Provista Hospice

Quality assessment & performance improvement (42 CFR 418.58)

“Upon observation, there was no evidence the organization develops, implements, and maintains an effective, on-going, organization wide Quality Assessment and Performance Improvement (QAPI) program. There were no evidence QAPI minutes, no annual review and no performance improvement activities.”

Rule L0559. Condition-level.

Timeframe for completion of assessment (42 CFR 418.54(b))

“Upon patient record review 1 of 16 (Patient #5) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #5: The spiritual care assessment was completed on 1-31-25 indicating greater than 5 days from admission on 01-23-25.”

Rule L0523. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(6))

Rule L0530. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(7))

Rule L0531. Standard-level.

Content of plan of care (42 CFR 418.56(c)(2))

Rule L0547. Standard-level.

Review of the plan of care (42 CFR 418.56(d))

“Upon patient record review, 1 of 16 (Patient #14) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #14: Physical therapy “eval and treat” was ordered on 04-04-25, but there was no evidence that goals and interventions were updated in the plans of care on 04-15-25 and 04-29-25.”

Rule L0553. Standard-level.

Coordination of services (42 CFR 418.56(e)(2))

Rule L0555. Standard-level.

Coordination of services (42 CFR 418.56(e)(3))

Rule L0556. Standard-level.

Program data (42 CFR 418.58(b)(3))

“Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. There was no evidence of a QAPI plan approved by the governing body.”

Rule L0565. Standard-level.

Program activities (42 CFR 418.58(c)(2))

“Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. There is no evidence that plans of correction were developed to prevent patient falls.”

Rule L0569. Standard-level.

Program activities (42 CFR 418.58(c)(3))

“Upon observation, there was no evidence a written plan of correction is developed in response to any QAPI activity that does not meet an acceptable threshold. There is no evidence of measurement or analyses of collected data or that a plan of correction was developed.”

Rule L0570. Standard-level.

Performance improvement projects (42 CFR 418.58(d)(1))

“Upon observation, there was no evidence the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice’s population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice’s services and operations. There is no evidence that QAPI projects were chosen or conducted for 2024 or 2025.”

Rule L0572. Standard-level.

Performance improvement projects (42 CFR 418.58(d)(2))

“Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. There is no evidence of projects being conducted in 2024 or 2025.”

Rule L0573. Standard-level.

Executive responsibilities (42 CFR 418.58(e)(1))

“Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. There is no evidence of the involvement of the governing body in the QAPI program, no QAPI minutes or annual review.”

Rule L0574. Standard-level.

Executive responsibilities (42 CFR 418.58(e)(2))

“Upon observation, there was no evidence the hospice’s governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. There is no evidence of a hospice wide QAPI plan approved by the board of directors which addressed priorities, patient safety and improvement actions.”

Rule L0575. Standard-level.

Control (42 CFR 418.60(b)(2))

“Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. There is no evidence that the hospice maintains a coordinated infection program which identifies infections to be reported and which uses data to assess the effectiveness of the infection control program and apply corrective action plans as needed.”

Rule L0581. Standard-level.

Counseling services (42 CFR 418.64(d)(1)(i))

“Upon personnel record review, 1 of 15 (Personnel #5 ) did not have evidence that all bereavement services are provided by a qualified counselor in accordance with applicable laws and regulations, professional practice standards, the hospice’s policies and procedures and/or job descriptions which includes experience or education in grief or loss counseling. Personnel #5: The Bereavement Coordinator job description required “Experience in bereavement and grief counseling.” There was no evidence of experience grief and bereavement in the personnel file and the personnel’s application indicated she applied for the “receptionist” role.”

Rule L0596. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(1))

Rule L0625. Standard-level.

Cost saving (42 CFR 418.78(d))

Rule L0646. Standard-level.

Level of activity (42 CFR 418.78(e))

“Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. There was no evidence that volunteer labor equaled 5% of all paid employee and contract labor.”

Rule L0647. Standard-level.

Governing body and administrator (42 CFR 418.100(b))

“Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. While there is a compliant Board of Directors Agenda, there is no evidence of meeting minutes that are dated or document attendees.”

Rule L0651. Standard-level.

Content (42 CFR 418.104(a)(3))

“Upon patient client record review, 1 of 16 (Patient #5) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient #5: On 02-25-25, the patient developed pain and new orders for Oxycodone and Prednisone were given. There was no follow-up visit or phone call to the patient or caregiver to assess the effectiveness of the medication until 03-06-25.”

Rule L0674. Standard-level.

Authentication (42 CFR 418.104(b))

“Upon patient client record review, 1 of 16 (Patient #6) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #6: The RN completed a supervisory visit on 04-23-24, but there were no visits by the aide to the patient, and there was a missed visit documented on 04-18-25.”

Rule L0679. Standard-level.

Discharge or transfer of care (42 CFR 418.104(e)(3))

“Upon client record review, 1 of 16 (Patient #4) did not have evidence that the discharge summary includes all required information. Patient #4: There was no evidence of a discharge summary.”

Rule L0684. Standard-level.