Interim Healthcare Hospice

“Based on interview, and record review, the agency failed to ensure bereavement risks assessments (a questionnaire used by a hospice (end of life care) team to identify how likely a grieving person is to struggle after a loved one dies and to determine who will be able to cope naturally and who is at a higher risk for developing severe, ongoing depression (persistent sadness, low energy and loss of interests) or complicated grief) were completed on the initial comprehensive assessments for eight of 14 sampled patients (Patient 2, 4, 9, 10, 11, 12, 13, and Patient 14). This failure had the potential to not identify high risk family members and loved ones experiencing a loss that could lead to complicated grief requiring additional resources needed to accept the loss and adapt to life without their loved one. During a review of Patient 2’s Plan of Care, dated 5/6/26, it indicated Patient 2 was admitted to the agency on 5/6/26 with diagnoses that included malignant neoplasm of the left fallopian tube (cancer in the area of the female reproductive system that connects the ovaries to the uterus,) asthma, and pain.During a review of Patient 2’s “BPOC,” undated, the “BPOC” indicated Patient 2 did not have a bereavement risk assessment completed on the initial assessment dated 5/6/26 or within five days. During a review of Patient 4’s Plan of Care, dated 3/26/26, it indicated Patient 4 was admitted to the agency on 3/26/26 with diagnoses that included Parkinson’s disease (a progressive disorder that effects the brain and nerves,) high blood pressure, heart failure, and urinary retention (inability to fully empty the bladder.) During an interview and concurrent record review on 6/30/26 at 2:50 pm with the Intake Coordinator (IC,) she confirmed that Patient 7’s “BPOC,” undated, indicated Patient 7 had not received a bereavement risk assessment dated 3/26/26, or within five days. Findings: During a review of the agency’s policy and procedure (P&P) titled, “Bereavement Services and Coordination,” dated 4/2021, the P&P indicated, “Bereavement services and coordination is provided by or under the supervision of a qualified professional with experience in grief or loss counseling. Bereavement counseling services is an organized program which must be available to the patient and family before and after the patient’s death to assist the patient and family in minimizing the stress and problems that arise from the terminal illness, related conditions, and the dying process. An initial bereavement assessment is completed as part of the initial comprehensive assessment. The bereavement assessment will identify the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment must be incorporated into the plan of care and considered in the bereavement plan of care. The bereavement plan of care will note the kind of bereavement services to be offered and the frequency of service delivery. Bereavement services will be available to the family and other individuals in the bereavement plan of care at least one year following the death of the patient.” During a review of Patient 9’s “POC,” dated 12/16/25, the “POC” indicated, Patient 9 was admitted to the agency on 12/16/25 with diagnoses that included malignant neoplasm of the bronchus and lung metastasized to the bones (stage four lung cancer that has spread to the bones), hypothyroidism (underactive thyroid), high blood pressure, migraines (recurring moderate to severe headache that can include nausea and sensitivity to light) and gastroesophageal reflux disease (GERD, chronic lasting longer than three months acid reflux when the muscle valve between your stomach and food pipe do not close properly, allowing harsh stomach acid to splash backwards, burning the throat). During a review of Resident 9’s “Bereavement Plan of Care (BPOC),” undated, the “BPOC” indicated, Patient 9 did not have a bereavement risk assessment completed on the initial assessment completed on 12/16/25 or within five days. During a review of Patient 10’s “POC,” dated 6/18/26, the “POC” indicated, Patient 10 was admitted to the agency on 6/18/26 with diagnoses that included secondary malignant neoplasm of unspecified site (stage four cancer that has spread to from its original starting point to another place in the body, unable to determine where the new tumor is located), dysphagia (difficulty swallowing), anxiety (feelings of dread, worry, and uneasiness), glaucoma (eye disease caused from too much pressure that causes optic nerve damage), deep vein thrombosis of the right leg (blood clot forming in the right leg) ascites (abnormal buildup of excess fluid in the abdomen), diabetes (too much sugar in the blood) , thrombocytopenia (the body does not have enough platelets that help clot the blood), and lymphadenopathy (swollen lymph nodes). During a review of Resident 10’s “Bereavement Plan of Care (BPOC),” undated, the “BPOC” indicated, Patient 10 did not have a bereavement risk assessment completed on the initial assessment completed on 6/18/26 or within five days. During a review of Patient 11’s “POC,” dated 11/24/25, the “POC” indicated, Patient 11 was admitted to the agency on 11/24/25 with diagnoses that included Parkinsonism (umbrella term for a group of conditions causing movement problems such as tremors, stiffness and slow movement), heart disease, vascular dementia (blood flow is reduced in the brain causing a decline in thinking and memory skills, high blood pressure, and multiple falls. During a review of Resident 11’s “Bereavement Plan of Care (BPOC),” undated, the “BPOC” indicated, Patient 11 did not have a bereavement risk assessment completed on the initial assessment completed on 11/24/25 or within five days. During a review of Patient 12’s “POC,” dated 4/24/26, the “POC” indicated, Patient 12 was admitted to the agency on 4/24/26 with diagnoses that included malignant neoplasm of the mandible (cancerous tumor in the lower jaw bone), malignant neoplasm of the bone (cancerous tumors that can spread to other parts of the body), mild intellectual disability disorder (a person learns and develops new skills slower than average), history of mental health condition with irritability (mood disorder with intense emotions ranging from ups and downs and agitated), and seizures (sudden, uncontrolled surge of electrical activity in the brain). During a review of Resident 12’s “Bereavement Plan of Care (BPOC),” undated, the “BPOC” indicated, Patient 12 did not have a bereavement risk assessment completed on the initial assessment completed on 4/24/26 or within five days. During a review of Patient 13’s “POC,” dated 5/25/25, the “POC” indicated, Patient 13 was admitted to the agency on 5/25/25 with diagnoses that included Alzheimer’s disease (A physical brain disease that slowly destroys memory, thinking skills, and the ability to carry out simple tasks), occipital tumor (abnormal growth of cells in the very back part of the brain that controls vision), diabetes (too much sugar in the blood), unsteady gait (problem with balance and walking), and frequent falls. During a review of Resident 13’s “Bereavement Plan of Care (BPOC),” undated, the “BPOC” indicated, Patient 13 did not have a bereavement risk assessment completed on the initial assessment completed on 5/25/25 or within five days. During a review of Patient 14’s “POC,” dated 4/1/26, the “POC” indicated, Patient 14 was admitted to the agency on 4/1/26 with diagnoses that included hepatic failure (liver failure, unable to filter waste from the blood, aid digestion, regulate energy and control bleeding), seizures (sudden, uncontrolled surge of electrical activity in the brain), ascites (abnormal buildup of excess fluid in the abdomen), depression (persistent sadness, low energy and loss of interests) and recent cardiac arrest (the heart suddenly stops beating requiring emergency intervention). During a review of Resident 14’s “Bereavement Plan of Care (BPOC),” undated, the “BPOC” indicated, Patient 14 did not have a bereavement risk assessment completed on the initial assessment completed on 4/1/26 or within five days. During a concurrent interview and record review on 6/30/26 at 12:30 pm, with Intake Coordinator (IC), IC confirmed no bereavement assessments were completed on Patient 2, 4, 9, 10, 11, 12, 13, and Patient 14 during the initial comprehensive assessment or within five working days after the initial comprehensive assessment was completed. IC stated, “I confirm these bereavement risk assessments were never completed, we did not know they had to be done. We will know from now on to make sure the risk assessments are completed within five days of the start of care date.” During an interview on 6/30/26 at 3:20 pm, with Director of Health Care Services (DHCS), DHCS confirmed eight of fourteen sampled patients did not have a bereavement risk assessment completed within five days of the initial comprehensive assessment or completed at all. DHCS stated, “I am still learning this job, and the Medical Social Worker is new. We did not know this had to be completed within five days of the initial comprehensive assessment. I will make sure moving forward this is completed, I know it is important and we want to learn. I will implement this process immediately.””

“Based on interview and record review, the agency failed to include outcome measures (the amount of time, or dates for patient goals to be completed) on a plan of care (POC, a personalized, day-to-day roadmap for keeping a terminally ill patient comfortable that outlines how the healthcare team will manage symptoms, medications, and support the family’s emotional and spiritual needs) and did not individualize specific patient needs when: 1. Five of seven sampled patients (Patient 1, 3, 4, 5 and Patient 7) did not have specific dates included for patient and family goals needed for safety and education with a individualized time frame needed. 2. One of four discharged patients, (Patient 11) did not have revisions needed with an increased frequency for symptom management and family support. These failures had the potential for poor symptom management and family support and education needed. Findings:1. During a review of the agency’s policy and procedure (P&P) titled “Frequency Ranges,” dated 1/2022, the P&P indicated, “Frequency ranges ordered services may be used to provide more flexibility in meeting the patient’s needs in the plan of care. The purpose of this policy is to specify guidelines for using frequency ranges. Frequency ranges may be used in developing the plan of care to ensure that the most appropriate level of services is provided to the patient. When a range of frequencies is ordered, the upper limit of the range is considered the specific-ordered frequency. Changes in frequency outside of the ordered range will require an additional physician/allowed practitioner’s order. The patient or patient representative will be notified of frequency changes prior to the alteration and will be documented in the patient’s clinical record. Frequency of visits will be lowered or increased based on the needs and changes in patient status. Ranges will not be utilized for staffing purposes of agency convenience.” During a review of the agency’s policy and procedure (P&P) titled “Notification Regarding Missed Service or Treatment,” dated 1/2026, the P&P indicated, “A missed visit or treatment is an alteration in the plan of care, and therefore, requires notification to the ordering physician/allowed practitioner, patient and/or patient representative. The organization must notify the relevant physician/allowed practitioner to any changes in ordered frequency of ordered services or treatment, including reason. A missed visit or treatment which cannot be rescheduled in the order duration of visits shall be documented and communicated to the physician/ practitioner.” During a review of Patient 1’s Plan of Care, (POC, a personalized, day to day roadmap for keeping a terminally ill patient comfortable that outlines how the healthcare team will manage symptoms, medications, and support the family’s emotional and spiritual needs),” dated 6/29/26, the “POC” indicated, Patient 1 was admitted to the agency on 6/29/26 with diagnoses that included malignant neoplasm of larynx (cancer of the voice box), chronic obstructive pulmonary (COPD, a progressive lung disease causing shortness of breath), atrial fibrillation (fast and irregular heart beat), high blood pressure, depression (persistent sadness, low energy and loss of interests) and anxiety (feelings of dread, worry, and uneasiness). A review of Patient 1’s “POC”, dated 6/29/26, there were no dates included in the POC for specific goals, education, and measurable outcomes. During a review of Patient 3’s “POC,” dated 6/25/26, the “POC” indicated, Patient 3 was admitted to the agency on 6/25/26 with diagnoses that included Alzheimer’s disease (A physical brain disease that slowly destroys memory, thinking skills, and the ability to carry out simple tasks), senile degeneration of the brain (severe age related cognitive decline, ability to think, reason and make decisions), osteoarthritis (wear and tear of joints with bone rubbing bone causing pain and stiffness), and urinary tract infection (UTI, or bladder infection). During a review of Patient 3’s “POC”, dated 6/25/26, there were no dates included in the POC for specific goals, education, and measurable outcomes. During a review of Patient 5’s “POC,” dated 5/28/26, the “POC” indicated, Patient 5 was admitted to the agency on 5/28/26 with diagnoses that included neoplasm (new) malignant (growth is cancerous) of the cervix and uterus (womb), adult failure to thrive (gradual decline in physical, mental sharpness, and ability to care for themselves, weight loss, poor eating and isolation), and schizophrenia (complex brain mental health disorder characterized by paranoid thoughts or delusions, unable to distinguish between thoughts and reality). During a review of Patient 5’s “POC”, dated 5/28/26, there were no dates included in the POC for specific goals, education, and measurable outcomes. During an interview on 7/1/26 at 3:45 pm with Director of Health Care Services (DHCS), DHCS confirmed all POCs need specific dates for measurable goals to meet for all of the POC. DHCS stated, “I confirm the registered nurse can add dates even with the drop-down box that states ongoing, and the dates will make the POC more patient specific and individualized. I confirm the goals need to be measured with a specific date for medication administration, symptom management, and oxygen safety. The education and all goals are different for every patient.” 2. During a review of Patient 11’s “POC,” dated 11/24/25, the “POC” indicated, Patient 11 was admitted to the agency on 11/24/25 with diagnoses that included Parkinsonism (umbrella term for a group of conditions causing movement problems such as tremors, stiffness and slow movement), heart disease, vascular dementia (blood flow is reduced in the brain causing a decline in thinking and memory skills, high blood pressure, and multiple falls. During a review of Patient 11’s clinical record, there was no additional Registered Nurse (RN) assessment, evaluation of a new medication ordered, or change in frequency on the POC once Patient 11 needed more symptom management as Patient 11 was transitioning (the body is naturally slowing down and preparing for end of life, typically over a period of hours or days). During a concurrent record review and interview on 7/1/26 at 4:30 pm with Director of Health Care Services (DHCS), DHCS confirmed reading the clinical record for Patient 11 when the family called the office to provide an update Patient 11 had passed, no phone call or visit was completed the day prior after a new medication had been ordered to check on the patient and family. DHCS stated, “I confirm we need to increase the visit frequency or use as needed visits for the transitioning period or at the minimum make a call to make sure the family does not need any thing or extra support. My expectation would be if a new medication is needed, they need a visit for the standard of practice for hospice care. Best practice is we do extra visits for all patients when they are so close to dying. Even if the family declines a visit, we would have called to check on them and feel like we did all we could do to support them.” During a review of Patient 4’s Plan of Care, dated 3/26/26, it indicated Patient 4 was admitted to the agency on 3/26/26 with diagnoses that included Parkinson’s disease (a progressive disorder that effects the brain and nerves,) high blood pressure, heart failure, and urinary retention (inability to fully empty the bladder.) There were no dates included in the POC for specific goals, education, and measurable outcomes. During a concurrent interview and record review with DHCS, on 7/2/26 at 3 pm, she reviewed the initial Plan of Care, dated 3/26/26, for Patient 4. DHCS verbalized confirmation that the goals in the plan of care were not specific and included no dates or meaningful measurements. DHCS stated that she was aware of the issue. During a review of Patient 7’s Plan of Care, dated 3/29/26, it indicated Patient 7 was admitted with diagnoses that included Parkinson’s disease, anxiety, and agitation. There were no dates included in the POC for specific goals, education, and measurable outcomes. During a concurrent interview and record review with DHCS, on 7/2/26 at 3 pm, she reviewed the initial Plan of Care, dated 3/29/26, for Patient 7. DHCS verbalized confirmation that the goals in the plan of care were not specific and included no dates or meaningful measurements. Findings:1. During a review of the agency’s policy and procedure (P&P) titled “Frequency Ranges,” dated 1/2022, the P&P indicated, “Frequency ranges ordered services may be used to provide more flexibility in meeting the patient’s needs in the plan of care. The purpose of this policy is to specify guidelines for using frequency ranges. Frequency ranges may be used in developing the plan of care to ensure that the most appropriate level of services is provided to the patient. When a range of frequencies is ordered, the upper limit of the range is considered the specific-ordered frequency. Changes in frequency outside of the ordered range will require an additional physician/allowed practitioner’s order. The patient or patient representative will be notified of frequency changes prior to the alteration and will be documented in the patient’s clinical record. Frequency of visits will be lowered or increased based on the needs and changes in patient status. Ranges will not be utilized for staffing purposes of agency convenience.” During a review of the agency’s policy and procedure (P&P) titled “Notification Regarding Missed Service or Treatment,” dated 1/2026, indicated, “A missed visit or treatment is an alteration in the plan of care, and therefore, requires notification to the ordering physician/allowed practitioner, patient and/or patient representative. The organization must notify the relevant physician/allowed practitioner to any changes in ordered frequency of ordered services or treatment, including reason. A missed visit or treatment which cannot be rescheduled in the order duration of visits shall be documented and communicated to the physician/ practitioner.” During a review of Patient 1’s Plan of Care, (POC, a personalized, day to day roadmap for keeping a terminally ill patient comfortable that outlines how the healthcare team will manage symptoms, medications, and support the family’s emotional and spiritual needs),” dated 6/29/26, indicated, Patient 1 was admitted to the agency on 6/29/26 with diagnoses that included malignant neoplasm of larynx (cancer of the voice box), chronic obstructive pulmonary disease (COPD, a progressive lung disease causing shortness of breath), atrial fibrillation (fast and irregular heart beat), high blood pressure, depression (persistent sadness, low energy and loss of interests) and anxiety (feelings of dread, worry, and uneasiness). A review of Patient 1’s POC, dated 6/29/26, there were no dates included in the POC for specific goals, education, and measurable outcomes. During a review of Patient 3’s POC, dated 6/25/26, indicated Patient 3 was admitted to the agency on 6/25/26 with diagnoses that included Alzheimer’s disease (a physical brain disease that slowly destroys memory, thinking skills, and the ability to carry out simple tasks), senile degeneration of the brain (severe age related cognitive decline, ability to think, reason and make decisions), osteoarthritis (wear and tear of joints with bone rubbing bone causing pain and stiffness), and urinary tract infection (UTI, or bladder infection). During a review of Patient 3’s POC, dated 6/25/26, there were no dates included in the POC for specific goals, education, and measurable outcomes. During a review of Patient 5’s POC, dated 5/28/26, indicated Patient 5 was admitted to the agency on 5/28/26 with diagnoses that included neoplasm (new) malignant (growth is cancerous) of the cervix and uterus (womb), adult failure to thrive (gradual decline in physical, mental sharpness, and ability to care for themselves, weight loss, poor eating and isolation), and schizophrenia (complex brain mental health disorder characterized by paranoid thoughts or delusions, unable to distinguish between thoughts and reality). During a review of Patient 5’s POC, dated 5/28/26, there were no dates included in the POC for specific goals, education, and measurable outcomes. During an interview on 7/1/26 at 3:45 pm with Director of Health Care Services (DHCS), DHCS confirmed all POCs need specific dates for measurable goals to meet for all of the POC. DHCS stated, “I confirm the registered nurse can add dates even with the drop-down box that states ongoing, and the dates will make the POC more patient specific and individualized. I confirm the goals need to be measured with a specific date for medication administration, symptom management, and oxygen safety. The education and all goals are different for every patient.” 2. During a review of Patient 11’s POC, dated 11/24/25, the “POC” indicated, Patient 11 was admitted to the agency on 11/24/25 with diagnoses that included Parkinsonism (umbrella term for a group of conditions causing movement problems such as tremors, stiffness and slow movement), heart disease, vascular dementia (blood flow is reduced in the brain causing a decline in thinking and memory skills, high blood pressure, and multiple falls. During a review of Patient 11’s clinical record, there was no additional Registered Nurse (RN) assessment, evaluation of a new medication ordered, or change in frequency on the POC once Patient 11 needed more symptom management as Patient 11 was transitioning (the body is naturally slowing down and preparing for end of life, typically over a period of hours or days). During a concurrent record review and interview on 7/1/26 at 4:30 pm with Director of Health Care Services (DHCS), DHCS confirmed reading the clinical record for Patient 11 when the family called the office to provide an update Patient 11 had passed, no phone call or visit was completed the day prior after a new medication had been ordered to check on the patient and family. DHCS stated, “I confirm we need to increase the visit frequency or use as needed visits for the transitioning period or at the minimum make a call to make sure the family does not need any thing or extra support. My expectation would be if a new medication is needed, they need a visit for the standard of practice for hospice care. Best practice is we do extra visits for all patients when they are so close to dying. Even if the family declines a visit, we would have called to check on them and feel like we did all we could do to support them.” During a review of Patient 4’s Plan of Care, dated 3/26/26, it indicated Patient 4 was admitted to the agency on 3/26/26 with diagnoses that included Parkinson’s disease (a progressive disorder that effects the brain and nerves,) high blood pressure, heart failure, and urinary retention (inability to fully empty the bladder.) There were no dates included in the POC for specific goals, education, and measurable outcomes. During a concurrent interview and record review with DHCS, on 7/2/26 at 3 pm, she reviewed the initial Plan of Care, dated 3/26/26, for Patient 4. DHCS verbalized confirmation that the goals in the plan of care were not specific and included no dates or meaningful measurements. DHCS stated that she was aware of the issue. During a review of Patient 7’s Plan of Care, dated 3/29/26, it indicated Patient 7 was admitted with diagnoses that included Parkinson’s disease, anxiety, and agitation. There were no dates included in the POC for specific goals, education, and measurable outcomes. During a concurrent interview and record review with DHCS, on 7/2/26 at 3 pm, she reviewed the initial Plan of Care, dated 3/29/26, for Patient 7. DHCS verbalized confirmation that the goals in the plan of care were not specific and included no dates or meaningful measurements.”

“Based on interview and record review, the agency failed to follow the Plan of Care (POC, a personalized, day-to-day roadmap for keeping a terminally ill patient comfortable that outlines how the healthcare team will manage symptoms, medications, and support the family’s emotional and spiritual needs) frequencies for five of seven sampled patients (Patient 2, 3, 4, 5, and Patient 7) when Skilled Nurse (SN) visit frequencies were written as a range for one to two weeks times weekly for 13 and 14 weeks. This failure had the potential for poor symptom management for patient needs and the potential for family needs to not be identified in a timely manner. During a review of Patient 2’s Plan of Care, dated 5/6/26, it indicated Patient 2 was admitted to the agency on 5/6/26 with diagnoses that included malignant neoplasm of the left fallopian tube (cancer in the area of the female reproductive system that connects the ovaries to the uterus,) asthma, and pain.During a review of Patient 2’s “POC,” dated 5/6/26, the “POC” indicated the SN frequency is 1-2 times per wk for 14 weeks.During a review of Patient 2’s clinical record only 1 SN visit occurred on the weeks of 5/9 - 5/15, 5/23 - 5/29, and 5/30 - 6/5. (3 missed visits) There was no documentation to indicated the physician had been notified that a single visit was performed. During an interview and concurrent record review with the Intake Coordinator (IC) on 7/2/26 at 2:35 pm, she reviewed the POC and documentation of scheduled skilled nurse visits for Patient 2. IC confirmed that the POC indicated a skilled nursing visit frequency of 1-2 visits per week, but stated that this order meant the patient could be seen as infrequently as once every 14 days. She denied that the physician’s order had not been followed and asserted no visits had been missed. During an interview and concurrent record review with the Director of Health Care Services (DHCS,) on 7/2/26 at 2:40 pm, she reviewed the POC, dated 5/6/26 for Patient 2. DHCS stated that she had recently reviewed the policy and, when a range of visits is ordered, such as 1 - 2 per week, that 2 visits per week is the expectation. DHCS clarified that a single visit would be considered a missed visit. DHCS confirmed that Patient 2 experienced 3 missed visits during the period reviewed and that the physician had not been notified. During a review of Patient 4’s Plan of Care, dated 3/26/26, it indicated Patient 4 was admitted to the agency on 3/26/26 with diagnoses that included Parkinson’s disease (a progressive disorder that effects the brain and nerves,) high blood pressure, heart failure, and urinary retention (inability to fully empty the bladder.)During a review of Patient 4’s “POC,” dated 3/26/26, the “POC” indicated the SN frequency is 1-2 times per wk for 13 weeks.During a review of Patient 4’s clinical record only 1 SN visit occurred on the weeks of 3/26/26 - 6/5/26, and 6/13/26 - 6/19/2. (2 missed visits) There was no documentation to indicate the physician had been notified that only a single visit was performed. During an interview and concurrent record review with DHCS, on 7/2/26 at 3 pm, she reviewed the clinical record for Patient 4. DHCS confirmed that they physician’s order indicated Patient 4 should be seen by skilled nursing twice weekly. DHCS confirmed that Patient 4 experienced 2 missed visits during the period reviewed and that the physician had not been notified. During a review of Patient 7’s Plan of Care, dated 3/29/26, it indicated Patient 7 was admitted to the agency on 3/29/26 with diagnoses that included Parkinson’s disease, cardiac arrhythmias (irregular beats), and depressionDuring a review of Patient 7’s POC, dated 3/299/26 the POC indicated the SN frequency is 1 -2 times per week for 13 weeks.During a review of Patient 7’s clinical record only 1 SN visit occurred on the weeks of 4/4/26 - 4/10 26, 4/18 - 4/24, 4/25 - 5/1/26, 5/9/26 - 5/15/26, 5/16 - 5/22/26, 5/30/26 - 6/5/26, 6/13/26 - 6/19/26, and 6/20 - 6/26. There was no indication the physician had been notified for the 9 missed visits. During the week of 5/23/26 - 5/28/26 no SN visits occurred. The physician was notified once. The total number of missed visits was 11. During an interview and concurrent record review with DHCS, on 7/2/26 at 3 pm, she reviewed the clinical record for Patient 7. DHCS confirmed that they physician’s order indicated Patient 7 should be seen by skilled nursing twice weekly. DHCS confirmed that Patient 7 experienced 11 missed visits during the period reviewed and that the physician had not been notified for 10 of those missed. Findings:During a review of the agency’s policy and procedure (P&P) titled “Frequency Ranges,” dated 1/2022, the P&P indicated, “Frequency ranges ordered services may be used to provide more flexibility in meeting the patient’s needs in the plan of care. The purpose of this policy is to specify guidelines for using frequency ranges. Frequency ranges may be used in developing the plan of care to ensure that the most appropriate level of services is provided to the patient. When a range of frequencies is ordered, the upper limit of the range is considered the specific-ordered frequency. Changes in frequency outside of the ordered range will require an additional physician/allowed practitioner’s order. The patient or patient representative will be notified of frequency changes prior to the alteration and will be documented in the patient’s clinical record. Frequency of visits will be lowered or increased based on the needs and changes in patient status. Ranges will not be utilized for staffing purposes of agency convenience.” During a review of the agency’s policy and procedure (P&P) titled “Notification Regarding Missed Service or Treatment,” dated 1/2026, the P&P indicated, “A missed visit or treatment is an alteration in the plan of care, and therefore, requires notification to the ordering physician/allowed practitioner, patient and/or patient representative. The organization must notify the relevant physician/allowed practitioner to any changes in ordered frequency of ordered services or treatment, including reason. A missed visit or treatment which cannot be rescheduled in the order duration of visits shall be documented and communicated to the physician/ practitioner.” During a review of Patient 3’s “POC,” dated 6/25/26, the “POC” indicated, Patient 3 was admitted to the agency on 6/25/26 with diagnoses that included Alzheimer’s disease (A physical brain disease that slowly destroys memory, thinking skills, and the ability to carry out simple tasks), senile degeneration of the brain (severe age related cognitive decline, ability to think, reason and make decisions), osteoarthritis (wear and tear of joints with bone rubbing bone causing pain and stiffness), and urinary tract infection (UTI, or bladder infection). During a review of Patient 3’s “POC,” dated 6/25/26, the “POC” indicated the SN frequency is 1-2 times per week (wk) for 13 weeks. During a review of Patient 3’s clinical record, only one SN visit was completed the week of 6/25/26 and the week of 6/27/26. There was no documentation to the Medical Doctor (MD) for missed visits. During a review of Patient 5’s “POC,” dated 5/28/26, the “POC” indicated, Patient 5 was admitted to the agency on 5/28/26 with diagnoses that included neoplasm (new) malignant (growth is cancerous) of the cervix and uterus (womb), adult failure to thrive (gradual decline in physical, mental sharpness, and ability to care for themselves, weight loss, poor eating and isolation), and schizophrenia (complex brain mental health disorder characterized by paranoid thoughts or delusions, unable to distinguish between thoughts and reality). During a review of Patient 5’s “POC,” dated 5/28/26, the “POC” indicated the SN frequency is 1-2 times per wk for 14 weeks. During a review of Patient 5’s clinical record, only one SN visit was completed for Patient 5 for the weeks of 5/30/26, 6/6/26, 6/13/26, 6/20/26 and 6/27/26. There was no documentation to the Medical Doctor (MD) for missed visits. During an interview on 6/30/26 at 2:10 pm with Director of Health Care Services (DHCS), DHC services confirmed all patients with a frequency range has missed visits for SN. DHCS stated, “I confirm we have to complete the highest number for SN visits if a range is ordered. I did not know until I read the policy. We will make sure we use only one frequency moving forward and use our as needed visits or increase the frequency if indicated for changes. I do confirm all the patients who had a SN frequency range ordered on the initial comprehensive assessment would be a missed visit per our policy.””

“Based on interview, and record review, the agency failed to complete an annual report for 2025 and first quarter report for 2026 Quality Assessment and Performance Improvement Plan (QAPI) to include measurable improvement outcomes for hospice (end of life care) services. This failure had the potential to have negative clinical symptom management for patients and the potential for inadequate family/care giver support through hospice services. Findings: During a review of the agency’s policy and procedure (P&P) titled, “Quality Assessment and Performance Improvement Plan (QAPI),” dated 12/2/2008, the P&P indicated, “The results of QAPI program, including specific performance improvement projects are documented and evaluated at least annually with the expectation of measurable improvement for palliative outcomes and hospice services. Ensure that identified quality assessment and performance improvement activities, including designated performance improvement projects (PIP), are implemented and evaluated throughout the year. Communicate the results of the QAPI activity to the governing body/owner and at regular intervals to the Interdisciplinary Group (IDG, a team of different professionals who meet and work together to establish, review, and revise specific needs for every patient and family) and other employees of hospice, and settings where care is provided. Monitor and evaluate the hospice’s delivery of care and hospice operations with regard to the selected performance expectations. Ensure compliance and applicable quality improvement provisions of law or regulation; and be knowledgeable about state law or regulation as it applies to quality improvement and quality assurance and any protection afforded by peer review. The purpose is to define the scope of the quality assessment and performance improvement program and related activities. The scope is quality assessment and performance improvement program. The performance improvement projects conducted annually are documented; based on identified needs of the hospice population served as well as internal organizational needs; reflect the scope, complexity and past performance of hospice services and operations; include the reason the PIP was conducted and the measurable progress made.” During a concurrent interview and record review on 7/2/26 at 10:40 am with Director of Health Care Services (DHCS), DHCS confirmed the QAPI report for 2025 was incomplete missing specific goals and outcome measurements. DHCS confirmed the 2025 QAPI report did not include signatures from the IDG team to include the Medical Director, Registered Nurse, Licensed Vocational Nurse, Medical Social Worker, Chaplain and Home Health Aide for review and discussion for hospice outcomes and performance improvement plans to implement for 2026. During a concurrent interview and record review on 7/2/26 at 11:30 am with DHCS, DHCS confirmed the QAPI report for quarter one was missing specific goals and outcome measurement data needed to implement performance improvement plans for hospice end of life care. During an interview on 7/2/26 at 11:50 am, with DHCS, DHCS confirmed the QAPI annual report for 2025 and the first quarter for 2026 was incomplete and needed specific details and data to follow the QAPI policy and procedures to include performance improvement plans and attendance signatures for meetings of the IDG team’s review. DHCS stated, “I have been working on the QAPI report trying to get it organized and will make sure to include all of the outcome measurement data and performance improvement plans moving forward. I will also make sure we discuss the QAPI report annually and each quarter with the IDG team to ensure they are included for discussions of goals and will make sure the signature sheet is in the QAPI binder.””

“Based on interview and record review, the agency failed to ensure that hospice aids were provided supervision by a registered nurse for 1 of 10 patients (Patient 7.) This had the potential for patient or caregiver concerns with aid services and care tasks to remain unaddressed for two periods of review. Findings: The policy titled “Aide Supervisory Visits,” dated 2024, indicated : “A supervisory visit will be performed by a Registered Nurse (RN) every 14 days, at a minimum, and as needed in order to evaluate the quality and appropriate care provided by the hospice aid.” During a review of Patient 7’s Plan of Care (POC), dated 3/29/26, indicated Patient 7 was admitted to the agency on 3/29/26 with diagnoses that included Parkinson’s disease (progressive neurological disorder that impacts movement and coordination), cardiac arrhythmias (irregular beats), and depression. During a review of Patient 7’s POC, dated 3/29/26, indicated the Home Hospice Aid (HHA) was scheduled at a frequency of 2 times per week for 13 weeks. During a review of Patient 7’s clinical record between the dates of 4/2/26 - 5/5/26, there was no documentation of an RN providing supervision for the HHA. (2 periods of review missed) During an interview and concurrent record review on 7/2/26 at 3 pm with the Director of Health Care Services (DHCS), she reviewed the record for Patient 7. DHCS confirmed that the facility expectation is for a registered nurse to document supervision for the HHA every 14 days. She confirmed that Patient 7 was receiving HHA services and that supervision was not performed for two periods of review between 4/2/26 and 5/5/26.”