Rejoice Hospice Inc.

“It is required that the hospice maintains a written comprehensive emergency preparedness program that demonstrates compliance with applicable federal, state, and local emergency preparedness requirements, uses an “all hazards” approach, describes the hospice’s approach to meeting the health, safety, and security of the staff, the patient population, with attention to their mobility, [and] describes how the hospice coordinates with other healthcare facilities, as well as the community, during an emergency or disaster situation. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This standard was not met as evidenced by document review and interview which revealed the agency: Failed to ensure the Emergency Preparedness plan included a documented hospice-based and community-based risk assessment using an all-hazards approach specific to the geography and population served {HSEP.2. D/E6}; Failed to ensure that the emergency preparedness plan was maintained, reviewed, and updated at least annually per agency policy. {HSEP.2. D/E4}; Failed to ensure that the EP communication plan included all contact information and was updated annually per agency policy {HSEP.4. D/E29} and Failed to ensure that exercises were completed to test the emergency preparedness plan {HSEP.6. I/E39}. 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 418.113: Emergency Preparedness. 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 develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program. The hospice’s governing body must ensure that the program: reflects the complexity of its organization and services; involves all hospice services (including those services furnished under contract or arrangement); focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance. The hospice must maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS. THIS IS A CMS CONDITION LEVEL DEFICIENCY This standard was not met as evidenced by document review and interview which revealed the agency: Failed to ensure that quality indicators of performance were measured, analyzed, and tracked for the assessment of processes of care, hospice services, operations, and adverse patient events {HQPI.4. I/L562}; Failed to ensure that quality indicator data, including patient care data and other relevant data, was used in the Quality Assessment Performance Improvement (QAPI) program {HQPI.5. I/L563}; Failed to ensure it maintained documentary evidence of its quality assessment and performance improvement program and that the program included approval of the defined data detail and frequency of collection {HQPI. 1. D/L565}; Failed to ensure that the governing body approved the frequency and detail of data collection for the Quality Assessment Performance Improvement program {HQPI.1. I/L565}; Failed to ensure that action was taken to improve Performance, assess the success of the action after implementing and tracks ongoing results to ensure Improvement is sustained {HQPI.8. I/L570}; Failed to ensure that performance improvement projects conducted represented the needs of the hospice population served, represented the internal needs of the organization, and reflected the scope, complexity, and past performance of the hospice’s services and operations. {HQPI.9. I/L572}; Failed to ensure it maintained documentary evidence of its quality assessment and performance improvement program that included how the program was defined, implemented, maintained, and evaluated annually {HQPI 1. D/L574}; and Failed to ensure it maintained documentary evidence of its quality assessment and performance improvement program, addressed efforts and set priorities for improved quality of care and patient safety and ensured that all improvement actions were evaluated for effectiveness {HQPI.1. D/575}. 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 & Performance Improvements. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. A review of the Emergency Preparedness binder revealed that the agency did not ensure that the emergency preparedness plan was maintained, reviewed, and updated at least annually per agency policy. Policy EC.40-TX Emergency Preparedness Plan and Response Plan-Addendum review date 07/01/2023 stated in part “The Hospice will complete an internal review of the Emergency Preparedness Response Plan at least annually, and after each actual emergency response, to evaluate its effectiveness and to update the plan as needed.” The Emergency Preparedness (EP) binder was reviewed on 05/30/2024. The EP binder included an EP plan and hazard risk assessment dated 03/15/2018 (six years ago). The EP binder did not include documentation demonstrating that the EP was reviewed and updated at least annually per agency policy. In a joint review of the Emergency Preparedness (EP) binder on 05/30/2024, during the interview, the administrator confirmed findings that the EP binder did not contain an updated EP plan. A review of the Emergency Preparedness binder revealed that the agency did not ensure that the emergency preparedness plan was maintained, reviewed, and updated at least annually per agency policy.”

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. This standard was not met as evidenced by document review and interview. A review of the Emergency Preparedness binder revealed that the agency did not ensure the Emergency Preparedness plan included a documented hospice-based and community-based risk assessment using an all-hazards approach specific to the geography and population served. Document 1: Policy EC.40-TX Emergency Preparedness Plan and Response Plan-Addendum review date 07/01/2023 stated in part “The Hospice will complete an internal review of the Emergency Preparedness Response Plan at least annually, and after each actual emergency response, to evaluate its effectiveness and to update the plan as needed.” Document 7: The Emergency Preparedness (EP) binder was reviewed on 05/30/2024. The EP binder included a completed hazard risk assessment dated 03/15/2018 (six years). The EP did not include documentation demonstrating that the risk assessment was completed annually per agency policy. In a joint interview and review of the Emergency Preparedness (EP) binder on 05/30/2024, the administrator confirmed findings that the hazard risk assessment had not been updated since 03/18/2018. A review of the Emergency Preparedness binder revealed that the agency did not ensure the Emergency Preparedness plan included a documented hospice-based and community-based risk assessment using an all-hazards approach specific to the geography and population served.”

“It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state, and local laws; includes all contact information, and is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. A review of the Emergency Preparedness (EP) binder revealed that the agency did not ensure that the EP communication plan included all contact information and was updated annually per agency policy. Policy EC.40-TX Emergency Preparedness Plan and Response Plan-Addendum review date 07/01/2023 stated in part “The Hospice will complete an internal review of the Emergency Preparedness Response Plan at least annually, and after each actual emergency response, to evaluate its effectiveness and to update the plan as needed.” The Emergency Preparedness (EP) binder was reviewed on 05/30/2024. The EP binder included an EP plan and hazard risk assessment dated 03/15/2018 (six years). The EP binder did not include documentation demonstrating that the EP communication plan was reviewed and updated at least annually per agency policy. In a joint interview and review of the Emergency Preparedness (EP) binder on 05/30/2024, the administrator confirmed findings that the EP binder did not contain an updated EP communication plan. A review of the Emergency Preparedness (EP) binder revealed that the agency did not ensure that the EP communication plan included all contact information and was updated annually per agency policy.”

“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. It is required that the hospice providing care in the patient’s home conduct 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 (EP) binder revealed that the agency did not ensure that exercises were completed to test the emergency preparedness plan. There was no evidence of testing the emergency preparedness plan during the public health emergency from 03/01/2020 to 05/11/2023. Document 7: The Emergency Preparedness (EP) binder was reviewed on 05/30/2024. The EP binder included an EP plan and hazard risk assessment dated 03/15/2018 (six years). The EP binder did not include documentation demonstrating that the agency participated in exercises to test the emergency preparedness plan. In a joint interview and review of the Emergency Preparedness (EP) binder on 05/30/2024, the administrator (personnel record 1) confirmed findings and stated in part “We have had actual emergencies, but we don’t have that documented.” A review of the Emergency Preparedness (EP) binder revealed that the agency did not ensure that exercises were completed to test the emergency preparedness plan.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed revealed that the agency did not ensure that the individualized written plan of care included spiritual and psychosocial goals and interventions for problems identified in the initial and updated comprehensive assessments. Clinical Record 3: The Hospice Plan of Care effective 02/28/2024 and recertification effective 05/04/2024 included orders for Chaplain (CH) visits one time per month and as needed for increasing spiritual needs/support and Medical Social Worker (MSW) visits one time per month and as needed for increased psychological needs/support. A Chaplain visit note completed 04/02/2024 stated in part “spiritual support and assistance provided (prayer/meditation).” An MSW visit note completed on 04/15/2024 stated in part “MSW will provide psychoeducation around identified needs, will evaluate current financial resources and needs, will assess the need for additional caregiver(s) resources.” A review of the plans of care revealed that the patient’s individualized written plan of care did not include any goals or interventions that addressed spiritual or psychosocial needs. Clinical Record 4: The Hospice Plan of Care effective 03/25/2024 and recertification effective 05/24/2024 included orders for MSW visits one time per month and as needed for increased psychosocial needs/support. An MSW visit note completed on 05/20/2024 stated in part “MSW will provide psychoeducation around identified needs, will evaluate current financial resources and needs, will assess the need for additional caregiver(s) resources.” A review of the plan of care revealed that the patient’s individualized written plan of care did not include any goals or interventions that addressed psychosocial needs. Clinical Record 6: The Hospice Plan of Care effective 04/17/2024 included orders for CH visits one time per month and as needed for increased spiritual needs/support. A CH visit note completed on 04/18/2024 stated in part “teach patient/caregiver anxiety reduction and coping techniques.” A review of the plan of care revealed that the patient’s individualized written plan of care did not include any goals or interventions that addressed spiritual needs. Clinical Record 10: The Hospice Plan of Care effective 03/25/2024 included orders for CH visits one time per month and as needed for increasing spiritual needs/support and MSW visits one time per month and as needed for increased psychological needs/support. A CH visit note completed on 03/26/2024 stated in part “spiritual support and assistance provided (prayer/meditation).” An MSW visit note completed on 003/28/2024 stated in part “MSW will provide psychoeducation around identified needs, will evaluate current financial resources and needs, will assess the need for additional caregiver(s) resources.” A review of the plan of care revealed that the patient’s individualized written plan of care did not include any goals or interventions that addressed spiritual or psychosocial needs. Clinical Record 14: The Hospice Plan of Care effective 04/17/2023 and recertification effective 07/16/20234 included orders for CH visits one time per month and as needed for increasing spiritual needs/support. A CH visit note completed on 04/19/2023 stated in part “spiritual support and assistance provided (prayer/meditation).” A review of the plan of care revealed that the patient’s individualized written plan of care did not include any goals or interventions that addressed spiritual needs. In a joint record review and interview on 05/29/2024, the administrator confirmed findings that clinical records 3, 4, 6, 10, and 14 did not include goals and interventions based on spiritual and psychosocial needs identified and stated in part “I’m not sure why there are no goals and interventions for social worker and chaplain.””

“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, and adverse patient events. This standard was not met as evidenced by document review and interview. A review of the Quality Meeting binder revealed that the agency did not ensure that quality indicators of performance were measured, analyzed, and tracked for the assessment of processes of care, hospice services, operations, and adverse patient events. Document 2: The Quality Assessment/Performance Improvement Plan dated 10/02/2018 approved at the 01/09/2021 Governing Bady Meeting stated in part “Hospice will measure, analyze, and track quality indicators that enable the hospice to assess processes of care, hospice services, and operations. Hospice will also monitor, trend, and identify significant outcomes that are essential to optimal care: 4. Adverse Events.” Document 4: The Quality Meeting binder was reviewed on 05/30/2024. The binder documents revealed that a quality meeting was held on 03/30/2023. The Quality Meeting binder did not include documentation that additional meetings were held in 2023 or 2024 through the review date or that the hospice measured, analyzed, or tracked quality indicators assessing the processes of care, hospice services, operations, and adverse patient events. In an interview on 05/30/2024, the administrator confirmed that the last documented quality meeting was 03/30/2023 and stated in part “The Director of Nursing was in the process of working on QAPI, but we don’t have any documentation of projects, meetings, or data collected.” A review of the Quality Meeting binder revealed that the agency did not ensure that quality indicators of performance were measured, analyzed, and tracked for the assessment of processes of care, hospice services, operations, and adverse patient events.”

“It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the Quality Assessment Performance Improvement Program (QAPI) program. This standard was not met as evidenced by document review and interview. A review of the Quality Meeting binder revealed that the agency did not ensure that quality indicator data, including patient care data and other relevant data, was used in the Quality Assessment Performance Improvement (QAPI) program. Document 4: The Quality Meeting binder was reviewed on 05/30/2024. The binder documents revealed that a quality meeting was held on 03/30/2023. The Quality Meeting binder did not include documentation that additional meetings were held in 2023 or 2024 through the review date or that quality indicator data was collected. Document 2: Quality Assessment/Performance Improvement Plan dated 10/02/2018 approved at the 01/09/2021 Governing Bady Meeting stated in part “Hospice will measure, analyze, and track quality indicators that enable the Hospice to assess processes of care, hospice services, and operations.” In an interview on 05/30/2024, the administrator, confirmed that the last documented quality meeting was 03/30/2023 and stated in part “The Director of Nursing was in the process of working on QAPI, but we don’t have any documentation of projects or meetings.” A review of the Quality Meeting binder revealed that the agency did not ensure that quality indicator data, including patient care data and other relevant data, was used in the Quality Assessment Performance Improvement (QAPI) program.”

“It is required that the frequency and detail of the data collection used in the Quality Assessment Performance Improvement (QAPI) program are approved by the hospice’s governance. This standard was not met as evidenced by document review and interview. A review of the Governing Body binder revealed that the agency did not ensure that the governing body approved the frequency and detail of data collection for the Quality Assessment Performance Improvement program. Document 2: Quality Assessment/Performance Improvement Plan (QAPI) dated 10/02/2018 approved at the 01/09/2021 Governing Bady Meeting stated in part “2 Governing Body: a. These leaders are responsible for ensuring the following: (1) That the QAPI program reflects the complexity of its organization and services; involves all hospice services; focuses on indicators related to improved outcomes, approving frequency and detail of data collection; and takes actions to demonstrate improvement in performance.” Document 5: The Governing Body binder was reviewed on 05/30/2024. The binder documents revealed that a governing body meeting was held on 01/09/2021. The Governing Body binder did not include documentation that additional meetings were held in 2022, 2023, or 2024 to approve the frequency and detail of data collection for the Quality Assessment/Performance Improvement Plan. In an interview on 05/30/2024, the administrator (personnel record 1), confirmed that the last documented governing body meeting was 01/09/2021. The administrator showed the site visitor his phone with group communication and stated in part “The board communicates through this but we don’t have anything documented.” The Governing body binder did not include documentation of meetings demonstrating the governing body’s approval of frequency and the detail of data collection for 2022, 2023, or 2024. A review of the Governing Body binder revealed that the agency did not ensure that the governing body approved the frequency and detail of data collection for the Quality Assessment Performance Improvement program.”

“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 includes defined data detail and frequency of collection and approves such. 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 agency’s governing body binder and quality meeting binder revealed that the agency did not ensure it maintained documentary evidence of its quality assessment and performance improvement program and that the program included approval of the defined data detail and frequency of collection. Document 2: Quality Assessment/Performance Improve Plan (QAPI) dated 10/02/2018 approved at the 01/09/2021 Governing Bady Meeting stated in part “2. Governing Body: a. These leaders are responsible for ensuring the following: (1). That the QAPI program reflects the complexity of its organization and services; involves all hospice services; focuses on indicators related to improved outcomes, approving frequency and detail of data collection; and takes actions to demonstrate improvement in performance.” Document 5: The Governing Body binder was reviewed on 05/30/2024. The binder documents revealed that a governing body meeting was held on 01/09/2021. The Governing Body binder did not include documentation that additional meetings were held in 2021, 2022, 2023, or 2024 through the review date to approve the defined data detail and the frequency of data collection. In an interview on 05/30/2024, the administrator confirmed that the last documented governing body meeting was 01/09/2021 and stated in part “The board communicates through this, but we don’t have anything documented.” The binder did not include documentation of meetings demonstrating the approval of the defined data detail and the frequency of data collection. A review of the agency’s governing body binder and quality meeting binder revealed that the agency did not ensure it maintained documentary evidence of its quality assessment and performance improvement program and that the program included approval of the defined data detail and frequency of collection.”

“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 improvement is sustained. This standard was not met as evidenced by document review and interview. A review of the Quality Meeting binder revealed that the agency did not ensure that action was taken to improve performance. Document 2: Quality Assessment/Performance Improvement Plan (QAPI) dated 10/02/2018 approved at the 01/09/2021 Governing Bady Meeting stated in part “Hospice will take actions aimed at performance improvement and, after implementing those actions, will measure their success and track performance to ensure that improvements are sustained.” Document 4: The Quality Meeting binder was reviewed on 05/30/2024. The binder documents revealed that a quality meeting was held on 03/30/2023. The Quality Meeting binder did not include documentation that additional meetings were held in 2023 or 2024 through the review date or that the hospice took action to improve performance. In an interview on 05/30/2024, the administrator (personnel record 1), confirmed that the last documented quality meeting was 03/30/2023 and stated in part “The Director of Nursing was in the process of working on QAPI, but we don’t have any documentation of projects or meetings.” A review of the Quality Meeting binder revealed that the agency did not ensure that action was taken to improve performance.”

“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, and reflect the scope, complexity, and past performance of the hospice’s services and operations. This standard was not met as evidenced by document review and interview. A review of the Quality Meeting binder revealed that the agency did not ensure that performance improvement projects conducted represented the needs of the hospice population served, represented the internal needs of the organization, and reflected the scope, complexity, and past performance of the hospice’s services and operations. Document 2: The Quality Assessment/Performance Improvement Plan dated 10/02/2018 approved at the 01/09/2021 Governing Bady Meeting stated in part “The number and scope of distinct Performance Improvement Projects (PIPs) conducted annually will reflect the scope, complexity, and past performance of the services and operations. Document 4: The Quality Meeting binder was reviewed on 05/30/2024. The binder documents revealed that a quality meeting was held on 03/30/2023 and included a performance project (PIP) for bereavement support. The PIP was to be continued per quality meeting minutes. The Quality Meeting binder did not contain documentation that follow-up was completed for the bereavement PIP or that additional PIPs were developed. Document 6: Medicare Care Compare was reviewed on 05/28/2024 and revealed two areas below the national benchmark: 1. Patients who got an assessment of all 7 HIS quality measures at the beginning of hospice care to meet the HIS Comprehensive Assessment Measure requirements Agency: 67% and 2. Percentage of patients who received visits from a registered nurse or medical social worker on at least 2 of the final 2 days of their life Agency: 35.2% In an interview on 05/30/2024, the administrator confirmed that the last documented quality meeting was 03/30/2023 and stated in part “The Director of Nursing was in the process of working on QAPI, but we don’t have any documentation of projects or meetings.” A review of the Quality Meeting binder revealed that the agency did not ensure that performance improvement projects conducted represented the needs of the hospice population served, represented the internal needs of the organization, and reflected the scope, complexity, and past performance of the hospice’s services and operations.”

“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 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 agency’s governing body binder and quality meeting binder revealed that the agency did not ensure it maintained documentary evidence of its quality assessment and performance improvement program that included how the program was defined, implemented, maintained, and evaluated annually. Document 2: Quality Assessment/Performance Improvement Plan dated 10/02/2018 approved at the 01/09/2021 Governing Bady Meeting stated in part “Hospice leaders (including the Board of Directors, IDG/IDT, management, QAPI Committee) will participate in an annual evaluation of the total organization’s performance, including those under contract and arrangement. Findings will be utilized to correct identified problems, revise hospice policy, and address priorities for improved quality of care and patient safety.” “2. Governing Body: a. These leaders are responsible for ensuring the following: (2) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually.” Document 4: The Quality Meeting binder was reviewed on 05/30/2024. The binder documents revealed that a quality meeting was held on 03/30/2023. The Quality Meeting binder did not include documentation that additional meetings were held in 2023 or 2024 through the review date (greater than one year). Document 5: The Governing Body binder was reviewed on 05/30/2024. The binder documents revealed that a governing body meeting was held on 01/09/2021. The Governing Body binder did not include documentation that additional meetings were held in 2021, 2022, 2023, or 2024 through the review date (greater than one year). In an interview on 05/30/2024, the administrator confirmed that the last documented quality meeting was 03/30/2023 and the last documented governing body meeting was 01/09/2021. The administrator showed the site visitor his phone with group communication and stated in part “The board communicates through this, but we don’t have anything documented.” The binder did not include documentation of meetings demonstrating the annual evaluation and approval of the quality assessment/performance improvement plan. A review of the agency’s governing body binder and quality meeting binder revealed that the agency did not ensure it maintained documentary evidence of its quality assessment and performance improvement program that included how the program was defined, implemented, maintained, and evaluated annually.”

“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 addresses efforts, sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness.; The hospice must maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS.1. D/L575 This standard was not met as evidenced by document review and interview. A review of the agency’s governing body binder and quality meeting binder revealed that the agency did not ensure it maintained documentary evidence of its quality assessment and performance improvement program, addressed efforts and set priorities for improved quality of care and patient safety, and ensured that all improvement actions were evaluated for effectiveness. Document 2: Quality Assessment/Performance Improve Plan (QAPI) dated 10/02/2018 approved at the 01/09/2021 Governing Bady Meeting stated in part “2. Governing Body: a. These leaders are responsible for ensuring the following: (3) That the hospice-wide QAPI efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness.” Document 4: The Quality Meeting binder was reviewed on 05/30/2024. The binder documents revealed that a quality meeting was held on 03/30/2023. The binder included one performance improvement project (PIP) related to bereavement support and indicated that the PIP would continue. The binder did not contain documentation that additional PIPs were initiated or that follow-up and evaluation of the PIP was completed. Document 5: The Governing Body binder was reviewed on 05/30/2024. The binder documents revealed that a governing body meeting was held on 01/09/2021. The Governing Body binder did not include documentation that additional meetings were held in 2021, 2022, 2023, or 2024 through the date of review. In an interview on 05/30/2024, the administrator confirmed that the last documented quality meeting was 03/30/2023 and stated in part “The Director of Nursing was in the process of working on QAPI, but we don’t have any documentation of projects or meetings.” A review of the agency’s governing body binder and quality meeting binder revealed that the agency did not ensure it maintained documentary evidence of its quality assessment and performance improvement program, addressed efforts and set priorities for improved quality of care and patient safety, and ensured that all improvement actions were evaluated for effectiveness.”

“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 document review, interview and personnel record review. In 1 of 12(8%) personnel records reviewed revealed that the agency did not ensure that the skills and competencies of individuals providing care were assessed. Document 1: Policy HR.10 Staff Competency Revision Date 10/01/2021 stated in part “The Hospice will provide for competency assessments by qualified individuals on hire and annually to assess direct care staff’s basic skill levels for all staff providing care, including paraprofessionals and professionals.” Personnel Record 7: The chaplain/Volunteer Coordinator/Bereavement Coordinator (CH/VC/BC) was hired on 09/29/2022. The chaplain (Personnel Record 7) accepted additional roles of the Volunteer Coordinator and Bereavement Coordinator on 06/15/2023. The personnel record lacked evidence that an assessment of skills and competencies was completed for the roles of Volunteer Coordinator and Bereavement Coordinator. In a joint review of personnel record 7 and interview on 05/29/2024, the administrator confirmed findings and stated in part “We will get completed.””

“I t is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 3 (33%) clinical records reviewed that were discharged from hospice revealed that the agency did not ensure that a discharge summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation was provided upon discharge to assist in the post-discharge continuity of care. Policy PE.20 Patient Discharge Review Date 10/01/2021 stated in part “The Hospice discharge summary which includes but is not limited to: A summary of the patient’s care (pain management, symptoms, and treatments), The patient’s current plan of care including the medication profile, the latest physician orders, and any other documentation re3quested or that may assist with the patient’s post-discharge continuity of care. Policy PE.35 Patient Revocation Review Date 10/01/2021 stated in part “The patient’s attending physician is notified by the hospice of the patient’s intent to revoke the hospice benefit. The hospice will forward copies of the following information to the patient’s attending physician: The hospice discharge summary that includes but is not limited to: The patient’s current plan of care including the medication profile, the latest physician orders, and any other documentation requested or that may assist with the patient’s post-discharge continuity of care.” Clinical Record 11: The patient’s election of benefits was dated 03/27/2023. The patient revoked the hospice benefit due to aggressive treatment on 01/05/2024. The discharge summary sent to the hospital and attending physician did not include a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. The administrator confirmed findings in a joint interview and record review on 05/30/2024 and stated in part “No the summary isn’t completed and doesn’t include the plan of care and orders when faxed.””