Hope Beyond Hospice

“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 hospice measured, analyzed, and tracked quality indicators of performance to enable the assessment of processes of care, hospice services, operations, and adverse patient events after 05/11//2023 (end of the PHE) {HQPI.4. I/L562}; Failed to ensure there was documented evidence of performance improvement activities to focus on high-risk, high-volume, or problem-prone areas after 05/11//2023 (end of the PHE). (HQPI.6. I/L566}; Failed to ensure that any PIP’s were developed or tracked in the year after 05/11//2023 (end of the PHE) or the first two quarters of 2024{HQPI.9. I/L571}; and Failed to ensure that the governing body developed, implemented, and maintained an effective QAPI program after 05/11/2023 (end of PHE) and the first 2 quarters of 2024 {HQPI.1. D/L574}. 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 each patient’s individualized written plan of care 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 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that the patient’s written plan of care included planned interventions based on a problem identified in the comprehensive assessment. Clinical Record 1: The patient elected the hospice benefit on 09/10/2024 with a diagnosis of senile degeneration of brain and a secondary diagnosis of seizures. The initial certification of terminal illness (CTI) dated 09/10/2024 and the initial RN comprehensive assessment dated 09/10/2024 documents that the patient has a history of seizures. The patient takes Klonopin for maintenance of this diagnosis. A review of the initial plan of care dated 09/10/2024, there was no documented goals or interventions for seizures. In an interview with the Director of Nursing she agreed that the RN should have included goals and interventions for seizures.”

“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 the following, 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 6 of 14 (43%) clinical records reviewed revealed that the agency did not ensure that the patient’s individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 2: The patient elected the hospice benefit on 09/16/2024 with a diagnosis of Parkinson’s disease. On the plan of care dated 09/16/2024 problems identified were patient at risk for aspirating, occasional coughing when swallowing food or fluids and patient is anxious/has agitation. In a joint review of the clinical record and interview with the director of nursing it was agreed and confirmed that there were no documented measurable goals on the plan of care for this patient. Clinical Record 3: The patient elected the hospice benefit on 01/12/2024 with a diagnosis of senile degeneration of the brain. On the plan of care dated 01/16/2024 problems identified were “Current active infection. Patient has chronic recurrent UTI’s and despite being on Macrobid prophylactically, she currently has a UTI, the NP started her on cipro 250mg twice a day for 5 days.” Goal documented was “patient infection will be resolved.” A second problem identified on the same plan of care was “sadness of disease process with acceptance.” The goal documented was “patient will experience support.” On the plan of care dated 11/08/2024 a problem identified was, “patient has complicating mental issues, patient has recent history of yelling out. She is anxious with care at times. She is disoriented and does not effectively make her needs known.” A second problem identified was, “patient has complicating emotional issues.” The goal documented was, “patient will remain free of injuries.” In an interview and joint review of the clinical record with the director of nursing she agreed and confirmed that these were not appropriate measurable goals for the problems identified. Clinical Record 4: The patient elected the hospice benefit on 10/18/2024 with a diagnosis of senile degeneration of the brain. The initial RN assessment dated 10/18/2024 identified problems of Risk of falls. The goal written was “patient will remain free of injury with the limits of disease progression.” Another problem Identified was “patient with significant cardiac history CAD, angina pectoris, coronary arteriosclerosis in native artery, paroxysmal a-fib, sinus bradycardia, PVD, systolic murmur. Patient moves slowly and has evident dyspnea with minimal energy exertion and also slight tinting of his fingers after minimal energy exertion.” The documented goal was “maintain comfort within the limits of disease progression.” A third problem identified on the plan of care dated 10/30/2024 was “patient incontinent of bowel and bladder.” The goal documented was “skin integrity will be maintained withing the limits of disease progression.” These goals did not reflect any measurable outcomes. In an interview with the Director of Nursing she agreed and confirmed that the goals were did not include any measurable outcomes. Clinical Record 5: The patient elected the hospice benefit on 02/09/2024 with a diagnosis of Malignant neoplasm of unspecified ovary. In an RN comprehensive assessment, the RN documented, “patient has a history of headaches, muscle pain form spasms and nerve pain to lower extremities for neuropathy. Currently managed with Tylenol and methocarbamol as needed as well as gabapentin scheduled at bedtime.” On the plan of care dated 10/25/2024 the problem of pain was identified the goal documented was, “pt will maintain pain controlled at the acceptable level for Pt/CG.” In a joint review of clinical record and interview with the director of nursing she agreed and confirmed that this was not an acceptable measurable goal. Clinical Record 6: The patient elected the hospice benefit on 08/04/2024 with a diagnosis of acute on chronic diastolic heart failure. The plans of care dated 11/13/2024 and 11/27/2024 identified a problem of “patient is a fall risk.” The goal documented was, “patient will remain free from injury.” A second problem identified was, “patient has pain/symptoms associated with shortness of breath.” The goal documented was, “patient/caregiver educated regarding physical status and respiratory limitations.” Clinical Record 10: The patient elected the hospice benefit on 11/16/2024 with a diagnosis of malignant neoplasm of the prostate. In an RN comprehensive assessment dated 11/19/2024 the RN documented “constant lower back pain due to recent injury and surgery. Mild pain to sacrum. Worst pain 7/10, best pain 1/10, current pain is a 1. On the plan of care dated 11/20/2024 the problem of pain was identified as “Pain controlled with current medications/methods.” Goal documented was, “patient will maintain pain controlled at an acceptable level for patient/caregiver.” A second problem of “patient has wound to coccyx and wound to lower back.” The goal documented was, “skin integrity will be maintained or improved as feasible.” In joint clinical record review and interview with the director of nursing, she agreed and confirmed that these were not acceptable measurable goals.”

“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 revealed the “Agency Annual Evaluation-Hospice” and was dated 01/16/2023 for year review 2023. The document stated in part “The purpose of this evaluation is to ensure maximum efficiency in informing individuals of the organizational structure and lines of authority and their responsibilities and accountability. The results were as follows “Criteria met. Basic structure of systems in place however we need to focus on more specific information to provide a more in-depth analysis. Several issues have been identified with a POC created and implemented but no documentation created to show action plan in place or to monitor outcomes. My recommendation is to hire a dedicated QAPI manager to maintain compliance whenever financially viable.” This document only included a check list of things to be reviewed. There was no written evidence of the information to be reviewed according to this check list. There was no written documented evidence that the agency was measuring, analyzing, or tracking quality indicators of performance after 05/11/2023 (end of the PHE) or the first 2 quarters of 2024. In an interview with the DON and the individual responsible for QAPI it was stated “The QAPI position was not full-time during 2023 or first part of 2024. The employed Nurse Practitioner took over the oversight of the QAPI program in September 2024. The DON stated that the EMR is capable of running reports for infections and adverse events. She also stated that these topics were discussed in IDG meetings as well as beginning and end of day calls. The Administrator admitted that the QAPI process of tracking and maintaining was lacking in 2023. There was no one person that was appointed to oversee the program, according to the administrator and DON everybody played a role in keeping up with things.” Several documents were presented to this surveyor for review of the QAPI program. One of the documents was titled “Agency Annual Evalution-Hospice” and was dated 01/16/2023 for year review 2023. The document stated in part “The purpose of this evaluation is to ensure maximum efficiency in informing individuals of the organizational structure and lines of authority and their responsibilities and accountability. The results were as follows “Criteria met. Basic structure of systems in place however we need to focus on more specific information to provide a more in-depth analysis. Several issues have been identified with a POC created and implemented but no documentation created to show action plan in place or to monitor outcomes. My recommendation is to hire a dedicated QAPI manager to maintain compliance whenever financially viable.” This document only included a check list of things to be reviewed. There was no evidence written evident of the information was to be reviewed according to this check list. There was no written documented evidence that the agency was measuring, analyzing or tracking quality indicators of performance in the year of 2023 or the first 2 quarters of 2024. In an interview with the DON and the individual responsible for QAPI it was stated “The QAPI position was not full-time during 2023 or first part of 2024. The employed Nurse Practitioner took over the oversight of the QAPI program in September 2024. The DON stated that the EMR is capable of running reports for infections and adverse events. She also stated that these topics were discussed in IDG meetings as well as beginning and end of day calls. The Administrator admitted that the QAPI process of tracking and maintaining was lacking in 2023. There was no one person that was appointed to oversee the program, according to the administrator and DON everybody played a role in keeping up with things.””

“It is required that hospice performance improvement (PI) activities focus on high-risk, high-volume, or problem-prone areas. This standard was not met as evidenced by document review and interview which revealed the “Performance Improvement Patient Indicators Report” dated 11/ 08/2024 and according to an interview with the individual responsible for compliance, this report was done to trigger ideas to develop performance improvement plans (PIP). Some of the ideas listed for new PIP’s included pain, respiratory comfort, anxiety, sadness, restlessness, agitation and family education and training. However, the only PIP’s the agency could provide were initiated on 11/19/2024 and included, (1) Improve professionalism in appearance, speech, and presence when with a patient or in a facility. (2) Excessive antibiotic orders in hospice patients. There was no written evidence that any PIP’s were initiated after 05/11/2023 (end of the PHE) or the first 2 quarters of 2024 to focus on high-risk, high-volume, or problem-prone areas. In an interview with the individual responsible for QAPI and the DON they confirmed that there were no performance improvement (PI) activities for this timeframe. A document was presented to the surveyor titled, “Performance Improvement Patient Indicators Report”. This report was dated 11/ 08/2024 and according to an interview with the individual responsible for compliance, this report was done to trigger ideas to develop performance improvement plans (PIP). Some of the ideas listed for new PIP’s included pain, respiratory comfort, anxiety, sadness, restlessness, agitation and family education and training. However, the only PIP’s the agency could provide were initiated on 11/19/2024 and included, (1) Improve professionalism in appearance, speech, and presence when with a patient or in a facility. (2) Excessive antibiotic orders in hospice patients. There was no written evidence that any PIP’s were initiated in the year 2023 or the first 2 quarters of 2024. In an interview with the individual responsible for QAPI and the DON they confirmed that there were no PIP’s for this timeframe.”

“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, and past performance of the hospice’s services and operations. This standard was not met as evidenced by document review and interview which revealed the document titled “Performance Improvement Patient Indicators Report” done on 11/08/2024. The document was different topics on it that were being considered to develop performance improvement plans (PIP). Some of the ideas for new PIP’s included pain, respiratory comfort, anxiety, sadness, restlessness, agitation and family education and training. A review of the actual PIP’s in progress currently for the agency that were developed on 11/19/2024 was, (1) Improve professionalism in appearance, speech, and presence when with a patient or in a facility. (2) Excessive antibiotic orders in hospice patients. There was no written documented evidence that any PIP’s were developed or tracked after 05/11/2023 (end of the PHE) or the first two quarters of 2024. In an interview with Administrator and Director of Nursing it was stated that, “The QAPI position was not full-time during 2023. The employed Nurse Practitioner took over the oversight of the QAPI program in September 2024. The DON stated that the EMR is capable of running reports for infections and adverse events. She also stated that these topics were discussed in IDG meetings as well as beginning and end of day calls. The Administrator admitted that the QAPI process was lacking in 2023. There was no one person that was appointed to oversee the program, according to the administrator and DON everybody played a role in keeping up with things.” They admitted they could not produce any PIPs for 2023 or the first two quarters of 2024. A document was presented to the surveyor that was titled “Performance Improvement Patient Indicators Report” done on 11/08/2024. The document was different topics on it that were being considered to develop performance improvement plans (PIP). Some of the ideas for new PIP’s included pain, respiratory comfort, anxiety, sadness, restlessness, agitation and family education and training. In reviewing actual PIP’s in progress currently for the agency that were developed on 11/19/2024 was, (1) Improve professionalism in appearance, speech, and presence when with a patient or in a facility. (2) Excessive antibiotic orders in hospice patients. There was no written documented evidence that any PIP’s were developed or tracked in the year 2023 or the first two quarters of 2024. In an interview with Administrator and Director of Nursing it was stated that, “The QAPI position was not full-time during 2023. The employed Nurse Practitioner took over the oversight of the QAPI program in September 2024. The DON stated that the EMR is capable of running reports for infections and adverse events. She also stated that these topics were discussed in IDG meetings as well as beginning and end of day calls. The Administrator admitted that the QAPI process and maintained was lacking in 2023. There was no one person that was appointed to oversee the program, according to the administrator and DON everybody played a role in keeping up with things.” The admitted they could not produce any PIP’s for 2023 or the first two quarters of 2024.”

“It is required that the hospice’s governing body is responsible for ensuring that the program assumes legal authority and responsibility or the organization’s ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually and 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 which revealed that the governing body did not ensure that an effective QAPI program was developed, implemented, and maintained after 05/11/2023 (end of PHE) for the year of 2023 and the first 2 quarters of 2024. The agency was unable to provide any viable documents or documentation of a QAPI program after 05/11/2023 (end of PHE) for the year of 2023 and the first 2 quarters of 2024. The Administrator Job Description signed on 12/01/2021 states “Primary function is to assume overall responsibility and authority for administrative and leadership functions, supervision of the organizational plan, and responsibility for ongoing communication with the Governing body and the interdisciplinary group/team, as well as the hospice staff. This was discussed with the administrator, and he stated “it just fell through the cracks. We were so busy with other things. 2023 was a hard year for us.” Agency Document: “Agency Annual Evaluation-Hospice” was dated 01/16/2023 for year review 2023. The purpose of this evaluation is to ensure maximum efficiency in informing individuals of the organizational structure and lines of authority and their responsibilities and accountability. The results were as follows “Criteria met. Basic structure of systems in place however we need to focus on more specific information to provide a more in-depth analysis. Several issues have been identified with a POC created and implemented but no documentation created to show action plan in place or to monitor outcomes. My recommendation is to hire a dedicated QAPI manager to maintain compliance whenever financially viable.” This was only a check sheet of things that needed to be reviewed to ensure the QAPI was complete. There was no documentation to prove that the tasks on the checklist had been done. QAPI Action Plan was dated 08/13/2024 that stated “QAPI not being utilized to full extent due to staffing (QAPI) is only part-time. QAPI needs to be a full-time position to improve our care provided and to minimize risks. (QAPI was made full-time 09/01/2024). Modification and steps going forward are to expand the role of QAPI, September is used for catching up and October can initiate meaningful performance improvement projects.” “Performance Improvement Patient Indicators Report” was done on 11/08/2024 to trigger ideas to develop performance improvement plans (PIP), these topics included pain, respiratory comfort, anxiety, sadness, restlessness, agitation and family education and training. The only actual PIPs found to be in progress 11/19/2024 (1) Improve professionalism in appearance, speech, and presence when with a patient or in a facility. (2) Excessive antibiotic orders in hospice patients. There was no documented evidence of PIPs for the year after 05/11/2023 (end of PHE) 3 and the first 2 quarters of 2024. Quality Assessment Performance Improvement Program states in part that “The QAPI Committee will meet at least twice a year or more often, if needed, and will maintain a written record of the meetings with appropriate signatures.” There is no documented evidence of meetings held the year of 2023. In an interview with Administrator and Director of Nursing conducted on 12/04/2024 they stated, “The QAPI position was not full-time during 2023. The employed Nurse Practitioner took over the oversight of the QAPI program in September 2024.” The DON stated that the EMR is capable of running reports for infections and adverse events. She also stated that these topics were discussed in IDG meetings as well as beginning and end of day calls. The Administrator admitted that the QAPI process was lacking in 2023. There was no one person that was appointed to oversee the program, according to the administrator and DON everybody played a role in keeping up with things. During review of multiple documents and in an interview with nurse practitioner responsible for QAPI and director of nursing it was found that the agency did not ensure that an effective QAPI program was developed, implemented, and maintained during the year of 2023 and the first 2 quarters of 2024. The agency was unable to provide any viable documents or documentation of a QAPI program for 2023 or the first 2 quarters of 2024. In an interview with Administrator and Director of Nursing conducted on 12/04/2024 they stated, “The QAPI position was not full-time during 2023. The employed Nurse Practitioner took over the oversight of the QAPI program in September 2024.” The DON stated that the EMR is capable of running reports for infections and adverse events. She also stated that these topics were discussed in IDG meetings as well as beginning and end of day calls. The Administrator admitted that the QAPI process and maintained was lacking in 2023. There was no one person that was appointed to oversee the program, according to the administrator and DON everybody played a role in keeping up with things. The Administrator Job Description signed on 12/01/2021 states “Primary function is to assume overall responsibility and authority for administrative and leadership functions, supervision of the organizational plan, and responsibility for ongoing communication with the Governing body and the interdisciplinary group/team, as well as the hospice staff. This was discussed with the administrator, and he stated “it just fell through the cracks. We were so busy with other things. 2023 was a hard year for us.” The following documents were presented to the surveyor: Document #1 provided by agency titled “Agency Annual Evalution-Hospice” was dated 01/16/2023 for year review 2023. The purpose of this evaluation is to ensure maximum efficiency in informing individuals of the organizational structure and lines of authority and their responsibilities and accountability. The results were as follows “Criteria met. Basic structure of systems in place however we need to focus on more specific information to provide a more in-depth analysis. Several issues have been identified with a POC created and implemented but no documentation created to show action plan in place or to monitor outcomes. My recommendation is to hire a dedicated QAPI manager to maintain compliance whenever financially viable.” This was only a check sheet of things that needed to be reviewed to ensure the QAPI was complete. There was no documentation to prove that the tasks on the checklist had been done. Document #2, a second QAPI Action Plan was dated 08/13/2024 that stated “QAPI not being utilized to full extent due to staffing (QAPI) is only part-time. QAPI needs to be a full-time position to improve our care provided and to minimize risks. (QAPI was made full-time 09/01/2024). Modification and steps going forward are to expand the role of QAPI, September is used for catching up and October can initiate meaningful performance improvement projects.” Document #3 titled “Performance Improvement Patient Indicators Report” was done on 11/08/2024 to trigger ideas to develop performance improvement plans (PIP), these topics included pain, respiratory comfort, anxiety, sadness, restlessness, agitation and family education and training. The only actual PIP’s found to be in progress 11/19/2024 (1) Improve professionalism in appearance, speech, and presence when with a patient or in a facility. (2) Excessive antibiotic orders in hospice patients. There was no documented evidence of PIP’s for the year 2023 or the first 2 quarters of 2024. The hospice also has a policy, #QAPI.1 Quality Assessment Performance Improvement Program states in part that “The QAPI Committee will meet at least twice a year or more often, if needed, and will maintain a written record of the meetings with appropriate signatures.” There is no documented evidence of meetings held the year of 2023.”

“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 interview and personnel record review. In 4 of 11 (36%) personnel records reviewed revealed that the agency did not ensure that skills and competencies were assessed of all individuals providing care. Personnel Record 1: During review of personnel record for the Administrator (Personnel Record 1) with a hire date of 12/02/2021, there was no documented evidence that the licensed professional who provides patient care completed any skills, or competency checks for 2023. Personnel Record 2: During review of personnel record for the Director of Nursing (Personnel Record 2) with a hire date of 12/01/2021, there was no documented evidence that the licensed professional who provide patient care completed any skills, or competency checks for 2023. Personnel Record 5: During review of personnel record for the registered nurse (RN) Case Manager (Personnel Record 5) with a hire date of 12/01/2021, there was no documented evidence that the licensed professional who provides patient care completed any skills, or competency checks for 2023. Personnel Record 6: During review of personnel record for the RN Case Manager (Personnel Record 6) with a hire date of 04/02/2024, there was no documented evidence that the licensed professionals who provides patient care completed any skills, or competency checks. In an interview with director of nursing and administrator they stated, “these have been done but we cannot locate the documents because the individual responsible for them is out on vacation.””