Century Hospice LLC

“Based on record review and interview the program failed to use quality indicator data, including patient care, and other relevant data to examine all facets of a hospice operation. [DH1] In the design and implementation of its quality management program for 2 (2023 and 2024) of 2 years.The failure meant potential patients were subjected to care by an agency that not monitoring agency services and quality. During the entrance conference on 06/10/2025 the surveyor requested all QAPI documents for the past three years. Record review revealed an agency provided Quality Assessment / Performance Improvement Plan dated “110108” which read in part: “Agency will enhance organization performance by fulfilling the mission. The program will be ongoing and focused on patient outcomes that are measurable. All aspects of hospice care will be reviewed and analyzed in order to provide quality care and outcomes…. The program will show measurable improvement in indicators related to improved palliative outcomes and hospice services. Hospice will measure, analyze, and track quality indicators that enable the agency to assess processes of care, hospice services, and operations…. The leaders are responsible for improving care and services. They establish expectations and manage processes to measure, assess, and improve Agency’s governance, management, clinical, and support processes… Annual Agency Evaluation: Hospice leaders (including the Board of Directors, 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 agency policy, and address prioritites for improved quality of care and patient safety.” Record review of the agency completed QAPI program documents provided by the Alternate Administrator / DON on 06/11/2025 revealed documents that stated: “First Quarter 2023 no patient at this time,” ‘Second Quarter 2023 no patient at this time,” “Fourth Quarter 2023 no patient at this time” all signed by the Alternate Administrator / DON. The quality assurance documents provided included one clinical record audit documented for third quarter 2023. No other quality program documents were provided for 2023 and 2024. No QAPI committee meeting minutes were provided for 2023 and 2024. No agency annual evaluations were provided for 2023 and 2024. An interview was conducted with the Alternate Administrator / Supervising Nurse on 06/11/2025 at 2PM. The surveyor shared the findings of the review of the QAPI documents provided to the surveyor. The surveyor asked about QAPI meetings. The Alternate Administrator / Supervising Nurse stated the Administrator takes care of the QAPI meetings. The surveyor asked if the Supervising Nurse attended and QAPI committee meetings in 2023 and 2024. The supervising nurse stated the agency didn’t have any patients so there were no actual meetings in 2024. The supervising nurse stated the agency had one patient in 2023 and thought they had a meeting after the IDT for the one patient. The surveyor asked for the meeting minutes for the 2023 meeting. The Alternate Administrator / Supervising nurse stated the Administrator was responsible for the meeting minutes. The surveyor asked about the agency QAPI plan and if the agency had completed the requirements in the agency QAPI program documents provided to the surveyor. policy for QAPI meetings. The Alternate Administrator stated the policy was to do them quarterly after their IDT meetings. The Alternate Administrator stated the last IDT meeting was 2023 for the one patient admitted in 2023, and the agency had not had any other meetings since the 2023 IDT because the agency didn’t have any patients. The surveyor asked about the agency annual evaluations. The Alternate Administrator stated they were not done. The surveyor asked who was responsible for the Agency annual evaluations. The Alternate Administrator stated the Administrator was responsible for the Quality Improvement program and the Agency annual evaluations. The surveyor attempted to reach the Administrator upon entrance to the survey on 06/10/2025 at 11am. The Alternate Administrator / Supervising Nurse stated the Administrator was not available and agreed to conduct the survey entrance via telephone at 12:04 PM. The surveyor left a message on the Administrator’s phone number provided by the agency on 06/11/2025 at 3:01 PM and left a voice mail message requesting a return call. No response was received by the end of the survey.Review of agency policy titled: “Quality Assessment Performance Improvement Program QAPI.1” dated “120119” read in part: “Purpose – To develop, implement, evaluate, and maintain an effective, ongoing, Agency-wide, data-driven Quality Assessment Performance Improvement (QAPI) Program as defined by its QAPI Plan … The Agency will develop, implement, and maintain an effective, ongoing, hospice-wide data-driven QAPI plan that is evaluated, reviewed, and updated or revised at least once within the calendar year, or more often if needed, by the QAPI committee… Areas for improvement will be identified through collection of data for analysis of Agency services. Systems that measure significant outcomes for optimal care include… Annual evaluation of total operations… at a minimum, the QAPI committee will consist of the administrator, the supervising nurse, and individuals representing the scope of services provided by the Agency. 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…””