Every finding on record at Foglim Hospice, LLC

Based on review of quality assessment and performance improvement (QAPI) data, policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” and staff interview, it was determined the agency failed to ensure that the requirements for QAPI were met as evidenced by lack of a complete an ongoing performance improvement project that included measurable progress toward desired outcomes. --- Findings include:Review of policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” revised June 2019, revealed the following:Policy Purpose: To define the QAPI programAchieved and Sustained Improvement5. All improved processes will continue to be analyzed for a specified time to determine if test piloted action has resulted in sustained improvement·                     7. Hospice will document what performance improvement projects are being conducted, the reasons for conducting these projects and the measurable progress achieved on them. Review of the agency's Performance Improvement Project (PIP) titled "Missed Visit Documentation," dated 2/12/25, revealed the PIP lacked a specified time frame of completion, a frequency for monitoring collected data to assess the effectiveness of the project, and lacked data collection to identify measurable progress toward identified goal. Interview with Director of Nursing (DON) on 4/2/25 at 3:00 pm, revealed no further documentation was available.