Every finding on record at Cfhc No18 Inc

It is required that hospice performance improvement (PI) activities focus on high-risk, high-volume, or problem-prone areas. This standard was not met as evidenced by document review and interview. During the review of the agency's documentation related to performance improvement activities it was revealed that agency did not ensure there were performance improvement activities for 2024 and 2025. Agency Policy, Quality Assessment/Performance Improvement Plan (10/02/2018), stated in part, "Performance Improvement Activities will focus on high risk, high volume, or problem-prone areas… Hospice will document what the PIPs are, the reason for conducting these projects and the measurable progress achieved.” Documentation provided by the agency revealed that the last performance improvement activities were initiated 2023 without any additional follow-up. Governing Body minutes data 06/21/2023 listed a performance improvement project (PIP) but lacked determinative status of the PIP. The agency lacks documentation to support any performance improvement activities focused on high-risk, high-volume, or problem-prone areas for 2024 and 2025. The agency provided copies of quarterly chart audits for 2024 and 1st quarter of 2025, however, there is a lack of aggregation of the data to determine areas of concerns. An interview was conducted with the Administrator on 10/15/2025 were she stated we have collected data but have not used it for any performance improvement activity. The standard was not met by review of the agency's documentation related to performance improvement activities. The agency did not ensure performance improvement activities for 2024 and 2025. The latest performance improvement activities was 2023. Governing Body minutes data 06/21/2023 listed a performance improvement project (PIP) lacked determinative status of the PIP. The agency lacks documentation to support any performance improvement activities focus on high-risk, high-volume, or problem-prone areas for 2024 and 2025. The agency provided copies of quarterly total chart audits for 2024 and 1st quarter of 2025. There is a lack of aggregation of the data to determine areas of concerns.

It is required that the hospice’s governing body assumes full legal authority and responsibility for the organization’s ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. This standard was not met as evidenced by document review and interview. A review of the agency documentation to support activity of governing body legal authority and responsibility revealed the agency was unable to provide documentation that the performance improvement and patient safety program were evaluated annually. Agency Policy LD.15, Governing Body (10/01/2021), stated in part, "Participating annually in the establishment, organization and revision of policies." The last documented governing body meeting was conducted on 06/21/2023. There was no documented Governing Body activity in 2024 and 2025. A list of governing body members was provided but no agency or minutes for meetings in 2024 and 2025. During an interview on 10/16/2025 the Administrator stated the Governing Body met in January 2025 but there was no documentation to support the meeting. At the time of exit the agency was unable to present any meeting minutes, meeting agendas, or any other documentation to support that the Governing Body had annually reviewed the performance improvement and patient safety programs.

It is required that the hospice’s governing body assumes full legal authority and responsibility for the organization’s overall management and operation, provision of care and services, and fiscal operations. This standard was not met as evidenced by document review and interview. A review of the agency documentation to support activity of governing body legal authority and responsibility revealed the agency was unable to provide documentation to support overall management and operation, provision of care, and fiscal operations. Agency Policy LD.15, Governing Body (10/01/2021), stated in part, "Participating annually in the establishment, organization and revision of policies." The last documented governing body meeting was conducted on 06/21/2023. There was no documented Governing Body activity in 2024 and 2025. A list of governing body members was provided but no agency or minutes for meetings in 2024 and 2025. During an interview on 10/16/2025 the Administrator stated the Governing Body met in January 2025 but there was no documentation to support the meeting. At the time of exit the agency was unable to present any meeting minutes, meeting agendas, or any other documentation to support that the Governing Body provided full responsibility for the overall management and operation of the organization. The standard was not met by review of the agency documentation to support activity of governing body legal authority and responsibility. The agency was unable to provide documentation to support overall management, operation provision of care, fiscal operation and ongoing performance improvement and patient safety program. The last documented governing body meeting was conducted on 06/21/2023. There has been no documented Governing Body activity in 2024 and 2025. The governing body membership changed after the change of ownership (CHOW) on 06/01/2023. The agency was unable to provide evidence of Medicare Administrative Contractor approval letter for CHOW, but did provide a copy of approved Medicare enrollment record from https://pecos.cms.hhs.gov.The document supports CHOW dated 06/01/2023. A list of governing body members was provided but no agency or minutes for meetings in 2024 and 2025. At the time of exit the agency was unable to present any meeting minutes, meeting agendas, or any other documentation to support that a meeting had occurred.