Every finding on record at Amazing Hospice Care Inc.

Upon patient record review 1 of 6 (Patient #3) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #3: Record review stated the patient's admission/EOB date as 11/20/2024. There was not evidence that initial assessment was completed within the 48 hour timeframe. The comprehensive assessment was documented as completed 11/29/2024.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. Upon review of the governing body minutes there was no evidence that the frequency and detail of the data collection for the QAPI program was approved for 2024.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. Upon review of the QAPI meeting minutes there was no evidence that the hospice documents the reasons for conducting QAPI projects, and the measurable progress achieved on these projects. In addition, a written summary of the hospice's projects was not contained in a QAPI annual report.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. Upon review of QAPI program minutes, there is no evidence that the governing body reviewed and approved the frequency and detail of the data collection.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 Upon review of the Governing Board Minutes. there was not evidence the governing body received a report that demonstrates the cost savings of volunteer activities for 2024.

Upon client record review, 3 of 6 (Patients # 4, 5, 6) did not have evidence that the discharge summary includes all required information Patient # 4: Upon review of the patient record, there was no evidence of discharge planning activities, coordination with other care providers, the patient's response and understanding to these activities, patient care instructions and a reasonable notice prior to discharge. The record did not contain evidence of a discharge summary. Patient # 5: Upon review of the patient record, there was no evidence of discharge planning activities, coordination with other care providers, the patient's response and understanding to these activities, patient care instructions and a reasonable notice prior to discharge. The record did not contain evidence of a discharge summary. Patient # 6: Upon review of the patient record, there was no evidence of discharge planning activities, coordination with other care providers, the patient's response and understanding to these activities, patient care instructions and a reasonable notice prior to discharge. The record did not contain evidence of a discharge summary.

Upon personnel record review, 1 of 12 (Personnel # 2) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel # 2: No evidence contained in file that a criminal background check was performed on hire.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #1: Patient with sliding scale insulin on the med profile. Med profile does not contain the parameters for administration of the sliding scale.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: Medication Insulin Lispro 100u/ml 4x/day per sliding scale denoted on both medication profile and on plan of care. Placed on hold from SOC date. Medication profile denotes resumed 1/12/22. No evidence of order to update plan of care. Additionally, no evidence of the sliding scale parameters in the POC orders.

Upon client record review, 2 of 5 (Patient #3,4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: POC dated 11/24/21 orders indicate MSW 1xmo and 3 prns. Social Worker performed visits on 12/3/21 and 12/17/21 with No indication either visit was a PRN. Patient #4: POC dated 8/19/21 orders MSW 1x mo. No evidence of visit nor missed visit documentation by the MSW for the month of Aug.

Upon patient, review, 1 of 2 applicable (Patient # 4) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #4: Plan of care orders starting 8/19/21 for Aide 2xweek. Aide visited 8/25/21 and 8/27/21 but No visit performed for first week. No evidence of missed visit/refusal documentation or additional order.

Condition of Participation: Emergency Preparedness

Upon observation, there was no evidence the hospice has developed an emergency preparedness plan that was complete and accurate for the agency. The agency had an emergency plan template that included information for California and Nevada. The emergency plan was not individualized to the agency's location in Saginaw MI. This was reflected in the agency's communication plan and a separate hazard analysis but the emergency plan itself contained information unrelated to the agency or the service area the agency provides care.

Upon observation, there was no evidence the The Emergency Preparedness plan addresses patient population, including, but not limited to: • The type of services the hospice has • The ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans

Upon observation, there was no evidence the Emergency Preparedness plan includes a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. This information was included in the communication plan but the emergency plan itself included information for California and Nevada instead of Michigan.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #2 admitted on 10/11/21, no evidence of a signature confirming the patient received a copy of the Patient's Rights and Responsibilities. Document was signed on 12/17/21 during the survey.

Upon patient record review, 3 of 5 (Patient #1, 2 and 3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #1 initial plan of care included fleet enema prn constipation. No evidence of fleet enema on medication profile. Patient #2 initial plan of care included fleet enema prn constipation. No evidence of fleet enema on medication profile. Patient #3 plan of care order dated 12/8/21 included oxygen 2L NC prn. No evidence of oxygen on medication profile.

Upon patient record review, 3 of 5 (Patient #1, 2, and 3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1 initial plan of care included fleet enema prn constipation, no evidence of a frequency of administration. Patient #2 initial plan of care included fleet enema prn constipation, no evidence of a frequency of administration. Patient #3 plan of care dated 12/8/21 included oxygen 2L via NC prn, no evidence of an indicator for prn.

Upon client record review, 1 of 5 (Patient #1) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #1 admitted on 11/1/21, plan of care updates on 11/3/21, 11/10/21, 11/24/21, and 12/8/21 did not have evidence of collaboration with the attending physician.

Condition of Participation: Quality Assessment and Performance Improvement.

Upon observation, there was no evidence the hospice measures, analyzes, and tracks quality indicators, including other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. No evidence of a 2021 QAPI plan that included evidence of program objectives, description of how the program will be administered and coordinated, and methodology for monitoring and evaluating the quality of care.

Upon observation, there was no evidence the program must use quality indicator data, including patient care, and other relevant data, in the design of the program.

Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. There is evidence in the governing body meeting minutes that the governing body approved the QAPI plan but the agency does not have a QAPI plan.

Upon observation, there was no evidence QAPI activities focus on high risk ,high volume, or problem prone areas. Agency had the initiation of one PIP related to comprehensive assessment but there were no other QAPI activities or QAPI plan that evidenced that activities would focus on high risk or problem prone areas.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by considering incidence, prevalence, and the severity of problems.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by understanding how they affect palliative outcomes, patient safety and quality of care.

Upon observation, there was no evidence the hospice documents the reasons for conducting these projects, and the measurable progress achieved on these projects. Performance improvement project observed for completion of the comprehensive included one patient that the comprehensive assessment was not completed on and the education provided. No evidence of future audits and if the goals were achieved for this project.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. Agency does not have a defined QAPI program.

Upon observation, there was no evidence the hospice ensures the implementation of a hospice wide Quality Assessment/Performance Improvement (QAPI) program by the designation of a person responsible for coordinating QAPI activities. Agency has identified someone as responsible for the implementation of QAPI but there is no written QAPI program and no evidence of the implementation of the QAPI program.

Upon patient record review, 2 of 2 applicable (Patient #1 and 4) did not have evidence in the patient record that hospice aide assignments and duties include all patient-specific instructions. Patient #1 initial plan of care and initial nursing assessment identified patient as high fall risk, no evidence of fall precautions on aide care plan. Patient #4 initial plan of care and initial nursing assessment identified patient as high aspiration risk, no evidence of aspiration precautions on aide care plan.

Upon patient record review 1 of 2 applicable (Patient #1) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #1 aide care plan dated 11/2/21 included straight shave 2x/week. Aide visit on 11/11/21 documented electric shave, no evidence of electric shave on aide care plan.

Upon patient client record review, 1 of 5 (Patient #1) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #1 election of benefit identified Dr. FA as attending physician. Certification of terminal illness signed by Hospice Medical Director, no evidence of certification of terminal illness from attending physician.

Upon client record review, 1 of 5 (Patient #2) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #2 admitted on 10/11/21, no evidence that patient/family was provided with written policy on managing controlled drugs. Agency practice is for patient to sign documenting patient has received this policy. Caregiver signed on 12/17/21 during the survey.