Every finding on record at Teton Healthcare, Inc.

Based on hospice policy review, QAPI program review, meeting minute review, and staff interview, it was determined the hospice agency did not develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program. The hospice's Governing Body failed to ensure the program reflected the complexity of its organization and services, focused on indicators related to improved outcomes, and also failed to maintain documentary evidence of its QAPI program. Findings include: --- Refer to L - 562 as it relates to the agency's failure to ensure the QAPI program continuously measured, analyzed and tracked quality indicators to improve patient care. Refer to L - 572 as it relates to the agency's failure to maintain a robust QAPI program with Governing Body oversight and patient centered Performance improvement projects. The agency failed to ensure the QAPI program was continuous, sustained, and analyzed frequently.

Based on policy review, Governing Body minutes review, QAPI meeting minutes review, and staff interview, it was determined the hospice failed to ensure its QAPI program measured, analyzed and tracked quality indicators. This resulted in the inability of the agency to maintain a QAPI program that assessed processes of care, services and operations. Findings include: --- A hospice policy titled "Patient Focused Performance Improvement, Policy No. 5-002.1," revised November 2022, stated, "when an opportunity to improve performance is identified, a focused study will be developed to measure and improve associated processes." This policy was not followed. An example included: A QAPI Program Performance Improvement Project, initiated 6/18/24, was reviewed with the DCS on 2/26/25, beginning at 10:10 AM. She stated the PIP was titled "Insufficient QI Monitoring Events" as infections were not being captured as QI events because nurses were not entering an order for an antibiotic as an incident for a potential infection. The goals and objectives of this PIP were: "At least 5 events entered average by August 1st, 2024; At least 8 events entered average by October 1, 2024; At least 10 events entered average by December 1, 2025; Maintain 20 events entered average for 6 months." The DCS stated that her goal was to increase occurrence reports to 20 per quarter. When asked how she would confirm that antibiotic orders would flag an incident report, she did not know. The DCS was asked if she had documentation of patient chart audits to flag patients with antibiotic orders and then evaluate and analyze whether those orders generated an incident report. The DCS stated she did not have such documentation. The DCS was asked on 2/26/25, beginning at 10:10 AM to provide the focused study related to this PIP. She was unable to provide the focused study. The PIP stated, "Project Progress and Findings: monthly averages obtained, documented and reviewed for progress and change review as needed." The DCS was asked for the analysis of data collected since the PIP was initiated on 6/18/24. She confirmed there had been no follow up at this time. The hospice failed to demonstrate a QAPI program that continuously measured, analyzed and tracked quality indicators to improve patient care.

Based on policy review, staff interview, and meeting minutes review, it was determined the hospice failed to ensure its QAPI program included PIPs that improved patient care in a measurable manner. This resulted in a failure of the agency to maintain a robust QAPI program with patient centered Performance improvement projects. Findings include: --- A hospice policy titled, "Patient Focused Performance Improvement, Policy No. 5-002.1," revised November 2022, stated, "When an opportunity to improve performance is identified, a focused study (indicator) will be developed to measure and improve associated processes. QAPI documentation will be maintained by the QAPI Coordinator." This policy was not followed. Examples include: A QAPI Program Performance Improvement Project, titled "Insufficient QI Monitoring Events" initiated 6/18/24, was reviewed with the DCS on 2/26/25, beginning at 10:10 AM. She stated the PIP was regarding a lack of infections reported as QI events because nurses were not entering an order for an antibiotic as an incident for a potential infection. The goal of this PIP was to "maintain 20 events entered average for 6 months." When the DCS was asked how this goal would improve quality of hospice care delivered to patients, she was unsure. The activities for this PIP included: "monthly in-services held with QI Event Reporting Education provided and on agenda." Surveyor requested a log of in-services provided with attendees. The DCS was unable to provide a log of in-services. A request for the data gathered for this PIP since its initiation on 6/18/24 to present, as well as the analysis was requested from the DCS on 2/26/25 at 10:10 AM. The DCS was unable to provide this data. The "Outcomes" of this PIP stated, "PIP team will monitor monthly progress with the QAPI committee." A request for the monitored progress of the PIP since its initiation on 6/18/24 to present was requested from the DCS on 2/26/25 at 10:10 AM. The DCS was unable to provide this data. The PIP was not patient focused. 2. A QAPI Program Performance Improvement Project, initiated 7/02/24, titled, "Increase CAHPS Results and Patient Satisfaction" was reviewed with the DCS on 2/26/25, beginning at 10:10 AM. She stated the PIP was initiated to increase overall CAHPS score to >90%. When the DCS was asked how this goal would improve quality of hospice care delivered to patients, she was unsure. The DCS was asked on 2/26/25 at 10:10 AM to provide data gathered for this PIP since its initiation on 7/02/24 to present, as well as the analysis. She was unable to provide this data. The DCS was asked on 2/26/25 at 10:10 AM to provide an update on the progress of this PIP since its initiation on 7/02/24 to present. She was unable to provide any update to the PIP. There was no further information or outcome written for this PIP. The Performance improvement Projects initiated failed to affect patient care, show progress, or measured improvement.

Based on policy review, contract review, organizational chart review, and staff interview, it was determined the agency failed to ensure counseling services were provided directly by hospice employees. Bereavement counseling services were provided by a contracted outside agency which created the potential for decreased utilization of the service due to not being provided by agency staff. There was no extraordinary or non-routine circumstance which caused the agency to use the bereavement contractor. Additionally, the agency failed to designate an individual as the Bereavement Coordinator. Findings include: --- An agency policy titled, ";COORDINATION OF CARE WITH CONTRACTS/AGREEMENTS," revised November 2022 stated, ";Core services including physician, nursing, social work, counselors are provided directly by the hospice as evidenced by issuance of a W-2." An agency policy titled, ";BEREAVEMENT SERVICES," revised November 2022 included but was not limited to the following: "The program will provide bereavement services to the families/caregivers of hospice patients both before and after the patients death." "The bereavement counselor will render a professional judgement as to whether the bereaved is experiencing normal grief, moderate grief, or a severe grief reaction." ";If a person is noted as experiencing normal grief, the bereavement counselor will make contact with the bereaved person for ongoing assessment and support." ";In addition to the services outlined above, persons deemed to be experiencing moderate or severe grief will be followed by the bereavement program with increased services and contact offered as noted in the plan of care." ";The Bereavement Coordinator will evaluate each bereaved on a case-by-case basis and evaluate the need for individual counseling." A contract titled ";Aftercare Service Agreement – Plus Bereavement," was provided. It was dated 4/08/24. It stated the contracted bereavement services provided included the following: 13 months of bereavement follow up Receive and carry out direction from Bereavement coordinator according to initial assessment Bereavement letters mailed and/or emailed to clients at intervals of 1, 2, 3, 6, 12, and 13 months Four phone call ";check-ins" over 13 months Sympathy cards at the events of holidays, birthday of deceased, and 1 year anniversary of death Offer access to grief groups to NOK [next of kin] Bereavement library available to NOK Report to Bereavement Coordinator notes from any interactions with NOK Notify Bereavement Coordinator if there is a perceived issue or need for the NOK An agency organizational chart was provided. It listed ";Full Circle Aftercare," the bereavement contractor, as the Bereavement Coordinator. The Chaplain was interviewed on 2/26/25 beginning at 2:15 PM. When asked if he was the Bereavement Coordinator, he stated, ";I work [sic] in that role in the past." He stated the bereavement contractor would reach out to people, and he would watch for ";significant grief." When asked how he would become aware if someone experienced significant grief, he stated the bereavement contractor would send him an email. He stated, ";A lot of the responsibilities have shifted to the company [bereavement contractor]." When asked why the agency switched to the bereavement contractor, he said the contractor was more consistent. A contact with the bereavement contractor was interviewed by phone on 2/26/25 beginning at 2:30 PM. She was asked her role in bereavement services. She said she helped with correspondence, mailings, and telephone calls. She said families got 4 telephone calls by a staff at the bereavement contractor. She said the telephone calls are, ";to check in," and ";assess how theyre doing – how theyre feeling." The agency failed to ensure bereavement services were provided directly by hospice employees. Refer to L – 596 as it refers to the agencys failure to ensure the bereavement counseling program was organized under the supervision of a Bereavement Coordinator. This systemic practice had the potential to affect all individuals and their families who used hospice services.

Based on policy review, organizational chart review, and staff interview, it was determined the agency failed to ensure the bereavement program was organized under the supervision of a qualified professional. Lack of supervision of the bereavement program had the potential to result in unmet patient and family needs. Findings include: --- An agency policy titled, ";BEREAVEMENT SERVICES," revised November 2022 stated, ";Hospice Magic Valley will provide an organized bereavement program supervised by a qualified Bereavement Coordinator." This policy was not followed. An example includes: An agency organizational chart was provided. It listed ";Full Circle Aftercare," the bereavement contractor, as the Bereavement Coordinator. A contact with the bereavement contractor was interviewed by phone on 2/26/25 beginning at 2:30 PM. When she was asked who the Bereavement Coordinator was, she stated it was the Administrator. The Administrator was interviewed on 2/26/25 at 3:09 PM and he stated he considered himself the Bereavement Coordinator because he oversaw the service. The Chaplain was interviewed by phone on 2/26/25 beginning at 2:15 PM. When asked if he was the Bereavement Coordinator, he stated, ";I work [sic] in that role in the past," and he currently worked in conjunction with the bereavement contractor. It was unclear who the Bereavement Coordinator was. It was unclear how the bereavement counseling program was organized and overseen. The agency failed to ensure the bereavement program was organized under the supervision of a qualified professional.

Based on policy review and staff interview, it was determined the agency failed to ensure that volunteers were used in day-to-day administrative and/or direct patient care services in an amount that, at minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff. Additionally, the agency failed to demonstrate viable and ongoing efforts to recruit and retain volunteers. The agency also failed to document the cost savings achieved through the use of volunteers. This had the potential to negatively impact the quality of care provided to hospice patients. Findings include: --- Refer to L – 644 as it refers to the agencys failure to ensure that volunteers were used in day-to-day administrative and/or direct patient care roles. Refer to L – 645 as it refers to the agencys failure to demonstrate viable and ongoing efforts to recruit and retain volunteers. Refer to L – 646 as it refers to the agencys failure to document the cost savings achieved through the use of volunteers. The agency failed to ensure that volunteers were recruited and retained, used in day-to-day administrative and/or direct patient care services in an amount that equals 5 percent of the total patient care hours, and document the cost saving achieved through the use of volunteers.

Based on policy review, document review, and staff interview it was determined the agency failed to ensure the proper use of volunteers. This had the potential for patients and their familys needs going unmet. Findings include: --- An agency policy titled ";VOLUNTEER SERVICES Policy No. 4-007.1," was reviewed. The policy stated, ";Volunteers may work in a variety of capacities, including:" and then lists the following: ";Patient care volunteers...Bereavement volunteers... Errands and transportation volunteers... and Office volunteers." This policy was not followed. An example includes: A binder with volunteer notes was provided to surveyors. There were various volunteer notes ranging from 2023 to current from a single volunteer which stated, ";Office Special Project." The notes did not state what the project was, or if the volunteer was working in an approved capacity as outlined in agency policy. None of the notes identified if the volunteer was working with a specific hospice patient. On 2/26/25 at 3:45 PM the DCS was interviewed, and the above documents were reviewed in her presence. The DCS was asked to clarify the term ";Office Special Project." She stated the term meant the volunteer knitted blankets. The DCS was asked where the volunteer knitted the blankets. The DCS stated the knitting was completed in the volunteers home as far as she knew. It was unclear how the activity met the requirement of patient care, bereavement, errands, or office volunteer. The agency failed to use volunteers in direct patient care or for day-to-day administrative services.

Based on policy review, volunteer documentation review, and staff interview, it was determined the agency failed to successfully recruit and retain volunteers to maintain a functioning volunteer program. This resulted in the potential for the quality of support services provided to patients and their families to be impacted. Findings include: --- An agency policy titled, ";VOLUNTEER SERVICES Policy No. 4-007.1" was reviewed. Under the section titled ";PROCEDURE" was ";5. The Volunteer Coordinator will document ongoing efforts to recruit, train, and retain volunteers of all ages and ethnic backgrounds.". This policy was not followed. An example includes: Agency volunteer documents were reviewed. There was no documentation of efforts to recruit or retain volunteers. On 2/25/25 3:00 PM a request was made to the administrator to speak to the volunteer coordinator and surveyors were told she was out of town and unavailable. On 2/26/25 at 3:45 PM the DCS was interviewed, and the above documents were reviewed in her presence. When asked who the volunteer coordinator was, she stated it was the social worker. She stated they were trying to hire someone for the position who will ";own it." The DCS was asked how her current volunteer was recruited. She stated, ";I dont know she has been here forever." When asked how the hospice was recruiting volunteers, she said they advertise in parades and community events. When asked what the last event they recruited at, she stated it was a trunk or treat event. When asked if there was any success of gaining volunteers from the event she stated, ";No, it didnt bring us any new volunteers.". The DCS stated when the hospice did have a few volunteers sign up, ";they never made it through orientation." On 2/27/25 at 9:30 AM the Administrator stated that they had ";5 or 6" volunteers sign up in ";mid 2024" but none had worked any volunteer hours. The agency failed to successfully recruit and retain volunteers.

Based on policy review and record review it was determined that the agency failed to document cost savings achieved through the use of volunteers. This had the potential to compromise the agencys ability to demonstrate the essential role of volunteers in its operations. Findings include: --- An agency policy titled, ";VOLUNTEER SERVICES Policy No. 4-007.1" was reviewed. Under the section titled ";PROCEDURE" included: ";4. The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel. The Volunteer Coordinator will provide an annual report to the Governing Body to demonstrate the cost savings of volunteer activities." This policy was not followed. Examples include: A binder labeled ";Volunteer" was provided and reviewed. There was no documentation of cost savings. The Governing Body minutes and agenda was requested for 2024 and reviewed . There was no documentation of the cost savings of volunteer activities. On 2/26/25 at 3:45 PM the DCS was interviewed. She was asked when the last time the agency was in compliance with the 5 percent of total care hours for volunteers. She said the agency was in compliance the last time a survey was completed. When asked why it has been so long since the 5 percent was met, she stated that in "July or August" of 2024 the Volunteer Coordinator left the agency. On 2/27/25 at 9:30 AM the Administrator stated that they had ";5 or 6" volunteers sign up in ";mid 2024" but none had worked any volunteer hours. The agency failed to demonstrate cost savings provided by volunteer services.

Based on medical record review and staff interview, it was determined the hospice failed to ensure that care and services were provided in accordance with the plan of care for 1 of 11 patients (Patient #6) whose records were reviewed. This resulted in administering medications without prior approval. This had the potential to interfere with patient safety and coordination of patient care. Findings include: Patient #6 was a 69 year old male admitted to hospice services on 12/05/21, with a terminal diagnosis of COPD. A physician's order to start a 75mcg fentanyl patch on 4/7/22 was noted. A nursing note dated 4/5/22 stated:, "applied new fentanyl patch that [medical director] ordered.". There was no documentation of communication with Patient #6's physician that the fentanyl order was changed. It was not clear why Patient #6's fentanyl patch was administered 2 days before it was ordered by his physician. An interview with the DCS on 7/27/22, starting at 3:10 PM, was conducted. Patient #6's chart was reviewed in her presence. She confirmed that the hospice RN applied Patient #6's fentanyl patch on 4/5/22 and his physician's order stated that the fentanyl patch would be started on 4/7/22. Patient #6's physician's order was not followed. The hospice RN administered medications that were not in accordance to a physician's order.

Based on staff interview and review of medical records and agency policies, it was determined the hospice failed to ensure documentation of coordination of patient care between disciplines for 1 of 11 patients (Patient #2) whose records were reviewed. This resulted in a lack of clarity as to the course of care and whether physicians or other hospice care staff had been contacted related to care that required practitioner input. Findings include: A hospice policy titled, "INTERDISCIPLINARY GROUP PLAN OF CARE," dated 10/31/19, stated, "Agency personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication." This policy was not followed. An example includes: Patient #2 was a 93 year old male admitted to the hospice on 8/18/21, with a terminal diagnosis of cerebral infarction. He received SN, MSW, hospice Aide, massage therapy, and chaplain services. His record, including the POC, was reviewed. Patient #2's record included an MSW visit note, dated 2/01/22. The MSW documented Patient #2 claimed his 40 - 50 pound dresser fell on him the day before. Additionally, the MSW documented Patient #2 was experiencing back pain from the injury, and she spoke to his caregiver and the staff at the nursing facility where he resided. Patient #2's record did not include documentation of communication between the MSW and hospice staff or Patient #2's physician related to his accident and back pain. The DCS was interviewed on 7/27/22, beginning at 4:00 PM. She confirmed Patient #2's record did not include documentation his MSW notified hospice staff of his accident and injury. The agency failed to ensure Patient #2's care was coordinated between disciplines to meet his needs.

Based on medical record review, policy review, incident log review, and staff interview, it was determined the hospice failed to ensure its QAPI program measured, analyzed and tracked quality indicators, including all adverse patient events. This resulted in the inability of the agency to utilize information to measure the effectiveness of hospice services. Findings include: The hospice policy titled, "INCIDENT REPORTING," dated 10/31/19, stated, "The incident reporting system will be part of the organization's overall performance improvement and risk management plan ... When an incident occurs, the individual discovering the incident will: Notify your supervisor immediately ... Complete an incident report form within 24 hours of the incident." This policy was not followed. Examples include: 1. Patient #6 was a 69 year old male admitted to hospice on 12/05/21, with a terminal diagnosis of COPD. He received SN, MSW, and chaplain services. His record, including the POC, was reviewed. a. Patient #6's medical record included an RN visit note, dated 4/05/22. The note documented his RN applied a fentanyl transdermal patch. An RN visit note, dated 4/11/22, stated, "He does report crashing his car and blacking out over the weekend but cannot state why or how it happened." The hospice's incident log did not include a report of Patient #6's motor vehicle accident. b. Patient #6's medical record included an RN discharge note, dated 5/21/22, which stated, "...Pt was found down at home by friend, POA chose to revike [sic] hospice for pt to be tansported to hospital for treatment." A revocation form was not found in the record. The hospice's incident log did not include a report of Patient #6's ED visit. An interview with the DCS was conducted on 7/27/22, beginning at 3:10 PM. She reviewed the above mentioned notes in the record of Patient #6. When asked if the motor vehicle accident report should have been captured as an incident, she replied, "I would say so, yes." During this same interview, the DCS was asked about the absence of an incident report for Patient #6's purported revocation and ED encounter, she confirmed this should have been included in an incident report. The hospice failed to track and analyze Patient #6's incidents. 2. Patient #2 was a 93 year old male admitted to the hospice on 8/18/21, with a terminal diagnosis of cerebral infarction. He received SN, MSW, hospice Aide, massage therapy, and chaplain services. His record, including the POC, was reviewed. Patient #2's record included an MSW visit note, dated 2/01/22. The MSW documented Patient #2 claimed his 40 - 50 pound dresser fell on him the day before. Additionally, the MSW documented Patient #2 was experiencing back pain from the injury, and she spoke to his caregiver and the staff at the nursing facility where he resided. Patient #2's record did not include documentation of communication between the MSW and hospice staff or Patient #2's physician related to his fall and back pain. The DCS was interviewed on 7/27/22, beginning at 4:00 PM. Patient #2's record and the hospice's incident logs were reviewed in her presence. She confirmed Patient #2's accident was not reported as an incident. The hospice failed to track and analyze Patient #2's incident.

Based on administrative document review and staff interview, the hospice failed to track and document the COVID-19 vaccination status of all staff providing services for its patients. This resulted in the hospice's failure to include the vaccination status of its medical equipment contractor whose staff were required to enter patients' homes, and had the potential to place hospice patients at increased risk of COVID-19 exposure. The hospice's policy titled, "COVID-19 Mandatory Vaccination Policy," stated, "The Company requires all employees and contractors to obtain and maintain up-to-date COVID-19 vaccinations, when available." This policy was not followed. An example includes: Documentation of the hospice's COVID-19 vaccination tracking was reviewed. The tracking did not include the hospice's medical equipment contractor's staff. The Administrator was interviewed on 7/26/22, beginning at 4:15 PM. He confirmed the hospice did not track and document the COVID-19 vaccination status of its medical equipment contractor's staff. The hospice failed to track and document the COVID-19 vaccination status of all staff providing services for its patients.