Every finding on record at Alliance Healthcare Hospice

Based on staff interview, patient medical record reviews, social worker job description, and policy and procedure review, the facility failed to ensure a comprehensive assessment was completed within five (5) days of the admission which included an assessment of the psychosocial and emotional needs  related to the terminal illness and that the needs were addressed in the plan of care to support the palliation and management of the patient throughout the dying process for two (2) of 14 patient medical records reviewed: Patient #6 and #8. The facility also failed to ensure the comprehensive assessment was updated by the interdisciplinary group (IDT) in collaboration with the attending physician as frequently as required but no less frequently than every 15 days for five (5) of 14 records reviewed; Patient #2, #7, #8, #9 and #11. Findings Include: --- Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 from 12:15 p.m. to 12:30 p.m. confirmed the facility’s social worker did not perform a psychosocial and emotional assessment as part of the initial comprehensive assessment of the patient to support development of the plan of care within five (5) days of admission on Patient #6 and Patient #8.  The interview also confirmed the facility had no Interdisciplinary Team (IDT) meeting documentation for review and update of the plan of care no less frequently than every 15 days for routine home care in medical record for Patient #2, #7, #8, and #9; and no documentation of an IDT meeting for Patient #11 for review and update the plan of care within seven (7) days for general inpatient care. Review of medical record for Patient #2 revealed no documentation of IDT meetings between dates 04/16/2025 and 05/07/2025 for a routine home care plan update. Review of the medical record for Patient #6 revealed no documentation in the medical record of the social worker performing a psychosocial and emotional assessment for the initial comprehensive assessment within five (5) days of the admission 02/18/2025 and no documented evidence of attempted or missed visits were presented.  Review of medical record for Patient #7 revealed no documentation of IDT meetings between dates 11/15/2024 and 12/13/2024 and between dates 04/16/2025 and 05/07/2025 for routine home care plan updates.  Review of the medical record for Patient #8 revealed no documentation in the medical record of the social worker performing a psychosocial and emotional assessment for the initial comprehensive assessment within five (5) days of the admission date 11/15/2024, no documented evidence of attempted or missed visits were presented, and no documentation of IDT meetings between dates 04/16/2025 and 05/07/2025 for a routine home care plan update.  Review of medical record for Patient #9 revealed no documentation of IDT meetings between dates 04/16/2025 and 05/07/2025 for a routine home care plan update. Review of medical record for Patient #11 revealed no documentation of IDT meetings between dates 04/24/2025 and 05/14/2025 for general inpatient care plan updates. Review of the facility policy and procedure titled, “Subject: Plan of Care,” no date revealed, “…Procedure…3. The psychosocial, spiritual assessment and plan of care will be completed within five (5) days…”. Review of the facility policy and procedure titled, “Subject: Interdisciplinary Team Responsibilities,” number #C-3, effective date 08/05/2022 revealed, “…Policy…Social Worker…initial assessment and POC to be completed and signed within five (5) days of admission…Responsibilities…Attend IDT meetings every 14 days for home-based patients and every 7 days for inpatient…”. Review of the facility policy and procedure titled “Policy and Procedure, #C-2…Subject: Plan of Care,” no date, revealed “…Policy…POC will be reviewed and updated when patient condition changes and a minimum of every 14 days for home care and every 7 days for general inpatient care with the IDT…”.Review of the facility’s social worker job description revealed, “…Responsibilities…Assessment of the social and emotional factors having an impact on the patient’s health status, assist in the formulation of the Plan of Care (POC)…assess each new admission and complete assessment paperwork within five (5) days of patient admission…complete each visit according to POC schedule for Social Worker…”. During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.

Based on staff interview, patient medical record reviews and facility policy and procedure review, the facility failed to perform and document an initial comprehensive psychosocial and emotional assessment by the social worker within five (5) days of admission on two (2) of 14 patient medical records reviewed: Patient #6 and #8. Findings Include: --- Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 from 12:15 p.m. to 12:30 p.m. confirmed the social worker did not perform a psychosocial and emotional assessment within five (5) days of admission as part of the initial comprehensive assessment to support development of the plan of care for Patient #6 and Patient #8.Review of medical record for Patient #6 revealed no social worker psychosocial and emotional assessment was documented in the initial comprehensive assessment within five (5) days of the admission 02/18/2025 and no documented evidence of attempted or missed visits was presented for review.Review of medical record for Patient #8 revealed no social worker psychosocial and emotional assessment was documented in the initial comprehensive assessment within five (5) days of the admission date 11/15/2024 and no documented evidence of attempted or missed visits was presented for review.Review of the facility policy and procedure titled, “Subject: Plan of Care” with no date revealed, “…Procedure…3. The psychosocial, spiritual assessment and plan of care will be completed within five (5) days…”. Review of the facility policy and procedure titled, “Subject: Interdisciplinary Team Responsibilities,” numbered #C-3, effective date 08-05-2022, revealed “…Policy…Social Worker…initial assessment and POC to be completed and signed within five (5) days of admission…”.Cross reference to L 520/418.54 for additional information.During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.

Based on staff interview, patient medical record reviews, and facility policy and procedure review, the facility failed to perform a comprehensive assessment that identifies the psychosocial and emotional needs related to their terminal illness that must be addressed in the plan of care to promote well-being and comfort throughout the dying process for two (2) of 14 patient medical records reviewed: Patient #6 and #8. Findings Include: --- Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 from 12:15 p.m. to 12:30 p.m. confirmed the social worker did not perform a psychosocial and emotional assessment to identify and address the needs related to their terminal illness as part of initial comprehensive assessments of the patient to support development of the plan of care for Patient #6 and Patient #8.Review of the medical record for Patient #6 revealed no social worker psychosocial and emotional assessment was documented in the initial comprehensive assessment within five (5) days of the admission 02/18/2025 and no documented evidence of attempted or missed visits was presented for review. Review of the medical record for Patient #8 revealed no social worker psychosocial and emotional assessment was documented in the initial comprehensive assessment within five (5) days of the admission date 11/15/2024 and no documented evidence of attempted or missed visits was presented for review.Review of the facility social worker job description revealed, “…Responsibilities…Assessment of the social and emotional factors having an impact on the patient’s health status, assist in the formulation of the Plan of Care (POC)…assess each new admission and complete assessment paperwork within five (5) days of patient admission…complete each visit according to POC schedule for Social Worker…”. Review of the facility policy and procedure titled, “Subject: Interdisciplinary Team Responsibilities,” number #C-3, effective date 08/05/2022, revealed, “…Policy…Social Worker…initial assessment and POC to be completed and signed within five (5) days of admission…”.Cross reference to L 520/418.54 for additional information.During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.

Based on staff interview, patient record reviews, and facility policy and procedures review, the facility failed to ensure the Interdisciplinary Team (IDT) updated the comprehensive assessment in collaboration with the attending physician based on changes in the patient’s condition, progress toward outcomes, and a reassessment of the patient’ response to care as frequently as the patient condition requires and no less frequently than every 15 days for five (5) of 14 records reviewed; patient record #2, #7, #8, #9 and #11. Findings Include: --- Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 from 12:15 p.m. to 12:30 p.m. confirmed no Interdisciplinary Team (IDT) meeting documentation for review and update of the plan of care no less frequently that every 15 days for routine home care in medical record for Patient #2, #7, #8, and #9; and no documentation of IDT meeting for Patient #11 for review and update the plan of care within 7 days for general inpatient care. Review of medical record for Patient #2 revealed no documentation of IDT meetings between dates 04/16/2025 and 05/07/2025 for a routine home care plan update. Review of medical record for Patient #7 revealed no documentation of IDT meetings between dates 11/15/2024 and 12/13/2024 and between dates 04/16/2025 and 05/07/2025 for routine home care plan updates. Review of medical record for Patient #8 revealed no documentation of IDT meetings between dates 04/16/2025 and 05/07/2025 for a routine home care plan update. Review of medical record for Patient #9 revealed no documentation of IDT meetings between dates 04/16/2025 and 05/07/2025 for a routine home care plan update. Review of medical record for Patient #11 revealed no documentation of IDT meetings between dates 04/24/2025 and 05/14/2025 for general inpatient care plan updates. Review of the facility policy and procedure titled “Policy and Procedure, #C-2…Subject: Plan of Care,” no date, revealed “…Policy…POC will be reviewed and updated when patient condition changes and a minimum of every 14 days for home care and every 7 days for general inpatient care with the IDT…”.Review of the facility policy and procedure titled “Policy and Procedure #C-3…Subject: Interdisciplinary Team Responsibilities,” effective date 08/05/2022, revealed “…Responsibilities…Attend IDT meetings every 14 days for home-based patients and every 7 days for inpatient…”. Cross reference to L 520/418.54 for additional information.During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.

Based on staff interview, patient record reviews, the facility policy and procedure review for the plan of care, the facility failed to ensure care and services were provided in accordance with the plan of care for three (3) of 14 patient medical records reviewed: Patient #6, #7, #8. Findings Include: --- Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 12:15 p.m. to 12:30 p.m. confirmed no nurse visits for Patient # 7 during dates of 02/25/2025 to 03/11/2025 and 05/13/2025 to 06/03/2025 and no nurse visits for Patient #8 from 12/18/2024 to 01/03/2025 and further confirmed no social worker visit for initial assessment on Patient #6 admitted 02/18/2025 and Patient #8 admitted 11/15/2024. Review of the medical record for Patient #6 revealed no social worker initial comprehensive visit within five days of admission 02/18/2025 with no attempted or missed visit documentation presented for review. Review of the medical record for Patient #7 revealed no nurse visit documentation from 02/25/2025 to 03/11/2025 and no nurse visit documentation from 05/13/2025 to 06/03/2025 for a plan of care Skilled Nurse (SN) frequency of one (1) time a week and no documentation of a missed visit presented for review. Review of the medical record for Patient #8 revealed no social worker initial comprehensive visit within five days of admission date 11/15/2024 and revealed no nurse visit from 12/18/2024 to 01/03/2025 with SN frequency one (1) time a week and as needed and no documentation of a missed visit presented for review. Review of the Facility’s Registered Nurse job description revealed, “…3…Implements physician orders in accordance with plan of care…”.Review of the facility social worker job description revealed, “…Responsibilities…Assessment of the social and emotional factors having an impact on the patient’s health status, assist in the formulation of the Plan of Care (POC)…assess each new admission and complete assessment paperwork within 5 days of patient admission…complete each visit according to POC schedule for Social Worker…”. Review of the facility policy and procedure titled “Subject: Plan of Care,” no date, revealed “…Procedure…3. The psychosocial, spiritual assessment and plan of care will be completed within five (5) days…”. Review of the facility policy and procedure titled, “Policy and Procedure #C-2; Subject: Plan of Care,” no date, revealed “…Procedure:…The frequency of services established in the Plan of Care will be sufficient to effectively manage the terminal diagnosis of the patient…”. Review of the facility policy and procedure titled, “Policy and Procedure #C-3; Subject: Interdisciplinary Team Responsibilities,” effective date 08-05-2022, revealed “Responsibilities…Social Worker…Initial assessment and plan of care to be completed and signed within 5 days of admission…”.During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.

Based on staff interview, review of the facility Quality Assessment and Performance Improvement (QAPI) documents, review of the facility Governing Body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility failed to have a documented, operational, effective, ongoing, data-driven QAPI program in which the Governing Body assumes oversite an ensures the program  reflects the complexity of its services, focuses on indicators to improved palliative outcomes, takes actions to demonstrate improvements in performance and maintains documentation of the program during six (6) of six (6) days of survey. Findings Include: --- Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the QAPI performance improvement plans were not reassessed and the facility has no documentation of the collection, aggregation., and analysis of data to submit to support the continual assessment of the hospice performance, actions for improvement, outcomes, meetings, or reports to the Governing Body. Review of the facility’s quarterly “QAPI Report Form,” documents areas of focus indicators for improvements.  No documentation of monitoring, outcome measurements, updated plans, meetings, or reporting to the Governing Body was presented for review. Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation related to an ongoing QAPI program review and approval for performance improvement plans, measurements, and outcomes. Review of the facility policy and procedure titled “Governance of Hospice,” no date, revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.

Based on staff interview, Quality Assessment and Performance Improvement (QAPI) document review, review of the facility governing body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the facility to assess processes of care, hospice services, and operations on six (6) of six (6) survey days. Findings Include: --- Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility did not have documentation of collection, aggregation, and analysis of any data to submit that supports the ability of the hospice to assess processes of care, services, and operations. Review of the facility’s documents “QAPI Reports,” dated quarterly, reveal the facility does not have data to support reviews or evidence reviews were completed.Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation related to an ongoing QAPI program review and approval for performance improvement plans, measurements, and outcomes. Review of the facility policy and procedure titled “Governance of Hospice,” no date, revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.Cross reference to L 559/418.58 for additional information.During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.

Based on staff interview, Quality Assessment and Performance Improvement (QAPI) document review, review of the facility governing body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility failed to monitor the effectiveness and safety of services and quality of care and identify opportunities and priorities for improvement on six (6) of six (6) survey days. Findings Include: --- Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility did not have documentation of collection, aggregation, and analysis of any data to submit that supports the ability of the hospice to assess processes of care, services, and operations. Review of the facility’s documents titled “QAPI Reports,” dated quarterly, reveal different indicators to assess with monthly chart audits to monitor.  No documentation of monthly chart audit data provided to support the facility’s action taken, monitoring of indicators, and assessing compliance to evaluate its effectiveness and safety of services and quality of care.Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation related to an ongoing Facility QAPI program review, identification of indicators for monitoring/measuring outcomes, or approval of performance improvement plans. Review of the facility policy and procedure titled “Governance of Hospice,” no date, revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.Cross reference to L 559/418.58 for additional information.During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.

Based on staff interview, Quality Assessment and Performance Improvement (QAPI) document review, review of the facility governing body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility failed to have approval from the governing body for frequency and detail of data collection on six (6) of six (6) survey days. Findings Include: --- Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility failed to have documentation evidence of the collection, aggregation, and analysis of any data to submit that supports the ability of the hospice to assess processes of care, services, and operations. Review of the facility’s documents titled “QAPI Reports,” dated quarterly, reveal different indicators to assess with monthly chart audits.  There is no documented evidence that the facility completed monthly audits, or that the Governing Body reviewed a QAPI Plan indicating the type and frequency detail of the data collection.Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation related to an ongoing facility-wide QAPI program review and approval for performance improvement plans, data collection, measurements, and outcomes. Review of the facility policy and procedure titled “Governance of Hospice,” no date, revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.Cross Reference to L 559/418.58 for additional information During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.

Based on staff interview, Quality Assessment and Performance Improvement (QAPI) document review, review of the facility governing body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility failed to track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice on six (6) of six (6) days of survey. Findings Include: --- Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility did not have any documentation of collection, aggregation, and analysis of adverse patient events or any QAPI data to submit that supports the ability of the hospice to assess processes of care, services, and operations. Review of the facility’s documents titled “QAPI Reports,” dated quarterly, reveal different indicators to assess with monthly chart audits.  The facility is unable to provide QAPI data for adverse events, monthly chart audits or other monitoring activities.Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation of adverse events related to an ongoing QAPI program review and approval for performance improvement plans, data collection, measurements, and outcomes. Review of the facility policy and procedure titled “Governance of Hospice,” no date, revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.Cross reference to L 559/ 418.58 for additional informationDuring an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.

Based on staff interview, Quality Assessment and Performance Improvement (QAPI) document review, review of the facility governing body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility failed to take actions aimed at performance improvement and failed to measure outcomes and track performance to ensure that improvements are sustained on six (6) of six (6) survey days. Findings Include: --- Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility does not have documentation of collection, aggregation, and analysis of any QAPI data that supports the ability of the hospice to assess processes of care, services, and operations. Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation related to an ongoing QAPI program review and approval for performance improvement plans, data collection, measurements, and outcomes. Review of the facility’s documents titled “QAPI Reports,” dated quarterly, reveal different indicators to assess with monthly chart audits.  The facility is unable to provide QAPI data for the measurement of outcomes and tracking performance for identified area of improvement.Review of the facility policy and procedure titled “Governance of Hospice,” no date, revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.Cross reference to L 559; 418.58 for additional information on the QAPI programDuring an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.

Based on staff interview, Quality Assessment and Performance Improvement (QAPI) document review, review of the facility governing body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility failed to develop, implement and evaluate performance improvement projects on six (6) of six (6) survey days.  Findings Include: --- Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility did not have any documentation of collection, aggregation, and analysis of any QAPI data to submit that supports the ability of the hospice to assess processes of care, services, and operations. Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation related to an ongoing QAPI program review and approval for performance improvement plans, data collection, measurements, and outcomes. Review of the facility’s documents titled “QAPI Reports,” dated quarterly, reveal different indicators to assess with monthly chart audits.  The facility is unable to provide QAPI data for development, implementation and evaluation performance improvement projects. Review of the facility policy and procedure titled “Governance of Hospice,” no date, revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.Cross reference to L 559; 418.58 for QAPI programDuring an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.

Based on staff interview, Quality Assessment and Performance Improvement (QAPI) document review, review of the facility governing body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility failed to document measurable progress achieved on performance improvement projects on six (6) of 6 days of survey. Findings Include: --- Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility did not have any documentation of collection, aggregation, and analysis of any QAPI data to submit that supports the ability of the hospice to assess processes of care, services, and operations. Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation related to an ongoing QAPI program review and approval for performance improvement plans, data collection, measurements, and outcomes. Review of the facility’s documents titled “QAPI Reports,” dated quarterly, reveal different indicators to assess with monthly chart audits.  The facility is unable to provide QAPI data for the collection, aggregation and analysis of data.Review of the facility policy and procedure titled “Governance of Hospice,” no date, revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.Cross reference to L 559; 418.58 for additional information on the QAPI programDuring an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.

Based on staff interview, Quality Assessment and Performance Improvement (QAPI) document review, review of the facility governing body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility’s Governing Body failed to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained, and is evaluated annually on six (6) of six (6) survey days. Findings Include: --- Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility did not have any documentation of collection, aggregation, and analysis of any QAPI data to submit that supports the ability of the hospice to assess processes of care, services, and operations. Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation related to an ongoing QAPI program review and approval for performance improvement plans, data collection, measurements, and outcomes. Review of the facility’s documents titled “QAPI Reports,” dated quarterly, reveal different indicators to assess with monthly chart audits.  The facility is unable to provide QAPI data for adverse events, monthly chart audits or other monitoring activities and show documentation of review by the governing body.Review of the facility policy and procedure titled “Governance of Hospice,” no date, revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.Cross reference to L 559; 418.58 for additional information on the QAPI programDuring an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.

Based on staff interview, Quality Assessment and Performance Improvement (QAPI) document review, review of the facility governing body meeting minutes, and review of the facility policy and procedure for a QAPI program, the facility failed to ensure that all improvement actions were evaluated for effectiveness on six (6) of 6 survey days. Findings Include: --- Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility did not have any documentation of collection, aggregation, and analysis of any QAPI data to submit that supports the ability of the hospice to assess processes of care, services, and operations. Review of the facility Governing Body meeting minutes for the last 12 months revealed no documentation related to an ongoing QAPI program review and approval for performance improvement plans, data collection, measurements, and outcomes. Review of the facility’s documents titled “QAPI Reports,” dated quarterly, reveal different indicators to assess with monthly chart audits.  The facility is unable to provide QAPI data for adverse events, monthly chart audits or other monitoring activities.Review of the facility policy and procedure titled “Governance of Hospice,” no date revealed “…Procedure…1. The governing body will have the responsibility for overseeing all the activities…including…continuous quality assessment and performance improvement…8. The Governing Body must ensure that the QAPI program reflects the complexity of its organization and services: involves all services and focuses on indicators related to improved palliative outcomes: and takes actions to demonstrate improvement in hospice performance through active participation in the QAPI Program…A. The governing body shall ensure that the hospice care program conducts ongoing quality assurance and utilization review…”.Cross reference to L 559; 418.58 for additional information on the QAPI programDuring an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.

Based on staff interview, review of the Quality Assessment and Performance Improvement (QAPI) documents, review of the Governing Body meeting minutes for the past 12 months, and review of the facility policy and procedure for infection control, the facility failed to maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's quality assessment and performance improvement program on six (6) of 6 days of surveys. Findings Include: --- Interview with the Administrator/Director of Nursing (DON) on 06/16/2025 at 11:30 a.m. confirmed the facility did not have any documentation of collection, aggregation, or analysis of any infection control data that includes monitoring employee illness/infections and analyzing the data in relation to patient infections.Review of the facility policy and procedure titled, “Subject: Infection Control,” dated 11/09/2023, revealed no documentation of a procedure for surveillance, reporting, preventing, and controlling infectious and communicable diseases. Review of the facility’s documents titled “QAPI Reports,” dated quarterly, reveal different indicators to assess with monthly chart audits.  The facility is unable to provide QAPI data for infection control, adverse events, monthly chart audits or other monitoring activities.During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.

Based on staff interview, review of the volunteer program documentation provided, review of the volunteer job description, and review of the facility policy and procedures, the facility failed to ensure the hospice has an active Volunteer Program to provide day-to-day administrative and/or direct patient care services which equals five (5) percent of the total patient care hours.  Further the hospice does not have documentation of Volunteer Policies and Procedures, a Volunteer Training Program, a Volunteer Recruitment and Retaining program, and Cost Saving documentation with the details required for six (6) of six (6) survey days. Findings Include: --- Interview with the Administrator/Director of Nursing (DON) and the Office Manager/Volunteer Coordinator on 06/16/2025 from 10:30 a.m. to 11:00 a.m.  confirmed the facility does not have an active volunteer program, no volunteers, and no volunteer services are being provided. Interview with the DON on 06/16/2025 at 11:25 a.m. confirmed the facility had no documented Volunteer Policies and Procedures including a policy and procedure for the volunteer cost savings requirement.Review of the volunteer program documentation provided revealed no active volunteers, no training program, no formal recruitment/retaining program, no cost savings report.Review of facility’s document titled, “Provider Summary Report for 01/01/2024 through 12/31/2024,” and review of the facility document titled, “Income Statement,” for the period January through December 31, 2024, revealed no report of cost savings obtained through the use of volunteers. Review of the volunteer job description revealed the facility assigns the Volunteer Coordinator to provide volunteers for patients as needed. Review of the Facility’s Policy and Procedures revealed the facility did present policies and procedures for the volunteer program or required volunteer cost savings. During an exit conference at 1:00 p.m. on 06/16/2025 with the DON and the office manager/volunteer coordinator, survey findings were discussed, and no additional information was submitted for review.

Based on interview, medical record review, policy and procedure review, and the chaplain general agreement review the facility failed to provide initial and comprehensive patient assessments on nine (9) of 12 medical records reviewed, Patient Records #3, #4, #5, #6, #7, #9, #10, #11, and #12 on four (4) of four (4) survey days. Findings Include: Cross Refer to L523/418.54(b) and L533/418.54(d) for the facility's failure to ensure initial and comprehensive assessments were completed on patients.

Based on interview, medical record review, policy and procedure review, and the chaplain general agreement review the facility failed to ensure the completion of the comprehensive assessment by the interdisciplinary group no later than five (5) calendar days after the election of hospice care in seven (7) of 12 medical records reviewed, Patients #4, #5, #6, #7, #8, #9 and #10 on four (4) of four (4) survey days. Findings Include: During an interview with the Hospital Liaison and Office Manager on 08/31/2022 at 3:50 p.m., the surveyor requested policy and procedures for following Physician's orders, treatment team meetings and plan of care updates. No further documents were submitted. During a phone interview with the Director of Nursing on 08/31/2022 at 3:55 p.m. the surveyor requested documentation for initial assessments, ongoing assessments, interdisciplinary team meeting documentation for survey sample and policy and procedure for admission process and interdisciplinary treatment team. No further documents were submitted. During an interview on 08/31/2022 at 4:30 p.m. the Office Manager confirmed all admission dates and confirmed some documentation may still be in filing and she will update charts. Surveyor requested all documentation for initial assessments, ongoing assessments, interdisciplinary team meeting documentation for survey sample and policy and procedure for admission process and interdisciplinary treatment team. No documentation was submitted for review. During an interview with Office Manager and Director of Nursing on 09/01/2022 at 5:15 p.m. during the exit conference, both confirm Interdisciplinary Team Meetings include all core members and are held every 14 days to review and update all patients' care plans. Medical record review for Patients #4, #5, #7, #9 and #10 revealed no documented evidence of a comprehensive assessment by social work an no documentation of declination by patient/family no later than fove (5) calendar days after the election of hospice care. Medical record review for Patient #6 revealed no documented evidence of a social work initial comprehensive assessment completed or declined by patient/family no later than five (5) calendar days after the election of hospice care. Medical record review for Patient #8 revealed no documented evidence of a chaplain initial comprehensive assessment completed or declined by patient/family no later than five (5) calendar days after the election of hospice care. Review of policy and procedure "Guidelines for Physicians Orders," No policy number, No dates, received 08/31/2022 at 4:00 p.m. reveals no documentation related to following orders for initial assessments. Review of policy and procedure "Level of Care," No policy number, No dates, received at 4:00 p.m. on 08/31/2022 reveals no documentation related to initial assessment and comprehensive plan of care. Review of "General Agreement" for Chaplain services dated March 20, 2018, reveals ..." hospice chaplain services to assess and care for patients according to all federal and state regulations." During Exit Conference on 09/01/2022 at 5:15 p.m. survey findings were discussed and no further documentation was submitted for review.

Based on interview, medical record documentation review, policy and procedure review, and the chaplain general agreement review the facility failed to ensure the update of the comprehensive assessment by the hospice interdisciplinary group and document changes or progress toward desired outcomes as well as a reassessment of the patient's response to care since the initial assessment on six (6) of 12 medical records reviewed, Patients #3, #5, #9, #10, #11, and #12 on four (4) of four (4) survey days. Findings Include: During an interview with the Hospital Liaison and Office Manager on 08/31/2022 at 3:50 p.m., the surveyor requested policy and procedures for following Physician's orders, interdisciplinary treatment team meetings and plan of care updates. No further documents were submitted. During a phone interview with the Director of Nursing on 08/31/2022 at 3:55 p.m. the surveyor requested documentation for initial assessments, ongoing assessments, interdisciplinary team meeting documentation for survey sample and policy and procedure for admission process and interdisciplinary treatment team. No further documents were submitted. During an interview on 08/31/2022 at 4:30 p.m. the Office Manager confirmed all admission dates and confirmed some documentation may still be in filing and she will update charts today. Surveyor requested all documentation for initial assessments, ongoing assessments, interdisciplinary team meeting documentation for survey sample and policy and procedure for admission process and interdisciplinary treatment team. No further documentation was submitted for review at this time. During an interview with Office Manager and Director of Nursing on 09/1/2022 at 5:15 p.m. during the exit conference, both confirm Interdisciplinary Team Meetings include all core members and are held every 14 days to review and update all patients' care plans. Medical record review of Patient #3 reveals patient admitted 07/13/2021 and the first treatment team document to update plan of care is dated 07/14/2021 with a social work frequency of one (1) time a month, no documented evidence of a social work update summary or social work signature; review further reveals a subsequent interdisciplinary treatment team document to update plan of care dated 07/28/2021 with social work frequency one (1) time a month and no documented evidence of a social work update summary or social work signature. Medical record review of Patient #5 reveals patient admitted 12/03/2021, the interdisciplinary group meeting 12/15/2021, review further reveals the interdisciplinary group document 12/15/2021, did not include updates, changes, or progress toward the desired outcomes or reassess the patient's response to care since the initial assessment, no registered nurse frequency documented, no social work frequency documented, no core member social work signature or comment documented, no core member chaplain signature, and no chaplain comment documented. Review of treatment plan of care dated 12/03/2021 reveals social work frequency one (1) time a month and chaplain frequency one (1) time a month. Review of treatment plan of care dated 12/15/2021 reveals chaplain frequency one (1) time a month. Medical record review of Patient #9 reveals the patient admitted on 06/20/2022 and the interdisciplinary group meeting held 06/29/2022, review reveals the interdisciplinary group meeting document for 06/29/2022, did not include the core member social worker signature, no social work comment documented, no update documented by core member medical director. Review of the plan of care further reveals a frequency for social work at one (1) time a month. Medical record review of Patient #10 reveals the patient admitted on 07/05/2022, the interdisciplinary group meeting held 07/13/2022, review of the 07/13/2022 interdisciplinary group document further reveals no update to the plan of care, no social worker signature or social work comment documented, frequency of social worker one (1) time a month. Medical record review of Patient #11 reveals the patient admitted on 06/20/2022, the interdisciplinary group meeting held 06/29/2022, review reveals the interdisciplinary group meeting document 06/29/2022, did not include core member medical director documentation or medical director signature, did not include core member social worker documentation or social work signature, did not include core member chaplain documentation or chaplain signature. Review further reveals a frequency of one (1)time a month for social work services and one (1) time a month for chaplain services. Medical record review of Patient #12 reveals the patient admitted on 11/29/2021, the interdisciplinary group meeting held 12/01/2021, review reveals the interdisciplinary group meeting document 12/02/2021, did not include patient progress or changes to plan of care problems or current status, and did not include core member social worker documentation or social work signature. Review further reveals a frequency for social worker services at one (1) time a month. Review of policy and procedure "Level of Care," No policy number, No dates, received at 4:00 p.m. on 08/31/2022 reveals " ...1. The Interdisciplinary Team will perform ongoing assessments of the patient's condition and the family's needs which will be addressed on the IDT Care Plan ...5. Hospice Interdisciplinary Team meets every fourteen (14) days ...". Review of "General Agreement" for Chaplain services dated March 20, 2018, reveals ..." hospice chaplain services to assess and care for patients according to all federal and state regulations." During Exit Conference on 09/01/2022 at 5:15 p.m. survey findings were discussed and no further documentation was submitted for review.

Based on interview, medical record review, policy and procedure review, and the chaplain general agreement review the facility failed to ensure that a complete interdisciplinary group provided care planning and coordination of services on 12 of 12 medical records reviewed, Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12 on four (4) of four (4) survey days. Findings Include: Cross Refer to L-553/418.56(d) and L-555/418.54(e)(2) for the facility's failure to ensure a complete interdisciplinary group provided updated care planning and coordination of services.

Based on interview, medical record review, policy and procedure review, and the chaplain general agreement review the facility failed to revise the plan of care to include information from the patient's updated comprehensive assessment and note the patient's progress toward outcomes and goals specified in the plan of care on 12 of 12 medical records reviewed, Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12 on four (4) of four (4) survey days. Findings Include: During an interview with the Hospital Liaison and Office Manager on 08/31/2022 at 3:50 p.m., the surveyor requested policy and procedures for following physician's orders, interdisciplinary treatment team meetings and plan of care updates. No further documents were submitted. During a phone interview with the Director of Nursing on 08/31/2022 at 3:55 p.m. the surveyor requested documentation for initial assessments, ongoing assessments, interdisciplinary team meeting documentation for survey sample and policy and procedure for admission process and interdisciplinary treatment team. No further documents were submitted. During an interview on 08/31/2022 at 4:30 p.m. the Office Manager confirmed all admission dates and confirmed some documentation may still be in filing and she will update charts. Surveyor requested all documentation for initial assessments, ongoing assessments, interdisciplinary team meeting documentation for survey sample, and policy and procedures for admission and interdisciplinary treatment team. No documentation was submitted for review. During an interview with Office Manager and Director of Nursing on 09/01/2022 at 5:15 p.m. during the exit conference, both confirm Interdisciplinary Team Meetings include all core members and are held every 14 days to review and update all patients' care plans. Medical record review of Patient #1 reveals, " ...Physician Orders ...5/15/22 ...DC home health aide per daughters request ...". Record review further reveals, " ...Updated Plan of care ...6/1/2022 ...MSW 1 x monthly and as needed (prn) ...HHA 3 times a week and prn ..." no documented evidence of continuing or resolved problems, changes, current status, social work documentation, or social work signature. Record review of plan of care dated 06/15/2022 reveals, " ...MSW 1 time monthly and prn ... HHA 3 times weekly and prn ..." and no documented evidence of continuing or resolved problems identified, changes or current status, no social worker documentation or social work signature. Review of Plan of care dated 07/13/22 reveals no frequencies for nurse services, social work, or chaplain; no identified plan of care problems, no continuing or resolved problems, no changes or current status since last treatment plan of care update, no nurse documentation, no social work documentation, no social worker signature. Review of plan of care dated 07/27/2022 reveals no continuing or resolved problems, no changes or current status to plan of care, no physician's documentation or signature, no nurse documentation, no social worker documentation, or social work signature with social work frequency one (1) time monthly and prn. Review of plan of care dated 08/10/2022 reveals no continuing or resolved problems, no current status or changes since last plan of care, no social worker documentation or signature with social work frequency one (1) time a month. Review of plan of care dated 08/24/2022 reveals no documented evidence of continuing or resolved problems, no changes since last plan of care, nurse comment reveals," ...stg 1 ulcer R heel ...", no problem initiated for skin integrity in plan of care, no social worker documentation or social work signature with social work frequency one (1) time a month and prn. Medical record review of Patient #2 reveals plan of care dated 06/29/2022 reveals no social worker documentation or signature, no physician's signature or documentation, social worker frequency one (1) time monthly and prn, current status documentation and nurse comments documented further reveals, " ...monitor skin issues ...skin cracks ...", no updated problem identified on plan of care for skin integrity. Review of plan of care dated 07/13/2022 reveals no social work documentation or social work signature, no identified problems on plan of care, no social work frequency. Review of plan of care dated 07/27/2022 reveals no social work documentation or social work signature and a social work frequency of one (1) time monthly and prn. Medical record review of Patient #3 reveals no documented evidence of social work documentation or social work signatures for interdisciplinary group meeting or plan of care update documents for dates 07/28/2021, 08/11/2021, 08/25/2021, 09/8/2021, 09/22/2021, 10/20/21, 11/17/2021, 12/01/2021, 12/15/2021, 01/26/2021, 02/9/2022, 02/23/2022, 03/9/2022, 03/23/20222, 04/6/2022, 04/20/2022, 05/4/2022, 05/18/2022, 06/1/2022, 07/13/2022, 07/27/2022, and 08/10/2022. Record review further reveals plan of care dated 11/03/2021 with no medical director signature or documentation of identified plan of care problems with current status or changes since last plan of care and no discipline frequencies. Review of treatment plan dated 04/20/2022 reveals patient " ...location inpatient ... changes since last plan of care ...just home from hospital ...just in hospital for 10 days ...urinary tract infection ...". Further review of Plan of care document dated 6/1/2022 reveals, " ...location ...homebased ...comments ...RN ...admitted to inpatient hospice 05/29/2022 ...IV antibiotics ...". No interdisciplinary treatment team plan of care updates documented until plan of care document dated 07/13/2022 with no changes or current status documented for general inpatient plan of care. Review of plan of care dated 07/27/2022 reveals location change to home from inpatient with no medical director signature, no nurse signature, no identified plan of care problems, no changes or current status documented, no documentation from medical director or nurse. Review of plan of care dated 08/24/2022 with social worker signature but no updated documentation of patient status. Medical record review of Patient #4 reveals plan of care dated 06/15/2022, 06/29/2022, 07/13/22, 07/27/2022, and 08/10/2022 with no social worker documentation or signature on updated plan of care. Review of plan of care dated 08/24/2022 reveals social worker signature but no documentation of patient status with current plan of care. Further review of plan of care dated 06/29/2022 reveals no medical director signature or documentation of current plan of care or patient status. Review of chaplain participation in plan of care reveals projected visit for chaplain services at one (1) time a month and prn for plan of care dated 06/15/2022 and no chaplain documentation or chaplain signature, plan of care dated 06/29/2022 reveals chaplain services declined. Review of plan of care dated 07/27/2022 reveals chaplain services one (1) time a month and prn with no chaplain signature or documentation. Medical record review of Patient #5 reveals plan of care dated 12/29/2021 with no social work or chaplain signature or updated documentation, frequency documented one (1) time a month for social work and chaplain. Review of plan of care dated 01/12/2022 reveals no chaplain signature or documentation or frequency. Review of plan of care dated 01/26/2022 reveals no social worker or chaplain signatures or updated documentation or frequencies. Review of plan of care dated 02/9/2022 reveals no social work or chaplain documentation or signatures or frequencies. Review of plan of care dated 02/23/2022 reveals no social work or chaplain documentation or signatures; frequencies documented for one (1) time a month for social work and chaplain. Review of plan of care dated 3/9/2022 reveals no social work or chaplain signature or documentation with one(1) time a month frequency for social work and chaplain. Review of plan of care dated 3/23/2022 reveals no social work or chaplain signatures or documentation of patient updates with frequencies for each at one (1) time a month. Plan of care dated 04/06/2022 reveals no social work or chaplain signature or documentation of patient current status with frequency documented for each at one (1) time a month and prn. Review of plan of care dated 05/04/2022 reveals no chaplain signature or updated documentation with frequency at one (1) time a month. Review of plan of care documents dated 06/29/2022 and 07/27/2022 reveals no medical director signature or updated plan of care documentation. Medical record review of Patient #6 reveals plan of care documents dated 07/29/2022 and 08/10/2022 with social work service frequency one (1) time a month and no documented evidence of social work update or social work signature. Further review reveals plan of care dated 08/24/2022 with social work frequency one (1) time a month and no social work update documentation. Medical record review of Patient #7 plan of care documents dated 06/01/2022, 06/15/2022, 06/29/2022, 07/13/2022, 07/27/2022, and 08/10/2022 reveals no social worker signature or updated current patient status. Review of plan of care dated 08/24/2022 reveals no updated patient documentation by the social worker. Further review of plan of care dated 06/29/2022 reveals no signature or updated patient status information or changes in plan of care by the medical director or nurse. Medical record review of Patient #8 reveals no social worker signature or updated documentation by the social worker for plan of care documents dated 06/15/2022, 06/29/2022, 07/13/2022, 07/27/2022, 08/10/2022. Review of plan of care document 08/24/2022 reveals no updated documentation by the social worker. Further review of plan of care document dated 06/29/2022 reveals no medical director signature or documentation. Medical record review of Patient #9 reveals plan of care document dated 06/29/2022 with no updated patient documentation by the medical director or social worker and no signature by the social worker. Documentation review further reveals a physician order for general inpatient care dated 07/06/2022 with no plan of care document the month of 07/2022. Review of plan of care dated 08/10/2022 reveals no social worker signature or update to patient status or plan of care for social worker services. Review of plan of care dated 08/24/2022 reveals patient transfer back to hospital with no social worker update or summary of patient status. Medical record review of Patient #10 reveals plan of care documents dated 07/27/2022 and 08/10/2022 with no social worker signature or documentation on patient update. Review of plan of care dated 08/24/2022 reveals no social work documentation of patient status. Medical record review of Patient #11 reveals plan of care documents dated 07/13/2022 and 07/27/2022 with no signature or updated patient information documented by the medical director, chaplain, or social worker. Medical record review of Patient #12 reveals no social worker signature or documentation of patient updates on plan of care documents dated 12/15/2021, 1/26/2022, 2/9/2022, and 2/23/2022. Review of policy and procedure "Level of Care, "No policy number, No policy date, received at 4:00 p.m. on 08/31/2022 reveals " ...1. The Interdisciplinary Team will perform ongoing assessments of the patient's condition and the family's needs which will be addressed on the IDT Care Plan ...5. Hospice Interdisciplinary Team meets every fourteen (14) days ...". Review of "General Agreement" for Chaplain services dated March 20, 2018, reveals ... "hospice chaplain services to assess and care for patients according to all federal and state regulations." During Exit Conference on 09/01/2022 at 5:15 p.m. survey findings were discussed and no further documentation was submitted for review.

Based on interview, medical record documentation review and policy and procedure review the facility failed to ensure that the care and services are provided in accordance with the plan of care on eight (8) of 12 medical records reviewed, Patients #1, #2, #3, #4, #7, #8, #9, and #12 on four (4) of four (4) survey days. Findings Include: During an interview with the Hospital Liaison and Office Manager on 08/31/2022 at 3:50 p.m., the surveyor requested policy and procedures for following physician's orders, interdisciplinary treatment team meetings and plan of care updates. No further documents were submitted. During a phone interview with the Director of Nursing on 08/31/2022 at 3:55 p.m. the surveyor requested documentation for initial assessments, ongoing assessments, interdisciplinary team meeting documentation for survey sample and policy and procedure for admission process and interdisciplinary treatment team. No further documents were submitted. During an interview on 08/31/2022 at 4:30 p.m. the Office Manager confirmed all admission dates and confirmed some documentation may still be in filing and she will update charts today. Surveyor requested all documentation for initial assessments, ongoing assessments, interdisciplinary team meeting documentation for survey sample and policy and procedures for admission process and interdisciplinary treatment team. No documentation was submitted for review at that time. Medical record review of Patient #1 reveals nursing frequency for two (2) times a week according to plan of care documents dated 06/01/2022, 06/15/2022, 07/13/2022, 07/27/2022, and 08/10/2022. Review of week 06/5/2022 through 06/11/2022, reveals one nurse visit note for 06/10/2022; review of week 06/12/2022 through 06/18/2022, reveals one nurse visit on 06/15/2022; review of week 06/26/2022 through 07/02/2022, reveals one nurse visit on 06/29/2022; review of week 07/03/2022 through 07/09/2022 reveals no nursing documented visits, review of week 07/17/2022 through 07/23/2022 reveals one nurse visit on 07/19/2022; review of week 07/31/2022 through 08/06/2022, reveals one nurse visit on 08/02/2022; review of week 08/07/2022 through 08/13/2022, reveals one nurse visit on 08/09/2022; review of week 08/14/2022 through 08/20/2022, reveals no documented nurse visits and no documented evidence of missed visits. Medical record review of Patient #2 reveals home health aide frequency as five (5) times a week on plan of care dated 06/29/2022 and on the home health aide assignment dated 07/19/2021; review further reveals nursing frequency of three (3) times a week on plan of care documents dated 07/27/2022, 08/10/2022, and 08/24/2022. Review of week 07/03/2022 through 07/09/2022, reveals home health aide visits documented on 07/05/2022, 07/06/2022, 07/07/2022 and 07/08/2022 with no missed visit documentation. Review of week 08/07/2022 through 08/13/2022, reveals nursing visit documented on 08/08/2022 and 08/09/2022; review of week 08/14/2022 through 08/20/2022 reveals no documented nurse visits no documented evidence of missed visits. Medical record review of Patient #3 reveals nurse visit frequency of three (3) times a week on plan of care documents dated 05/18/2022, 06/01/2022, 07/13/2022, and 08/10/2022. Review of week 05/29/2022 through 06/04/2022 reveals nursing visit documentation for 05/29/2022 and 06/03/2022; review of week 07/17/2022 through 07/23/2022 reveals nursing visit documentation for 07/21/2022 and 07/22/2022; review of week 08/14/2022 through 08/20/2022 reveals nurse visit documentation for 08/13/2022 and 08/17/2022 no documented evidence of missed visits. Medical record review of Patient #4 reveals nurse frequency of three (3) times a week on plan of care documents dated 06/15/2022, 06/29/2022, 07/27/2022, 08/10/2022, and 08/24/2022. Review of week 06/12/2022 through 06/18/2022 reveals nurse visit dates of 06/16/2022 and 06/17/2022; review of week 06/19/2022 through 06/25/2022 reveals nurse visits on 06/21/2022 and 06/24/2022; review of week 06/26/2022 through 07/2/2022 reveals nurse visits on 06/30/2022 and 07/1/2022; review of week 07/03/2022 through 07/09/2022 reveals nurse visit on 07/05/2022; review of week 07/24/2022 through 07/30/2022 reveals nurse visits on 07/26/2022 and 07/30/2022; review of week 07/31/2022 through 08/06/2022 reveals nurse visit on 08/02/2022 and 08/05/2022; review of week 08/07/2022 through 08/13/2022 reveals nurse visit on 08/08/2022. Further review of plan of care dated 06/29/2022 reveals home health aide visit frequency of three (3) times a week with one missed visit documented 07/06/2022 and a visit on 07/08/2022. Medical record review of Patient #7 reveals nurse frequency as two (2) times a week on plan of care documents dated 06/01/2022, 06/15/2022, 06/29/2022, 07/13/2022, 07/27/2022, 08/10/2022, 08/24/2022. Review of week 06/12/2022 through 06/18/2022 reveals one nurse visit on 06/15/2022; review of week 06/19/2022 through 06/25/2022 reveals nurse visit on 06/24/2022; review of week 06/26/2022 through 07/02/2022 reveals nurse visit on 06/29/2022; review of week 07/03/2022 through 07/09/2022 reveals nurse visit on 07/10/2022; review of week 07/10/2022 through 07/23/2022 reveals nurse visit on 07/21/2022; review of week 07/24/2022 through 07/30/2022 reveals nurse visit on 07/26/2022; review of week 07/31/2022 through 08/06/2022 reveals nurse visit on 08/02/2022; review of week 08/07/2022 through 08/13/2022 reveals nurse visit on 08/09/2022; review of week 08/14/2022 through 08/20/2022 reveals nurse visit on 08/19/2022; review of week 08/21/2022 through 08/27/2022 reveals nurse visit on 08/24/2022. Medical record review of Patient #8 reveals nurse visit frequency for two (2) times a week on plan of care documents dated 06/15/2022, 06/29/2022, 07/13/2022, and 07/27/2022. Review of week 06/26/2022 through 07/02/2022 reveals nurse visit dated 06/27/2022; review of week 07/03/2022 through 07/09/2022 reveals no nurse visit documentation; review of week 07/10/2022 through 07/16/2022 reveals one nurse visit 07/15/2022; review of week 07/17/2022 through 07/23/2022 reveals one nurse visit 07/22/2022; review of week 07/24/2022 through 07/30/2022 reveals one nurse visit 07/25/2022. Further review of plan of care dated 06/29/2022 reveals frequency for home health aide three (3) times a week; review of week 07/03/2022 through 07/09/2022 reveals home health aide visits 07/06/2022 and 07/08/2022. Medical record review of Patient #9 reveals nurse frequency three (3) times a week on plan of care dated 06/29/2022, doctor's order dated 07/6/2022 reveals, " ...admit to inpatient hospice ...", no change in nurse frequency noted. Review of week 07/03/2022 through 07/09/202 reveals nurse visit 07/04/2022 and 07/06/2022; review of week 7/10/2022 through 7/16/2022 reveals no nursing documentation of visits; review of week 07/17/2022 through 07/23/2022 reveals no nursing documentation; review of week 07/24/2022 through 07/30/2022 reveals no nursing visit documentation; review of week 07/31/2022 through 08/06/2022 reveals no nursing visit documentation; review of month 07/2022 reveals no updated plan of care. Medical record review of Patient #12 reveals the nurse frequency three (3) times a week on plan of care document dated 01/12/2022; review of week 01/09/2022 through 01/15/2022 reveals no nursing visits documented; review of week 01/16/2022 through 01/22/2022 reveals no nursing visits documented. Further review reveals social work frequency one (1) time a month on plan of care documents 12/15/2021, 01/12/2022, 02/9/2022, 02/23/2022 and plan of care 01/26/2022 the physician documents to continue plan of care. Review of the month of 01/2022 and 02/2022 reveals no social work visit documented. Review of "General Agreement" for Chaplain servicces dated March 20, 2018, reveals ..." hospice chaplain services to assess and care for patients according to all federal and state regulations." During Exit Conference on 09/01/2022 at 5:15 p.m. survey findings were discussed and no further documentation was submitted for review.