Every finding on record at Professional Healthcare Resources, Inc.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties: The needs and concerns of patients and families coping with a terminal illness; Education regarding the hospice’s policies and procedures on advance directives. THIS IS A CONTINUED REQUIRED ACTION THERE WERE NO NEW HIRES SINCE THE LAST SITE VISIT This standard was not met as evidenced by interview and personnel record review. In 1 of 10 (10%) This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) personnel records reviewed, it was revealed that the agency did not ensure that Orientation included the following, as appropriate to the employee’s specific job duties: the needs and concerns of patients and families coping with a terminal illness. PERSONEL RECORD 7: his Registered Nurse Case Manager was hired on 05/22/2023. The personnel record was reviewed for the years of 2023, 2024, and 2025. There was no evidence of hospice specific orientation which included the hospice philosophy. In an interview conducted with the Human Resources Director on 08/07/2025, it was stated that the hospice orientation was missing. The HR Director stated this nurse worked mainly in home health upon hire. She stated that the agency would ensure that the employee receive orientation to the hospice philosophy

It is required that the hospice has a written Patient Bill of Rights and Responsibilities (Bill of Rights). The patient has the right to be informed of his or her rights and responsibilities, and the hospice defines, protects, and promotes the exercise of these rights. This is a CMS CONDITION LEVEL DEFIENCY. This CONDITION was not met, as evidenced by clinical record reviews and interviews with the Registered Nurse/QAPI Coordinator which revealed the hospice: Failed to ensure the patient received effective pain management [HPFC.2. D/L512/418.52(c)(1)]. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.52: Patient Rights. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the hospice agency.

It is required that the written Patient Bill of Rights includes the right to receive effective pain management and symptom control for conditions related to the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (9%) clinical records reviewed, the agency did not ensure that the patient received effective pain management and symptom control for conditions related to the terminal illness. CLINICAL RECORD 5: This patient elected the hospice benefit on 06/20/2024 with a terminal diagnosis of protein calorie malnutrition. On 06/27/2024 the Senior Leader for Clinical Operations (SLCO) documented that there had been a "clinically significant medication issue". The agency documented that a comfort kit had been ordered for the patient on 06/19/2025 per the request of the assisted living facility (ALF) nurse prior to admission to hospice. The nurse's note for 06/21/2024 documented the patient was experiencing pain at 10/10 and severe agitation. In an interview with the Registered Nurse (RN) on 08/07/2025, it was stated that this nurse reached out to the Senior Leader for Clinical Operations because the comfort medications had not arrived. She was instructed to go to Staples and fax a script to the Hospice Medical Director because he was out of the country and could only receive faxes. Once the RN arrived at Staples, she was instructed to go back to the ALF. The RN returned to the ALF and then left. There was no documentation present of the patient's pain level or agitation at the time the RN left. On 06/22/2023, the RN made a visit and stated that the comfort pack had not arrived. It was documented that "patient states he is not uncomfortable because of pain" and that patient was transitioning to the end-of-life process. It was also documented that patient was "non-verbal". The patient was pronounced on 06/23/2024. The Senior Leader for Clinical Operations documented on 06/27/2025 that the patient died in pain and did not receive pain medication. In an interview conducted with the Registered Nurse/QAPI Coordinator on 08/07/2025, it was stated that the patient did not receive medications to provide effective treatment of pain and agitation.

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, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (9%) clinical records reviewed, the agency did not ensure that the hospice interdisciplinary team completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. CLINICAL RECORD 1: This patient elected the hospice benefit 07/17/2025 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed that the Chaplain called the daughter on 07/28/2025, and the spiritual assessment, completed as part of the initial comprehensive assessment, was conducted by the Chaplain on 07/29/2025, a total of 12 days after the patient elected the hospice benefit. In an interview conducted with the Administrator/Clinical Manager on 08/07/2025, it was stated that the Chaplain was new to this position and would be provided further training.

It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. The policies and procedures ensure that care and services provided are in accordance with the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (9%) clinical records reviewed, the agency did not ensure that the care and services were provided in accordance with the plan of care. CLINICAL RECORD 5: This patient elected the hospice benefit on 06/20/2024 with a terminal diagnosis of protein calorie malnutrition. The plan of care reviewed for the dates of 06/20/2024-06/23/2024 and included orders for a comfort kit. On 06/22/2023, the RN made a visit and stated the comfort kit had not been delivered. The patient was pronounced on 06/23/2024. The Senior Leader for Clinical Operations documented on 06/27/2025 that the patient died in pain and did not receive the pain medication.

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 clinical record review and interview. In 1 of 11 (9%) clinical records reviewed, the agency did not ensure that the nursing needs of the patient were met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. CLINICAL RECORD 5: This patient elected the hospice benefit on 06/20/2024 with a terminal diagnosis of protein calorie malnutrition. On 06/27/2024 the Senior Leader for Clinical Operations (SLCO) documented that there had been a "clinically significant medication issue". The agency documented that a comfort kit had been ordered for the patient on 06/19/2025 per the request of the assisted living facility (ALF) nurse prior to admission to hospice. The nurse's note for 06/21/2024 documented the patient was experiencing pain at 10/10 and severe agitation. In an interview with the Registered Nurse (RN) on 08/07/2025, it was stated that this nurse reached out to the Senior Leader for Clinical Operations because the comfort medications had not arrived. She was instructed to go to Staples and fax a script to the Hospice Medical Director because he was out of the country and could only receive faxes. Once the RN arrived at Staples, she was instructed to go back to the ALF. The RN returned to the ALF and then left. There was no documentation present of the patient's pain level or agitation at the time the RN left. On 06/22/2023, the RN made a visit and stated that the comfort pack had not arrived. It was documented that "patient states he is not uncomfortable because of pain" and that patient was transitioning to the end-of-life process. It was also documented that patient was "non-verbal". The patient was pronounced on 06/23/2024. The Senior Leader for Clinical Operations documented on 06/27/2025 that the patient died in pain and did not receive pain medication. In an interview with the Administrator/Clinical Manager on 08/07/2025, it was stated that she had been out of the state during the time of this patient's hospice admission. She stated that she was never notified of the issue with the patient not receiving the comfort kit, but the process was for the ALF to obtain the comfort kit from the ALF pharmacy. She believed that it was never delivered to the patient. The RN that assessed the patient on 06/21/2025 stated that she did not contact the Hospice Medical Director as he was out of the country and she had no number to contact him. When asked if the Alternate Hospice Medical Director was available, it was stated that he was available, but the RN was told by the SLCO that the SLCO would contact the physician. This SLCO was no longer employed at the time of this site visit. The Administrator stated that the agency did not ensure that the patient's needs were met and the patient never received the medications for pain or agitation.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. A review of the documentation of the volunteer hours that were provided for 2024 per the Annual QAPI Report for 2024 did not equal five percent of the total patient care hours of all paid hospice employees and contract staff. In an interview conducted with the Volunteer Coordinator on 08/07/2025, it was stated that the volunteer hours did not meet the five percent requirement at this time, but she was new to the role and there were currently two volunteers onboarded. The percentage for 2024 was (0.0%) A review of the documentation of the volunteer hours that were provided for 2024 per the Annual QAPI Report for 2024 did not equal five percent of the total patient care hours of all paid hospice employees and contract staff. In an interview conducted with the Volunteer Coordinator on 08/07/2025, it was stated that the volunteer hours did not meet the five percent requirement at this time, but she was new to the role and there were currently two volunteers onboarded. The percentage for 2024 was (0.0%)

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties: the needs and concerns of patients and families coping with a terminal illness and education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) personnel records reviewed, it was revealed that the agency did not ensure that Orientation included the following, as appropriate to the employee’s specific job duties: the needs and concerns of patients and families coping with a terminal illness. PERSONNEL RECORD 1: This Registered Nurse Case Manager was hired on 05/22/2023. The personnel record was reviewed for the years of 2023, 2024, and 2025. There was no evidence of hospice specific orientation which included the hospice philosophy. In an interview conducted with the Human Resources Director on 08/07/2025, it was stated that the hospice orientation was missing. The HR Director stated this nurse worked mainly in home health upon hire. She stated that the agency would ensure that the employee receive orientation to the hospice philosophy.

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: Current subjective and objective medical findings. This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (9%) clinical records reviewed, the agency did not ensure that the Hospice Medical Director reviewed document review of current subjective and objective medical findings for each patient being evaluated for hospice services. CLINICAL RECORD 3: This patient elected the hospice benefit on 03/01/2023 with a terminal diagnosis of essential hypertension. The CTI dated 12/12/2023 documented "82 yo male, seen in his home for F2F certification on 12/12/23. Mr. Bhatti was recently hosp". This written certification did not consider current subjective and objective findings. In an interview conducted with the Administrator/Clinical Manager on 08/07/2025, it was stated that the CTI did not include the information that was necessary to support the hospice eligibility.

It is required that the Interdisciplinary Group ensures instruction of the patient, as appropriate, and the family and/or other caregivers on the proper handling, storage, and safe utilization of durable medical equipment and/or supplies. This standard was not met as evidenced by clinical record review and interview. In 2 of 11 (18%) clinical records reviewed, the agency did not ensure that the patient, as appropriate and the family and/or other caregivers were instructed on the proper handling, storage, and safe utilization of durable medical equipment and/or supplies. CLINICAL RECORD 3: This patient elected the hospice benefit on 03/01/2023 with a terminal diagnosis of essential hypertension. Clinical record review revealed physician orders for a glucometer, hospital bed, and incentive spirometer on 03/01/2023. There was no documented evidence in the clinical record that the patient and/or caregiver were instructed on the proper handling, storage, and safe utilization of the durable medical equipment ordered for the patient. CLINICAL RECORD 5: This patient elected the hospice benefit on 06/20/2024 with a terminal diagnosis of protein calorie malnutrition. Clinical record review revealed physician orders for a bedside commode, hospital bed and concentrator on 06/20/2024. There was no documented evidence in the clinical record that the patient and/or caregiver were instructed on the proper handling, storage, and safe utilization of the durable medical equipment ordered for the patient. During an interview and joint review of records on 08/06/2025, the Administrator/Clinical Manager stated there was no documentation in the clinical record of DME education provided to the patient.

It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: physician certification and recertification of the terminal illness. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 1 (100%) home visits conducted in a skilled nursing facility (SNF), the agency did not ensure that the SNF was provided with the physician certification and recertification of the terminal illness. HOME VISIT 1/ CLINICAL RECORD 1: This patient elected the hospice benefit on 07/18/2025 with a terminal diagnosis of senile degeneration of the brain. During the home visit conducted in the skilled nursing facility (SNF) (Clinical Record 1) on 08/05/2025 to observe the Registered Nurse (Personnel Record 1), the hospice binder was reviewed and there was no documentation present of the physician certification of illness. An interview was conducted with the Administrator/Clinical Manager on 08/05/2025 and it was stated that the agency would ensure that the physician certification of terminal illness would be added to the hospice binder in the SNF.

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; Reassessment of the patient’s response to care. The assessment update is completed: As frequently as the condition of the patient requires; No less frequently than every 15 days. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 1 (100%) record reviewed revealed that the organization did not ensure the Comprehensive Assessment was updated to include a change in the patient's condition. Clinical Record 1: the election of benefit was on 8/24/2022. The IDG/IDG dated 9/19/2022 did not include the assessment of the "dry blister on the left back," documented and dated by the SN notes of 9/17/2022 and 9/19/2022. There was no documented evidence of the protection to be provided for the blister on pressure area. The plan of care was not updatied to reflect the identified change in the integumentary system. In an interview the Administrator/Director of Nurses stated that “the information should be documented.”

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; The frequency of service delivery. This standard was not met as evidenced by a review of document reviews and interviews. 1 of 2 (50%) applicable clinical records reviewed with a bereavement plan of care revealed the hospice did not ensure bereavement services were provided up to one year following the death of the patient. Clinical Record # 2 identified the patient elected hospice on 11/4/2021. The date of death was on 11/5/2021. The Bereavement Coordinator mailed a Bereavement Card on 11/5/2022, with a follow-up phone call on 12/6/2022. Further Bereavement material was sent to the caregiver on 2/5/2022, and 5/10/2022. There were no further documented Bereavement services after 5/10/2022 or documented refusal of Bereavement services. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated 11/08/2022, after death, did not indicate the types of bereavement services to be provided for the caregiver(s) for the one year after the death of the loved one. There was no documented evidence of the type of services provided, or the frequencies of the services. There was no documentation explaining the reason the bereavement services stopped after 5/10/2022. In an interview with the Administrator/Director of Nurses (Staff #1), she stated that “the IDG/IDT should have documented the Bereavement Plan of Care.” In addition, it was stated,” these services are documented at the IDG after death and their services include support groups, memorial services, informational and educational resources, counseling, and referrals to appropriate therapeutic and community resources as needed, through Bereavement letters and invitations 12 months after the death.”

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; included in the plan of care; [and] consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 3 (33%) applicable records reviewed revealed the aide services provided were inconsistent with the interdisciplinary related to the visit frequency. Clinical Record # 1, the patient election of benefits was on 8/24/2022. The ordered hospice aide visit frequency on 8/24/2022 was daily. Missed visits were identified on 9/10/2022 and 9/11/2022. There was no documentation explaining the reason for the missed visits. In an interview with the Administrator/ Director of Nurses on 10/5/2022, it was stated that “the IDG did not document the frequency change“.

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, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 2 (100%) records reviewed revealed the hospice did not ensure that the initial comprehensive assessment was completed no later than five (5) calendar days after the election of hospice care. Clinical Record #4 was reviewed and identified that the patient elected hospice care on 06/04/2020. The patient was discharged from hospice services on 01/02/2022. The record was missing evidence that an initial psychosocial assessment was completed. There was no evidence of communication that documented the patient refused or delayed the assessment. Clinical Record #1 was reviewed and identified that the patient elected hospice care on 08/18/2022. The patient was discharged from hospice services on 08/29/2022. The record was missing evidence that an initial psychosocial assessment was completed. There was no evidence of communication that documented the patient refused or delayed the assessment. The Director was interviewed on 09/23/2022. She confirmed that the initials psychosocial initial assessments were not completed within 5 calendar days after the election of hospice care.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, is permitted to be performed under state law and regulation, is consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 2 (50%) records reviewed of patients receiving hospice aide services revealed the hospice did not ensure the hospice aide provided services ordered by the Interdisciplinary Group (IDG) and included in the plan of care (POC). Clinical Record #3: The aide care plan assigned the hospice aide task, "shampoo weekly." The record was missing documentation explaining the reason the assigned task, "shampoo weekly" was not provided during visits completed the weeks of 04/05/2022, 04/07/2022 and 04/11/2022. The Director was interviewed on 09/26//2022. She confirmed that the aide did not follow the care plan the week of 04/05/2022, as ordered by the interdisciplinary group.

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, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records. 3 of 13 (100%) records reviewed revealed the hospice did not ensure that the initial comprehensive assessment was completed within 5 calendar days after the election of hospice care. Record #12 was reviewed and identified the patient elected hospice care on 1/13/2021. The bereavement assessment was completed on1/27/2021, 14 days outstanding. The record was missing evidence to support the delay in the assessment. Record #5 was reviewed and identified the patient elected hospice care on 8/29/21. The bereavement assessment was completed on 9/29/21, 31 days outstanding. The record was missing evidence to support the delay in the assessment. Record #9 was reviewed and identified the patient elected hospice care on 9/23/21. The bereavement assessment was completed on 10/28/21, 35 days outstanding. The record included documentation that a contact was attempted by phone on 9/29/2021, but no other supporting evidence was found to explain the delay in the assessment. The agency did not have evidence to prove that initial comprehensive assessment was completed in the 5 day window that is in accordance with standards.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by a review of clinical records. 1 of 1 (100%) record reviewed of a patient with occupational therapy ordered revealed the hospice did not ensure that the visits were consistent with the order on the plan of care. Record #1 was reviewed and identified the patient elected hospice care on 2/20/2020. The physician's order dated 2/20/2022 ordered, Occupational therapy (OT) to evaluate the patient. The record was missing evidence that an OT visit was completed and documentation as to why the visit was missed, as of the date of death on 2/27/2022. Occupational Therapy services were not provided according to the plan of care.

It is required that 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 DEFICENCY This CONDITION was not met as evidenced by review of Governing Body documents, policies and procedures, Quality Improvement documents, and interviews with the Vice President of Operations, which revealed issues with the organization's Quality Assessment 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 use quality indicator data collected, including patient care data, and other relevant data in the QAPI program [HQPI 5.I/L564]; Failure of the organization to focus performance activities on high -risk, problem-prone area [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 that include feedback and learning throughout the hospice [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 hospice and ensure the provision of high quality care and services. Upon review of the agencies policy for their QAPI, policy number CQI.I-6/QAPI.I-9 states in part "agency maintains documentary evidence of its quality assessment and performance improvement program and is able to demonstrate its operation. The program is capable of showing measurable improvement in indicators related to outcomes, patient safety, and quality of care. The Governing board evaluates the program annually". There was no documented evidence to show that the agency has maintained this standard or policy. In interview with VP of Operations he stated that the agency has not had a viable QAPI program since the previous Administrator had left which was just short of a year. There was no documentation of any meetings being held nor of any priorities set for improved quality of care or patient safety and no evidence of any frequency of collection of data.

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 review of the agency’s QAPI program documents and interview, which revealed there was no documentation available for review related to measurable improvement among indicators related to improved hospice services. There was no documented evidence that the agency had collected data and tracked indicators to demonstrate measurable improvement. The agency's policy "CQI.1.-6/QAPI.1-9" stated in part "the program is capable of showing measurable improvement in indicators related to outcomes, patient safety and quality of care." During an interview with Vice President of Operations, he stated that the agency has not had a viable QAPI program since the previous Administrator left, which was just short of a year ago. Agency policy number CQI.1.-6/QAPI.1-9 states in part "the program is capable of showing measurable improvement in indicators related to outcomes, patient safety and quality of care." The agencies QAPI program lacks indicators that would demonstrate measurable improvement. There was no documented evidence that the agency had any data or tracks any improvement indicators.

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, 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. Following the review of multiple administrative documents provided by the agency, there was no evidence of patient care data collected to monitor the effectiveness and safety of services and quality of care, identify opportunities and priorities for improvement. The agency did not provide evidence that a benchmarking program is currently being used. The agency's policy "CQI.1-6/QAPI. 1-9" stated in part "at minimum, agency measures, analyzes, and tracks quality indicators of performance that enable the assessment of: processes of care, hospice services, operations, and adverse events (as indicated by the CQI/QAPI and leadership teams)." The Vice President of Operations confirmed there was no data collection documented since the previous Administrator was in place. Agency policy number CQI.1-6/QAPI. 1-9 states in part "at minimum, agency measures, analyzes, and tracks quality indicators of performance that enable the assessment of: processes of care, hospice services, operations, and adverse events (as indicated by the CQI/QAPI and leadership teams)." After review of multiple documents provided by the agency there was no viable evidence that there was any data collected to monitor any of the indicators needed to met this standard, The VP of Operations confirmed there was no data collection documented since the previous Administrator was in place. The agency also does not have any evidence that a benchmarking program is currently being used.

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 reviews and interviews. A review of administrative documents revealed no evidence that the agency identified any problem areas or needs for improvement in process. There were no governing body minutes, no performance improvement plans, no documented incidence logs or evidence of performance improvement activities. The Vice President of Operations during an interview confirmed that the evidence to meet this standard was absent. There was no documented evidence that the agency identified any problem areas or needs for improvement in process. There were no governing body minutes, no performance improvement plans, no documented incidence logs or any data collection by benchmarking program. VP of Operations interview also confirmed that the evidence to meet this standard was absent.

It is required that performance improvement activities track adverse patient events, analyze the causes, 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. A review of the administrative documents provided by the agency 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. The agency policy "CQI.1.-6/QAPI.1-9" stated in part, "Based on the findings in the QAPI data review, clinical charts may be audited. Trends are identified by the team and performance improvement action items are chosen. the BA/CM develop and track the ongoing performance improvement plan and interventions. They monitor weekly and update and evaluate progress toward identified goals as appropriate. Agency utilizes the Performance Improvement plan of Actions as a means of identifying a target area that is measurable." During an interview with Vice President of Operations, he stated that the agency has not had a viable QAPI program since the previous Administrator left, which was just short of a year ago. Agency policy CQI.1.-6/QAPI.1-9 states in part "Based on the findings in the QAPI data review, clinical charts may be audited. Trends are identified by the team and performance improvement action items are chosen. the BA/CM develop and track the ongoing performance improvement plan and interventions. They monitor weekly and update and evaluate progress toward identified goals as appropriate. Agency utilizes the Performance Improvement plan of Actions as a means of identifying a target area that is measurable." There was no documentation presented by the agency that supports the tracking of adverse patient events. There was no data showing areas of high risk and no evidence that the agency had implemented any performance improvement plans. This was confirmed in an interview with the VP of Operations.

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 and evaluated annually. This standard was not met as evidenced by document reviews and interviews. Review of the governing body (GB) minutes revealed a meeting was held on July 27,2022. The GB meeting minutes provided did not address the agency's quality program and patient safety. The GB minutes dated November 2019, were the last meeting minutes in which the GB addressed the evaluation of the Quality program. There were no meeting minutes provided for 2020 and 2021. The agency's policy "CQI.1.-6/QAPI.I-9" stated in part, "The Governing Board evaluates the program annually." The Vice President of Operations confirmed that there were no additional Governing Body minutes that addressed the Quality Program. There was no documentation found in the Governing Body minutes that reflect Governing Body oversite of a Quality Program. Agency Policy #CQI.1.-6/QAPI.I-9 states in part, "The Governing Board evaluates the program annually." The last meeting held on July 27, 2022 did not address any Quality issues and the last time documentation was found that the Quality program was evaluated was November 2019. The VP of Operations confirmed that there were no additional Governing Body minutes that addressed the Quality Program.

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 document reviews and interviews. The hospice failed to ensure that one or more individuals were appointed by the governing body to operate the QAPI program. A review of administrative and governing body documents revealed no evidence that one or more individuals had been appointed by the governing body to oversee the the QAPI program for 2020, 2021, and 2022 to date. During an interview, the Vice President of Operations stated that the agency had not operated a viable program since the previous Administrator, who was responsible for the QAPI program, left just short of a year ago. Upon review of governing body documents there was no written evidence to support that there has been someone appointed to operate the QAPI program. In an interview with VP of Operations he stated that the agency has not had a viable program since the previous administrator who was responsible for the QAPI program left just short of a year ago.

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. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. 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. 2 of 9 (22%) records reviewed of patients who had died revealed the hospice did not ensure to document bereavement services being offered. Record #6 was reviewed and identified the patient elected hospice care 04/20/2021. The patient expired on 5/23/2021. There was no documentation found to support that the agency provided bereavement services or that the bereaved refused bereavement services. Record #1 was reviewed and identified the patient elected hospice care on 2/20/2020. The patient expired on 2/27/2022. There was no documentation found to support that the agency provided bereavement services or that the bereaved refused bereavement services. The agency did not document that they provided any bereavement services following the death of a patient.