Every finding on record at Dynamic Health Care Systems, LLC

Based on review of policy titled “Quality Assessment and Performance Improvement,” record reviews, and staff interview, it was determined the agency failed to maintain a Quality Improvement Plan (QAPI) program with indicators that are measured, analyzed and tracked for improvement and quality of care. --- Findings included: Review of agency’s policy titled “Quality Assessment and Performance Improvement,” revised June 2019 revealed the following:“Objectives:•           To collect and analyze data to improve identified processes and outcomes of care•           To collect and analyze date to improve identified processes of patient care/services as well as outcomes of patient care, leadership and managerial process, as indicatedResponsibility/Accountability:The Administrator/Director is responsible for assigning staff to the Quality Assessment Performance Improvement (QAPI) committee. The QAPI committee will be responsible for coordination of all QAPI activities, reviewing collection of data, analyzing data, assisting staff in developing design or improvement activities, planning actions, collection data, analyzing the effectiveness of action and implementing effective actions.” Review of document titled “Hospice QAPI KPI Dashboard,” with no date indicates the agency has three active/ongoing performance projects (PIPs) however, the PIPs failed to contain data collection, audits, or relevant data collection from identified quality indicators for improving hospice services. On 04/27/2026 at 1:15 PM, during an office interview, the Director of Nursing (DON) confirmed the Quality Improvement Plan (QAPI) program did not contain Performance Improvement Projects (PIP) with indicators that are measured, analyzed and tracked for improvement and quality of care. Furthermore, when PIP documentation for the last two quarters was requested the DON stated she did not have any data for the PIPs because the nurse who was over QAPI resigned and she is not able to locate any data for the PIPs.

Based on review of policy titled “Infection Control Surveillance System: Prioritized Ricks Defined,” record reviews, and staff interview, it was determined the agency failed to maintain an Infection Control Surveillance System program with indicators that are measured, analyzed and coordinated with quality assessment performance improvement (QAPI) team to be tracked for improvement and quality of care. --- Findings included: Review of agency’s policy titled “Infection Control Surveillance System: Prioritized Ricks Defined,” revised June 2019 ,” revealed the following:“Purpose: To define infection control surveillance identification and reporting for patients and staff.Procedure:3.  At least quarterly, the Director and infection control and QAPI committees will review and assess the infection control logs. Data will be aggregated and analyzed on the Infection Control Quarterly Data Aggregation and Analysis: Patients and Employees form.5.  The committees will make recommendations for and implement improvement activities” Review of documents titled “30-Minute Hospice QAPI Meeting Agenda," dated 11/17/25 and  2/9/26  indicates the agency has had two QAPI meetings however, the QAPI agenda failed to discuss Infection control surveillance and tracking. On 04/27/2026 at 2:00 PM, during an office interview, the Director of Nursing confirmed that infection control logs have not been discussed during the QAPI meeting and they should as she has noted a trend of urinary infections.  She also states that she understands infection control is a part of QAPI and should be discussed during the meetings.

Based on the review of policies and procedures, records review, and staff interviews, it was determined the facility failed to ensure that a governing body (or designated persons so functioning) assumes full legal authority and responsibility for the management of the hospice, and the provision of all hospice services to include the following:1. failure to measure, analyze, and track Quality Improvement Plan (QAPI) program indicators.2. failure to maintain an infection control program that measures, analyzes, and coordinates with the QAPI team to be tracked.3. failure to provide medications related to the palliation and management of the terminal illness and related conditions for three patients (P) (P6, P7, P8) of 14 sampled patients. --- Findings included: Review of policy titled “Governing Body,” revised June 2019, revealed the following:“POLICYThe Governing Body assumes full legal authority and responsibility for the management of hospice, the provision of all hospice services, its fiscal operations and assumes responsibility for the safety and quality of care provided including QAPI.RESPONSIBILITIES2. All Governing Body members fulfill their responsibilities (including attending meetings, budget oversight and evaluating senior management).”            Cross reference to L0562 relating to the hospice’s failure to maintain a Quality Improvement Plan (QAPI) program with indicators that are measured, analyzed and tracked. Cross reference to L0580 relating to the hospice’s failure to maintain an Infection Control Surveillance System program with indicators that are measured, analyzed and coordinated with quality assessment performance improvement (QAPI) team to be  tracked. Cross reference to L0686 relating to the hospice’s failure to cover drugs, biologicals, and medical supplies.

Based on record reviews, and staff interviews, it was determined that the agency failed to cover medications related to admission diagnoses for three patients (P) (P6, P7, P8) of 14 sampled patients. --- Findings included: 1. Review of the clinical records for P6 revealed that the start of care was completed by a skilled nurse on 12/22/2025. The admission diagnoses were Parkinson’s disease (a progressive, incurable neurodegenerative disorder that impacts the nervous system and motor control), and dementia disease (a decline in mental ability severe enough to interfere with daily life, caused by physical changes in the brain), comorbidity of mixed hyperlipidemia [it is commonly referred to as high cholesterol]. The agency failed to cover the following medication:• Atorvastatin Calcium (Lipitor), [use to prevent heart attacks and strokes] 40 milligrams (mg), take one tablet by mouth daily at bedtime. On 04/29/2026 at 1:30 PM, a phone interview was conducted with Registered Nurse (RN) CC, who said that she did not know why the diagnosed medication for P6 was not covered. RN CC also said that she was training with RN BB at that time. RN BB was not available for interview because she was on vacation and travelled out of country. 2. Review of the clinical records for P7 revealed that the start of care was completed by a skilled nurse on 09/05/2025. The admission diagnoses were (a hypertensive heart disease with heart failure [a chronic condition where the heart muscle is too weak to pump blood efficiently and causing fluid backup], comorbidity hyperlipidemia [it is commonly referred to as high cholesterol]. The agency failed to cover the following medication:•Atorvastatin Calcium (Lipitor), [use to prevent heart attacks and strokes] 20mg take one tablet by mouth daily at bedtime. 3. Review of the clinical records for P8 revealed that the start of care was completed by skilled nurse on 12/30/2025. The admission diagnosed was Alzheimer’s disease (a decline in mental ability severe enough to interfere with daily life, causing the brain to shrink). The hospice agency failed to cover the following medication for P8:• Donepezil HCI [it works by increasing acetylcholine in the brain, which can help improve memory] 10mg taking one tablet by mouth daily at bedtime. On 04/29/2026 at 1:49 PM, an interview was conducted with the Director of Nursing (DON) in the conference room. She confirmed that RN BB and RN CC did not cover the diagnosed medications for P6, P7 and P8. DON also said that they were audited by the pharmacist who confirmed that the hospice was paid to cover the diagnoses and comorbidities medications. DON said that RN AA and RN DD resigned. Policy was requested but was not available upon exit.

Based on review of records, staff interview, and review of agency policy, it was determined the interdisciplinary group failed to ensure that the initial bereavement assessments and bereavement plan of care (POC), were completed after patients death for two patients (P) (P#7, P#8) of 11 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11). The Findings Include: --- 1. Review of the clinical record for P#7, admitted on 3/28/2023, with a diagnosis of congestive heart failure (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), revealed that P#7 expired on 4/7/2023. The initial bereavement assessment and bereavement plan of care was not completed. The clinical record lacked documentation regarding the staff's delay in completing the assessment and POC. 2. Review of the clinical record for P#8, who was admitted on 3/30/2023, with a diagnosis of malignant neoplasm of liver (liver cancer), and severe protein-calorie malnutrition (insufficient energy (kilocalories), fat, protein and/or other nutrients (vitamins and minerals, etc.) to cover individual needs), revealed that P#8 expired on 4/16/2023. The initial bereavement assessment and bereavement plan of care was not completed. The clinical record lacked documentation regarding the staff's delay in completing the assessment and POC. On 5/3/2023 at 11:50 a.m., an interview was conducted with the Administrator revealed that the initial bereavement assessment and bereavement POC were not done because both patients were admitted in a brief period of time before they passed away. The Administrator confirmed that the surveyor has been provided with all available documentation for the patients records. The agency failed to provide bereavement policy.

Based on review of records, it was determined the hospice agency failed to provide Performance Improvement Project (PIP) records for 11 patients (P) (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, and P#11) of 11 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, and P#11). The Findings include: --- On 5/1/2023 at 12:30 p.m., a review of the clinical records revealed that the Administrator failed to complete performance improvement projects (PIP). On 5/1/2023 at 1:00 p.m., an interview conducted with the Administrator revealed that she was busy and unable to do the PIP. The Administrator additionally revealed that she would do the PIP by Wednesday 5/3/2023. On 5/3/2023 at 3:00 p.m., interview conducted with Administrator regarding the PIP. Administrator revealed she was busy at that time because she was the only nurse doing the billing, and also covering for on call nurse after hours. The Administrator confirmed that she was unable to complete the PIP.

Based on review of clinical records, it was determined that the hospice agencys governing body failed to complete or provide Performance Improvement Projects (PIP) records for 11 patients (P) (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, and P#11) of 11 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, and P#11). The findings include: --- On 5/1/2023 at 12:30 p.m., a review of the clinical records revealed that the governing body failed to complete performance improvement projects (PIP). On 5/1/2023 at 1:00 p.m., an interview conducted with the Administrator revealed that she was busy and unable to do the PIP. The Administrator additionally revealed that she would do the PIP by Wednesday 5/3/2023. On 5/3/2023 at 3:00 p.m., an interview was conducted with Administrator regarding the PIP. The Administrator revealed she was busy at that time because she was the only nurse doing the billing and covering for on-call nurse after hours. The Administrator confirmed that she was unable to complete the PIP.

Based on review of records, it was determined that the agency failed to provide patients Certificate of Terminal Illness (CTI), for seven patients (P) (P#3, P#6, P#7, P#8, P#9, P#10, P#11), of 11 sampled patients (P#1, P#2, P#3, P#6, P#7, P#8, P#9, P#10, P#11, P#4, P#5). The findings include: --- 1. Patient #3 was admitted to the hospice agency on 7/20/2022, with a diagnosis of amyotrophic lateral sclerosis (a nervous system disease that affects nerve cells in the brain and spinal cord). The initial CTI for P#3 was signed by physician and dated 7/21/2023, which was one year ahead. 2. Patient #6 was admitted to the hospice agency on 5/3/2022, with a diagnosis of chronic obstructive pulmonary disease (refers to a group of diseases that cause airflow blockage and breathing-related problems); the initial CTI was not completed. 3. Patient #7 was admitted to the hospice agency on 3/28/2023, with a diagnosis of congestive heart failure (a long-term condition that happens when your heart cannot pump blood well enough to give your body a normal supply); the initial CTI was not completed. 4. Patient #8 was admitted to the hospice agency on 3/30/2023, with a diagnosis of congestive heart failure (a long-term condition that happens when your heart cannot pump blood well enough to give your body a normal supply); the initial CTI was not completed. 5. Patient #9 was admitted to the hospice agency on 3/28/2023, with a diagnosis of malignant neoplasm of breast (breast cancer); the initial CTI was not completed. 6. Patient #10 was admitted to the hospice agency on 4/11/2023, with a diagnosis of congestive heart failure (a long-term condition that happens when your heart cannot pump blood well enough to give your body a normal supply); the initial CTI was not completed 7. Patient #11 was admitted to the hospice agency on 9/27/2022, with a diagnosis of morbid severe obesity (a serious health condition that results from an abnormally high body mass); the initial CTI was not completed. On 5/3/2023 at 3:30 p.m., an interview conducted with the Administrator revealed that she was having problems with the physician, because he was not signing the CTIs in a timely manner. On 5/3/2023 at 3:25 p.m., a review of P#3 record revealed that initial CTI was missing for the patient P#3. On May 3, 2023 at approximately 4:00 p.m., the Administrator provided a CTI for P#3. The CTI was signed by physician, and the physician dated it 7/21/ 2023. The date was twelve months ahead. The Administrator confirmed that the CTIs for P#6, P#7, P#8, P#9, P#10, and P#11 were not completed.

Based on review of records, it was determined that the hospice agency failed to provide patients records on two consecutive days for eight patients (P) (P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11), of 11 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11). The findings include: --- The hospice Administrator failed to supply patients clinical records to surveyors for two consecutive days. Clinical records were requested on Monday 5/1/2023; the Administrator supplied the documents on Wednesday 5/3/2023. In an interview on 5/3/2023 at 3:55 p.m., the Administrator revealed that she was having a problem with her copier machine, and some of the patients documents were not available in the office because she worked from home. The Administrator confirmed that all available documentation for the patients records have been provided.

Based on record review, staff interview, and review of agencys policy, it was determined that the agency failed to provide drugs and biologicals related to the management and palliation of the terminal illness and related conditions identified on patients hospice plan of care. The agency failed to provide medications related to the comorbidities (a disease or medical condition that is simultaneously present with another or others in a patient) for two patients (P) (P#1, P#2), of 11 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, and P#11). The findings include: --- 1. Review of plan of care for P#1 for certification period (hospice benefit period) 2/21/2023 to 4/21/2023 revealed the patient was admitted to hospice services on 2/21/2023 with a primary diagnosis of Alzheimers disease (a brain disorder that gets worse over time). Record review revealed the agency failed to provide coverage for payment for the following medications used to manage the primary diagnosis: Namenda (Memantine) 10 milligrams (MG), take one tablet oral daily use to treat moderate to severe confusion related to Alzheimers disease. 2. Review of plan of care for P#2 for certification period, 7/20/2022 to 9/17/2023. revealed the patient was admitted to hospice services on 7/20/2022 with a primary diagnosis of Alzheimers disease (a brain disorder that gets worse over time). Record review revealed the agency failed to provide coverage for payment for the following medication used to manage the comorbidities of essential primary hypertension (type of high blood pressure): Metoprolol tartrate (beta-blocker used to treat chest pain (angina), heart failure, and high blood pressure) 50mg take one tablet oral daily to lower blood pressure. On 5/2/2023 at 4:00p.m., an interview was conducted with the Administrator revealed that she was unaware that it was a requirement for the hospice agency to pay for medications related to the listed diagnosis and comorbidities on the patients plan of care. Policy was not available at time of exit.