow her manager to take it from there. Personnel #6: The personnel record of this ADS leadership position contained a signed job description titled “Executive Director”. The job description read in part, “Reports to the board of directors”. There was no indication that the branch leader reported to the parent administrator. Office Visit: During a visit to the alternate delivery site on 09/05/2025, the Executive Director was absent when the site visitor arrived for the scheduled observation. Upon return to the parent, the Administrator stated she is not aware of the executive director’s schedule. In an interview with the owner on 09/05/2025, the owner (governing body) confirmed there was intentional separation between the parent and ADS 2 and 3 because of conflicts with leadership. The agency did not ensure that the alternate delivery sites shared administration with the parent hospice.”

“It is required that a hospice continually monitors and manages all services provided at each of its multiple locations to ensure services are delivered in a safe and effective manner, each patient and family receives the necessary care and services outlined in the plan of care, the scope of care and services is the same as offered directly or under contract at the location with the certification number. This standard was not met as evidenced by document review and interview. Review of a documented communication to staff and staff interviews reveals the agency organizational structure did not ensure that all alternate delivery sites were continually monitored and managed to ensure that the services were provided the same as offered by the parent location. Memo to Staff: A memo to all staff dated May 28, 2025, read in part, “Today I want to share an update about our leadership structure, not as a reflection of any individual, but as a natural next step in building the most supportive, servant driven culture in hospice care. Moving forward I will be directly overseeing our (ADS 2 and 3 markets to ensure we remain deeply connected to our teams and communities. Administrator will focus her leadership on the parent and ADS 1, where she will continue to guide operations and support excellence in care delivery. To support this transition: ADS 2 leadership will report directly to our Executive Director, of ADS 2 who will keep a direct line to me for all support and oversight. The SW in ADS 2 will take on responsibility for ADS 2 and 3 as we start that region. Ancillary and spiritual care services will remain under current leadership. Our compliance will oversee parent and ADS 1. Signed by “owner” who is not reflected on the organization chart. QAPI: Review of QAPI materials and data collection for quarters 1 and 2, 2025.revealed no data specific information was documented for the alternate delivery sites 2 and 3. The Administrator confirmed in an interview on 09/05/2025 that she had not had oversight of ADS 2 since February of 2025. The agency did not ensure that all alternate delivery sites were continually monitored and managed to ensure that the services were provided the same as offered by the parent location.”