Every finding on record at Grant County Hospice

Based on record review and interview the agency failed to maintain an effective, ongoing, hospice-wide data driven program in 1 of 1 Quality Assessment & Performance Improvement programs (QAPI) reviewed. --- Findings include:The agency failed to identify and implement performance improvement projects. See tag L0561.The agency failed to measure, analyze and track quality indicators. See tag L0562.The agency's governing body failed to ensure implementation and ongoing oversight of a Quality Assessment and Improvement (QAPI) program. See tag L0574.

Based on record review and interview the agency failed to show measurable improvement through performance improvement projects in 1 of 1 Quality Assessment and Performance Improvement programs reviewed. --- Findings include:Review of agency policy titled, "Performance Improvement Plan" dated 08/23/2005 revealed, "Purpose: Grant County Hospice participates in an organizational performance improvement (PI) program designated to monitor, evaluate and improve hospice quality and services by input from the following sources: Patient, staff, and physician surveys and complaints, previous performance improvement studies, incident reports, State survey findings and chart reviews."Review of agency QAPI program revealed no current or past performance improvement projects (PIPs) were conducted and documented showing measurable improvement in hospice services. No documented evidence of an effective QAPI program was provided.During an interview with Substitute Administrator A on 07/08/2025 at 2:00 PM, Substitute Administrator A stated that the QAPI program "just started back up." When asked if there was any documentation of past or present PIPs Substitute Administrator A stated, "I don't know I wasn't in charge back then. I think that's all we have."

Based on record review and interview the agency failed to measure, analyze, and tracking quality indicators in 1 of 1 Quality Assessment and Performance Improvement programs reviewed. --- Findings include:Review of agency policy titled, "Performance Improvement Plan" dated 08/23/2005 revealed, "Purpose: Grant County Hospice participates in an organizational performance improvement (PI) program designated to monitor, evaluate and improve hospice quality and services by input from the following sources: Patient, staff, and physician surveys and complaints, previous performance improvement studies, incident reports, State survey findings and chart reviews."Review of agency QAPI program revealed no evidence the agency is measuring, analyzing, and track quality indicators and other aspects of performance that enable the hospice to assess processes of care, services, and operations. No documentary evidence of an effective QAPI program was provided.During an interview with Substitute Administrator A on 07/08/2025 at 2:00 PM, Substitute Administrator A stated that the QAPI program "just started back up." When asked if there was any documentation of past or present PIPs Substitute Administrator A stated, "I don't know I wasn't in charge back then. I think that's all we have."

Based on record review and interview the agency's governing body failed to ensure that the agency implemented & maintained a Quality Assessment and Improvement Program (QAPI) in 1 of 1 QAPI programs reviewed. --- Findings include:Review of agency policy titled "Performance Improvement Plan Policy" not dated revealed under heading, "Annual Evaluation of Quality Improvement Program, Hospice services shall evaluate the effectiveness of the performance improvement monitoring and evaluation program on at least an annual basis...The evaluation shall be documented and forwarded through the appropriate medical staff reporting structure to the Medical Advisory Committee."Review of the agency's documentation provided for the QAPI program revealed no evidence that the governing body ensured the program is defined, implemented, and maintained. No documentation of an annual review of program was provided.During an interview with Substitute Administrator A on 07/08/2025 at 2:00 PM, Substitute Administrator A stated that the QAPI program "just started back up." When asked if there was any documentation of past or present PIPs Substitute Administrator A stated, "I don't know I wasn't in charge back then. I think that's all we have."

Based on observation and record review, the agency staff failed to follow standards of practice to prevent the transmission of infection and communicable diseases for 1 of 2 patients (Patient #5) observed in a total of 3 patient home visits completed. --- Findings include:Review of agency policy titled “Standard Precautions/Infection Control Policy” not dated revealed in part, “Handwashing: Use an alcohol -based hand rub for routine cleaning of the hands…Activities necessitating the use of gloves include, but not limited to, the following: cleaning reusable patient care equipment.”Review of "Clorox disinfecting wipes-Directions for Use" not dated revealed "Use enough wipes for treated surfaces to remain visibility wet for 4 minutes. Let surface completely dry."During an observation on 07/08/2025 starting at 1:30 PM, observed Registered Nurse (RN) C perform the following while assessing Patient #5:RN C was observed using a Clorox disinfecting wipe to clean the stethoscope without donning gloves. RN C did not perform hand hygiene before or after cleaning the stethoscope. Without waiting the four minute dry time, RN C proceeded place the stethoscope on Patient #5's chest while still visibly wet. RN C proceeded to obtain Patient #5's vital signs and then documented the findings on the computer without completing hand hygiene between tasks. RN C then assessed Patient #5's legs for injury, without the use of gloves, and proceeded to document the findings on the computer without completing hand hygiene between tasks.During an interview on 07/08/2025 at 4:00 PM with Substitute Administrator A and Administrator B the above findings were reviewed and confirmed.

Based on record review and interview the agency failed to provide orientation to the hospice program and specific job duties in 4 of 10 personnel files (Registered Nurse C, Medical Social Worker E, Spiritual Counselor F and Medical Director G) in 10 personnel files reviewed. --- Findings include:Review of RN C’s employee file revealed a date of hire of 11/07/2016 with no evidence of orientation to the program or to specific job duties provided.Review of MSW E’s employee file revealed a date of hire of 12/27/2022 with no evidence of orientation to the program or to specific job duties provided. Review of Spiritual Counselor F’s employee file revealed a date of hire of 11/30/2016 with no evidence of orientation to the program or to specific job duties provided.Review of Medical Director G’s employee file revealed a date of hire of 09/12/2023 with no evidence of orientation to the program or to specific job duties provided.During an interview with Administrator B on 07/09/2025 at 10:09 AM, Administrator B stated there was no agency policy regarding employee orientation.

Based on record review and interview, the agency failed to develop plans of care that outlined the specific responsibilities of hospice and facility staff for the care and services of patients receiving care in an Assisted Living Facility (ALF) setting in 1 of 1 patients that resided in a facility (Patient #13) in a total of 19 records reviewed. --- Findings include:Review of agency policy titled "Grant County Hospice and Nursing Home” dated 07/09/2025 revealed in part, “Purpose: To Delineate responsibility for development of one plan of care in order to meet Federal/State regulations…”Record review of Patient #13's “Team Care Plan” for certification period 05/18/2025 to 07/16/2025 revealed Patient #13 was admitted to hospice on 11/19/2024 with a primary diagnosis of hypertensive heart and chronic kidney disease and resided in an ALF. Review of plan of care revealed no delineation to outline which provider was responsible for care and interventions to be provided.During an interview on 07/09/2025 at 10:45 AM, Administrator B stated, "We expect that our Hospice nurses are delineating services in the plan of care for our patients residing in facilities.”

Based on record review and interview, the agency staff failed to ensure that individualized plans of care were developed for each patient in 11 out of 11 patient records reviewed (Patients #1-11). Findings include: Review of policy "Interdisciplinary Team Plan of Care" effective 8/23/2005 revealed in part "Policy: A Plan of Care is developed and reviewed regularly. This plan is based on identified and individualized problems, goals, and interventions." Patient #1 was admitted to hospice service on 4/6/2022 with a primary diagnosis of lung cancer. Secondary diagnoses included alcoholic liver disease, emphysema and schizophrenia. Patient #2 was admitted to hospice service on 6/22/2022 with a primary diagnosis of diabetes type 2. Secondary diagnoses included atherosclerotic heart disease, pressure ulcer of sacral region (unstageable) and acquired absence of right and left legs below knee. Patient #3 was admitted to hospice service on 12/23/2021 with a primary diagnosis of Alzheimer's Disease. Secondary diagnoses included essential tremor, hypercholesterolemia and unstable gait. Patient #4 was admitted to hospice service on 5/13/2022 with a primary diagnosis of melanoma cancer with spread to the lung. Secondary diagnoses included hypertensive chronic kidney disease stage 3, history of thyroid and colon cancer. Patient #5 was admitted to hospice service on 5/11/2022 with a primary diagnosis of thyroid cancer with spread to the lung. Secondary diagnoses included neoplasm related pain, primary hypertension and tracheostomy and gastrostomy placements. Patient #6 was admitted to hospice service on 4/5/2022 with a primary diagnosis of acute on chronic combined systolic and diastolic congestive heart failure. Secondary diagnoses included acute kidney failure, chronic kidney disease and unspecified atrial flutter. Patient #7 was admitted to hospice service on 3/7/2022 with a primary diagnosis of bladder cancer. Secondary diagnoses included Alzheimer's Disease, type 2 diabetes and chronic atrial fibrillation. Patient #8 was admitted to hospice service on 2/2/2022 with a primary diagnosis of Parkinson's Disease. Secondary diagnoses included dysphagia, Alzheimer's Disease, and essential hypertension. Patient #9 was admitted to hospice service on 8/31/2022 with a primary diagnosis of chronic obstructive pulmonary disease with exacerbation. Secondary diagnoses included coronary artery disease, atrial fibrillation, and hypertension. Patient #10 was admitted to hospice service on 2/18/2022 with a primary diagnosis of hypertensive heart and kidney disease. Secondary diagnoses included acute on chronic congestive heart failure, chronic atrial fibrillation, and mitral stenosis. Patient #11 was admitted to hospice service on 12/31/2021 with a primary diagnosis of hypertensive heart and chronic kidney disease. Secondary diagnoses included chronic congestive heart failure, chronic kidney disease stage 3 and pulmonary hypertension. The goal of "Patient/family verbalizes understanding of medication regime" was present on Patients #2, #3, #4, #5, #6 and #9 plan of care. The goal was not individualized to meet each patient's need. The goal of "Patient maintains level of mobility and participation in ADLs (Activities of Daily Living) within disease limitations" was present on Patients #1, #7 and #9 plan of care. The goal was not individualized to meet each patient's need. The goal of "Patient maintains adequate airway and respiratory function within limits of the disease" was present on Patients #1, #6, #8 and #9 plan of care. The goal was not individualized to meet each patient's need. The goal of "Patient's incontinence episodes are managed" was present on Patients #2, #4, #8, #9 and #10 plan of care. The goal was not individualized to meet each patient's need. The goal of "Patient/family demonstrates successful adaptation to disease process limitations" was present on Patients #3, #10 and #11. The goal was not individualized to meet each patient's need. The goal of "Patient maintains bowel function within limits of disease progression" was present on Patients #3, #4. and #9 plan of care. The goal was not individualized to meet each patient's need. The goal of "Patient/family will be given adequate support to maintain a safe and growth-promoting environment" was present on Patients #3, #6 and #7 plan of care. The goal was not individualized to meet each patient's need. The goal of "Patient's personal hygiene is maintained" was present on Patients #2, #3, #9, #10 and #11. The goal was not individualized to meet each patient's need. An interview was conducted with Director of Nursing A on 7/26/2022 at 11:15 a.m. Director of Nursing A stated "The expectation is staff are to individualize standard goals."

Based on record review and interview, the agency staff failed to ensure that measurable goals were developed for each patient in 11 out of 11 patient records reviewed (Patients #1-11). Findings include: Review of policy "Interdisciplinary Team Plan of Care" effective 8/23/2005 revealed in part "Policy: A Plan of Care is developed and reviewed regularly. This plan is based on identified and individualized problems, goals, and interventions." Patient #1 was admitted to hospice service on 4/6/2022 with a primary diagnosis of lung cancer. Secondary diagnoses included alcoholic liver disease, emphysema and schizophrenia. Patient #2 was admitted to hospice service on 6/22/2022 with a primary diagnosis of diabetes type 2. Secondary diagnoses included atherosclerotic heart disease, pressure ulcer of sacral region (unstageable) and acquired absence of right and left legs below knee. Patient #3 was admitted to hospice service on 12/23/2021 with a primary diagnosis of Alzheimer's Disease. Secondary diagnoses included essential tremor, hypercholesterolemia and unstable gait. Patient #4 was admitted to hospice service on 5/13/2022 with a primary diagnosis of melanoma cancer with spread to the lung. Secondary diagnoses included hypertensive chronic kidney disease stage 3, history of thyroid and colon cancer. Patient #5 was admitted to hospice service on 5/11/2022 with a primary diagnosis of thyroid cancer with spread to the lung. Secondary diagnoses included neoplasm related pain, primary hypertension and tracheostomy and gastrostomy placements. Patient #6 was admitted to hospice service on 4/5/2022 with a primary diagnosis of acute on chronic combined systolic and diastolic congestive heart failure. Secondary diagnoses included acute kidney failure, chronic kidney disease and unspecified atrial flutter. Patient #7 was admitted to hospice service on 3/7/2022 with a primary diagnosis of bladder cancer. Secondary diagnoses included Alzheimer's Disease, type 2 diabetes and chronic atrial fibrillation. Patient #8 was admitted to hospice service on 2/2/2022 with a primary diagnosis of Parkinson's Disease. Secondary diagnoses included dysphagia, Alzheimer's Disease, and essential hypertension. Patient #9 was admitted to hospice service on 8/31/2022 with a primary diagnosis of chronic obstructive pulmonary disease with exacerbation. Secondary diagnoses included coronary artery disease, atrial fibrillation, and hypertension. Patient #10 was admitted to hospice service on 2/18/2022 with a primary diagnosis of hypertensive heart and kidney disease. Secondary diagnoses included acute on chronic congestive heart failure, chronic atrial fibrillation, and mitral stenosis. Patient #11 was admitted to hospice service on 12/31/2021 with a primary diagnosis of hypertensive heart and chronic kidney disease. Secondary diagnoses included chronic congestive heart failure, chronic kidney disease stage 3 and pulmonary hypertension. The goal of "Patient/family verbalizes understanding of medication regime" was present on Patients #2, #3, #4, #5, #6 and #9 plan of care. The goal was not individualized to meet each patient's need. The goal of "Patient maintains level of mobility and participation in ADLs (Activities of Daily Living) within disease limitations" was present on Patients #1, #7 and #9 plan of care. The goal was not individualized to meet each patient's need. The goal of "Patient maintains adequate airway and respiratory function within limits of the disease" was present on Patients #1, #6, #8 and #9 plan of care. The goal had no objective data with which to measure progress. The goal of "Patient's incontinence episodes are managed" was present on Patients #2, #4, #8, #9 and #10 plan of care. The goal had no objective data with which to measure progress. The goal of "Patient/family demonstrates successful adaptation to disease process limitations" was present on Patients #3, #10 and #11. The goal had no objective data with which to measure progress. The goal of "Patient maintains bowel function within limits of disease progression" was present on Patients #3, #4. and #9 plan of care. The goal had no objective data with which to measure progress. The goal of "Patient/family will be given adequate support to maintain a safe and growth-promoting environment" was present on Patients #3, #6 and #7 plan of care. The goal had no objective data which which to measure progress. The goal of "Patient's personal hygiene is maintained" was present on Patients #2, #3, #9, #10 and #11. The goal had no objective data with which to measure progress. The goal of "Patient will maintain adequate nutrition and hydration within disease limitations" was present on Patient #7's plan of care. The goal had no objective data with which to measure progress. The goal of "Patient seizure activity is controlled within limits of disease process" was present on Patient #2's plan of care. The goal had no objective data with which to measure progress. An interview was conducted with Director of Nursing A on 7/26/2022 at 11:15 a.m. Director of Nursing A stated "The expectation is staff are to develop measureable goals."