Every finding on record at Precious Love Hospice

It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state and local laws. The communication plan includes the names and contact information for hospice employees, patients’ physicians, entities providing services under arrangement, and primary and alternate means for communicating with hospice staff. This standard was not met as evidenced by document review and interview. A review of the emergency preparedness communication plan revealed the hospice did not ensure the plan complied with federal, state, and local law including as well as the agency's emergency management policy. Document 3: The agency policy Emergency Management Plan Policy No 7-001.1 revised April 2020 did not include Appendix A titled "Pyramid Phone Communication Plan" as indicated in the policy. There was no employee contact information listed in the communication plan. An interview with the Alternate Administrator/DPCS on 11/8/2023 confirmed that Appendix A was missing from the policy. In 1 of 1 (100%) review of the emergency preparedness communication plan the hospice did not ensure the plan complied with federal, state, and local law including their emergency management agency plan.

It is required that the hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually. Exercises may include participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include but is not limited to a second full-scale exercise that is community-based or a facility-based functional exercise, a mock disaster drill, tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. In 1 of 1 (100%) document reviewed as part of the emergency management program revealed the hospice did not ensure a mock disaster drill or tabletop exercise was conducted. Document 3: The Emergency Preparedness Program manual was reviewed. There was no evidence that the staff participated in a tabletop exercise. An interview with the Alternate Administrator/DPCS on 11/8/2023 confirmed this finding. In 1 of 1 (100%) document reviewed as part of the emergency management program revealed the hospice did not ensure a mock disaster drill or tabletop exercise was conducted.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. This standard was not met as evidenced by clinical record review and interview. In 1 of 12 (8%) clinical records reviewed in which a comprehensive assessment was performed, revealed the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care. Clinical Record 3: The patient’s benefit election was dated 10/19/2023. The need for a spiritual care evaluation was documented in the comprehensive assessment. There was no evidence of documentation that the chaplain performed a spiritual care assessment within 5 calendar days after the election of hospice care. An interview with the Alternate Administrator/DPCS on 11/7/2023 confirmed this finding. In 1 of 12 (8%) clinical records reviewed in which a comprehensive assessment was performed, revealed the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by document review, interview and observation. 1 of 1 (100%) home visits made in which wound care was provided revealed the hospice did not ensure standard precautions were being followed. Home Visit 1: The patient’s benefit election was dated 9/2/2022. A home visit was made with the RN Melinda on 11/6/2023 at 1140. The patient had a wound on her right forearm. The RN was observed performing wound care. During wound care, the old blood-soaked dressing was removed and thrown in a general waste receptacle. There was no plastic bag in the general waste receptacle. After wound care, the gauze that was used to clean the wound (also blood-soaked) was thrown in the general waste receptacle. The old dressing and the gauze used to cleanse the wound was not bagged or double bagged. Document 1: The agency policy Standard Precautions Policy No 9-007.1 revised April 2020 reads in relevant parts, "Items that are caked with blood or other potentially infectious materials.... should be placed into a leak-proof, heavy duty, securely fastened plastic bag." The RN who conducted the visit on 11/6/2023 is also the Alternate Administrator/DPCS was interviewed on 11/6/2023 and confirmed the finding. She stated she should have properly disposed of the old dressing and soiled gauze.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed in which bereavement services were offered revealed the hospice did not ensure the bereavement plan of care was followed as documented. Clinical Record 10: The patient’s benefit election was dated 1/20/23. The patient's date of death was dated 5/18/2023. On 5/18/2023 the RN documented the patient's daughter declined bereavement letters and calls but was open to phone calls from the hospice. Documentation also stated the hospice would continue to follow up with phone calls to check on the patient's daughter. There was no evidence of phone calls to patient's daughter from 5/18/2023 through 11/8/2023. An interview with the Alternate Administrator/DPCS on 11/7/2023 confirmed this finding. In 1 of 9 (11%) clinical records reviewed in which bereavement services were offered revealed the hospice did not ensure the bereavement plan of care was followed as documented.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed in which the need for a spiritual care assessment was identified revealed that the hospice did not ensure that a spiritual care assessment was completed as ordered. Clinical Record 3: The patient’s benefit election was dated 10/19/23. The need for a spiritual care (SC) assessment was documented on the RN initial assessment as the patient and his wife had been married for 40 years. There was no documentation as to why the SC assessment was not completed. During an interview with the Alternate Administrator/DPCS on 11/7/23, she stated she spoke with the chaplain who in turn said he had tried to reach the family but didn't document the attempts. In 1 of 7 (14%) clinical records reviewed in which the need for a spiritual care assessment was identified revealed that the hospice did not ensure that a spiritual care assessment was completed as ordered.

It is required that a hospice aide provides services that are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) clinical records reviewed in which a hospice aide was ordered on admission, did not include documented evidence the hospice aide followed the plan of care as ordered. Clinical Record 5: The patient’s benefit election was dated 3/7/23. The HA was ordered 2 times a week. During the week of 7/30/2023-8/5/2023, the HA documented a visit on 8/1/23. There was no documented evidence of a second hospice aide visit for that week. During an interview with the Alternate Administrator/DPCS on 11/7/23, she stated she did not know why a second HA visit was not made that week. In 1 of 10 (10%) clinical records reviewed in which a hospice aide was ordered on admission, did not include documented evidence the hospice aide followed the plan of care as ordered.

It is required that the hospice maintains, documents, and provides hospice volunteer orientation and training that is consistent with hospice industry standards; it includes the volunteer’s duties and responsibilities, the person to whom they report, the person to contact if they need assistance and instruction, hospice goals, services, and philosophy, confidentiality and protection of the patient’s and family’s rights, family dynamics and psychological issues surrounding terminal illness, death, and bereavement, procedures to be followed in an emergency and/or following the death of a patient, and guidance specific to individual responsibilities. Volunteers are supervised by a designated hospice employee. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel record reviewed in which the employee was employed as a volunteer revealed the hospice did not ensure that the volunteer received volunteer training. Personnel Record 9: The personnel record of the volunteer, hire date 9/30/2023 was reviewed and did not contain evidence of volunteer training. An interview with the Alternate Administrator/DPCS on 11/8/2023 confirmed this finding. In 1 of 1 (100%) personnel record reviewed in which the employee is employed as a volunteer, the hospice did not ensure that the volunteer received volunteer training.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. In 1 of 1 (100%) document reviewed related to the volunteer program, the hospice did not ensure that efforts were being made to recruit volunteers. Document 2: The Volunteer Program binder was reviewed on 11/8/2023. There was no evidence of documented efforts to recruit volunteers. The volunteer coordinator was interviewed on 11/7/2023. When asked how she recruited volunteers, she stated "I ask friends." She stated she did not provide other means to recruit such as flyers and/or use of websites/social media. An interview with the Alternate Administrator/DPCS on 11/8/2023 confirmed that they had not been actively recruiting volunteers. In 1 of 1 (100%) document reviewed related to the volunteer program, the hospice did not ensure that efforts were being made to recruit volunteers.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed in which a discharge summary was required revealed the hospice did not ensure that the information provided to the receiving facility contained a summary of the patient's hospice stay. Clinical Record 6: The patient’s benefit election was dated 7/24/2023. The patient's date of death was dated 8/25/2023. The discharge summary stated "patient/family relocating and transferring to another hospice." The discharge summary did not include evidence of a brief summery related to dx, symptoms, pain management and the extent to which goals were met and/or not met. An interview with the Alternate Administrator/DPCS on 11/7/2023 confirmed this finding. In 1 of 1 (100%) clinical record reviewed in which a discharge summary was required revealed the hospice did not ensure that the information provided to the receiving facility contained a summary of the patient's hospice stay.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 2 (100%) applicable clinical records of patients requiring a recertification face-to-face encounter, the hospice did not ensure face-to-face encounters were completed. THIS IS A CONTINUING PRIOR REQUIRED ACTION. Clinical Record 3: Review of the clinical record revealed the patient was recertified by the Medical Director for the 7th benefit period 1/4/23 through 3/4/23. The Recertification form included a section titled, "Face-to-Face Encounter date" which was blank. Review of the clinical record revealed a missing Face-to-Face Encounter visit note from the Medical Director. During interview 1/10/23, the Alternate Director Patient Care Services/Alternate Administrator stated, "Yes, the Medical Director stated she did complete the Face-to-Face visit to the patient, however I do not know the date of the visit and the Medical Director has not completed the Face-to-Face visit documentation yet." Clinical Record 2: Review of the clinical record revealed the patient was recertified by the Medical Director for the 3rd benefit period 1/4/23 through 3/4/23. The Recertification form included a section titled, "Face-to-Face Encounter" that included the date "12/30/22". Review of the clinical record revealed a missing Face-to-Face Encounter visit note from the Medical Director. During interview 1/10/23, the Alternate Director Patient Care Services/Alternate Administrator stated, "The Medical Director has not sent her Face-to-Face visit documentation yet." THIS IS A CONTINUING PRIOR REQUIRED ACTION.

It is required that the written Patient Bill of Rights includes the right to choose his or her attending physician. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 1 (100%) record reviewed of a patient electing hospice care after 10/11/22 revealed the hospice did not ensure the written Patient Bill of Rights included the patient's right to choose his or her attending physician. Clinical Record 4: was reviewed and identified the patient elected hospice services on 10/21/22. The "Patient Rights" form signed by the patient did not include informing the patient of the right to choose an attending physician. The "Election" form did not contain an area for the patient to identify the name of their attending physician. During a joint record review and an interview on 11/21/22, the Administrator/Owner and Case Coordinator confirmed the finding.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes, and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 3 (100%) records reviewed of patients on service greater than 21 days revealed the hospice did not ensure that the comprehensive assessment was updated by the Interdisciplinary Group (IDG) no less frequently than every 21 days in accordance with the CMS issued Public Health Emergency (PHE) blanket waivers. Clinical Record 2: was reviewed and identified the "IDG Discussion/Updated Comprehensive Assessment Review" section of the "POC/IDG Review" forms dated 10/12/22, 10/26/22 and 11/9/22 did not include the psychosocial update of the comprehensive assessment. Clinical Record 3: was reviewed and identified the "IDG Discussion/Updated Comprehensive Assessment Review" section of the "POC/IDG Review" forms dated 10/12/22, 10/26/22 and 11/9/22 did not include the psychosocial update of the comprehensive assessment. Clinical Record 1: was reviewed and identified the "IDG Discussion/Updated Comprehensive Assessment Review" section of the "POC/IDG Review" forms dated 10/12/22, 10/26/22 and 11/9/22 did not include the psychosocial update of the comprehensive assessment. During interview on 11/21/2022, the Administrator and Case Coordinator confirmed the psychosocial update of the comprehensive assessment was blank and not completed. During interview on 11/21/2022, the Administrator and Case Coordinator stated the psychosocial update of the comprehensive assessment was blank and not completed.

It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. IDG members provide the care and services offered by the organization. The IDG, in its entirety, supervises the care and services provided to the patient and family. THIS IS A CMS CONDITON-LEVEL DEFICIENCY This CONDITION was not met as evidenced by clinical record review, document review and interview. The hospice failed to ensure care and services furnished to patients and their families followed an individualized written plan of care established by the hospice IDG [HCPC.19.I/L543]; to ensure the designated registered nurse member of the IDG provided continuous assessment of the patient's and family's needs [HCPC.19.I/L540]; to ensure the Interdisciplinary Group prepared an initial written plan of care [HCPC.18.I/L537]; and to ensure the IDG reviewed, revised, and documented the individualized plan as frequently as the patient’s condition required, but no less frequently than every 15 calendar days [HCPC.22.I/L552]. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality patient care in a safe environment.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 1 (100%) record reviewed of patient electing hospice care on or after 10/11/22 revealed the Interdisciplinary Group did not prepare an initial written plan of care (POC) for the patient. Clinical Record 4: was reviewed and identified the patient elected hospice care on 10/21/22. Review of the clinical record revealed a missing initial plan of care. The hospice plan of care was not established by the Interdisciplinary Group (IDG) until the "Update POC" at the first IDG meeting on 10/26/22. During phone interview 11/21/22, the Director Patient Care Services Designee stated "I do not know what happened and why the initial plan of care is not there." During joint clinical record review and interview, the Administrator/Owner and Case Coordinator confirmed the missing initial plan of care.

It is required that the hospice designates a registered nurse member of the IDG to ensure continuous assessment of each patient’s and family’s needs. This standard was not met as evidenced by a review of clinical records and interviews. 4 of 4 (100%) records reviewed on or after 10/11/22 revealed the hospice did not ensure the designated registered nurse member of the IDG provided continuous assessment of each patient’s and family’s needs. Clinical Record 1: was reviewed and revealed the Registered Nurse (RN) did not perform continuous assessment of the patient needs on or after 10/11/22. The RN performed "aide and LVN supervisory" visit documentation only and did not complete a patient nursing note to document the continuous assessment of the patient's and family's needs. Clinical Record 2: was reviewed and revealed the Registered Nurse (RN) did not perform continuous assessment of the patient needs on or after 10/11/22. The RN performed "aide and LVN supervisory" visit documentation only and did not complete a patient nursing note to document the continuous assessment of the patient's and family's needs. Clinical Record 3: was reviewed and revealed the Registered Nurse (RN) did not perform continuous assessment of the patient needs on or after 10/11/22. The RN performed "aide and LVN supervisory" visit documentation only and did not complete a patient nursing note to document the continuous assessment of the patient's and family's needs. Clinical Record 4: was reviewed and revealed the Registered Nurse (RN) did not perform continuous assessment of the patient needs after the initial nursing assessment on 10/21/22, The patient elected hospice services on 10/21/22, continuous care was initiated by the LVN on 10/23/22, the RN completed a "Aide and LVN Supervisory" note only on 10/26/22, and the RN performed the death attendance documentation on 10/29/22. The RN did not complete a patient nursing note on 10/26/22 to document the continuous assessment of the patient's and family's needs. During a joint record review and an interview on 11/21/22, the Administrator/Owner and Case Coordinator confirmed the missing RN continuous assessments of the patients. During joint record review and interview 11/21/22, the Administrator/Owner and Case Coordinator confirmed the missing RN continuous assessments of the patients.

It is required that all hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. This standard was not met as evidenced by a review of clinical records and interviews. 4 of 4 (100%) records reviewed of patients receiving hospice care on or after 10/11/22 revealed the individualized written plan of care was not followed. Clinical Record 3: was reviewed and identified the patient elected hospice care on 9/6/22. The Licensed Vocational Nurse (LVN) visit frequency ordered was one time a week. Review of the record revealed the LVN did not complete one visit for the weeks of 10/9/22, 11/6/22 and 11/13/22. Clinical Record 2: was reviewed and identified the patient elected hospice care on 9/2/22. The LVN visit frequency ordered was one time a week. Review of the record revealed the LVN did not complete one visit for the week of 10/9/22. There was no evidence of weekly LVN visits since 10/31/22. Clinical Record 4: was reviewed and identified the patient elected hospice care on 10/21/22. There were no social worker and spiritual counselor assessment/evaluation orders and/or plan of care visit frequency orders. The initial psychosocial assessment completed 10/24/22 and the initial spiritual counselor assessment and visit completed on 10/23/22 and 10/27/22, respectively speaking were completed without orders and/or plan of care visit frequencies. Clinical Record 1: was reviewed and identified the patient elected hospice care on 9/6/22. The LVN visit frequency ordered was one time a week. Review of the record revealed the LVN did not complete one visit for the week of 10/9/22. There was no evidence of weekly LVN visits since 10/31/22. During joint record review and interview 11/21/22, the Administrator/Owner and Case Coordinator confirmed the missing and/or extra nursing, social worker and/or spiritual counselor visits, missed visit reports and/or subsequent orders to justify the missing and/or extra visit notes.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by a review of clinical records and interviews. 4 of 4 (100%) records reviewed revealed the hospice did not ensure the Interdisciplinary Group reviewed, revised, and documented the individualized care plan no less frequently than every 15 calendar days. Clinical Record 1: was reviewed and identified the patient elected hospice care on 9/6/22. There was no documented evidence that the plan of care was reviewed and updated by the social worker on the "POC/IDG Review" forms dated 10/12/22 and 10/26/22. The section of the form labeled "POC was reviewed and updated by the following IDG members" was blank for the social worker. Additionally, the "POC/IDG Review" dated 11/9/22 was missing evidence that the social worker, spiritual counselor and medical director attended the IDG to review/update the plan of care. Clinical Record 2: was reviewed and identified the patient elected hospice care on 9/2/22. There was no documented evidence that the plan of care was reviewed and updated by the social worker on the "POC/IDG Review" forms dated 10/12/22 and 10/26/22. The section of the form labeled "POC was reviewed and updated by the following IDG members" was blank for the social worker. Additionally, the "POC/IDG Review" dated 11/9/22 was missing evidence that the social worker, spiritual counselor and medical director attended the IDG to review/update the plan of care. Clinical Record 3: was reviewed and identified the patient elected hospice care on 5/9/22.There was no documented evidence that the plan of care was reviewed and updated by the social worker on the "POC/IDG Review" forms dated 10/12/22 and 10/26/22. The section of the form labeled "POC was reviewed and updated by the following IDG members" was blank for the social worker. Additionally, the "POC/IDG Review" 11/9/22 was missing evidence that the social worker and spiritual counselor attended the IDG to review/update the plan of care. Clinical Record 4: was reviewed and identified the patient elected hospice care on 10/21/22. There was no documented evidence that the plan of care was reviewed and updated by the social worker on the "POC/IDG Review" form dated 10/26/22. The section of the form labeled "POC was reviewed and updated by the following IDG members" was blank for the social worker. During an interview on 11/21/22, the Administrator/Owner stated "The IDG members are required to sign into the clinical record during IDG meetings, and we do not have another IDG attendance log or form to show the IDG members who attended IDG". During phone interview 11/21/22, the Director of Patient Care Services Designee stated, "We hold IDGs by Zoom and the social worker, RN, spiritual counselor and medical director are on the call". During interview 11/21/22, the Administrator/Owner stated "The IDG members are required to sign into the clinical record during IDG meetings, and we do not have another IDG attendance log or form to show the IDG members who attended IDG". During phone interview 11/21/22, the Director of Patient Care Services Designee stated, "We hold IDGs by Zoom and the social worker, RN, spiritual counselor and medical director are on the call".

The hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program reflects the complexity of the hospice and services, involves all hospice services, including those provided under contract, addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness, focuses on indicators related to improved palliative outcomes, includes investigation and analysis of sentinel and adverse events, includes defined data detail and frequency of collection, and approves such, has evidence of action taken that results in improvement in hospice performance, and is evaluated annually. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of Governing Body documents, Quality Improvement documents, and interviews with the Administrator, which revealed issues with the organization's Quality Assurance Performance Improvement (QAPI) program in the following areas: Failure of the organization to implement quality improvement activities that are capable of showing measurable improvement [HQPI 3.I/L561]; Failure of the organization to demonstrate evidence of the measurement, analysis and tracking of quality indicators [HQPI 4.I/L562]; Failure of the organization to use quality indicator data collected [HQPI 5.I/L564]; Failure of the organization's governing body to approve the frequency and detail of the data collection [HQPI 5.I/L565]; Failure of the organization to focus performance improvement activities on high-risk-problem-prone areas [HQPI 6.I/L566]; Failure of the organization's performance improvement activities to track adverse patient events, analyze their causes, and implement preventive actions, and mechanisms [HQPI 7.I/L569]; and Failure of the Governing Body to demonstrate responsibility for ensuring the QAPI program is defined, implemented, maintained, and evaluated [HSLG 2.I/L574]. The cumulative effect of these deficiencies could impact the organization's ability to assess care and services provided by the hospice and ensure the provision of high-quality care and services. This CONDITION was not met as evidenced by a review of Governing Body documents, Quality Improvement documents, and interviews with the Administrator, which revealed issues with the organization's Quality Assurance Performance Improvement (QAPI) program in the following areas: Failure of the organization to implement quality improvement activities that are capable of showing measurable improvement [HQPI 3.I/L561]; Failure of the organization to demonstrate evidence of the measurement, analysis and tracking of quality indicators [HQPI 4.I/L562]; Failure of the organization to use quality indicator data collected [HQPI 5.I/L564]; Failure of the organization to focus performance improvement activities on high-risk-problem-prone areas [HQPI 6.I/L566]; Failure of the organization's performance improvement activities to track adverse patient events, analyze their causes, and implement preventive actions, and mechanisms [HQPI 7.I/L569]; and Failure of the Governing Body to demonstrate responsibility for ensuring the QAPI program is defined, implemented, maintained, and evaluated [HSLG 2.I/L574]. The cumulative effect of these deficiencies could impact the organization's ability to assess care and services provided by the hospice and ensure the provision of high-quality care and services.

It is required that the QAPI program demonstrates measurable improvement among indicators related to improved palliative outcomes and hospice services. This standard was not met as evidenced by document reviews and interview which revealed the hospice did not ensure that the agency had collected data and tracked indicators to demonstrate measurable improvement. CONTINUING PRIOR REQUIRED ACTION The review of the Governing Body Minutes binder and the Quality Assurance Performance Program (QAPI) documents revealed there was no evidence, on or after 10/11/22, that the QAPI program had collected data and tracked indicators to demonstrate measurable improvement with indicators related to improved palliative outcomes and hospice outcomes. During an interview 11/21/22, the Administrator/Owner/CEO stated, "We do not have any QAPI forms or documents since the last site visit 10/11/22" and we received QAPI forms to fill out from the new consultant last week but we have not completed them". This standard was not met as evidenced by document reviews and interview which revealed the hospice did not ensure that the agency had collected data and tracked indicators to demonstrate measurable improvement. The review of the Governing Body Minutes binder and the Quality Assurance Performance Program (QAPI) documents revealed there was no evidence, on or after 10/11/22, that the QAPI program had collected data and tracked indicators to demonstrate measurable improvement with indicators related to improved palliative outcomes and hospice outcomes. THIS IS A REPEATED CONTINUED PRIOR ACTION During interview 11/21/22, the Administrator/Owner/CEO stated, "We got a new consultant who did the plan of correction for us but she has not returned to train us and implement the plan of correction", "The new consultant said she would train us the first week in December", "We do not have any QAPI forms or documents since the last site visit 10/11/22" and "We received QAPI forms to fill out from the new consultant last week but we have not completed them".

It is required that the hospice measures, analyzes, and tracks quality indicators of performance that enable the assessment of processes of care, hospice services, operations, and adverse events. This standard was not met as evidenced by a review of document reviews and interviews. The hospice did not ensure to measure, analyze, and track quality indicators of performance that enabled the assessment of processes of care, hospice services, operations, and adverse events. CONTINUING PRIOR REQUIRED ACTION The review of the Governing Body Minutes binder and the Quality Assurance Performance Program (QAPI) documents revealed there was no evidence, on or after 10/11/22, that quality indicators of performance had been measured, analyzed or trended to enable the assessment of processes of care, hospice services, operations, and adverse events. During an interview on 11/21/22, the Administrator/Owner/CEO stated, "We do not have any completed QAPI forms or documents since the last site visit 10/11/22 and we received QAPI forms to fill out from the new consultant last week but we have not completed them". THIS IS A REPEATED CONTINUED PRIOR ACTION The hospice did not ensure to measure, analyze, and track quality indicators of performance that enabled the assessment of processes of care, hospice services, operations, and adverse events. The review of the Governing Body Minutes binder and the Quality Assurance Performance Program (QAPI) documents revealed there was no evidence, on or after 10/11/22, that quality indicators of performance had been measured, analyzed or trended to enable the assessment of processes of care, hospice services, operations, and adverse events. During interview 11/21/22, the Administrator/Owner/CEO stated, "We got a new consultant who did the plan of correction for us but she has not returned to train us and implement the plan of correction", "We do not have any completed QAPI forms or documents since the last site visit 10/11/22" and "We received QAPI forms to fill out from the new consultant last week but we have not completed them".

It is required that the hospice must use the data collected to do the following: monitor the effectiveness and safety of services and quality of care; and identify opportunities and priorities for improvement. This standard was not met as evidenced by document review and interviews. CONTINUING PRIOR REQUIRED ACTION-- The review of the Governing Body Minutes binder and the Quality Assurance Performance Program (QAPI) documents revealed there was no evidence, on or after 10/11/22, that the hospice ensured patient care data was collected to monitor the effectiveness and safety of services and the quality of care to identify and prioritize opportunities for improvement. Additionally, review of the QAPI binder revealed a "QAPI Plan" which was not approved by the hospice’s governance. During interview 11/21/22, the Administrator/Owner/CEO stated "That is the old QAPI Plan that was in place back during the start up in 2020". During an interview on 11/21/22, the Administrator/Owner/CEO stated, "We do not have any completed QAPI forms or documents since the last site visit 10/11/22 and we do not have governing body minutes or documents for the approval of the QAPI Plan". THIS IS A REPEATED CONTINUED PRIOR ACTION The review of the Governing Body Minutes binder and the Quality Assurance Performance Program (QAPI) documents revealed there was no evidence, on or after 10/11/22, that the hospice ensured patient care data was collected to monitor the effectiveness and safety of services and the quality of care to identify and prioritize opportunities for improvement. Additionally, review of the QAPI binder revealed a "QAPI Plan" which was not approved by the hospice’s governance. During interview 11/21/22, the Administrator/Owner/CEO stated "That is the old QAPI Plan that was in place back during the start up in 2020". During interview 11/21/22, the Administrator/Owner/CEO stated, "We got a new consultant who did the plan of correction for us but she has not returned to train us and implement the plan of correction", "We do not have any completed QAPI forms or documents since the last site visit 10/11/22", "We received QAPI forms to fill out from the new consultant last week but we have not completed them" and "We do not have governing body minutes or documents for the approval of the QAPI Plan".

It is required that the frequency and detail of the data collection must be approved by the hospice’s governing body. This standard was not met as evidenced by document review and interviews which revealed the hospice's governing body did not ensure to approve the frequency and detail of the data collection. The review of the Governing Body Minutes binder and the Quality Assurance Performance Program (QAPI) documents revealed there was no evidence, on or after 10/11/22, that the hospice's governing body approved the frequency and detail of the data collection. Additionally, review of the QAPI binder revealed a "QAPI Plan" which was not approved by the hospice’s governance. During interview and review of the documents on 11/21/22, the Administrator/Owner/CEO stated "That is the old QAPI Plan that was in place back during the start up in 2020...We do not have any completed QAPI forms or documents since the last site visit 10/11/22 and we do not have governing body minutes or documents for the approval of the QAPI Plan."

It is required that hospice performance improvement (PI) activities focus on high-risk, high-volume, or problem-prone areas. This standard was not met as evidenced by document review and interviews. The hospice did not ensure to conduct performance improvement activities that focused on high-risk, high-volume, or problem-prone areas. CONTINUING PRIOR REQUIRED ACTION The review of the Governing Body Minutes binder and the Quality Assurance Performance Program (QAPI) documents revealed there was no evidence, on or after 10/11/22, that the hospice conducted performance improvement (PI) activities that focused on high-risk, high-volume, or problem-prone areas. During interview 11/21/22, the Administrator/Owner/CEO stated, "We got a new consultant who did the plan of correction for us but she has not returned to train us and implement the plan of correction and we do not have any completed QAPI forms or documents since the last site visit 10/11/22." THIS IS A REPEATED CONTINUED PRIOR ACTION The review of the Governing Body Minutes binder and the Quality Assurance Performance Program (QAPI) documents revealed there was no evidence, on or after 10/11/22, that the hospice conducted performance improvement (PI) activities that focused on high-risk, high-volume, or problem-prone areas. During interview 11/21/22, the Administrator/Owner/CEO stated, "We got a new consultant who did the plan of correction for us but she has not returned to train us and implement the plan of correction", "We do not have any completed QAPI forms or documents since the last site visit 10/11/22" and "We received QAPI forms to fill out from the new consultant last week but we have not completed them".

It is required that performance improvement activities track adverse patient events, analyze the causes, and implement preventive action and mechanisms that include feedback and learning throughout the hospice. This standard was not met as evidenced by document reviews and interviews. The hospice did not ensure that performance improvement activities tracked and analyzed adverse events, and implemented preventive action. CONTINUING PRIOR REQUIRED ACTION The review of the Governing Body Minutes binder and the Quality Assurance Performance Program (QAPI) documents revealed there was no evidence, on or after 10/11/22, that the hospice tracked and analyzed patient adverse events and implemented preventive actions as part of performance improvement activities. During an interview on 11/21/22, the Administrator/Owner/CEO stated, "We got a new consultant who did the plan of correction for us but she has not returned to train us and implement the plan of correction and we do not have any completed QAPI forms or documents since the last site visit 10/11/22." THIS IS A REPEATED CONTINUED PRIOR ACTION The review of the Governing Body Minutes binder and the Quality Assurance Performance Program (QAPI) documents revealed there was no evidence, on or after 10/11/22, that the hospice completed performance improvement activities to tracked and analyzed patient adverse events and implemented preventive action. A review of the QAPI documents and Governing Body minutes revealed the hospice did not complete performance improvement activities. There was no evidence of activities involving adverse events and the implementation of preventive actions. During interview 11/21/22, the Administrator/Owner/CEO stated, "We got a new consultant who did the plan of correction for us but she has not returned to train us and implement the plan of correction", "We do not have any completed QAPI forms or documents since the last site visit 10/11/22" and "We received QAPI forms to fill out from the new consultant last week but we have not completed them".

It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. This standard was not met as evidenced by document review and interviews. The hospice's governance did not ensure that performance improvement and patient safety program were defined, implemented, maintained, and evaluated annually. CONTINUING PRIOR REQUIRED ACTION-- The review of the Governing Body Minutes binder and the Quality Assurance Performance Program (QAPI) documents revealed there was no evidence, on or after 10/11/22, that the hospice ensured quality indicator data was collected to include patient care data to monitor the effectiveness and safety of services and the quality of care to identify and prioritize opportunities for improvement. There was no evidence that performance improvement and patient safety program were defined, implemented, maintained, and evaluated annually. During an interview on 11/21/22, the Administrator/Owner/CEO stated, "We do not have any completed QAPI forms or documents since the last site visit 10/11/22 and we do not have governing body minutes or documents for the approval of the QAPI Plan". THIS IS A REPEATED CONTINUED PRIOR ACTION The review of the Governing Body Minutes binder and the Quality Assurance Performance Program (QAPI) documents revealed there was no evidence, on or after 10/11/22, that the hospice ensured quality indicator data was collected to include patient care data to monitor the effectiveness and safety of services and the quality of care to identify and prioritize opportunities for improvement. Additionally, the hospice did not ensure the frequency and detail of the data collection was approved by the hospice’s governance. During interview 11/21/22, the Administrator/Owner/CEO stated, "We got a new consultant who did the plan of correction for us but she has not returned to train us and implement the plan of correction", "We do not have any completed QAPI forms or documents since the last site visit 10/11/22", "We received QAPI forms to fill out from the new consultant last week but we have not completed them" and "We do not have governing body minutes or documents for the approval of the QAPI Plan".

It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including: conducting ongoing interdisciplinary comprehensive assessments; and developing and evaluating the plan of care. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review, interviews and review of clinical records which revealed the hospice failed to ensure that the nursing needs of the patient were met [HCDT.6.I/L591]; and to ensure the bereavement plan of care reflected the needs of the bereaved [HCDT.22.I/L596]. This cumulative effects of these deficiencies could impact the agency's ability to provide safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 1 of 1 (100%) record reviewed of a patient who received continuous care after 10/11/22, revealed the hospice did not ensure continuous care was provided as required per agency policy. The agency's policy #2-0015, "Continuous Care Services" stated in part, "The need for continuous care and the skill level of hospice personnel needed in the home will be evaluated daily by the hospice case manager or designee and clearly documented in the patient care notes and plan of care...Continuous care level of care must be provided a minimum of eight (8) hours to 24 hours a day...The hospice RN will assess if the patient's condition requires continuous care...A minimum of eight hours of care must be provided during a 24 hour day...The RN cases manager will make daily evaluations to determine if continuous care is warranted...The hospice case manager or designee will determine, along with the attending physician and hospice medical director, when continuous care is no longer needed and notify interdisciplinary group members to resume routine home care plan of care." Clinical Record 4: was reviewed and identified the patient elected hospice care on 10/21/22. A physician's order dated 10/23/22 ordered "continuous care (CC) level of care for seizures and rapid decline". Review of the clinical record revealed the Licensed Vocational Nurse (LVN) provided 6 hours of continuous care on 10/23/22, 10/24/22, 10/25/22 and 10/26/22, and a 30-minute nursing visit on 10/28/22. There were no subsequent orders and/or plan of care update to discontinue the CC level of care. The RN documented an "aide and LVN supervisory visit" on 10/26/22 and a death attendance note on 10/29/22. There was no documented evidence that the need for CC and the skill level of the hospice personnel needed in the home was evaluated daily by the hospice RN, that the CC level of care was provided a minimum of eight (8) hours a day and that the hospice RN determined, along with the attending physician and hospice medical director, when continuous care was no longer needed. In addition, there was no evidence that the hospice RN, along with the attending physician and hospice medical director notified the interdisciplinary group members to resume the routine home care plan of care, as required in agency policy. During a joint clinical record review and an interview on 11/21/22, the Administrator/Owner and Case Coordinator confirmed the missing daily evaluation of CC by the RN, that the LVN provided only 6 hours of CC daily from 10/23/22 through 10/29/22, and the missing documentation that the hospice RN determined, along with the attending physician and hospice medical director, when continuous care was no longer needed and then notified the interdisciplinary group members to resume routine home care plan of care. Policy, "Continuous Care Services", Policy number 2-0015, included in part, "The need for continuous care and the skill level of hospice personnel needed in the home will be evaluated daily by the hospice case manager or designee and clearly documented in the patient care notes and plan of care", "Continuous care level of care must be provided a minimum of eight (8) hours to 24 hours a day", "The hospice RN will assess if the patient's condition requires continuous care", "A minimum of eight hours of care must be provided during a 24 hour day", "The RN cases manager will make daily evaluations to determine if continuous care is warranted", and "The hospice case manager or designee will determine, along with the attending physician and hospice medical director, when continuous care is no longer needed and notify interdisciplinary group members to resume routine home care plan of care".

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 1 (100%) records reviewed of a patient that expired on or after 10/11/22 revealed the hospice did not ensure the bereavement plan of care reflected the needs of the bereaved. Clinical Record 4: was reviewed and identified the patient elected hospice care on 10/21/22 and expired on 10/29/22. The clinical record did not include a bereavement plan of care that included the types of bereavement services to be offered and the frequency of service delivery. During a joint review of the clinical record and interview on 11/21/2022, the Administrator and Case Coordinator confirmed the blank section of the bereavement plan of care for bereavement services to be provided and the frequency of service. During phone interview 11/21/22, the Bereavement Counselor stated "yes, I see that section of the bereavement plan of care is blank for the type and frequency of services".

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 4 (25%) records reviewed revealed the hospice did not ensure the Hospice Aide visit frequency did not include "PRN" visits. . Clinical Record 3: was reviewed and identified the Hospice Aide visit frequency "two times a week and PRN for any changes." The PRN visit frequency is not specific instructions for the Hospice Aide. During a joint record review and an interview on 11/21/22, the Administrator/Owner and Case Coordinator confirmed the Hospice Aide visit frequency order included "PRN for any changes".

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care and documented in the patient record, including the time spent. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 1 (100%) records reviewed of patients admitted to hospice service on or after 10/11/22 revealed the hospice did not ensure the need for volunteer services was completed at the time of admission. Clinical Record 4: was reviewed and identified the patient elected hospice care on 10/21/22. Review of the nursing, psychosocial and spiritual assessments revealed no evidence that the hospice evaluated the patient's need for a volunteer at the time of admission. The first hospice plan of care was established by the Interdisciplinary Group (IDG) at the first IDG meeting on 10/26/22. The plan of care did not include an evaluation of the patient's need for volunteer services. During a phone interview on 11/21/22, the Director Patient Care Services Designee stated, "We usually put the volunteer evaluation on the initial plan of care and I do not know why the initial plan of care is not there". During joint clinical record review and interview on 11/21/22, the Administrator/Owner and Case Coordinator confirmed the missing need for a volunteer at the time of admission.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: the primary terminal condition, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders and information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 1 (100%) records reviewed of patients admitted to hospice services on or after 10/11/22 revealed the hospice did not ensure the initial certification requirements were met. Clinical Record 4: was reviewed and identified the patient elected hospice services on 10/21/22, at the start of the 2nd benefit period. The initial certification form did not contain a physician's dated signature, a verbal certification, and a physician's narrative. During an interview on 11/21/22, the Administrator/Owner and Case Coordinator confirmed the missing signed initial certification, verbal certification, and physician narrative.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes, at a minimum, signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 1 (100%) applicable records reviewed of patients electing the hospice Medicare benefit on or after 10/11/22 revealed missing signed copies of the notice of patient rights and the hospice election statement. Clinical Record 4 was reviewed and identified the patient elected hospice services on 10/21/22. The effective date of election was not documented on the "Election of the Medicare Hospice Benefit Election" form. The form did not contain a section to fill in the date of election. The patient's choice of attending physician was not documented on the form. Additionally, the hospice did not provide documented evidence of notification of the patient's (or representative's) right to receive an election statement addendum if there are conditions, items, services, and drugs the hospice has determined to be unrelated to the individual's terminal illness and related conditions and would not be covered by the hospice. During a joint record review and an interview on 11/21/22, the Administrator/Owner and Case Coordinator confirmed the Election form did not include the effective date of the election, the patient's choice of attending physician, and documented evidence of notification of the patient's (or representative's) right to receive an election statement addendum.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 1 (100%) applicable records reviewed of patients that were recertified on or after 10/11/22 revealed missing recertification requirements. . Clinical Record 3 was reviewed and identified the patient started the 3rd benefit period on 11/5/22. The recertification form did not contain a physician's dated signature, a verbal certification and a physician's narrative. Additionally, review of the record revealed a missing face-to-face encounter. During an interview on 11/21/22, the Administrator/Owner and Case Coordinator confirmed the missing signed recertification, verbal certification, face-to-face encounter, and physician narrative.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the counter (OTC) drugs. The medication review process includes the identification of the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug therapy associated with lab monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 5 (20%) records reviewed revealed the hospice did not ensure that the patient's medication profile was updated to include the patient's current medications. Clinical Record #1: was reviewed and identified the patient elected hospice care on 9/6/2022. A review of the patient's "Current Treatment/Medication/DME List" revealed the medication list did not contain oxygen. During an interview on 10/11/2022, the Administrator/Director of Nurses confirmed the finding and “was not aware that Oxygen should have been added to the Medication/DME list."

It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 5 of 5 (100%) records reviewed revealed the hospice did not ensure that the comprehensive assessment included an initial bereavement assessment of the needs of the patient's family and other individuals. Clinical record #1: was reviewed and identified the patient elected hospice care on 9/6/2022. Review of the record revealed no evidence that an initial bereavement assessment was included and completed as part of the comprehensive assessment. There was no documentation explaining the reason for the delay. Clinical record #2: was reviewed and identified the patient elected hospice care on 9/2/2022. Review of the record revealed no evidence that an initial bereavement assessment was included and completed as part of the comprehensive assessment. There was no documentation explaining the reason for the delay. Clinical record #3: was reviewed and identified the patient elected hospice care on 5/9/2022. Review of the record revealed no evidence that an initial bereavement assessment was included and completed as part of the comprehensive assessment. There was no documentation explaining the reason for the delay. Clinical record #4: was reviewed and identified the patient elected hospice care on 9/17/2022. Review of the record revealed no evidence that an initial bereavement assessment was included and completed as part of the comprehensive assessment. There was no documentation explaining the reason for the delay. Clinical record #5: was reviewed and identified the patient elected hospice care on 2/10/2022. Review of the record revealed no evidence that an initial bereavement assessment was included and completed as part of the comprehensive assessment. There was no documentation explaining the reason for the delay. The Administrator/ Director of Nursing (DON) confirmed this finding during the exit conference conducted on 10/11/2022 and indicated that the spiritual and psychosocial assessments were completed on admission. This Administrator/DON stated they were not aware that the initial bereavement assessment was part of the comprehensive assessment.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes, and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 5 (20%) records reviewed revealed the hospice did not ensure that the comprehensive assessment was updated. Clinical Record #1: was reviewed and identified the patient elected hospice care on 9/6/2022. The Licensed Vocational Nurse (LVN) visit note dated 9/16/2022 documented, “Daughter expressed concerns with pain and would like something stronger than Tylenol. She also requested tubing for oxygen and peri care supplies.” The plan of care and Interdisciplinary Group review dated 9/28/2022 did not include the changes the daughter had requested for pain management and supplies. During an interview on 10/11/2022, the Administrator/Director of Nursing (DON) stated that she "was not aware that the Comprehensive Nursing Assessment discussions should be documented at IDG/IDT."

The hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program reflects the complexity of the hospice and services, involves all hospice services, including those provided under contract, addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness, focuses on indicators related to improved palliative outcomes, includes investigation and analysis of sentinel and adverse events, includes defined data detail and frequency of collection, and approves such, has evidence of action taken that results in improvement in hospice performance, and is evaluated annually. This CONDITION was not met as evidenced by a review of Governing Body documents, Quality Improvement documents, and interviews with the Administrator, which revealed issues with the organization's Quality Assurance Performance Improvement (QAPI) program in the following areas: Failure of the organization's Governing Body to appoint one or more individual(s) who are responsible for operating the quality assessment and performance improvement program [HQPI 2.I/L576]; Failure of the organization to implement quality improvement activities that are capable of showing measurable improvement [HQPI 3.I/L561]; Failure of the organization to demonstrate evidence of the measurement, analysis and tracking of quality indicators [HQPI 4.I/L562]; Failure of the organization to use quality indicator data collected [HQPI 5.I/L564]; Failure of the organization to focus performance improvement activities on high-risk, problem-prone areas [HQPI 6.I/L566]; Failure of the organization's performance improvement activities to track adverse patient events, analyze their causes, and implement preventive actions, and mechanisms [HQPI 7.I/L569]; and Failure of the Governing Body to demonstrate responsibility for ensuring the QAPI program is defined, implemented, maintained, and evaluated [HSLG 2.I/L574]. The cumulative effect of these deficiencies could impact the organization's ability to assess care and services provided by the hospice and ensure the provision of high-quality care and services.

It is required that the QAPI program demonstrates measurable improvement among indicators related to improved palliative outcomes and hospice services. This standard was not met as evidenced by document reviews and interview which revealed the hospice did not ensure that the agency had collected data and tracked indicators to demonstrate measurable improvement. The review of the Governing Body Minutes, and the Quality Assurance Performance Program (QAPI) revealed there was no documented evidence, as of 8/15/2020 through 2022, that the QAPI program had collected data and tracked indicators to demonstrate measurable improvement with indicators related to improved palliative outcomes and hospice outcomes. During an interview on 10/11/2022, the Administrator/Director of Nurses (DON) stated that" the Consultant had taken the manuals and had not returned them to the office." In review of the Governing Body Minutes, and the Quality Assurance Performance Program (QAPI), there was no documented evidence from 8/15/2020, that the QAPI program had demonstrated any measurable improvements with indicators related to improved palliative outcomes and hospice outcomes. This entails the period of time for services from 2021 and 2022. In an interview with the Administrator/Director of Nurses (DON), on 10/11/2022, this manager stated that" the Consultant had taken the manuals and had not returned them to the office."

It is required that the hospice measures, analyzes, and tracks quality indicators of performance that enable the assessment of processes of care, hospice services, operations, and adverse events. CONTINUED PRIOR ACTION This standard was not met as evidenced by document reviews and interviews. The hospice did not ensure to measure, analyze, and track quality indicators of performance that enabled the assessment of processes of care, hospice services, operations, and adverse events. Review of the Governing Body Minutes, and the Quality Assurance Performance Program (QAPI) revealed there was no documented evidence from 8/15/2020 through 2022, that data had been analyzed, trended, tracked to correct identified problems. This included tracking of quality indicators such as infection control, falls, and adverse events. There was no evidence of chart reviews. During an interview on 10/11/2022, the Administrator/Director of Nurses (DON) stated that the Consultant had taken the manuals and had not returned them to the office. In review of Governing Body Minutes, and the Quality Assurance Performance Program (QAPI), there was no documented evidence from 8/15/2020, that data had been analyzed, trended, tracked to correct identified problems for 2021 and 2022. This included tracking of quality indicators such as Infection Control, Falls, or Adverse Events. Nor was there any evidence of Chart Reviews. In an interview with the Administrator/Director of Nurses (DON), on 10/11/2022, was stated that the Consultant had taken the manuals and had not returned them to the office.

It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the QAPI program. Data elements abstracted and aggregated from comprehensive patient assessments are used in quality assessment and improvement. Data collected is used to monitor the effectiveness and safety of services and quality of care and Identify opportunities and priorities for improvement. The frequency and detail of the data collection is approved by the hospice’s governance. This standard was not met as evidenced by document reviews and interviews. The review of the Governing Body Minutes and the Quality Assurance Performance Program (QAPI) revealed no evidence that patient data was collected to monitor the effectiveness and safety of services and the quality of care to identify and prioritize opportunities for improvement for 2021 and 2022. During an interview on 10/11/2022, the Administrator/Director of Nurses (DON) stated that "the Consultant had taken the manuals and had not returned them to the office. In review of the Governing Body Minutes, and the Quality Assurance Performance Program (QAPI), there was no documented evidence of any data collection, to include safety, prioritizing care by identifying needs for improvement for 2021 and 2022. In an interview with the Administrator/Director of Nurses (DON), on 10/11/2022, was stated that "the Consultant had taken the manuals and had not returned them to the office."

It is required that hospice performance improvement (PI) activities focus on high-risk, high-volume, or problem-prone areas. . This standard was not met as evidenced by a review of document reviews and interviews. The hospice did not ensure to conduct performance improvement (PI) activities that focused on high-risk, high-volume, or problem-prone areas. A review of the Quality Assurance Performance Program (QAPI) revealed was no evidence that the hospice identified any problem areas or needs for improvement in process. There were no performance improvement plans or evidence of performance improvement activities that focused on any high risk, high volume, or problem areas for 2021 and 2022. During an interview on 10/11/2022, the Administrator/Director of Nurses (DON), on 10/11/2022, was stated that the Consultant had taken the manuals and had not returned them to the office. In review of the Quality Assurance Performance Program (QAPI), there was no documented evidence that the hospice had any performance improvement activities that focused on any high risk, high volume, or problem areas for 2021 and 2022. In an interview with the Administrator/Director of Nurses (DON), on 10/11/2022, was stated that the Consultant had taken the manuals and had not returned them to the office.

It is required that performance improvement activities track adverse patient events, analyze the causes, and implement preventive action and mechanisms that include feedback and learning throughout the hospice. This standard was not met as evidenced by document reviews and interviews. The agency did not ensure that performance improvement activities tracked and analyzed patient adverse events, and implemented preventive action. A review of the administrative documents and the agency's Quality Assurance Performance Program (QAPI) revealed the agency was not tracking and analyzing patient adverse events. There was no evidence of activities involving adverse events and the implementation of preventive actions as part of a performance improvement plan for 2021 and 2022. During an interview on 10/11/2022, the Administrator/Director of Nurses (DON) stated that the Consultant had taken the manuals and had not returned them to the office. In review of the Quality Assurance Performance Program (QAPI), there was no documented evidence that the agency had developed or had tracked or analyzed any patient events or implemented any preventive actions for learning purposes for 2021, and 2022. In an interview with the Administrator/Director of Nurses (DON), on 10/11/2022, was stated that the Consultant had taken the manuals and had not returned them to the office.

It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s overall management and operation, provision of care and services, and ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. This standard was not met as evidenced by document reviews and interviews. The hospice's governance did not ensure that performance improvement and patient safety were defined, implemented, maintained, and evaluated annually. During a review of the Governing Body Minutes, and the Quality Assurance Performance Program (QAPI) revealed no evidence of governing body meeting minutes since August 15. 2020, when the agency prepared for their initial survey. The Administrator/Director of Nurses (DON) confirmed during a joint review of the documents that there was no evidence of governing body participation or performance improvement documentation for the years 2021, and 2022. During an interview on 10/11/2022, the Administrator/Director of Nurses (DON stated that the Consultant had taken the manuals and had not returned them to the office. In review of the Governing Body Minutes, and the Quality Assurance Performance Program (QAPI), there were no documented Governing Board minutes since August 15. 2020, when the agency had prepared for their initial survey. Per the Administrator/Director of Nurses (DON), there is no evidence of Governing Board participation or Performance Improvement documentation for the years 2021, and 2022, and overall management or operations. In addition, any oversight for the provision of care and services, and ongoing Performance Improvement, Patient Safety Program had not been maintained annually. In an interview with the Administrator/Director of Nurses (DON), on 10/11/2022, was stated that the Consultant had taken the manuals and had not returned them to the office.

It is required that one or more individual(s) is appointed by the governance as responsible for operating the QAPI program. This standard was not met as evidenced by a review of documents and interviews. The hospice did not ensure to appoint one or more individuals to be responsible for operating the QAPI program. A review of the Governing Body meeting minutes, and the Quality Assurance Performance Program (QAPI) revealed no evidence that the Governing Body appointed an individual(s) to be responsible for operating the QAPI program as of 8/15/2020, 2021 and 2022. During an interview on 10/11/2022, the Administrator/Director of Nurses (DON) stated that "the Consultant had taken the manuals and had not returned them to the office." In review of the Governing Body Minutes, and the Quality Assurance Performance Program (QAPI), there was no documented evidence from 8/15/2020, that the Governing Body had appointed individuals to implement the QAPI program, or that the Governing Body had provided any oversight of the QAPI program for 2021, and 2022. In an interview with the Administrator/Director of Nurses (DON), on 10/11/2022, was stated that "the Consultant had taken the manuals and had not returned them to the office."

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 1 (100%) record reviewed of an expired patient revealed the agency did not ensure that bereavement services detailed the type and the frequency of services to be provided to the family and other individuals. Clinical Record #4: was reviewed and identified the patient elected hospice care on 9/17/2022 and died on 9/19/2022. The bereavement plan of care dated 9/28/2022, did not indicate the types of bereavement services to be offered and the frequency of service delivery to be provided to the family. During an interview on 10/11/2022 , the Administrator/Director of Nurses stated that she provided "a card and was not aware that documented services included Bereavement letters/materials, or informational and educational resources for 12 months after the patient’s death, for Caregivers."

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. CONTINUED REQUIRED ACTION This standard was not met as evidenced by a review of clinical records and interviews. 1 of 2 (50%) records reviewed of discharged patients revealed that the hospice did not ensure the patient’s attending physician was forwarded a copy of the hospice discharge summary. Clinical Record #5: was reviewed and identified the patient elected hospice care on 2/10/2022. The patient was discharged from hospice services on 5/10/2022, due to "extended prognosis." There was no evidence that the hospice sent a copy of the discharge summary to the patient's attending physician. During an interview on 10/11/2022, the Administrator/Director of Nursing (DON) stated she "called the physician but had not provided a discharge summary."