Every finding on record at Still Waters Hospice, LLC

Based on interview and record review, the agency failed to develop and maintain an Emergency Preparedness Plan that was reviewed and updated at least every 2 years. --- Review of the agencys Emergency Preparedness Plan revealed the last documented review was on 03/15/2020 and the last documented approval was on 03/20/2020. Interview with S1 Administrator/DON on 03/26/2024 at 1:16 p.m. confirmed the last documented review and approval of the agencys emergency prepardness plan had been completed on 03/20/2020 which was not at least every two years as required and should have been.

Based on interview and record review the agency failed to ensure exercises to test the Emergency Plan were conducted at least annually by having a full-scale exercise that is community-based; or an annual individual, facility-based functional exercise and an additional exercise that may include, a second full-scale exercise that is community or facility-based or a tabletop exercise that includes group discussion, as evidenced by failure to have documented evidence that two such exercises had been conducted annually. --- Review of the Agencys Emergency Preparedness binder revealed a plan activation log dated 2019. Review also revealed there was no documentation that an annual full scale facility based, table top, or community events exercises for 2020, 2021, 2022, or 2023 had been conducted. Interview on 03/26/2024 at 1:16 p.m. with S1 Administrator/DON stated the agency had completed table top reviews of the agencys emergency preparedness plan, but had not completed table top exercises for specific identified risk. S1 Administrator/DON stated the agencys emergency preparedness plan was activated during the freezing weather of January 2024, but there was no documentation. Interview on 03/26/2024 at 1:30 p.m. with S1 Administrator/DON confirmed there was no documentation emergency preparedness drills/exercises had been completed at least annually.

Based on interview and record review the agency failed to follow the individualized written plan of care established by the IDG in collaboration with the attending physician, the patient, or representative, and the primary caregiver for 1 (Patient #10) of 13 patient records reviewed. Findings: --- Review of Patient #10s Plan of Care for certification period 10/02/2023 through 12/06/2023 revealed a visit frequency for hospice aides at 5 times a week. Review of Patient #10s completed visit report revealed Patient #10 received 3 hospice aide visits during the week of 11/19/2023 through 11/25/2023. Review of Patient #10s 11/2023 Physician Orders revealed no orders approving missed hospice aide visits for 11/19/2023 through 11/25/2023. Interview on 03/26/2024 at 1:03 p.m. with S1 Administrator/DON confirmed that Resident #10 received only 3 hospice aide visits during the week beginning 11/19/2023. S1 Administrator confirmed there was no Physician order for the 2 missed visits and there should have been.

Based on record review and staff interview, the Hospice Agency failed to ensure an ongoing effective hospice-wide, data-driven, Quality Assessment and Performance Improvement (QAPI) program was developed, implemented and maintained. The Hospice Agency failed to ensure quarterly QAPI reports and meetings were conducted. Findings: --- Review of the Agencys QAPI binder provided by S1 Administrator/DON revealed the last performance indicators review was performed in 2014. Interview on 03/26/2024 at 3:00 p.m. with S1 Administrator/DON revealed she did not have any QAPI monitoring on hand. S1 Administrator/DON stated she had the data saved on her computer. Review of the documentation provided by S1 Administrator/DON revealed data for 2nd quarter 2023 which reflected varying review dates that included 01/28/2023 and 01/25/2023. Review of data for 1st quarter 2022 reflected varying review dates including 01/17/2022, 02/01/2022, and 03/01/2022. Interview on 03/26/2024 at 3:50 p.m. with S1Administrator/DON confirmed she did not have documentation that QA indicators had been reviewed quarterly for Performance Improvement and that she had no documentation of quarterly QA committee meeting minutes.