Every finding on record at Orange County Hospice, LLC

Based on interview and record review, the hospice failed to ensure the patient and PCG were advised of the accurate information for filing a complaint for three or three sampled patients (Patients 1, 2, and 3). This failure had the potential risk of violating the patient’s rights to be informed of the accurate information for filing a complaint to these patients.Findings: --- Review of the hospice’s P&P titled Patient Rights and Responsibilities undated showed patient rights included the right to access the State home health and hospice care-toll free hotline.  This hotline is available on a 24-hour basis to receive complaints and questions regarding hospice.Review of the hospice’s admission packet was initiated on 3/25/26.  The admission packet indicated the Procedure for Making Complaints.However, the listed 24-hour tollfree number was not a working number.  In addition, the address to file for complaints was incorrect.  a.  Review of Patient 1’s clinical record was initiated on 3/25/26, and showed the PCG signed the Informed Consent and Treatment Authorization dated 11/21/23, with the inaccurate 24-hour tollfree number and address.b.  Review of Patient 2’s clinical record was initiated on 3/25/26, and showed the PCG signed the Informed Consent and Treatment Authorization dated 1/15/25, with the inaccurate 24-hour tollfree number and address.c.  Review of Patient 3’s clinical record was initiated on 3/26/26, and showed the patient signed the Informed Consent and Treatment Authorization dated 12/2/25, with the inaccurate 24-hour tollfree number and address.On 3/25/26 at 1038 hours, an interview was conducted with the Administrator.  The Administrator confirmed the 24-hour tollfree hotline and address to file a complaint was incorrect.

Based on observation, interview, and record review, the hospice failed to ensure the medication profile was reviewed to include all current medications for one of three sampled patients (Patient 1).  This failure had the potential for the patient not receiving the appropriate care and necessary services that could negatively affect the patient’s well-being. --- The hospice’s P&P titled Medication Regimen Review undated showed the medication profile is part of the patient-specific comprehensive assessment.  A Registered Nurse creates and maintains a current medication profile and reviews all patient medications, both prescription and non-prescription, on an on-going basis in collaboration with other interdisciplinary group members.Review of Patient 1’s clinical record was initiated on 3/25/26.  The clinical record showed the SOC was 11/21/23.  The patient was certified for hospice services during the certification periods from 11/21/23 to 11/19/24, 1/20/24 to 3/19/24, 3/20/24 to 5/18/24, 5/19/24 to 7/17/24, 7/18/24 to 9/15/24, 9/16/24 to 11/14/24, 11/15/24 to 1/13/25, 1/14/25 to 3/14/25, 3/15/25 to 5/13/25, 5/14/25 to 7/12/25, 7/13/25 to 9/10/25, 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26, and 3/10/26 to 5/8/26.The Current Medication List showed the patient’s medications included the following:-morphine sulfate IR (opioid analgesic) 20 mg/ml 0.5 ml orally every two hours as needed for moderate pain.-morphine sulfate IR 20mg/ml 1 ml orally every two hours as needed for severe pain.-morphine sulfate IR 20 mg/ml 1 ml orally every two hours as needed for severe respiratory distress.-Duoneb 3 mg-0.5 mg/3 ml (broncholdilator) one unit via respiratory inhalation three times a day as needed for wheezing/shortness of breath.-Calmoseptine (topical ointment) 0.44% one inch topically, re-apply every time incontinence care is provided as needed to prevent excoriation.-aspirin (nonsteroidal anti-inflammatory drug) 81 mg enteric coated one tablet orally once daily as preventative measure for stroke.A joint home visit with HA 1 was conducted on 3/26/26 at 1040 hours, to the patient’s home.Review of the patient’s medications at Patient 1’s home with HA 1 and the PCG showed the following:-morphine sulfate IR 20mg/ml 1 ml orally every two hours routinely for moderate to severe pain. The PCG checked the indication for the medication and confirmed it was to be given routinely.-Duoneb 3 mg-0.5 mg/3 ml one unit via respiratory inhalation three times a day as needed for wheezing/shortness of breath was not used by the patient as confirmed by the PCG.-Calmoseptine 0.44% one inch topically, re-apply every time incontinence care is provided as needed to prevent excoriation was not used by the patient as confirmed by the PCG.  The PCG stated the hospice provided Phytoplex Protectant-guard Paste (topical cream) to be used to prevent excoriation.-aspirin 81 mg enteric coated one tablet orally once daily as preventative measure for stroke.  The PCG stated the aspirin medication was discontinued a month ago.On 3/27/26 at 1027 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director.  The DPCS and QAPI Director acknowledged the above findings.

Based on interview and record review, the hospice failed to ensure individualized care plans were developed for three of three sampled patients (Patients 1, 2, and 3).  This failure had the potential to cause inconsistent delivery of care which could result in the decline or lack of improvement in the patients’ health conditions. --- Review of the hospice’s P&P titled Plan of Care undated, showed the content of the plan of care.  The hospice will develop an individualized written plan of care for each patient which will reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments.  The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions, including the following:a.Start of care dateb.Certification periodc.Patient demographicsd.Principle diagnosis and other pertinent diagnosese.Medications: dose/frequency/routef.Allergiesg.Orders for specific hospice and palliative care services and disciplines, treatments, procedures (specify amount/frequency/duration)h.Interventions to manage pain and symptomsi.Equipment and supply needsj.Family needsk.Spiritual needsl.End-of-life care preferencesm.Bereavement needsn.Patient goals/outcomeso.Functional limitationsp.Diet and nutritional needsq.Anticipated discharge needsr.And safety measures1.Review of Patient 1’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 11/21/23. The patient was certified for hospice services during the certification periods from 11/21/23 to 11/19/24, 1/20/24 to 3/19/24, 3/20/24 to 5/18/24, 5/19/24 to 7/17/24, 7/18/24 to 9/15/24, 9/16/24 to 11/14/24, 11/15/24 to 1/13/25, 1/14/25 to 3/14/25, 3/15/25 to 5/13/25, 5/14/25 to 7/12/25, 7/13/25 to 9/10/25, 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26, and 3/10/26 to 5/8/26.Review of the RN Visit Note dated 3/24/26, showed the PCG reported the patient had a rash on the left armpit which was itching. The physician was notified and ordered Miconazole Nitrate 2% (antifungal topical powder).The POC/IDG Review dated 3/25/26, showed a new wound care treatment order started on 3/18/25, for the left armpit rash: cleanse with water and mild soap, pat dry, apply Miconazole Nitrate 2% lightly to the affected area twice daily, PRN if needed.However, there was no documentation the IDG had developed an individualized POC to address Patient 1’s left armpit rash.On 3/27/26 at 1007 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS and QAPI Director.  The DPCS and QAPI Director confirmed the findings.2. Review of Patient 2’s clinical record was initiated on 3/25/26.  The clinical record showed the SOC was 1/15/25.  The patient was certified for hospice services during the certification periods from 1/15/25 to 4/14/25, 4/15/25 to 7/13/25, 7/14/25 to 9/11/25, 9/12, 25 to 11/10/25, 11/1125 to 1/9/26, 1/10/26 to 3/10/26, and 3/11/26 to 5/9/26.Review of the Visit Note Short Form showed the following dates:-On 1/31/26, the patient found on the floor.-On 2/10/26, the patient had an unwitnessed fall.  The patient had multiple bruises and some excoriation on the chest and posterior occipital (back of the head).In addition, the Skin Assessment dated 2/10/26, showed the following skin problems and treatments:-Abrasion/excoriation in the posterior occipital, to cleanse with normal saline, pat dry, apply triple antibiotic ointment to affected area, leave open to air.-Abrasion/excoriation in the right-side upper chest area, to cleanse with normal saline, pat dry, apply triple antibiotic ointment to affected area, leave open to air.-Ecchymosis (bruising) in the right-side chin, to continue monitoring.-Ecchymosis (bruising) in the right lateral wrist, to continue monitoring.  Review of the POC/IDG Review dated 2/11/26, showed the following order:-Abrasion/excoriation posterior occipital: to cleanse area with normal saline solution, pat dry, apply triple antibiotic, leave open to air, daily and PRN till healed.  The SN will do every Monday and Friday and PRN.  The B&C staff will do every Sunday, Tuesday, Wednesday, Thursday, Saturday, and PRN.- Abrasion/excoriation right side upper chest area: to cleanse area with normal saline solution, pat dry, apply triple antibiotic, leave open to air, daily and PRN till healed.  The SN will do every Monday and Friday and PRN.  The B&C staff will do every Sunday, Tuesday, Wednesday, Thursday, Saturday, and PRN.-Bed rail pads-Floor/fall mat-Extend the full bed rails to cover as much length of the bed.However, there was no documented evidence the IDG had developed an individualized POC to address Patient 2’s fall and abrasion/excoriation.On 3/27/26 at 1030 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director.  The DPCS and QAPI Director confirmed the findings.3. Review of Patient 3’s clinical record was initiated on 3/26/26.  The clinical record showed the SOC was 12/2/25.  The patient was certified for hospice services during the certification periods from 12/2/25 to 3/1/26 and 3/2/26 to 5/30/26.Review of the Comprehensive Nursing Assessment dated 12/2/25, showed the Braden Risk Chart (evidence-based tool for assessing risk of developing pressure ulcers) for Patient 3 was 12, indicating high risk for pressure injury.However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s potential risk for pressure injury.On 3/27/26 at 1046 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director.  The DPCS and QAPI Director confirmed the findings.

Based on interview and record review, the hospice failed to ensure the initial and revised POCs included the indication for the PRN discipline visits for three of the three sampled patients (Patients 1, 2, and 3).  This failure had the potential of not providing necessary services for these patients. --- 1.Review of Patient 1’s clinical record was initiated on 3/25/26.  The clinical record showed the SOC was 11/21/23.  The patient was certified for hospice services during the certification periods from 11/21/23 to 11/19/24, 1/20/24 to 3/19/24, 3/20/24 to 5/18/24, 5/19/24 to 7/17/24, 7/18/24 to 9/15/24, 9/16/24 to 11/14/24, 11/15/24 to 1/13/25, 1/14/25 to 3/14/25, 3/15/25 to 5/13/25, 5/14/25 to 7/12/25, 7/13/25 to 9/10/25, 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26, and 3/10/26 to 5/8/26.The POC/IDG Review dated 12/17/25, 12/31/25, 1/14, 1/28, 2/11, 2/25, 3/11 and 3/25/26, showed SN visits one time per week and one PRN visit and MSW visits one time per month and one PRN visit.However, there was no documented evidence showing the indication for the SN and MSW PRN visits.On 3/27/26 at 1007 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director.  The Administrator and DPCS confirmed the findings.2.Review of Patient 2’s clinical record was initiated on 3/25/26.  The clinical record showed the SOC was 1/15/25.  The patient was certified for hospice services during the certification periods from 1/51/25 to 4/14/25, 4/15/25 to 7/13/25, 7/14/25 to 9/11/25, 9/12, 25 to 11/10/25, 11/1125 to 1/9/26, 1/10/26 to 3/10/26, and 3/11/26 to 5/9/26.The POC/IDG Review dated 1/14, 1/28, and 2/11/26, showed SN visits one per week and one PRN visit and MSW visits one time per month and one PRN visit.In addition, the POC/IDG Review dated 2/25, 3/11 and 3/25/26 , showed SN visits two per week plus one PRN visit and MSW visits one per month plus one PRN visit.However, there was no documented evidence showing the indication for the SN and MSW PRN visits.On 3/27/26 at 1030 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director.  The Administrator and DPCS confirmed the findings.3.Review of Patient 3’s clinical record was initiated on 3/26/26.  The clinical record showed the SOC was 12/2/25.  The patient was certified for hospice services during the certification periods from 12/2/25 to 3/1/26 and 3/2/26 to 5/30/26.The POC/IDG Review dated 12/3, 12/17, 12/31/25, 1/14, 1/28, 2/11, 2/25, 3/11, and 3/25/26, showed SN visit one per week and one PRN visit.However, there was no documented evidence showing the indication for the SN PRN visit.On 3/27/26 at 1046 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director.  The DPCS and QAPI Director confirmed the findings.

Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for three of three sampled patients (Patients 1, 2, and 3).  This failure had the potential risk of not evaluating the POC and providing appropriate care and services to these patients. --- 1. Review of Patient 1’s clinical record was initiated on 3/25/26.  The clinical record showed the SOC was 11/21/23.  The patient was certified for hospice services during the certification periods from 11/21/23 to 11/19/24, 1/20/24 to 3/19/24, 3/20/24 to 5/18/24, 5/19/24 to 7/17/24, 7/18/24 to 9/15/24, 9/16/24 to 11/14/24, 11/15/24 to 1/13/25, 1/14/25 to 3/14/25, 3/15/25 to 5/13/25, 5/14/25 to 7/12/25, 7/13/25 to 9/10/25, 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26, and 3/10/26 to 5/8/26.The POC/IDG Review dated 12/17/25, 12/31/25, 1/14, 1/28, 2/11, 2/25, 3/11 and 3/25/26, showed the patient’s identified problems with established goal and interventions.  However, the POC failed to include measurable outcomes for the patient’s identified problems.  For example, Patient 1 had a care plan addressing altered bowel elimination with one of the goals to have optimal bowel elimination. However, there was no documented evidence as to what the optimal bowel elimination for the patient was.On 3/27/26 at 1007 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director.  The DPCS confirmed the findings.2. Review of Patient 2’s clinical record was initiated on 3/25/26.  The clinical record showed the SOC was 1/15/25.  The patient was certified for hospice services during the certification periods from 1/15/25 to 4/14/25, 4/15/25 to 7/13/25, 7/14/25 to 9/11/25, 9/12, 25 to 11/10/25, 11/1125 to 1/9/26, 1/10/26 to 3/10/26, and 3/11/26 to 5/9/26.The POC/IDG Review dated 12/31/25, 1/14, 1/28, 2/11, 2/25, 3/11, and 3/25/26, showed the patient’s identified problems with established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems.  For example, Patient 2 had a care plan addressing intermittent burning during urination with the goal to verbalize/express understanding of medication/treatment orders and side effects. However, there was no documented evidence what medication/treatment provided and the side effects for the medication.On 3/27/26 at 1030 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director. The DPCS and QAPI Director confirmed the findings.3.Review of Patient 3’s clinical record was initiated on 3/26/26.  The clinical record showed the SOC was 12/2/25.  The patient was certified for hospice services during the certification periods from 12/2/25 to 3/1/26 and 3/2/26 to 5/30/26.The POC/IDG Review dated 12/17/25, 12/31/25, 1/14, 1/28, 2/11, 2/25, 3/11 and 3/25/26, showed the patient’s identified problems with established goal and interventions.  However, the POC failed to include measurable outcomes for the patient’s identified problems.  For example, Patient 3 had a care plan addressing potential harm due to alteration in posture with the goal to increase strength/energy for functional activities.However, there was no documented evidence as to what the increase strength/energy for functional activities was.On 3/27/26 at 1046 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director. The DPCS and QAPI Director confirmed the findings.

Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patients’ POCs no less frequently than every 15 calendar days for three of three sampled patients (Patients 1, 2, and 3).  This failure had the potential for not providing appropriate, consistent, and quality care to these patients. --- The hospice’s P&P titled Interdisciplinary Team Services undated, showed core members include at least the following individuals:i.A Doctor of Medicine or Osteopathyii.A Registered Nurseiii.A Social Workeriv.Chaplain, Pastoral Services and/or other counselors.The IDT meetings will be held on a regular basis (no less often than every 15 days).  It is the expectation that all members of the interdisciplinary team will be present.  The IDT meeting will include among others evaluating patient/family progress toward achievement of expected outcomes, and revising goals and objectives as needed.1. Review of Patient 1’s clinical record was initiated on 3/25/26.  The clinical record showed the SOC was 11/21/23.  The patient was certified for hospice services during the certification periods from 11/21/23 to 11/19/24, 1/20/24 to 3/19/24, 3/20/24 to 5/18/24, 5/19/24 to 7/17/24, 7/18/24 to 9/15/24, 9/16/24 to 11/14/24, 11/15/24 to 1/13/25, 1/14/25 to 3/14/25, 3/15/25 to 5/13/25, 5/14/25 to 7/12/25, 7/13/25 to 9/10/25, 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26, and 3/10/26 to 5/8/26.The POC/IDG Review dated 12/17/25, 12/31/25, 1/14, 1/28, 2/11, 2/25, 3/11, and 3/25/26, showed the patient’s identified care plan problem included potential for altered bowel elimination, bilateral lower extremity weakness due to bedrest, trouble making needs known related to disease progression, increased risk of aspiration, potential for increasing pain, potential for altered respiratory status and altered sleep patterns.  The identified problems were started on 11/21/23.There was no documented evidence the identified care plan problems were updated to ensure necessary care provided to meet the patient's care needs.On 3/27/26 at 1007 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director.  The DPCS confirmed the findings.2. Review of Patient 2’s clinical record was initiated on 3/25/26.  The clinical record showed the SOC was 1/15/25.  he patient was certified for hospice services during the certification periods from 1/15/25 to 4/14/25, 4/15/25 to 7/13/25, 7/14/25 to 9/11/25, 9/12, 25 to 11/10/25, 11/1125 to 1/9/26, 1/10/26 to 3/10/26, and 3/11/26 to 5/9/26.The POC/IDG Review dated 12/31/25, 1/14, 1/28, 2/11, 2/25, 3/11, and 3/25/26, showed the patient’s identified care plan problems included potential for altered cardiac status, potential for altered neurological status, and potential for increased pain requiring increasing dosage of analgesics.  The identified problems were started on 1/15/25.In addition, the POC/IDG Review dated 12/31/25, showed patient’s identified care plan problem for decrease in MAC measurement, was 20 cm two weeks ago now at 19 cm decreased by one cm.  The identified problem was started on 3/24/25.There was no documented evidence the identified care plan problems were updated to ensure necessary care provided to meet for the patient's care needs.On 3/27/26 at 1030 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director. The DPCS and QAPI Director confirmed the findings.3. Review of Patient 3’s clinical record was initiated on 3/26/26.  The clinical record showed the SOC was 12/2/25.  The patient was certified for hospice services during the certification periods from 12/2/25 to 3/1/26 and 3/2/26 to 5/30/26.The POC/IDG Review dated 12/17/25, 12/31/25, 1/14, 1/28, 2/11, 2/25, 3/11, and 3/25/26, showed the patient’s identified problems included deficit in self-care, potential for harm and increased risk related to unsteady gait, potential harm due to alteration in posture, weakness, potential for altered neurological status and potential for altered nutritional status.  The problems identified were started on 12/2/25.There was no documented evidence the identified care plan problems were updated to ensure necessary care provided to meet the patient's care needs.On 3/27/26 at 1046 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director.  The DPCS and QAPI Director confirmed the findings.

Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing and supervising the care and services provided for one of three sampled patients (Patient 3).  This failure had the potential of not addressing the care needs for this patient. --- Review of the hospice’s P&P titled Interdisciplinary Team Services, undated, showed the hospice is provided by an interdisciplinary team made up of professionals and volunteers with special training in caring for the terminally ill patient and family.  The interdisciplinary team provides support to the client/family throughout the continuum of care.  There is communication and coordination and availability of care with all members of the interdisciplinary group.Review of the hospice’s P&P titled Interdisciplinary (IDT) Conferences, undated, showed each staff member will be responsible for discussing appropriate issues/concerns with other disciplines involved in the patient’s care and planning for future care and services, including patient progress, patient education, care/treatment changes, and scheduling needs.Review of Patient 3’s clinical record was initiated on 3/26/26.  The clinical record showed the SOC was 12/2/25.  The patient was certified for hospice services during the certification periods from 12/2/25 to 3/1/26 and 3/2/26 to 5/30/26.The POC/IDG Review dated 12/3/25, showed an order for referral and treatment for PT times three visits to instruct caregiver on safe transfer/ambulation and range of motion exercises.Review of the PT Evaluation dated 12/31/25, showed the planned treatment and schedule.  Frequency would be two to three times a week for one to two weeks.  Planned procedures may include: therapeutic exercise, therapeutic activities, neuromuscular re-education and gait.  The PT service dates were 1/5, 1/7, and 1/12/26.However, there was no documented evidence the PT coordinated with the IDG regarding the PT evaluation, frequency of visits, and progress of the patient.  On 3/27/26 at 1046 hours, an interview and concurrent clinical record review were conducted with the Administrator, DPCS, and QAPI Director.  The DPCS and QAPI Director confirmed the findings.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2, On 8/21/25 order for Sinemet 10/100mg 1 tablet every 6 hours. On 9/16/25 order for Sinemet 25/100mg. No evidence documented if these medications are to be taken together or if the order on 8/21 should have been discontinued.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 5 (Patient #4) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #4, No evidence of interventions and goals for patient being full code status.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #3, Order written for Roxanol 20mg/ml 1 ml every 2 hours PRN sever pain, with additional order written for Roxanol 20mg/ml every 2 hours severe respiratory distress. No evidence documented if they can give only one or the other. Otherwise patient could potentially receive 40mg every 2 hours.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #2, RN initial assessment identified patient has a walker and needs a wheel chair. No evidence of these items documented on plan of care.

Upon client record review, 1 of 5 (Patient #2) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #2, No evidence of MD signature or participation in IDG meeting on 9/10/25.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #2, Wound orders from Wound Pro's for wound care on 9/4 and 9/18/25. No evidence care plan was updated with new orders. IDG note dated 9/24/25, update wound orders from 9/4/25 when new wound care orders were received on 9/18/25.

Upon client record review, 2 of 5 (Patient #1,3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, 8/22/25 SN frequency 1x/week and 1 PRN, 8/24/25 3x/week 1 PRN, 9/1/25 SN 2x/week 1 PRN, 9/7/25 SN 2x/week 1 PRN, 9/12/25 SN 1x/week. SN visits completed 8/30, 9/2, 9/4, 9/9, 9/16/2025. Order written on Thurs 9/9 for SN 2x/week, only has 1 visit that week. MSW documented as declined, will add an order if PRN need arises. MSW made an initial visit on 8/21/25 and PRN visit on 8/28/25. No evidence of orders for these visits. Patient #3, No evidence of order for SN frequency on plan of care. IDG has SN order frequency without any MD signatures on IDG notes. No evidence of a frequency order for SN services. SN visits were made on 9/4, 9/11, 9/18/2025.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient #2, No evidence of coordination of care with wound pro's documentation in IDG meeting. IDG meeting today, care plan for skin integrity updated with wound care order from 9/4/25 from wound pro's when there are new orders from wound pro's documented on 9/18/25. No evidence of new wound order were updated in orders or care plan. RN made visit on Thursday 9/18/25, when order states wound pro's will visit every Thursday. No evidence of coordination when RN makes visit on same day as wound pro's.

Upon observation, there was no evidence the hospice that is using contract personnel for core services met the following exception: The hospice may use contracted personnel, if necessary, to supplement hospice personnel in order to meet the needs of patients under extraordinary or other non-routine circumstances. A hospice may also enter into a written arrangement with another Medicare certified hospice program for the provision of core services to supplement hospice personnel to meet the needs of patients. Circumstances under which a hospice may enter into a written arrangement for the provision of core services include: unanticipated periods of high patient loads, staffing shortages due to illness or other short-term temporary situations that interrupt patient care; and temporary travel of a patient outside of the hospice's service area. Patient #2, No evidence of documentation that wound care provided by Wound Pro's is not related to terminal diagnosis. No evidence document on the CTI or in IDG meeting notes. Patient had multiple wounds that required debridement with the exception of Left Midline plantar stage 2 wound. No evidence this wound required debridement, Wound Pro's provided care to this wound when the hospice nurse is capable to manage this wound.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice as evidenced by ensuring that a qualified Administrator is employed-Personnel # 1, Job descriptions states Administrator will have bachelor in business or Healthcare degree. Administrator has High school education with Administrator certificate. In addition, the lack of oversight for ensuring core services, such as nursing, are being performed, staff practice according to acceptable standards and scope, and ensuring agency is following CMS 418.56 Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance Patient #5, Upon record review LVN made death visit arrived at 12:50pm. Narrative note documents Upon arrival, family at bedside. No heart rate, no respirations, and no response to painful stimulus. Assessment completed, time of death 1254. Dr Moran notified at1258. LVN did not work within her scope of practice as LVN does not meet criteria in California Subchapter 3. Health Care Operations Article 4. Nursing Care section 3999.327. Registered Nurse Pronouncement of Death.

Upon patient record review, 2 of 5 (Patient #2,3) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #2, 3,No evidence of clinical information in CTI narrative. Narrative documents, see documentation in patient chart.

Upon patient client record review, 2 of 5 (Patient #4,5) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #4,5, Election statement is found within Informed consent and treatment authorization form. This form does not identify the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), including the right to immediate advocacy and BFCC-QIO contact information.

Upon observation, there was no evidence the patient record, whether hard copy or in electronic form, is made readily available on request by an appropriate authority. Upon arrival to agency, patient records were not readily available to the surveyor until 930am, more than an hour after surveyor arrived.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 3 of 14 (Patient #1,5,6) 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. Patient 1: There was no psychosocial assessment completed, no evidence the SN completed in the SOC comprehensive assessment. Patient 5: There was no SC assessment performed within the first 5 days. Patient refused, and SN did not complete the assessment in the comprehensive assessment. Patient 6: There was no SC assessment performed within 5 days of SOC. The RN did not complete during SOC comprehensive assessment.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1,2,3,4,5,6,7,8,9,10 No imminence of death assessed on comprehensive assessment.

Upon patient record review, 6 of 14 (Patient #2,3,4,5,6,9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 2: The medication profile 7/15/25 contains an order for Lidocaine patch with no site to apply patch. Corrected on site order updated. Patient 3: The current medication profile contains an order for Optimag Neuro powder 1 scoop oral daily with no diluent. Corrected on site order updated. Patient 4: The medication profile contains an order for Topical ointment 0.44% apply 1 inch topically; Frequency: as needed if no bm on second day; Indication: redness on buttocks area. Order frequency is not appropriate for medication ordered. Corrected on site order updated. Patient 5: The medication profile has orders for 7/31/25 Fentanyl 50mcg/hr every 72 hours, on 7/26/25 Fentanyl 50mcg/hr every 72 hours and on 7/15/25 Fentanyl 50mcg/hr every 72 hours, on 7/10/25 Fentanyl 25mcg patch apply every 72 hours. It is unclear what dose of Fentanyl patch the patient is taking. All of the Fentanyl orders remain active on the medication profile. Corrected on site, extra orders discontinued. Patient 6: Medication profile listed a 12/10/24 Medication: Mupirocin 2% Topical cream; Frequency: apply thin layer to affected areas three times daily for 7 days. No indication of where to apply. The SN did not update medication list to remove once discontinued. Corrected on site, medication discontinued. Patient 9: Medication profile listed Robitussin 15mg cough gels with no indication of frequency, noted as: “Q^hrs PRN”.

Upon patient record review, 2 of 14 (Patient #13, 14) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patients 13 and 14: The medical record did not have an initial bereavement assessment completed within the first 5 days on service.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 5: The SN documented on 7/7/25 patient pain “0, pt refused to state pain”. The SN also documented “Nurse explained she was there to place his fentanyl patch which had been increased due to his pain”. There is no evidence the SN performed a non verbal or pain AD assessment on the patient to assess pain while increasing a fentanyl patch. There is no documentation regarding which dose of Fentanyl patch was applied. The SN documented on 6/25/25 the Safety Risk Assessment & Fall risk assessment both checked as yes however corresponding assessments are not completed.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 4: No evidence of teaching completed related to fall preventions after high fall risk scores noted by SN on 1/15/25, 4/7/25 or 6/30/25.

Upon patient record review, 5 of 14 (Patient #3,4,7,8,10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 3: Orders on 5/10/25 indicate barrier cream to coccyx daily and prn diaper changes. No care plan with goals and interventions for skin integrity initiated. Corrected on site, care plan added. Patient 4: Fall risk was assessed on admission with a score of 22. No goals and interventions for fall risk. Orders for topical barriers to prevent skin breakdown; there was no skin integrity care plan with goals and interventions initiated. Pt on routine ASA with no risk for bleeding care plan with goals and interventions. Patient also has pruritis with associated daily use topical cream; no care plan initiated for related pruritis. Corrected on site, all care plans added Patient 7: Area to right buttock with orders for excoriation, no skin integrity care plan initiated with goals and interventions. Corrected on site, care plan added. Patient 8: Fall risk score dated 6/24/25, 12 (high risk), mobility care plan notes “ambulatory with fall risk”. No care plan for fall risk with interventions and goals initiated. Corrected on site, care plan added. Patient 10: Patient has a medication order for Eliquis (anticoagulant) without a risk for bleeding care plan with appropriate goals and interventions. Corrected on site, care plan added.

Upon patient record review, 6 of 14 (Patient #2,3,4,5,6,9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2: The POC 7/15/25 contains an order for Lidocaine patch with no site to apply patch. The current POC has an order from 7/22/24 to cleanse mouth with colloidal silver and apply rolled gauze with no frequency. Corrected on site, orders updated. Patient 3: The current POC contains an order for Optimag Neuro powder 1 scoop oral daily with no diluent. Corrected on site. Patient 4: The current POC contains an order for Topical ointment 0.44% apply 1 inch topically; Frequency: as needed if no bm on second day; Indication Orders: redness on buttocks area. Order frequency is not appropriate for medication ordered. Corrected on site. Patient 5: The POC has orders for 7/31/25 Fentanyl 50mcg/hr every 72 hours, on 7/26/25 Fentanyl 50mcg/hr every 72 hours and on 7/15/25 Fentanyl 50mcg/hr every 72 hours, on 7/10/25 Fentanyl 25mcg patch apply every 72 hours. It is unclear what dose of Fentanyl patch the patient is taking. All of the Fentanyl orders remain active on the POC. Corrected on site, orders discontinued for extra Fentanyl. Patient 6: Order dated 12/10/24 Medication: Mupirocin 2% Topical cream; Frequency: apply thin layer to affected areas three times daily for 7 days. No indication of where to apply. The SN did not update the POC to remove once discontinued. Corrected on site, medication discontinued. In addition, the POC 5/20/25 contains an order to insert and irrigate a foley catheter but does not state who will perform the insertion and irrigations. The POC contains orders for a dressing change to a Stage II Pressure ulcer on coccyx, there is no indication of who will complete the dressing changes. Corrected on site foley order has who is to perform and the pressure ulcer dressing discontinued. Patient 9: Order for Robitussin 15mg cough gels with no indication of frequency, noted as: “Q^hrs PRN”. Corrected on site, order updated.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: The Comprehensive assessment 8/6/24 contains evidence patient uses a wheelchair. There is no wheelchair on the POC. Corrected on site, order obtained.

Upon patient record review, 3 of 14 (Patient #4,6,9) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 4: Fall occurrence noted 4/1/2025 at 4:15pm unwitnessed in patients room at B&C while transferring, no injury noted. Narrative notes patient found sitting on floor in no acute distress. Patient states she hit her head on the dresser, lost her balance standing up from wheelchair. Subsequent recertification assessment dated 4/7/2025 and visit dated 6/30/25 indicate patient is a high risk with a risk score of 15. No fall care plan initiated. Patient 6: Patient currently receiving antibiotics and topical cream related to infection/MRSA. On 10/24/2024, UA & CNS indicates MRSA; 12/02/2024 UA obtained with culture indicates MRSA. No infection plan of care initiated. Corrected on site, care plan added. Patient 9: Current care plan for skin integrity has not been updated with current orders dated 6/6/2025. Corrected on site, new order obtained. POC updated.

Upon patient record review, 5 of 14 (Patient #2,4,5,6,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: There is an order for Massage therapy on POC for 7/1/25 for a 1 time visit. There is no evidence the visit was made. There was no evidence of refusal of massage therapy. The current POC contains an order to cleanse the mouth with colloidal silver, apply rolled gauze insert to side of mouth to protect lips from teeth clenching. The SN documented on 7/24/25 and 7/30/25 “Applied rolled gauze soaked with colloidal silver to protect lips from teeth clenching.” The SN did not follow the order to cleanse the mouth. Patient 4: RN Routine visit noted 3/31/2025; PRN on call for fall 4/1/2025; PRN on call for Burning with urination/ with new orders 4/7/2025; RN routine visit again noted 4/14/2025. Visit frequency is for weekly and 1 prn. Routine visit missed / assessment not completed for the week of 4/7/2025. Patient 5: The POC 6/25/25 order for SN is for 2 times per week with 1 PRN. There is evidence SN made visits on 6/25/25 for SOC, a PRN on 6/25/25 for pain control, 6/27/25 routine and 6/28/25 routine. There is no order for an increase in visits. The SN documented on 6/25/25 "12.5mcg patch applied to Lt ACW". There is no order for a Fentanyl 12.5 patch on the POC. In addition, the POC contains an order for SN twice a week and 1 PRN per week. SN is visiting patient three times per week routinely due to Fentanyl patch needing changed. Pt was seen twice on 7/1/25 and then on 7/3/25. The SN made visits on 7/6,7/8,7/10. The SN made visits 7/16, 7/18,7/19. There is evidence the SN is seeing the patient 3 times per week routinely to change Fentanyl patch though no evidence the SN updated the POC to SN 3 times per week. Corrected on site, new order obtained and POC updated. Patient 6: The current POC orders are for SN once a week. The SN made two visits the week of 7/20-7/26. There was no order to increase the visits. Patient 9: SC frequency has been 2x/month and 1 prn. 1 visit made 05/29/25; 1 visit made 6/25/25; no visits made in July.

Upon patient record review 1 of 14 (Patient #5) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 5: The MSW documented on 7/15/25, MSW was asked by the daughter of the patient for possibility of PT for her father. The MSW informed her to “follow up with appropriate medical provider or case manager for further evaluation and referral”. There is no evidence this was followed up on.

Upon patient record review, 2 of 14 (Patient #13,14) did not have evidence the hospice offers bereavement counseling that includes: Patient 13 and 14: The medical record did not include a bereavement plan of care.

Upon patient record review, 8 of 14 (Patient #1,2,3,4,5,6,7,10) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 1:The aide POC 7/24/25 contains an order for turn and reposition, transfer, change linens with no frequency. Corrected on site, frequency added. Patient 2:The aide POC 7/9/25 contains an order for “chair to bed”, record BM, feeding assistance, change linens all with no frequencies. Corrected on site, frequency added. Patient 3:The aide POC 7/29/25 contains orders to turn and reposition, transfer, street clothes, change linens all with no frequency. The diet is ordered as “other”.Corrected on site, frequency and diet added. Patient 4: The aide POC contains order to turn and reposition, chair to bed, record BM, pajamas/gown, change patient linens all with no frequencies. Corrected on site, frequency added. Patient 5: The aide POC 7/21/25 contains orders for turn and reposition, record bowel movements, and change patient linens without frequencies. Corrected on site, frequency added. Patient 6: The aide POC contains orders to turn and reposition, empty collection bag with no frequency. There is a directive to dress patient every visit but does not indicate street clothes or pajamas to dress the patient in. Pt is confused. Corrected on site, care plan updated. Patient 7: The aide POC documentation listed a frequency of "NA" for change patient linens. Corrected on site, frequency added. Patient 10: The aide POC documentation listed a frequency of "NA" for turn and reposition. Encourage fluids as tolerated unless contraindicated. Corrected on site, frequency and diet order added.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. For 2024 year end was 0.45%, up through June 2025 is 0.54%. This is less than the required 5% of the total patient care hours of all paid hospice employees and contract personnel.

Upon personnel record review, 2 of 13 (Personnel #7,9) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 7 and 9: did not have evidence of competencies in personnel files and have been used by the hospice for services.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that each patient record contains Advance Directives. Patient 1: Advance Directive section both check boxes indicating the patient has an Advance Directive and does not have an Advance Directive are checked. Daughter (YK) is listed as agent and signed consents however there is no POA paperwork on file.

Upon patient record review, 4 of 14 (Patient #1,4,5,6) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: Advance Directive section both check boxes indicating the patient has an Advance Directive and does not have an Advance Directive are checked. Patient 4: The SN documented S-I-L in narrative on 7/14/25. This is not an approved abbreviation. Patient 5: The SN made an aide supervisory visit on 6/27/25, there is evidence the aide did not start seeing the patient until 6/30/25. The SN documented on 6/28/25 “Fentanyl patch change place in left upper chest”. There is no evidence of the dose of Fentanyl patch applied. SN documented on 7/1/25 “ROLC” This is not an approved abbreviation. Patient 6: Advance Directive section both check boxes indicating the patient has an Advance Directive and does not have an Advance Directive are checked. The SN documented F/C on 6/30/25 this is not an approved abbreviation. The SN documented 7/21/25 “New 18F catheter inserted, Pt tolerate well”. There is no evidence of balloon size or that sterile technique was used.

Upon patient record review, 2 of 11 records (Patient #1,#7) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1,#7: The record indicated Miralax powder 17 GM by mouth daily constipation. There was not evidence of a diluent. Corrected on site.

Upon patient record review, 1 of 11 records (Patient #11) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family's needs and coordinated activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #11:The record indicated that the patient had numerous extensive wounds, which included but were not limited to her left lower leg, her sacrum, heels and hips. There was not evidence of a full assessment including measurements and documentation of the wound care that was completed. Documentation revealed 'wound care performed on leg ulcer.'

Upon patient record review, 3 of 11 records (Patient #1,#4,#7) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1,#7: The order indicated Miralax powder 17 GM by mouth daily constipation. There was not evidence of a diluent. Corrected on site. Patient #4: The record indicated an order dated 7/5/22 for the second toe left foot, soak in 1/2C Epsom salts and warm water as needed until further orders. There was not evidence of a reason or of a specific frequency. Corrected on site.

Upon patient record review, 2 of 11 records (Patient #4,#8) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and notes the patient's progress towards outcome/goals from the plan of care. Patient #4: The terminal diagnosis was chronic systolic congestive heart failure. The cardiac problems were listed as resolved on 3/31/22 however this remained an active problem. Corrected on site. Patient #8: The record indicated that the patient developed a wound on her coccyx measuring 3.5cm x 6cm. There was not evidence that skin /integumentary was added to the plan of care noting the patient's progress towards outcome/goals. Corrected on site.

Upon client record review, 7 of 11 records (Patient #1,#3,#5,#7,#8,#9,#11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The visit frequency for the spiritual care counselor was an evaluation then 1x/month and 1prn. The evaluation which was conducted on 5/18/22 and was done by telephone. There was not evidence that telehealth was in the plan of care. Corrected on site. Patient #3: There was not evidence of a visit frequency for the spiritual care counselor. The record indicated that visits were conducted on 4/17/22, 5/3/22, 5/11/22, 5/17/22, and 6/7/22. Corrected on site. Patient #5: The record indicated a phone visit by the spiritual care counselor on 7/5/22 without evidence that telehealth was a part of the care plan. Corrected on site. Patient #7: The initial assessment by the spiritual care counselor was conducted via phone. There was not evidence that telehealth was a part of the plan of care. Corrected on site. Patient #8: The record indicated that the assessment conducted by the spiritual care counselor was done by phone on 4/9/22 without evidence that telehealth was in the plan of care. Corrected on site. Patient #9: The record indicated that the assessment conducted by the spiritual care counselor was done by phone on 6/11/22 without evidence that telehealth was in the plan of care. Corrected on site. Patient #11: The record indicated that the assessment conducted by the spiritual care counselor was done by phone without evidence that telehealth was in the plan of care. In addition the psycho-social assessment conducted by the social worker was done by phone without evidence that telehealth was in the plan of care.

Upon patient record review, 3 of 7 applicable records (Patient #2,#5,#7) did not have evidence in the patient record that hospice aide assignments and duties are: • Specific written patient care instructions including alerts, for a hospice aide that are prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care specifically indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #2: The aide plan of care indicated a 1 person transfer and a 2 person transfer. Corrected on site. Patient #5: The record indicated that the patient was a fall risk with periods of dizziness when standing, general muscle atrophy. There was not evidence that fall precautions were on the aide plan of care. Corrected on site. Patient #7: The record indicated that the patient was on Plavix 75mg q am. There was not evidence of bleeding precautions on the aide plan of care. Corrected on site.

Upon contract review, 1 of 3 applicable contracts (Care To You) did not have evidence that the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Delivered in accordance with the patient's plan of care. Corrected on site.

Upon personnel record review, 1 of 11 applicable records (Personnel #7) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #7: There was not evidence of a competency for the role of bereavement coordinator. Corrected on site.

Upon contract review, 1 of 2 applicable contracts (Alt MD) did not contain evidence that the contract specifically identified an alternate medical director. Contracts indicated a Medical Director and 1 team physician. Corrected on site

Upon patient record review, 2 of 6 applicable records (Patient #6,#7) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #6: The second certification period had the dates of 6/21/22-9/18/22. The record indicated that the recertification by the medical director was signed and dated 6/22/22. Patient #7: The second certification period had the dates of 7/4/22-10/1/22. The record indicated that the recertification by the medical director was signed and dated 7/6/22.

Upon patient client record review, 2 of 11 (Patients #2 and 8) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #2: The record indicated that the patient had stage IV wounds with black eschar and foul odor on both heels with extensive wound care orders. The nurse documentation for the wound care that was provided did not contain evidence of the care that was completed, including a note dated 7/13/22, in which the documentation revealed, 'wound care provided per order.' Also, on 7/6/22, 'wound care provided per MD order.' Corrected on site. Patient #8: The record indicated that the patient developed a wound on her coccyx measuring 3.5cm x 6cm. Wound care consisted of cleansing with normal saline, patting dry and applying Optifoam bordered dressing to include SDTI (2cm x 2cm round partial thickness wound). The nurse documentation for the wound care that was provided did not contain evidence of the care that was completed, including a note from 7/16/22, 'husband assisting during wound care' and a note dated 7/18/22, 'nurse provided wound care as ordered.' Corrected on site.

Upon client record review, 1 of 1 applicable record (Patient #10) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice forwarded to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #10: The record indicated that the patient revoked hospice services on 3/11/22. There was not evidence that the discharge summary was forwarded to the patient's attending physician.

Based on interview and record review, the hospice failed to conduct the comprehensive assessments to identify the care needs for two of two sampled patients (Patients A and B), creating the risk of not addressing the care needs for these patients. Findings: 1. Review of Patient A's closed clinical record was initiated on 2/8/22. The clinical record showed the SOC was 9/14/20. The patient was certified for hospice services during the certification period from 6/21/21 to 8/19/21. The patient resided at the board and care facility and had expired on 7/10/21. The hospice's Communication Log dated 7/8/21 at 1550 hours, showed Patient A's PCG (at the board and care facility) called regarding the patient's "choking" incident as reported by the family member while the family member and patient went out for lunch on 7/7/21. The documentation showed the PCG had not personally witnessed any choking or coughing while eating, but the time spent with Patient A during meals was limited. The PCG had noticed Patient A asking for food excessively and putting food in the mouth even when the patient still had food in the mouth. According to the PCG, on 7/8/21, the PCG did not witness any incident during meals and Patient A ate her meals as usual. The documentation showed the hospice staff informed Patient A's family member that the Case Manager and LVN were off today; however, she would inform the team to follow up with the swallow evaluation being requested. The documentation showed the Case Manager was informed. Review of an email document sent by the QAPI Director to the DPCS, RN 1, and LVN 1 dated 7/8/21 at 1614 hours, showed the QAPI Director informed them of the reported choking incident of Patient A and an update on the incident was requested by the Administrator. Review of another email document sent to the hospice staff dated 7/9/21, showed Patient A had "Choking Episode" and LVN 1 would conduct a visit. The SN note completed by LVN 1 dated 7/9/21, showed Patient A was asleep in the hospital bed and had consumed a half glass of smoothie on the lunch table. During the SN visit, Patient A was talkative and shared that she went out for a meal with her family members and they had salad, pasta/beef and rustic pizza which were just delicious. Documentation showed the patient had been requesting for food all the time and had some snacks in the room provided by the family. The SN noted completed by RN 1 dated 7/10/21 at 1225 hours, showed the patient was her usual self and being able to communicate her needs. The patient talked about enjoying going out with the family member and ordered a salad, pasta with beef, and pizza desert. Documentation showed the patient's lunch included chicken and a cup of smoothie. Documentation showed the patient stated she ate her meal okay. Documentation showed the patient had been eating more and asking food over the past week. The SN talked to the patient about eating appropriate amount of food. The SN discussed with the facility staff regarding not giving too much food and less portions. The SN discussed with the facility's PCGs regarding aspiration precaution and they verbalized understanding. * However, there was no documented evidence in the clinical record showing the SNs had conducted an observation of the patient eating to assess if the patient had any problems or concerns with swallowing or eating. Review of the hospice's Communication Log dated 7/10/21 at 1738 hours, showed the PCG had called frantically and stated the patient was choking and not breathing. The log showed 911 was called and the patient was pronounced death by the paramedics at 1804 hours. A telephone interview was conducted with LVN 1 on 3/7/22 at 1000 hours. LVN 1 stated an email was received from the QAPI Director regarding the patient's episode of choking. LVN 1 was asked if the patient was observed eating during the SN visit. She stated she asked the patient if the patient ate okay, and the patient stated okay. LVN 1 stated the patient was asked if the patient had choked, and the patient denied. A telephone interview was conducted with RN 1 on 3/17/22 at 0914 hours. RN 1 stated an email was received from the QAPI Director regarding patient's episode of choking. RN 1 stated he did not perform an observation of the patient eating. RN 1 stated he interviewed the board and care staff. RN 1 stated the board and care staff said the patient was eating okay and there was no difficulty swallowing. RN 1 stated LVN 1 informed him that the patient was eating okay. On 4/5/22 at 1117 hours, a concurrent telephone interview and clinical record review was conducted with the DPCS. He was informed of the findings. 2. Review of Patient B's closed clinical record was initiated on 4/25/22. The clinical record showed the SOC was 8/4/21. The patient was certified for hospice services during the certification period from 8/4/21 to 11/1/21. The patient had expired on 9/24/21. The initial comprehensive assessment dated 8/4/21, showed the patient had excoriation to the buttocks and redness to the skin "flat under the abdomen." The Skin Impairment Assessment form showed the patient had excoriation to the coccyx, "recurrent rash/redness," and redness to the left heel. * However there was no documented evidence of the size of the excoriation on the buttocks/coccyx and redness on the left heel. On 4/27/22 at 0815 hours, a concurrent interview and clinical record review was conducted with the DPCS. The DPCS was asked for the measurement of the excoriation on the buttocks/coccyx and redness on the left heel. The DPCS stated the hospice only measured the size of pressure injuries.

This CONDITION was not met as evidenced by: Based on interview and record review, the hospice failed to ensure the IDG, care planning, and coordination of services were provided to meet the patients' care needs as evidenced by: 1. The hospice failed to develop an individualized written POC that reflected goals and interventions based on the problems identified. Cross reference to L545. 2. The hospice failed to develop an individualized written POC with measurable outcomes. Cross reference to L548. 3. The hospice failed to revise the POC. Cross reference to L552. 4. The hospice failed to ensure the IDG had maintained responsibility for directing, coordinating, and supervising the care and services provided. Cross reference to L554. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the interdisciplinary team, care planning and coordination of services to meet the patients' care needs.

Based on interview and record review, the agency failed to ensure the individualized care plans were developed for eight of 13 sampled patients (Patients 2, 3, 4, 5, 6, 7, 10, and 12). This failure had the potential to cause inconsistent delivery of care which can result in the decline or lack of improvement of the patients' health condition. Findings: Review of the clinical records for Patients 2, 3, 4, 5, 6, 7, 10, and 12 showed no documented evidence the individualized care plans were developed to address the identified problem and care needs for these patients. For example: 1. Review of Patient 2's clinical record was initiated on 9/20/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. a. The SN note dated 7/18/22, showed the patient had a "Foley catheter" which was last changed on 7/15/22. Review of the patient's care plan showed a care plan problem addressing patient's "Foley/Supra-pubic catheter/Renal issues and or Incontinence" * However, the patient's care plan was not individualized as to what the patient had. The SN note dated 7/19/22, showed the patient had a drain site on the right side of the abdomen The SN note dated 7/21/22, showed the patient had redness to coccyx. Documentation showed Calmoseptine (moisture barrier) was applied routinely. Cross reference L554 b. The physician's order dated 7/18/22, showed peritoneal drainage with sterile technique once a week not to exceed one liter. The SN note dated 7/21/22, showed peritoneal catheter was drained. Documentation showed 1600 ml of yellow fluid. The SN note dated 7/21/22, showed the patient had redness to coccyx. Documentation showed Calmoseptine (moisture barrier) was applied routinely. The SN note dated 8/1/22, showed the patient's penis had a small amount of yellow drainage. Documentation showed the daughter was educated to use soap and water to clean the penis as the solution she was using is irritating The SN note dated 8/29/22 showed the patient had slight throat pain due to thrush which is being treated with Nystatin (anti-fungal) oral suspension. The SN note dated 9/5/22, showed the patient had hiccups all night long. Documentation showed the physician was notified with new order for Thorazine (antipsychotic) * However, review of the patient's care plan showed no documented evidence the care plan was developed for the identified problem such as peritoneal drainage; coccyx redness; thrush; hiccups and use of Thorazine; On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 2. Review of Patient 3's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 12/3/21. The patient was certified for hospice services during the certification period from 7/31/22 to 9/28/22. a. The physician's order dated 12/4/21, showed lorazepam (anxiolytic) 0.5 mg one tablet PO PRN for anxiety/agitation/SOB. b. The physician's order dated 7/8/22, showed nystatin (antifungal) 100,000 u/gm one application Q 12 hours c. The PT notes dated 8/12, 8/22, and 8/29/22, showed the patient received PT. * However, review of the patient's care plan showed no documented evidence the care plan was developed to address the use of lorazepan, nystatin, and PT services. On 9/19/22 at 1010 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the POCs included measurable outcomes for six of 13 sampled patients (Patients 1, 4, 5, 7, 11, and 12 ), creating the risk of not evaluating the POC and providing appropriate care and services to these patients. Findings: Review of the clinical records for Patients 1, 4, 5, 7, 11, and 12 showed the POCs did not include the measurable outcomes anticipated to evaluate the effectiveness of the plan of care to meet the patients' needs. For example: 1. Review of Patient 7's clinical record was initiated on 9/8/22. The patient's clinical record showed the SOC was 8/11/22. The patient was certified for hospice services during the certification period from 8/11/22 to 11/8/22. The POC, for the certification period from 8/11/22 to 11/8/22, showed patient's identified problems with the established goals and interventions. However, the POC failed to include the measurable outcomes for the patient's identified problems. For example, the expected outcome for disease/diagnosis progression or other specified etiology was for the patient to achieve and maintain optimal/acceptable pain/discomfort relief as evidenced by assessed pain level with each SN visit and/or report from patient/family/caregivers However, there was no measurable outcome as to what the patient's optimal/acceptable pain/discomfort relief would be. On 9/19/22 at 1120 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 2. They were informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the IDG had reviewed/revised the patient's POCs at least every 15 days for -- of 13 sampled patients (Patients --), creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The physician's order dated 7/18/22, showed peritoneal drainage with sterile technique once a week not to exceed one liter. The SN note dated 8/1/22, showed the patient has been having "moderated ascites with order for peritoneal drainage 2 times a week. Drainage not to exceed 1 liter." On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator, RN 1, and LVN 1. The Demonstrator stated the physician's order for the peritoneal drainage should be done twice a week and should never have been one a week. They were informed and acknowledged the findings. * The IDG failed to update the POC to address the frequency of the peritoneal drainage. 2. Review of Patient 3's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 12/3/21. The patient was certified for hospice services during the certification period from 7/31/22 to 9/28/22. The IDG Comprehensive Assessment Details dated 8/23/22, showed HA visits 3W The HA notes showed the HA conducted five visits during Week 5 (8/28/22 to 9/3/22) * However, the HA visits conducted were not consistent with the POC On 9/19/22 at 1010 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. The Administrator stated the HA visit frequency should have been increased in the POC. They were informed and acknowledged the findings. 2. Review of Patient 10's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 4/15/22. The patient was certified for hospice services during the certification period from 4/15/22 to 6/13/22. The patient was transferred to another hospice on 5/23/22. The SOC-Recertification-Continuation of Service Order dated 4/15/22, showed the first week of frequency was HA 3W then for the next eight weeks "Re evaluation for hospice criteria" The HA notes showed the HA conducted two visits during Week 1 (4/15/22 to 4/16/22). However, the visit frequency was not consistent with the HA visits. Further review of the HA notes showed the HA conducted visits on Week 2 (4/17/22 to 4/23/22), Week 3 (4/24/22 to 4/30/22), Week 4 (5/1/22 to 5/7/22), Week 5 (4/8/22 to 4/14/22), and Week 6 (4/15/22 to 4/21/22). However, there was no documented evidence on what was the HA visit frequency after Week 1. On 9/19/22 at 1230 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 3. The Administrator stated the POC related to visit frequency should have been revised. They were informed and acknowledged the findings. On 9/19/22 at 1230 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 3. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing and supervising the care and services provided for one of 13 sampled patients (Patient --), creating the risk of not addressing the care needs for this patient. Findings: The hospice's P&P titled Interdisciplinary Group (undated), showed the hospice agency designates an IDG composed of qualified individuals who assess, plan, provide, and evaluate the care and services provided to hospice patients/caregivers. The IDG is responsible for establishing, implementing, reviewing, and revising the plan of care; providing or coordinating care and services in accordance with the patient's plan of care. 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The SN note dated 7/21/22, showed the patient had redness to coccyx. Documentation showed Calmoseptine (moisture barrier) was applied routinely. However, there was no documented evidence the SN had assessed for the size of the redness to coccyx. In addition, The IDG failed to supervise the care and services provided to the patient. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 2. Review of Patient 10's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 4/15/22. The patient was certified for hospice services during the certification period from 4/15/22 to 6/13/22. The SN note dated 5/19/22, showed the family member had concerns about a small healing bed sore at patient's right buttock. Documentation showed the family member was advised "continuing with A&D ointment and cover with dry dressing with no paper tape." However, there was no documented evidence the SN had assessed for the size and wound bed of the small healing bedsore. The IDG failed to supervise the care and services provided to the patient. On 9/19/22 at 1230 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 3. They were informed and acknowledged the findings.

This CONDITION was not met as evidenced by: Based on clinical record and document review and interview, the hospice failed to develop an effective, on-going, hospice-wide date-driven QAPI program as evidenced by: 1. The hospice failed to develop, implement, and maintain an effective, on-going, hospice-wide data-driven quality assessment and performance improvement program. Cross reference to L560. 2. The hospice failed to have a PI activity that focused on high risk, high volume, and problem-prone areas. Cross reference to L566. 3. The hospice failed to have the PI activities that tracked adverse patient events, analyzed, developed, and implemented preventive action plans. Cross reference L569 4. The hospice's GB failed to ensure the ongoing QAPI program for quality improvement and patient safety was evaluated annually. Cross reference to L574. 5. The hospice failed to document the PI projects being conducted, the reason for conducting the projects, and the measurable progress achieved on these projects. Cross reference to L573. The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with continuous QAPI to ensure the provision of quality healthcare in a safe environment for the patients.

Based on interview and record review, the hospice failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and PI program. This failure created the risk for the hospice to resolve and improve problem prone areas. Findings: 1. Review of the hospice's P&P titled Quality Assurance/Performance Improvement (undated) showed the following: - The hospice will measure, analyze, and track quality indicators including patient adverse events and other aspects of performance that enable the agency to assess processes of care, services, and operations. - The QAPI committee's chairperson is responsible for the PI activities of the hospice by implementing and coordinating the program activities such as reviewing and summarizing all audit, investigation and study findings, identifying trends, weaknesses, and issues. - When undesirable patterns or trends in performance and sentinel events are identified, the agency analyzes the pattern/trend intensively to determine where best to focus for change of improvement. - A root cause analysis is performed for a serious adverse or sentinel event occurrence. - Analysis activities include current level of performance and appropriateness of the current process, new design application evaluated with positive results, areas for improvement, actions to improve the performance of the process, and evaluation of changes to the process. Review of the QAPI program for 2021 was conducted on 4/26/22. The QAPI program showed the hospice performed several QAPI studies for 2021. The QAPI program binder showed the data collected from the QAPI studies and the meeting minutes for each quarter. However, further review of the QAPI program showed the following: -The hospice failed to develop a performance improvement activity that focused on high risk, high volume, and problem-prone areas. Cross reference to L566. -The hospice failed to provide documented evidence showing the hospice had analyzed the data, tracked patterns and trends, implemented preventive actions, and evaluated whether the current practices were effective in improving the overall care and services provided to the patients. Cross reference to L569. -The hospice failed to document the reasons for conducting the PI projects and the measurable progress achieved on these projects for 2021. Cross reference to L573. - The hospice failed to ensure the licensed staff participated in the hospice QAPI program and in-service training. Cross reference to L586. 2. Review of the hospice's P&P titled Governing Body dated 2019 showed the hospice's governing body will ensure that the QAPI program reflects the complexity of its organization and services; an ongoing program for quality improvement and patient safety is defined, implemented, maintained and is evaluated annually; the hospice's QAPI efforts address priorities for improved quality of care and patient safety; and all improvement actions are evaluated for effectiveness. Review of the hospice's documents titled Governing Board Meeting Agenda showed the GB discussed the QAPI program on 1/19, 7/25, and 10/10/21; however, there was no documented evidence showing the GB conducted a meaningful evaluation of the hospice's QAPI program including identifying the lack of documented analysis, action plans, and whether the implemented actions were effective. Cross references to L574 and L651, example #2.

Based on interview and record review, the hospice failed to ensure the PI activities focused on high risk, high volume, and problem-prone areas. This failure had the potential to adversely affect the quality of care provided to the patients. Findings: Review of the hospice's P&P titled Quality Assessment/Performance Improvement (undated) showed the hospice's PI activities will focus on high risk, high volume, or problem prone areas and consider incidence, prevalence, and the severity of problems in those areas. Review of the QAPI program binder for 2021 was conducted on 4/26/22. The QAPI program binder showed the data collected from the QAPI studies and the meeting minutes for each quarter. The QAPI meetings were conducted quarterly on 4/13, 7/21, 10/20/21, and 1/19/22. Review of the hospice's document titled QAPI Studies 2021 showed 26 performance studies for 2021, including personnel files, collaboaration of POC, ADL assessment matchs HA assignment, level of care, volunteer notes, contractor vendor files, frequencies, recertification, and etc. On 4/26/22 at 1404 hours, an interview and concurrent document review was conducted with the QAPI Coordinator. When asked how the agency chose which PI studies to focus on, the QAPI Coordinator replied she conducted the studies based on the list created by the agency's previous coordinator. She continued the same studies and updated the list for any changes.

Based on interview and record review, the hospice failed to have the PI activities that tracked the adverse patient events, analyzed, developed, and implemented preventive action plans. This created the risk of not identifying areas for PI to improve care and services provided to the patients. Findings: Review of the hospice's P&P titled Quality Assurance/Performance Improvement (undated) showed the following: - The hospice will measure, analyze, and track quality indicators including patient adverse events and other aspects of performance that enable the agency to assess processes of care, services, and operations. - The QAPI committee's chairperson is responsible for the PI activities of the hospice by implementing and coordinating the program activities such as reviewing and summarizing all audit, investigation and study findings, identifying trends, weaknesses, and issues. - When undesirable patterns or trends in performance and sentinel events are identified, the agency analyzes the pattern/trend intensively to determine where best to focus for change of improvement. - A root cause analysis is performed for a serious adverse or sentinel event occurrence. - Analysis activities include current level of performance and appropriateness of the current process, new design application evaluated with positive results, areas for improvement, actions to improve the performance of the process, and evaluation of changes to the process. Review of the QAPI program for 2021 was conducted on 4/26/22. The QAPI program showed the hospice performed several QAPI studies for 2021. The PI Meetings for 2021 showed the summary of the data collected for each quarter. For example, review of the PI Meetings for 2021 showed the following: -For the first quarter, the document showed there were 16 incidents (one adverse reaction and 15 falls). -For the second quarter, the document showed there were 10 incidents (two "other" and eight falls). -For the third quarter, the document showed there were 13 fall incidents. -For the fourth quarter, the document showed there were 17 incidents (one "other" and 16 falls). Further review of the QAPI program showed the data was collected for each PI study and identified specific problem areas; however, there was no documented evidence showing the agency had analyzed the data, tracked patterns and trends, implemented preventive actions, and evaluated whether the current practices were effective in improving the overall care and services provided to the patients. In addition, the hospice failed to include Patient A's episode of choking as part of the reported incidents that occurred during the third quarter of 2021. Cross reference to L554, example #1. On 4/27/22 at 0826 hours, an interview and concurrent document review was conducted with the QAPI Coordinator. When asked to show the analysis and action plans for the 2021 QAPI program, the QAPI Coordinator was unable to provide the documentation. The QAPI Coordinator stated she only collected the data and if she identified a deficient practice, she would inform the specific staff involved to correct the problem. When asked if Patient A's episode of choking was included as part of the incidents reported for the third quarter of 2021, the QAPI Coordinator stated no. The QAPI Coordinator stated she recognized that the incident should have been included in the report since choking was considered an adverse event.

Based on interview and record review, the agency failed to document the reasons for conducting the PI projects and measurable progress achieved on these projects for 2021. These failures created the risk of not being able to ensure whether the PI projects conducted accurately reflected the scope, complexity, and past performance of the agency. Findings: Review of the hospice's P&P titled Quality Assessment/Performance Improvement (undated) showed the program will at least be capable of showing measurable improvement in indicators related to improved palliative outcomes and agency services and will document what PI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. Review of the QAPI program for 2021 was conducted on 4/26/22. The QAPI program showed the hospice performed several QAPI studies for 2021. On 4/26/22 at 1404 hours, an interview and concurrent document review was conducted with the QAPI Coordinator. When asked how the agency chose which PI studies to focus on, the QAPI Coordinator replied she conducted the studies based on the list created by the hospice's previous coordinator. She continued the same studies and updated the list for any changes. For example, in 2021, there were four additional problem specific areas included in the study. The QAPI Coordinator explained she collected the data to ensure the staff was submitting the documents timely for the patient notification of non-coverage, death and disposal summary, collaboration of POC, and incident reports. Further review of the QAPI program showed the data was collected for each PI study and identified specific problem areas; however, there was no documented evidence showing the reasons for conducting each of the PI study and measurable progress.

Based on interview and record review, the hospice's GB failed to ensure the ongoing QAPI program for quality improvement and patient safety was evaluated annually. This failure created the increased risk of not providing quality of care and services to the patients. Findings: Review of the agency's P&P titled Governing Body dated 2019 showed the hospice's GB will ensure the QAPI program reflects the complexity of its organization and services; an ongoing program for quality improvement and patient safety is defined, implemented, maintained and is evaluated annually; the hospice's QAPI efforts address priorities for improved quality of care and patient safety; and all improvement actions are evaluated for effectiveness. Review of the QAPI program binder for 2021 was conducted on 4/26/22. The QAPI program binder showed the data collected from the QAPI studies and the meeting minutes for each quarter. The QAPI meetings were conducted quarterly on 4/13/21, 7/21/21, 10/20/21, and 1/19/22; however, there was no documented evidence showing the GB evaluated the QAPI program. On 4/27/22 at 0826 hours, an interview and concurrent record review was conducted with the QAPI Coordinator. The QAPI Coordinator was asked what happened after the data was collected for each QAPI study. The QAPI Coordinator stated after she informed the specific staff involved to correct the deficient practice, she then notified the Administrator and DPCS via e-mail. When asked if the hospice's GB provided feedback and evaluation of the data collected including the overall effectiveness of the QAPI program, the QAPI Coordinator stated no and that she was not involved in the GB meetings. On 4/27/22 at 0850 hours, an interview and concurrent record review was conducted with the Administrator who was a member of the GB. The Administrator stated the GB met monthly to discuss the overall operation of the hospice. When asked if the GB discussed the QAPI program, the Administrator replied yes but the monthly discussions were mostly about the financial aspects of the hospice. When asked if the GB evaluated the data collected for the QAPI studies, the Administrator stated they did not discuss every data collected from each quarter but only discussed the significant incidents or ongoing problems which were documented in the GB meeting minutes. Review of the agency's documents titled Governing Board Meeting Agenda showed the GB discussed the QAPI program on 1/19, 7/25, and 10/10/21; however, there was no documented evidence showing the GB conducted a evaluation of the agency's QAPI program, including identifying the lack of documented analysis, action plans, and whether the implemented actions were effective. Cross reference to L651, example #2.

Based on interview and record review, the hospice failed to ensure the licensed staff participated in the hospice QAPI program and in-service training. This failure had the potential to create a lack of systems for improvement which could affect the provision of quality care and services to the patients and their families. Findings: Review of the hospice's P&P titled Quality Assurance/Performance Improvement (undated) showed the agency's governing body/owner will ensure that the licensed professionals will participate in the hospice's QAPI program and sponsored in-service training about QAPI. Review of the QAPI program binder for 2021 was conducted on 4/26/22. The QAPI program binder showed the data collected from the QAPI studies and the meeting minutes for each quarter. The QAPI meetings were conducted quarterly on 4/13, 7/21, 10/20/21, and 1/19/22. Further review of the QAPI program binder showed no documented evidence the agency ensured the licensed staff participated in their QAPI in-service training programs. On 4/27/22 at 0826 hours, an interview and concurrent document review was conducted with the QAPI Coordinator. The QAPI Coordinator was asked how the hospice informed the staff regarding the QAPI program. The QAPI Coordinator stated if she identified a deficient practice, she would inform the specific staff involved to correct the problem. When asked if the hospice informed all licensed staff and provided in-service trainings regarding the hospice's QAPI program, the QAPI Coordinator stated no.

Based on interview and record review, the hospice's GB failed to assume full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operation, and continuous QAPI. This failure had the potential to negatively affect the provision of quality care provided to the patients. Findings: 1. Review of the hospice's P&P titled Employee Personnel Files dated 2019 showed the employees' health files will include the examination by a physician, nurse practitioner, or physician's assistant for all persons providing physician, nursing, or home health aide services that confirms the employee is physically and medically qualified to perform duties to be assigned and the employee has no medical condition that would create a hazard to patients. This examination shall be completed six months prior to employment or within 14 days of the date of employment. The employee health files will also include a TST or chest X-ray upon hire and annual tuberculosis screenings. Review of the personnel files for the Administrator, DPCS, LVNs 1, and 2 was conducted on 4/26/22. The personnel files showed the health assessments were not completed within six months prior to employment or within 14 days of assuming employment and did not have the TB testing or chest x-ray upon hiring as follows: - The Administrator's personnel file showed the date of hire was 8/10/12. However, the physical examination and chest x-ray were completed on 3/5/13 and 7/10/13, respectively, more than 14 days of assuming employment. - The DPCS's personnel file showed the date of hire was 4/23/13. However, the chest x-ray was completed on 2/11/16, more than 14 days of assuming employment. - LVN 1's personnel file showed the date of hire was 1/22/14. However, the chest x-ray was completed on 2/25/13, more than six months prior to assuming employment. - LVN 2's personnel file showed the date of hire was 7/1/14. However, the physical examination and TB testing were completed on 7/30/14 and 9/10/14, respectively, more than 14 days of assuming employment. On 4/27/22 at 0810 hours, an interview and concurrent document review was conducted with the HR Assistant/Volunteer Director. The HR Assistant/Volunteer Director verified the findings. 2. Review of the agency's P&P titled Governing Body dated 2019 showed the hospice's GB will ensure that the QAPI program reflects the complexity of its organization and services; an ongoing program for quality improvement and patient safety is defined, implemented, maintained and is evaluated annually; the agency's QAPI efforts address priorities for improved quality of care and patient safety; and all improvement actions are evaluated for effectiveness. On 4/27/22 at 0826 hours, an interview and concurrent record review was conducted with the QAPI Coordinator. The QAPI Coordinator was asked what happened after the data was collected for each QAPI study. The QAPI Coordinator stated after she informed the specific staff involved to correct the deficient practice, she then notified the Administrator and DPCS via e-mail. When asked if the agency's GB provided feedback and evaluation of the data collected including the overall effectiveness of the QAPI program, the QAPI Coordinator stated no and that she was not involved in the GB meetings. On 4/27/22 at 0850 hours, an interview and concurrent record review was conducted with the Administrator who was a member of the GB. The Administrator stated the GB met monthly to discuss the overall operation of the hospice. When asked if the GB discussed the QAPI program, the Administrator replied yes but the monthly discussions were mostly about the financial aspects of the hospice. When asked if the GB evaluated the data collected from the QAPI studies, the Administrator stated they did not discuss every data collected from each quarter but only discussed the significant incidents or ongoing problems which were documented in the GB meeting minutes. Review of the agency's documents titled Governing Board Meeting Agenda, showed the governing body discussed the QAPI program on 1/19, 7/25, and 10/10/21; however, there was no documented evidence showing the GB conducted a meaningful evaluation of the agency's QAPI program including identifying the lack of documented analysis, action plans, and whether the implemented actions were effective. Cross reference to L574.

Based on interview and document review, the hospice failed to ensure their COVID-19 Vaccination P&P included the process to track and document the COVID-19 vaccination status of the agency's contracted providers and any staff who have obtained any booster doses as recommended by the CDC. This failure created the risk of not meeting the health and safety needs of the staff and patient population. Findings: Review of the QSO-22-07 showed the agency's P&Ps must include the process for tracking and securely documenting the COVID-19 vaccination status of all staff specified including individuals under contract and for those staff who have obtained any booster doses as recommended by the CDC. Review of the hospice's P&P titled Mandatory Vaccination Policy (undated) showed the process for tracking and documenting the COVID-19 vaccination status of the hospice's employees; however, it did not include the process for the contracted individuals who provided care, treatment, or other services for the hospice and/or its patients. In addition, the P&P did not include the process to ensure all staff obtained any recommended booster doses and any recommended additional doses for immunocompromised individuals. On 4/27/22 at 0915 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.