Every finding on record at Evergreen Hospice, LLC

Based on interview and record review, the agency failed to ensure that an individualized written plan of care established by the hospice interdisciplinary group was followed for services provided to 1 (MR# 3) of 5 records reviewed, resulting in the potential for unmet care needs for all patients receiving care from this agency. Findings include: --- MR #3: This 83-year-old patient was admitted to Hospice on 9/27/22 with the terminal diagnosis of secondary malignant neoplasm of the liver and intrahepatic bile duct. During record review on 5/31/23, the plan of care dated 9/27/22 ordered hospice aide services 2 times per week. It was noted that the first hospice aide visit was on 10/26/22. There was no documentation regarding the reason for a delayed initiation of service. Upon further review of the record, the documentation of the interdisciplinary group meeting during held on 10/3/22 did not show any evidence of an order to change the frequency or delay the start of care. The administrative assistant (Staff-B) was queried regarding the reason for delay of care during an interview on 5/31/23 at 3:00 p.m. She reported that maybe the patient had refused to start care on time, but was unable to provide any evidence of this documented in the chart. Findings were further reviewed with and acknowledged by the Administrator during an interview on 5/31/23 at 4:00 p.m.

Based on interview and record review, the agency failed to ensure the plan of care was reviewed, revised and documented by the interdisciplinary group at least every 15 days in 2 (MR #3, 4) of 5 records reviewed, resulting in the potential for unmet care needs for all patients receiving care from this agency. Findings include: --- MR #4: This patient was admitted to Hospice on 10/14/22 with the terminal diagnosis of dementia. During record review on 5/31/23, it was determined that interdisciplinary group (IDG) meetings were held on 10/3/22, 11/14/22 and 11/28/22. There were 5 missing IDG meetings. The requirement for an IDG meeting at least every 15 days was not met. The administrative assistant (Staff-C) was interviewed on 5/31/23 at 4:05 p.m. regarding the missing meeting notes. Staff-C was able to provide a binder of sign in sheets for IDG meetings, but there was no evidence of any documentation of what was discussed. Findings were reviewed with and acknowledged by the administrator on 5/31/23 at 4:15 p.m. MR #3: This 83-year-old patient was admitted to Hospice on 9/27/22 with the terminal diagnosis of secondary malignant neoplasm of the liver and intrahepatic bile duct. During record review on 5/31/23, it was determined that an interdisciplinary group (IDG) meeting was held on 10/3/22 and not again until 11/18/22. There should have been 3 other IDG meetings held during this time period to discuss and update the patient's plan of care. The administrative assistant (Staff-B) was interviewed on 5/31/23 at 3:00 p.m. regarding the missing meeting notes. Staff-B was able to provide a binder of sign in sheets for IDG meetings during this time, but there was no documentation of what was discussed at these meetings. Findings were reviewed with and acknowledged by the Administrator during an interview on 5/31/23 at 4:00 p.m.

Based on record review and interview, the hospice failed to develop and maintain an emergency preparedness program that includes an emergency plan, policies, procedures, communication plan, training, and testing. These deficient practices could affect all 43 of the agency's current patients. The cumulative effect of these systemic problems results in the hospice's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation at 42 CFR 418.113, Emergency Preparedness. Findings include: 1. The hospice did not develop an emergency preparedness plan that was pertinent to their location in Troy, MI and include guidance for Emerging Infectious Diseases. (See E0004) 2. The hospice did not develop emergency preparedness policies and procedures. (See E0013) 3. The hospice did not develop and maintain an Emergency Preparedness communication plan that complies with Federal, State, and local laws and must be reviewed and updated at least every 2 years. (See E0029) 4. The hospice did not develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan. (See E0036)

Based on record review and interview, the hospice failed to develop an emergency preparedness plan and included guidance for Emerging Infectious Diseases, resulting in lack of direction for hospice personnel in the event of an actual emergency or disaster. These deficient practices could negatively affect the health and safety of the hospice's 43 current patients in the event of a natural, man-made, or agency-based emergency. Findings include: On 12/3/21, the hospice's Emergency Preparedness documentation was reviewed. During the review, it was noted that the hospice had no documented evidence an emergency preparedness plan had been developed for the hospice agency located in Troy, MI. The plan states the organization participates in "California Shakeout" as a home health agency in the community. This indicates their emergency plan is developed for an agency in California and not for an agency located in Troy, MI. The hospice's hazard vulnerability assessment indicates that their highest priority emergencies are earthquakes, fire, and flash flood. These high priority emergencies are more indicative of an agency located in California. Preparedness activities included in the plan indicate that hospice staff are to call a Shell Gas Station in Scottsdale, AZ regarding back up vehicles and gas during an emergency. The current plan further directs the employees and staff of Hope Hospice Care, Inc to phone a contractor for assistance during an emergency. Many elements of the emergency preparedness plan for Evergreen Hospice indicate that the plan was developed for another agency or agencies located in either California or Arizona. The hospice's Emergency Preparedness documentation also failed to include guidance regarding Covid-19 or other Emerging Infectious Diseases. The findings were reviewed with the Administrator (Adm #1) during an interview on 12/3/21 at 2:00 p.m. Adm #1 confirmed that the emergency preparedness plan had been developed by a consultant located in California for another hospice also located in California.

Based on record review and interview, the hospice failed to develop and establish written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan including strategies for the global Covid-19 pandemic and other emerging infectious diseases. Resulting in the hospice's inability to implement appropriate emergency actions. These deficient practices could negatively affect the health and safety of the hospice's 43 current patients in the event of a natural, man-made, or agency-based emergency. Findings include: On 12/3/21, the hospice's Emergency Preparedness documentation was reviewed. During the review, it was noted that the hospice had no documented evidence of emergency preparedness policies and procedures that were based on an emergency preparedness plan, a documented risk assessment, communication plan, and strategies for the Covid-19 pandemic and emerging infectious diseases. The hospice has an emergency preparedness plan and risk assessment that were developed by a consultant in California for Hope Hospice Care in California. The emergency plan and risk assessment are not pertinent to the hospice agency's location in Troy, MI. The findings were reviewed with and confirmed by the Administrator during an interview on 12/3/21 at 2:00 p.m.

Based on record review and interview, the hospice failed to develop and maintain an Emergency Preparedness communication plan that complies with Federal, State, and local laws. Resulting in the hospice's inability to ensure the coordination of patient care in the event of an actual emergency. These practices could negatively affect the health and safety of the hospice's 43 current patients. Findings include: On 12/3/21, the hospice's Emergency Preparedness documentation was reviewed. During the review, it was noted that there was no documented evidence of a communication plan the hospice would utilize during an emergency. The communication plan failed to indicate how the hospice would interact and coordinate with staff, patients, and emergency management agencies to protect patient health and safety in the event of a disaster. These findings were reviewed with and confirmed by the Administrator during an interview on 12/3/21 at 2:00 p.m.

Based on record review and interview, the hospice failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan. Resulting in the hospice's inability to ensure staff actions align with the emergency plan. These practices could negatively affect the health and safety of the hospice's 43 current patients in the event of a facility-based emergency or community disaster. Findings include: The hospice's Emergency Preparedness Plan was reviewed with the Administrator (Adm #1) on 12/3/21 at 2:00 p.m. During the review, it was noted that there was no documented evidence that the hospice had developed a training and testing program to guide personnel and agency actions during an emergent situation that was based on the Emergency Preparedness plan. There was no documentation of an agency-based emergency drill, a community-based drill, an actual emergency event, and no documentation of the hospice's efforts during the Covid-19 pandemic. The findings were acknowledged by Adm #1 at the time of discovery.

Based on record review and interview, the hospice failed to ensure the patient received adequate and appropriate wound care management for 1 (MR #6) of 1 record reviewed in which the patient had a wound from a total sample of 11 sampled records reviewed, resulting in the potential for worsening of the wound, development of infection and unmet care needs. Findings include: A complaint on file alleged the facility failed to provide appropriate care and services to prevent/treat pressure sores. MR #6: The patient was admitted to hospice services on 9/30/21. The initial comprehensive assessment was conducted on 10/1/21. During the onsite investigation, an interview was conducted with the Office Manager (OM #1) on 12/2/21 at 1:38 p.m. When asked if the patient had pressure sores on admission, OM #1 reported, "She was with us for approximately a week and that's when the aide reported it to us. The aide identified small redness to the patient's bottom and notified the Nurse (RN #1)." The first nursing note that identified the pressure sore was 10/8/21 and the nurse wrote there was just redness. Around 10/25/21 the nurse (RN #1) said the wound was a Stage II. The patient was transferred to another facility on 11/1/21 and I think her wound was a Stage IV at that time." The "Comprehensive Nursing Assessment" dated 10/1/21 completed by the Director of Nursing (DON #1) documented that the patient was non-verbal and unable to verbalize pain A Skilled Nurse (SN) visit note by RN #1, dated 10/8/21 documented, "skin integrity assessed, noted blanchable redness to sacrum and buttocks." A SN visit note by RN #1, dated 10/12/21 documented, "Skin integrity assessed, noted blanchable redness to sacrum and buttocks." A home visit was made by the Director of Nursing (DON #1) on 10/17/21 who documented, "Integumentary-Skin: Ulcer/Bed Sores: Severe..." There was no evidence that a skin assessment had been conducted. There was no documentation of the status of the wound or any communication with the wound care specialists regarding the "severe" status of the patient's wound. A visit note by RN #1, dated 10/25/21 documented, "Integumentary-Skin: Ulcer/Bed Sores: Moderate..., Skin integrity assessed, wound care provided per order..., wash area with wound cleanser, pat dry, apply Bacitracin (antibiotic) and Calmoseptine (skin protectant) with each diaper change." There was no documentation of the size or status of the wound. An interview was conducted with DON #1 on 12/3/21 at 1:15 p.m. with OM #1 present. During the interview, DON #1 reported that she was the one who conducted the initial assessment of the patient and didn't recall seeing any redness or wounds on the patient's buttocks or other areas at the time of admission. A review of the "Comprehensive Nursing Assessment" dated 10/1/21, completed by DON #1 documented,"Pt (patient) has open areas bedsores in coccyx/has 2 areas with eschars/small amt. (black dead tissue) of serosang. (yellowish bloody) drainage noted/has areas with yellow slough (dead/necrotic tissue) and irregular shaped open sores. will consult wound care pro." There was no documented evidence that DON #1 had notified the wound care specialist regarding the patient's deteriorating wound. On 12/3/21 at 3:35 p.m., a subsequent interview was conducted with DON #1. During the interview DON #1 acknowledged that the patient had a wound upon admission and stated, "I cleaned under the eschar (dead tissue) with the saline I had with me and I applied an Allevyn dressing for more protection. I used her diaper to act as an ABD (bulky dressing) pad. I didn't document the dressing change." When asked if she had obtained an order for the dressing change, DON #1 stated, "No." DON #1 went on to state that during her last visit to see the patient on 10/28/21, she got the patient out of bed and into a chair and performed wound care during that visit. The clinical record revealed the patient was transferred to another assisted living facility on 11/1/21. A wound care "Progress Note" revealed that the patient was seen by the wound doctors on 11/1/21 after her transfer and was diagnosed with a "non-healing pressure ulcer of the sacrum which is not associated with the admitting diagnosis." As part of the initial interview with OM #1, when asked if the patient had been seen by a wound doctor, OM #1 reported, "They (Wound Pros) don't see patients unless their wound is at least a stage III. This record review revealed that the patient had a stage IV pressure ulcer that warranted evaluation. It was further noted, according to an email provided by OM #1, that no request for the wound care specialist to evaluate the patient's wound was made prior to 10/21/21 (21 days after admission). The hospice agency failed to ensure the patient received adequate and appropriate wound care management.

Based on record review and interview, the hospice failed to conduct and document a patient-specific comprehensive assessment (521); failed to ensure the registered nurse completed the initial assessment within 48 hours (522); failed to ensure the comprehensive assessment was completed within 5 days (523); failed to ensure the comprehensive assessment included a bereavement assessment (531); and failed to include data elements that allow for measurable outcomes (534). These practices impacted 10 of 11 patients (MR# 1, 2, 3, 4, 5, 7, 8, 9, 10, 11) in which the patient was on hospice care for a period of time greater than 5 days, from a total sample of 11 records reviewed. 1. There was no documented comprehensive assessment of a patient for more than 3 months. (See L521) 2. The hospice failed to ensure the the registered nurse completed the initial assessment within 48 hours (See L522); 3. The hospice failed to ensure the comprehensive assessment was completed within 5 days (See L523). 4. The hospice failed to ensure the comprehensive assessment included an initial bereavement assessment. (See L531) 5. The hospice failed to include data elements that allow for measurable outcomes (See L534). The cumulative effect of these systemic problems resulted in the hospice's inability to ensure the provision of quality end of life care in a safe environment for the Condition of Participation at 42 CFR 418.54, Initial and Comprehensive Assessment. Findings include:

Based on record review and interview, the hospice failed to conduct and document a patient-specific comprehensive assessment in 1 of 11 (MR#7) records reviewed, resulting in no assessment of the patient's care needs or services for the management of the terminal illness and related conditions for this patient. Findings include: MR#7: The patient was discharged from the hospital on 8/16/21 after getting tangled up in his wheelchair resulting in a right ankle fracture and laceration. On 8/13/21 the patient underwent surgery to debride the laceration along with a closed reduction of the fracture. The patient was admitted to hospice on 8/17/21 with diagnoses of a stroke and right-hand contracture. During record review on 12/2/21, it was noted that there was no documentation of a comprehensive assessment for this post-operative hospice patient. On 12/3/21 at 12:24 p.m., the office manager (OM #1) explained that she spoke to the director of nursing (DON #1) who completed the comprehensive assessment and DON#1 has not uploaded the comprehensive assessment into their system since 8/17/21, which was more than 3 months ago. It is unclear how the hospice can determine the patient's need for hospice care and services without a documented comprehensive assessment.

Based on record review and interview, it was determined that the hospice failed to ensure the registered nurse completed an initial assessment within 48 hours, for 2 of 11 records (MR# 2, 5) reviewed, resulting in the potential for unmet patient care needs. Findings include: .MR#2: This patient's hospice admission date was 10/16/21 and the terminal diagnosis was heart failure. The initial assessment was not completed by a registered nurse (RN) until 11/3/21, 16 days after the start of care (SOC). MR#5: This patient's hospice admission date was 10/25/21 and the terminal diagnosis was heart disease. The initial assessment was not completed by an RN until 10/30/21, 5 days after the SOC. During an interview on 12/7/21 at 11:00 a.m., the administrator (Adm #1) and the office manager (OM #1) acknowledged the findings.

Based on record review and interview, the hospice failed to ensure all members of the interdisciplinary group were involved in completing the comprehensive assessment of the patient for 7 of 11 records reviewed (MR # 1, 2, 3, 4, 5, 7, 8), resulting in unidentified and unmet spiritual and psychosocial needs of the patient and family. Findings include: MR#7: This patient was admitted to hospice on 8/17/21 with diagnoses of a stroke and right-hand contracture. During record review on 12/2/21, it was noted that there was no documented comprehensive assessment by the nurse, no assessment by social work, and no assessment by spiritual care. There was no documented evidence spiritual care and social work services were declined or delayed. MR#8: This patient was admitted to hospice on 4/28/21 with diagnoses of Parkinson's disease, high blood pressure and depression. During record review on 12/1/21, it was noted that the comprehensive assessment completed by the nurse on 4/29/21 indicates that the patient may need both social work and spiritual care visits. There was no documented evidence that social work or spiritual care assessed the patient. There was no documented evidence these counseling services were declined or delayed. MR#1: This patient was admitted to hospice on 8/23/21 with a diagnosis of heart disease. During record review on 11/30/21, it was discovered that there was no documented comprehensive assessment by skilled nursing, spiritual care or bereavement services within 5 days of election of services. There was no documented evidence skilled nursing, spiritual care or bereavement services were declined or delayed. MR#2: This patient's hospice admission date was 10/16/21, and the terminal diagnosis was heart failure. During record review on 12/1/21, it was discovered that there was no documented comprehensive assessment by skilled nursing, spiritual care or bereavement services within 5 days of election of services. There was no documented evidence skilled nursing, spiritual care or bereavement services were declined or delayed. MR#3: This patient's hospice admission date was 9/2/21, and the terminal diagnosis was cerebrovascular disease. During record review on 12/2/21, it was discovered that there was no documented comprehensive assessment by skilled nursing, spiritual care or bereavement services within 5 days of election of services. There was no documented evidence skilled nursing, spiritual care or bereavement services were declined or delayed. MR#4: This patient's hospice admission date was 6/11/21, and the terminal diagnosis was spastic quadriplegic cerebral palsy. During record review on 12/2/21, it was discovered that there was no documented comprehensive assessment for the medical social worker (MSW), spiritual care or bereavement services within 5 days of election of services. There was no documented evidence MSW, spiritual care or bereavement services were declined or delayed. MR#5: This patient's hospice admission date was 10/25/21, and the terminal diagnosis was heart disease. During record review on 12/3/21, it was discovered that there was no documented comprehensive assessment for spiritual care or bereavement services within 5 days of election of services. There was no documented evidence that spiritual care or bereavement services were declined or delayed. During an interview on 12/7/21 at 11:00 a.m., the administrator (Adm #1) and the office manager (OM #1) acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the comprehensive assessment included an initial bereavement assessment of the patient's family to determine factors that may impact the family's ability to cope with the patient's impending death for 10 of 11 (MR# 1, 2, 3, 4, 5, 7, 8, 9, 10, 11) records reviewed. This deficient practice has the potential to negatively affect the loss/grief issues for these 5 patients and their family members. Findings include: MR#1: This patient's hospice admission date was 8/23/21/21 and the terminal diagnosis was heart disease. The comprehensive assessment was completed by the nurse on 8/23/21. Record review on 11/30/21, indicates a bereavement assessment was not completed for this patient and his family. MR#2: This patient's hospice admission date was 10/16/21 and the terminal diagnosis was heart failure. Record review for this patient on 12/1/21, indicated no documented bereavement assessment in the patient's record. MR#3: This patient's hospice admission date was 9/2/21 and the terminal diagnosis was cerebrovascular disease. During record review on 12/2/21, it was discovered that there was no documented bereavement assessment in the patient's record. MR#4: This patient's hospice admission date was 9/9/21 and the terminal diagnosis was spastic quadriplegic cerebral palsy. During review of the record on 12/2/21, it was discovered that there was no documented bereavement assessment in the patient's record. MR#5: This patient's hospice admission date was 10/25/21 and the terminal diagnosis was heart disease. Record review on 12/2/21, indicates a bereavement assessment was not completed for this patient and his family. During an interview on 12/3/21 at 10:30 a.m., the bereavement coordinator (BC#1) was questioned regarding the assessment documentation. BC#1 stated, "I am just recently transitioning into the bereavement coordinator role. I did not document the assessments in the records." During an interview on 12/7/21 at 11:00 a.m., the administrator (Adm #1) and the office manager (OM #1) acknowledged the findings. MR#7: This patient was admitted to hospice on 8/17/21. Record review on 12/2/21 indicates there was no documented bereavement assessment. MR#8: This patient was admitted to hospice on 4/28/21. Record review on 12/1/21 indicates there was no documented bereavement assessment. MR#9: This patient was admitted to hospice on 8/13/21. Record review on 12/1/21 indicates there was no documented bereavement assessment. MR#10: This patient was admitted to hospice on 10/9/21. Record review on 11/30/21 indicates there was no documented bereavement assessment. MR#11: This patient was admitted to hospice on 8/23/21. Record review on 11/30/21 indicates there was no documented bereavement assessment.

Based on record review and interview, the hospice failed to include data elements that allow for measurable outcomes on the start of care (SOC) for 4 of 11 records (MR #1, 2, 3, 5) reviewed, resulting in the potential for unmet care needs. Findings include: MR#1: This patient was admitted to hospice on 8/23/21 with a diagnosis of heart disease. During record review on 11/30/21, it was discovered that there were no documented goals on the SOC. MR#2: This patient's hospice admission date was 10/16/21, and the terminal diagnosis was heart failure. During record review on 12/1/21, it was discovered that there was no documented goals on the SOC. MR#3: This patient's hospice admission date was 9/2/21, and the terminal diagnosis was cerebrovascular disease. During record review on 12/2/21, it was discovered that there was no documented goals on the SOC. MR#5: This patient's hospice admission date was 10/25/21, and the terminal diagnosis was heart disease. During record review on 12/3/21, it was discovered that there was no documented goals on the SOC. During an interview on 12/7/21 at 11:00 a.m., the administrator (Adm #1) and the office manager (OM #1) acknowledged the findings.

Based on record review and interview the hospice failed to ensure the interdisciplinary group prepared a plan of care (L537); failed to ensure the plan of care specified the care and services necessary to meet patient/family needs(L538); failed to ensure the interdisciplinary group supervised the provision of care and services (L539); failed to ensure the interdisciplinary group was comprised of a physician, a registered nurse, a social worker, and a counselor (L541); failed to document essential information necessary for the development of the plan of care (L545); failed to ensure the plan of care included the services and frequency of visits necessary to meet the specific needs of the patient and family (L547); and failed to ensure the plan of care was reviewed, revised, and documented by the interdisciplinary group at least every 15 days (L552). These practices impacted 11 of 11 patients (MR# 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) in which the patient was on hospice care for a period of time greater than 5 days, from a total sample of 11 records reviewed. The cumulative effect of these systemic problems resulted in the hospice's inability to ensure the provision of quality end of life care for the condition of participation of 42 CFR §418.56: Interdisciplinary Group, Care Planning and Coordination of Services. Findings include: 1. The IDG did not prepare a plan of care. (See L537) 2. The plan of care did not include the necessary care and services to meet the needs of the patient or family. (See L538) 3. The IDG did not supervise the care and services provided. (See L539) 4. There was no indication who participated in IDG and contributed to the plans of care. (See 541) 5. There was no documentation of essential information needed to develop plans of care. (See L545) 6. The plans of care did not include the frequency of visits and other services to meet the needs of the patient or family (See L547) 7. There was no indication the plans of care were reviewed or revised by the IDG. (See L552)

Based on record review and interview, the hospice failed to ensure the interdisciplinary group prepared a plan of care for 6 of 11 (MR# 2, 3, 5, 7, 8, 10) records reviewed, resulting in no plan to meet the patient and family-specific needs of this patient. Findings include: MR#7: The patient was discharged from the hospital on 8/16/21 after getting tangled up in his wheelchair resulting in a right ankle fracture and laceration. The patient underwent surgery on 8/13/21 to debride the laceration along with a closed reduction of the fracture. The patient was admitted to hospice on 8/17/21 with diagnoses of a stroke and right-hand contracture. During record review on 12/2/21, it was noted that there was no care plan developed by the interdisciplinary group (IDG) until 9/8/21, which is 22 days after the patient was admitted to hospice. The 9/8/21 IDG care plan is virtually blank of content or patient specific information. The IDG failed to develop a plan of care for this recent post-operative hospice patient. MR#8: This patient was admitted to hospice on 4/28/21 with diagnoses of Parkinson's disease, high blood pressure and depression. During record review on 12/1/21, it was noted that the plan of care (POC) is virtually blank and is dated January 1, 1900. It is unclear why this POC is dated 121 years ago. There was no evidence the IDG developed a plan of care for this hospice patient. MR#10: This patient was admitted to hospice care on 10/9/21 with diagnoses of rheumatoid arthritis and high blood pressure. During record review on 11/30/21, it was noted that the IDG failed to develop a POC for this patient. The patient was on hospice services for approximately 6 weeks, from 10/9/21 through 11/16/21, without a POC to direct the care and services for this patient. The IDG failed to follow hospice policy III.7 Hospice Plan of Care (not dated), which states the plan of care shall be developed within 5 days of the comprehensive assessment. The findings were reviewed with and acknowledged by the Administrator and the Office Manager during an interview on 12/7/21 at 10:00 a.m. MR#2: This patient's hospice admission date was 10/16/21 and the terminal diagnosis was heart failure. During record review on 12/1/21, it was discovered that the plan of care (POC) was not completed by the interdisciplinary group (IDG) until 11/3/21, 16 days after the start of care (SOC). The POC was mostly blank and did not provide basic information to meet the needs of the patient. MR#3: This patient's hospice admission date was 9/2/21 and the terminal diagnosis was spastic quadriplegic cerebral palsy. During review of the POC on 12/2/21, it was discovered that spiritual care had not been involved with the IDG in developing the POC. The IDG care plan was mostly blank and lacked basic information to meet the needs of the patient. The IDG did not develop a POC with all disciplines required. MR#5: This patient's hospice admission date was 10/25/21 and the terminal diagnosis was heart disease. During record review on 12/2/21, it was noted that there was no care plan developed by the IDG until 10/30/21, which is 5 days after the patient was admitted to hospice. The 10/30/21 IDG care plan was virtually blank and did not provide basic information to meet the needs of the patient. During an interview on 12/7/21 at 11:00 a.m., the administrator (Adm #1) and the office manager (OM #1) acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the plan of care specified the care and services necessary to meet patient/family needs in 2 of 11 (MR# 7, 8), records reviewed, resulting in the potential for unmet care needs for these patients. Findings include: MR#7: The patient was discharged from the hospital on 8/16/21 after getting tangled up in his wheelchair resulting in a right ankle fracture and laceration. The patient underwent surgery on 8/13/21 to debride the laceration along with a closed reduction of the fracture. The patient was admitted to hospice on 8/17/21 with diagnoses of a stroke and right-hand contracture. During record review on 12/2/21, it was noted that there was no care plan developed by the interdisciplinary group (IDG) until 9/8/21, which is 22 days after the patient was admitted to hospice. The 9/8/21 IDG care plan is virtually blank of content and information. No care or services are specified to meet the needs of the patient or family. MR#8: This patient was admitted to hospice on 4/28/21 with diagnoses of Parkinson's disease, high blood pressure and depression. During record review on 12/1/21, it was noted that the plan of care (POC) is virtually blank of content, listing only the patient's name, date of birth, and diagnoses. The POC is dated January 1, 1900. It is unclear why this POC is dated 121 years ago. No care or services are specified to meet the needs of the patient or family.

Based on record review and interview, the hospice failed to ensure the interdisciplinary group supervised the provision of care and services for 2 of 11 (MR# 9, 11) records reviewed, resulting in the potential for unmet care needs for these patients. Findings include: MR#9: This patient was admitted to hospice on 8/13/21 with diagnoses of Alzheimer's disease and a stage 3 pressure ulcer on the coccyx. During record review on 12/1/21, it was noted that the POC (plan of care) summary indicates the registered nurse (RN) is to make 4 visits per week. The 8/26/21, 9/8/21, and the 10/6/21 POC/interdisciplinary group (IDG) documents indicate the RN is to make 4 visits per week. Record review indicates the patient receives one nursing visit per week from 8/13/21 to 12/1/21. There was no documented evidence the patient or family declined the other 3 visits each week for the past 17 weeks. MR#11: This patient was admitted to hospice on 8/23/21 with diagnoses of Alzheimer's disease and a stage 3 pressure ulcer on the lower left leg. During record review on 11/30/21, it was noted that the POC summary indicates the RN is to make 4 visits per week. The 9/8/21 and the 10/6/21 POC/IDG documents indicate the RN is to make 4 visits per week. Record review indicates the patient receives one nursing visit per week from 8/23/21 to 11/22/21. There was no documented evidence the patient or family declined the other 3 visits each week for the past 14 weeks. The IDG failed to supervise and ensure the provision of nursing care and services. The findings were reviewed with and acknowledged by the Administrator and the Office Manager during an interview on 12/7/21 at 10:00 a.m.

Based on record review and interview, the hospice failed to ensure the interdisciplinary group was comprised of a physician, a registered nurse, a social worker, and a counselor for 11 of 11 (MR# 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) records reviewed, resulting in a lack of hospice core services contributing to the development of care plans and ongoing assessments for all of the hospice's 43 current patients. Findings include: MR#1-11: During record reviews from 11/30/21 to 12/7/21, there was no documented evidence or indication as to which persons participated in the interdisciplinary group (IDG) meetings. There was no documented evidence that a physician, registered nurse, social worker, and a counselor were involved in developing plans of care and ongoing assessments and updates or revisions to the plans of care for each of these 11 patients. During an interview on 12/7/21 at 10:00 a.m., the above findings were reviewed with the Administrator (Adm #1) and the Office Manager (OM #1). Adm #1 explained that the hospice is conducting IDG meetings and updating the plans of care, but they are failing to document their efforts appropriately.

Based on interview and record review, the RN failed to document essential information necessary for the development of the plan of care (POC) for 4 of 11 records (1, 2, 3, 5) reviewed, resulting in an undeveloped POC, and the potential for unmet patient care needs. Findings include: **Agency Policy: Evergreen Hospice III.7, undated, Hospice Plan of Care: "The plan of treatment shall include; date established, diagnosis, specific discipline and frequency of services, functional limitations, safety precautions, mental status, and patient/caregiver understanding, prognosis, allergies, diet, medical supplies and equipment (DME), activity permitted and restricted, interventions, goals/outcomes anticipated and discharge plans. MR#1: This patient's hospice admission date was 10/16/21 and the terminal diagnosis was heart failure. During review of the POC on 11/30/21, it was discovered that no interventions or goals, level of care, or DME needs were documented. MR#2: This patient's hospice admission date was 10/16/21 and the terminal diagnosis was heart failure. During review of the POC on 12/1/21, it was discovered that no interventions or goals, level of care, functional limitations, diet or DME needs were documented. MR#3: This patient's hospice admission date was 9/2/21 and the terminal diagnosis was spastic quadriplegic cerebral palsy. During review of the POC on 12/2/21, it was discovered that no disaster triage, mental status, diet, interventions, goals, treatments, or DME needs were documented. MR#5: This patient's hospice admission date was 10/30/21 and the terminal diagnosis was heart disease. During review of the POC on 12/2/21, it was discovered that no activities permitted, functional limitations, diet, interventions, goals, or DME needs were documented. During an interview on 12/7/21 at 11:00 a.m., the administrator (Adm #1) and the office manager (OM #1) acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the plan of care included the services and frequency of visits necessary to meet the specific needs of the patient and family for 3 of 11 (MR# 2, 7, 10) clinical records reviewed, resulting in the potential for unmet care needs for the agency's current census of 43 patients. Findings include: MR#7: The patient was discharged from the hospital on 8/16/21 after getting tangled up in his wheelchair resulting in a right ankle fracture and laceration. The patient underwent surgery on 8/13/21 to debride the laceration along with a closed reduction of the fracture. The patient was admitted to hospice on 8/17/21 with diagnoses of a stroke and right-hand contracture. During record review on 12/2/21, it was noted that there was no care plan developed by the interdisciplinary group (IDG) until 9/8/21, which is 22 days after the patient was admitted to hospice. The 9/8/21 IDG care plan is virtually blank of content or patient specific information but does include a once-a-week frequency for the skilled nurse. The IDG failed to develop an initial plan of care, so it is unclear how many nursing visits or other services may have actually been needed for this post-operative patient in the first 3 weeks of hospice care. MR#10: This patient was admitted to hospice care on 10/9/21 with diagnoses of rheumatoid arthritis and high blood pressure. During record review on 11/30/21, it was noted that there was no plan of care developed by the IDG for this patient. The patient was on hospice services for approximately 6 weeks, from 10/9/21 through 11/16/21. There was no indication of the scope and frequency of services that were necessary to meet the needs of this hospice patient. During an interview on 12/7/21 at 10:00 a.m., the above findings were reviewed with and confirmed by the Administrator (Adm #1) and the Office Manager (OM #1). MR#2: The patient was admitted to hospice on 10/16/21 with a diagnosis of heart failure. During record review on 12/2/21, it was noted that there was no care plan developed by the interdisciplinary group (IDG), no IDG meetings were documented in the record. The IDG failed to develop an initial plan of care or any subsequent plans of care, so it is unclear what care/updates/changes were needed for this patient throughout the certification period. During an interview on 12/7/21 at 11:00 a.m., the administrator (Adm #1) and the office manager (OM #1) acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the plan of care was reviewed, revised, and documented by the interdisciplinary group at least every 15 days for 10 of 11 (MR# 1, 2, 3, 4, 5, 7, 8, 9, 10, 11) clinical records reviewed, resulting in no review or update of the patient's plan of care and the potential for unmet care needs for these patients. Findings include: MR#7: The patient was discharged from the hospital on 8/16/21 after getting tangled up in his wheelchair resulting in a right ankle fracture and laceration. The patient underwent surgery to debride the laceration along with a closed reduction of the fracture. The patient was admitted to hospice on 8/17/21 with diagnoses of a stroke and right-hand contracture. During record review on 12/2/21, it was noted that an IDG meeting was held on 9/8/21 which is 22 days after the patient was admitted to hospice. It is unclear if this meeting was to create the initial plan of care (since there is no initial plan of care) or to update the plan of care. The next IDG meeting on 10/6/21 was 28 days later. The plan of care/IDG reviews dated 9/8/21, 10/6/21, 10/17/21, 11/3/21 and 11/17/21 are all virtually blank of content or specific care needs for this patient or family. MR#8: This patient was admitted to hospice on 4/28/21. The patient was on hospice services for approximately 10 weeks, from 4/28/21 through 6/30/21. Throughout the 10-week period, there was only one documented IDG meeting dated 1/1/1900 (120 years ago). The 1/1/1900 POC was virtually blank of content, listing the patient's name, date of birth, and diagnosis. MR#9: This patient was admitted to hospice on 8/13/21 and is still currently on hospice care at the time of record review on 12/1/21. There is a documented IDG meeting on 9/8/21. The next IDG meeting is on 10/6/21 which is 28 days later. There have been no documented IDG meetings from 10/7/21 through 12/1/21, which is a period of 56 days. MR#10: This patient was admitted to hospice care on 10/9/21 through 11/16/21. Throughout the 6-week period there were no documented IDG meetings for this patient. MR#11: This patient was admitted to hospice care on 8/23/21 and is still currently on hospice care at the time of record review on 11/30/21. There is a documented IDG meeting on 9/8/21. The next IDG meeting is on 10/6/21 which is 28 days later. After 10/6/21, there are no documented IDG meetings covering a period of 55 days without a review or revision to the patient's POC. During an interview on 12/7/21 at 10:00 a.m., the above findings were reviewed with the administrator (Adm #1) and the office manager. Adm #1 explained that the hospice is conducting IDG meetings and updating the plans of care, but they are failing to document their efforts appropriately. **Policy: Hospice policy III.14 IDG (interdisciplinary group) Case Conference/Update of Comprehensive Assessment (not dated), which states that case conferences shall be held...to review the plan of treatment...and to update the comprehensive assessment, as often as necessary but at least every 15 days. MR#1: The patient was admitted to hospice on 8/23/21, with a diagnosis of heart disease. During record review on 11/30/21, it was discovered that a plan of care (POC)/interdisciplinary group (IDG) meeting was held on 9/8/21 and 10/12/21. A POC/IDG meeting should have occured between those 2 dates and 2 more meetings should have occured after the 10/12/21 meeting. The 2 POC/IDG reviews had inadequately documented patient care, with most areas being blank of content or specific care needed for the patient/family. MR#2: The patient was admitted to hospice on 10/16/21, with a diagnosis of heart failure. During record review on 12/1/21, it was discovered that no POC/IDG meetings were documented in the record. MR#3: The patient was admitted to hospice on 9/2/21, with a diagnosis of cerebrovascular disease. During record review on 12/2/21, it was discovered that a POC/IDG meeting was held on 9/8/21 and 10/6/21. A POC/IDG meeting should have occured between those 2 dates and 3 more meetings should have occured after the 10/12/21 meeting. The POC/IDG reviews that were recorded in the record, had inadequately documented patient care, with most areas being blank of content or specific care needed for the patient/family. MR#4: The patient was admitted to hospice on 6/11/21, with a diagnosis of spastic quadraplegic cerebral palsy. During record review on 12/2/21, it was discovered that a POC/IDG meeting was held on 9/8/21 and 10/6/21. A POC/IDG meeting should have occured between those 2 dates and 3 more meetings should have occured after the 10/6/21 meeting. The POC/IDG reviews that were recorded in the record, had inadequately documented patient care, with most areas being blank of content or specific care needed for the patient/family. MR#5: The patient was admitted to hospice on 10/25/21, with a diagnosis of heart disease. During record review on 12/2/21, it was discovered that a POC/IDG meeting was held on 11/3/21 and 11/17/21 and 12/17/21. The 12/17/21 meeting had information documented and is 15 days from now. The POC/IDG reviews that were recorded in the record, had inadequately documented patient care, with most areas being blank of content or specific care needed for the patient/family. During an interview on 12/7/21 at 11:00 a.m., the administrator (Adm #1) and the office manager (OM #1) acknowledged the findings.

Based on document review, policy review and interview, it was noted that the hospice failed to ensure a Quality Assessment Performance Improvement (QAPI) program was developed, implemented and maintained that was based on hospice wide data involving all hospice services which was aimed at improving palliative outcomes and took actions to demonstrate improvement in hospice services. (See L560); failed to ensure the Quality Assessment Performance Improvement program (QAPI) demonstrated measurable improvement in palliative outcomes and hospice service indicators. (See L561); failed to ensure accurate data was measured, analyzed and tracked to evaluate the hospice's processes of care, hospice services and operations. (See L562); failed to use data to monitor the effectiveness and safety of services and identify opportunities and priorities for improvement. (See L564); failed to include activities that would affect palliative outcomes, patient safety and quality of care. (See L568); failed to clearly document what performance improvement projects were being conducted, the reasons for conducting those projects and the measurable progress achieved on these projects. (See L573); and failed to ensure the Quality Assessment Performance Improvement (QAPI) program looked at hospice wide data to ensure that the QAPI efforts addressed agency specific priorities for improved quality of care/outcomes and patient safety, implemented improvement actions and evaluated the QAPI program for effectiveness. (See L575). The systemic effects of these failures resulted in an ineffective quality assessment and performance improvement program that allowed for the provision of substandard care.

Based on record review and interview, it was noted that the hospice failed to ensure a Quality Assessment Performance Improvement (QAPI) program was developed, implemented and maintained that was based on hospice wide data involving all hospice services which was aimed at improving palliative outcomes and took actions to demonstrate improvement in hospice services, which resulted in prolonged provision of substandard care. **Agency policy: VI.1 QAPI program, undated: "QAPI's goal is to improve the hospice's performance by designing its processes well and systematically collecting data, monitoring, analyzing, and improving patient outcomes. The objective is to administer and coordinate the hospice's QAPI program which is designed to ensure all QAPI activities are implemented...." On 12/7/21, during review of the "Performance Improvement" binder presented as this hospice's 2021 "QAPI" documentation, it was noted that the binder contained data from a hospice in California. It was unclear what data was from a California hospice and this hospice. During an interview on 12/7/21 at 11:00 a.m., the administrator (Adm#1) was asked about the California documents and stated, "We have a hospice in California, and it looks like this data is from that hospice." The QAPI documentation provided for 2021, failed to include clear and accurate data that was hospice wide and was utilized to develop actions to be taken that would improve palliative outcomes. Due to the discrepancies of the data collected and mixing of documentation from 2 different hospice providers, the QAPI program could not demonstrate effectiveness. The governing body failed to ensure an effective, hospice wide, data-driven quality assessment performance inprovement program involved all hospice services, including services provided under arrangement, focused on improving palliative outcomes and documented actions taken to improve the hospice's performance. During an interview on 12/7/21 at 11:00 a.m., Adm#1 and the office manager (OM#1) acknowledged the findings.

Based on record review and interview, it was determined that the hospice failed to ensure the Quality Assessment Performance Improvement program (QAPI) demonstrated measurable improvement in palliative outcomes and hospice service indicators, which resulted in the potential for negative patient outcomes and failure to meet patient needs. Findings include: **Agency policy: VI.1 QAPI program, undated: "QAPI's goal is to improve the hospice's performance by designing its processes well and systematically collecting data, monitoring, analyzing, and improving patient outcomes. The objective is to administer and coordinate the hospice's QAPI program which is designed to ensure all QAPI activities are implemented...." On 12/7/21, during review of the "Performance Improvement" binder presented as this hospice's 2021 "QAPI" documentation, it was noted that the binder contained data from a hospice in California. It was unclear what data was from a California hospice and this hospice. During an interview on 12/7/21 at 11:00 a.m., the administrator (Adm#1) was asked about the California documents and stated, "We have a hospice in California, and it looks like this data is from that hospice." Due to the lack of data collection related to patient care, hospice services provided and palliative outcomes, the inaccurate data numbers and the agency's lack of analyzing data and comparing it over time to look for evidence of improvement, it was noted that the hospice's QAPI program did not show measurable improvement in indicators related to improved patient outcomes.

Based on record review and interview, it was determined that the hospice failed to ensure accurate data was measured, analyzed and tracked to evaluate the hospice's processes of care, hospice services and operations, which resulted in the potential for negative patient outcomes or failure to meet patient needs. Findings include: **Agency policy: VI.1 QAPI program, undated: "QAPI's goal is to improve the hospice's performance by designing its processes well and systematically collecting data, monitoring, analyzing, and improving patient outcomes. The objective is to administer and coordinate the hospice's QAPI program which is designed to ensure all QAPI activities are implemented....Tracking identified problems to ensure improvement or resolution." On 12/7/21, during review of the "Performance Improvement" binder presented as this hospice's 2021 "QAPI" documentation, it was noted that the binder contained data from a hospice in California. It was unclear what data was from a California hospice and this hospice. During an interview on 12/7/21 at 11:00 a.m., the administrator (Adm#1) was asked about the California documents and stated, "We have a hospice in California, and it looks like this data is from that hospice." Due to the intermixing of documents between multiple hospice providers it was difficult to determine the validity of the data collected for this provider number. The agency failed to ensure that accurate hospice wide data was collected, measured, analyzed and tracked. The review of the data forms provided for the 2021 QAPI program revealed that the data collected did not necessarily reflect care and services provided by Beacon Hospice of Michigan. There was no documented analysis or tracking of the data collected that could be used to assess processes of care, hospice services, and operations of this hospice provider.

Based on record review and interview, it was determined that the hospice failed to use data to monitor the effectiveness and safety of services and identify opportunities and priorities for improvement, which resulted in the potential for negative patient outcomes and unmet patient needs. Findings include: **Agency policy: VI.1 QAPI program, undated: "QAPI's goal is to improve the hospice's performance by designing its processes well and systematically collecting data, monitoring, analyzing, and improving patient outcomes. The objective is to administer and coordinate the hospice's QAPI program which is designed to ensure all QAPI activities are implemented....Tracking identified problems to ensure improvement or resolution." On 12/7/21, during review of the "Performance Improvement" binder presented as this hospice's 2021 "QAPI" documentation, it was noted that the binder contained data from a hospice in California. It was unclear what data was from a California hospice and this hospice. During an interview on 12/7/21 at 11:00 a.m., the administrator (Adm#1) was asked about the California documents and stated, "We have a hospice in California, and it looks like this data is from that hospice." During the review of the QAPI data, it was noted that there was no data collection related to patient care and outcomes, the data did not include all hospice services including contracted services, the data was inconsistent and there was no analysis of the data to demonstrate the effectiveness of the hospice program. There was no evidence the hospice collected data that reflected the effectiveness of hospice services provided, the safety of services and the quality of patient care for this hospice's specific performance. There was no evidence the hospice used the data that was collected in 2021 to identify opportunities and priorities for improvement of hospice performance.

Based on document review and interview it was noted that the hospice's Quality Assessment Performance Improvement (QAPI) program failed to include activities that would affect palliative outcomes, patient safety and quality of care, which resulted in the potential for negative patient outcomes and failure to meet patient needs. Findings include: **Agency policy: VI.1 QAPI program, undated: "QAPI's goal is to improve the hospice's performance by designing its processes well and systematically collecting data, monitoring, analyzing, and improving patient outcomes. The objective is to administer and coordinate the hospice's QAPI program which is designed to ensure all QAPI activities are implemented....Tracking identified problems to ensure improvement or resolution." On 12/7/21, during review of the "Performance Improvement" binder presented as this hospice's 2021 "QAPI" documentation, it was noted that the binder contained data from a hospice in California. It was unclear what data was from a California hospice and this hospice. During an interview on 12/7/21 at 11:00 a.m., the administrator (Adm#1) was asked about the California documents and stated, "We have a hospice in California, and it looks like this data is from that hospice." It was also noted that there was no documentation of any actions taken to improve the quality of care and patient outcomes. During the same interview, Adm#1 stated, "We do things to improve patient safety and reduce infections, but we don't have any documentation for this hospice, to show it." There was no documentation of performance improvement actions taken or data analysis that showed the QAPI program had any effect on palliative outcomes, patient safety and quality of care.

Based on record review and interview, it was determined that the hospice failed to clearly document what performance improvement projects were being conducted, the reasons for conducting those projects and the measurable progress achieved on these projects, which resulted in the potential for missed opportunities for improvement of patient care processes and outcomes. **Agency policy: VI.1 QAPI program, undated: "QAPI's goal is to improve the hospice's performance by designing its processes well and systematically collecting data, monitoring, analyzing, and improving patient outcomes. The objective is to administer and coordinate the hospice's QAPI program which is designed to ensure all QAPI activities are implemented....Tracking identified problems to ensure improvement or resolution." On 12/7/21, during review of the "Performance Improvement" binder presented as this hospice's 2021 "QAPI" documentation, it was noted that the binder contained data from a hospice in California. It was unclear what data was from a California hospice and this hospice. During an interview on 12/7/21 at 11:00 a.m., the administrator (Adm#1) was asked about the California documents and stated, "We have a hospice in California, and it looks like this data is from that hospice." During the review of the Performance Improvement/QAPI binder, it was noted that there was no mention of specific performance improvement projects being conducted by this hospice. There were no documents provided that showed the agency had conducted any activities to improve the quality of patient care, patient safety and patient outcomes as part of performance improvement projects. The hospice failed to document that provider specific performance improvement projects were being conducted, the reason for conducting these projects, actions taken to improve the hospice performance in the selected areas and measurable progress achieved on these projects.

Based on record review and interview, it was determined that the hospice's governing body failed to ensure the Quality Assessment Performance Improvement (QAPI) program looked at hospice wide data to ensure that the QAPI efforts addressed agency specific priorities for improved quality of care/outcomes and patient safety, implemented improvement actions and evaluated the QAPI program for effectiveness, which resulted in the agency providing substandard care for a prolonged period of time. Findings include: **Agency policy: VI.1 QAPI program, undated: "QAPI's goal is to improve the hospice's performance by designing its processes well and systematically collecting data, monitoring, analyzing, and improving patient outcomes. The objective is to administer and coordinate the hospice's QAPI program which is designed to ensure all QAPI activities are implemented....Tracking identified problems to ensure improvement or resolution." On 12/7/21, during review of the "Performance Improvement" binder presented as this hospice's 2021 "QAPI" documentation, it was noted that the binder contained data from a hospice in California. It was unclear what data was from a California hospice and this hospice. During an interview on 12/7/21 at 11:00 a.m., the administrator (Adm#1) was asked about the California documents and stated, "We have a hospice in California, and it looks like this data is from that hospice." During review of the Performance Improvement/QAPI binder, it was noted that there was no documentation of hospice wide data collection related to patient care, hospice services provided and palliative outcomes. There was no documentation of analysis or tracking comparing the data over time to show evidence of improvement related to improved palliative outcomes and hospice services. There was no evidence of any identification of areas for improvement. There was no documentation that any actions had been taken to improve patient care processes and outcomes. Due to intermixing multiple documents from another hospice provider operating out of another state, the QAPI documentation provided for 2021 failed to include clear and accurate data. Due to the discrepancies of the data collected and mixing of documentation form 2 different hospice providers, the QAPI program could not demonstrate effectiveness. There was no documentation of performance improvement actions taken or data analysis that showed the QAPI program had any effect on palliative outcomes, patient safety and quality of care. There was no evidence the Governing Body ensured the QAPI efforts were hospice wide and addressed priorities for improved quality of care and patient safety for this specific hospice provider. The Governing Body failed to evaluate QAPI improvement actions for effectiveness.

Based on record review and interview, it was determined the hospice failed to maintain and document an effective infection control program that protects patients, families, visitors and hospice personnel by preventing and controlling infections and communicable diseases (L578); failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that was an integral part of the hospice's quality assessment and performance improvement program (L580); failed to maintain records and document an operational, coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that included a method of identifying infectious and communicable disease problems and a plan for implementing the appropriate actions that are expected to result in improvement and disease prevention (L581). Findings included: There was no evidence the agency maintained an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases. (Refer to L578). There was no evidence the agency maintained a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that was an integral part of the hospice's quality assessment and performance improvement (QAPI) program. (Refer to L580). There was no evidence the agency maintained records and documented an operational, coordinated agency-wide program for surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that included a method of identifying infectious and communicable disease problems and a plan for implementing the appropriate actions that are expected to result in improvement and disease prevention. (Refer to L581). These systemic problems resulted in the hospice's inability to maintain adequate infection control and ensure the provision of quality health care in a safe environment.

Based on record review and interview, it was determined the hospice failed to maintain and document an effective infection control program that monitors the staff for compliance with hospice policies and procedures as it relates to infection control. Findings include: **Agency Policy: X.3 Infection Control Program, undated: "The agency will maintain an infection control program, which is based upon current scientific knowledge for surveillance and prevention of adverse outcomes related to infections. The program is appropriate to the demographics of the patient population and addresses epidemiological issues that are relevant to the organization. The program will educate staff in the prevention and control of infections initially and annually thereafter. The program will maintain a surveillance system to track the occurrences and transmission of infections related to the care/services provided...." During review of the agency's infection control program documents on 12/7/21, it was discovered that no documentation of the hospice agency employees was included in a surveillance program identifying, reporting and analyzing infections. When asked if there was documented evidence of monitoring for compliance with infection control policies the administrator (Adm #1) and the office manager (OM #1) responded, "We do it, we just have not documented it." When asked if there was an Employee Health Program which monitored employee illnesses and tracked them to determine any correlation between patient and employee illnesses, Adm#1 and OM#1 stated, "We have not documented it." There was no actual data available for review upon request. There was no documented evidence that employees were included in any infectious disease monitoring, and there was no documented evidence the hospice agency monitored the employees' compliance with the infection control policies. During an interview on 12/7/21 at 11:00 a.m., the Adm #1 and OM #1 acknowledged the findings.

Based on record review and interview, it was determined that the hospice program failed to ensure that its performance improvement activities included a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases potentially negatively affecting all patients serviced by the hospice. Findings include: **Agency Policy: X.3 Infection Control Program, undated: "The agency will maintain an infection control program, which is based upon current scientific knowledge for surveillance and prevention of adverse outcomes related to infections. The program is appropriate to the demographics of the patient population and addresses epidemiological issues that are relevant to the organization. The program will educate staff in the prevention and control of infections initially and annually thereafter. The program will maintain a surveillance system to track the occurrences and transmission of infections related to the care/services provided...." On 12/7/21, during a review of the agency's performance improvement activities, it was noted that the quality program failed to include a comprehensive infection control component such as surveillance, tracking and trending of infections and accurate data collection. During an interview on 12/7/21 at 11:00 a.m., the administrator (Adm #1) and the office manager (OM #1) acknowledged the findings.

Based on record review and interview, the hospice failed to maintain records and document an operational, coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that included a method of identifying infectious and communicable disease problems and a plan for implementing the appropriate actions that are expected to result in improvement and disease prevention. On 12/7/21 at 11:00 a.m., during an interview, when asked to describe the hospice's infection control program and what methods were used to identify infectious and communicable disease problems and the plan for implementing appropriate actions, the administrator (Adm#1) stated, "We do not really have a program in place."

Based on record review and interview, the hospice failed to provide counseling services for the hospice patient and family for 7 of 11 (MR # 1, 2, 3, 4, 5, 7, 8) records reviewed, resulting in a lack of assistance for these patients and family members in coping with the stress and problems that arise from the terminal illness and the dying process. Findings include: MR#7: This patient was admitted for hospice care on 8/17/21 with diagnoses of a stroke. During record review on 12/2/21, it was noted that the 8/17/21 plan of care (POC) summary indicated that the social worker is to make an initial visit within 5 days to identify psychosocial issues and support needed by the patient and family. The POC also indicates the spiritual counselor is to make an initial visit within 5 days to identify spiritual issues and support needed by the patient and family. There was no documentation to indicate the patient or family had declined these counseling services. During an interview on 12/3/21 at 12:24 p.m., the findings were reviewed with OM#1 (office manager) who explained that the patient and family declined counseling services, but the nurse has not yet uploaded the information from the comprehensive assessment into their system. The comprehensive assessment of this patient took place on 8/17/21, which was more than 3 months ago. MR#8: This patient was admitted to hospice care on 4/28/21 with diagnoses of Parkinson's disease, high blood pressure, and depression. During record review on 12/1/21, it was noted that the 4/29/21 comprehensive assessment indicates that social work, spiritual care, and bereavement counseling services were needed for this patient. There was no documented evidence that these services had been provided and no documentation to indicate the patient or family had declined these counseling services. MR#1: This patient was admitted to hospice on 8/23/21 with a diagnosis of heart disease. During record review on 11/30/21, it was discovered that there was no comprehensive assessment or bereavement plan documented in the record by bereavement/counseling services. There was no documented evidence bereavement counseling services were declined. MR#2: This patient's hospice admission date was 10/16/21, and the terminal diagnosis was heart failure. During record review on 12/1/21, it was discovered that there was no comprehensive assessment or bereavement plan documented in the record by bereavement/counseling services. There was no documented evidence bereavement/counseling services were declined. MR#3: This patient's hospice admission date was 9/2/21, and the terminal diagnosis was cerebrovascular disease. During record review on 12/2/21, it was discovered that there was no comprehensive assessment or bereavement plan documented in the record by bereavement/counseling services. There was no documented evidence bereavement/counseling services were declined. MR#4: This patient's hospice admission date was 6/11/21, and the terminal diagnosis was spastic quadriplegic cerebral palsy. During record review on 12/2/21, it was discovered that there was no comprehensive assessment or bereavement plan documented in the record by bereavement/counseling services. There was no documented evidence bereavement/counseling services were declined. MR#5: This patient's hospice admission date was 10/25/21, and the terminal diagnosis was heart disease. During record review on 12/3/21, it was discovered that there was no comprehensive assessment or bereavement plan documented in the record by bereavement/counseling services. There was no documented evidence bereavement/counseling services were declined. During an interview on 12/3/21 at 10:30 a.m., the bereavement coordinator (BC#1) was questioned regarding the assessment documentation. BC#1 stated, "I am just recently transitioning into the bereavement coordinator role. I am not yet familiar with the bereavement program here. I only see patients that are referred to me and not all patients are referred to me. I have done assessments and counseling on some patients but I did not document the assessments in the records." During an interview on 12/7/21 at 11:00 a.m., the administrator (Adm #1) and the office manager (OM #1) acknowledged the findings.

Based on interview and record review, the agency failed to have an organized bereavement program in place for the provision of bereavement services to meet the bereavement needs of family members, resulting in the potential for unmet family bereavement needs. Findings include: **Agency Policy: III.37 Bereavement Program, undated: Evergreen Hospice, LLC will provide an organized bereavement program supervised by a qualified bereavement coordinator for up to 13 months following the death of a patient. A bereavement risk assessment will be completed by the hospice social worker, bereavement coordinator, or spiritual counselor within 5 days of the patient's admission to hospice." During an interview with the Bereavement Coordinator (BC#1) on 12/3/21 at 10:30 a.m., CH#1 was asked to give an overview of the agency's Bereavement Program. CH#1 failed to include any information to substantiate an active, operational bereavement program that would service the needs of bereaved family members. CH#1 was queried if the agency had any deceased patients who had family members in need of bereavement counseling, CH#1 stated, "I have only worked here for a few months and I have only attended 2 IDG meetings. I am just recently transitioning into the BC position. No bereavement records were identified during the survey and no bereavement assessments or bereavement care plans were documented. The agency failed to be prepared to meet the needs of bereaved family members cared for by this hospice. During an interview on 12/7/21 at 11:00 a.m., the administrator (Adm #1) and the office manager (OM #1) acknowledged the findings.

Based on observation, record review and interview, the hospice failed to ensure aide services were provided by individuals who meet the personnel requirements specified in paragraph (a) of this section; ensure aides have successfully completed a training program, competency, or State licensure program; ensure the written plan of care for the hospice aide provides a visit frequency, specific guidance, and care instructions on the needs of the patient; ensure the aide provides services as ordered in the plan of care; and ensure the registered nurse documents a relevant on-site supervisory visit. These practices impacted 5 of 7 patients (MR# 7, 8, 9, 10, 11) in which the aide services were provided or ordered. The cumulative effect of these systemic problems results in the hospice's inability to ensure the provision of quality end of life health care in a safe environment for the Condition of Participation at 42 CFR 418.76, Hospice aide and homemaker services. Findings include: 1. Hospice services were provided by aides that did not meet the personnel requirements for 3 of 4 (Aide#1, Aide#2, Aide#3) aides employed by the agency. (See L608) 2. Hospice aide qualifications were not met for 3 of 4 aides (Aide#1, Aide#2, Aide#3). (See L609) 3. Aide care plans did not include visit frequencies and care instructions pertinent to the patient's needs for 4 of 7 (MR# 7, 8, 9, 10 ) records reviewed with aide services ordered. (See L625) 4. Aide did not provide care as ordered in the plan of care for 4 of 7 (MR# 7, 8, 9, 11) records reviewed with aide services ordered. (See L626) 5. The registered nurse documented aide supervisory visits even though the aide had not provided patient care. (See L629)

Based on observation, record review and interview, the hospice failed to ensure that hospice aide services are provided by individuals that meet the requirements specified in paragraph (a) of this section for 3 of 4 (Aide#1, Aide#2, Aide#3) aides employed by the agency, resulting in the provision of substandard care for 1 patient. Findings include: On 12/3/21 the personnel files for Aide#1, Aide#2, Aide#3, and Aide#4 were reviewed and the following was noted: Aide#1: Date of hire 11/19/21. The personnel file contained no evidence that Aide#1 had completed an aide training program, a competency evaluation program, or a State licensure program. Aide#2: Date of hire 10/1/21. The personnel file contained documentation that Aide#2 had completed 80 hours of certified nurse assistance training on 11/1/19. There was no documented evidence that Aide#2 had completed a competency evaluation program or a State licensure program. Aide#3: Date of hire 8/27/21. The personnel file contained documentation that Aide#3 had completed 75 hours of nurse assistant training with the Red Cross. There was no documented evidence that Aide#3 had completed a competency evaluation program or a State licensure program. MR#7: This patient was admitted to hospice on 8/17/21 with diagnoses of a stroke and right-hand contracture. A joint surveyor home visit was conducted with Aide#1 on 12/2/21 at 12 noon in the patient's home. The aide was observed performing a bed bath with MR#7. The patient was lying in bed completely naked with no covering. The patient was denied dignity, privacy, comfort, and warmth throughout the entire bed bath process. The aide did not dry the patient's skin with a towel or other cloth after washing each area of the patient's body. A new brief was put on the patient without first drying the moisture on the patient's back, buttocks, or groin area. The patient was then dressed without drying the moisture on the remainder of the patient's body. The patient was repositioned in bed and remained on the same 2 blue chucks pads (used to protect the bedding and mattress) that were under the patient during the bed bath. The chucks pads were now soiled and damp after the completion of the bed bath. The above findings and observations were reviewed with and acknowledged by the Director of Nursing and the office manager during an interview on 12/3/21 at 3:00 p.m.

Based on record review and interview, the hospice failed to ensure 3 of 4 aides (Aide#1, Aide#2, Aide#3) had successfully completed a training program and competency evaluation, or a competency evaluation, or a nurse aide training program and evaluation, or a State licensure program, resulting in the potential provision of substandard care for the hospice's 43 current patients. Findings include: On 12/3/21 the personnel files for Aide#1, Aide#2, Aide#3, and Aide#4 were reviewed and the following was noted: Aide#1: Date of hire 11/19/21. The personnel file contained no evidence that Aide#1 had completed an aide training program, a competency evaluation program, or a State licensure program. Aide#2: Date of hire 10/1/21. The personnel file contained documentation that Aide#2 had completed 80 hours of certified nurse assistance training on 11/1/19. There was no documented evidence that Aide#2 had completed a competency evaluation program or a State licensure program. Aide#3: Date of hire 8/27/21. The personnel file contained documentation that Aide#3 had completed 75 hours of nurse assistant training with the Red Cross. There was no documented evidence that Aide#3 had completed a competency evaluation program or a State licensure program. The hospice failed to follow its own policy IV.16 Hospice Aide Testing/Competency (not dated) which states that each hospice personal care aide shall demonstrate competence for their position as demonstrated by evidence of completion of an approved 75-hour training program and "on-site observation of competency (required)." The above findings were reviewed with the Director of Nursing (DON #1)and the office manager during an interview on 12/3/21 at 3:00 p.m. DON#1 acknowledged the findings and confirmed that the hospice does not offer an aide training program and has not completed a competency evaluation of the aides.

Based on observation, record review and interview, the registered nurse failed to ensure the written plan of care for the hospice aide provides a visit frequency and specific guidance and care instructions on the needs of the patient, for 4 of 7 (MR# 7, 8, 9, 10) records reviewed with aide services ordered, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: MR#7: This patient was admitted to hospice on 8/17/21 with diagnoses of a stroke and right-hand contracture. A joint surveyor home visit was conducted with Aide#1 on 12/2/21 at 12 noon in the patient's home. It was observed that the patient had a dressing on the right ankle/foot and a dressing on the left ankle/foot along with wearing a heel protector boot. During record review on 12/2/21, it was noted that the aide care plan failed to document the presence of the dressings and the heel protector boot along with any instructions for the aide regarding the dressings and boot during the bed bath. The plan of care summary indicates that on 8/17/21 aide care was ordered twice a week for assistance with activities of daily living. The aide care plan prepared by the registered nurse failed to include a visit frequency. During the joint surveyor home visit, Aide #1 was queried regarding the frequency of visits. Aide#1 replied that she looks at what visits are put on her schedule and confirmed that the aide care plan does not have visit frequency instructions for the aide. MR#8: This patient was admitted to hospice care on 4/28/21 with diagnoses of Parkinson's disease, high blood pressure, and depression. During record review on 12/1/21, it was noted that both the 4/28/21 and the 5/3/21 aide care plans failed to include a visit frequency for the aide. MR#9: This patient was admitted to hospice care on 8/13/21 with diagnoses of Alzheimer's disease and a stage 3 pressure ulcer on the coccyx. During record review on 12/1/21, it was noted that the 8/14/21 aide care plan failed to include a visit frequency for the aide and failed to include any instructions for the aide regarding the pressure ulcer while providing a bed bath. MR#10: This patient was admitted to hospice care on 10/9/21 with diagnoses of rheumatoid arthritis and high blood pressure. During record review on 11/30/21, it was noted that the 10/12/21 aide care plan failed to include a visit frequency for the aide. The above findings were reviewed with and acknowledged by the Administrator and the Office Manager during an interview on 12/7/21 at 10:00 a.m.

Based on observation, record review and interview, the hospice failed to ensure the aide provides services as ordered in the plan of care for 4 of 7 (MR# 7, 8, 9, 11) records reviewed with aide services ordered, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: MR#7: This patient was admitted to hospice on 8/17/21 with diagnoses of a stroke and right-hand contracture. The 9/15/21 aide care plan orders the aide to brush the patient's teeth and provide a bed bath. A joint surveyor home visit was conducted with Aide#1 on 12/2/21 at 12 noon in the patient's home. It was observed that the aide failed to brush the patient's teeth. The aide did not offer to brush the patient's teeth or offer to assist the patient with oral care. The patient did not decline assistance with oral care. It was also observed that the aide applied lotion to the patient's face, back abdomen, arms, and legs. The aide care plan does not instruct the aide to apply lotion. The above findings and observations were reviewed with and acknowledged by the Director of Nursing and the office manager during an interview on 12/3/21 at 3:00 p.m. The plan of care (POC) summary indicates that on 8/17/21 aide care was ordered twice a week for assistance with activities of daily living (ADLs). No aide visits were documented from 8/17/21 through 9/5/21. For three weeks (9/5/21 through 9/25/21) the aide provided 5 visits each week. Then for the next nine weeks (9/26/21 through 11/27/21) the aide provided three visits each week. It was unclear why the aide was providing different visit frequencies. There were no physician orders to provide anything other than two visits each week and the registered nurse made no changes to the aide care plan. During the joint surveyor home visit, Aide #1 was queried regarding the frequency of visits. Aide#1 replied that she looks at what visits are put on her schedule and confirmed that the aide care plan does not have visit frequency instructions for the aide. MR#8: This patient was admitted to hospice care on 4/28/21 with diagnoses of Parkinson's disease, high blood pressure, and depression. During record review on 12/1/21, it was noted that the POC summary indicates the aide is to provide 1 visit per week for assistance with ADLs beginning on 4/28/21. There was no evidence that aide visits were provided and no evidence that aide visits were declined by the patient. On 5/10/21, the POC summary indicates the aide is to provide 2 visits per week. There were no documented aide visits in weeks 3 and 4, from 5/10/21 through 5/22/21. There was one documented aide visit in week 5 on 5/26/21 and one visit in week 6 on 6/3/21. There was no documented evidence as to why the aide did not provide 2 visits each week. There was no indication that the patient or family had declined aide visits. MR#9: This patient was admitted to hospice on 8/13/21 with diagnoses of Alzheimer's disease and a stage 3 pressure ulcer on the coccyx. During record review on 12/1/21, it was noted that there were no physician orders for the aide to make visits to this patient. The 8/14/21 aide care plan failed to indicate a visit frequency for the aide. The aide documented 12 of 12 aide visits were declined from 9/7/21 through 10/14/21. It was unclear why the aide was attempting to make visits to this patient when no visits were ordered by the physician. MR#11: This patient was admitted to hospice on 8/23/21 with diagnoses of Alzheimer's disease and a stage 3 pressure ulcer on the lower left leg. During record review on 11/30/21, it was noted that the POC summary indicates the aide is to make 2 visits each week starting on 8/27/21. The aide care plan created by the nurse on 8/25/21 also instructs the aide to provide 2 visits each week. There were no documented aide visits throughout the 14-week episode of care from 8/23/21 to 11/27/21. There was no indication that the patient or family had declined aide visits. The aide failed to provide services as ordered in the plan of care. The above findings were reviewed with and confirmed by the Administrator and the Office Manager during an interview on 12/7/21 at 10:00 a.m.

Based on record review and interview, the hospice failed to ensure the registered nurse documented a relevant on-site supervisory visit for 2 of 7 records reviewed (MR# 9, 11) in which hospice aide services had been ordered or provided, resulting in the inability of the hospice to ensure patients received appropriate hospice aide care and services. Findings include: MR#9: This patient was admitted to hospice on 8/13/21 with diagnoses of Alzheimer's disease and a stage 3 pressure ulcer on the coccyx. During record review on 12/1/21, it was noted that there were no physician orders for the aide to make visits to this patient. The 8/14/21 aide care plan failed to indicate a visit frequency for the aide. The aide documented 12 of 12 aide visits were declined from 9/7/21 through 10/14/21. The registered nurse (RN) documented 8 aide supervisory visits (9/1/21, 9/17/21, 9/29/21, 10/12/21, 10/26/21, 11/4/21, 11/9/21, and 11/24/21) that indicate the aide was competent with assigned tasks, had good communication with the patient, aide services meet the patient's needs, and the aide complies with infection control practices. It is unclear how the RN could make claims of the aide's competency and infection control practices when the aide had not provided any patient visits throughout the 15 weeks of hospice care (8/14/21 through 12/1/21). MR#11: This patient was admitted to hospice on 8/23/21 with diagnoses of Alzheimer's disease and a stage 3 pressure ulcer on the lower left leg. During record review on 11/30/21, it was noted that the RN documented an aide supervisory visit on 9/2/21 that indicates the aide was competent with assigned tasks, had good communication with the patient, aide services meet the patient's needs, and the aide complies with infection control practices. It is unclear how the RN could make claims of the aide's competency and infection control practices when the aide had not provided any patient visits throughout the episode of care. The above findings were reviewed with and acknowledged by the Administrator and Office Manager during an interview on 12/7/21 at 10:00 a.m.

Based on record review and interview, the hospice failed to ensure that each patient's record included an initial plan of care, updated plans of care, initial assessment, comprehensive assessment and updated comprehensive assessment for 1 of 11 (MR#7) records reviewed, resulting in a lack of documented care. Findings include: MR#7: The patient was discharged from the hospital on 8/16/21 after getting tangled up in his wheelchair resulting in a right ankle fracture and laceration. On 8/13/21 the patient underwent surgery to debride the laceration along with a closed reduction of the fracture. The patient was admitted to hospice on 8/17/21 with diagnoses of a stroke and right-hand contracture. During record review on 12/2/21, it was noted that there was no documentation of an initial assessment, comprehensive assessment, initial plan of care, updated plans of care, and updated comprehensive assessments for this post-operative hospice patient. On 12/3/21 at 12:24 p.m., the office manager (OM #1) explained that she spoke to the director of nursing (DON #1) who completed the comprehensive assessment and DON#1 has not uploaded the information into their system since 8/17/21, which was more than 3 months ago.

Based on record review and interview, the hospice failed to ensure clinical documentation was appropriately authenticated by the discipline completing the visits for 2 of 11 (MR# 7, 10) records reviewed, resulting in an incomplete clinical record. Findings include: MR#7: This patient was admitted to hospice on 8/17/21 with diagnoses of a stroke and right-hand contracture. During record review on 12/2/21, it was noted that 4 of 15 (27%) skilled nursing visit notes were not signed/authenticated by the person that documented the visit note. The unsigned visit notes are dated 8/20/21, 9/14/21, 9/28/21, and 11/26/21. MR#10: This patient was admitted to hospice on 10/9/21 with diagnoses of rheumatoid arthritis and high blood pressure. During record review on 11/30/21, it was noted that 2 of 4 (50%) skilled nursing visit notes were not signed/authenticated by the person that documented the visit note. The unsigned visit notes are dated 10/12/21 and 10/23/21. The above findings were reviewed with and confirmed by the Administrator and the Office Manager during an interview on 12/7/21 at 10:00 a.m.

Based on record review and interview, the hospice failed to ensure to document a discharge summary that includes a summary of the patient's course of care, including treatments, symptoms, pain management, the current plan of care, the latest physician orders, and any other documentation that would have assisted in post-discharge continuity of care in 1 of 1 (MR# 10) records reviewed in which the patient declined further hospice services, resulting in a lack of information available to the patient's primary care physician to ensure continuity of care. Findings include: MR#10: This patient was admitted to hospice care on 10/9/21 with diagnoses of rheumatoid arthritis and high blood pressure. During record review on 11/30/21, it was noted that there was no documented hospice care after 11/9/21. The clinical record contained a discharge summary note dated 11/16/21, that stated, "Declined further services." There was no summary of the patient's course of care, including treatments, symptoms, pain management, medications, the current plan of care, the latest physician orders, and any other documentation that would have assisted in post-discharge continuity of care for this patient. The above findings were reviewed with and acknowledged by the Administrator and the Office Manager during an interview on 12/7/21 at 10:00 a.m.

Based on record review and interview, the hospice failed to obtain a criminal background check including fingerprint checks, on personnel providing services directly to patients for 4 of 4 ( Aide#1, Aide#2, Aide#3, aide#4) hospice aides providing direct patient care, resulting in potential beneficiary mistreatment when receiving services in the home. Findings include: Aide#1: Date of hire 11/19/21. Personnel file review on 12/3/21 revealed no evidence that the required criminal background check including a fingerprint check had been completed. Aide#2: Date of hire 10/1/21. Personnel file review on 12/3/21 revealed no evidence that the required criminal background check including a fingerprint check had been completed. Aide#3: Date of hire 8/27/21. Personnel file review on 12/3/21 revealed no evidence that the required criminal background check including a fingerprint check had been completed. Aide#4: Date of hire 10/22/21. Personnel file review on 12/3/21 revealed no evidence that the required criminal background check including a fingerprint check had been completed. The findings were reviewed with and acknowledged by the Director of Nursing and the Office Manager during an interview on 12/3/21 at 3:00 p.m.