Every finding on record at County of Crawford

Based on review of agency emergency preparedness policies and staff interview, the agency failed to ensure the development of a written policy and procedure to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. Failure to have procedures in place for to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency placed agency patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: --- Review of the agency policy, titled Emergency Preparedness Policy, dated 4/2024, revealed a process for contacting on duty staff.  The policy failed to identify a procedure for informing state an local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. During an interview on 6/3/25 at 3:00 PM, the Administrator stated the policy did not include procedures for the agency to  inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. The above findings shared with the Administrator and Clinical Manager.

Based on hospice staff interview and clinical record review the hospice failed to ensure the documentation and correct identification, in a prominent part of the patient's record, any advance directives executed by the patient for 1 of 14 sampled patients (Patient #2).    Failure to ensure the hospice documented and correctly identified any executed advance directives in a prominent part of the record placed patients at risk for their advance directives not being correctly carried out.    Findings include: --- Patient #2 had a start of care date of 12/19/24 and received hospice services while residing in an assisted living facility.  Clinical record review revealed:   The Plan of Care, dated 3/19/25 to 6/16/25, identified the patient's advance directive information as full code and do not resuscitate.   The hospice agency failed to include accurate advance directive information on the patient's plan of care.    The above findings were reviewed with the Administrator and Clinical Manager.

Based on staff interview, clinical record reviews and hospice policy review, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group (IDG) updated the comprehensive assessment with changes to the patient condition regarding wound descriptions and measurements for 4 of 6 sampled patients with a wound (Patient #5, #10, #11 and #12). Failure by the IDG registered nurses (RN) to update the comprehensive assessment with complete wound descriptions and measurements placed the patients at risk for ineffective staff collaboration and communication regarding patients' wound status and effectiveness of treatments and interventions.   Findings include: --- 4. Patient #10 had a start of care date of 11/26/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 2/24/25 to 5/24/25, included orders for skilled nursing services.  The POC identified the patient had a diagnosis of Unspecified protein calorie malnutrition.    b.  The skilled nurse visit notes, dated 3/24/25, 3/26/25, 3/31/25, 4/3/25, 4/7/25, 4/11/25, 4/14/25, 4/17/25, 4/21/25, 4/28/25 and 5/1/25 identified the patient had open wounds.  The documentation failed to include assessments of wounds and measurements by hospice skilled nurse and/or nursing home staff.    The hospice skilled nurse failed to include documentation of wound assessments and measurements of the patient's wounds.    The above findings were reviewed with the Administrator and Clinical Manager.   2. Patient #11 had a hospice admission date of 11/1/24 and a death date of 11/26/24, and received hospice services while residing in a private home.  Clinical record review revealed:  a. The POC, dated 11/1/24 to 1/29/24, included orders for skilled nursing, social worker services, hospice aide and chaplain.  The POC identified the patient had diagnosis of Heart Failure.  b. The comprehensive assessment at admission, dated 11/1/24, Staff J, RN, included documentation of three venous stasis ulcers.  Wound #1 is documented as a venous stasis ulcer to the right inner leg measured 14 CM length  by 3 CM width  by 0 cm  depth.,  Wound #2  is documented as a venous stasis ulcer to the right outer leg and measured 14 CM length by 8 CM width and 0 CM depth.   Wound #3 was documented as a venous stasis ulcer to the left inner leg and measured 8 CM length by 8 CM width by 0 CM depth.  All three wounds were documented as having a beefy red wound bed.  The hospice skilled nurse failed to include documentation of complete measurements of the patients wounds.  3. Patient #5 had a hospice admission date of 5/3/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 5/3/25 to 7/31/25, included orders for skilled nursing, social worker services, hospice aide and chaplain.  The POC identified the patient had diagnosis cerebral infarction (stroke) with Dysphagia (difficulty swallowing).   b. The skilled nurse service note, dated 5/12/25, Staff F, RN, included documentation of three wounds to the left lower extremity.  Wound #1 is documented as a venous stasis ulcer to the left lower calf,  Wound #2  is documented as a venous stasis ulcer to the inside of the left ankle. Wound #3 was documented to the 3rd great toe but did not have a wound classification. The documentation lacked measurements and assessment of all three wounds. c. The skilled nurse service note dated 5/15/25, Staff E, RN included documentation of three wounds to the left lower extremity. Wound #1 is documented as a venous stasis ulcer to the left lower calf,  Wound #2  is documented as a venous stasis ulcer to the inside of the left ankle. Wound #3 is documented as a venous stasis ulcer to the 3rd great toe. The documentation lacked measurements and assessment of all three wounds. d. The skilled nurse service note, dated 5/19/25, Staff H, LPN, included documentation of three wounds to the left lower extremity.  Wound #1 is documented as a venous stasis ulcer to the left lower calf,  Wound #2  is documented as a venous stasis ulcer to the inside of the left ankle. Wound #3 was documented to the 3rd great toe but did not have a wound classification. The documentation lacked measurements and assessment of all three wounds. e. The skilled nurse service note dated 5/22/25, Staff E, RN included documentation of three wounds to the left lower extremity. Wound #1 is documented as a venous stasis ulcer to the left lower calf,  Wound #2  is documented as a venous stasis ulcer to the inside of the left ankle. Wound #3 is documented as a venous stasis ulcer to the 3rd great toe. The documentation lacked measurements and assessment of all three wounds. The hospice skilled nurse failed to include documentation of complete measurements of the patients wounds.    According to the policy titled Wound Care Assessment, dated 5/15/23, wound assessment and documentation by the Registered Nurse (RN) will include, but not be limited to: type of wound, location of wound (including laterally), color/description of wound bed, descrption of wound edges, description of surrounding skin and skin color, description of wound drainage and odor, wound measurements (height x length x depth). During an interview on 6/3/25 at 9:25 AM the Clinical Manager stated the expectation of hospice staff to assess and measure wounds weekly and to include length, width and depth. 1. Patient #12 had a hospice admission date of 10/31/24 and date of death of 11/6/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The plan of care (POC), dated 10/31/24 to 1/28/25, included orders for skilled nursing and social worker services. The POC identified the patient had diagnosis of cancer of the vulva. b. The comprehensive assessment at admission, dated 10/31/24, Staff J, RN, included documentation of a cyst with 2 open wounds to the pubis area. Wound #1 measured 2 centimeters (CM) length  by 2 cm width  by 0 cm  depth. Wound #2 measured 2.5 cm by 1 cm by 0 depth.  The documentation included wound description of both wound beds beefy red. The documentation failed to included measurement of the depth of either of the wound beds.  The hospice skilled nurse failed to include documentation of complete measurements of the patients wounds.

Based on clinical record review and hospice policy review, the hospice failed to ensure the provision of care in accordance with the patient's plan of care for 4 of 14 sampled patients (Patients #2, #7, #11 and #13).    Failure to follow the patient's plan of care as directed by the Interdisciplinary Group (IDG) put the patients at risk for inconsistent care that may not meet the needs of the patients.    Findings include: --- 3. Patient #7 had a start of care date of 3/21/25, and received hospice services while residing at home.   a. The POC, dated 3/21/25 to 6/18/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease.  The POC included orders for the hospice Chaplain to provide religious support 1-2 times monthly.    b. Staff K, Hospice Chaplain, provided services on 4/1/25, 4/8/25, 4/15/25, 4/22/25 and 4/29/25 exceeding the ordered visit frequency for April by two visits three visits.    The hospice failed to follow all orders as written on the POC. 4. Patient #11 had a start of care date of 11/1/24, a death date of 11/26/25 and received hospice services while residing at home.   a. The POC, dated 11/1/24 to 1/29/25, identified the patient had diagnosis of heart failure.  The POC included orders for the hospice Chaplain to provide religious support 2 times monthly.    b. Staff K, Hospice Chaplain, provided services on 11/5/24, 11/12/24, 11/19/24, and 11/26/24, exceeding the ordered visit frequency for November by two visits.    The hospice failed to follow all orders as written on the POC.  The above findings were reviewed with the Administrator and Clinical Manager.   According the hospice policy titled Hospice Plan of Care and Interdisciplinary Group (IDG), dated 7/25/22, all hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the (IDG) in collaboration with the attending physician, the patient or their representative and the primary caregiver in accordance with the patient's needs.    1.Patient #2 had a start of care date of 12/19/24 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The Plan of Care (POC), dated 3/19/25 to 6/16/25, identified the patient had a diagnosis of Hypertensive heart disease.  The POC included orders for skilled nurse to monitor patient's weight each visit.    b. The skilled nurse visit note, dated 4/24/25, completed by Staff C, Registered Nurse (RN), failed to include documentation of the patient's weight.    The hospice failed to follow orders as written on the POC.    2. Patient #13 had a start of care date of 8/5/22, a discharge date of 5/17/24 and received hospice services while residing in a nursing home.    a. The POCs, dated 1/27/24 to 3/26/24 and 3/27/24 to 5/25/24, identified the patient had a diagnosis of Parkinson's disease.  The POCs included orders for the hospice Chaplain to provide religious support two times monthly.    b. Staff K, Hospice Chaplain, provided services on 3/5/24, 3/12/24, 3/19/24 and 3/26/24; exceeding the ordered visit frequency for March by two visits.    c. Staff K, Hospice Chaplain, provided services on 4/2/24, 4/9/24, 4/17/24, 4/23/24 and 4/30/24; exceeding the ordered visit frequency for April by three visits.   The hospice failed to follow all orders as written on the POC.

Based on clinical record review, hospice policy review, and hospice staff review, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments and/or a complete order for all medications and treatments to meet the needs of the patient for 5 of 14 sampled patients (Patient #3, #6, #7, #8 and #13). Failure to ensure the plan of care included complete orders for medications and treatments placed patients at risk to receive inappropriate treatment of symptoms and/or not meet the needs of the patients. Findings include: --- 4. Patient #6 had a start of care date of 2/24/25 and received hospice services while residing in a private residence.  Review of the clinical record revealed:   a. The POC, dated 2/24/25 to 5/24/25, included orders for nursing visits two times per week.  The POC identified the patient had a diagnosis of Ovarian cancer.  b. The skilled nurse visit note, dated 3/21/25, completed by Staff E, RN, identified the RN accessed the patient's port with sterile technique and flushed with four sterile normal saline flushes.    c. The skilled nurse visit note, dated 4/7/25, completed by Staff E, RN, identified the RN accessed and flushed the patient's port without difficulty.    d. Review of the electronic medical record lacked physician orders to flush the patient's port.    The hospice failed to obtain orders for the patient's port flushes.    5. Patient #13 had a start of care date of 8/5/22, a discharge date of 5/17/24 and received hospice services while residing in a nursing home.  Review of the clinical record revealed:   a. The initial POC, dated 8/5/22 to 11/2/22, included orders for nursing and social worker services.  The POC identified the patient had a diagnosis of Parkinson's disease.    b. The initial comprehensive assessment, dated 8/5/22, completed by Staff J, RN identified the patient utilized cold therapy for a pain intervention.    c. Review of the electronic medical record lacked physician orders for cold therapy.   The hospice failed to obtain orders for the patient's use of cold therapy as a pain intervention.    The above findings were reviewed with the Administrator and Clinical Manager.   3. Patient #7 had a hospice admission date of 3/21/25 and received hospice services while residing in a private residence.   Review of the clinical record revealed the following: a.  The Plans of Care POC, dated 3/21/25 to 6/18/25, included an orders for nursing visits 2 times per week. The POC identified the patient had a chronic obstructive pulmonary disease and had dependence on supplemental oxygen. The POC lacked orders for liter flow rate, route or frequency of oxygen. b. The comprehensive assessment at admission, dated 3/21/25, Staff B, RN included documentation the patient utilized continuous oxygen at 3 liters per minute per nasal cannula. c. Review of the electronic medical record lacked physician orders for the oxygen. The hospice failed to obtain orders for the patient's use of oxygen including rate of flow, route and frequency.   According to the hospice policy titled, Hospice Plan of Care and Interdisciplinary Team, dated 7/25/22, The plan of care must include all services necessary for the managemant of the terminal illness and related conditions, including drugs, treatment, medical supplies, and appliances necessary to meet the needs of the patient. During an interview on 6/4/25 at 2:30 PM the Clinical Manager stated staff expected to write orders for medications and treatments and they should roll over to the plan of care in the electronic record. 1. Patient #3 had a hospice admission date of 2/28/24 and received hospice services while residing in a private residence.   Review of the clinical record revealed the following: a.  The Plans of Care (POCs), dated 2/22/25 to 4/22/25 and 4/23/25 to 6/1/25, included an orders for nursing visits 1 time per week. The POCs identified the patient had a diagnosis of congestive heart failure and had dependence on supplemental oxygen. The POCs lacked orders for liter flow rate, route or frequency of oxygen. b. The skilled nurse note, dated 3/25/25, Staff J, Registered Nurse (RN) included documentation the patient utilized continuous oxygen at 3 liters per minute.  c. Review of the electronic medical record lacked physician orders for the oxygen. The hospice failed to obtain orders for the patient's use of oxygen including rate of flow, route and frequency. 2. Patient #8 had a hospice admission date of 2/27/25 and received hospice services while residing in a nursing home.   Review of the clinical record revealed the following: a.  The POC's, dated 2/27/25 to 5/27/25 and 5/28/25 to 8/25/25, included an orders for nursing visits 2 times per week. The POCs identified the patient had a diagnosis of acute respiratory failure with hypoxia and had dependence on supplemental oxygen. The POCs included for oxygen per physician orders but lacked liter flow rate, route or frequency.  b. The skilled nurse note, dated 4/22/25, Staff J, RN, included documentation the patient utilized continuous oxygen at 3 liters per minute.  c. Review of the electronic medical record lacked specific physician orders for the oxygen. The hospice failed to obtain orders for the patient's use of oxygen including rate of flow, route and frequency.

Based on hospice clinical record review and hospice policy review, the hospice failed to ensure the Plans of Care (POC) for 5 of 14 sampled patients (Patient #2, #3, #6, #8 and #10) identified all medical equipment and supplies necessary to meet identified patient needs.   Failure to include all needed items of medical equipment and supplies the patient used on the POC placed the patients at risk of unanticipated decline or injury and of needs not met.   Findings include: --- 3. Patient #2 had a start of care date of 12/19/24 and received hospice services while residing in an assisted living facility.  Review of the clinical record revealed:   a. The POC, dated 3/19/25 to 6/16/25, identified the patient had a diagnosis of Hypertensive heart disease and used the following medical equipment and supplies: hospital bed, shower chair, walker, cane, incontinence products, edema wear, grabber/reacher, handles of the stool, lift chair, medication planner, scale, side rails and continuous positive airway pressure (CPAP) machine.    b. During a home observation visit on 5/28/25 at 9:35 AM with Staff C, RN, they surveyor identified the patient utilized a pill cutter and a medical alert button.  During the same home visit, the patient stated both devices had been utilized for great than 3 months.    c.  The interdisciplinary group (IDG) meeting notes, dated 3/25/25, 4/8/25, 4/22/25, 5/6/25 and 5/22/25, failed to identify the medical equipment and supplies, pill cutter and medical alert button.    The hospice failed to include all medical equipment and supplies utilized by the patient.    4. Patient #6 had a start of care date of 2/24/25 and received hospice services while residing in a private residence.  Review of the clinical record revealed:   a. The POC, dated 2/24/25 to 5/24/25, identified the patient had a diagnosis of Ovarian cancer and used the following medical equipment and supplies: shower chair, walker and hospital bed.    b. The initial comprehensive visit note, completed by the Clinical Manager, identified the patient utilized incontinence products.   c. The IDG note, dated 2/25/25, failed to identify the medical supplies incontinence products.    The hospice failed to include all medical equipment and supplies utilized by the patient.      5. Patient #10 had a start of care date of 11/26/24 and received hospice services while residing in a nursing home.  Review of the clinical record revealed:   a. The POC, dated 2/24/25 to 5/24/25, identified the patient had a diagnosis of Unspecified protein calorie malnutrition and used the following medical equipment and supplies: bedside table, edema wear, walker, wheelchair, sit stand lift, neck pillow, handles over toilet, lift chair and hospital bed.      b. The social worker note, dated 4/16/25, completed by Staff D, identified the social worker delivered incontinence products for the patient.   c. The IDG note, dated 4/22/25, failed to identify the medical supplies incontinence products.    The hospice failed to include all medical equipment and supplies utilized by the patient.    The above findings were reviewed with the Administrator and Clinical Manager.     According to the hospice policy titled, Hospice Plan of Care and Interdisciplinary Team, dated 7/25/22, The plan of care must include all services necessary for the managemant of the terminal illness and related conditions, including drugs, treatment, medical supplies, and appliances necessary to meet the needs of the patient. 1.Patient #3 had a hospice admission date of 2/28/24 and received hospice services while residing in a private residence.   Review of the clinical record revealed the following:  a. The POC, dated 4/23/25 to 6/21/25, identified the patient had a diagnosis of congestive heart failure and used the following medical equipment and supplies: bedside table, commode, depends/incontinent pads, gait belt, glasses, med box/planner, pulse oximeter, stool riser, walker, lift chair, chair cushion and bedside commode. b. During a home observation visit on 5/27/25 at 10:30 AM, Staff J, RN, the surveyor observed the patient utilized a wheelchair, oxygen and supplies, urinal, reacher and gait belt. During the same home visit the patient stated the medical equipment and supplies utilized a long time greater than a year. The oxygen had been restarted in March of 2025. c. The interdisciplinary group meeting notes, dated 3/25/25, 4/8, 4/22/25, 5/6 and 5/20/25, failed to identify the medical equiment and supplies, wheelchair, oxygen and supplies, urinal, reacher and gait belt. The hospice failed to include all medical equipment and supplies utilized by the patient. 2. Patient #8 had a hospice admission date of 2/27/25 and received hospice services while residing in a nursing home.   Review of the clinical record revealed the following:  a. The POC's, dated 2/27/25 to 5/27/25 and 5/28/25 to 8/25/25, identified the patient had a diagnosis of acute respiratory failure with hypoxia and used the following medical equipment and supplies: bedside table, dentures, depends/incontinent pads, gait belt, handles for over stool, oxygen, hospital bed, lift chair, shower chair, side rails, walker, wheelchair and heel protectors. d. The social worker note, dated 3/31/25, identified the patient now using a Hoyer lift for transfers. c. The interdisciplinary group meeting notes, dated 4/8, 4/22/25, 5/6 and 5/20/25, failed to identify the medical equiment and supplies Hoyer lift. The hospice failed to include all medical equipment and supplies utilized by the patient.

Based on agency staff interviews, governing body chairperson interview, agency policy review, review of the governing body minutes and the Quality Assessment Process Improvement (QAPI) meeting minutes, the hospice failed to: --- 1.Show measurable improvement in indicators related to improved palliative outcomes and hospice services (L561),  2. Measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations (L562) 3. Use quality indicator data, including patient care, and other relevant data, in the design of its program (L563), 4. Use the data collected to do the following: (i) Monitor the effectiveness and safety of services and quality of care. (ii) Identify opportunities and priorities for improvement (L564),  5. The frequency and detail of the data collection must be approved by the hospice’s governing body (L565),  6. Identify a quality improvement focus (L566),  7. Consider incidence, prevalence, and severity of problems in those areas (L567),  8.  Affect palliative outcomes, patient safety, and quality of care (L568), 9. Track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice (L569), 10. Take actions aimed at performance improvement and, after implementing those actions, the hospice must measure its success and track performance to ensure that improvements are sustained (L570), 11. develop, implement and evaluate performance improvement projects (L571), 12. Develop a performance improvement program annually, based on the needs of the hospice's population and internal organizational needs, must reflect the scope, complexity, and past performance of the hospice's services and operations  (L572), 13.  Document what performance improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects (L573), 14. Ensure the  governing body is responsible that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually. (L574) and 15. Ensure the governing body is responsible that the hospice-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness (L575). The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure ongoing means that there is a continuous and periodic collection and assessment of data. Assessment of such data enables areas of potential problems to be identified and indicates additional data that should be collected and assessed in order to identify whether a problem exists to meet the needs of their hospice patients.

Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to develop a QAPI program which showed measurable improvement in indicators related to palliative outcomes and hospice services.  Failure to develop a QAPI program which showed measurable improvements in indicators related to  palliative outcomes and hospice services, placed the patients at risk for not having patient care problems and needs identified and addressed. --- Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency's performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs).  The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually.  The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise.  Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings.  The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation.  During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators.   During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue.   The agency failed to develop a QAPI program which showed measurable improvements in indicators related to palliative outcomes and hospice services. The above findings were reviewed with the Administrator and the Clinical Manager.

Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. Failure to collect and analyze data as part of a developed  QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. --- Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency's performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs).  The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually.  The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise.  Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings.  The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation.  During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators.  During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review.  During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings The agency failed to collect and analyze data for the year of 2024 and for January 2025 through April 2025 as part of a QAPI program.  The above findings were reviewed with the Administrator and the Clinical Manager.

Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to use quality indicator data, including patient care and other relevant data in in the design of the program.   Failure to use quality indicator data, patient care data, and other relevant data as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. --- Findings Include:According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency's performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs).  The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually.  The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise.  During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review.  During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators.  During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings. Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings.  The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation.   The agency failed to use quality indicator data, patient care data, and other relevant data as part of a developed QAPI program. The above findings were reviewed with the Administrator and the Clinical Manager.

Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to use quality indicator data, to monitor the effectiveness and safety of the services and quality care, and to identify opportunities and priorities for improvement.  Failure to use quality indicator data, to monitor effectiveness and safety of the services and quality care, and to identify and priorities for improvement, as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. --- According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency's performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs).  The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually.  The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise.  During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review.  During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators.  During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings.  The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation.  The agency failed to to use quality indicator data, to monitor effectiveness and safety of the services and quality care, and to identify and priorities for improvement, as part of a developed QAPI plan.  The above findings were reviewed with the Administrator and the Clinical Manager.

Based on review of the governing body minutes, staff interview and policy review, the hospice failed to ensure the governing body approved the frequency and detail of quality assessment and performance impovement data collection for 1 of 2 sampled years. Failure of the governing body to approve the specific areas and frequency of data collection for the quality assessment and performance improvement (QAPI) program placed the hospice at risk of not identifying and tracking appropriate details in order to make improvements or changes as needed to the hospice program. Findings include: --- According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency's performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs).  The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually.  The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise.   During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they are provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or approved during the governing body meetings.  Review of the governing body meeting minutes, dated 3/17/24, 9/23/24, 11/4/24, 12/9/24, 1/13/25, lacked documentation the board approved the frequency and details of data collection by the hospice QAPI program.  Review of the board of health reports, dated 1/2024, 3/2024, 5/2024, 8/2024, 12/2024 and 5/2024,  identified a total of 6 reports.  The board of health reports for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation.  The agency failed to ensure the board approved the frequency and details of data collection by the hospice QAPI program.  The above findings were reviewed with the Administrator and the Clinical Manager.

Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to conduct performance improvement activities that focus on high risk, high volume or problem prone areas.  Failure to conduct performance improvement activities  as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. --- According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency's performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs).  The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually.  The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise.  During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review.  During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators.  During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings.  The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation.  The agency failed to conduct performance improvement activities.  The above findings were reviewed with the Administrator and the clinical manager.

Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice performance improvement activities failed to consider incidence, prevalence and severity of problems in those areas as part of a developed QAPI program.  Failure to consider incidence, prevalence and severity of problems in those areas as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. --- Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency's performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs).  The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually.  The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise.  During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review.  During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators.  During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings.  The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation.  The agency failed to consider incidence, prevalence and severity of problems in those areas as part of a developed QAPI program  as part of a QAPI program.  The above findings were reviewed with the Administrator and the Clinical Manager

Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to use performance improvement activities to affect palliative outcomes, patient safety, and quality of care Failure to use performance improvement activities to affect palliative outcomes, patient safety, and quality of care as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. --- Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency's performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs).  The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually.  The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise.  During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review.  During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators.  During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings.  The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation.  The agency failed to use performance improvement activities to affect palliative outcomes, patient safety, and quality of care as part of a developed QAPI program,  The above findings were reviewed with the Administrator and the Clinical Manager.

Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to identify how adverse event is defined and failed to track adverse events, analyze the cause, and implement preventive actions.  Failure to to identify how adverse event is defined and failure to track adverse events, analyze the cause, and implement preventive actions as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. --- Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency's performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs).  The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually.  The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise.  During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review.  During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators.  During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings.  The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation.  The agency failed to define and track adverse events and to implement preventative actions as part of a QAPI program.  The above findings were reviewed with the Administrator and the Clinical Manager.

Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to show any action taken to improve and/or sustain performance improvement.  Failure to show action taken to improve and/or sustain performance improvement as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. --- Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency's performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs).  The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually.  The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise.  During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review.  During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators.  During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings.  The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation.  The agency failed to show any action taken to improve and/or sustain improvement as part of a QAPI program.  The above findings were reviewed with the Administrator and the Clinical Manager

Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to develop, implement and evaluate performance improvement.  Failure to develop, implement and evaluate performance improvement as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. --- Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency's performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs).  The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually.  The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise.  During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review.  During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators.  During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings.  The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation.  The agency failed to develop, implement and evaluate performance improvement as part of a QAPI program.  The above findings were reviewed with the Administrator and the Clinical Manager

Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to conduct annually the number and scope of distinct performance improvement projects, based on the needs of the hospice's population and internal organizational needs, must reflect the scope, complexity, and past performance of the hospice's services and operations. Failure to ensure implementation of performance improvement projects as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. --- Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency's performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs).  The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually.  The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise.  During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review.  During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators.  During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings.  The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation.  The agency failed to ensure implementation of performance improvement projects as part of a QAPI program.  The above findings were reviewed with the Administrator and the Clinical Manager.

Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the hospice failed to document what performance improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. Failure to ensure documentation of performance improvement projects as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. --- Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency's performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs).  The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually.  The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise.  During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review.  During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators.  During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings.  The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation.  The agency failed to ensure documentation of the performance improvement projects as part of a QAPI program.  The above findings were reviewed with the Administrator and the Clinical Manager.

Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the governing body failed to ensure that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually. Failure of the governing body to maintain an on-going performance improvement program as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. --- Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency's performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs).  The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually.  The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise.  During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review.  During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators.  During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings.  The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation.  The governing board failed to maintain an ongoing performance improvement plan as part of a QAPI program.  The above findings were reviewed with the Administrator and the Clinical Manager.

Based on agency and governing body interviews, review of the Quality Assessment Process Improvement (QAPI) meeting minutes, review of the governing body meeting minutes, and agency policy review, the governing body failed to ensure that the hospice-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. Failure of the governing body to ensure a hospice wide assessment  as part of a developed QAPI program, placed the patients at risk for not having patient care problems and needs identified and addressed. --- Findings include: According to the policy titled Quality Assurance and Performance Improvement (QAPI), dated 5/25, the agency will develop, implement, evaluate and maintain a QAPI program in accordance with federal guidelines. The intent of the program is to improve outcomes and track actions that address the agency's performance across the spectrum of care. The agency selects indicators that will be used based on identified adverse or negative patient outcomes or agency processes that it wishes to monitor and measure. Each indicator must be measurable through data to evaluate change in procedure, policy or interventions. The Clinical Manager will review the agency data, clinical data, and quality data. This information will be used to develop Performance Improvement Projects (PIPs).  The PIP will document the project, the reason for the project, and progress achieved on the project. The agency will have at least one PIP each calendar year for the program and be presented to the Board of health for approval annually.  The QAPI team will consist of the Clinical Manager, Administrator and a variety of field staff. The team will meet at least twice yearly, or more frequently if needed to address any issues that arise.  During an interview 6/3/25, at 9:30 AM, Staff B, Clinical Manager, stated the agency had some current QAPI projects including late documentation, medication discrepancies and drug regimen review in progress, but acknowledged no formal documentation with measurable data was available. The Clinical Manager stated agency had been meeting as a group for a while with all of the different departments within the Public Health including hospice and home health, and stated meeting minutes were taken by the Administrator, but that format did not continue. The Clinical Manager stated there was no documentation of data collection available for review.  During an interview 6/3/25 at 1:30 PM, Staff A, Administrator, stated there were meeting minutes available from the QAPI meetings held during the year 2024, but acknowledged the minutes contained no measurable data for quality measures/indicators.  During an interview on 6/3/25 at 10:40 AM, the Governing Body Representative stated if they were provided information to read over, they absolutely do. She was not able to identify specific QAPI or quality improvement items discussed or provided during the governing body meetings Review of the governing body meeting minutes from January 2024 through May of 2025, identified a total of 6 meetings.  The governing body meeting minutes for the months of January 2024, March 2024, May 2024, August 2024 and December 2024 included documentation that the QAPI program was on hold related to staffing issues. For the year of 2025 no report was available for the first quarter, the meeting notes from May 2025 identified quality projects for hospice of drug regimen review and documentation.  The governing body failed  to ensure a hospice-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness, as part of a QAPI program.   The above findings were reviewed with the Administrator and the Clinical Manager.

Based on clinical record review and policy reviews, the hospice failed to follow a bereavement plan of care to ensure the hospice provided bereavement counseling according to identified needs and risks of the bereaved for 1 of 2 sampled bereavement records (Patient #12).   Failure to provide bereavement counseling according to identified needs placed the bereaved at an increased risk for worsening or unresolved issues related to grief.   Findings include: --- According to the policy titled Bereavement Referral/Contact, dated 7/2024, the hospice Bereavement Coordinator is responsible for initiating the bereavement contact form.  An assessment of the bereaved will be made by a hospice Registered Nurse (RN), social worker or other Interdisciplinary Group (IDG) member shortly following the death of the hospice patient.  The bereavement contact form may be used at IDG meetings to help develop a plan of care for assisting the bereaved family members.   According to the hospice policy titled Hospice Plan of Care and Interdisciplinary Team dated 7/25/22, the hospice will ensure that care and services are provided in accordance with the plan of care and based on all assessments of the patinet and family needs. 1.Patient #12 had a start of care date of 10/31/24, a death date of 11/6/24 and received hospice services while residing in a nursing home.  Review of the clinical record revealed:  a. A bereavement assessment post death form, dated 12/29/24, was completed and identified the daughter of Patient #12 as the bereaved.   b. The post death form identified the planned date of next contact on 2/6/25. c. Review of the clinical record lacked further contact with the bereaved. The hospice failed to complete further contact according to the plan/interventions with the bereaved following the death of the patient. The above information was reviewed with the Administrator and Clinical Manager.

Based on staff interview, review of employee personnel files, and clinical record reviews, the hospice failed to ensure 1 of 3 hospice aides (Staff I) demonstrated competency in the performance of any skills which exceeded the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient's bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 3 of 3 sampled patients (Patients #2, #8 and #13) who required an extra skill be performed.    Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice skills increased the risk for patients to receive inadequate or inappropriate care.    Findings include: --- The Medicare Conditions of Participation direct the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan.    During an interview on 6/3/25 at 2:40 PM, the Clinical Manager identified the registered nurse who assigned the skill(s) beyond basic is required to competency test the hospice aide in the extra skill(s).    1.Patient #2 had a start of care date of 12/19/24 and received hospice services while residing in an assisted living facility.    a. The aide care plan included Registered Nurse (RN) instructions to the aide to check weight.  b. Review of the clinical record showed Staff I, Hospice Aide, provided aide services independently for Patient #2.    c. Staff I, Hospice Aide, had a hire date of 2/28/94.  Staff I's personnel file lacked documentation an RN had observed Staff I competently perform the task of checking weight.    2. Patient #8 had a start of care date of 2/27/25 and received hospice services while residing in a nursing home.    a. The aide care plan included RN instructions to the aide to apply lotion to arms, legs and trunk, assist with dressing/undressing, brush/style hair, offer oral cares and sponge bath.    b. The hospice aide note, completed by Staff I, dated 5/12/25, identified the hospice aide provided feeding assistance to the patient.    c. Review of the clinical record showed Staff I, Hospice Aide, provided services independently for Patient #8.    d. Staff I, Hospice Aide, had a hire date of 2/28/94.  Staff I's personnel file lacked documentation an RN had observed Staff I competently perform the task of feeding assistance.    3. Patient #13 had a start of care date of 8/5/22, a discharge date of 5/17/24 and received hospice services while residing in a nursing home.    a. The aide care plan included RN instructions to the aide to apply edema wear if not already on.  b. Review of the clinical record showed Staff I, Hospice Aide, provided aide services independently for Patient #13.    c. Staff I, Hospice Aide, had a hire date of 2/28/94.  Staff I's personnel file lacked documentation an RN had observed Staff I competently perform the task of applying edema wear.    The above findings were reviewed with the Administrator and Clinical Manager.

Based on agency staff interviews, Medical Director interview, contract review, and Interdisciplinary Group (IDG) meeting notes, the hospice failed to ensure the medical director or a physician designated by the hospice has responsibility for the medical director component of the hospice's patient care program.   Failure to ensure the medical director or physician designee has the responsibility for the medical director component of the hospice program, placed patients at risk of not receiving hospice services and/ or inadequate or inappropriate care. --- Findings Include: According to the contract for the hospice medical director, dated 7/1/16, the agency Medical Director shall attend the Hospice Interdisciplinary Group (IDG) meetings for the purpose of reviewing and planning patient care. The Medical Director shall be available by phone for consultation 24 hours per day, 7 days a week. The Medical Director shall arrange appropriate medical coverage if unavailable subject to prior written approval of the agency.    During an interview on 6/3/25, at 1:10 PM, the Medical Director stated in the event he is absent,  the Nurse Practitioner (NP) or the patients attending physician would be available for any hospice patient needs, and that the Nurse Practitioner could attend IDG meetings when needed.  During review of the IDG meeting notes between 3/1/24 through 3/31/25, the Medical Director was not in attendance for the dates of 9/24/24, 1/28/25, and 3/11/25. The hospice NP was in attendance for those IDG meetings in the Medical Directors absence.  During an interview on 6/3/25, at 3:15 PM, the Administrator stated the agency had a alternate Medical Director in place with a signed contract until that physician retired about a year ago. The Administrator acknowledged the agency did not have a designed physician contracted to fulfill the duties of the Medical Director was not available.  The hospice failed to ensure the medical director or physician designee has responsibility for the medical director component of the hospice's patient care program. The above findings were reviewed with the hospice Administrator and the Clinical Manager.

Based on hospice staff interview, clinical record review, and hospice policy review the hospice failed to ensure all required components of physician initial certification of the patient’s terminal illness (CTI) signed by both the Medical Director and personal care physician obtained for 3 of 14 sampled patients (Patient #7, #9 and #10).   Failure to obtain the physician’s certification of terminal illness puts the patient at risk of receiving hospice care inappropriately and/or without a funding source. Findings include: --- 3. Patient #10 had a start of care date of 11/26/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The Election of Hospice Medicare Benefit form signed by the patient/patient representative for services to being on 11/26/24 included the name of the patient's attending physician.    b. The CTI for benefit period 1, dated 11/26/24 to 2/23/25, included the medical director's signature.    c. The CTI for benefit period 1, dated 11/26/24 to 2/23/25, failed to include the patient's attending physician's signature.    The hospice failed to ensure the initial CTI included signatures from both the medical director and the patient's attending physician.    The above findings were reviewed with the Administrator and Clinical Manager.   2. Patient #7 had a hospice admission date of 3/21/25, and received hospice services while residing at home.  Clinical record revealed: a. The Election of Hospice Care form signed by the patient for services to begin on 3/21/25 included the name of the patient’s attending physician.  b. The CTI for benefit period 1, dated 03/21/25 to 6/18/25, included the medical director’s signature. c.  The CTI for benefit period 1, dated 03/21/25 to 6/18/25, failed to include the patient’s attending physician’s signature. The hospice failed to ensure the initial CTI completed by both the medical director and patient's attending physician.    During an interview with the Clinical Manager on 6/4/25 at 8:50 AM she stated the physician and Advanced Registered Nurse Practitioner (ARNP) were both documented on the patient's election form as their personal care provider. She further stated the agency did not send the initial CTI because the ARNP was listed first. 1. Patient #9 had a hospice admission date of 12/20/24 and received hospice services while residing in a nursing home.  Clinical record revealed: a. The Election of Hospice Care form signed by the patient for services to begin on 12/20/24 included the name of the patient’s attending physician.  b. The CTI for benefit period 1, dated 12/20/24 to 3/19/25, included the medical director’s signature. c.  The CTI for benefit period 1, dated 12/20/24 to 3/19/24, failed to include the patient’s attending physician’s signature. The hospice failed to ensure the intial CTI completed by both the medical director and patient's attending physician.

Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure all documentation was completed timely and appropriately authenticated in accordance with accepted standards of practice and agency standards for 9 of 14 sampled patients (Patients #1, #5, #6, #7, #8, #9, #10, #11 and #13).    Failure to ensure all documentation was completed, dated, and signed in a timely manner decreased the ability of hospice staff to communicate and coordinate patient care effectively and to provide safe, effective hospice services to its patients.    Findings include: --- 8. Patient # 8 had a start of care date of 2/27/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC's, dated 2/27/25 to 5/27/25 and 5/28/25 to 8/25/25, identified the patient had a diagnosis of acute respiratory failure with hypoxia and included orders for skilled nursing, social worker services and hospice aide services.   b. The skilled nurse visit note, dated 4/29/25, not completed and signed 4/18/25 by Staff F, RN, per agency policy.   c. The skilled nurse visit note, dated 4/29/25, completed and signed 5/13/25 by Staff E, RN, 14 days after the visit and 12 days late (per agency policy).   d. The skilled nurse visit note, dated 5/2/25, completed and signed 5/13/25 by Staff E, RN, 11 days after the visit and 9 days late (per agency policy).   e. The hospice aide visit notes, dated 4/14/25, 4/17/25 and 5/12/25, completed by Staff G, Hospice Aide, lacked a signature with title of individual completing the visit notes. The hospice failed to ensure timely completion of all documentation.   9. Patient # 9 had a start of care date of 12/20/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC's, dated 3/20/25 to 6/17/25, identified the patient had a diagnosis of acute respiratory failure with hypoxia and included orders for skilled nursing and social worker services.  b. The skilled nurse visit note, dated 5/3/25, not completed and signed 5/8/25 by Staff F, RN, 5 days after the visit and 3 days late (per agency policy).   c. The skilled nurse visit note, dated 5/9/25, completed and signed 5/15/25 by Staff F, RN, 6 days after the visit and 4 days late (per agency policy).   The hospice failed to ensure timely completion of all documentation.   The above findings reviewed with the Administrator and Clinical Manager. 4. Patient #1 had a start of care date of 12/9/24, and received hospice services while residing in a nursing home.   a. The POC, dated 3/9/25 to 6/6/25, identified the patient had a primary diagnosis of Alzheimer's disease and included orders for skilled nurse, hospice aide, and social worker. b. The chaplain visit notes, dated 3/11/25, 3/18/25, 3/25/25, 4/1/25, 4/8/25, 4/15/25, 4/22/25 and 4/29/25, completed by Staff K, Chaplain, lacked a signature with date, time and title of individual completing visit notes.    c. The hospice aide visit notes, dated 3/18/25, 3/28/25 and 4/18/25, completed by Staff G, Hospice Aide, lacked a signature with title of individual completing the visit notes.  The hospice failed to ensure appropriate authentication of all documentation.    5. Patient # 5 had a start of care date of 5/3/25, and received hospice services while residing in a nursing home.   a. The POC, dated 5/3/25 to 7/31/25, identified the patient had primary diagnosis of dysphagia (difficulty swallowing) as a result of a cerebral infarction (stroke) and included orders for skilled nurse, hospice aide, social worker and chaplain.  b. The hospice aide visit notes, dated 5/9/25, 5/13/25, 5/16/25, 5/20/25 and 5/23/25 completed by Staff G, Hospice Aide, lacked a signature with title of individual completing the visit notes.  The hospice failed to ensure appropriate authentication of all documentation.  6.  Patient #7 had a start of care date of 3/21/25, and received hospice services while residing at home.    a. The POC, dated 3/21/25 to 6/18/25, identified the patient had a primary diagnosis of chronic obstructive pulmonary disease and included orders for skilled nurse, social worker, hospice aide and chaplain.  b.The hospice aide visit notes, dated 3/24/25, 4/1/25, 4/14/25, 4/28/25, 5/1/25, 5/12/25, 5/15/25 and 5/17/25, completed by Staff G, Hospice Aide, lacked a signature with title of individual completing the visit notes. c.The chaplain visit notes, dated 3/25/25, 4/1/25, 4/8/25, 4/15/25, 4/22/25, and 4/29/25 completed by Staff K, Chaplain, lacked a signature with date, time and title of individual completing visit notes. The hospice failed to ensure appropriate authentication of all documentation.   7. Patient #11 had a start of care date of 11/1/24, a death date of 11/26/24 and received hospice services while residing in a private home.    a. The POCs, dated 11/1/24 to 1/29/25,  identified the patient had a primary diagnosis of heart failure and included orders for skilled nurse, hospice aide, social worker, chaplain and volunteer services.    b. The chaplain visit notes, dated, 11/5/25, 11/12/25, 11/19/25 and 11/26/25 completed by Staff K, Chaplain, lacked a signature with full name and title of individual completing visit notes.   The hospice failed to ensure appropriate authentication of all documentation.      According to the agency policy titled Documentation, dated 7/19/21, routine visit notes for all disciplines will be completed as part of the visit.  If it is impossible to complete the documentation immediately following the visit, it may be completed in the office, preferably on the same day as the visit but within two business days at most.   During an interview on 6/3/25 at 9:25 AM, the Clinical Manager identified agency staff are to complete routine visit documentation within 2 business days of the visit.  1.Patient # 6 had a start of care date of 2/24/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The Plan of Care (POC), dated 2/24/25 to 5/24/25, identified the patient had a diagnosis of Ovarian Cancer and included orders for skilled nurse and social worker services.    b. The skilled nurse visit note, dated 4/4/25, completed and signed 4/18/25 by Staff F, Registered Nurse (RN), 14 days after the visit and 10 days late (per agency policy).    c. The skilled nurse visit note, dated 4/21/25, completed and signed 4/24/25 by Staff F, RN, 3 days after the visit and 1 day late (per agency policy).    The hospice failed to ensure timely completion of all documentation.    2. Patient #10 had a start of care date of 11/26/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 2/24/25 to 5/24/25, identified the patient had a primary diagnosis of Unspecified protein calorie malnutrition and included orders for skilled nurse, hospice aide and social worker services.    b. The hospice aide visit notes, dated 5/5/25, 5/8/25, 5/12/25, 5/15/25, 5/19/25 and 5/22/25, completed by Staff G, Hospice Aide, lacked a signature with title of individual completing the visit notes.  The hospice failed to ensure appropriate authentication of all documentation.    3. Patient #13 had a start of care date of 8/5/22, a discharge date of 5/17/24 and received hospice services while residing in a nursing home.    a. The POCs, dated 1/27/24 to 3/26/24 and 3/27/24 to 5/25/24 identified the patient had a primary diagnosis of Parkinson's disease and included orders for skilled nurse, hospice aide, social worker, chaplain and volunteer services.    b. The skilled nurse visit notes, dated 3/18/24, 3/25/24, 4/2/24, 4/5/24, 4/12/24 and 4/16/24, completed by Staff J, RN, lacked a signature with full name and title of clinician completing the visit notes.  c. The chaplain visit notes, dated 3/19/24, 3/26/24, 4/2/24, 4/9/24, 4/17/24, 4/23/24, 4/30/24, 5/7/24, 5/14/24 and 5/17/24, completed by Staff K, Chaplain, lacked a signature with full name and title of individual completing visit notes.    d. The hospice aide visit notes, dated 3/22/24, 3/26/24, 3/29/24, 4/2/24, 4/5/24, 4/10/24 and 4/16/24, completed by Staff G, Hospice Aide, lacked a signature with title of individual completing the visit notes.  The hospice failed to ensure appropriate authentication of all documentation.

Based on hospice staff interview and clinical record reviews the hospice failed to ensure the hospice staff sent a copy of the patient's discharge summary to the attending physician for 2 of 2 sampled, live discharged patients (Patients #13 and #14).    Failure to ensure the hospice staff included the attending physician in the process of discharge placed the patients at risk for not receiving ongoing medical care and services to meet the needs of the patient.    Findings include: --- 2. Patient #14 had a start of care date of 12/12/24, and revoked services on 12/17/24, and received hospice services while residing in a private residence.   a. The POC, dated 12/12/24 to 3/11/25, identified the patient had a primary diagnosis of malignant neoplasm of the exocervix.  The POC included orders for skilled nursing and social worker services.   b. The discharge summary, dated 12/18/24, included a summary of hospice services and a list of the patient's current medications. c. Clinical record review lacked documentation the discharge summary was forwarded to the patient's attending physician.   The hospice failed to forward a copy of the discharge summary to the patient's personal care provider. The above information was reviewed with the Administrator and clinical manager. During an interview on 6/3/25 at 2:30 PM, the Clinical Manager identified she could not see in the electronic medical record if the discharge summary was faxed to the primary care physician.   1. Patient #13 had a start of care date of 8/5/22, a discharge date of 5/17/24 (no longer terminally ill) and received hospice services while residing in a nursing home.    a. The Plan of Care (POC), dated 3/27/24 to 5/25/24, identified the patient had a primary diagnosis of Parkinson's disease.  The POC included orders for skilled nursing services.    b. The discharge summary, dated 5/17/24, included a summary of hospice services and a list of the patient's current medications.    c. Clinical record review lacked documentation the discharge summary was forwarded to the patient's attending physician.

Based on review of contracts with facilities (hospitals) for short term respite services and interview with hospice staff, the hospice failed to ensure contractual agreements with 2 of 2 sampled facilities (Hospital A and B) providing short term respite level of care services to hospice patients included specifications of the requirement that each patient must receive all nursing services as prescribed and must be kept comfortable, clean, well-groomed and protected from accident, injury and infection.    Failure to include these specifications in the contractual agreements placed patients at risk of not having all of their needs adequately met in accordance with the patient's plan of care.    Findings include: --- During an interview on 6/3/25 at 2:05 PM, the Administrator identified the agency utilizes Hospital A and B for respite services and noted the contractual agreements needed to be updated.    1.The hospice agency had a contractual agreement with Hospital A, dated 10/4/21.  The contractual agreement failed to specify each patient receiving respite care must receive all nursing services as prescribed and must be kept comfortable, clean, well-groomed and protected from accident, injury and infection.    2.The hospice agency had a contractual agreement with Hospital B, dated 11/8/21.  The contractual agreement failed to specify each patient receiving respite care must receive all nursing services as prescribed and must be kept comfortable, clean, well-groomed and protected from accident, injury and infection.    The above findings were reviewed with the Administrator and Clinical Manager.

Based on review of the written agreements between the hospice and inpatient facilities (hospitals), the hospice failed to ensure the written agreement identified the hospice's responsibility to maintain a description of the training and documentation of the names of those giving the training for 2 of 2 sampled written agreements (Hospital A and B).    Failure to ensure the written agreements with hospitals specified the hospice's responsibility to ensure hospital staff caring for hospice patients received training and the hospice maintained appropriate documentation of the training placed hospice patients at risk for receiving inpatient care in conflict with the hospice philosophy.    Findings include: --- 1.The hospice agency had a contractual agreement with Hospital A, dated 10/4/21.  The contractual agreement failed to specify the agency responsibility to include a description of the training provided and documentation of the training facilitators.    2.The hospice agency had a contractual agreement with Hospital B, dated 11/8/21.  The contractual agreement failed to specify the agency responsibility to include a description of the training provided and documentation of the training facilitators.    The above findings were reviewed with the Administrator and Clinical Manager.

Based on review of criminal background checks, child abuse and dependent adult abuse record checks, the agency allowed 1 of 7 sampled employees hired or contracted after 5/25/2022 (the date of the last survey conducted by the Department of Inspections and Appeals) without completing the required evaluation by the Department of Human Services (DHS) with employees who had positive criminal background checks within 30 days prior to hire (Staff L, Volunteer).   The systemic practice resulted in the failure to ensure the organizational framework of the agency promoted and supported the adherence to state regulations and coordination of safe and effective delivery of care to the agency's 11 patients.   481 IAC (Iowa Administrative Code) rule 50.9 requires Hospices complete a criminal background history check, a dependent adult abuse background history check and a child abuse background history check on each prospective employee who will have direct patient contact.  The hospice must complete these record checks prior to the date of hire of a prospective employee.  If a positive criminal history, dependent adult abuse history or child abuse history is identified, the agency must seek approval to hire from the Department of Human Services. 481 IAC rule 50.9(4) limits the validity of criminal history, dependent adult abuse history, and child abuse history record checks to a period of 30 days from the date the results of the background checks were received by the agency. Should a potential employee have a delayed hire date exceeding the allowed 30 days, the agency is required to run the background checks again to search for changes that may have occurred since the last background checks. Failure to complete the required backgrounds checks according to the State of Iowa requirements placed agency patients at risk for potential harm. Findings include: --- According to the undated policy titled Policy of Checking the Criminal & Abuse Record Results, upon the employee accepting a position with the hospice, an internet criminal and abuse check will be completed after appropriate signatures are obtained. Background checs will be kept in the employee file and dates documented on the orientation checklist. During an interview on 6/3/25 at 10:25 AM the Administrator stated she had not been aware of the requirement for the positive criminal background check to be evaluated by the Department of Human Services. Staff L, Volunteer, had a hire date of 2/15/24.  Staff L's personnel file included an initial criminal history check, dependent adult abuse history check and child abuse history check, completed on 2/4/24.  The history background check, finalized 2/7/24, identified evidence of past criminal history, but found no dependent adult abuse or child abuse history.    Staff L's personnel file lacked documentation of DHS evaluation for approval to work with patients at the hospice.  The hospice failed to complete DHS evaluation for approval for Staff L, volunteer.  The findings were reviewed with the Administrator and Clinical Manager.

Based on review of the emergency preparedness plan and related policies and staff interview, the hospice failed to ensure the development of a policy and procedure for a medical documentation system that preserves patient information and confidentiality of patient information. Failure to have procedures in place for preservation of patient information and confidentiality of patient information place patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: Review of the review of the emergency preparedness plan and related policies revealed the hospice did not have a written policy and procedure for a system of medical documentation that preserves patient information and protects confidentiality of patient information. During an interview on 5/25/22 at 11:30 AM, the Administrator reported she was unable to find a policy for the above concern. The hospice provided no further information prior to the end of the survey.

Based on review of the Emergency Preparedness (EP) plan documentation and staff interview, the hospice failed to ensure the emergency preparedness plan included development of arrangements of other facilities and providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services for hospice patients. Failure to ensure the EP plan included the development of arrangements of other facilities and providers to receive patients in the event of limitations or cessation of operations could potentially lead to hospice staff providing unsafe and ineffective care during an emergency or disaster which could cause poor patient outcomes or death in an actual emergency or disaster situation. Findings include: Review of the hospices' emergency preparedness (EP) plan lacked any arrangements of facilities or providers to receive patients in the event of limitations or cessation of operations. On 5/25/22 at 11:30 AM, interview with the Hospice Administrator reported the previous Administrator was in charge of the EP plan and would check with her to see if any agreements existed. On 5/25/22 at 1:15 PM, the Hospice Administrator reported spoke with previous Administrator and no agreements were in place as the previous Administrator felt in an emergency all other providers would also be facing challenges and would contact the regional Emergency Operations Center for guidance. Hospice staff provided no additional information prior to the end of the survey.

Based on staff interview, hospice Emergency Plan review and review of training documentation, the hospice failed to ensure participation in 2 emergency preparedness exercises prior to 11/15/17 and failed to document the analysis for one of two drills/ actual events in 2018. Failure to conduct or participate in emergency preparedness exercises placed hospice patients at risk for not having trained and prepared staff to assist them in the event of an emergency. Findings include: On 5/25/22 at 7:45 AM, the Hospice Clinical Director provided the surveyor with the hospice's Emergency Preparedness Binder. The Emergency Plan stated the agency would focus on an agency specific potential emergency situation yearly, alternating with a full scale exercise every other year, and opposite years being another type of exercise, such as a tabletop drill or other exercise of choice. The hospice will coordinate with other agencies in the community and providers to participate in a full scale emergency drill at least every other year. The binder had evidence of an actual event dated, 2/16/21 which summarized an emergency preparedness activity and notification of staff, patients, and law enforcement and EMS along with documentation of the event. The event did not include an analysis of the response or an after action report to include how the agency updated it's emergency program based on this analysis. The binder had evidence of an actual event dated, 12/15/21 which summarized a potential for severe thunderstorms and high winds and notification of staff and patients, along with documentation of the event. The event did not include an analysis of the response or an after action report to include how the agency updated it's emergency program based on this analysis. The above findings were discussed with the Hospice Administrator and Clinical Manager. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice staff completed medication reviews which included all the required components of a drug regimen review and was completed at least every 15 days with the update to the comprehensive assessment for 7 of 11 sampled patients (Patients #2, #3, #4, #6, #7, #8 and #10). Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs completed a drug regimen review (DRR) based on a review of all of the patient's medications and included all the required components of the DRR with each update to the comprehensive assessment increased the risk of the patient developing an undetected side effect or adverse reaction in relation to medication therapy. Findings include: According to a hospice policy titled Drug Regimen Review, dated 5/16/22, drug regimen review, to include effective medication therapy, medication side effects, actual or potential drug interactions, duplicate and/or unnecessary medications, and identification of medications associated with laboratory testing will be completed by the registered nurse (RN) for all hospice clients with every comprehensive assessment or anytime significant medication issues are identified throughout the care episode. During an interview on 5/23/22 at 10:45 AM, the Clinical Manager reported the DRR is completed on admission, with every comprehensive assessment and IDG meeting, documented on IDG meeting documentation and service note. 1. Patient #6 had a hospice admission date of 1/13/22 and received hospice services while residing in a private home. Clinical record review revealed: a. The Plans of Care (POC), dated 1/13/22 to 4/12/22 and 4/13/22 to 7/11/22, included physician orders for medications. b. The DRR, dated 3/22/22, was signed and dated as completed on 3/28/22, 6 days after the IDG meeting date of 3/22/22. c. The DRR, dated 4/5/22, was signed and dated as completed on 4/8/22, 3 days after the IDG meeting date of 4/5/22. d. The DRR, dated 4/11/22, was signed and dated as completed on 4/22/22, 6 days after the recertification comprehensive assessment, dated 4/5/22. e. The DRR, dated 4/19/22, was signed and dated as completed on 4/29/22, 10 days after the IDG meeting date of 4/19/22. f. The DRR, dated 5/17/22, was signed and dated as completed on 5/22/22, 5 days after the IDG meeting date of 5/17/22. The DRRs failed to be completed on the date of the IDG meetings and recertification comprehensive assessment. 2. Patient #2 had a hospice admission date of 9/3/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. POCs, dated 3/2/22 to 4/30/22 and 5/1/22 to 6/29/22, included physician orders for the patient's medication. b. The IDG meeting notes, dated 3/22/22, 4/5, 4/19/22 and 5/17/22, failed to include documentation of a DRR. c. The DRR completed by the RN, dated 3/22/22, failed to include a signature and date of completion. d. The DRR completed by the RN, dated 4/5/22, signed and dated 4/7/22, 2 days after the IDG. e. The DRR completed by the RN, dated 4/19/22, signed and dated 4/19/22, 10 days after the IDG. f. The DRR completed by the RN, dated 5/17/22, signed and dated 5/22/22, 5 days after the IDG. The DRRs failed to be completed on the date of the IDG meetings and recertification comprehensive assessment. 3. Patient #7 had a hospice admission date of 2/17/22 and revocation date of 3/5/22 and received hospice services while residing in a private home. Review of the clinical record revealed the following: a. POC dated 2/17/22 to 5/17/22, included physician orders for the patient's medication. b. The comprehensive assessment on admission, dated 2/17/22, failed to include documentation of a DRR. c. The IDG meeting notes, dated 2/22/22, failed to include documentation of a DRR. d. The DRR completed by the RN, dated 2/22/22, signed and dated 5/27/22, 5 days after the IDG. e. The skilled nurse visit note, dated 3/5/22, failed to include documentation of a DRR. The DRRs failed to be completed on the date of the IDG meetings and recertification comprehensive assessment. 4. Patient #10 had a hospice admission date of 11/29/21 and date of death of 3/1/22 received hospice services while residing in a private home. Review of the clinical record revealed the following: a. POCs, dated 11/29/21 to 2/26/22 and 2/27/22 to 5/27/22, included physician orders for the patient's medication. b. The IDG meeting notes, dated 1/11, 1/25/22, 2/8 and 2/22/22, failed to include documentation of a DRR. c. The DRR completed by the RN, dated 1/11/22, signed and dated 1/19/22, 8 days after the IDG. d. The DRR completed by the RN, dated 1/25/22, signed and dated 1/31/22, 6 days after the IDG. e. The DRR completed by the RN, dated 2/8/22, signed and dated 2/9/22, 1 days after the IDG. f. The DRR completed by the RN, dated 2/22/22, signed and dated 2/27/22, 5 days after the IDG. The DRRs failed to be completed on the date of the IDG meetings and recertification comprehensive assessment. 5. Patient #3 had a hospice admission date of 8/11/21 and received hospice services while residing in an assisted living facility. Clinical record review revealed the following: a. The Plans of Care (POC), dated 8/11/21 to 11/8/21, 11/9/21 to 2/6/22, and 2/7/22 to 4/7/22, included orders for ferrous sulfate 325 milligrams (mg) daily and multiple vitamin with minerals 1 tablet daily (both used as supplements). b. The initial DRR, dated 8/11/21, and IDG updates to the POC, dated identified the patient was taking medications associated with laboratory monitoring. The review identified the patient was taking duplicate medications for bowels and pain. The DRR lacked identification of the duplicate medications the patient was taking for supplements. c. The DRR associated with the IDG update to the POC, dated 9/7/21, was not completed until 9/14/21, 7 days after the IDG update occurred and lacked identification of the duplicate medications the patient was taking for supplements. d. The DRR associated with the IDG update to the POC, dated 9/21/21, was not completed until 9/22/21, 1 day after the IDG update occurred and lacked identification of the duplicate medications the patient was taking for supplements. e. The DRR associated with the IDG update to the POC, dated 10/5/21, was not completed until 10/6/21, 1 day after the IDG update occurred and lacked identification of the duplicate medications the patient was taking for supplements. f. The DRR associated with the IDG update to the POC, dated 10/19/21 was not completed until 10/20/21, 1 day after the IDG update occurred and lacked identification of the duplicate medications the patient was taking for supplements. g. The DRR associated with the IDG update to the POC, dated 11/2/21, was not completed until 11/3/21, 7 days after the IDG update occurred and lacked identification of the duplicate medications the patient was taking for supplements. h. The DRR associated with the IDG update to the POC, dated 11/16/21, was not completed until 11/19/21, 3 days after the IDG update occurred and lacked identification of the duplicate medications the patient was taking for supplements. i. The DRR associated with the IDG update to the POC, dated 11/30/21, was not completed until 12/7/21, 7 days after the IDG update occurred . j. The DRR associated with the IDG update to the POC, dated 12/14/21, was not completed until 12/15/21, 1 day after the IDG update occurred and lacked identification of the duplicate medications the patient was taking for supplements. k. The DRR associated with the IDG update to the POC, dated 12/28/21 was not completed until 12/29/21, 1 day after the IDG update occurred and lacked identification of the duplicate medications the patient was taking for supplements. l. The DRR associated with the IDG update to the POC, dated 1/11/22, was not completed until 1/19/22, 8 days after the IDG update occurred and lacked identification of the duplicate medications the patient was taking for supplements. m. The DRR associated with the IDG update to the POC, dated 1/25/22, was not completed until 1/31/22, 6 days after the IDG update occurred and lacked identification of the duplicate medications the patient was taking for supplements. n. The DRR associated with the IDG update to the POC, dated 2/22/22, was not completed until 2/27/22, 5 days after the IDG update occurred. o. The DRR associated with the IDG update to the POC, dated 3/22/22, was not completed until 3/28/22, 6 days after the IDG update occurred. p. The DRR associated with the IDG update to the POC, dated 4/5/22, was not completed until 4/8/22, 3 days after the IDG update occurred. q. The DRR associated with the IDG update to the POC, dated 4/19/22, was not completed until 4/29/22, 10 days after the IDG update occurred. r. The DRR associated with the IDG update to the POC, dated 5/17/22, was not completed until 5/18/22, 1 day after the IDG update occurred. The hospice lacked documentation of a DRR identifying all required components and completion at the time the IDG updates to the POC occurred. 6. Patient #4 had a hospice admission date of 4/7/21 and received hospice services while residing in a private home residence. Clinical record review revealed the following: a. The Plans of Care (POCs), dated 4/7/21 to 7/5/21, 12/31/21 to 1/31/22, and 2/1/22 to 4/1/22, included orders for levothyroxine 88 micrograms (mcg) daily. This medication is often associated with laboratory monitoring of the patient's thyroid levels. b. The initial DRR, dated 4/7/21, documented the patient was taking medications associated with laboratory monitoring, however, did not identify the levothyroxine the medication associated with laboratory monitoring. c. The DRR associated with the IDG update to the POC, dated 4/20/21, was not completed until 10/6/21, 1 day after the IDG update occurred and lacked identification of the duplicate medications the patient was taking for supplements. d. The DRR associated with the IDG update to the POC, dated 4/5/22, was not completed until 4/7/22, 2 days after the IDG update occurred. e. The DRR associated with the IDG update to the POC, dated 4/19/22, was not completed until 4/29/22, 10 days after the IDG update occurred. The hospice lacked documentation of a DRR identifying all required components and completion at the time the IDG updates to the POC occurred. 7. Patient #8 had a hospice admission date of 3/2/22, received hospice services while residing in a nursing home, and died at the facility on 5/21/22. Clinical record review revealed the following: a. The Plan of Care (POC), dated 3/2/22 to 5/30/22, included orders for diltiazem 240 mg daily and metoprolol 50 mg daily, both medications prescribed for blood pressure management. b. The initial DRR, dated 3/2/22, documented the patient was taking duplicate medications for pain and bowel medications, however, did not identify the patient was taking duplicate blood pressure medications. c. The DRR associated with the IDG update to the POC, dated 3/8/22, documented the patient was taking duplicate medications for pain and bowel medications, however, did not identify the patient was taking duplicate blood pressure medications. d. The DRR associated with the IDG update to the POC, dated 3/22/22, was not completed until 3/28/22, 6 days after the IDG update meeting occurred and documented the patient was taking duplicate medications for pain and bowel medications, however, did not identify the patient was taking duplicate blood pressure medications. e. The DRR associated with the IDG update to the POC, dated 4/5/22, was not completed until 4/8/22, 3 days after the IDG update meeting occurred and documented the patient was taking duplicate medications for pain and bowel medications, however, did not identify the patient was taking duplicate blood pressure medications. f. The DRR associated with the IDG update to the POC, dated 4/19/22, was not completed until 4/29/22, 10 days after the IDG update meeting occurred and documented the patient was taking duplicate medications for pain and bowel medications, however, did not identify the patient was taking duplicate blood pressure medications. g. The DRR associated with the IDG update to the POC, dated 5/3/22, documented the patient was taking duplicate medications for pain and bowel medications, however, did not identify the patient was taking duplicate blood pressure medications. h. The DRR associated with the IDG update to the POC, dated 5/17/22, was not completed until 5/22/22, 5 days after the IDG update meeting occurred and documented the patient was taking duplicate medications for pain and bowel medications, however, did not identify the patient was taking duplicate blood pressure medications. The hospice lacked documentation of a DRR identifying all required components and completion at the time the IDG updates to the POC occurred. The above findings were reviewed with the Administrator, Clinical Manager, Social Worker and Staff C, RN and hospice staff provided no further evidence prior to the end of the survey.

Based on clinical record review and hospice policy review, the hospice failed to ensure the hospice Interdisciplinary Group (IDG) developed patient plans of care which specified the scope and frequency for all services required by and provided to patients for 2 of 11 sampled patients (Patients #2 and #4) Failure to identify a scope and frequencies for all ordered services increased the potential for hospice services to not adequately meet the needs of hospice patients and families. Findings include: According to the hospice policy titled Hospice Plan of Care, dated October 2005, all needed services will be documented on the plan of care, to include frequency and scope of services provided. 1. Patient #2 had a hospice admission date of 9/3/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The Plans of Care (POC), dated 3/2/22 to 4/30/22 and 5/1/21 to 6/29/21, included orders for skilled nursing, social worker and hospice aide services. b. The IDG notes, dated 3/22/22, 4/5, 4/19/22, 5/3 and 5/17/22, included volunteer services ordered prn (as needed). The volunteer services order lacked a frequency for the services. 2. Patient #4 had a hospice admission date of 4/7/21 and received hospice services while residing in a private home residence. The POC, dated 4/2/22 to 5/31/22, included orders for twice per week skilled nurse visits and weekly social worker visits. a. The IDG meeting to update the POC, dated 4/5/22, lacked any new orders for services. b. The volunteer visit note, dated 4/9/22, documented a volunteer visit occurred. c. The IDG meeting to update the POC, dated 4/19/22, documented the patient would not have a volunteer visit the week of 4/11/22, due to the Easter holiday per family request and the volunteer would visit on 4/23/22 per family request. The clinical record lacked IDG orders for the completed 4/9/22 volunteer visit. d. The IDG meeting to updates the POC, dated 5/3/22 and 5/17/22, documented the patient continued to have volunteer visits. The clinical record lacked IDG orders for the frequency of volunteer visits the patient was receiving. The above findings were reviewed with the Hospice Administrator and Clinical Manager. Hospice staff provided no additional information prior to the end of the survey.

Based on clinical record review, medication/treatment administration record and hospice policy review, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments and/or a complete order for all medications and treatments to meet the needs of the patient for 1 of 11 sampled patients (Patient #7). Failure to ensure the plan of care included physician orders for all necessary medications and and complete orders for medications placed patients at risk to receive inappropriate treatment of symptoms. Findings include: According to the hospice policy titled Hospice Plan of Care, dated October 2005, The admitting nurse will receive orders form the client's primary physician on admission to hospice, in order to establish the plan of care. The admitting or primary nurse will coordinate services between disciplines which are needed to meet client and caregiver needs. These disciplines may include, but are not limited to, physician, nursing, health care aide, homemaker, social worker, counselor, bereavement services, chaplain or other spiritual provider, physical therapy, occupational therapy, speech therapy, volunteer services, durable medical equipment provider and other services as deemed necessary by the team. Patient #7 had a hospice admission date of 2/17/22 and revocation date of 2/17/22 and received hospice services while residing in a private home residence. a. The Plan of Care (POC), dated 2/17/22 to 5/17/22, included orders for current medications. The POC included orders to change Foley catheter 2 times monthly and as needed and irrigate Foley catheter with 30 cc (cubic centimeters) normal saline as needed. b. The Interdisciplinary Group (IDG) meeting notes, dated 2/22/22, lacked specific orders for catheter and size or catheter balloon size including orders to inflate the catheter balloon. The hospice failed to ensure the patient's specific catheter orders on the POC. The Administrator, Clinical Manager, Social Worker and Staff C, RN received the above findings and hospice staff provided no further evidence prior to the end of the survey.

Based on clinical record review and hospice policy review, the hospice failed to ensure the hospice Interdisciplinary Team revised the patient's plan of care to include the patient's progress towards outcomes and goals specified in the plan of care for 2 of 11 sampled patients (Patients #2 and #10) requiring an updated plan of care. Failure of the hospice to ensure the Interdisciplinary Group (IDG) revised the patient's plan of care based on the updated comprehensive assessment and include patients' progress towards outcomes and goals placed patients at risk to not receive care and services based on their current assessed needs. Findings include: According to the hospice policy titled Hospice Plan of Care, dated October 2005, the IDT (Interdisciplinary Team) will meet regularly, no less than every 14 days, to review the plan of care, determine if client/caregiver needs are being meet and update the plan as necessary. In order to meet client/caregiver needs, tem members may need to coordinate/update plans more frequently than every 14 days. Symptom control, pain management, and physical and psychosocial needs must be assess on an ongoing basis by the appropriate provider. 1. Patient #2 had a hospice admission date of 9/3/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/28/22 to 7/26/22, included IDG identified orders, interventions and goals for skilled nursing, social worker, hospice aide and volunteer services. b. The IDG meeting, dated 3/22, 4/5, 4/19, 5/3 and 5/17/22, lacked documentation of progress towards interventions and the goal related to hospice aide, social worker and volunteer services. The hospice failed to include updates to the POC for hospice aide, social worker and volunteer services. 2. Patient #10 had a hospice admission date of 1129/21 and date of death of 3/1/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POCs, dated 11/29/21 to 2/26/22 and 2/27/22 to 5/27/22, included IDG identified orders, interventions and goals for skilled nursing, social worker and hospice aide services. b. The IDG meeting, dated 1/11, 1/25/22, 2/8/22 and 2/22/22, lacked documentation of progress towards interventions and the goal related to hospice aide and social worker services. The hospice failed to include updates to the POC for hospice aide and social worker services. The Administrator, Clinical Manager, Social Worker and Staff C, RN received the above findings and hospice staff provided no further evidence prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the coordination and collaboration among Interdisciplinary Group (IDG) members occurred to ensure hospice staff provided treatment and services to the patients according to team decisions. The survey identified this concern with 2 of 2 sampled patients with wounds (Patients #1 and #11). Failure of the hospice IDG members to communicate and collaborate with each other to update the plan of care increased the risk that patients did not receive services and treatments to meet the needs of the patients. Findings include: Review of the hospice's policy, titled Wound Care Assessment and Documentation, Home Health and Hospice, dated 3/15/21, wound assessment and documentation by the registered nurse will include wound measurements (height by length by depth). Wounds will be assessed and measured no less than one time a week, unless otherwise ordered by the provider. In cases of client/caregiver performing wound care, the registered nurse will fully assess/measure the wound/s no less than one time a week to evaluate healing progress. During an interview on 5/23/22 at 10:45 AM, the Clinical Manager reported wounds are measured weekly and should include length, width and depth. 1. Patient #11 had a hospice admission date of 3/25/22, a death date of 4/6/22, and received routine home care hospice services while residing at a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 3/25/22 to 6/22/22, identified the patient had stage 2 pressure ulcer of left buttock and stage 2 pressure ulcer of right buttock. b. Skilled nursing visit notes, dated 3/28/22 and 3/31/22, included documentation of red or open areas, dressings intact on coccyx, nurse from nursing home will measure wound when dressing removed on bath day and red or open areas, client has open sores on left and right buttocks, dressing intact unable to view; but lacked wound measurements. c. Skilled nursing visit notes, dated 4/5/22 and 4/6/22, included documentation of red or open areas, open area to coccyx and red or open areas; but lacked wound measurements. The clinical record lacked wound measurements for the weeks of 3/28/22 and 4/4/22. 2. Patient #1 had a hospice admission date of 5/13/22 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The plan of care (POC), dated 5/13/22 to 8/10/22, identified the patient had a stage 4 sacral wound. The POC included physician order for wound care to clean the wound with wound cleaner then insert iodiform into wound, place meplix transfer over top of hole then place island dressing over the entire wound. Dressing changes will be performed by nursing home staff daily. Nursing home staff will measure wound weekly during dressing change and report changes to hospice nurse. b. Skilled nurse visit note, dated 5/16/22 identified the patient had a stage 4 wound with measurements of 0.2 cm by 0.2 cm and no depth of the wound documented. c. Skilled nurse visit note, dated 5/19/22 identified the patient had an unstageable wound with measurements of 0.2 cm by 0.2 cm and no depth of the wound documented. The clinical record lacked documentation of complete wound measurements including depth, the week of 5/15/22 to 521/22. The Administrator, Clinical Manager, Social Worker and Staff C, RN received the above findings and hospice staff provided no further evidence prior to the end of the survey.

Based on hospice policy review, clinical record review, and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group (IDG) maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the Plan of Care for 2 of 11 sampled patients (Patients #6 and #10). Failure of the hospice IDG members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. Findings include: Review of the hospice policy, titled Plan of Care (POC), dated 10/2005, identified all needed services will be documented on the plan of care, to include frequency and scope of services provided. Interdisciplinary Group (IDG) will meet regularly, no less than every 14 days, to review the plan of care, determine if client/caregiver needs are being met, and update the plan as necessary. 1. Patient #6 had a hospice admission date of 1/13/22 and received hospice services while residing in a private home. Clinical record review revealed: a. The POC, dated 4/13/22 to 7/11/22, included physician orders for skilled nursing services one time a week, social work services one time a week and hospice aide services two times a week. b. Clinical note, dated 4/25/22, included documentation client canceled hospice aide services today. The IDG update to the POC, dated 5/3/22, lacked documentation of the missed hospice aide visit on 4/25/22. 2. Patient #10 had a hospice admission date of 11/29/21 and date of death of 3/1/22, and received hospice services while residing in a private residence. Clinical record review revealed: a. IDG meeting note, dated 2/24/22, 3/9, 3/24/22, 4/7/22 and 4/21/22, included documentation the IDG had ordered skilled nursing services 1 time a week. The week of 2/20/22 to 2/26/22 lacked documentation of a hospice aide visit. The medical record, lacked documentation the IDG was aware of the missed skilled nurse visit on 2/22/22. The Administrator, Clinical Manager, Social Worker and Staff C, RN received the above findings and hospice staff provided no further evidence prior to the end of the survey.

Based on review of written contractual agreements, the hospice failed to ensure the written agreement between the hospice and 1 of 3 sampled services under arrangement included all of the required contract components. The hospice reported a total of 10 written agreements for services under arrangement with individuals/companies at the time of the survey. Failure to include the required contract components within the contractual agreement increased the potential that hospice management and oversight failed to occur and the patient would not receive services as specified on the plan of care. Findings include: A hospice chaplain contract, dated 2/1/15, failed to include the following contractual language: the hospice retains administrative management, financial management, oversight of staff and services; all services are authorized by the hospice, and delivered in accordance with the patient's plan of care. The above findings were reviewed with the Administrator, Clinical Manager, Social Worker and Staff C, RN and hospice staff provided no further evidence prior to the end of the survey.

Based on review of a written hospice agreement for services under arrangement and staff interview, the hospice failed to ensure the hospice provided orientation about the hospice philosophy for contracted staff with patient and family contact for 1 of 1 sampled contracted staff (Staff E). The hospice reported 1 new contracted individual was hired since the last survey. Failure to provide orientation on hospice philosophy increased the potential for provision of services in a manner contradictory to the hospice philosophy. Findings include: The hospice staff list, identified one new contracted staff was hired since the last survey. Staff E, Physical Therapist, provided physical therapy services. Staff E's personnel file only included a hospital employee orientation sheet and lacked documentation of orientation to the hospice philosophy. During interview with the Hospice Clinical Manager on 5/25/22 at 11:30 AM, the Clinical Manager reported the hospice did not provide any orientation to contracted staff on the hospice philosophy. The above findings were reviewed with the Hospice Administrator and Clinical Manager. No further information was provided by the hospice staff prior to the end of the survey.

Based on patient clinical record review and hospice staff interview, the hospice failed to ensure the medical director of the hospice or the hospice physician designee, provided written certification of terminal illness and the certification of terminal illness was a part of the clinical record, for 2 of 11 sampled patients (Patients #9 and #11). Failure of the hospice to ensure the medical director or designee provided written certification of terminal illness placed patients at risk for not meeting the eligibility requirements for hospice and have unexpected medical expenses. Findings include: During an interview on 5/24/22 at 4:10 PM, the Clinical Manager reported the medical director dictates his physician narrative for the certification of terminal illness (CTI) and it is sent from the physician office to the hospice agency where it is matched with the signed CTI form and scanned into the patient's electronic medical record (EMR). The medical director has reasonable time for submission of the dictation to the hospice agency. During an interview on 5/25/22 at 10:15 AM, Staff F, medical biller, reported the registered nurse completes the CTI order in the EMR, the Clinical Manager approves the order, prints the CTI, and places the printed CTI in a folder for the medical biller. Staff F sends orders from the folder daily or every other day, depending on quantity of orders/CTIs in folder, to physicians for signature. Staff F tracks these orders and CTIs, if the orders/CTIs are not back within 1 month/30 days, the document is printed again and resent to the physician. The hospice agency picks up signed orders/CTIs from physician offices twice a week. Staff F reported not having a good process for following up on outstanding physician dictation. 1. Patient #9 had a hospice admission date of 4/15/22, a death date of 4/21/22, and received routine home care hospice services while residing at a private residence until 4/18/22, and then was admitted to inpatient respite services at the local hospital until 4/21/22. Clinical record review revealed: a. Plan of Care, dated 4/15/22 to 7/13/22, included documentation which identified the hospice medical director as the attending physician. b. The electronic clinical record lacked documentation of an initial, written and signed CTI completed by the hospice's Medical Director or hospice physician designee. During an interview on 5/24/22 at 3:45 PM, the Clinical Manager reviewed the patient's EMR and agreed no CTI was in the EMR. During an interview on 5/24/22 at 4:10 PM, the Clinical Manager provided the surveyor with the CTI that included a handwritten signature from the medical director, dated as signed on 4/27/22, and the physician narrative: see physicians dictation. The Clinical Manager reported the CTI was with the clerical staff waiting on the physicians dictation so both documents could be scanned into the patient's EMR. The patient's EMR lacked a completed CTI (physician narrative not completed). 2. Patient #11 had a hospice admission date of 3/25/22, a death date of 4/6/22, and received routine home care hospice services while residing at a nursing home. Clinical record review revealed: a. Plan of Care, dated 3/25/22 to 6/22/22, included documentation which identified the hospice medical director as the attending physician. b. The electronic clinical record lacked documentation of an initial, written and signed CTI completed by the hospice's Medical Director or hospice physician designee. During an interview on 5/24/22 at 3:45 PM, the Clinical Manager reviewed the patient's EMR and agreed no CTI was in the EMR. During an interview on 5/24/22 at 4:10 PM, the Clinical Manager provided the surveyor with the CTI that included a handwritten signature from the medical director, dated as signed on 4/4/22, and the physician narrative: see physicians dictation. The Clinical Manager reported the CTI was with the clerical staff waiting on the physicians dictation so both documents could be scanned into the patient's EMR. During an interview on 5/25/22 at 11:42 AM, the Clinical Manager provided the surveyor with the dictated physician narrative, dated 5/17/22, for the CTI. The Clinical Manager reported the documentation was received today from the physician's office when the folder of signed documents was picked up. The patient's EMR lacked a completed CTI. The above findings were reviewed with the Administrator, Clinical Manager, Social Worker and Staff C, RN and hospice staff provided no further evidence prior to the end of the survey.

Based on patient clinical record review, staff interview and agency policy review, the hospice failed to ensure all clinical entry notes included a date entered in a timely manner for 2 of 11 sampled patients (Patients #7 and #10). Failure to ensure all clinical record documentation completed timely, increased the risk of ineffective communication between staff members providing services to its patients. Findings include: According to the hospice policy titled Documentation Policy, dated 1/25/21, it is the expectation that routine visit notes for all disciplines will be completed as part of the visit. If it is impossible to complete the documentation immediately following the visit, it may be completed in the office, preferably on the same day as the visit but within 2 business days at most. During an interview on 5/25/22 at 9:10 AM the Clinical Manager stated documentation expected to be completed within 2 business days. 1. Patient #7 had a start of care date of 2/17/22 and revocation date of 3/5/22 and received services in a private home. The Plan of Care, dated 2/17/22 to 5/17/22, included orders for skilled nursing services. Electronic health record review revealed the skilled nursing visit note, documented the visit occurred on 2/28/22, with an electronic signature indicating completion on 3/3/22, 1 day late according to agency expectation. 2. Patient #10 had a start of care date of 11/29/21 and date of death on 3/1/22. The Plans Of Care, dated 11/29/21 to 2/26/22 and 2/27/22 to 5/27/22, included orders for skilled nursing and social work services. a. Electronic health record review revealed the social worker visit note, documented the visit occurred on 2/8/21, with an electronic signature indicating completion on 2/8/22, 1 day late according to agency expectation. b. Electronic health record review revealed the skilled nursing visit note, documented the visit occurred on 2/27/22, with an electronic signature indicating completion on 3/2/21, 1 day late according to agency expectation. Hospice staff failed to complete documentation in a timely manner. The Administrator, Clinical Manager, Social Worker and Staff C, RN received the above findings and hospice staff provided no further evidence prior to the end of the survey.

Based on clinical record review, the hospice interdisciplinary group failed to document the assessment of the patient and/or caregiver's ability to safely and accurately administer medications for 1 of 1 sampled patients who received hospice services while living in an assisted living facility (Patient #3). The hospice provided services to one patient who resided in an assisted living facility at the time of the survey. Failure to ensure the Interdisciplinary Group (IDG) evaluated either the patient and/or family caregiver's ability to safely and accurately administer medications decreased the ability of the hospice to ensure the safe effective delivery of ordered medications. Findings include: Patient #3 had a hospice admission date of 8/11/2021, received hospice services while residing in an assisted living facility. Clinical record review revealed: The Plans of Care (POCs), dated 8/11/21 to 11/8/21, 11/9/21 to 2/6/22, 2/7/22 to 4/7/22, and 4/8/22 to 6/6/22, included IDG orders for skilled nursing, hospice aide, and social work services. The POC and the IDG meeting updates to the POC, dated 8/24/21, 3/22/22, 4/5/22, 4/19/22, 5/3/22, and 5/17/22, lacked any documentation which identified whether or not the IDG members determined the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in the patient's home. Interview with Hospice Clinical Manager on 5/24/22 at 9:30 AM revealed the agency believed there was no need to document the safety of administration of medication as the patient resided in an assisted living facility and the facility staff administered the medications for the patient, so no documentation of patient and/or caregiver's ability to safely administer medications was completed. The above findings were reviewed with the Hospice Administrator and Clinical Manager. Hospice staff provided no additional information prior to the end of the survey.

Based on clinical record review, hospice policy review, patient and staff interview, the hospice failed to maintain documentation in the patient clinical records as evidence that patients received a copy of the hospice policy concerning the disposition of controlled medications and hospice staff discussed this policy with the patient/caregiver for 1 of 1 sampled patients who received routine home care while living in an assisted living facility and had physician ordered controlled medications (Patients #3). The hospice reported 1 patient was residing in an assisted living facility at the time of the survey. Failure to ensure patients and/or caregivers received adequate education on the use and disposition of controlled substances increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for whom the medication was prescribed. Findings include: According to undated hospice policy, titled Hospice Policy for Disposal of Controlled Medications, the hospice shall provide education and guidance to hospice patients and caregivers in the home regarding the proper use and disposal of controlled (narcotic) medications, in order to assure compliance with state and federal regulations. The hospice nurse will educate the patient and/or caregiver about the proper use and safe storage of all controlled medications. A copy of this policy will be supplied to the patient and/or caregiver at the time of admission to services in the home, or when controlled medications are first ordered. Hospice staff will discuss the policy and procedure for safe use and disposal of controlled medications with the patient and/or caregiver in order to assure understanding of the policy and procedure. Hospice staff will document in the patient's clinical record regarding the verbal discussion of the policy/procedure and that a copy of the policy/procedure was provided to the patient and/or caregiver. Patient #3 had a hospice admission date of 8/11/2021, received hospice services while residing in an assisted living facility. Clinical record review revealed: The Plans of Care (POCs), dated 8/11/21 to 11/8/21, 11/9/21 to 2/6/22, 2/7/22 to 4/7/22, and 4/8/22 to 6/6/22, included IDG orders for skilled nursing, hospice aide, and social work services. The POCs, dated 8/11/21 to 11/8/21, 11/9/21 to 2/6/22, 2/7/22 to 4/7/22, and 4/8/22 to 6/6/22, included orders for Morphine concentrate 20 milligrams (mg) per 1 milliliter (ml) and orders to administer 0.5 ml every 1 hour as needed for pain or air hunger. The clinical record included orders for the controlled medication on admission. The clinical record lacked documentation the nurse provided the written policy and education on the disposal of controlled medications to the patient and/or caregiver. Interview with Hospice Clinical Manager on 5/24/22 at 9:30 AM reported the patient did not receive the policy or education for narcotics as the patient resided in an assisted living facility and the facility staff administers the medication. Surveyor explained assisted living facilities are independent living facilities and the education and policy should be provided. The above findings were reviewed with the Hospice Administrator and Clinical Manager. Hospice staff provided no additional information prior to the end of the survey.

Based on clinical record review, hospice policy review and nursing home medication and treatment administration records the hospice failed to ensure hospice staff provided overall coordination of the hospice care with the long-term care (nursing home) staff for 2 of 2 sampled patients (Patient #1 & #2) with a review of the patient's nursing home residence medication and treatment administration records. Failure to ensure the hospice staff provided overall coordination of patient care with the nursing home placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings Include: According to the hospice policy titled Hospice Plan of Care, dated October 2005, the IDT (Interdisciplinary Team) will meet regularly, no less than every 14 days, to review the plan of care, determine if client/caregiver needs are being meet and update the plan as necessary. In order to meet client/caregiver needs, tem members may need to coordinate/update plans more frequently than every 14 days. Symptom control, pain management, and physical and psychosocial needs must be assess on an ongoing basis by the appropriate provider. 1. Patient #1 had a hospice admission date of 5/13/22 and received hospice services while residing in a nursing home. Review of the hospice and patient's nursing home clinical record revealed the following discrepancies: a. The hospice Plan of Care (POC), dated 5/13/22 to 8/10/22, included an order for Bisacodyl suppository daily prn (as needed). b. The nursing home Medication Review Report, dated 5/23/22, included an order for Bisacodyl suppository every 2 days prn, effective 8/1/21. c. The hospice POC, dated 5/13/22 to 8/10/22, included an order for Miralax 17 gm (grams) daily prn, effective 8/1/21. d. The nursing home Medication Review Report, dated 5/23/22, included an order for Miralax 17 gm daily and 17 gm every other day prn. e. The hospice POC, dated 5/13/22 to 8/10/22, included an order for Lorazepam 0.25 mg (milligrams) every hour prn, effective 8/1/21. f. The nursing home Medication Review Report, dated 5/23/22, included an order for Lorazepam 0.5 mg every hour of sleep and 0.25 mg prn. The hospice Registered Nurse (RN) and IDG failed to ensure coordination of patient care with nursing home staff. 2. Patient #2 had a hospice admission date of 9/3/21 and received hospice services while residing in a nursing home. Review of the hospice and patient's nursing home clinical record revealed the following discrepancies: a. The hospice Medication Profile, dated 5/17/22, included an order for Loratidine 10 mg daily as needed for allergies. b. The nursing home Medication Review Report, dated 5/23/22, included an order for Diphenhydramine 25 mg daily prn, effective 8/1/21. The hospice RN and IDG failed to ensure coordination of patient care with nursing home staff. The Administrator, Clinical Manager, Social Worker and Staff C, RN received the above findings and hospice staff provided no further evidence prior to the end of the survey.

The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history background record check on all prospective directly hired or contracted employees and all volunteers with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check. Based on review of hospice personnel files and hospice staff interview, the hospice failed to ensure completion of a criminal background history check for 1 of 3 sampled employees (Staff D) who began serving hospice patients since their last survey, dated 6/6/19. The hospice reported hiring 3 employees since the last survey. Failure to complete criminal background checks as required by Federal and State regulation, increased the potential risk of harm to hospice patients. Findings include: Review of hospice personnel files revealed the following: Staff D, Registered Nurse, had a hire date of 2/18/2020. The Registered Nurse's personnel file included documentation of a criminal history check completed through SING, dated 1/14/2020, 35 days before the hospice had hired Staff D. The hospice failed to complete the criminal history background check within 30 days of employment with the hospice. The above findings were reviewed with the Hospice Administrator and Clinical Manager. Hospice staff provided no additional information prior to the end of the survey.

The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a child abuse and dependent adult abuse background record check on all prospective directly hired or contracted employees and all volunteers with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check. Based on review of hospice personnel files and hospice staff interview, the hospice failed to ensure completion of a child abuse and dependent adult abuse background record check for 1 of 3 sampled employees (Staff D) who began serving hospice patients since their last survey, dated 6/6/19. The hospice reported hiring 3 employees since the last survey. Failure to complete child abuse and dependent adult background checks as required by Federal and State regulation, increased the potential risk of harm to hospice patients. Findings include: Review of hospice personnel files revealed the following: Staff D, Registered Nurse, had a hire date of 2/18/20. Staff D's personnel file included documentation of a child abuse and dependent adult abuse check completed through SING, dated 1/14/2020, 35 days before Staff G's date of hire. The hospice failed to complete the child abuse and dependent adult abuse background within 30 days of hire as required by regulation. The hospice provided no additional information prior to the end of the survey. The above findings were reviewed with the Hospice Administrator and Hospice Clinical Manager. Hospice staff provided no additional information prior to the end of the survey.