Regional Hospice Services

“Based on record review the agency staff failed to develop plans of care that included measurable goals to meet the patient’s needs in 14 of 21 (Patients #2, #3, #4, #6, #8, #9 #10, #11, #12 #13, #14, #17, #20, and #21) patient records reviewed. Findings include:Review of agency’s Policy and Procedure titled “Plan of Care” (POC) revealed under Procedure: “Using data obtained during the initial and ongoing Hospice assessments, the interdisciplinary team members develop a list of patient problems and needs with corresponding goals, interventions and anticipated target dates for reaching goals.” No reference to making patient goals measurable was documented within policy.Record review for Patient #2 revealed Patient #2 was admitted to the hospice 11/24/2023 with a primary diagnosis of rectal carcinoma. Patient #2’s POC dated 03/18/2025 - 05/17/2025 revealed “Goal: Identify/report bowel changes for term of care with goal of avoiding painful obstructions, ongoing.” The goal stated on the POC was not measurable to meet the specific needs of Patient #2.Record review for Patient #3 revealed Patient #3 was admitted to the hospice 07/01/2024 with a primary diagnosis of biliary cirrhosis. Patient #3’s POC dated 02/26/2025 – 04/26/2025 revealed “Goal: Report pain is relieved/controlled, ongoing.” The goal stated on the POC was not measurable to meet the specific needs of Patient #3. Record review for Patient #4 revealed Patient #4 was admitted to the hospice 02/13/2025 with a primary diagnosis of pulmonary fibrosis. Patient #4’s POC dated 02/13/2025 – 05/13/2025 revealed “Goal: Coordinate care with patient, caregiver, attending physician and family. Hospice team will assist patient and his family regarding patient’s comfort, caregiving needs and concerns in a timely manner, ongoing.” The goal stated on the POC was not measurable to meet the specific needs of Patient #4. Record review for Patient #6 revealed Patient #6 was admitted to the hospice 03/10/2025 with a primary diagnosis of myelodysplastic syndrome. Patient #6’s POC dated 03/10/2025 – 06/07/2025 revealed “Goal: Coordinate care with patient, caregiver, attending physician and family to achieve patient’s hospice goals, ongoing.” The goal stated on the POC was not measurable to meet the specific needs of Patient #6. Record review for Patient #8 revealed Patient #8 was admitted to the hospice 03/26/2022 with a primary diagnosis of Alzheimer’s disease. Patient #8’s POC dated 03/10/2025 – 05/08/2025 revealed “Goal: Coordinate care with patient, caregiver, attending physician and family… to achieve comfort and manage symptoms, ongoing.” The goal stated on the POC was not measurable to meet the specific needs of Patient #8.Record review for Patient #9 revealed Patient #9 was admitted to the hospice 04/12/2025 with a primary diagnosis of malnutrition. Patient #9’s POC dated 04/12/2025 – 07/10/2025 revealed “Goal: Maintain safe home environment addressing declining mobility and needs related to those changes as disease progresses, ongoing.” The goal stated on the POC was not measurable to meet the specific needs of Patient #9. Record review for Patient #10 revealed Patient #10 was admitted to the hospice 02/26/2025 with a primary diagnosis of malnutrition. Patient #10’s POC dated 02/26/2025 – 05/26/2025 revealed “Goal: Adjust to changing nutritional needs related to appetite and or ability to swallow without aspiration, ongoing.” The goal stated on the POC was not measurable to meet the specific needs of Patient #10.Record review for Patient #11 revealed Patient #11 was admitted to the hospice 03/28/2025 with a primary diagnosis of abdominal aortic aneurysm without rupture. Patient #11’s POC dated 03/28/2025 – 06/25/2025 revealed “Goal: Effective grieving pt., family, and facility staff will be able to express their thoughts and feelings in ways meaningful to them relating to end-of-life experience, ongoing.” The goal stated on the POC was not measurable to meet the specific needs of Patient 11. Record review for Patient #12 revealed Patient #12 was admitted to the hospice 02/26/2025 with a primary diagnosis of heart failure. Patient #12’s POC dated 02/26/2025 – 05/26/2025 revealed “Goal: Begin the grieving process associated with a loss, patient will be able to express her thoughts and feelings in ways meaningful to them relating to the end-of-life experience, ongoing.” The goal stated on the POC was not measurable to meet the specific needs of Patient #12. Record review for Patient #13 revealed Patient #13 was admitted to the hospice 03/27/2025 with a primary diagnosis of pancreatic cancer. Patient #13’s POC dated 03/27/2025 – 06/25/2025 revealed “Goal: Coordinate care with patient, caregiver, attending physician and family. Patient will make needs and wants known, with hospice team to address questions or concerns in a timely manner to support comfort and caregiving, ongoing.” The goal stated on the POC was not measurable to meet the specific needs of Patient #13. Record review for Patient #14 revealed Patient #14 was admitted to the hospice 04/11/2025 with a primary diagnosis of malnutrition. Patient #14’s POC dated 04/11/2025 – 07/09/2025 revealed “Goal: Effective grieving patient, family, and facility staff will be able to express their thoughts and feelings in ways meaningful to them relating to end-of-life experience, ongoing.” The goal stated on the POC was not measurable to meet the specific needs of Patient #14. Record review for Patient #17 revealed Patient #17 was admitted to the hospice 03/21/2025 with a primary diagnosis of metastatic bone cancer. Patient #17’s POC dated 03/21/2025 – 06/20/2025 revealed “Goal: Begin verbalizing feelings associated with the loss, patient and her family will be able to express their thoughts and feelings in ways meaningful to them relating to end-of-life experience, ongoing.” The goal stated on the POC was not measurable to meet the specific needs of Patient #17. Record review for Patient #20 revealed Patient #20 was admitted to the hospice 01/28/2025 with a primary diagnosis of critical left lower extremity ischemia with gangrene. Patient #20’s POC dated 01/28/2025 – 04/27/2025 revealed “Goal: Achieve preferred level of relief from grief symptoms with hospice staff to address any s/sx of negative grieving, ongoing.” The goal stated on the POC was not measurable to meet the specific needs of Patient #20. Record review for Patient #21 revealed Patient #21 was admitted to the hospice 01/22/2025 with a primary diagnosis of metastatic bone cancer. Patient #21’s POC dated 4/22/2025 – 07/20/2025 revealed “Goal: Achieve preferred level of relief from grief symptoms with hospice staff to address any s/sx of negative grieving, ongoing.” The goal stated on the POC was not measurable to meet the specific needs of Patient #21.”

“Based on record review and interview, agency failed to ensure that relevant data was used in the design of its program in 1 of 1 Quality Assessment and Process Improvement (QAPI) program reviewed. Findings include:Review of the agency’s QAPI program revealed no documentation of quality indicator data being used in the design of the program.During an interview conducted with Administrator A on 4/24/2025 at 8:12 a.m., Administrator A was asked what quality indicators are used to design the program. Administrator A stated that the indicators are analyzed quarter to quarter. Administrator A further stated “We’re analyzing, we’re just not documenting.””

“Based on record review and interview, the agency failed to ensure that performance improvement projects had reasons for conducting the projects as well as measurable data and documentation of progress/improvement in 1 of 1 Quality Assessment Performance Improvement (QAPI) program reviewed. Findings include:Review of the agency’s current performance improvement projects revealed 5 current projects:-Volunteer Connect team calls. -Implementation of centralized electronic cloud faxing. -Advance Directive workshops strategic plan to address community need and increase program awareness.-Review and update Employee Handbook.-Update Clinical Care Coordinator binders.There was no documentation of any data with which to measure improvement and no documentation of the reasons for conducting these projects. During an interview conducted with Administrator A on 4/24/2025 at 8:12 a.m., Administrator A was asked if these projects were data driven and reasons for selecting the projects was documented. Administrator A stated no and that the projects are more process and task oriented.”

“Based on record review and interview the agency failed to establish policies/procedures to screen/monitor continuing employees for communicable diseases in 1 of 1 infection control programs reviewed. Findings include:Review of policy tilted, “Infection Control Policy” dated 2011, last reviewed 08/2024 revealed no documentation on how the agency planned to screen or monitor continuing employees for communicable diseases.During an interview with Executive Director A on 04/24/2025 at 9:05 AM, Executive Director A confirmed that the agency had no written polices related to above information. Executive Director a stated that the agency relies on employee self reporting.”