Kaiser Foundation Hospital Valley Continuing Care

“Based on observation, interview, and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients who have six months or less to live) failed to ensure compliance with the Condition of Participation (CoP, conditions that healthcare organizations must meet in order to begin and continue participating in Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) related to the Initial and Comprehensive Assessment (an assessment to identify the physical, psychosocial [relating social conditions to mental health], emotional, and spiritual needs associated with the terminal illness that must be addressed to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process) as evidenced by the following: 1. The HA failed to identify and address patient needs required to promote the patient’s well-being, comfort, and dignity throughout the dying process for one of 24 sampled patients (Patient 5).This failure resulted in the patient experiencing stress, anxiety, discomfort, and the potential for the patient’s end-of-life wishes not to be honored. (Refer to L525).2. The HA failed to maintain an accurate and current medication profile for two of 24 sampled patients (Patient 13 and Patient 14).This failure had the potential to place the patients at risk for medication errors and adverse drug reactions. (Refer to L530). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the Federal regulations for Initial and Comprehensive Assessment of the patient to ensure hospice benefits and services were furnished in accordance with accepted standards of practice.”

“Based on interview and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure compliance with the Condition of Participation (CoP, requirements that healthcare organizations must meet to participate in federal healthcare programs) related to the Interdisciplinary Group, Care Planning, and Coordination of Services as evidenced by the following: 1. The HA failed to ensure medications were available as indicated in the plan of care, for one of 24 sampled patients (Patient 19)This deficient practice had the potential to result in uncontrolled symptoms, negatively affecting the patient’s quality of life. (Refer to L549).2. The HA failed to ensure timely coordination of care for one of 24 sampled patients (Patient 11) when the physical therapy (PT) evaluation was completed late and not as required. This deficient practice resulted in a delay in the provision of ordered care and services for Patient 11. (Refer to L554).3. The HA Registered Nurse (RN 6) failed to notify the HA and the physician regarding the development of a pressure ulcer (areas of damaged skin and tissue caused by sustained pressure) to the sacral (triangular bone located at the base of your spine, just below the lower back) area for one of 24 sampled patients (Patient 13).This deficient practice resulted in the absence of physician wound care orders and lack of wound treatment contributing to the worsening of the pressure ulcer. (Refer to L554).4. The HA failed to ensure a completed Physician’s Order for Life-Sustaining Treatment (POLST, portable medical order form designed for seriously ill or frail patients to specify their medical treatment and it is a legally binding doctor’s order meant for current, immediate use across all care settings) was available in the patient’s home for two of 24 sampled patients (Patient 13 and Patient 14).This deficient practice had the potential to result in care and treatment inconsistent with the patients documented wishes. (Refer to L557). The cumulative effect of this systemic practices resulted in the Hospice Agency’s inability to deliver statutorily (written rules or laws) mandated compliance with the Federal regulations for Interdisciplinary Group, Care planning, Coordination of services to ensure the highest quality of care was being provided to ensure hospice benefits and services were furnished in accordance with accepted standards of practice.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure that one of twenty-four sampled patients (Patient 5) was an active participant in his plan of care.This failure resulted in the patient’s care preferences to not be respected. During a review of Patient 5’s Skilled Nurse (SN, a licensed nurse in general) Hospice Admission Assessment, dated 4/6/2025, the SN Hospice Admission Assessment indicated that Patient 5 was admitted to the HA on 4/6/2025 with a primary diagnosis of heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body’s needs for blood and oxygen), with reduced left ventricle (the thickest, most muscular chamber of the heart, responsible for pumping oxygenated blood from the left atrium throughout the entire body via the aorta [the main artery of the body]) ejection fraction (LVEF) less than or equal to 30%. The ejection fraction is the percentage of blood pumped out of the ventricle after a contraction. The lower the ejection fraction, the weaker the heart’s pumping action is – this occurs in people with severe heart failure.The SN Hospice Admission Assessment, under the cardiovascular assessment section, indicated that Patient 5 had an active defibrillator (a device that delivers electric shock to the heart to stop dangerous, irregular rhythms [arrhythmias] like ventricular fibrillation, allowing a normal heart rhythm to resume). The encounter notes section of Patient 5’s SN Hospice Admission Assessment indicated the presence of an automatic implantable cardioverter-defibrillator (a surgically implanted medical device to treat abnormal heart rhythms). There was no documentation on whether the admitting nurse had a discussion with Patient 5 or the family member/caregiver regarding deactivation of the AICD. The SN Hospice Admission was completed by Registered Nurse 3 (RN 3).During a telephone interview with Family Member 1 (FM 1) on 2/4/2026 at 9:15 a.m., FM 1 stated that both she (FM 1) and another family member of Patient 5 (FM 2), had informed the nurses at Hospital 1, where Patient 5 was hospitalized prior to his hospice admission, that they wanted Patient 5’s AICD to be deactivated prior to discharge. FM 1 stated that Patient 5 was aware he was going home with hospice care. FM 1 stated, “The device delivers shocks and we don’t want that. It’s uncomfortable. We wanted him to be comfortable.” FM 1 stated the nurses at Hospital 1 told her they could not do it. FM 1 stated the hospital nurse told her (FM 1) that once Patient 5 was home, “Someone’s going to come and turn it off.” FM 1 stated the hospice nurse came the day Patient 5 was discharged home. FM 1 stated that she informed the nurse about the patient’s and the family’s wish to have the AICD deactivated. FM 1 stated the hospice nurse (RN 3) told her (FM 1) that she (RN 3) could not turn the AICD off. FM 1 stated the AICD was never turned off until Patient 5 passed away on 4/9/2025. FM 1 stated, “Talking about this brings bad memories, painful memories.”During an interview with the Nurse Director (ND) and the Director of Patient Care Services (DPCS) on 2/4/2026 at 3:27 p.m., the ND and DPCS were asked regarding the hospice agency’s process when admitting a patient with AICD. The DPCS stated that if the patient had an AICD, the admitting nurse would have a discussion with the patient and/or family regarding whether they wanted the AICD to be turned off. The DPCS stated the admitting nurse would explain the advantages and disadvantages of having the AICD deactivated. The DPCS stated, “If the patient or family have decided they wanted it off, we will speak to the physician and get an order to deactivate it, then we need to figure out what type of AICD it is. If we can’t figure it out, we call the cardiologist office. Once figured out, we reach out to the company, the manufacturer of the AICD, to coordinate the deactivation. The company will send a representative to deactivate it while the hospice nurse or hospice physician is present. The nurse or the physician will then document the deactivation.” Per DPCS, the hospice nurse could use magnets to temporarily turn off the AICD in an emergency, while waiting for a representative from the AICD manufacturer to come and permanently turn off the AICD. The ND stated that it was the hospice nurse’s responsibility to coordinate the AICD deactivation.On 2/4/2026 at 3:45 p.m., the survey team requested to interview RN 3. The survey team was informed by the hospice agency that RN 3 was currently on a union strike and would return to work on 2/9/2026.During a review of Patient 5’s Home Care Visit note, dated 4/9/2025, the Home Care Visit note indicated that RN 4 made a visit to Patient 5’s residence due to shortness of breath. There was no documentation regarding discussion of an AICD deactivation.During a telephone interview with RN 4 on 2/5/2026 at 7:43 a.m., RN 4 was asked if he had a discussion with Patient 5 or his family member regarding AICD deactivation during his visit on 4/9/2025. RN 4 stated that he only remembered calling the physician because Patient 5 was having difficulty breathing. RN 4 stated, “By the time I got to their home, the patient was no longer verbally responsive, he was transitioning (actively dying).”During a concurrent interview and record review with the DPCS on 2/5/2026 at 12:05 p.m., the DPCS reviewed Patient 5’s SN Hospice Admission Assessment, Home Care Visit note, dated 4/9/2025, and Discharge Summary from Hospital 1, dated 4/6/2025, and the SOP for ICD Deactivation, effective 3/13/2025. The DPCS also reviewed Telephone Encounter Notes, dated 5/2/2025, which indicated that Patient 5’s AICD was still active until he passed away. The DPCS acknowledged there was no documented evidence that the hospice RN discussed with the patient and/or the family regarding AICD deactivation as the hospice agency’s SOP suggested. The DPCS stated that discussing AICD deactivation during admission was very important. The DPCS stated the AICD might deliver shocks and make beeping sounds that stress out the patient and the family. The DPCS stated the hospice agency needed to honor the patient’s wishes to be comfortable and to be free from stress and discomfort during end-of-life care.During a review of the hospice agency’s Standard Operating Procedure (SOP), titled “Rights / Responsibilities,” revised 4/20/2023, the SOP indicated that each patient would be an active, informed participant in his/her plan of care. The patient has the right to have cultural, psychosocial, spiritual/religious, and personal values, beliefs, and preferences respected.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to identify patient needs that must be addressed to promote the patient’s well-being, comfort, and dignity throughout the dying process for one of twenty-four sampled patients (Patient 5).This failure resulted in the patient experiencing stress, anxiety and discomfort, and the potential for the patient’s end-of-life wishes not to be honored. During a review of Patient 5’s Skilled Nurse (SN, a licensed nurse in general) Hospice Admission Assessment, dated 4/6/2025, the SN Hospice Admission Assessment indicated that Patient 5 was admitted to the HA on 4/6/2025 with a primary diagnosis of heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body’s needs for blood and oxygen), with reduced left ventricle (the thickest, most muscular chamber of the heart, responsible for pumping oxygenated blood from the left atrium throughout the entire body via the aorta [the main artery of the body]) ejection fraction (LVEF) less than or equal to 30%. The ejection fraction is the percentage of blood pumped out of the ventricle after a contraction. The lower the ejection fraction, the weaker the heart’s pumping action is – this occurs in people with severe heart failure.The SN Hospice Admission Assessment, under the cardiovascular assessment section, indicated that Patient 5 had an active defibrillator (a device that delivers electric shock to the heart to stop dangerous, irregular rhythms [arrhythmias] like ventricular fibrillation, allowing a normal heart rhythm to resume). The encounter notes section of Patient 5’s SN Hospice Admission Assessment indicated the presence of an automatic implantable cardioverter-defibrillator (a surgically implanted medical device to treat abnormal heart rhythms). There was no documentation on whether the admitting nurse had a discussion with Patient 5 or the family member/caregiver regarding deactivation of the AICD. The SN Hospice Admission was completed by Registered Nurse 3 (RN 3).During a telephone interview with Family Member 1 (FM 1) on 2/4/2026 at 9:15 a.m., FM 1 stated that both she (FM 1) and another family member of Patient 5 (FM 2), had informed the nurses at Hospital 1, where Patient 5 was hospitalized prior to his hospice admission, that they wanted Patient 5’s AICD to be deactivated prior to discharge. FM 1 stated that Patient 5 was aware he was going home with hospice care. FM 1 stated, “The device delivers shocks and we don’t want that. It’s uncomfortable. We wanted him to be comfortable.” FM 1 stated the nurses at Hospital 1 told her they could not do it. FM 1 stated the hospital nurse told her (FM 1) that once Patient 5 was home, “Someone’s going to come and turn it off.” FM 1 stated the hospice nurse came the day Patient 5 was discharged home. FM 1 stated that she informed the nurse about the patient’s and the family’s wish to have the AICD deactivated. FM 1 stated the hospice nurse (RN 3) told her (FM 1) that she (RN 3) could not turn the AICD off. FM 1 stated the AICD was never turned off until Patient 5 passed away on 4/9/2025. FM 1 stated, “Talking about this brings bad memories, painful memories.”During an interview with the Nurse Director (ND) and the Director of Patient Care Services (DPCS) on 2/4/2026 at 3:27 p.m., the ND and DPCS were asked regarding the hospice agency’s process when admitting a patient with AICD. The DPCS stated that if the patient had an AICD, the admitting nurse would have a discussion with the patient and/or family whether they wanted the AICD to be turned off. The DPCS stated the admitting nurse would explain the advantages and disadvantages of having the AICD deactivated. The DPCS stated, “If the patient or family have decided they wanted it off, we will speak to the physician and get an order to deactivate it, then we need to figure out what type of AICD it is. If we can’t figure it out, we call the cardiologist office. Once figured out, we reach out to the company, the manufacturer of the AICD, to coordinate the deactivation. The company will send a representative to deactivate it while the hospice nurse or hospice physician is present. The nurse or the physician will then document the deactivation.” Per DPCS, the hospice nurse could use magnets to temporarily turn off the AICD in an emergency, while waiting for a representative from the AICD manufacturer to come and permanently turn off the AICD. The ND stated that it was the hospice nurse’s responsibility to coordinate the AICD deactivation.On 2/4/2026 at 3:45 p.m., the survey team requested to interview RN 3. The survey team was informed by the hospice agency that RN 3 was currently on a union strike and would return to work on 2/9/2026.During a review of Patient 5’s Home Care Visit note, dated 4/9/2025, the Home Care Visit note indicated that RN 4 made a visit to Patient 5’s residence due to shortness of breath. There was no documentation regarding discussion of AICD deactivation.During a telephone interview with RN 4 on 2/5/2026 at 7:43 a.m., RN 4 was asked if he had a discussion with Patient 5 or his family member regarding AICD deactivation during his visit on 4/9/2025. RN 4 stated that he only remembered calling the physician because Patient 5 was having difficulty breathing. RN 4 stated, “By the time I got to their home, the patient was no longer verbally responsive, he was transitioning (actively dying).”During a review of the hospice agency’s Standard Operating Procedure (SOP), titled “Implantable Cardioverter-Defibrillator (ICD) Deactivation,” effective 3/13/2025, the SOP indicated that if AICD was identified during admission, the Hospice RN was to begin discussions with the patient/family about the risks and issues of keeping the ICD activated. Per the HA’s SOP, if the patient/family has decided to deactivate an implanted device, an order is required from the hospice physician.During a concurrent interview and record review with the DPCS on 2/5/2026 at 12:05 p.m., the DPCS reviewed Patient 5’s SN Hospice Admission Assessment, Home Care Visit note, dated 4/9/2025, and Discharge Summary from Hospital 1, dated 4/6/2025, and the SOP for ICD Deactivation, effective 3/13/2025. The DPCS also reviewed Telephone Encounter Notes, dated 5/2/2025, which indicated that Patient 5’s AICD was still active until he passed away. The DPCS acknowledged there was no documented evidence that the hospice RN discussed with the patient and/or the family regarding AICD deactivation as the hospice agency’s SOP suggested. The DPCS stated that discussing AICD deactivation during admission was very important. The DPCS stated the AICD might deliver shocks and make beeping sounds that stress out the patient and the family. The DPCS stated the hospice agency needed to honor the patient’s wishes to be comfortable and to be free from stress and discomfort during end-of-life care.During a review of the hospice agency’s SOP, titled “Comprehensive Assessment,” reviewed 8/15/2023, the SOP indicated that during the comprehensive assessment, all baseline data and other relevant information would be documented in the patient’s clinical record, including patient’s past and present medical and psychosocial history, including pertinent diagnosis and any comorbid conditions.”

“Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to maintain an accurate, current medication profile for two of 24 sampled patients (Patient 13 and Patient 14).This deficient practice had the potential to place patients at risk for medication errors and adverse drug reactions. a. During a review of Patient 13’s “Hospice Plan of Care” (POC, an individualized, legally mandated document that outlines the comprehensive medical, physical, emotional, and spiritual services to address for a terminally ill patient and their family), with an effective date from 1/22/2026 to 2/4/2026, the POC indicated Patient 13’s start of care date was 12/27/2025, with a terminal diagnosis of cerebrovascular disease (conditions that affect blood flow to your brain). The POC indicated the frequency of visits for the skilled nurse (SN) included one visit every week for 12 weeks and nine visits as needed.During a joint home visit, on 2/4/2026 at 12:10 p.m. at Patient 13’s residence, with the Registered Nurse (RN 5) and the Nurse Director (ND), Patient 13 was observed lying in bed watching television and was accompanied by a caregiver (PCG 3).During a review of Patient 13’s current medication, on 2/4/2026 at 1:54 p.m. with RN 5 and the ND, the following medications were not available in Patient 13’s residence but were listed in Patient 13’s medication profile and plan of care provided by the HA:Acetaminophen (used to treat mild-to-moderate pain and reduce fever) 325 milligrams (mg – unit of measurement) oral tablet.Acetaminophen 650 mg rectal suppository.Diclofenac Sodium (used to relieve mild-to-moderate pain, inflammation, swelling, and joint stiffness) one percent topical gel.Lidocaine (used to provide temporary, localized pain relief by numbing the skin and blocking nerve signals) four percent topical PTMD patch.Magnesium Hydroxide (used to treat occasional constipation [bowel movements become less frequent and stools become difficult to pass]) 400 mg per 5 milliliters (ml – unit of measurement) oral suspension.During a review of Patient 13’s current medication, on 1/28/2026 at 11:01 a.m. on 2/4/2026 at 1:54 p.m. with RN 5 and the ND, the following medications were available at Patient 13’s residence but not listed in Patient 13’s medication profile or plan of care provided by the HA:Extra Strength Tylenol (used to reduce fever, relieves minor aches and pains) 500 mg.b. During a review of Patient 14’s “Hospice Plan of Care” (POC, an individualized, legally mandated document that outlines the comprehensive medical, physical, emotional, and spiritual services for a terminally ill patient and their family), with an effective date of 1/22/2026 to 2/4/2026, the POC indicated Patient 14 ’s start of care date was 1/04/2026, with a terminal diagnosis of major neurocognitive disorder due to Alzheimer’s (a progressive, irreversible brain disorder, commonly known as dementia—characterized by a significant decline from previous performance in one or more cognitive domains like memory, executive function, language). The POC indicated the frequency of visits for the skilled nurse (SN) included two visits every week for nine weeks and six visits as needed.During a joint home visit, on 2/4/2026 at 10:35 a.m. at Patient 14’s residence, with the Licensed Vocational Nurse (LVN 1) and the Nurse Director (ND), Patient 14 was observed lying in bed watching television and was accompanied by a caregiver (PCG 4).During a review of Patient 14’s current medication, on 2/4/2026 at 11:25 a.m. with LVN 1 and the ND, the following medications were not available in Patient 14’s residence but were listed in Patient 14’s medication profile and plan of care provided by the HA:Atropine (used for secretions and congestion) one percent ophthalmic (relating to the eyes) drop.During an interview on 2/5/2026 at 2:35 p.m. with the Director of Patient Care Services (DPCS) and the Nurse Director (ND), the DPCS and the ND, both stated that medication reconciliation should be completed every visit. The DPCS further stated that completing medication reconciliation at each visit is important to ensure medications are being taken as prescribed, the medication profile remains current and accurate, and potential medication interactions are identified. During an interview conducted on During a record review of the agency’s policy and procedure, titled “Medication Profile,” dated 11/2022, the policy and procedure indicated, patients receiving medication administered by hospice will have a current and accurate medication profile in the clinical record and the medication profile will be updated for each change to reflect current medications and new and/or discontinued medications.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure medications were available as indicated in the plan of care, for one of 24 sampled patients (Patient 19)This deficient practice had the potential to result in uncontrolled symptoms, negatively impacting the patient’s quality of life. Findings:During a review of Patient 19’s Hospice Plan of Care (POC, an individualized, legally mandated document that outlines the comprehensive medical, physical, emotional, and spiritual services for a terminally ill patient and their family), with an effective date from 1/22/2026 to 3/22/2026, the POC indicated Patient 19’s start of care date was 3/28/2025, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). The POC included the frequency of visits for the skilled nurse (SN) was one visit for one week, and then 2 visits every week for 8 weeks plus 4 visits as needed for wound assessment/care, comfort measures and symptom management, pain assessment and management, and medication management. The POC further indicated Patient 19 was receiving cyanocobalamin (or Vitamin B12, provides essential nutrients to the body to make and support healthy nerve cells) 2,500 mcg (microgram, a unit of measurement) one tablet under the tongue daily for the prevention of vitamin B12 deficiency. During a joint home visit, on 2/5/2026 at 11:30 a.m. at Patient 19’s residence, with registered nurse (RN 1), Patient 19 was observed sitting on a sofa, awake, alert and oriented x 3 (to person, place and time), and was accompanied by a caregiver (PCG1). During Patient 19’s medication review with RN 1, the cyanocobalamin 2,500 mcg bottle was missing. PCG1 confirmed that the patient continues to take it daily but has run out, often experiencing delays in getting a new supply. During an interview, on 2/6/2026 at 11:45 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated that the HA staff should perform medication reconciliation at every visit and ensure patient medications are always available. During a review of the agency’s policy and procedure (P&P) titled The Plan of Care, revised March 2024, the P&P indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The written plan of care will contain, but will not be limited to, the following: drugs and treatments (including allergies).”

“Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to:1. Coordinate the care of one of 24 sampled patients (Patient 11) when Patient 11’s physical therapy (PT) evaluation was completed late.This failure resulted in a delay in the provision of ordered care and services for Patient 11.2. Registered Nurse (RN 6) failed to notify the HA and the physician regarding the development of a pressure ulcer (areas of damaged skin and tissue caused by sustained pressure) to the sacral (triangular bone located at the base of your spine, just below the lower back) area for two of 24 sampled patients (Patient 13).This deficient practice resulted in the absence of physician wound care orders and a lack of wound treatment contributing to the worsening of Patient 11’s pressure ulcer. During a review of Patient 11’s “Plan of Care,” dated 8/22/2023 to 10/17/2023, the Plan of Care indicated a start of care (SOC) date of 8/22/2023 with diagnoses including renal failure (when kidneys no longer function well on their own), hypertension (high blood pressure), and altered mental status (change in a person’s normal brain function, alertness, or mental clarity).During a record review of Patient 11’s Verbal Orders dated 9/6/2023, the Verbal Orders indicated, “Physical Therapy referral requested for strengthening and transfer training.”During a concurrent interview and record review on 2/5/2026 at 2:45 p.m. with the Director of Patient Care Services (DPCS), Patient 11’s Hospice Case Communication dated 9/13/2023 was reviewed. The Hospice Care Communication indicated, “No physical therapist is currently available to visit [Patient 11] but will call once staff becomes available. Patient Caregiver 2 (PCG 2) was advised and assured that skilled nurse will continue to follow up.” The DPCS stated physical therapists are expected to complete PT evaluations within 5 days from verbal order. The DPCS stated there would be a delay in PT evaluation order placed if the patient or patient caregiver requests that the PT evaluation is completed after the 5 day window.During a concurrent interview and record review on 2/5/2025 at 2:50 p.m. with the DPCS, Patient 11’s “PT Hospice Evaluation,” dated 9/26/2023 was reviewed. The PT Hospice Evaluation indicated, “Patient 11 was seen for PT evaluation. Patient 11 presents with generalized weakness affecting ability to perform functional activities safely and requiring maximum assist in activities of daily living (ADLs).” The DPCS stated the PT evaluation was completed late. The DPCS stated there was no verbal order to delay the PT evaluation. The DPCS stated PT evaluations should be done within 5 days because a patient or caregiver is requiring medical intervention. The DPCS stated completing a PT evaluation late could lead to a patient’s condition deteriorating and further injury.During an interview on 2/5/2026 at 3:58 p.m. with the Nurse Director (ND) the Nurse Director stated the agency does not have a policy that indicates the timeframe for carrying out a PT evaluation. The ND stated clinicians are expected to complete PT evaluations within 5 days.During a review of the facility’s policy and procedure (P&P) titled, “Rehabilitative Care Services,” revised 10/10/23, the P&P indicated, “All services will be provided in accordance with accepted standards of practice by or under the direction of a qualified physical, occupational, or speech therapist.” a. During a review of Patient 13’s “Hospice Plan of Care” (POC, an individualized, legally mandated document that outlines the comprehensive medical, physical, emotional, and spiritual services for a terminally ill patient and their family), effective date from 1/22/2026 to 2/4/2026, the POC indicated Patient 13’s start of care date of 12/27/2025, with a terminal diagnosis of cerebrovascular disease (conditions that affect blood flow to your brain). The POC indicated the frequency of visits of skilled nurse (SN) to one visit every week for 12 weeks and nine visits as needed. The POC did not indicate that Patient 13 had a pressure ulcer to the sacral area.During a review of Patient 13’s “Skilled Nurse Visit and Progress Note”, dated 1/28/2026, the “Skilled Nurse Visit and Progress Note” indicated that RN 6 documented that upon examination Patient 13 had a mepilex (soft silicone foam wound dressings) on the sacrum and when the mepilex was peeled back the skin was red and non-blanchable (an area of intact skin with persistent redness that does not turn white when pressed).During a review of Patient 13’s “Wound Trending Record”, dated 1/28/2026, the “Wound Trending Record” indicated that RN 6 documented a Stage 1 (intact skin with a localized area of non-blanchable erythema [redness]) pressure ulcer to the sacral area.During a joint home visit, on 2/4/2026 at 12:10 p.m. at Patient 13’s residence, with the Registered Nurse (RN 5) and Nurse Director (ND), Patient 13 was observed lying in bed watching television and was accompanied by a caregiver (PCG 3). Observed RN 5 and PCG 3 turning Patient 13 to the side to assess the skin and back. Once Patient 13 was turned to the side, observed a mepilex dressing on the coccyx (the last bone at the bottom of the spine) area. RN 5 removed the mepelix dressing and observed a pressure ulcer to the coccyx which RN 5 stated was a Stage 2 (partial-thickness skin loss, meaning the top layer [epidermis] and part of the second layer [dermis] are damaged, presenting as a shallow, open sore, or sometimes a fluid-filled blister)During a review of Patient 13’s “Home Care Visit”, dated 2/4/2026, the “Home Care Visit” indicated that RN 5 documented a wound pressure injury to the coccyx, Stage 2. The “Home Care Visit” further indicated that the pressure wound was deteriorating (a localized injury to the skin or underlying tissue—typically over a bony prominence—that is worsening in severity, depth, or size due to sustained pressure, friction, or shear) from Stage 1 to Stage 2.During a concurrent record review and interview on 2/5/2026 at 11:57 a.m. and 2:35 p.m., with Director of Patient Care Services (DPCS), the DPCS stated that RN 6 did not report to the hospice agency or notify the physician regarding Patient 13’s pressure ulcer to the coccyx/sacral area so there was no wound care ordered which resulted to in delay in care. The DPCS stated that it is important for staff to report new wounds to help with continuity of care and make sure physicians are aware and wound care orders are obtained and plan of care is updated.During a record review of the agency’s policy and procedure, titled “The Plan of Care” dated 3/2024, the policy and procedure indicated that care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against preference, goals and outcomes.During a record review of the agency’s policy and procedure, titled “Ongoing Comprehensive Assessment” dated 9/12/2023, the policy and procedure indicated that based on assessments, the plan of care – including problems, needs, goals, and outcomes – will be reviewed and updated by the interdisciplinary group members responsible for the case. The policy and procedure indicated that based on findings of the assessment, additional orders will be generated and forwarded to the physician or other authorized licensed independent practitioner for signature(s).”

“Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure a completed Physician’s Order for Life-Sustaining Treatment (POLST, portable medical order form designed for seriously ill or frail patients to specify their medical treatment and it is a legally binding doctor’s order meant for current, immediate use across all care settings) was available at the patient’s home for two of 24 sampled patients (Patient 13 and Patient 14).This deficient practice had the potential to result in care and treatment inconsistent with the patients’ documented wishes. a. During a review of Patient 13’s “Hospice Plan of Care” (POC, an individualized, legally mandated document that outlines the comprehensive medical, physical, emotional, and spiritual services for a terminally ill patient and their family), with an effective date from 1/22/2026 to 2/4/2026, the POC indicated Patient 13’s start of care date was 12/27/2025, with a terminal diagnosis of cerebrovascular disease (conditions that affect blood flow to your brain). The POC indicated the frequency of visits for the skilled nurse (SN) was one visit every week for 12 weeks and nine visits as needed.During a joint home visit, on 2/4/2026 at 12:10 p.m. at Patient 13’s residence, with Registered Nurse (RN 5) and the Nurse Director (ND), Patient 13 was observed lying in bed watching television and was accompanied by a caregiver (PCG 3).During a review of Patient 13’s hospice admission folder on 2/4/2026 with RN 5 and the ND, the admission folder indicated that the POLST was blank and no completed copy was observed in Patient 13’s hospice admission folder.b. During a review of Patient 14’s “Hospice Plan of Care” (POC, an individualized, legally mandated document that outlines the comprehensive medical, physical, emotional, and spiritual services for a terminally ill patient and their family), with an effective date from 1/22/2026 to 2/4/2026, the POC indicated Patient 14 ’s start of care date was 1/04/2026, with a terminal diagnosis of major neurocognitive disorder due to Alzheimer’s (a progressive, irreversible brain disorder, commonly known as dementia—characterized by a significant decline from previous performance in one or more cognitive domains like memory, executive function, language). The POC indicated the frequency of visits for the skilled nurse (SN) was two visits every week for nine weeks and six visits as needed.During a joint home visit, on 2/4/2026 at 10:35 a.m. at Patient 14’s residence, with the Licensed Vocational Nurse (LVN 1) and the Nurse Director (ND), Patient 14 was observed lying in bed watching television and was accompanied by a caregiver (PCG 4).During a review of Patient 14’s hospice admission folder on 2/4/2026 with LVN 1 and the ND, the admission folder indicated that the POLST was blank and no completed copy was observed in Patient 14’s hospice admission folder.During an interview on 2/5/2026 at 2:35 p.m. with the Director of Patient Care Services (DPCS) and the Nurse Director (ND), the DPCS and the ND stated that a patient’s POLST should be completed and signed, and a copy of the completed POLST should be at the patient’s home. The DPCS stated that it is important to have a completed POLST, at the patient’s home, because the POLST guides and provides directions to emergency individuals on what to do and identifies comfort measures and level of care for the patients.During a record review of the agency’s policy and procedure, titled “Do Not Resuscitate” dated 4/2025, the policy and procedure indicated that a written Do Not Resuscitate (DNR) order or Physician’s Order for Life-Sustaining Treatment (POLST), signed by the patient’s physician or other authorized licensed independent practitioner, must be on file in the patient’s clinical record and admission folder in the patient’s home.”