Every finding on record at Charles Ford Memorial Home, Inc.

It is required that one or more individual(s) is appointed by the governing body as responsible for operating the QAPI program. This standard was not met as evidenced by document review and interview. A review of the governing body meeting minutes (quarterly meetings, no dates provided) revealed that the agency did not ensure that the governing body appointed one or more individuals responsible for operating the QAPI program. An interview was conducted 10/31/2024 with the Administrator and the Clinical Director who both reported the governing body met quarterly, but none of the meetings documented appointment of the Administrator as the QAPI Coordinator. The Administrator verified that she was performing all the requirements of the QAPI Coordinator. The Clinical Director stated the agency was going to need to do a Performance Improvement Plan (PIP) and ensure that the governing body minutes included the appointment of the Administrator as the QAPI Coordinator. A review of the governing body meeting minutes revealed that the agency did not ensure that the governing body appointed one or more individuals responsible for operating the QAPI program. An interview was conducted 10/31/2024 with the Administrator and the Clinical Director. The Administrator verified that she was performing all the requirements of the QAPI Coordinator. The Clinical Director verified there was no documentation in the governing body notes that the Administrator was appointed as the QAPI Coordinator. She stated the agency was going to need to do a Performance Improvement Plan (PIP) and ensure that the governing body minutes included the appointment of the Administrator as the QAPI Coordinator.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed that included a patient that resided in a skilled nursing facility, the agency did not ensure that the plan of care specifically identified the care and services that were needed, nor did it specify which provider was responsible for performing the respective functions. Clinical Record 4: The patient elected the hospice benefit on 06/28/2024, with a terminal diagnosis of senile degeneration of the brain. On admission the patient was a home patient and was admitted to a skilled nursing facility on 07/15/2024. There was evidence that the plan of care included coordination with the skilled nursing facility, but it did not identify the care and services that were needed nor specify which provider was responsible to perform the respective functions. During an interview with the Administrator on 10/30/2024, she stated she remembered taking the skilled nursing home task form to the skilled nursing facility, but the agency forgot to bring back a copy of the task form. The administrator also stated the skilled nursing facility was not able to produce the form.