Every finding on record at Journeys Hospice

Based on policy review, EP plan review, and staff interview, it was determined the agency failed to ensure the EP plan, including the all hazards risk assessment, was updated on an annual basis.  Failure to update the plan on an annual basis had the potential for necessary updates to the EP plan to be missed.  Findings include: --- An agency policy titled, “Emergency Operations Plan” was reviewed.  The policy stated, “Hazard Vulnerability Analysis (HVA) will be conducted and evaluated annually in October.”  This policy was not followed.  An example includes:The facility’s EP plan was reviewed.  The last time the all hazards risk assessment was reviewed was August 2023.The HR director was interviewed on 6/16/26 beginning at 12:42 PM.  He confirmed the all hazards risk assessment had not been updated since August 2023.The agency failed to ensure the EP plan, including the all hazards risk assessment, was updated on an annual basis.

Based on medical record review and staff interview, it was determined the agency failed to maintain responsibility for coordinating care for 1 of 11 current patients (Patient #7) whose medical records were reviewed.  Failure to ensure coordination of care created the potential for unmet patient social work needs.  Findings include: --- Patient #7 was an 88 year old male admitted to the agency with a primary diagnosis of atherosclerotic heart disease.  He received SN services.  Social work services were ordered but he initially refused them.  His record for the certification period 3/04/2026 to 6/01/2026 was reviewed.An SN visit note dated 3/22/26 was reviewed.  It stated, “I did speak one on one with the daughter and asked about bring out a social worker for a visit/eval. Daughter is ok with this.”An SN visit note dated 3/18/26 was reviewed.  It stated, “I did speak one on one with the daughter and asked about bring out a social worker for a visit/eval. Daughter is ok with this.”An SN visit note dated 6/03/26 was reviewed.  It stated, “Daughter [name] states she needs to talk to someone about possibly getting guardianship over her dad. Referred to HSW [hospice social worker].”The medical record was reviewed for social work visits or notes and did not include any at the time of record review.The Social Worker was interviewed on 6/16/26 beginning at 11:04 AM and Patient #7’s record was reviewed with her.  She stated she had reached out to the daughter about social work visits but had not been able to contact her.  She confirmed there were no notes regarding the attempted contact.The agency failed to maintain responsibility for coordinating care for Patient #7.

Based on QAPI plan review and staff interview, it was determined the agency failed to ensure performance improvement projects (PIPs) included the reason for conducting the project and measurable progress toward the PIP’s goals.  The agency failed to ensure the PIP had clear direction and showed progress.  Findings include: --- QAPI meeting minutes from 2025 to 2026 were reviewed and included the following: The QAPI meeting minutes from 10/15/25 stated, “QAPI team has decided to perform a PIP for our Volunteer Program.  By the next QAPI meeting we will form a PIP team and create a plan to grow our Volunteer program, this PIP will also include retention.”The QAPI meeting minutes from 2/04/26 stated, “QAPI team has decided to form a PIP for our Volunteer Program.  By the next QAPI meeting we will form a PIP team and create a plan to grow our Volunteer Program.”The QAPI meeting minutes from 4/15/26 stated, “Presented the Volunteer Cost savings, QAPI team decided to do a PIP for our Volunteer Program.  [Name], [Name] and [Name] will be the PIP team.  They will meet on 4/29/26 11 am to create a plan and present the PIP at the next QAPI meeting.”Minutes were requested from the PIP team meeting that was said to occur on 4/29/26 in the QAPI meeting minutes, but were unable to be located.A document titled, “Performance Improvement Plan (PIP): Hospice Volunteer Program” was provided.  The document did not have a date.  It stated “The purpose of this Performance Improvement Plan is to stabilize and strengthen the hospice volunteer program by increasing active volunteer utilization, and ensuring reliable support for patient care needs.”  It included the following: “Goal…increase the number of active hospice volunteers from 2 to 8 within 90 days, ensuring volunteers are consistently engaged and contributing to patient support.”“Launch targeted recruitment through community outreach, local organizations, and partnerships”“Track recruitment activity weekly to ensure steady progress toward goal.”“Track active volunteer status weekly … monitor volunteer hours and participation consistency … conduct biweekly reviews to assess progress toward 8 active volunteers within 90 days”A document titled “Volunteer Recruitment and Retention Tracking for 2026” was provided.  It stated the following: “Activity … PIP volunteer program recruitment strategies” dated 4/29/26.  It did not include what recruitment strategies included“Ad at American Legion Society” dated 5/08/26.  It did not include what the advertisement included.It was unclear if the PIP had been started yet.  There was no documentation of tracking of volunteers or volunteer hours.  There was no documentation of progress toward the goal of 8 volunteers.  At the time of survey the agency did not have any active volunteers.The DON was interviewed on 6/16/26 beginning at 12:42 PM and the QAPI plan was reviewed in her presence.  She confirmed the QAPI plan was missing information on the progress toward the goal.The agency failed to ensure the PIP had clear direction and showed progress.

Based on EP document review and staff interview the agency failed to base their emergency preparedness policies and procedures on a facility-based and community-based risk assessment, utilizing an all-hazards approach. This failure put all patients and staff at risk during a potential emergency. Findings include: --- The agency provided a document titled, ";Hazard Vulnerability Analysis." The document listed types of emergencies but did not identify how those emergencies were chosen, how they would affect agency operations and how they would affect agency patients and staff. The hazards identified on the HVA did not have strategies for response, or specific policies and procedures related to each identified hazard. On 7/27/23, beginning at 9:30 AM the Administrator was asked if the agency created policies and procedures based on their HVA, she stated, ";no." She stated the agencys EP policies and procedures were generalized. The agency failed to establish emergency preparedness policies and procedures based on HVA.

Based on EP document review and staff interview the agency failed to conduct exercises to test the emergency plan annually. This failure put all patients and staff at risk during a potential emergency. Findings include: --- The EP documents were reviewed and there were no documented EP exercises. On 7/27/23, beginning at 9:00 AM the Administrator was asked when the last EP exercise was conducted. The Administrator confirmed that no exercise was conducted in 2022 and 2023. The agency failed to conduct EP exercises to test the emergency plan annually.

Based on staff interview, review of meeting minutes, and quality documents, it was determined the agency failed to ensure its QAPI program used the data collected to monitor the effectiveness of services and identify opportunities for improvement. This impeded the ability of the agency to evaluate its processes. Findings include: --- Quality data, and quality meeting minutes were requested for the past 2 years. The Administrator provided quality meeting minutes from: 7/13/21, 12/01/21, 2/09/22, 4/03/23, and 7/25/23 the day of survey entrance. - The meeting from 7/13/21 included a discussion on assigning a new QAPI coordinator, to ";reestablish" QAPI efforts, and that the agency was ";tracking and monitoring" adverse events. There was no discussion on data related to adverse events and infections with hospice patients. There was no overall analysis of data that would effectively monitor services and identify opportunities for improvement for the hospice agency. - The meeting from 12/01/21 included a discussion on establishing on a facility PIP related to ";Facility Agreements. The PIP included a goal and audit methods. The meeting also included a discussion on the use of chart reviews to identify opportunities for improvement. However, there was no discussion on what in the charts would be audited, and overall data analysis methods. - The meeting from 2/09/22 included a discussion on the Agencys PIP of ";Facility agreements. It included ";Team clarified that the PIP regarding Facility Agreements in the Patient Chart was discontinued as all Facilities have Agreements with this agency. There was no discussion on if the Agency was starting on a new PIP. The meeting also included a discussion on the Agencys chart reviews. It stated: ";[QAPI coordinator] presented findings from her chart review process stating that there were no relevant trends discovered. However, the following findings were discussed: A. Found that there are some issues around patient DME items not being entered in to the patient chart under the DME section. This was discovered primarily from reviewing DME invoices prior to payment B. Found that occasionally nurses are no approving medication profile when medication changes are being made C. Found that major drug to drug interaction section is also occasionally not being completed. "; There was no discussion on if the results of chart audit led to changes in agency process, or what was being done with chart review findings. - The meeting from 4/03/23 14 months after the 2/09/22 meeting included: ";Survey Readiness PIP." There was no discussion on what the PIP included, methods of data collection, goals and purpose of the PIP. There was no discussion on data collected for the prior 14 months. There was no discussion on chart audits mentioned in the previous QAPI meeting. The Administrator was interviewed on 7/26/23 beginning at 1:00 PM. She stated, except for the examples noted above, there was no documentation of analysis of the data or monitoring the effectiveness of Hospice services. She stated the Agencys QAPI program was paired down during the COVID-19 pandemic to only include Infection control and adverse events. She confirmed there was no overall data analysis of infection control data and adverse events data collected.to ensure an ongoing quality program. The agency did not use the data collected to monitor the effectiveness of services and identify opportunities for improvement

Based on staff interview, review of quality documents, and review of governing body meeting minutes, it was determined the hospice's governing body failed to assume responsibility for ensuring an ongoing program for quality improvement and patient safety was defined, implemented, maintained, this interfered with the agency's ability to implement changes to improve care. Findings include: --- Governing body meeting minutes were reviewed for the past 2 years. - The meeting from 2/09/22 included a discussion on the Agencys PIP of ";Facility Agreements". It included ";Team clarified that the PIP regarding Facility Agreements in the Patient Chart was discontinued as all Facilities have Agreements with this agency. There was no discussion on if the agency was starting on a new PIP. - The meeting from 4/03/23 14 months after the 2/09/22 meeting included: ";Survey Readiness PIP." There was no discussion on what the PIP included, methods of data collection, goals and purpose of the PIP. There was no discussion on data collected for the prior 14 months. The owner of the agency who was part of the QAPI Committee and the sole member of the governing body was interviewed on 7/27/23 beginning at 9:00 AM, and governing body meeting minutes and quality meeting minutes were reviewed in her presence. She stated the agencys QAPI program was paired down to only include infection control and adverse events. She confirmed the last agency PIP ended in February of 2022. She confirmed there was no overall data analysis of infection control data and adverse events to ensure an ongoing quality program. There was no documentation in the governing body meetings of the above systemic changes to the quality program as explained by the owner of the agency. The agency failed to ensure That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually.