Grant County Hospice

“Based on record review and interview the agency failed to show measurable improvement through performance improvement projects in 1 of 1 Quality Assessment and Performance Improvement programs reviewed. Findings include:Review of agency policy titled, “Performance Improvement Plan” dated 08/23/2005 revealed, “Purpose: Grant County Hospice participates in an organizational performance improvement (PI) program designated to monitor, evaluate and improve hospice quality and services by input from the following sources: Patient, staff, and physician surveys and complaints, previous performance improvement studies, incident reports, State survey findings and chart reviews.”Review of agency QAPI program revealed no current or past performance improvement projects (PIPs) were conducted and documented showing measurable improvement in hospice services. No documented evidence of an effective QAPI program was provided.During an interview with Substitute Administrator A on 07/08/2025 at 2:00 PM, Substitute Administrator A stated that the QAPI program “just started back up.” When asked if there was any documentation of past or present PIPs Substitute Administrator A stated, “I don’t know I wasn’t in charge back then. I think that’s all we have.””

“Based on record review and interview the agency failed to measure, analyze, and tracking quality indicators in 1 of 1 Quality Assessment and Performance Improvement programs reviewed. Findings include:Review of agency policy titled, “Performance Improvement Plan” dated 08/23/2005 revealed, “Purpose: Grant County Hospice participates in an organizational performance improvement (PI) program designated to monitor, evaluate and improve hospice quality and services by input from the following sources: Patient, staff, and physician surveys and complaints, previous performance improvement studies, incident reports, State survey findings and chart reviews.”Review of agency QAPI program revealed no evidence the agency is measuring, analyzing, and track quality indicators and other aspects of performance that enable the hospice to assess processes of care, services, and operations. No documentary evidence of an effective QAPI program was provided.During an interview with Substitute Administrator A on 07/08/2025 at 2:00 PM, Substitute Administrator A stated that the QAPI program “just started back up.” When asked if there was any documentation of past or present PIPs Substitute Administrator A stated, “I don’t know I wasn’t in charge back then. I think that’s all we have.””

“Based on record review and interview the agency’s governing body failed to ensure that the agency implemented & maintained a Quality Assessment and Improvement Program (QAPI) in 1 of 1 QAPI programs reviewed. Findings include:Review of agency policy titled “Performance Improvement Plan Policy” not dated revealed under heading, “Annual Evaluation of Quality Improvement Program, Hospice services shall evaluate the effectiveness of the performance improvement monitoring and evaluation program on at least an annual basis...The evaluation shall be documented and forwarded through the appropriate medical staff reporting structure to the Medical Advisory Committee.”Review of the agency’s documentation provided for the QAPI program revealed no evidence that the governing body ensured the program is defined, implemented, and maintained. No documentation of an annual review of program was provided.During an interview with Substitute Administrator A on 07/08/2025 at 2:00 PM, Substitute Administrator A stated that the QAPI program “just started back up.” When asked if there was any documentation of past or present PIPs Substitute Administrator A stated, “I don’t know I wasn’t in charge back then. I think that’s all we have.””

“Based on observation and record review, the agency staff failed to follow standards of practice to prevent the transmission of infection and communicable diseases for 1 of 2 patients (Patient #5) observed in a total of 3 patient home visits completed. Findings include:Review of agency policy titled “Standard Precautions/Infection Control Policy” not dated revealed in part, “Handwashing: Use an alcohol -based hand rub for routine cleaning of the hands…Activities necessitating the use of gloves include, but not limited to, the following: cleaning reusable patient care equipment.”Review of “Clorox disinfecting wipes-Directions for Use” not dated revealed “Use enough wipes for treated surfaces to remain visibility wet for 4 minutes. Let surface completely dry.”During an observation on 07/08/2025 starting at 1:30 PM, observed Registered Nurse (RN) C perform the following while assessing Patient #5:RN C was observed using a Clorox disinfecting wipe to clean the stethoscope without donning gloves. RN C did not perform hand hygiene before or after cleaning the stethoscope. Without waiting the four minute dry time, RN C proceeded place the stethoscope on Patient #5’s chest while still visibly wet. RN C proceeded to obtain Patient #5’s vital signs and then documented the findings on the computer without completing hand hygiene between tasks. RN C then assessed Patient #5’s legs for injury, without the use of gloves, and proceeded to document the findings on the computer without completing hand hygiene between tasks.During an interview on 07/08/2025 at 4:00 PM with Substitute Administrator A and Administrator B the above findings were reviewed and confirmed.”

“Based on record review and interview the agency failed to provide orientation to the hospice program and specific job duties in 4 of 10 personnel files (Registered Nurse C, Medical Social Worker E, Spiritual Counselor F and Medical Director G) in 10 personnel files reviewed. Findings include:Review of RN C’s employee file revealed a date of hire of 11/07/2016 with no evidence of orientation to the program or to specific job duties provided.Review of MSW E’s employee file revealed a date of hire of 12/27/2022 with no evidence of orientation to the program or to specific job duties provided. Review of Spiritual Counselor F’s employee file revealed a date of hire of 11/30/2016 with no evidence of orientation to the program or to specific job duties provided.Review of Medical Director G’s employee file revealed a date of hire of 09/12/2023 with no evidence of orientation to the program or to specific job duties provided.During an interview with Administrator B on 07/09/2025 at 10:09 AM, Administrator B stated there was no agency policy regarding employee orientation.”

“Based on record review and interview, the agency failed to develop plans of care that outlined the specific responsibilities of hospice and facility staff for the care and services of patients receiving care in an Assisted Living Facility (ALF) setting in 1 of 1 patients that resided in a facility (Patient #13) in a total of 19 records reviewed. Findings include:Review of agency policy titled “Grant County Hospice and Nursing Home” dated 07/09/2025 revealed in part, “Purpose: To Delineate responsibility for development of one plan of care in order to meet Federal/State regulations…”Record review of Patient #13’s “Team Care Plan” for certification period 05/18/2025 to 07/16/2025 revealed Patient #13 was admitted to hospice on 11/19/2024 with a primary diagnosis of hypertensive heart and chronic kidney disease and resided in an ALF. Review of plan of care revealed no delineation to outline which provider was responsible for care and interventions to be provided.During an interview on 07/09/2025 at 10:45 AM, Administrator B stated, “We expect that our Hospice nurses are delineating services in the plan of care for our patients residing in facilities.””