Every finding on record at Superior Hospice VI, LLC

Based on interview and record review, the hospice failed to ensure that an ongoing program for quality improvement and patient safety was defined, implemented, maintained, and evaluated annually for 3 of 3 years requested to be reviewed (2023, 2024, and currently in 2025), in that:No QAPI documentation was provided for 2023, 2024 and currently in 2025. This failure resulted in the HHSC surveyor being unable to evaluate the hospice’s QAPI program for effectiveness and could result in failure to identify areas of concern which could result in harm to future patients and a failure to provide optimal patient care. --- Findings included:Record review of a QAPI binder dated 01/13/18 did not contain documentation of an ongoing program for quality assessment and performance improvement for the years 2023, 2024, and currently in 2025. The binder contained a QAPI “Plan”/policy and blank QAPI templates/forms. During an interview on 09/22/25 at 11:32 a.m., the Administrator said the agency did not have QAPI documentation for the last 3 years. She said the agency only had the “manual” with blank forms. She said the QAPI had to of been at the other office they were locked out of. She said the agency had QAPI prior to their relocation and she bet it was still at the previous location. The Administrator said the previous alternate administrator was responsible for QAPI prior to the agency selling and the Alternate Administrator/DOO would be responsible for QAPI now. She said the previous alternate administrator left the agency in November (2024) and after her the Alternate Administrator was over QAPI. The Administrator said a consulting company helped the agency with QAPI and QAPI was done quarterly. She said the last QAPI meeting was in May 2025. The Administrator said the staff involved in QAPI included the chaplain, SW, an RN, Administrator and the physician. She said in QAPI the agency went over patients, concerns, complaints, and had QAPI meetings during IDT. She said a potential negative outcome for not having QAPI was the agency would be cited. She said having a QAPI program was one of the requirements and it was a part of what should be done with the agency. She said it was how the agency addressed concerns and issues and fixed them. During an interview on 09/22/25 at 3:03 p.m., the Alternate Administrator said there had been no QAPI because there were no patients under the license, and he thought they were going to sell the license. He said the previous owner did not provide anything for QAPI that he was aware. He said if she did, it was locked in the other office the agency was evicted from and they could not access those records. He said he found out in August (2025) that he still had to keep agency records up to date even if there were no patients on the roster, or if they were going to sell the license. The Alternate Administrator said QAPI was done semiannually. He said the Administrator, Alternate Administrator, the DON, nurse consultant, Social Worker, Chaplain and Medical Director attended QAPI meetings. He said QAPI included incidents, goals, PIPs, complaints, updated processes and procedures.  During an interview on 09/22/25 at 3:40 p.m., the DON said she could not say if there was a QAPI for this license, but there should be. She said the Alternate Administrator/DOO was responsible for overseeing QAPI. She said she had not attended any QAPI meetings for this license. The DON said it was important for the agency to have QAPI to maintain patient safety, ensure the agency was following regulations, and for quality assurance (a systematic process for ensuring a service meets defined requirements and standards).  During an interview on 09/22/25 at 3:54 p.m., Chaplain F said he had been with the agency for about a year and 2 months and was also the bereavement coordinator (provides grief counseling and support to families coping with the loss of a loved one). He said he was not involved in QAPI. During an interview on 09/22/25 at 4:00 p.m., Hospice Aide G said she had been with the agency for more than 10 years. She said she never heard of QAPI and was not involved.  During an interview on 09/22/25 at 4:37 p.m., HR Manager E said she did not participate in QAPI.  During an interview on 09/22/25 at 4:47 p.m., SW D said she did not participate in the QAPI program and was not aware of the QAPI program. During an interview on 09/22/25 at 5:03 p.m., the Administrator said the Alternate Administrator was responsible for QAPI and by not doing it, it could affect patient safety and QAPI ensured patients’ needs were being met. During an interview on 09/22/25 at 5:21 p.m., Hospice Aide H said she had been with the agency 2.5 years. She said she was not involved in QAPI. The Agency did not provide any QAPI documentation. Record review of a Quality Assessment/Performance Improvement Plan policy dated 01/25/25 indicated “I. Purpose of Quality Assessment/Performance Improvement Program (QAPI)… The program will be ongoing and focused on patient outcomes that are measurable. All aspects of hospice care will be reviewed and analyzed in order to provide quality care and outcomes… (2) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually (3) That the Hospice wide QAPI efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness…” Record review of an Administrative Structure policy dated 02/01/25 indicated “…III. The Governing Body… will assume ultimate responsibility and legal authority for the management of all Hospice services, its fiscal operations, and continuous quality assessment and performance improvement as defined by state license…” Record review of a Governing Body policy dated 09/21/24 indicated “…D. The Hospice’s Governing Body (or designated persons so functioning) will have ultimate responsibility and legal authority… for the management of the Hospice's… Ongoing Quality Assessment Performance Improvement (QAPI) program that is defined, implemented, maintained, and evaluated annually… N. Ensuring the QAPI program… 5. Maintains documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS; 6. That the Hospice-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness…”

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. 2 of 11 (18%) records reviewed revealed the hospice did not ensure the plan of care (POC) specified the services necessary to meet the needs of the patient identified in the comprehensive assessment. Record #8 was reviewed and identified the patient elected hospice care on 2/7/22. The comprehensive initial assessment completed by the Registered Nurse (RN) on 2/7/22 documented that the patient had an ostomy, the POC dated 2/7/22 does not include an intervention or goal for ostomy care. Record #6 was reviewed and identified the patient elected hospice care on 1/29/22. The comprehensive initial assessment completed by the RN on 1/29/22 documented that the patient had an ostomy, the POC dated 1/29/22 does not include an intervention or goal for ostomy care. During an interview, the Alternate Administrator (Staff #2) confirmed that the plan of care did not include an intervention for ostomy care on these patients.