Every finding on record at Maximum Hospice and Palliative Care Inc

Condition of Participation: Quality Assessment and Performance Improvement.

Upon observation, there was no evidence the program shows measurable improvement in indicators related to improved palliative outcomes and hospice services. The documentation was not available to demonstrate compliance with QAPI program requirements. Agency was unable to produce necessary documents.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. The documentation was not available to demonstrate compliance with governing body approval of data collection. Agency was unable to produce necessary documents.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. The documentation was not available to demonstrate compliance with QAPI projects being conducted. Agency was unable to produce necessary documents.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. The documentation was not available to demonstrate compliance with governing body involvement in the QAPI program. Agency was unable to produce necessary documents.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. The documentation was not available to demonstrate compliance with governing body's responsibility for ensuring hospice-wide QAPI efforts. Agency was unable to produce necessary documents.

Upon patient record review 8 of 14 (Patient #2,3,6,7,8,11,13,14) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. (Patients #2,3,6,7,8,11,13,14) did not have evidence of comprehensive spiritual or psychosocial assessments. The admit nurse only answered the screen questions of "no needs" or "declines". The SC and SW services were documented as "declined" by the patient &/or family/ CG.

Condition of Participation: Quality Assessment and Performance Improvement.

Upon observation, there was no evidence the program shows measurable improvement in indicators related to improved palliative outcomes and hospice services. The information that was provided for review, were only print outs of tables with collected percentages. There was no evidence of measurable improvements in palliative outcomes and hospice services related to the data collected.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. The information that was provided for review, were only print outs of tables with collected percentages. There was no mention of QAPI in Governing Body minutes.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. The information that was provided for review, were only print outs of tables with collected percentages with no evidence of improvement measures discussed or performed.

Upon patient client record review, 3 of 14 (Patient #5,8,10) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 (Patient #5,8,10) Election statements were marked , "I elect to choose my attending physician". The physician name was left blank; therefore no documentation of choice for attending physician.