Every finding on record at Wellness Hospice and Palliative Care LLC

Based on a review of agency policy/procedure and an interview with the agency Administrator, agency failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers. --- Findings:Agency policy/procedure reviewed on January 30. 2026, at approximately 11:00 a.m. 'Volunteer Services' 'Policy' "Hospice will document active and ongoing efforts to recruit and retain volunteers..."An interview with the administrator on January 29, 2026, at approximately 9:30 a.m. revealed they had no documentation demonstrating ongoing efforts for recruitment and retainment of volunteers.An interview conducted with the agency Administrator on January 29, 2026, at approximately 9:45 a.m. confirmed the above findings.

Based on a review of agency policy/procedure, a review of agency volunteer use records, and an interview with the agency Administrator, agency failed to ensure volunteers provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours, for one (1) of one (1) volunteer hour report documentation reviewed (VD#1). --- Findings:Agency policy/procedure reviewed on January 30. 2026 at approximately 11:00 a.m. 'Volunteer Services' 'Policy' "Hospice uses volunteers in administrative or direct care roles ...."'Hospice will document and maintain a volunteer staff sufficient to provide administrative and/ or direct patient care in an amount that, at a minimum equals 5% of the total patient care hours of all paid hospice employees and contract staff..."Volunteer hour report was reviewed on January 29, 2026, at approximately 9:15 a.m.VD#1: Volunteer hour report was requested for the past (12) months. Total equaled 0.28%. An interview conducted with the agency Administrator on January 29, 2026, at approximately 9:45 a.m. confirmed the above findings.

Based on an interview with the administrator, review of agency policy, and the agency's emergency preparedness plan, the agency failed to base the emergency preparedness plan on/or to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings: A review of agency policy "Emergency Operations Plan and Policy" was conducted on May 9, 2023, at approximately 12:30 pm. Policy states, "Procedure: 3. The emergency preparedness program includes but is not limited to, the following elements: Hospice has developed and maintains an emergency preparedness plan and policies that are reviewed and updated at least biennially. The plan: Is based on and includes a documented, facility-based (Hospice) and community-based risk assessment, utilizing an all-hazards approach..." A review of the agency emergency preparedness plan was conducted on May 8, 2023, at approximately 1:30 pm revealed no documentation that the emergency preparedness plan was based on/or included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Interview with the administrator on May 9, 2023, at approximately 2:00 pm confirmed the above findings.

Based on a review of agency policy, agency's emergency preparedness plan, and an interview with the administrator, it was determined the agency failed to establish and maintain an emergency preparedness communication plan that included contact information for local/regional/state/federal emergency preparedness staff. Findings included: Review of the agency policy "Emergency Operations Plan and Policies" was conducted on May 9, 2023, at approximately 1:30 pm. Policy states, "Procedure: 3. The emergency preparedness program includes but is not limited to, the following elements: During implementation of the emergency plan, Hospice will provide all services as possible but will minimally provide skilled nursing services to identified high priority patients or assist such patients in receiving care at alternate health care facility...Includes a process for cooperation and collaboration with local, tribal, regional, state and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the Hospice's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts..." Review of agency's emergency preparedness plan on May 8, 2023, at approximately 1:40 pm, revealed no documentation of a communication plan that included contact information for local/regional/state/federal emergency preparedness staff. An interview with the administrator on May 9, 2023, at approximately 2:00 pm confirmed the above findings.

Based on a review of agency policy, clinical records (CR), and an interview with the administrator, the agency failed to include skilled nursing interventions on the initial care plan for eleven (11) of eleven (11) CR's reviewed. (CR #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11). Findings include: A review of agency policy titled "Physician Orders" was conducted on May 9, 2023 at approximately 12:50 pm. Policy states, "The Interdisciplinary Group (IDG) plan of care is established in consultation with the physician, Medical Director, Hospice staff, the patient and members of the patient's family. The plan of care may include Diagnosis, Types of services required, Frequency of visits and duration, Nutritional requirements, Specific procedures deemed essential, Medications and treatments, Equipment and supplies required, Expected goals or outcomes to be achieved and the physician's signature and date..." A review of CR's was conducted on May 8, 2023 from approximately 1:00 pm to 2:30 pm and on May 9, 2023 from approximately 12:00 pm to 1:30 pm. CR #1, Start of Care: 4/4/2023. Certification period reviewed: 4/4/2023 through 6/2/2023. Record did not contain documentation of skilled nursing interventions as listed on the admission orders on the initial care plan. Admission orders state, "Admit to Hospice. Level of care: Routine home care. Assess vital signs and physiological systems as needed. Assess pain and symptoms and need for further intervention. May give medications related to palliative care sublingually or rectally if patient is unable to swallow. Assess bowel status with each visit. Oxygen 2-4 liters per nasal cannula as needed for dyspnea and/or respiratory distress. May check pulse oximetry for dyspnea, altered respirations, altered mental status and prior to oxygen delivery, notify physician if reading is under 90%. Teach safety measures, infection control, and emergency preparedness..." CR #2, Start of Care: 4/28/2023. Certification period reviewed: 4/28/2023 through 7/26/2023. Record did not contain documentation of skilled nursing interventions as listed on the admission orders on the initial care plan. Admission orders state, "Admit to Hospice. Level of care: Routine home care. Assess vital signs and physiological systems as needed. Assess pain and symptoms and need for further intervention. Assess bowel status with each visit. Oxygen 2-4 liters per nasal cannula as needed for dyspnea and/or respiratory distress. May check pulse oximetry for dyspnea, altered respirations, altered mental status and prior to oxygen delivery, notify physician if reading is under 90%. Initiate measures to prevent/manage skin breakdown: hydrocolloid dressing, pressure-relieving mattress as needed. Teach safety measures, infection control, and emergency preparedness..." CR #3, Start of Care: 5/5/2023. Certification period reviewed: 5/5/2023 through 8/2/2023. Record did not contain documentation of skilled nursing interventions as listed on the admission orders on the initial care plan. Admission orders state, "Admit to Hospice. Level of care: Routine home care. Assess vital signs and physiological systems as needed. Assess pain and symptoms and need for further intervention. May give medications related to palliative care sublingually or rectally if patient is unable to swallow. Assess bowel status with each visit. Oxygen 2-4 liters per nasal cannula as needed for dyspnea and/or respiratory distress. May check pulse oximetry for dyspnea, altered respirations, altered mental status and prior to oxygen delivery, notify physician if reading is under 90%. Initiate measures to prevent/manage skin breakdown: hydrocolloid dressing, pressure-relieving mattress as needed. Teach safety measures, infection control, and emergency preparedness. May place Hospice Emergency Medication Kit in patient's residence and use as needed as directed..." CR # 4, Start of Care: 3/16/2023. Certification period reviewed: 3/16/2023 through 6/13/2023. Record did not contain documentation of skilled nursing interventions as listed on the admission orders on the initial care plan. Admission orders state, "Admit to Hospice. Level of care: Routine home care. Assess vital signs and physiological systems as needed. Assess pain and symptoms and need for further intervention. Teach need for giving pain medication around the clock and potential side effects of medications. May anchor Foley catheter and change/irrigate per hospice protocol. Assess bowel status with each visit. Oxygen 2-4 liters per nasal cannula as needed for dyspnea and/or respiratory distress. May check pulse oximetry for dyspnea, altered respirations, altered mental status and prior to oxygen delivery, notify physician if reading is under 90%. Initiate measures to prevent/manage skin breakdown: hydrocolloid dressing, pressure relieving mattress as needed. Teach safety measures, infection control, and emergency preparedness..." CR #5, Start of Care: 4/20/2023. Certification period reviewed: 4/20/23 through 6/18/2023. Record did not contain documentation of skilled nursing interventions as listed on the admission orders on the initial care plan. Admission orders state, "Admit to Hospice. Level of care: Routine home care. Assess vital signs and physiological systems as needed. Assess pain and symptoms and need for further intervention. Assess bowel status with each visit. Oxygen 2-4 liters per nasal cannula as needed for dyspnea and/or respiratory distress. May check pulse oximetry for dyspnea, altered respirations, altered mental status and prior to oxygen delivery, notify physician if reading is under 90%. Teach safety measures, infection control, and emergency preparedness..." CR # 6, Start of Care: 3/14/2023. Certification period reviewed: 3/14/2023 through 6/11/2023. Record did not contain documentation of skilled nursing interventions as listed on the admission orders on the initial care plan. Admission orders state, "Admit to Hospice. Level of care: Routine home care. Assess vital signs and physiological systems as needed. Assess pain and symptoms and need for further intervention. Teach need for giving pain medications around the clock and potential side effects of medications. Assess bowel status with each visit. Oxygen 2-4 liters per nasal cannula as needed for dyspnea and/or respiratory distress. May check pulse oximetry for dyspnea, altered respirations, altered mental status and prior to oxygen delivery, notify physician if reading is under 90%. Initiate measures to prevent/manage skin breakdown: hydrocolloid dressing, pressure-relieving mattress as needed. Teach and support caregiver in care of patient. Teach safety measures, infection control, and emergency preparedness..." CR #7, Start of Care: 3/23/2023. Certification period reviewed: 3/23/2023 through 6/19/2023. Record did not contain documentation of skilled nursing interventions as listed on the admission orders on the initial care plan. Admission orders state, "Admit to Hospice. Level of care: Routine home care. Assess vital signs and physiological systems as needed. Assess pain and symptoms and need for further intervention. Assess bowel status with each visit. Oxygen 2-4 liters per nasal cannula as needed for dyspnea and/or respiratory distress. May check pulse oximetry for dyspnea, altered respirations, altered mental status and prior to oxygen delivery, notify physician if reading is under 90%. Initiate measures to prevent/manage skin breakdown: hydrocolloid dressing, pressure-relieving mattress as needed. Teach and support caregiver in care of patient. Teach safety measures, infection control, and emergency preparedness..." CR #8, Start of Care: 4/18/2023. Certification period reviewed: 4/18/2023 through 7/6/2023. Record did not contain documentation of skilled nursing interventions as listed on the admission orders on the initial care plan. Admission orders state, "Admit to Hospice. Level of care: Routine home care. Assess vital signs and physiological systems as needed. Assess pain and symptoms and need for further intervention. Oxygen 2-4 liters per nasal cannula as needed for dyspnea and/or respiratory distress. May check pulse oximetry for dyspnea, altered respirations, altered mental status and prior to oxygen delivery, notify physician if reading is under 90%..." CR #9, Start of Care: 3/28/2023. Certification period reviewed: 3/28/2023 through 6/25/2023. Record did not contain documentation of skilled nursing interventions as listed on the admission orders on the initial care plan. Admission orders state, "Admit to Hospice. Level of care: Routine home care. Assess vital signs and physiological systems as needed. Assess pain and symptoms and need for further intervention. Assess bowel status with each visit. Oxygen 2-4 liters per nasal cannula as needed for dyspnea and/or respiratory distress. May check pulse oximetry for dyspnea, altered respirations, altered mental status and prior to oxygen delivery, notify physician if reading is under 90%. Initiate measures to prevent/manage skin breakdown: hydrocolloid dressing, pressure-relieving mattress as needed. Teach and support caregiver in care of patient. Teach safety measures, infection control, and emergency preparedness..." CR #10, Start of Care: 4/21/2023. Date of death: 4/30/2023. Certification period reviewed: 4/21/2023 through 4/30/2023. Record did not contain documentation of skilled nursing interventions as listed on the admission orders on the initial care plan. Admission orders state, "Admit to Hospice. Level of care: Routine home care. Assess vital signs and physiological systems as needed. Assess pain and symptoms and need for further intervention. Assess bowel status with each visit. Oxygen 2-4 liters per nasal cannula as needed for dyspnea and/or respiratory distress. May check pulse oximetry for dyspnea, altered respirations, altered mental status and prior to oxygen delivery, notify physician if reading is under 90%..." CR #11, Start of Care: 4/26/2023. Date of death: 5/2/2023. Certification period reviewed: 4/26/2023 through 5/2/2023. Record did not contain documentation of skilled nursing interventions as listed on the admission orders on the initial care plan. Admission orders state, "Admit to Hospice. Level of care: Routine home care. Assess vital signs and physiological systems as needed. Assess pain and symptoms and need for further intervention. Assess bowel status with each visit. Oxygen 2-4 liters per nasal cannula as needed for dyspnea and/or respiratory distress. Initiate measures to prevent/manage skin breakdown: hydrocolloid dressing, pressure-relieving mattress as needed. Teach safety measures, infection control, and emergency preparedness..." An interview with the administrator conducted on May 9, 2023 at approximately 2:00 pm confirmed the above findings.

Based on a review of agency policy, clinical records (CR), and an interview with the administrator, the agency failed to include measurable outcomes anticipated from implementing and coordinating the plan of care on the initial care plan for eleven (11) of eleven (11) CR's reviewed. (CR #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11). Findings include: A review of agency policy titled "Physician Orders" was conducted on May 9, 2023 at approximately 12:50 pm. Policy states, "The Interdisciplinary Group (IDG) plan of care is established in consultation with the physician, Medical Director, Hospice staff, the patient and members of the patient's family. The plan of care may include Diagnosis, Types of services required, Frequency of visits and duration, Nutritional requirements, Specific procedures deemed essential, Medications and treatments, Equipment and supplies required, Expected goals or outcomes to be achieved and the physician's signature and date..." A review of CR's was conducted on May 8, 2023 from approximately 1:00 pm to 2:30 pm and on May 9, 2023 from approximately 12:00 pm to 1:30 pm. CR #1, Start of Care: 4/4/2023. Certification period reviewed: 4/4/2023 through 6/2/2023. Record did not contain documentation of measurable outcomes anticipated from implementing and coordinating the plan of care on the initial care plan. CR #2, Start of Care: 4/28/2023. Certification period reviewed: 4/28/2023 through 7/26/2023. Record did not contain documentation of measurable outcomes anticipated from implementing and coordinating the plan of care on the initial care plan. CR #3, Start of Care: 5/5/2023. Certification period reviewed: 5/5/2023 through 8/2/2023. Record did not contain documentation of measurable outcomes anticipated from implementing and coordinating the plan of care on the initial care plan. CR # 4, Start of Care: 3/16/2023. Certification period reviewed: 3/16/2023 through 6/13/2023. Record did not contain documentation of measurable outcomes anticipated from implementing and coordinating the plan of care on the initial care plan. CR #5, Start of Care: 4/20/2023. Certification period reviewed: 4/20/23 through 6/18/2023. Record did not contain documentation of measurable outcomes anticipated from implementing and coordinating the plan of care on the initial care plan. CR # 6, Start of Care: 3/14/2023. Certification period reviewed: 3/14/2023 through 6/11/2023. Record did not contain documentation of measurable outcomes anticipated from implementing and coordinating the plan of care on the initial care plan. CR #7, Start of Care: 3/23/2023. Certification period reviewed: 3/23/2023 through 6/19/2023. Record did not contain documentation of measurable outcomes anticipated from implementing and coordinating the plan of care on the initial care plan. CR #8, Start of Care: 4/18/2023. Certification period reviewed: 4/18/2023 through 7/6/2023. Record did not contain documentation of measurable outcomes anticipated from implementing and coordinating the plan of care on the initial care plan. CR #9, Start of Care: 3/28/2023. Certification period reviewed: 3/28/2023 through 6/25/2023. Record did not contain documentation of measurable outcomes anticipated from implementing and coordinating the plan of care on the initial care plan. CR #10, Start of Care: 4/21/2023. Date of death: 4/30/2023. Certification period reviewed: 4/21/2023 through 4/30/2023. Record did not contain documentation of measurable outcomes anticipated from implementing and coordinating the plan of care on the initial care plan. CR #11, Start of Care: 4/26/2023. Date of death: 5/2/2023. Certification period reviewed: 4/26/2023 through 5/2/2023.Record did not contain documentation of measurable outcomes anticipated from implementing and coordinating the plan of care on the initial care plan. An interview with the administrator conducted on May 9, 2023 at approximately 2:00 pm confirmed the above findings.

Based on a review of agency policy, clinical records (CR), and an interview with the administrator, the agency failed to include medical supplies and appliances necessary to meet the needs of the patient on the initial care plan for eleven (11) of eleven (11) CR's reviewed. (CR #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11). Findings include: A review of agency policy titled "Physician Orders" was conducted on May 9, 2023 at approximately 12:50 pm. Policy states, "The Interdisciplinary Group (IDG) plan of care is established in consultation with the physician, Medical Director, Hospice staff, the patient and members of the patient's family. The plan of care may include Diagnosis, Types of services required, Frequency of visits and duration, Nutritional requirements, Specific procedures deemed essential, Medications and treatments, Equipment and supplies required, Expected goals or outcomes to be achieved and the physician's signature and date..." A review of CR's was conducted on May 8, 2023 from approximately 1:00 pm to 2:30 pm and on May 9, 2023 from approximately 12:00 pm to 1:30 pm. CR #1, Start of Care: 4/4/2023. Certification period reviewed: 4/4/2023 through 6/2/2023. Record did not contain documentation of medical supplies and appliances necessary to meet the needs of the patient on the initial care plan. Admission orders state: "Durable Medical Equipment Orders: Oxygen" CR #2, Start of Care: 4/28/2023. Certification period reviewed: 4/28/2023 through 7/26/2023. Record did not contain documentation of medical supplies and appliances necessary to meet the needs of the patient on the initial care plan. Admission orders state: "Durable Medical Equipment Orders: Hospital bed, Pressure reducing mattress, Oxygen, Wheelchair." CR #3, Start of Care: 5/5/2023. Certification period reviewed: 5/5/2023 through 8/2/2023. Record did not contain documentation of medical supplies and appliances necessary to meet the needs of the patient on the initial care plan. Admission orders state: "Durable Medical Equipment Orders: Hospital bed, Oxygen, Wheelchair." CR # 4, Start of Care: 3/16/2023. Certification period reviewed: 3/16/2023 through 6/13/2023. Record did not contain documentation of medical supplies and appliances necessary to meet the needs of the patient on the initial care plan. Admission orders state: "Durable Medical Equipment Orders: Hospital bed, Oxygen, Wheelchair." CR #5, Start of Care: 4/20/2023. Certification period reviewed: 4/20/23 through 6/18/2023. Record did not contain documentation of medical supplies and appliances necessary to meet the needs of the patient on the initial care plan. Admission orders state: "Durable Medical Equipment Orders: Hospital bed, Oxygen, Wheelchair." CR # 6, Start of Care: 3/14/2023. Certification period reviewed: 3/14/2023 through 6/11/2023. Record did not contain documentation of medical supplies and appliances necessary to meet the needs of the patient on the initial care plan. Admission orders state: "Durable Medical Equipment Orders: Hospital bed, Shower bench/chair, Oxygen, Wheelchair." CR #7, Start of Care: 3/23/2023. Certification period reviewed: 3/23/2023 through 6/19/2023. Record did not contain documentation of medical supplies and appliances necessary to meet the needs of the patient on the initial care plan. Admission orders state: "Durable Medical Equipment Orders: Hospital bed, Pressure reducing mattress, Oxygen, Wheelchair." CR #8, Start of Care: 4/18/2023. Certification period reviewed: 4/18/2023 through 7/6/2023. Record did not contain documentation of medical supplies and appliances necessary to meet the needs of the patient on the initial care plan. Admission orders state: "Durable Medical Equipment Orders: Oxygen." CR #9, Start of Care: 3/28/2023. Certification period reviewed: 3/28/2023 through 6/25/2023. Record did not contain documentation of medical supplies and appliances necessary to meet the needs of the patient on the initial care plan. Admission orders state: "Durable Medical Equipment Orders: Hospital bed, Oxygen, Wheelchair." CR #10, Start of Care: 4/21/2023. Date of death: 4/30/2023. Certification period reviewed: 4/21/2023 through 4/30/2023. Record did not contain documentation of medical supplies and appliances necessary to meet the needs of the patient on the initial care plan. Admission orders state: "Durable Medical Equipment Orders: Hospital bed, Low air loss mattress, Oxygen, Wheelchair." CR #11, Start of Care: 4/26/2023. Date of death: 5/2/2023. Certification period reviewed: 4/26/2023 through 5/2/2023.Record did not contain documentation of medical supplies and appliances necessary to meet the needs of the patient on the initial care plan. Admission orders state: "Durable Medical Equipment Orders: Hospital bed, Low air loss mattress, Oxygen, Wheelchair." An interview with the administrator conducted on May 9, 2023 at approximately 2:00 pm confirmed the above findings.

Based on a review of agency policy, clinical records (CR), and an interview with the administrator, the agency failed to include the interdisciplinary group's documentation of the patient's or representative's level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's own policies, on the initial care plan for eleven (11) of eleven (11) CR's reviewed. (CR #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11). Findings include: A review of agency policy titled "Physician Orders" was conducted on May 9, 2023 at approximately 12:50 pm. Policy states, "The Interdisciplinary Group (IDG) plan of care is established in consultation with the physician, Medical Director, Hospice staff, the patient and members of the patient's family. The plan of care may include Diagnosis, Types of services required, Frequency of visits and duration, Nutritional requirements, Specific procedures deemed essential, Medications and treatments, Equipment and supplies required, Expected goals or outcomes to be achieved and the physician's signature and date..." A review of CR's was conducted on May 8, 2023 from approximately 1:00 pm to 2:30 pm and on May 9, 2023 from approximately 12:00 pm to 1:30 pm. CR #1, Start of Care: 4/4/2023. Certification period reviewed: 4/4/2023 through 6/2/2023. Record did not contain documentation of the interdisciplinary group's documentation of the patient's or representative's level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's own policies, on the initial care plan. CR #2, Start of Care: 4/28/2023. Certification period reviewed: 4/28/2023 through 7/26/2023. Record did not contain documentation of the interdisciplinary group's documentation of the patient's or representative's level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's own policies, on the initial care plan. CR #3, Start of Care: 5/5/2023. Certification period reviewed: 5/5/2023 through 8/2/2023. Record did not contain documentation of the interdisciplinary group's documentation of the patient's or representative's level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's own policies, on the initial care plan. CR # 4, Start of Care: 3/16/2023. Certification period reviewed: 3/16/2023 through 6/13/2023. Record did not contain documentation of the interdisciplinary group's documentation of the patient's or representative's level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's own policies, on the initial care plan. CR #5, Start of Care: 4/20/2023. Certification period reviewed: 4/20/23 through 6/18/2023. Record did not contain documentation of the interdisciplinary group's documentation of the patient's or representative's level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's own policies, on the initial care plan. CR # 6, Start of Care: 3/14/2023. Certification period reviewed: 3/14/2023 through 6/11/2023. Record did not contain documentation of the interdisciplinary group's documentation of the patient's or representative's level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's own policies, on the initial care plan. CR #7, Start of Care: 3/23/2023. Certification period reviewed: 3/23/2023 through 6/19/2023. Record did not contain documentation of the interdisciplinary group's documentation of the patient's or representative's level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's own policies, on the initial care plan. CR #8, Start of Care: 4/18/2023. Certification period reviewed: 4/18/2023 through 7/6/2023. Record did not contain documentation of the interdisciplinary group's documentation of the patient's or representative's level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's own policies, on the initial care plan. CR #9, Start of Care: 3/28/2023. Certification period reviewed: 3/28/2023 through 6/25/2023. Record did not contain documentation of the interdisciplinary group's documentation of the patient's or representative's level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's own policies, on the initial care plan. CR #10, Start of Care: 4/21/2023. Date of death: 4/30/2023. Certification period reviewed: 4/21/2023 through 4/30/2023. Record did not contain documentation of the interdisciplinary group's documentation of the patient's or representative's level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's own policies, on the initial care plan. CR #11, Start of Care: 4/26/2023. Date of death: 5/2/2023. Certification period reviewed: 4/26/2023 through 5/2/2023.Record did not contain documentation of the interdisciplinary group's documentation of the patient's or representative's level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's own policies, on the initial care plan. An interview with the administrator conducted on May 9, 2023 at approximately 2:00 pm confirmed the above findings.

Based on the review of agency policy, governing body meeting minutes, and an interview with the administrator, the agency failed to provide documentation that the governing body had designated a responsible party to determine the frequency and detail of the data collection. Findings: A review of agency policy "Governing Body" was conducted on May 8, 2023 at approximately 1:50 pm. Policy states, "The Governing Body appoints one or more individuals to handle the structure and administration of the QAPI. The Governing Body has appointed the Administrator and Director (and QAPI Coordinator, if Hospice has a QAPI Coordinator) as responsible for the ongoing administration of the QAPI program. The Governing Body approves the frequency and detail of QAPI data collection..." A review of agency policy "Quality Assurance and Performance Improvement (QAPI) Plan" was conducted on May 8, 2023 at approximately 1:45 pm. Policy states, "Responsibility/Accountability: 2. The governing body has designated responsibility for operating the QAPI program to the administrator/director, who, in turn, assigns certain activities to other staff members..." A review of agency governing body meeting minutes dated 1/20/2023, was conducted on May 8, 2023 at approximately 2:00 pm revealed there was no documentation that the governing body had designated a responsible party to determine the frequency and detail of the data collection of the QAPI program. An interview with the hospice administrator conducted on May 9, 2023 at approximately 2:00 pm confirmed the above findings.

Based on a review of agency policy, governing body meeting minutes, and an interview with the administrator, the agency failed to designate another individual to assume those assigned duties and responsibilities of the administrator in accordance with the hospices established policies and procedures if the administrator is not available to fulfill his or her assigned duties and responsibilities and the agency failed to provide documentation that the governing body members received orientation. Findings: A review of agency policy "Governing Body" was conducted on May 9, 2023 at approximately 12:15 pm. Policy states, "All Governing Body members fulfill their responsibilities (including attending meetings, budget oversight and evaluating senior management). All new Governing Body members participate in orientation (including an orientation to Hospice, responsibilities as Governing Body member and role of the Governing Body in QAPI) ...The Governing Body appoints the Administrator or approves an Administrator selected by the corporation or another group..." Policy does not address the appointment of another individual to act in the absence of the Administrator. A review of the governing body meeting minutes dated 1/20/2023, was conducted on May 8, 2023 at approximately 12:20 pm revealed there was no documentation of the designation of an another individual to assume those assigned duties and responsibilities of the administrator in accordance with the hospices established policies and procedures if the administrator is not available to fulfill his or her assigned duties and responsibilities and there was no documentation that the governing body members received orientation. An interview with the administrator conducted on May 9, 2023 at approximately 2:00 pm confirmed the above findings.