DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
551741 A. BUILDING __________
B. WING ______________ 		04/27/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
OC HOSPICE 13522 NEWPORT AVE, SUITE 200, TUSTIN, CA, 92780
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0521      
31929 Based on interview and record review, the hospice failed to conduct the comprehensive assessments to identify the care needs for two of two sampled patients (Patients A and B), creating the risk of not addressing the care needs for these patients. Findings: 1. Review of Patient A's closed clinical record was initiated on 2/8/22. The clinical record showed the SOC was 9/14/20. The patient was certified for hospice services during the certification period from 6/21/21 to 8/19/21. The patient resided at the board and care facility and had expired on 7/10/21. The hospice's Communication Log dated 7/8/21 at 1550 hours, showed Patient A's PCG (at the board and care facility) called regarding the patient's "choking" incident as reported by the family member while the family member and patient went out for lunch on 7/7/21. The documentation showed the PCG had not personally witnessed any choking or coughing while eating, but the time spent with Patient A during meals was limited. The PCG had noticed Patient A asking for food excessively and putting food in the mouth even when the patient still had food in the mouth. According to the PCG, on 7/8/21, the PCG did not witness any incident during meals and Patient A ate her meals as usual. The documentation showed the hospice staff informed Patient A's family member that the Case Manager and LVN were off today; however, she would inform the team to follow up with the swallow evaluation being requested. The documentation showed the Case Manager was informed. Review of an email document sent by the QAPI Director to the DPCS, RN 1, and LVN 1 dated 7/8/21 at 1614 hours, showed the QAPI Director informed them of the reported choking incident of Patient A and an update on the incident was requested by the Administrator. Review of another email document sent to the hospice staff dated 7/9/21, showed Patient A had "Choking Episode" and LVN 1 would conduct a visit. The SN note completed by LVN 1 dated 7/9/21, showed Patient A was asleep in the hospital bed and had consumed a half glass of smoothie on the lunch table. During the SN visit, Patient A was talkative and shared that she went out for a meal with her family members and they had salad, pasta/beef and rustic pizza which were just delicious. Documentation showed the patient had been requesting for food all the time and had some snacks in the room provided by the family. The SN noted completed by RN 1 dated 7/10/21 at 1225 hours, showed the patient was her usual self and being able to communicate her needs. The patient talked about enjoying going out with the family member and ordered a salad, pasta with beef, and pizza desert. Documentation showed the patient's lunch included chicken and a cup of smoothie. Documentation showed the patient stated she ate her meal okay. Documentation showed the patient had been eating more and asking food over the past week. The SN talked to the patient about eating appropriate amount of food. The SN discussed with the facility staff regarding not giving too much food and less portions. The SN discussed with the facility's PCGs regarding aspiration precaution and they verbalized understanding. * However, there was no documented evidence in the clinical record showing the SNs had conducted an observation of the patient eating to assess if the patient had any problems or concerns with swallowing or eating. Review of the hospice's Communication Log dated 7/10/21 at 1738 hours, showed the PCG had called frantically and stated the patient was choking and not breathing. The log showed 911 was called and the patient was pronounced death by the paramedics at 1804 hours. A telephone interview was conducted with LVN 1 on 3/7/22 at 1000 hours. LVN 1 stated an email was received from the QAPI Director regarding the patient's episode of choking. LVN 1 was asked if the patient was observed eating during the SN visit. She stated she asked the patient if the patient ate okay, and the patient stated okay. LVN 1 stated the patient was asked if the patient had choked, and the patient denied. A telephone interview was conducted with RN 1 on 3/17/22 at 0914 hours. RN 1 stated an email was received from the QAPI Director regarding patient's episode of choking. RN 1 stated he did not perform an observation of the patient eating. RN 1 stated he interviewed the board and care staff. RN 1 stated the board and care staff said the patient was eating okay and there was no difficulty swallowing. RN 1 stated LVN 1 informed him that the patient was eating okay. On 4/5/22 at 1117 hours, a concurrent telephone interview and clinical record review was conducted with the DPCS. He was informed of the findings. 2. Review of Patient B's closed clinical record was initiated on 4/25/22. The clinical record showed the SOC was 8/4/21. The patient was certified for hospice services during the certification period from 8/4/21 to 11/1/21. The patient had expired on 9/24/21. The initial comprehensive assessment dated 8/4/21, showed the patient had excoriation to the buttocks and redness to the skin "flat under the abdomen." The Skin Impairment Assessment form showed the patient had excoriation to the coccyx, "recurrent rash/redness," and redness to the left heel. * However there was no documented evidence of the size of the excoriation on the buttocks/coccyx and redness on the left heel. On 4/27/22 at 0815 hours, a concurrent interview and clinical record review was conducted with the DPCS. The DPCS was asked for the measurement of the excoriation on the buttocks/coccyx and redness on the left heel. The DPCS stated the hospice only measured the size of pressure injuries.
L0536      
31929 This CONDITION was not met as evidenced by: Based on interview and record review, the hospice failed to ensure the IDG, care planning, and coordination of services were provided to meet the patients' care needs as evidenced by: 1. The hospice failed to develop an individualized written POC that reflected goals and interventions based on the problems identified. Cross reference to L545. 2. The hospice failed to develop an individualized written POC with measurable outcomes. Cross reference to L548. 3. The hospice failed to revise the POC. Cross reference to L552. 4. The hospice failed to ensure the IDG had maintained responsibility for directing, coordinating, and supervising the care and services provided. Cross reference to L554. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the interdisciplinary team, care planning and coordination of services to meet the patients' care needs.
L0545      
31929 Based on record review and interview, the hospice failed to ensure the written POC was developed and updated to reflect the patient and family goals and interventions based on the problems identified for two of two sampled patients (Patients A and B), creating the risk of not addressing the care needs for these patients. Findings: The hospice's P&P titled Plan of Care showed it is the policy of the hospice that a written individualized interdisciplinary team care plan be established and maintained for each individual admitted to hospice and the care provided to the individual will be in accordance with the care plan. The IDG (in collaboration with the individual's attending physician, if any) must review, revise, and document the individual plan as frequently as the patient condition requires, but no less than frequently than Q 15 calendar days. 1. Review of Patient A's closed clinical record was initiated on 2/8/22. The clinical record showed the SOC was 9/14/20. The patient was certified for hospice services during the certification period from 6/21/21 to 8/19/21. The patient resided in the board and care facility and had expired on 7/10/21. The hospice's Communication Log dated 7/8/21 at 1550 hours, showed Patient A's PCG called regarding the patient "choking" as reported by the family member when they went out for lunch the day before (7/7/21). Documentation showed the PCG had not seen the patient choke or cough, but the time during meals with the patient was limited. The PCG had noticed the patient asking for food excessively and putting food in the mouth while the patient still had food in the mouth. Documentation showed today (7/8/21) per the PCG, there was no incident during meals and the patient ate meals normal as usual. Documentation showed the family member was informed the Case Manager and LVN were off today; and would inform the team to follow up on the swallow evaluation being requested. Documentation showed the Case Manager was informed. An email document dated 7/9/21, showed, "Stand up," in the subject line addressed to the hospice staff. Documentation showed the issues included Patient A had "Choking Episode," and LVN 1 would visit. An untitled email document from RN 1 to the hospice staff dated 7/10/21 at 1659 hours, showed the patient was visited for wound care. Documentation showed education was done with the staff regarding aspiration precaution due to recent choking episodes. Documentation showed the patient refused to change the diet. Documentation showed no new order from the physician. * However, there was no documented evidence the written individualized POC was developed to address the patient's choking episode as per the Communication Log dated 7/8/21. On 4/5/22 at 1117 hours, a concurrent telephone interview and clinical record review was conducted with the DPCS. He was informed of the findings. 2. Review of Patient B's closed clinical record was initiated on 4/25/22. The clinical record showed the SOC was 8/4/21. The patient was certified for hospice services during the certification period from 8/4/21 to 11/1/21. The patient expired on 9/24/21. a. The POC/IDG Review dated 8/4/21, showed under the POC Summary section, the medication included cephalexin (antibiotic) 500 mg one capsule BID for 10 days for cellulitis of the left arm. * However, there was no documented evidence the written individualized POC was developed to address the use of cephalexin for cellulitis of the left arm. b. The SN note dated 9/21/21, showed under the genitourinary section, the 16 Fr. "Coude" catheter with 10 ml was inserted per the patient's family member request as it was getting too difficult for a single "CG" to turn the patient. Documentation showed, "250 ml straw colored urine over in drainage bag." Documentation showed the Case Manager or physician was updated on the patient's status. The physician's order dated 9/21/21, showed an order for 16 Fr. "coude catheter - 10 ml NS." * However, there was no documented evidence the written individualized POC was developed to address the use of an indewelling urinary catheter. On 4/27/22 at 0815 hours, a concurrent interview and clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.
L0548      
31929 Based on record review and interview, the hospice failed to ensure the POC included measurable outcomes for two of two sampled patients (Patients A and B), creating the risk of not evaluating the POC and providing appropriate care and services to these patients. Findings: 1. Review of Patient A's closed clinical record was initiated on 2/8/22. The clinical record showed the SOC was 9/14/20. The patient was certified for hospice services during the certification period from 6/21/21 to 8/19/21. The patient had expired on 7/10/21. The POC/IDG Review dated 6/23/21, showed the patient's identified problems included potential for harm related to alteration in posture related to weakness, altered nutritional status related to decreased food consumption, alteration in comfort symptoms related to chronic pain, potential for altered respiratory status related to decreased lung compliance. The goals were established for these identified problems. * However, the goals listed were not measurable and specific to the patient's care needs. For example, the goal for potential for altered respiratory status was for the patient to have optimum level of oxygen on a day to day basis. There was no documentation of measurable outcome as to what the optimum level of oxygen was expected for the patient. 2. Review of Patient B's closed clinical record was initiated on 4/25/22. The clinical record showed the SOC was 8/4/21. The patient was certified for hospice services during the certification period from 8/4/21 to 11/1/21. The patient had expired on 9/24/21. The POC/IDG Review dated 8/4/21, showed the patient's identified problem included alteration in comfort symptoms related to chronic pain, potential for altered respiratory status related to oxygen therapy, and altered nutritional status related to loss of appetite as evidenced by reduced food consumption. The goals were established for these identified problems. * However, the goals listed were not measurable and specific to the patient's care needs. For example, the goal for altered alteration in comfort symptoms was for the patient to remain in comfortable level during the certification period. There was no documentation of measurable outcome as to what the comfortable level was expected for the patient. On 4/27/22 at 0815 hours, a concurrent interview and clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.
L0552      
31929 Based on record review and interview, the hospice failed to revise the POC for one of two sampled patients (Patient A), creating the risk of not addressing the care needs for these patients. Findings: The hospice's P&P titled Plan of Care showed it is the policy of the hospice that a written individualized interdisciplinary team care plan be established and maintained for each individual admitted to hospice and the care provided to the individual will be in accordance with the care plan. The IDG (in collaboration with the individual's attending physician, if any) must review, revise, and document the individual plan as frequently as the patient condition requires, but no less than frequently than Q 15 calendar days. Review of Patient A's closed clinical record was initiated on 2/8/22. The clinical record showed the SOC was 9/14/20. The patient was certified for hospice services during the certification period from 6/21/21 to 8/19/21. The patient had expired on 7/10/21. The SN note dated 6/30/21, showed the patient was on a regular diet and had uncontrollable appetite reported by the assisted living facility. The SN note dated 7/3/21, showed the PCG reported the patient had been eating a lot and asking for food all the time. Documentation showed for lunch today (7/3/21), the patient had meat with vegetables, side of salad, and drank smoothies every meal; and for breakfast, the patient had two eggs, bagel, grilled cheese, and smoothie. Documentation showed the SN discussed regarding appropriate amount of food per serving. The POC/IDG Review dated 7/7/21, showed a care plan problem addressing altered nutritional status related to reduced food consumption. The interventions included assess/monitor nutritional needs; ongoing assessment of intake, indigestion, food preference, and weight change; and provide nutritional support as appropriate within the context of palliative care goals. * However, there was no documented evidence the written individualized POC was updated to address patient's uncontrollable appetite as reported by the facility and the patient eating a lot. On 4/5/22 at 1117 hours, a concurrent telephone interview and clinical record review was conducted with the DPCS. He was informed of the findings.
L0554      
31929 Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing, coordinating, and supervising the care and services provided for two of two sampled patients (Patients A and B), creating the risk of not addressing the care needs for these patients. Findings: The hospice's P&P titled Continuity and Coordination of Care dated 2019 showed the hospice will develop and maintain a system of communication and integration in accordance with the hospice's own P&P in order to ensure the "IDT" maintains responsibility for directing, coordinating, and supervising the care and services provided; and provide for and ensure the ongoing sharing of information between disciplines, providing care, and services in all settings, whether the care and services are provided directly or under arrangement The hospice's P&P titled Coordination of Care dated 2019 showed the "IDT" responsibilities included participating in the establishment of the plan of care; participating in the review and updating in the plan of care for each individual receiving hospice; and reporting any unusual change in the patient's physical, mental, spiritual, or emotional status to the PCGs, attending physician, and the "IDT." The hospice's P&P titled Services provided-Scope of Services dated 2022 showed care is planned and provided by a medically supervised "IDT." The team member works together to plan and provide services that will see physical, emotional welfare of the patient and his/her family. 1. Review of Patient A's closed clinical record was initiated on 2/8/22. The clinical record showed the SOC was 9/14/20. The patient was certified for hospice services during the certification period from 6/21/21 to 8/19/21. The patient resided in the board and care facility and had expired on 7/10/21. a. The hospice's Communication Log dated 7/8/21 at 1550 hours, showed Patient A's PCG (at the board and care facility) called regarding the patient "choking" as reported by the family member when they went out for lunch the day before (7/7/21). Documentation showed the PCG had not seen the patient choke or cough, but the time during meals with the patient was limited. The PCG had noticed the patient asking for food excessively and putting food in the mouth while the patient still had food in the mouth. There was no incident during meals and the patient ate meals normal as usual for today (7/8/21). Documentation showed the family member was informed the Case Manager and LVN were off today; and would inform the team to follow up on the swallow evaluation being requested. Documentation showed the Case Manager was informed. However, there was no documented evidence the physician was notified of the choking episode when it was reported by the PCG. The SN note completed by LVN 1 dated 7/9/21, showed the patient was asleep in the hospital bed and had a half glass of smoothie on the lunch table. The patient was talkative during the visit and shared that the patient and the family members went out on "Wednesday" for a meal. Documentation showed the patient stated they had salad, pasta/beef, and rustic pizza which was just delicious. Documentation showed the patient had been requesting for food all the time and had some snacks in the room provided by the family. A section of the note showed the case manager or physician was updated on the patient's status. The SN noted completed by RN 1 dated 7/10/21 at 1225 hours, showed the patient was her usual self and being able to communicate her needs. The patient talked about enjoying going out with the family member and ordered a salad, pasta with beef, and pizza desert. Documentation showed the patient's lunch included chicken and a cup of smoothie. Documentation showed the patient stated she ate her meal okay. Documentation showed the patient had been eating more and asking for food over the past week. The SN talked to the patient about eating appropriate amount of food. The SN discussed with the facility staff regarding not giving too much food and less portions. The SN discussed with the facility's PCGs regarding aspiration precaution and they verbalized understanding. A telephone interview was conducted with LVN 1 on 3/7/22 at 1000 hours. LVN 1 stated an email was received from the QAPI Director regarding patient's episode of choking. LVN 1 stated the RN Case Manager was informed about her visit on 7/9/21. LVN 1 was asked if the physician was notified of the choking episode as per the Communication Log dated 7/8/21. She stated the RN Case Manager would do that. An untitled email document from RN 1 to the hospice staff dated 7/10/21 at 1659 hours, showed the patient was visited for wound care. Documentation showed education was done with the staff regarding aspiration precaution due to recent choking episodes. Documentation showed the patient refused to change the diet. Documentation showed no new order from the physician. However, this information was not included in the patient's clinical record. A telephone interview was conducted with RN 1 on 3/17/22 at 0914 hours. RN 1 stated the physician was informed about the choking episode and the request for swallow evaluation. RN 1 stated the physician had no new order. * The IDG failed to maintain responsiblitiies to direct, coordinate, and supervise to ensure the care and services provided to Patient A. The physician was not notified at the time when the hospice was made aware of Patient A's choking episode on 7/8/21, until two days later as showed in the email document dated 7/10/21, which was not included in the patient's clinical record. In addition, the SN failed to perform the comprehensive assessment to assess if the patient had any eating or swallowing difficulty during the SN visits on 7/9 and 7/10/21, after receiving the report of the patient's choking episode on 7/8/21. Cross reference to L521, example #1. Review of the hospice's Communication Log showed dated 7/10/21 at 1738 hours, showed the PCG had called frantically and stated the patient was choking and not breathing. The log showed 911 was called and the patient was pronounced death by the medics at 1804 hours. On 4/5/22 at 1117 hours, a concurrent telephone interview and clinical record review was conducted with the DPCS. He was informed of the findings. 2. Review of Patient B's closed clinical record was initiated on 4/25/22. The clinical record showed the SOC was 8/4/21. The patient was certified for hospice services during the certification period from 8/4/21 to 11/1/21. The patient had expired on 9/24/21. a. The written agreement between the hospice and Company 1 dated 5/16/19, showed Company 1 agreed to render OT and/or PT services to the patients of the hospice in accordance with the hospice plan of care. Company 1 would document all care and services to the hospice patients. This documentation would include all services furnished to the hospice patients in accordance with the agreement and identified in the hospice POC. Initial therapy evaluations will be submitted within 72 hours of evaluation. Contractors would submit clinical records on a weekly basis. Company 1 would review and audit all paperwork for completeness prior to submission to hospice. In compliance with Medicare regulations, the hospice retained professional management responsibility for care and services provided directly and by arrangement and assure that they would be furnished in a safe and effective manner by qualified personnel in accordance with the hospice approved integration of the hospice POC. All contracted services would be coordinated, supervised, and evaluated by the hospice IDG. The SN note dated 8/5/21, showed the family member requested PT/OT services for the patient. The physician's order dated 8/5/21, showed the order for PT/OT evaluation and treatment by Company 1 The Initial PT Evaluation dated 8/16/21, showed the PT recommended for maintenance of the patient's current level of mobility and increase ease of ADL care and decrease risk of pressure injuries. The plan of intervention included therapeutic exercises, therapeutic activities, neuromuscular reeducation, and gait when able 2W for 8W (two visits a week for eight weeks). * However, there was no documented evidence of an explanation why the PT evaluation was conducted 10 days after the physician's order on 8/5/21. The POC/IDG Review dated 8/18/21, showed no documented evidence the patient's PT/OT order/status was discussed in the IDG meeting. There was no documented evidence the OT evaluation was conducted at this time, 12 days after the OT evaluation was ordered. The SN note dated 8/24/21, showed the patient was awake, alert, and oriented, and able to make his needs known. Documentation showed the patient became mildly agitated during the visit when inquiring about PT services. Documentation showed the patient had an evaluation two weeks ago and had not heard back from Company 1. The patient believed that it was possible for the patient to fully recover so the patient could go back to work. Documentation showed active listening and empathy provided. Documentation showed the case manager or the physician was updated on the patient's status. * However, there was no documented evidence of what the case manager or the physician's response when the patient had not heard back from Company 1. The SN note dated 8/26/21, showed a care plan meeting with the MSW, family member, and patient. Documentation showed the patient wanted PT/OT services. * However, there was no documented evidence of PT/OT services provided for this patient from the PT/Company at this time time after the PT evaluation on 8/16/21. The Initial Occupational Therapy Evaluation and Care Plan dated 8/30/21, showed the patient would benefit from skilled therapy to reduce caregiver burden, prevent functional decline, and maintain or improve level of conditioning. Documentation showed frequency of treatment included 2W for 8W. Documentation showed the POC was discussed with the patient/PCG; and communication of care with the family member. * However, the clinical record review showed the initial OT evaluation was conducted 24 days after the physician had ordered OT evaluation on 8/5/21. There was no documented evidence of explanation why the initial OT evaluation was conducted 24 days after the physician's order. The POC/IDG Review dated 9/1/21, showed no documented evidence patient's PT/OT status was discussed in the IDG meeting. The SN note dated 9/9/21, showed the patient was doing PT exercises with the PT but was not strong enough. Documentation showed the patient was getting tired easily; non ambulatory; and bedbound. The patient required an extensive assistance for ADL care. Documentation showed the patient had a low BP during the PT session. The patient was assisted to elevate the legs, and the patient's BP was rechecked, which went up to 100/70 mm/Hg. * However, there was no documented evidence of the PT note/service from the PT/Company for the visit on 9/9/21. The POC/IDG Review dated 9/15/21, showed the patient was doing PT exercises with the PT but was not strong enough today. Documentation showed the patient was getting tired easily; non ambulatory; and bedbound. Documentation showed the patient required an extensive assistance for ADL care. * However, there was no documented evidence of the patient's OT status discussed in the IDG meeting. There was no documented evidence of any OT notes/services from the OT/Company 1 after the initial OT evaluation was conducted. There was no documented evidence of any PT notes/services from the PT/Company 1 after the initial PT evaluation. * The IDG failed to coordinate, supervise, and evaluate the PT/OT services for the patient. On 4/27/22 at 0815 hours, a concurrent interview and clinical record review was conducted with the DPCS. The DPCS was asked what would be the time frame for the PT/OT evaluation to be conducted once the PT/OT evaluation was ordered. The DPCS stated he was not sure. When asked for any other PT/OT notes aside from the PT/OT evaluation. The DPCS stated Company 1 was supposed to submit the PT/OT notes to the hospice. b. The comprehensive assessment dated 8/4/21, showed the patient had a history of back pain due to multiple back surgery from the past. The POC/IDG Review dated 8/4/21, showed the patient's medications included oxycodone hydrochloride/acetaminophen (opioid analgesic) 7.5 mg-325 mg one tablet PO Q four hours PRN, pregabalin (used for neuropathic pain) 50 mg one capsule PO BID, methotrexate (anti-rheumatic) 2.5 mg three tablets PO once a week Q Thursday, and leflunomide (anti-rheumatic) 10 mg one tablet PO QD. The SN note dated 8/5/21, showed the patient complained of pain level 4 (on a 0-10 pain scale, with 0 = no pain and 10 = worst pain) during the visit but refused to take any oral pain medication at this time. Documentation showed the patient's pain level was zero after the visit. The SN note dated 8/10/21, showed the patient's back pain level was 10. The patient was given oxycodone and was "somewhat effective." Documentation showed the pain level was reduced to 6. The PCG was educated on pain management and understood. The SN note dated 8/11/21, showed the patient's back pain level was 7. The patient was given oxycodone an hour before the visit, which was "somewhat effective." The PCG was educated on pain management and understood. The physician's order dated 8/11/21, showed an order for morphine sulfate (opioid analgesic) 20 mg/ml one ml PO Q two hours PRN for severe respiratory distress or pain, morphine sulfate 20 mg/ml 0.5 ml PO Q two hours PRN for moderate pain, and acetaminophen (analgesic) 325 mg two tablets PO Q four hours PRN for mild pain The SN note dated 8/12/21, showed the patient had no complaints of pain during the visit, but the PCG reported the patient had pain and took oxycodone PRN which was effective. The Communication Log dated 8/13/21, showed a call was received from the patient's PCP after an in-home visit with the patient. The PCP reported the patient's pain was not managed and ordered to increase pregabalin 50 mg BID to TID. Documentation showed the Case Manager was updated. The physician's order dated 8/13/21, showed an order for pregabalin 50 mg one capsule PO TID. The SN note dated 8/17/21, showed the patient reported a back pain level of 7. The oxycodone medication was administered and "somewhat effective" as evidenced by a pain level of 5. The physician's order dated 8/18/21, showed the orders for prednisolone (indication was for patient's arthritic pain) 5 mg one tablet PO BID and to discontinue methotrexate 2.5 mg three tablets PO once a week Q Thursday. The POC/IDG Review dated 8/18/21, showed the patient's medication included oxycodone hydrochloride/acetaminophen 7.5 mg-325 mg one tablet PO Q four hours PRN, pregabalin 50 mg one capsule PO TID, morphine sulfate 20 mg/ml one ml PO Q two hours PRN for severe respiratory distress or pain, morphine sulfate 20 mg/ml 0.5 ml PO Q two hours PRN for moderate pain, acetaminophen 325 mg two tablets PO Q four hours PRN for mild pain, leflunomide 10 mg one tablet PO QD, and prednisolone 5 mg one tablet PO BID. Documentation showed the PA visited the patient last week and adjusted the medications. The SN note dated 8/24/21, showed the patient reported a back pain level of 7 during the visit. Documentation showed the patient was taking oxycodone PRN which was "somewhat effective." The SN note dated 8/26/21, showed the patient complained of pain during the visit but refused to take "it" initially but eventually took Percocet (brand name for oxycodone hydrochloride/acetaminophen). Documentation showed the family member was present and the patient had been taking the Percocet Q four hours routine due to back pain. The SN note dated 8/31/21, showed the patient complained of back pain level of 5 during the visit. Documentation showed the patient was taking oxycodone PRN and "somewhat effective." The medication was given prior to the visit. Documentation showed after repositioning, the patient was more comfortable. The POC/IDG Review dated 9/1/21, showed the patient's medication included oxycodone hydrochloride/acetaminophen 7.5 mg-325 mg one tablet PO Q four hours PRN, pregabalin 50 mg one capsule PO TID, morphine sulfate 20 mg/ml one ml PO Q two hours PRN for severe respiratory distress or pain, morphine sulfate 20 mg/ml 0.5 ml PO Q two hours PRN for moderate pain, acetaminophen 325 mg two tablets PO Q four hours PRN for mild pain, leflunomide 10 mg one tablet PO QD, and prednisolone 5 mg one tablet BID. Documentation showed Norco (opioid analgesic, combination of hydrocodone and acetaminophen) was being given Q four hours for the patient's back pain. * However, there was no documented evidence the IDG had discussed the patient's pain with the administration of oxycodone that was "somewhat effective." In addition, there was no documented evidence the patient had a physician's order for Norco. The SN note dated 9/3/21, showed the patient complained of back pain level of 5 during the visit. Documentation showed the patient was administered oxycodone prior to the visit, which was "somewhat effective." The SN note dated 9/7/21, showed the patient reported a pain level of 6. The PCG reported the patient received Percocet 30 minutes ago and refused further pain medication intervention of morphine. The SN note dated 9/9/21, showed the patient denied any pain during the SN visit. The PCG reported the patient complained of back pain and was given Percocet PRN, fairly effective. The patient was able to do exercises with the PT with no discomfort. The SN note dated 9/10/21, showed the patient reported a pain level of 7 and Percocet was administered. The physician's order dated 9/10/21, showed an order to discontinue pregabalin 50 mg one capsule PO TID. The SN note dated 9/13/21, showed the patient's pain was assessed to be at a level 5. The patient had a change of condition and no longer able to answer all the questions regarding the pain. Documentation showed the patient was taking Percocet PRN which was "somewhat effective." The POC/IDG Review dated 9/15/21, showed the patient's medication included oxycodone hydrochloride/acetaminophen 7.5 mg-325 mg one tablet PO Q four hours PRN, morphine sulfate 20 mg/ml one ml PO Q two hours PRN for severe respiratory distress or pain, morphine sulfate 20 mg/ml 0.5 ml PO Q two hours PRN for moderate pain, acetaminophen 325 mg two tablets PO Q four hours PRN for mild pain, leflunomide 10 mg one tablet PO QD, and prednisolone 5 mg one tablet BID. Documentation showed the patient denied pain during the SN visit. Documentation showed the PCG reported the patient complained of pain on the back earlier "today" and was given Percocet PRN, fairly effective. The patient was able to do exercises with PT with no discomfort. * However, there was no documented evidence the IDG had discussed the patient's pain with the administration of oxycodone that was "somewhat effective," to better manage the patient's pain. The physician's order dated 9/17/21, showed and order for Percocet 7.5 mg-325 mg one tablet PO Q four hours for pain. c. The SN note dated 9/20/21, showed the PCG and family member requested an indwelling urinary catheter as the patient was becoming more incontinent. Documentation showed the nurse attempted to "cath" with much resistance. The patient asked the nurse to stop and the nurse honored the patient's wishes. The family member was informed. The case manager or physician was updated on the patient status. The SN note dated 9/21/21, showed under the genitourinary section, the 16 Fr "Coude" catheter with 10 ml was inserted per the family member's request as it was getting too difficult for a single "CG" to turn the patient. Documentation showed, "250 ml straw colored urine over in drainage bag." The case manager or physician was updated on the patient status. The physician's order dated 9/21/21, showed an order for 16 Fr. "coude catheter - 10 ml NS." * However, the use of indwelling urinary catheter was ordered one day after the SN had attempted to insert an indwelling urinary catheter on 9/20/21. On 4/27/22 at 0815 hours, a concurrent interview and clinical record review was conducted with the DPCS. The DPCS was asked the SN updated the patient's status to whom on 9/20/21. The DPCS stated he could not tell. d. The SN note dated 9/22/21, showed received a call from the afternoon shift PCG reporting blood tinged urine noted in the patient's urine drainage bag. Documentation at the time of the visit showed there was 780 ml of clear urine in the bag and blood tinged urine in the tubing. * However, there was no documented evidence the case manager or physician was notified of the patient's blood tinged urine in the tubing. e. The hospice's IDG failed to ensure the supervision related to accuracy of clinical records. For example: The POC/IDG Review dated 8/18, 9/1, and 9/15/21, showed the frequency of visits included HA 3W (three visits a week), MSW 1M (once a month) and 1 PRN visit, SC declined, and SN 2W and 2 PRN visits. The POC/IDG Review dated 9/1 and 9/15/21, showed Volunteer declined. The POC Summary dated 8/18, 9/1, and 9/15/21, showed under the frequency of visits: HA 3W, MSW 1M and 1 PRN, SC declined, Volunteer declined, SN daily until further notice. * However, the visit frequency for the SN was not consistent in the POC/IDG Review and POC Summary. On 4/27/22 at 0815 hours, a concurrent interview and clinical record review was conducted with the DPCS. The DPCS stated the correct visit frequency was SN 2W and 2 PRN visit. In addtion, the physician's order dated 8/11/21, showed MSW Visit x 1 to evaluate, Spiritual Counselor x 1 to evaluate, and Volunteer Coordinator x 1 to evaluate. On 4/27/22 at 0815 hours, a concurrent interview and clinical record review was conducted with the DPCS. The DPCS stated the date of the physician's order was not correct. The correct date of the physician's order was 8/4/21. f. The POC/IDG Review dated 9/1/21, showed the frequency of visit included HA 3W. The HA notes showed the HA had conducted two visits instead of three visits for Week 6 (9/5/21 to 9/11/21). The Communication Log dated 9/6/21, showed the family member refused for a service due to holiday. Documentation showed the case manager "noted." The POC/IDG Review dated 9/15/21, showed no documented evidence the IDG had discussed about the two HA visits conducted for Week 6 (9/5/21 to 9/11/21) instead of three visits due to the family member's refusal. g. The Physician's order dated 8/4/21 and the POC/IDG Review dated 8/18/21, showed SN visits 2W and 2 PRN visits. The SN notes showed the SN had conducted one visit instead of two visits during Week 3 (8/15/21 to 8/21/21). The Communication Log dated 8/20/21, showed a message was left to the family member for a telehealth visit or to provide the PCG with the phone number to "conductive." Documentation showed no response to the call. The POC/IDG review dated 9/1/21, showed no documented evidence the IDG had discussed about the one SN visit conducted during Week 3 (8/15/21 to 8/21/21) instead of two visits due to no response to the SN's call. h. The SN note dated 8/26/21, showed the patient had the Stage 2 right buttock pressure injury. Documentation showed the case manager or the physician was updated on the patient's status. However, there was no documented evidence on what was the physician's response on the updated status of the patient. The POC/IDG review dated 9/1/21, showed the excoriation on the coccyx and left heel resolved. Documentation showed Stage 2 pressure injury "8/26." Documentation showed a care plan problem to address altered skin integrity related to the Stage 2 right buttock pressure injury. Interventions included to instruct patient/PCG regarding new medication/treatment order and side effects; and to assess monitor effectiveness of wound treatments. * However, review of the clinical record showed no documented evidence of a physician's order for wound treatment of the patient's Stage 2 right buttock pressure injury, which was not consistent with the POC/ IDG review dated 9/1/21, which inlcuded a care plan problem addressing the patient's Stage 2 right buttock pressure injury, "to assess/monitor effectiveness of wound treatment." The IDG failed to maintains responsibility for directing, coordinating, and supervising the care and services provided to Patient B related to PT/OT services, pain management, the use of indwelling urinary catheter, notification of blood tinge urine, visit frequencies, and wound measurements. On 4/27/22 at 0815 hours, a concurrent interview and clinical record review was conducted with the DPCS. The DPCS stated it was the physician. The DPCS was informed and acknowledged the findings.
L0559      
27231 This CONDITION was not met as evidenced by: Based on clinical record and document review and interview, the hospice failed to develop an effective, on-going, hospice-wide date-driven QAPI program as evidenced by: 1. The hospice failed to develop, implement, and maintain an effective, on-going, hospice-wide data-driven quality assessment and performance improvement program. Cross reference to L560. 2. The hospice failed to have a PI activity that focused on high risk, high volume, and problem-prone areas. Cross reference to L566. 3. The hospice failed to have the PI activities that tracked adverse patient events, analyzed, developed, and implemented preventive action plans. Cross reference L569 4. The hospice's GB failed to ensure the ongoing QAPI program for quality improvement and patient safety was evaluated annually. Cross reference to L574. 5. The hospice failed to document the PI projects being conducted, the reason for conducting the projects, and the measurable progress achieved on these projects. Cross reference to L573. The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with continuous QAPI to ensure the provision of quality healthcare in a safe environment for the patients.
L0560      
39539 Based on interview and record review, the hospice failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and PI program. This failure created the risk for the hospice to resolve and improve problem prone areas. Findings: 1. Review of the hospice's P&P titled Quality Assurance/Performance Improvement (undated) showed the following: - The hospice will measure, analyze, and track quality indicators including patient adverse events and other aspects of performance that enable the agency to assess processes of care, services, and operations. - The QAPI committee's chairperson is responsible for the PI activities of the hospice by implementing and coordinating the program activities such as reviewing and summarizing all audit, investigation and study findings, identifying trends, weaknesses, and issues. - When undesirable patterns or trends in performance and sentinel events are identified, the agency analyzes the pattern/trend intensively to determine where best to focus for change of improvement. - A root cause analysis is performed for a serious adverse or sentinel event occurrence. - Analysis activities include current level of performance and appropriateness of the current process, new design application evaluated with positive results, areas for improvement, actions to improve the performance of the process, and evaluation of changes to the process. Review of the QAPI program for 2021 was conducted on 4/26/22. The QAPI program showed the hospice performed several QAPI studies for 2021. The QAPI program binder showed the data collected from the QAPI studies and the meeting minutes for each quarter. However, further review of the QAPI program showed the following: -The hospice failed to develop a performance improvement activity that focused on high risk, high volume, and problem-prone areas. Cross reference to L566. -The hospice failed to provide documented evidence showing the hospice had analyzed the data, tracked patterns and trends, implemented preventive actions, and evaluated whether the current practices were effective in improving the overall care and services provided to the patients. Cross reference to L569. -The hospice failed to document the reasons for conducting the PI projects and the measurable progress achieved on these projects for 2021. Cross reference to L573. - The hospice failed to ensure the licensed staff participated in the hospice QAPI program and in-service training. Cross reference to L586. 2. Review of the hospice's P&P titled Governing Body dated 2019 showed the hospice's governing body will ensure that the QAPI program reflects the complexity of its organization and services; an ongoing program for quality improvement and patient safety is defined, implemented, maintained and is evaluated annually; the hospice's QAPI efforts address priorities for improved quality of care and patient safety; and all improvement actions are evaluated for effectiveness. Review of the hospice's documents titled Governing Board Meeting Agenda showed the GB discussed the QAPI program on 1/19, 7/25, and 10/10/21; however, there was no documented evidence showing the GB conducted a meaningful evaluation of the hospice's QAPI program including identifying the lack of documented analysis, action plans, and whether the implemented actions were effective. Cross references to L574 and L651, example #2.
L0566      
39539 Based on interview and record review, the hospice failed to ensure the PI activities focused on high risk, high volume, and problem-prone areas. This failure had the potential to adversely affect the quality of care provided to the patients. Findings: Review of the hospice's P&P titled Quality Assessment/Performance Improvement (undated) showed the hospice's PI activities will focus on high risk, high volume, or problem prone areas and consider incidence, prevalence, and the severity of problems in those areas. Review of the QAPI program binder for 2021 was conducted on 4/26/22. The QAPI program binder showed the data collected from the QAPI studies and the meeting minutes for each quarter. The QAPI meetings were conducted quarterly on 4/13, 7/21, 10/20/21, and 1/19/22. Review of the hospice's document titled QAPI Studies 2021 showed 26 performance studies for 2021, including personnel files, collaboaration of POC, ADL assessment matchs HA assignment, level of care, volunteer notes, contractor vendor files, frequencies, recertification, and etc. On 4/26/22 at 1404 hours, an interview and concurrent document review was conducted with the QAPI Coordinator. When asked how the agency chose which PI studies to focus on, the QAPI Coordinator replied she conducted the studies based on the list created by the agency's previous coordinator. She continued the same studies and updated the list for any changes.
L0569      
39539 Based on interview and record review, the hospice failed to have the PI activities that tracked the adverse patient events, analyzed, developed, and implemented preventive action plans. This created the risk of not identifying areas for PI to improve care and services provided to the patients. Findings: Review of the hospice's P&P titled Quality Assurance/Performance Improvement (undated) showed the following: - The hospice will measure, analyze, and track quality indicators including patient adverse events and other aspects of performance that enable the agency to assess processes of care, services, and operations. - The QAPI committee's chairperson is responsible for the PI activities of the hospice by implementing and coordinating the program activities such as reviewing and summarizing all audit, investigation and study findings, identifying trends, weaknesses, and issues. - When undesirable patterns or trends in performance and sentinel events are identified, the agency analyzes the pattern/trend intensively to determine where best to focus for change of improvement. - A root cause analysis is performed for a serious adverse or sentinel event occurrence. - Analysis activities include current level of performance and appropriateness of the current process, new design application evaluated with positive results, areas for improvement, actions to improve the performance of the process, and evaluation of changes to the process. Review of the QAPI program for 2021 was conducted on 4/26/22. The QAPI program showed the hospice performed several QAPI studies for 2021. The PI Meetings for 2021 showed the summary of the data collected for each quarter. For example, review of the PI Meetings for 2021 showed the following: -For the first quarter, the document showed there were 16 incidents (one adverse reaction and 15 falls). -For the second quarter, the document showed there were 10 incidents (two "other" and eight falls). -For the third quarter, the document showed there were 13 fall incidents. -For the fourth quarter, the document showed there were 17 incidents (one "other" and 16 falls). Further review of the QAPI program showed the data was collected for each PI study and identified specific problem areas; however, there was no documented evidence showing the agency had analyzed the data, tracked patterns and trends, implemented preventive actions, and evaluated whether the current practices were effective in improving the overall care and services provided to the patients. In addition, the hospice failed to include Patient A's episode of choking as part of the reported incidents that occurred during the third quarter of 2021. Cross reference to L554, example #1. On 4/27/22 at 0826 hours, an interview and concurrent document review was conducted with the QAPI Coordinator. When asked to show the analysis and action plans for the 2021 QAPI program, the QAPI Coordinator was unable to provide the documentation. The QAPI Coordinator stated she only collected the data and if she identified a deficient practice, she would inform the specific staff involved to correct the problem. When asked if Patient A's episode of choking was included as part of the incidents reported for the third quarter of 2021, the QAPI Coordinator stated no. The QAPI Coordinator stated she recognized that the incident should have been included in the report since choking was considered an adverse event.
L0573      
39539 Based on interview and record review, the agency failed to document the reasons for conducting the PI projects and measurable progress achieved on these projects for 2021. These failures created the risk of not being able to ensure whether the PI projects conducted accurately reflected the scope, complexity, and past performance of the agency. Findings: Review of the hospice's P&P titled Quality Assessment/Performance Improvement (undated) showed the program will at least be capable of showing measurable improvement in indicators related to improved palliative outcomes and agency services and will document what PI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. Review of the QAPI program for 2021 was conducted on 4/26/22. The QAPI program showed the hospice performed several QAPI studies for 2021. On 4/26/22 at 1404 hours, an interview and concurrent document review was conducted with the QAPI Coordinator. When asked how the agency chose which PI studies to focus on, the QAPI Coordinator replied she conducted the studies based on the list created by the hospice's previous coordinator. She continued the same studies and updated the list for any changes. For example, in 2021, there were four additional problem specific areas included in the study. The QAPI Coordinator explained she collected the data to ensure the staff was submitting the documents timely for the patient notification of non-coverage, death and disposal summary, collaboration of POC, and incident reports. Further review of the QAPI program showed the data was collected for each PI study and identified specific problem areas; however, there was no documented evidence showing the reasons for conducting each of the PI study and measurable progress.
L0574      
39539 Based on interview and record review, the hospice's GB failed to ensure the ongoing QAPI program for quality improvement and patient safety was evaluated annually. This failure created the increased risk of not providing quality of care and services to the patients. Findings: Review of the agency's P&P titled Governing Body dated 2019 showed the hospice's GB will ensure the QAPI program reflects the complexity of its organization and services; an ongoing program for quality improvement and patient safety is defined, implemented, maintained and is evaluated annually; the hospice's QAPI efforts address priorities for improved quality of care and patient safety; and all improvement actions are evaluated for effectiveness. Review of the QAPI program binder for 2021 was conducted on 4/26/22. The QAPI program binder showed the data collected from the QAPI studies and the meeting minutes for each quarter. The QAPI meetings were conducted quarterly on 4/13/21, 7/21/21, 10/20/21, and 1/19/22; however, there was no documented evidence showing the GB evaluated the QAPI program. On 4/27/22 at 0826 hours, an interview and concurrent record review was conducted with the QAPI Coordinator. The QAPI Coordinator was asked what happened after the data was collected for each QAPI study. The QAPI Coordinator stated after she informed the specific staff involved to correct the deficient practice, she then notified the Administrator and DPCS via e-mail. When asked if the hospice's GB provided feedback and evaluation of the data collected including the overall effectiveness of the QAPI program, the QAPI Coordinator stated no and that she was not involved in the GB meetings. On 4/27/22 at 0850 hours, an interview and concurrent record review was conducted with the Administrator who was a member of the GB. The Administrator stated the GB met monthly to discuss the overall operation of the hospice. When asked if the GB discussed the QAPI program, the Administrator replied yes but the monthly discussions were mostly about the financial aspects of the hospice. When asked if the GB evaluated the data collected for the QAPI studies, the Administrator stated they did not discuss every data collected from each quarter but only discussed the significant incidents or ongoing problems which were documented in the GB meeting minutes. Review of the agency's documents titled Governing Board Meeting Agenda showed the GB discussed the QAPI program on 1/19, 7/25, and 10/10/21; however, there was no documented evidence showing the GB conducted a evaluation of the agency's QAPI program, including identifying the lack of documented analysis, action plans, and whether the implemented actions were effective. Cross reference to L651, example #2.
L0586      
39539 Based on interview and record review, the hospice failed to ensure the licensed staff participated in the hospice QAPI program and in-service training. This failure had the potential to create a lack of systems for improvement which could affect the provision of quality care and services to the patients and their families. Findings: Review of the hospice's P&P titled Quality Assurance/Performance Improvement (undated) showed the agency's governing body/owner will ensure that the licensed professionals will participate in the hospice's QAPI program and sponsored in-service training about QAPI. Review of the QAPI program binder for 2021 was conducted on 4/26/22. The QAPI program binder showed the data collected from the QAPI studies and the meeting minutes for each quarter. The QAPI meetings were conducted quarterly on 4/13, 7/21, 10/20/21, and 1/19/22. Further review of the QAPI program binder showed no documented evidence the agency ensured the licensed staff participated in their QAPI in-service training programs. On 4/27/22 at 0826 hours, an interview and concurrent document review was conducted with the QAPI Coordinator. The QAPI Coordinator was asked how the hospice informed the staff regarding the QAPI program. The QAPI Coordinator stated if she identified a deficient practice, she would inform the specific staff involved to correct the problem. When asked if the hospice informed all licensed staff and provided in-service trainings regarding the hospice's QAPI program, the QAPI Coordinator stated no.
L0651      
39539 Based on interview and record review, the hospice's GB failed to assume full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operation, and continuous QAPI. This failure had the potential to negatively affect the provision of quality care provided to the patients. Findings: 1. Review of the hospice's P&P titled Employee Personnel Files dated 2019 showed the employees' health files will include the examination by a physician, nurse practitioner, or physician's assistant for all persons providing physician, nursing, or home health aide services that confirms the employee is physically and medically qualified to perform duties to be assigned and the employee has no medical condition that would create a hazard to patients. This examination shall be completed six months prior to employment or within 14 days of the date of employment. The employee health files will also include a TST or chest X-ray upon hire and annual tuberculosis screenings. Review of the personnel files for the Administrator, DPCS, LVNs 1, and 2 was conducted on 4/26/22. The personnel files showed the health assessments were not completed within six months prior to employment or within 14 days of assuming employment and did not have the TB testing or chest x-ray upon hiring as follows: - The Administrator's personnel file showed the date of hire was 8/10/12. However, the physical examination and chest x-ray were completed on 3/5/13 and 7/10/13, respectively, more than 14 days of assuming employment. - The DPCS's personnel file showed the date of hire was 4/23/13. However, the chest x-ray was completed on 2/11/16, more than 14 days of assuming employment. - LVN 1's personnel file showed the date of hire was 1/22/14. However, the chest x-ray was completed on 2/25/13, more than six months prior to assuming employment. - LVN 2's personnel file showed the date of hire was 7/1/14. However, the physical examination and TB testing were completed on 7/30/14 and 9/10/14, respectively, more than 14 days of assuming employment. On 4/27/22 at 0810 hours, an interview and concurrent document review was conducted with the HR Assistant/Volunteer Director. The HR Assistant/Volunteer Director verified the findings. 2. Review of the agency's P&P titled Governing Body dated 2019 showed the hospice's GB will ensure that the QAPI program reflects the complexity of its organization and services; an ongoing program for quality improvement and patient safety is defined, implemented, maintained and is evaluated annually; the agency's QAPI efforts address priorities for improved quality of care and patient safety; and all improvement actions are evaluated for effectiveness. On 4/27/22 at 0826 hours, an interview and concurrent record review was conducted with the QAPI Coordinator. The QAPI Coordinator was asked what happened after the data was collected for each QAPI study. The QAPI Coordinator stated after she informed the specific staff involved to correct the deficient practice, she then notified the Administrator and DPCS via e-mail. When asked if the agency's GB provided feedback and evaluation of the data collected including the overall effectiveness of the QAPI program, the QAPI Coordinator stated no and that she was not involved in the GB meetings. On 4/27/22 at 0850 hours, an interview and concurrent record review was conducted with the Administrator who was a member of the GB. The Administrator stated the GB met monthly to discuss the overall operation of the hospice. When asked if the GB discussed the QAPI program, the Administrator replied yes but the monthly discussions were mostly about the financial aspects of the hospice. When asked if the GB evaluated the data collected from the QAPI studies, the Administrator stated they did not discuss every data collected from each quarter but only discussed the significant incidents or ongoing problems which were documented in the GB meeting minutes. Review of the agency's documents titled Governing Board Meeting Agenda, showed the governing body discussed the QAPI program on 1/19, 7/25, and 10/10/21; however, there was no documented evidence showing the GB conducted a meaningful evaluation of the agency's QAPI program including identifying the lack of documented analysis, action plans, and whether the implemented actions were effective. Cross reference to L574.