Arms of Compassion Hospice Care

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by clinical record review, document review, and interviews which revealed the hospice: Failed to ensure that the goals identified on the patient’s plan of care were reflective of patient and/or family goals and included measurable criteria in order to be able to track progress {HCPC.21. I/L548/418.56(c)(3)}; Failed to ensure that the plan of care reflected problems, interventions, and goals for all disciplines and for all care provided {HCPC.21.I/L545/418.56(c)}; and Failed to ensure that the patient’s plan of care was updated to reflect new information from the patient’s updated comprehensive assessment{HCPC.22.I/553 418.56(d)}. 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 418.56: Interdisciplinary group, care planning, and coordination of service. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the hospice agency.”

“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 an annual review of the QAPI program for 2025{HQPI.1.D/L574/418.58(e)(1)}; Failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program measured, analyzed, and tracked quality indicators of performance that enable the assessment of processes of care, hospice services, operations, and adverse patient events{HQPI.4.I/L562/418.58(a)(2)}; Failed to ensure the Quality Assessment and Performance Improvement (QAPI) program used quality indicator data, including patient care data and other relevant data, in the QAPI program{HQPI.5.I/L563/ 418.58(b)(1)}; Failed to ensure the QAPI program affected palliative outcomes, patient safety, and quality of patient/family care{HQPI.6.I/L568/ 418.58(c)(1)(iii)}; Failed to ensure the QAPI program was tracking, analyzing, and was following up on adverse events {HQPI.7. I/L569/ 418.58(c)(2)}; Failed to ensure the QAPI program documented Performance Improvement Projects (PIPs) from August 2023 through calendar year 2025. Documentation reflected that a PIP was not initiated until 05/28/2026{HQPI.8. I/L570/418.58(c)(3)}: and Failed to ensure that the organization maintained an ongoing, comprehensive approach to performance improvement activities. There was no evidence of analysis, selection of high-risk or high-volume problem areas, or implementation of targeted improvement initiatives that align with the scope and complexity of services provided to the hospice population {HQPI.9. I/L571/418.58(d)}. 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 reflect the patient and family goals and identify planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review. In 5 of 14 (36%) clinical records reviewed revealed that the agency did not ensure that the plan of care reflected problems, interventions, and goals for all disciplines and for all care provided. CLINICAL RECORD 3: The patient elected the hospice benefit on 12/22/2025. A review of the Plan of Care (POC) for the benefit periods 02/20/2026 to 04/20/2026 and 04/21/2026 to 06/19/2026 confirmed physician orders for Chaplain services to be provided once monthly. Chaplain visit documentation dated 03/17/2026 reflected empathetic listening and a ministry of presence, including a life review, and noted that the patient’s husband appeared frail and exhibited some memory concerns. The Chaplain indicated plans to continue assessing the spiritual needs of the patient and caregivers. On 05/12/2026, the Chaplain documented that the patient was alert and responsive but demonstrated limited understanding of her surroundings; family members were present, expressed gratitude for the visit, and an ongoing spiritual assessment was noted. The POC for the identified benefit periods did not include defined chaplain-related problems, interventions, or measurable goals to guide the delivery of spiritual care services. CLINICAL RECORD 4: The patient elected the hospice benefit on 04/07/2026. A review of the Plan of Care (POC) for the benefit periods 04/07/2026 to 06/05/2026 and 06/06/2026 to 08/04/2026 confirmed physician orders for Chaplain services to be provided twice monthly. Chaplain visit documentation reflected ongoing spiritual and psychosocial needs. On 04/08/2026, the Chaplain documented interventions including active and empathetic listening, bereavement counseling, grief counseling, assistance with verbalizing concerns, meaning-centered support, and ministry of presence. The Chaplain also documented that the patient expressed a need to “get her house in order” but continued to delay making funeral arrangements, contributing to distress between the patient and her adult children. The patient also expressed a desire to receive communion. On 05/06/2026, the Chaplain provided communion and again documented family tension related to unresolved end-of-life planning. On 06/02/2026, documentation reflected continued provision of communion and ministry of presence, with additional observations of family dynamics, including the daughter expressing frustration regarding the patient’s decision-making, gambling behaviors, and safety concerns following a recent fall resulting in a left hip fracture. Despite these clearly identified and ongoing spiritual, emotional, and family dynamic concerns, the POC did not include any chaplain-specific problems, interventions, or measurable goals to guide the provision of spiritual care services. CLINICAL RECORD 8: The patient elected the hospice benefit on 05/08/2025. A review of the Plan of Care (POC) for the benefit periods 03/04/2026 to 05/02/2026 and 05/03/2026 to 07/01/2026 confirmed physician orders for Chaplain services to be provided once monthly. There was no evidence of Social Work involvement documented during these benefit periods. Chaplain visit documentation reflected ongoing and significant emotional and spiritual concerns. On 03/11/2026, the Chaplain documented a need for “caring presence,” with the patient reporting improvement, stating he had not experienced nightmares for some time, though they had previously been emotionally and spiritually distressing. On 04/06/2026, the Chaplain documented a recurrence of nightmares contributing to emotional distress. During this visit, the patient acknowledged noncompliance with previously effective sleep medications. Documentation further indicated that the patient was frequently noncompliant with medications and oxygen therapy, and nursing staff expressed concern that the patient appeared disengaged and may have limited motivation to participate in care. On 06/01/2026, the Chaplain documented continued need for presence and support, noting the patient admitted to drinking beer and appeared withdrawn, expressing a passive approach toward his condition and declining to actively engage in interventions to improve his well-being. Despite consistent documentation of emotional distress, recurring nightmares, medication noncompliance, alcohol use, and psychosocial concerns indicative of spiritual and emotional suffering, the POC did not include any chaplain-specific problems, interventions, or measurable goals to guide care. Additionally, the absence of Social Work involvement further limited the interdisciplinary approach to addressing the patient’s complex psychosocial and behavioral needs. CLINICAL RECORD 9: The patient elected the hospice benefit on 01/09/2026. A review of the Plan of Care (POC) for the benefit periods 03/10/2026 to 05/08/2026 and 05/09/2026 to 07/07/2026 confirmed physician orders for Chaplain services to be provided once monthly. Chaplain visit documentation reflected ongoing opportunities to assess and address cognitive, emotional, and spiritual needs. On 05/05/2026, the Chaplain documented that the patient was alert and responsive, aware of self and surroundings, but acknowledged experiencing memory loss and recognizing a diagnosis of dementia. The patient also reported having recently discontinued care with a prior provider and planned to obtain care from a new one. Despite being wheelchair- and bed-bound, the patient expressed unrealistic perceptions regarding independence, including stating she would go to a restaurant when asked about meal preparation. The Chaplain provided active listening and ministry of presence, noting family involvement and no new expressed emotional or spiritual concerns. On 06/01/2026, the Chaplain again documented the provision of empathetic listening and ministry of presence, identifying a need for “caring presence” but no additional concerns. Supporting nursing documentation on 05/06/2026 indicated the patient was alert and oriented times three, able to communicate needs independently, but exhibited intermittent forgetfulness. Despite these documented findings related to cognitive decline, insight, safety awareness, and psychosocial context, the POC did not include any chaplain-specific problems, interventions, or measurable goals to guide the provision of spiritual care services. CLINICAL RECORD 10: The patient elected the hospice benefit on 05/02/2026. A review of the Plan of Care (POC) for the benefit period 05/02/2026 to 07/30/2026 confirmed physician orders for Chaplain services to be provided once monthly. Chaplain documentation dated 05/04/2026 reflected the provision of multiple interventions, including active listening, assistance with verbalizing concerns, brief counseling, comfort and support, assessment of family and friend dynamics, education of the care team regarding spiritual issues, life review, meaning-centered support related to illness, and ministry of presence. However, the outcomes of these interventions were not clearly defined or documented. Despite evidence of active chaplain involvement and the identification of potential spiritual and psychosocial needs, the POC did not include any chaplain-specific problems, interventions, or measurable goals to guide service delivery. A joint clinical record review and interviews with the Administrator (Personnel Record 2), the Clinical Director (Personnel Record 4), and the Team Lead (Personnel Record 7) on 06/16/2026 and 06/17/2026 confirmed that the Chaplain had not identified any problems, interventions, or goals to guide the spiritual-care services provided to the patients or to evaluate the effectiveness of care provided.”

“It is required that each patient’s individualized written plan of care reflect the patient and family goals and include measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review. In 5 of 14 (36%) clinical records reviewed revealed that the agency did not ensure that the goals identified on the patient’s plan of care were reflective of patient and/or family goals and included measurable criteria in order to be able to track progress. CLINICAL RECORD 2: During the Registered Nurse (RN) visit on 05/15/2026, the nurse documented a significant decline in the patient’s swallowing ability, including the need for continuous cueing and coaching during meals and total feeding assistance due to weakness, food pocketing, and delayed swallow initiation. The patient required nutritional supplementation with Ensure; however, the spouse was repeatedly required to prompt the patient to swallow. The RN identified the patient as being at risk for aspiration and documented caregiver education regarding aspiration risks associated with dysphagia and food pocketing. On 05/17/2026, a physician’s order was obtained for Thick-It Oral Powder (1.5 tablespoons per 4 oz of liquid as needed) to address swallowing impairment. A physician-signed LCD order also documented clinical decline and confirmed the need for thickened liquids. A review of the Plans of Care (POC) for the benefit periods 02/23/2026 to 05/23/2026 and 05/24/2026 to 08/21/2026 determined that, although weight loss was identified as a problem on 04/02/2026, the associated goals and interventions were not measurable, individualized, or reflective of the patient’s current clinical condition. The documented goals and interventions focused broadly on nutritional monitoring—such as encouraging small, frequent meals, assessing nutritional status, and instructing on signs and symptoms of weight loss—but did not establish clear, objective, or time-bound goals related to the patient’s dysphagia, aspiration risk, or need for thickened liquids and feeding assistance. CLINICAL RECORD 4: During the Registered Nurse (RN) visit on 04/14/2026, the nurse documented that the patient experienced dyspnea with minimal exertion. On 04/22/2026, the patient reported a dyspnea score of 2/10. A review of the Plans of Care (POC) for the benefit periods 02/25/2026 to 05/25/2026 and 05/26/2026 to 08/23/2026 determined that shortness of breath (SOB)/dyspnea was not incorporated as a problem until 05/13/2026, despite earlier documented symptoms. When dyspnea was added to the POC, the plan lacked specific, measurable, or patient-centered goals. The stated goals of “increased respiratory comfort” and “decreased SOB within 24 hours” lacked objective criteria, measurable benchmarks, and defined parameters for evaluating effectiveness. CLINICAL RECORD 7: Skilled nursing documentation on 06/04/2026 indicated a notable change in condition: the patient now requires a thickener for all beverages due to swallowing concerns, is experiencing increased shortness of breath with a reported dyspnea score of 4, and requires continuous oxygen at 3 liters per minute, with an oxygen saturation of 90%. The patient was further noted to be short of breath with minimal exertion or agitation, reflecting a progression in respiratory symptoms. A review of the Plan of Cares (POC) for the benefit periods 01/22/2026 to 04/21/2026 and 04/22/2026 to 07/20/2026 identified shortness of breath as a problem beginning 01/22/2026. However, the associated goal— “patient will have an increased level of respiratory comfort and decreased level of shortness of breath within 24 hours”—was not measurable, lacked objective criteria, and did not reflect the patient’s ongoing and progressive respiratory status. Additionally, despite the patient’s documented clinical decline, including increased oxygen requirements and worsening dyspnea, the goal remained static and was not revised to align with the patient’s current condition. CLINICAL RECORD 8: On 06/02/2026, the Registered Nurse (RN) documented oxygen saturation of 89% on room air, respiratory rate of 20, diminished lung sounds in all lobes, shortness of breath at rest, and a nonproductive cough. The patient required oxygen at 2–5 liters as needed and exhibited dyspnea during conversation. The patient reported pain rated at 4 in both legs and demonstrated fatigue, poor endurance, intermittent confusion, forgetfulness, continued cognitive decline, increased withdrawal from activities, and reduced participation in self-care. A Nurse Practitioner face-to-face visit on 06/08/2026 further documented complaints of joint pain with ambulation, poor lung compliance, and the need to rest with pursed-lip breathing for approximately five minutes to recover. A review of the Plans of Care (POC) for the benefit periods 03/04/2026 to 05/02/2026 and 05/03/2026 to 07/01/2026 identified pain and shortness of breath as ongoing problems; however, the associated goals were not measurable, objective, or patient specific. The goal for pain—stating that “assessment for pain will be done frequently and pain will be controlled or eliminated”—did not include quantifiable parameters such as target pain scale ratings, frequency thresholds, or functional outcomes. Similarly, the goal for shortness of breath—indicating the patient would have “increased level of respiratory comfort” and “decreased level of shortness of breath”—lacked objective benchmarks, such as defined dyspnea-scale targets, oxygen saturation goals, or activity-tolerance measures. While interventions addressed assessment, caregiver instruction, and oxygen use, they were not paired with measurable criteria to evaluate effectiveness or guide timely adjustments in care. CLINICAL RECORD 9: On 01/09/2026, the Registered Nurse (RN) documented that the patient reported pain at level 5, described as nagging, aching, and dull in both lower extremities, with a target goal of 3 and a level of 6 identified as warranting further attention. On 05/06/2026, the RN documented lower back pain at level 3, described as intermittent, aching, and dull, interfering with activities of daily living; the target goal was noted as 4, with a level of 5 warranting further intervention. The patient was prescribed Tramadol 50 mg every 8 hours as needed and Gabapentin 300 mg daily for pain management. A review of the Plans of Care (POC) for the benefit periods 03/10/2026 to 05/08/2026 and 05/09/2026 to 07/07/2026 determined that pain was included as a problem; however, the associated goal—stating that “assessment for pain will be done frequently and pain will be controlled or eliminated within one certification period”—was not measurable, specific, or patient-centered. Interventions included assessing and monitoring pain levels and vital signs and educating the patient and caregiver on the pain management regimen; however, they were not supported by measurable criteria to evaluate effectiveness or to determine when the plan required modification. A joint clinical record review and interviews with the Administrator (Personnel Record 2), the Clinical Director (Personnel Record 4), and the Team Lead (Personnel Record 7) on 06/16/2026 and 06/17/2026 confirmed that the goals documented did not include measurable criteria to evaluate care provided.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan: Information from the patient’s updated comprehensive assessment. Record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed that the agency did not ensure that the patient’s plan of care was updated to reflect new information from the patient’s updated comprehensive assessment. CLINICAL RECORD 2: During the Registered Nurse (RN) visit on 05/15/2026, documented clinical findings indicated a significant risk for aspiration related to dysphagia. The RN noted the patient required continuous cueing and coaching during meals and total feeding assistance due to generalized weakness, food pocketing, and delayed swallow initiation. Although nutritional supplementation with Ensure was in place, the spouse was required to repeatedly prompt the patient to swallow. The RN identified the patient as being at risk for aspiration and documented that education was provided to the spouse regarding aspiration precautions associated with dysphagia and food pocketing. On 05/17/2026, an order was obtained for Thick-It Oral Powder (1.5 tablespoons per 4 oz of liquid as needed) to address swallowing impairment. Additionally, a physician-signed LCD order documented clinical decline, including the new requirement for thickened liquids. A review of the Plans of Care (POCs) for the benefit periods 02/23/2026 to 05/23/2026 and 05/24/2026 to 08/21/2026 determined that the existing interventions focused on weight loss monitoring and nutritional support (including small, frequent meals, regular assessment, and caregiver instruction on signs and symptoms of weight loss); however, they did not address the newly identified swallowing impairment, aspiration precautions, or the use of thickened liquids. The care plan was not revised to reflect the patient’s increased risk of aspiration or documented dysphagia. CLINICAL RECORD 4: The patient resided at home and elected the hospice benefit on 02/25/2026 with a terminal diagnosis of unspecified severe protein-calorie malnutrition and comorbid conditions, including senile degeneration of the brain, adult failure to thrive, and status post left hip fracture repair following a fall. A physician’s order dated 04/10/2026 directed Physical Therapy (PT) and Occupational Therapy (OT) to evaluate and treat the patient, including implementation of a home exercise program with safety precautions, range of motion and strengthening exercises, gait and transfer training, balance activities, and bed mobility, with additional PRN visits as needed to complete the treatment plan. Skilled nursing documentation on 04/14/2026 reflected that the patient was dependent in all activities of daily living and remained at high risk for falls due to a recent left hip fracture and generalized weakness. The patient was also noted to experience dyspnea with minimal exertion. On 04/22/2026, nursing documentation further identified ongoing functional decline, including weakness, impaired ambulation, joint pain, stiffness, intermittent dizziness, and reliance on a rollator and wheelchair for mobility. During this visit, it was also documented that the patient’s daughter/caregiver expressed feeling overwhelmed and was actively seeking additional caregiving support. A dyspnea score of 2/10 was recorded. A review of the Plans of Care (POC) for the benefit periods 02/25/2026 to 05/25/2026 and 05/26/2026 to 08/23/2026 determined that although fall risk was identified as a problem on 04/07/2026, with interventions focused on assessment, home safety, and use of durable medical equipment, the POC did not incorporate the ordered and initiated PT and OT services. During a joint clinical record review and interview with the Administrator (Personnel Record 2), the Clinical Director (Personnel Record 4), and the Team Lead (Personnel Record 7) on 06/16/2026 and 06/17/2026, confirmed that the patients’ plans of care were not updated with the relevant clinical information and all indicated that further education was needed with the clinical staff in regard to updating the plans of care with newly identified clinical information.”

“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 did not ensure that the Quality Assessment and Performance Improvement (QAPI) program measured, analyzed, and tracked quality indicators of performance that enable the assessment of processes of care, hospice services, operations, and adverse patient events. There was no documented evidence of any QAPI meeting minutes, activities, or data collection for the calendar year 2024. Documentation beginning 04/10/2025 reflected a general discussion of the QAPI program structure and broad categories intended for review; however, subsequent quarterly QAPI meeting records dated 04/10/2025, 07/24/2025, 10/23/2025, 01/22/2026, and 04/16/2026 contained repetitive content and lacked documented evidence of evaluation or performance improvement activity. Although the documentation listed multiple clinical, operational, and administrative areas that were reportedly reviewed—including patient care processes, infection control, adverse events, personnel requirements, and satisfaction surveys—there was no supporting raw data to substantiate these reviews. Specifically, there was no documentation identifying the number of records audited, the number or type of complaints or adverse events reviewed, or any quantifiable findings. No audits of any clinical or personnel records were located. The repeated notation of “no deficiencies” across all categories, without supporting data, analysis, or evidence of review methodology, does not demonstrate a credible or comprehensive evaluation process. Additionally, although infection logs were maintained with monthly percentages, there was no evidence of trend analysis. Occurrence/adverse event logs for 2024, 2025, and 2026 lacked quantifiable data and trending, and there was no documentation of employee infection tracking. On-call data was not aggregated or analyzed, with references indicating “see EMR” without further evidence of review. Furthermore, there was no documentation of bereavement, physician, or facility survey results since 2024. Patient satisfaction data collected between 04/2025 and 05/12/2026 included numerical scores; however, there was no evidence of data aggregation, analysis, trend analysis, or follow-up actions based on the findings. Interviews on 06/15/2026 with the Administrator (Personnel Record 2) and Team Lead (Personnel Record 7), identified significant deficiencies in the implementation and documentation of a data-driven QAPI program. A review of the Quality Assessment and Performance Improvement (QAPI) program documentation, including meeting minutes and supporting materials, in conjunction with interviews conducted on 06/15/2026 with the Administrator (Personnel Record 2) and Team Lead (Personnel Record 7), identified significant deficiencies in the implementation and documentation of a data-driven QAPI program. There was no evidence of any QAPI meeting minutes, activities, or data collection for the calendar year 2024. Documentation beginning 04/10/2025 reflected a general discussion of the QAPI program structure and broad categories intended for review; however, subsequent quarterly QAPI meeting records dated 04/10/2025, 07/24/2025, 10/23/2025, 01/22/2026, and 04/16/2026 contained repetitive content and lacked substantive evidence of evaluation or performance improvement activity. Although the documentation listed multiple clinical, operational, and administrative areas that were reportedly reviewed—including patient care processes, infection control, adverse events, personnel requirements, and satisfaction surveys—there was no supporting raw data to substantiate these reviews. Specifically, there was no documentation identifying the number of records audited, the number or type of complaints or adverse events reviewed, or any quantifiable findings. No audits of any clinical or personnel records were located. The repeated notation of “no deficiencies” across all categories, without supporting data, analysis, or evidence of review methodology, does not demonstrate a credible or comprehensive evaluation process. Additionally, although infection logs were maintained with monthly percentages, there was no evidence of trend analysis. Occurrence/adverse event logs for 2024, 2025, and 2026 lacked quantifiable data and trending, and there was no documentation of employee infection tracking. On-call data was not aggregated or analyzed, with references indicating “see EMR” without further evidence of review. Furthermore, there was no documentation of bereavement, physician, or facility survey results since 2024. Patient satisfaction data collected between 04/2025 and 05/12/2026 included numerical scores; however, there was no evidence of data aggregation, analysis, trend analysis, or follow-up actions based on the findings. Meeting minutes did not reflect the identification of specific problem areas, the prioritization of risks, the establishment of measurable goals, or the implementation and monitoring of corrective actions. There was no evidence of a systematic process to evaluate outcomes, track performance over time, or ensure that identified issues informed performance improvement efforts. The absence of structured, data-driven evaluation and documented QAPI activities does not ensure that the hospice is effectively assessing the quality, safety, and effectiveness of care and services provided. Without verifiable data, analysis, and measurable outcomes, the organization cannot identify trends, detect systemic issues, or implement targeted improvements. This gap can lead to unrecognized deficiencies in clinical and operational processes, ineffective risk mitigation, variability in care delivery, and diminished patient safety, quality of care, and overall outcomes for patients and families.”

“It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the QAPI program. This standard was not met as evidenced by document review and interview revealed the agency did not ensure the Quality Assessment and Performance Improvement (QAPI) program used quality indicator data, including patient care data and other relevant data, in the QAPI program Additionally, there was no documented data collection or monitoring of key operational and clinical indicators, including, but not limited to, on-call volume and reasons for calls, comprehensive or focused clinical record audits, or personnel file audits. The scope of data collection did not reflect evaluation across all facets of hospice operations that impact patient and family care, including physician services, nursing services, medical social services, counseling, clinical records, infection control, pharmaceutical services, durable medical equipment (DME), patient rights, administrative and contract services, hospice aide services, and volunteer services. There was no evidence that selected quality measures were routinely monitored, analyzed, or reported in a timely manner to support performance improvement activities or organizational oversight. Interviews with the Administrator (Personnel Record 3) and the Team Lead (Personnel Record 7) on 06/15/2026, determined that the hospice did not maintain comprehensive or actionable data to support an effective, organization-wide quality program. The available “raw” data was limited to monthly infection-tracking logs from the previous three years, which included infection percentages, documented complaints, and occurrence/adverse-event reports. However, these data sets were not trended, analyzed, or used to identify patterns, opportunities for improvement, or measurable outcomes. A review of the Quality Assessment and Performance Improvement (QAPI) program documentation, in conjunction with staff interviews with the Administrator (Personnel Record 3) and the Team Lead (Personnel Record 7) on 06/15/2026, determined that the hospice did not maintain comprehensive or actionable data to support an effective, organization-wide quality program. The available “raw” data were limited to monthly infection-tracking logs from the previous three years, which included infection percentages, documented complaints, and occurrence/adverse-event reports. However, these data sets were not trended, analyzed, or used to identify patterns, opportunities for improvement, or measurable outcomes. Additionally, there was no documented data collection or monitoring of key operational and clinical indicators, including, but not limited to, on-call volume and reasons for calls, comprehensive or focused clinical record audits, or personnel file audits. The scope of data collection did not reflect evaluation across all facets of hospice operations that impact patient and family care, including physician services, nursing services, medical social services, counseling, clinical records, infection control, pharmaceutical services, durable medical equipment (DME), patient rights, administrative and contract services, hospice aide services, and volunteer services. There was no evidence that selected quality measures were routinely monitored, analyzed, or reported in a timely manner to support performance improvement activities or organizational oversight. The absence of comprehensive, trended, and analyzed data does not ensure the hospice’s ability to identify risks, monitor performance, prioritize improvement efforts, or evaluate the effectiveness of interventions. Without a structured, data-driven approach to quality assessment, the organization lacks the necessary insight to detect systemic issues or gaps in care delivery. This has the potential to result in unrecognized deficiencies, inconsistent care practices, diminished patient safety, and reduced quality of care and services provided to patients and families.”

“It is required that hospice performance improvement (PI) activities affect palliative outcomes, patient safety, and quality of patient/family care. This standard was not met as evidenced by document review and interview that revealed the agency did not ensure the QAPI program affected palliative outcomes, patient safety, and quality of patient/family care. Interviews conducted on 06/17/2026 with the Administrator (Personnel Record 2) and Team Lead (Personnel Record 7), determined that the hospice had no documented evidence of an established, ongoing process to identify, prioritize, and address opportunities for improvement. In addition, there was no documentation demonstrating measurable improvements, data analysis, or outcome trends related to palliative outcomes, patient safety, and quality of patient/family care. A review of the Quality Assessment and Performance Improvement (QAPI) program documentation, along with interviews conducted on 06/17/2026 with the Administrator (Personnel Record 2) and Team Lead (Personnel Record 7), determined that the hospice did not implement or document any Performance Improvement Projects (PIPs) from August 2023 through calendar year 2025. Documentation reflected the initiation of a single PIP on 05/28/2026; however, there was no evidence of an established, ongoing process to identify, prioritize, and address opportunities for improvement during the extended period preceding this date. Furthermore, there was no documentation demonstrating measurable improvements, data analysis, or outcome trends related to patient care or services. Additionally, the QAPI program lacked evidence of systematic evaluation of areas needing improvement, including palliative outcomes, patient safety concerns, and the overall quality of care for patients and families. There was no documentation to support the hospice’s consistent assessment, tracking, or analysis of care delivery processes or outcomes to inform performance improvement efforts. The absence of an active, data-driven performance improvement process does not ensure that the hospice is effectively identifying and addressing risks or deficiencies in care. Without ongoing evaluation and measurable improvement initiatives, the organization lacks the ability to monitor service effectiveness, implement timely corrective actions, or sustain quality improvements. This gap has the potential to lead to unaddressed patient safety concerns, inconsistent care practices, missed opportunities to improve palliative outcomes, and diminished quality of care and services for patients and their families.”

“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 which revealed the agency did not ensure the QAPI program was tracking, analyzing, and was following up on adverse events. Interviews conducted on 06/15/2026 with the Administrator (Personnel Record 2) and the Team Lead (Personnel Record 7) agreed although the agency maintained an adverse occurrence log, there was no evidence that the data were systematically analyzed to determine root causes, identify patterns, or detect trends over time. Additionally, there was no documentation demonstrating that adverse event findings were evaluated to inform preventive strategies, nor was there evidence that corrective actions were implemented, monitored for effectiveness, or communicated to staff. There was also no indication that identified issues were incorporated into structured learning or performance improvement initiatives. A review of the agency’s Quality Assessment and Performance Improvement (QAPI) program documentation, in conjunction with interviews conducted on 06/15/2026 with the Administrator (Personnel Record 2) and the Team Lead (Personnel Record 7), identified deficiencies in the tracking, analysis, and follow-through of adverse events. Although the agency maintained an adverse occurrence log, there was no evidence that the data were systematically analyzed to determine root causes, identify patterns, or detect trends over time. Additionally, there was no documentation demonstrating that adverse event findings were evaluated to inform preventive strategies, nor was there evidence that corrective actions were implemented, monitored for effectiveness, or communicated to staff. There was also no indication that identified issues were incorporated into structured learning or performance improvement initiatives. The absence of a comprehensive process to analyze adverse events and translate findings into measurable improvements does not ensure that the hospice is effectively mitigating risks or strengthening care delivery processes. Without root cause analysis, trend identification, and documented follow-through, the organization lacks the ability to proactively address system vulnerabilities and prevent recurrence of adverse outcomes. This gap has the potential to result in repeated safety events, unaddressed care delivery issues, increased risk to patient well-being, and diminished quality and reliability of hospice services provided to patients and families.”

“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 which revealed the agency did not ensure the QAPI program documented Performance Improvement Projects (PIPs) from August 2023 through calendar year 2025. Documentation reflected that a PIP was not initiated until 05/28/2026. Interviews conducted on 06/15/2026 with the Administrator (Personnel Record 2) and the Team Lead (Personnel Record 7), agreed there were significant gaps in the implementation of a comprehensive, data-driven QAPI program. A review of the organization’s Quality Assessment and Performance Improvement (QAPI) program documentation, together with interviews conducted on 06/15/2026 with the Administrator (Personnel Record 2) and the Team Lead (Personnel Record 7), identified significant gaps in the implementation of a comprehensive, data-driven QAPI program. Specifically, there was no evidence of documented Performance Improvement Projects (PIPs) from August 2023 through calendar year 2025. Documentation reflected that a PIP was not initiated until 05/28/2026. During the interview, the Administrator confirmed that deficiencies in the QAPI program were recognized following the resignation of the previous Director of Clinical Services in May 2026, at which time the program’s oversight and structure were identified as lacking. Although the agency maintained an adverse event/occurrence log and documented complaints, there was no evidence that these data were systematically analyzed or trended to identify patterns, prioritize areas for improvement, or guide performance improvement efforts. When adverse events were recorded, there was no documentation demonstrating that findings were translated into targeted interventions to reduce the likelihood of recurrence. Furthermore, there was no evidence that any identified process changes were implemented across the organization or monitored over time to evaluate their effectiveness and sustainability. The absence of an effective, data-driven QAPI program with ongoing performance improvement activities, measurable outcomes, and organization-wide implementation does not ensure continuous quality oversight or the hospice’s ability to identify, correct, and prevent deficiencies in care delivery. This gap has the potential to adversely affect patient safety, compromise the quality and consistency of care, and lead to unaddressed system issues, ultimately affecting patient outcomes and the overall reliability of services provided to patients and families.”

“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 which revealed the agency did not ensure that the organization maintained an ongoing, comprehensive approach to performance improvement activities. Specifically, there was no evidence of documented Performance Improvement Projects (PIPs) from August 2023 through calendar year 2025, with only a single PIP identified on 05/28/2026. Additionally, there was no evidence of analysis, selection of high-risk or high-volume problem areas, or implementation of targeted improvement initiatives that align with the scope and complexity of services provided to the hospice population. A review of the Quality Assessment and Performance Improvement (QAPI) program documentation, along with interviews were conducted on 06/15/2026 with the Administrator (Personnel Record 2) and the Team Lead (Personnel Record 7). A review of the Quality Assessment and Performance Improvement (QAPI) program documentation, along with interviews conducted on 06/15/2026 with the Administrator (Personnel Record 2) and the Team Lead (Personnel Record 7), demonstrated that the organization did not maintain an ongoing, comprehensive approach to performance improvement activities. Specifically, there was no evidence of documented Performance Improvement Projects (PIPs) from August 2023 through calendar year 2025, with only a single PIP identified on 05/28/2026. This level of activity does not reflect an annual, systematic, and data-driven QAPI program. There was no documentation to demonstrate that multiple PIPs were developed, prioritized, or implemented based on identified risks, adverse events, or areas of concern within clinical or operational services. Additionally, there was no evidence of analysis, selection of high-risk or high-volume problem areas, or implementation of targeted improvement initiatives that align with the scope and complexity of services provided to the hospice population. The absence of multiple active PIPs, supported by data analysis and measurable outcomes, does not ensure that the organization is adequately evaluating its performance or addressing the full range of patient care and service delivery needs. Without a sufficient number and scope of performance improvement activities, the hospice lacks the ability to respond effectively to identified deficiencies, monitor trends, or drive sustained quality improvement. This gap has the potential to result in unaddressed care delivery issues, inconsistent service quality, increased risk to patient safety, and diminished patient and family outcomes.”

“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. This standard was not met as evidenced by document review and interview which revealed the agency did not ensure an annual review of the QAPI program for 2025. Interview with the Administrator (Personnel Record 2) on 06/17/2026, an Annual Review of the hospice program dated 01/16/2025 was identified, reflecting evaluation of the program for calendar year 2024. However, there was no documented evidence of a completed or documented Annual Review for calendar year 2025. During the QAPI Program documentation review and interview with the Administrator (Personnel Record 2) on 06/17/2026, an Annual Review of the hospice program dated 01/16/2025 was identified, reflecting evaluation of the program for calendar year 2024. However, there was no evidence of a completed or documented Annual Review for calendar year 2025, indicating that the required annual evaluation of the hospice program had not been conducted or maintained.”

“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 safe handling of equipment in the patient’s care environment. This standard was not met as evidenced by document review and observation. In 1 out of 3 (33%) home visit observations revealed the agency did not ensure safe handling of equipment in the patient’s care environment. LABEL INSTRUCTIONS: The instructions for use for the Super Sani-Cloth disinfecting wipes include using a fresh wipe to wipe and disinfect the surface, ensuring the surface remains visibly wet for one (1) minute. Allow to air dry. HOME VISIT 2: During the home visit with the Registered Nurse (Personnel Record 12) on 06/16/2026, the RN was observed disinfecting the blood pressure cuff, thermometer, pulse oximeter, and stethoscope using an individually packaged Sani-Cloth. However, the equipment was returned to the visit bag immediately after wiping, without allowing sufficient contact time for the disinfectant to air dry in accordance with manufacturer guidelines for effective disinfection.”

“It is required that licensed professionals participate in hospice sponsored in-service training. 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 all employees received the annual required in-service education. HOSPICE POLICY: The hospice’s policy entitled “Agency In-Service (HR.13)” dated 04/01/2018 read in part that “The agency will provide ongoing in-service and continuing education programs...annually...” PERSONNEL RECORD 8: A review of the personnel record for the Social Worker, hired on 08/15/2024, revealed initial onboarding/in-service training in August of 2024 and on 03/20/2026. There was no in-service education documented for 2025. A joint personnel record review and interview with the Administrator (Personnel Record 2) on 06/17/2026, 2025 was conducted, confirming that no in-service education was documented for 2025. She relayed that this period fell during a change in overall management and a move in location, and that documentation could not be located.”

“It is required that the hospice provide an initial orientation for each employee that addresses the employee’s specific job duties. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by interview and personnel record review. In 1 of 12 (8%) personnel records reviewed revealed that the agency did not ensure all employees received a hospice orientation upon beginning their employment with the hospice agency. PERSONNEL RECORD 1: A review of the Medical Director’s personnel record, hired on 08/15/2025, revealed no hospice/agency orientation documented upon hire. A joint personnel record review and interview with the Administrator (Personnel Record 2) on 06/17/2026 confirmed that no orientation was documented for the hospice Medical Director.”

“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 8 (12%) direct care staff’s personnel records reviewed revealed that the agency did not ensure an initial and annual discipline-specific skills competency was assessed. PERSONNEL RECORD 8: A review of the personnel file for the Social Worker hired on 08/15/2024 revealed that no initial Social Worker Clinical Competency was completed upon hire, nor was one completed annually in 2025. During a joint personnel file review and interview with the Administrator (Personnel Record 2) on 06/17/2026, she confirmed that a change in management and office location occurred in 2025. She further stated that the former Clinical Director—who was responsible for completing clinical competency assessments—is no longer employed by the hospice.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure that the patient’s Discharge Summary was provided to the patient’s attending physician upon the patient’s discharge from hospice services. CLINICAL RECORD 12: The patient was discharged from hospice services on 03/14/2026. The “(HOPE) Discharge-Live” document, signed and dated by the Registered Nurse (RN) on 03/14/2026, indicated that the patient was discharged, but there was no documentation (nurse note, IDG documentation, scanned documents) that the Discharge Summary was provided to the patient’s attending physician upon the patient’s discharge from care. A joint clinical record review and interview with the Administrator (Personnel Record 2), the Clinical Director (Personnel Record 4), and the Team Lead (Personnel Record 7) was conducted on 06/17/2026 and confirmed there was no documentation that the patient’s discharge summary was provided to the patient’s attending/referring physician upon the patient’s discharge from hospice services.”

“It 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, and the patient’s latest physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records of discharged patients reviewed revealed that the agency did not ensure that the patient’s Discharge Summary included all required information: Plan of Care, summary of the patient’s hospice care - including treatments, symptoms, and pain management, and latest physician orders. CLINICAL RECORD 11: The patient elected the hospice benefit on 01/09/2026 and revoked it on 03/16/2026. The Discharge Summary did not include a summary of the patient’s hospice stay, the plan of care, or the latest physician orders. CLINICAL RECORD 12: The patient elected the hospice benefit on 09/16/2025 and was discharged on 03/14/2026. The Discharge Summary did not include a summary of the patient’s hospice stay, the plan of care, or the latest physician orders. A joint clinical record review and interview with the Administrator (Personnel Record 2), the Clinical Director (Personnel Record 4), and the Team Lead (Personnel Record 7) was conducted on 06/17/2026 and confirmed the patients’ Discharge Summaries did not include the required information.”