Angels on Earth Hospice

“Observed in Record Review. In 3 of 12 patient records reviewed, the organization failed to assess and manage the patient’s pain and develop an individualized care plan on pain. The surveyor observed in HOSRRHV #1 where the RN used an observational scale to assess the patient’s pain but the care plan documented that the acceptable level of pain for the patient was <5/10. In HOSRRNHV #6 a verbal tool was used to assess pain, no pain goal assessed, care plan states, assess non verbal pain. In HOSRRDC #1 patient states he had pain of 8/10, no pain goal assessed and care plan states, Assess patient for alteration in comfort. The patient is nonverbal and unable to state a numerator value to pain control. This was reviewed and validated with the DCPS.”

“Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to assess the bereavement needs of all family members. In HOSRRHV #1 the social worker completed a bereavement assessment on the step daughter who is the POA for the patient but the patient’s significant other her mother has been with the patient for 26 years and lives in the home with the patient and daughter but a bereavement assessment was not completed. In HOSRRHV #3 the social worker completed a bereavement assessment on the patient’s two daughters but the patient lives with the grandson and his wife and a bereavement assessment was not completed. This was reviewed and validated with the DCPS.”

“Observed in Record Review. In 3 of 12 patient records reviewed, the plan of care did not include specific safety precautions. In HOSRRHV #2 the patient was on Eliquis and the POC did not include a bleeding precautions care plan. In HOSRRDC #1 the patient was on ASA 81 mg and no care plan for bleeding precautions. In HOSRRDC #2 the patient was on Pradaxa 75mg twice a day and no care plan for bleeding. This was reviewed and validated with the DCPS. Observed in Record Review. In 1 of 12 patient records reviewed, the nurse surveyor observed that duplicate medications were ordered and the instructions for use were not clear. In HOSRRNHV #7 the patient had an order for Docusate Sodium 100mg daily, Lactulose 20 gm daily, and Senna Plus 50mg twice daily for constipation. It is not clear when he should take one over the other. This was reviewed and validated with the DPCS. Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to complete an accurate plan of care. The RN surveyor noted in HOSRRHV #1 that the plan of care states the patient was on a pureed diet. The POA step daughter stated that the patient was unable to swallow pureed food and has been consuming a mixture of Ensure, rice cereal, and Go Gurt. The plan of care was not accurate as the diet is liquid not pureed. This was reviewed and validated with the DCPS.”

“Observed in Record Review. In 7 of 12 patient records reviewed, the plan of care did not include specific safety precautions. The surveyor noted in HOSRRHV #2 that the patient was on Eliquis and the RN did not include a care plan addressing bleeding precautions for the home health aide. In HOSRRNHV #1 the home health assignment did not include the fall or aspiration precautions. In HOSRRNHV#2 the aide care plan did not include bleeding precaution as patient is on Clopidogrel and ASA. In HOSRRNHV #3 the home health aide care plan did not include bleeding or fall precautions. In HOSRRNHV #4 patient is aggressive and combative and this is not in the Home Health aide assignment as a precaution. In HOSRRNHV #5 fall risk, oxygen, and aggressive and combative behavior not entered as precautions. HOSRRNHV #6 and HOSRRNHV #7 fall risk not on HHA assignment. This was reviewed and validated with the DPCS.”

“Observed in Patient Home. In 2 of 3 home visits conducted, The medication list did not contain an up to date list of medications including dose, strength, frequency, and route. For example in HOSRRHV #1 the stepdaughter states that she is giving the patient Tylenol 500mg oral every 4 hours but the medication list states that the patient should be getting this medication every 6 hours. The step daughter also states that she crushes all of the medications and adds them to applesauce as the patient can no longer swallow. Instructions to crush the medications were not added to the Medication List. In HOSRRHV #2 the daughter is using Voltaren cream as needed for joint pain, and this was not included in the medication list. This patient also was unable to swallow and the daughter stated that she is crushing all of the medications and placing them in the applesauce to give to the patient. None of the medications for either patient were reviewed by the pharmacist to assure that they could be crushed and it was not added to the Medication List to instruct the family that they could crush the medications. This was reviewed and validated with the DCPS.”

“The agency failed to ensure that the Condition of Participation: L 520 §418.54 Initial and Comprehensive assessment of the patient was in compliance as follows: 1. Based on interview, and record review, the agency failed to ensure the patients’ initial assessment was completed within 48 hours of the physician’s referral date or on the physician-ordered start of care date for three of four sampled patients (Patients 1, 2, and 3). (Refer to L 522) 2. Based on interview and record review, the agency failed to ensure the patients’ comprehensive assessments were completed within five days after the start of care for four of four sampled patients (Patient 1, 2, 3, and 4) when no spiritual or psychosocial assessments were conducted. (Refer to L 523) 3. Based on observation, interview, and record review, the agency failed to ensure the comprehensive assessment identified and addressed the physical and safety needs of two of four sampled patients (Patients 3 and 4) when: a. Patient 3’s left great toe wound was not identified or assessed during the admission assessment. (Refer to L 524) b. Patient 4’s three falls in May 2024, and Patient 4s fear of falling were not identified or assessed. Patient 4’s inability to raise arms past his upper chest was not identified or assessed. (Refer to L 524) 4. Based on interview, and record review, the agency failed to ensure the comprehensive assessment was updated by the agency’s interdisciplinary group (in collaboration with the individuals attending physician) and considered changes that took place since the initial assessment for one of four sampled patients (Patient 1) when: a. Patient 1’s right great toe wound was not identified or assessed by the visiting Licensed Vocational Nurses. (Refer to L 533) b. No re-admission assessment was conducted after Patient 1’s hospitalization from May 6, 2024, to May 8, 2024. (Refer to L 533) c. No discharge summary for Patient 1 was documented and no discharge order for Patient 1 was obtained. (Refer to L 533) The cumulative effect of these systemic practices resulted in the potential to cause a delay in the determination of Patients 1, 2, and 3s immediate care and support needs and the patient and familys psychosocial, emotional, and spiritual needs to go unmet. These failures caused Patient 3 not to receive wound care for 12 days and Patient 4 not to receive care in order to address the inability of Patient 4 to raise his arms past his upper chest for six days. In addition, this failure had the potential to cause Patient 4 to fall again and suffer injuries and caused Patient 1 to suffer a delay in wound care, no re-assessment of care needs following an acute care hospital admission, and Patient 1s attending physician to be unaware of the medical condition and death of Patient 1 at discharge, and no physician oversight for Patient 1s discharge from the Palliative Care Program.”

“The agency failed to ensure that the Condition of Participation: L 536 §418.56 Interdisciplinary group, care planning, and coordination of services was in compliance as follows: 1. Based on interview and record review, the agency failed to ensure the Interdisciplinary Group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) members supervised and provided care and services to meet the physical, medical, psychosocial, emotional, and spiritual needs for four of four sampled patients (Patients 1, 2, 3, and 4) when: a. An admission order was not obtained for Patient 1. (Refer to L 539) b. Patient 1’s gastrointestinal (GI) bleeding episode on May 5, 2024, was not discussed or addressed by the IDG. (Refer to L 539) c. Patient 1’s hospital admission from May 6, 2024, to May 8, 2024, where Patient 1 received two units of blood was not discussed or addressed by the IDG. (Refer to L 539) d. Patient 1’s right great toe wound identified at the hospital on May 8, 2024, was not discussed or addressed by the IDG. (Refer to L 539) e. Patient 1’s death on May 20, 2024, and discharge on May 21, 2024, was not discussed or addressed by the IDG. (Refer to L 539) f. There was no documented evidence to show the IDG evaluated, discussed, or provided general oversight for Patient 2s care. (Refer to L 539) g. Patient 3’s left great toe wound was not discussed or addressed by the IDG. (Refer to L 539) h. Patient 4’s three falls in May 2024, and Patient 4s fear of falling was not discussed or assessed by the IDG. Patient 4’s inability to raise arms past his upper chest was not discussed or assessed by the IDG. (Refer to L 539) 2. Based on interview and record review, the agency failed to develop an individualized plan of care for four of four sampled patients (Patients 1, 2, 3, and 4) when: a. Patient 1’s a lower gastrointestinal (GI) bleeding episode on May 5, 2024, was not care planned. (Refer to L 545) b. Patient 1’s hospital admission from May 6, 2024, to May 8, 2024, where Patient 1 received two units of blood was not care planned. (Refer to L 545) c. Patient 1’s right great toe wound identified at the hospital on May 8, 2024, was not care planned. (Refer to L 545) d. Patient 1’s plan of care did not include discharge planning. (Refer to L 545) e. There was no documented evidence to show the IDG evaluated, discussed, or updated Patient 2’s care plan. (Refer to L 545) f. Patient 3’s dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally) and left great toe wound were not care planned. (Refer to L 545) g. Patient 4’s three falls in May 2024, and the patient’s fear of falling was not care planned. Patient 4’s inability to raise arms past his upper chest was not care planned. (Refer to L 545) 3. Based on interview and record review, the agency failed to ensure the interdisciplinary group documented the patients or representatives level of understanding, involvement, and agreement with the plan of care for one of four sampled patients (Patient 1) when Patient 1 nor Patient 1’s representative consented to: treatment, a financial agreement, hospitalization, blood transfusion, or receipt of the Notice of Privacy Rights and Advance Directive information. (Refer to L 551) The cumulative effect of these systemic practices resulted in the potential to cause Patient 1 and Patient 1s representative not to know and agree or disagree with the proposed care, treatment, services, medications, interventions, or procedures and Patient 1 to be admitted to the Palliative Care Program without a physicians order. These failures had the potential to cause Patient 1 to suffer additional GI bleeds and delayed healing or worsening of Patient 1s right great toe wound. This failure caused the IDG and attending physician to be unaware of the circumstances surrounding Patient 1s death and the discharge from the program. This failure had the potential to cause Patient 2 not to achieve her desired goals of care. This failure had the potential to cause delayed healing or worsening of Patient 3s left great toe wound and unrecognized complications from dialysis treatments. In addition, this failure had the potential to cause Patient 4 to suffer additional falls with injuries and his arm raising restriction to worsen.”

“The agency failed to ensure the Condition of Participation: L 648 §418.100 Organization and administration of services was in compliance when: Based on observation, interview, and record review, the Governing Body (GB) failed to operate and manage the agency from March 1, 2022, to June 6, 2024, in a universe of 129 Palliative Care Program patients when: 1. Based on interview, and record review, the agency failed to ensure the patients’ initial assessment was completed within 48 hours of the physician’s referral date or on the physician-ordered start of care date for three of four sampled patients (Patients 1, 2, and 3). (Refer to L 651) 2. Based on interview and record review, the agency failed to ensure the patients’ comprehensive assessments were completed within five days after the start of care for four of four sampled patients (Patient 1, 2, 3, and 4) when no spiritual or psychosocial assessments were conducted. (Refer to L 651) 3. Based on observation, interview, and record review, the agency failed to ensure the comprehensive assessment identified and addressed the physical and safety needs of two of four sampled patients (Patients 3 and 4) when: a. Patient 3’s left great toe wound was not identified or assessed during the admission assessment. (Refer to L 651) b. Patient 4’s three falls in May 2024, and Patient 4s fear of falling was not identified or assessed. Patient 4’s inability to raise arms past his upper chest was not identified or assessed. (Refer to L 651) 4. Based on interview, and record review, the agency failed to ensure the comprehensive assessment was updated by the agency’s interdisciplinary group (in collaboration with the individuals attending physician) and considered changes that took place since the initial assessment for one of four sampled patients (Patient 1) when: a. Patient 1’s right great toe wound was not identified or assessed by the visiting Licensed Vocational Nurses. (Refer to L 651) b. No re-admission assessment was conducted after Patient 1’s hospitalization from May 6, 2024, to May 8, 2024. (Refer to L 651) c. No discharge summary for Patient 1 was documented and no discharge order for Patient 1 was obtained. (Refer to L 651) 5. Based on interview and record review, the agency failed to ensure the Interdisciplinary Group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) members supervised and provided care and services to meet the physical, medical, psychosocial, emotional, and spiritual needs for four of four sampled patients (Patients 1, 2, 3, and 4) when: a. An admission order was not obtained for Patient 1. (Refer to L 651) b. Patient 1’s gastrointestinal (GI) bleeding episode on May 5, 2024, was not discussed or addressed by the IDG. (Refer to L 651) c. Patient 1’s hospital admission from May 6, 2024, to May 8, 2024, where Patient 1 received two units of blood was not discussed or addressed by the IDG. (Refer to L 651) d. Patient 1’s right great toe wound identified at the hospital on May 8, 2024, was not discussed or addressed by the IDG. (Refer to L 651) e. Patient 1’s death on May 20, 2024, and discharge on May 21, 2024, was not discussed or addressed by the IDG. (Refer to L 651) f. There was no documented evidence to show the IDG evaluated, discussed or provided general oversight for Patient 2s care. (Refer to L 651) g. Patient 3’s left great toe wound was not discussed or addressed by the IDG. (Refer to L 651) h. Patient 4’s three falls in May 2024, and Patient 4s fear of falling was not discussed or assessed by the IDG. Patient 4’s inability to raise arms past his upper chest was not discussed or assessed by the IDG. (Refer to L 651) 6. Based on interview and record review, the agency failed to develop an individualized plan of care for four of four sampled patients (Patients 1, 2, 3, and 4) when: a. Patient 1’s a lower gastrointestinal (GI) bleeding episode on May 5, 2024, was not care planned. (Refer to L 651) b. Patient 1’s hospital admission from May 6, 2024, to May 8, 2024, where Patient 1 received two units of blood was not care planned. (Refer to L 651) c. Patient 1’s right great toe wound identified at the hospital on May 8, 2024, was not care planned. (Refer to L 651) d. Patient 1’s plan of care did not include discharge planning. (Refer to L 651) e. There was no documented evidence to show the IDG evaluated, discussed, or updated Patient 2’s care plan. (Refer to L 651) f. Patient 3’s dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally) and left great toe wound were not care planned. (Refer to L 651) g. Patient 4’s three falls in May 2024, and the patient’s fear of falling was not care planned. Patient 4’s inability to raise arms past his upper chest was not care planned. (Refer to L 651) 7. Based on interview and record review, the agency failed to ensure the interdisciplinary group documented the patients or representatives level of understanding, involvement, and agreement with the plan of care for one of four sampled patients (Patient 1) when Patient 1 nor Patient 1’s representative consented to: treatment, a financial agreement, hospitalization, blood transfusion, or receipt of the Notice of Privacy Rights and Advance Directive information. (Refer to L 651) 8a. Based on interview, and record review, the agency failed to operate and furnish services in compliance with State Law (California Code, Health, and Safety Code (HSC) § 1747.3), in a universe of 129 Palliative Care Program patients, when the agency: a. Failed to provide the California Department of Public Health Licensing and Certification Division (CDPH L&C) the date the agency intended to begin providing a Palliative Care Program. (Refer to L 651) b. Failed to provide CDPH L&C the State form “HS 200 [a State licensing application].” (Refer to L 651) c. Failed to provide CDPH L&C the Federal form “CMS 417 [a Federal certification application].” (Refer to L 651) d. Failed to provide CDPH L&C information for the period of time in the prior calendar year during which the agency provided palliative care through the Online reporting portal, including but not limited to, all of the following: i. The number of nonhospice patients who received palliative care. (Refer to L 651) ii. The number of patients enrolled in hospice. (Refer to L 651) iv. The primary diagnoses of the patients for which the agency provided palliative care. (Refer to L 651) v. The numbers and types of providers hired during the previous 12 months. (Refer to L 651) vi. The numbers and types of providers who left employment during the previous 12 months. (Refer to L 651) e. Complaints received by the agency during the previous 12 months that related to all the following: i. Events that caused or were likely to cause serious injury, harm, impairment, or death. (Refer to L 651) ii. Events or incidents that negatively impacted a patient’s mental, physical, or psychosocial status and were of such consequence to the patient’s well-being that a rapid response was required. (Refer to L 651) iii. Delays in patient care for hospice and nonhospice patients who received palliative care pursuant to this section. (Refer to L 651) f. Failed to provide the qualifications of staff. (Refer to L 651) g. Failed to be approved by CDPH L&C to provide palliative care. (Refer to L 651) h. Failed to provide CDPH L&C all information the agency provided to the Office of Statewide Health Planning and Development. (Refer to L 651) 8b. Based on observation, interview, and record review, the agency failed to ensure patients met the criteria to be admitted into the agencys Palliative Care Program (a program which helps patients facing chronic or quality of life-limiting illnesses, with the relief of uncontrolled symptoms, pain and stress without focusing on the patients regaining their independence, or becoming as self-sufficient as possible) instead of a Home Health Program (a program which helps patients get better from an illness or injury, regain their independence, and become as self-sufficient as possible) for three of four sampled patients (Patients 1, 2, and 3) when: i. Patient 1 had been admitted to the agencys Palliative Care Program after recently starting dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally) treatments and had diagnoses that included end stage renal disease (a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant), diabetes mellitus (a disease that results in too much sugar in the blood) and congestive heart failure (a chronic condition in which the heart cannot pump or fill effectively). Patient 1s wife stated Patient 1 had been on oxygen but was not short of breath and Patient 1 did not have pain. Patient 1s wife stated Patient 1 wanted to be monitored while adjusting to the new dialysis treatments and help with managing his diabetes mellitus. Patient 1s wife stated Patient 1 wanted every treatment done to help him become as functional and independent as possible. (Refer to L 651) ii. Patient 2 had been admitted to the agencys Palliative Care Program after right knee surgery and had a diagnosis of osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). Patient 2 stated she had some right knee pain due to the surgery but otherwise everything was fine. Patient 2 stated she was excited to go back to work in a few weeks. (Refer to L 651) iii. Patient 3 had been admitted to the agencys Palliative Care Program after a hospital stay for chest pain. Patient 3 was receiving dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally) treatments and had diagnoses that included chest pain, diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Patient 3 stated she had been receiving dialysis treatments for two years and was used to it. Patient 3 stated she did not have chest pain or any other pain. Patient 3 stated she was not on oxygen and did not have shortness of breath. Patient 3 stated she did not know what services the agency provided but she would like help with transportation to her doctors appointments, some Physical Therapy so she could walk again and someone to clean her bathroom. (Refer to L 651) The cumulative effect of these systemic practices resulted in the potential to cause a delay in the determination of Patients 1, 2, and 3s immediate care and support needs and the patient and familys psychosocial, emotional, and spiritual needs to go unmet. These failures caused Patient 3 not to receive wound care for 12 days and Patient 4 not to receive to address the inability of Patient 4 to raise his arms past his upper chest for six days. In addition, this failure had the potential to cause Patient 4 to fall again and suffer injuries and caused Patient 1 to suffer a delay in wound care, no re-assessment of care needs following an acute care hospital admission, and Patient 1s attending physician to be unaware of the medical condition and death of Patient 1 at discharge, and no physician oversight for Patient 1s discharge from the Palliative Care Program. And The cumulative effect of these systemic practices resulted in the potential to cause Patient 1 and Patient 1s representative not to know and agree or disagree with the proposed care, treatment, services, medications, interventions, or procedures and Patient 1 to be admitted to the Palliative Care Program without a physicians order. These failures had the potential to cause Patient 1 to suffer additional GI bleeds and delayed healing or worsening of Patient 1s right great toe wound. This failure caused the IDG and attending physician to be unaware of the circumstances surrounding Patient 1s death and the discharge from the program. This failure had the potential to cause Patient 2 not to achieve her desired goals of care. This failure had the potential to cause delayed healing or worsening of Patient 3s left great toe wound and unrecognized complications from dialysis treatments. In addition, this failure had the potential to cause Patient 4 to suffer additional falls with injuries and his arm raising restriction to worsen. And The cumulative effect of these systemic practices resulted in the agency operating an unlicensed and unapproved Palliative Care Program without governmental oversight. In addition, the agency admitted Patients 1, 2, and 3 into a Palliative Care Program with the potential to cause Patients 1, 2, and 3 not to receive the care and services needed for them to achieve their highest level of functioning and independence.”

“The agency failed to ensure the Condition of Participation: L 797 418.116 Compliance with Federal, State, and local laws and regulations related to the health and safety of patients was in compliance when: 1. Based on interview, and record review, the agency failed to operate and furnish services in compliance with State Law (California Code, Health, and Safety Code (HSC) § 1747.3), in a universe of 129 Palliative Care Program patients, when the agency: a. Failed to provide the California Department of Public Health Licensing and Certification Division (CDPH L&C) the date the agency intended to begin providing a Palliative Care Program. b. Failed to provide CDPH L&C the State form “HS 200 [a State licensing application].” c. Failed to provide CDPH L&C the Federal form “CMS 417 [a Federal certification application].” d. Failed to provide CDPH L&C information for the period of time in the prior calendar year during which the agency provided palliative care through the Online reporting portal, including but not limited to, all of the following: i. The number of nonhospice patients who received palliative care. ii. The number of patients enrolled in hospice. iv. The primary diagnoses of the patients for which the agency provided palliative care. v. The numbers and types of providers hired during the previous 12 months. vi. The numbers and types of providers who left employment during the previous 12 months. e. Complaints received by the agency during the previous 12 months that related to all the following: i. Events that caused or were likely to cause serious injury, harm, impairment, or death. ii. Events or incidents that negatively impacted a patient’s mental, physical, or psychosocial status and were of such consequence to the patient’s well-being that a rapid response was required. iii. Delays in patient care for hospice and nonhospice patients who received palliative care pursuant to this section. f. Failed to provide the qualifications of staff. g. Failed to be approved by CDPH L&C to provide palliative care. h. Failed to provide CDPH L&C all information the agency provided to the Office of Statewide Health Planning and Development. 2. Based on observation, interview, and record review, the agency failed to ensure patients met the criteria to be admitted into the agencys Palliative Care Program (a program which helps patients facing chronic or quality of life-limiting illnesses, with the relief of uncontrolled symptoms, pain and stress without focusing on the patients regaining their independence, or becoming as self-sufficient as possible) instead of a Home Health Program (a program which helps patients get better from an illness or injury, regain their independence, and become as self-sufficient as possible) for three of four sampled patients (Patients 1, 2, and 3) when: a. Patient 1 had been admitted to the agencys Palliative Care Program after recently starting dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally) treatments and had diagnoses that included end stage renal disease (a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant), diabetes mellitus (a disease that results in too much sugar in the blood) and congestive heart failure (a chronic condition in which the heart cannot pump or fill effectively). Patient 1s wife stated Patient 1 had been on oxygen but was not short of breath and Patient 1 did not have pain. Patient 1s wife stated Patient 1 wanted to be monitored while adjusting to the new dialysis treatments and help with managing his diabetes mellitus. Patient 1s wife stated Patient 1 wanted every treatment done to help him become as functional and independent as possible. b. Patient 2 had been admitted to the agencys Palliative Care Program after right knee surgery and had a diagnosis of osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). Patient 2 stated she had some right knee pain due to the surgery but otherwise everything was fine. Patient 2 stated she was excited to go back to work in a few weeks. c. Patient 3 had been admitted to the agencys Palliative Care Program after a hospital stay for chest pain. Patient 3 was receiving dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally) treatments and had diagnoses that included chest pain, diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Patient 3 stated she had been receiving dialysis treatments for two years and was used to it. Patient 3 stated she did not have chest pain or any other pain. Patient 3 stated she was not on oxygen and did not have shortness of breath. Patient 3 stated she did not know what services the agency provided but she would like help with transportation to her doctors appointments, some Physical Therapy so she could walk again and someone to clean her bathroom. The cumulative effect of these systemic practices resulted in the agency operating an unlicensed and unapproved Palliative Care Program without governmental oversight. In addition, the agency admitted Patients 1, 2, and 3 into a Palliative Care Program with the potential to cause Patients 1, 2, and 3 not to receive the care and services needed for them to achieve their highest level of functioning and independence. Findings: 1. During an interview with the Administrator (Admin) on June 6, 2024, at 4:07 PM, the Admin stated he was the sole owner and Governing Body (GB) member of the agency. The Admin stated he had started the agencys Palliative Care Program on March 1, 2022, when he had signed a contract with a Professional Medical Corporation (PMC) to provide palliative care services to the PMCs patients. The Admin stated he operated the agencys Palliative Care Program under the umbrella of the Hospice Agency. The Admin stated all the employees who provided care and services to the patients of the Hospice Agency, also provided care and services to the patients enrolled in the agencys Palliative Care Program. A review of a contract titled “;Ancillary Services Agreement Between [name of a professional medical corporation-PMC] a California professional medical corporation and [name of the Hospice Agency],” dated March 1, 2022, indicated, “;Provider [Hospice Agency] is a provider for Palliative care services.” A review of the agencys “;State of California Department of Public Health License,” effective date of February 28, 2024, and an expiration date of February 27, 2026, was conducted. There was no documented evidence to show the agencys Palliative Care Program had been added to the license. During a concurrent interview and record review with the Admin on June 6, 2024, at 4:07 PM, the State Law (California Code, Health, and Safety Code (HSC) § 1747.3), was reviewed. The Admin verified the following: a. The Admin failed to provide the California Department of Public Health Licensing and Certification Division (CDPH L&C) the date the agency intended to begin providing a Palliative Care Program. b. The Admin failed to provide CDPH L&C the State form “HS 200 [a State licensing application].” c. The Admin failed to provide CDPH L&C the Federal form “CMS 417 [a Federal certification application].” d. The Admin failed to provide CDPH L&C information for the period of time in the prior calendar year during which the agency provided palliative care through the Online reporting portal, including but not limited to, all of the following: i. The number of nonhospice patients who received palliative care. ii. The number of patients enrolled in hospice. iv. The primary diagnoses of the patients for which the agency provided palliative care. v. The numbers and types of providers hired during the previous 12 months. vi. The numbers and types of providers who left employment during the previous 12 months. e. The Admin failed to report the complaints received by the agency during the previous 12 months that related to all the following: i. Events that caused or were likely to cause serious injury, harm, impairment, or death. ii. Events or incidents that negatively impacted a patient’s mental, physical, or psychosocial status and were of such consequence to the patient’s well-being that a rapid response was required. iii. Delays in patient care for hospice and nonhospice patients who received palliative care pursuant to this section. f. The Admin failed to report the qualifications of staff. g. The agency was not approved by CDPH L&C to provide a Palliative Care Program. h. The Admin failed to provide CDPH L&C all information the agency provided to the Office of Statewide Health Planning and Development. A review of the agencys policy and procedure titled, “;Legal Considerations,” undated, indicated, “;POLICY STATEMENT: This policy establishes guidelines to ensure that the provision of palliative care within our organization complies with federal, state, and local regulations and laws. Clinicians are required to be knowledgeable about legal and regulatory requirements related to patient care, disclosure of medical information, decision-making, advance care planning, and other relevant aspects of palliative care.” A review of the California Code, Health and Safety Code - HSC § 1747.3, dated January 1, 2018, to January 1, 2027, indicated, “;(a) Notwithstanding any other law, beginning January 1, 2018, a licensee pursuant to this chapter may provide any interdisciplinary hospice services described in this chapter, including, but not limited to, palliative care, to a patient with a serious illness as determined by the physician and surgeon in charge of the care of the patient, including, among other kinds of patients, a patient who continues to receive curative treatment from other licensed health care professionals. (b) A licensee that elects to provide palliative care pursuant to this section shall provide the department with the date the licensee intends to begin providing the palliative care no less than 45 days before that date and all of the following: (1) The completed relevant portions of a form HS 200, or a successor form, as determined by the department. (2) A complete federal form CMS 417, or a successor form, as determined by the department. (c)(1) The department shall not require the documents submitted pursuant to subdivision (b) to be approved prior to the licensee providing palliative care pursuant to this section. (2) The department shall not charge an application fee to provide any care or services pursuant to this section. (d)(1) On or before April 30, 2022, and each April thereafter until April 30, 2025, a licensee shall provide the department with information for the period of time in the prior calendar year during which the licensee provided palliative care pursuant to this section through the department’s online reporting portal, including, but not limited to, all of the following: (A) The number of nonhospice patients who received palliative care pursuant to this section. (B) The number of patients enrolled in hospice. (C) The primary diagnoses of the patients for which the licensee provided palliative care pursuant to this section. (D) The numbers and types of providers hired during the previous 12 months. (E) The numbers and types of providers who left employment during the previous 12 months. (F) Complaints received by the licensee during the previous 12 months that related to all the following: (i) Events that caused or were likely to cause serious injury, harm, impairment, or death. (ii) Events or incidents that negatively impacted a patient’s mental, physical, or psychosocial status and were of such consequence to the patient’s well-being that a rapid response was required. (iii) Delays in patient care for hospice and nonhospice patients who received palliative care pursuant to this section. (iv) Qualifications of staff. (2) A licensee that has been approved by the department to provide palliative care pursuant to this section that has either provided the department with the date the licensee intends to begin providing palliative care pursuant to this section, or has notified the department of its cessation of palliative care provision pursuant to subdivision (g), shall report to the department pursuant to paragraph (1) regardless of whether the licensee provided palliative care pursuant to this section during the prior calendar year. (e) During the period of time a licensee provides palliative care pursuant to this section, the licensee shall simultaneously submit to the department all information the licensee provides to the Office of Statewide Health Planning and Development. (f) Notwithstanding the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), the department may implement, interpret, or make specific the provisions of this section by means of all-facility letters, or similar instructions, without taking regulatory action. (g) If the licensee ceases to provide palliative care services pursuant to this section on or before January 1, 2027, the licensee shall submit to the department the same documents as required in subdivision (b). (h) The provisions of this section shall not be applicable to a hospice facility established pursuant to subdivision (n) of Section 1250, or Section 1339.30 or 1339.40. (i) This section shall not be deemed to modify the provision of hospice care required pursuant to Section 1368.2. (j) On or before January 15, 2026, the department shall convene a stakeholder meeting to discuss the results of the information collected pursuant to this section. The department may, at its discretion, use electronic means, such as a webinar, to convene the stakeholder meeting. (k) For purposes of this section, “;serious illness” shall mean a condition that may result in death, regardless of the estimated length of the patient’s remaining period of life. (l) This section shall remain in effect only until January 1, 2027, and as of that date is repealed.” 2a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, into the Palliative Care Program. Patient 1 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), end stage renal disease (a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant), diabetes mellitus (a disease that results in too much sugar in the blood) and congestive heart failure (a chronic condition in which the heart cannot pump or fill effectively). Patient 1 expired on May 20, 2024. A review of Patient 1s referral order dated February 19, 2024, indicated, “;palliative care.” During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated Patient 1s Medical Group (PMC-a Professional Medical Corporation) referred Patient 1 to the Hospice Agency for their Palliative Care Program. Patient 1s wife stated the PMC told her the Hospice Agency was the gate keeper for Patient 1s care and she had to approve all care, services and trips to the acute care hospital through the Hospice Agency. Patient 1s wife stated Patient 1 had been on oxygen, but he was not short of breath and Patient 1 did not have pain. Patient 1s wife stated Patient 1 wanted to be monitored while adjusting to the new dialysis treatments and help with managing his diabetes mellitus. Patient 1s wife stated Patient 1 wanted every treatment done to help him become as functional and independent as possible. Patient 1s wife stated on May 5, 2024, Patient 1 began bleeding from his rectum with bloody diarrhea. Patient 1s wife stated she called the Hospice Agency, and a nurse (Licensed Vocational Nurse (LVN 1)) came out and helped clean Patient 1, “;the blood was everywhere!” Patient 1s wife stated the nurse called the doctor and she (Patient 1s wife) was told it was not recommended for Patient 1 to go to the acute care hospital unless he started bleeding again. Patient 1s wife stated she took Patient 1 to his dialysis appointment the next day May 6, 2024, and told the dialysis nurse about the bleeding episode. Patient 1s wife stated the dialysis nurse told her dialysis could not be done on a patient who had been bleeding and to go to the acute care hospital immediately. Patient 1s wife stated she took Patient 1 to the acute care hospital where Patient 1 was admitted on May 6, 2024, through May 8, 2024, and received two units of blood and a wound was identified on his right great toe. Patient 1s wife stated she told the Hospice Agencys nurse (Licensed Vocational Nurse (LVN 3)) on May 16, 2024, about the acute care hospital admission, two units of blood and wound identification but nothing was done. Patient 1s wife stated she called the Hospice Agency on May 17, 2024, and asked for Patient 1s wound to be cared for. Patient 1s wife stated a nurse came out (Licensed Vocational Nurse (LVN 2)) who applied a dressing to Patient 1s right toe. Patient 1s wife stated she felt Patient 1 was treated like a Hospice patient, not a patient who wanted everything done to get better. Patient 1s wife stated Patient 1 died on May 20, 2024, 51 days after starting on the Hospice Agencys Palliative Care Program. Patient 1s wife stated the PMC, and the Hospice Agency did not provide the aggressive care and services Patient 1 wanted to prolong and improve his life to the extent possible. A review of Patient 1s Skilled Nursing (SN) visit notes from April 4, 2024, to May 17, 2024, were reviewed. There was no documented evidence to show Patient 1 had shortness of breath or pain. A review of Patient 1s SN visit note, dated May 5, 2024, by LVN 1, indicated, “;The patient was seen today for a PRN [as needed] visit due to experiencing bloody, loose stools. The patients wife reported multiple episodes since 3 [three] a.m., with the last occurring around 11:30 a.m. Upon examination, the patient was found sitting on the toilet, awake, alert, and oriented, denying any pain. The patient is on continuous oxygen without respiratory distress and is currently not experiencing further episodes of loose stools or bleeding. The patient managed to walk from the toilet to the bed for cleaning, with no external hemorrhoids detected. The abdomen is soft, non-distended, and non-tender. The patient denies dizziness but feels slightly weaker. Dialysis is scheduled for the following day. ... The wife has been instructed to monitor for additional episodes of bloody stools or any changes in condition ... The physician has been informed, and there are no new orders at this time. The wife will consult with the primary medical doctor for additional guidance and is aware that, should excessive bleeding continue, it is imperative to contact emergency services immediately. ...” A review of Patient 1s Acute Care Hospitals (ACH) clinical records dated May 6, 2024, to May 8, 2024, indicated Patient 1 had been admitted on May 6, 2024, and discharged on May 8, 2024. Patient 1s ACHs clinical records indicated Patient 1 had received two units of blood and wound care to his right great toe. During an interview with LVN 1 on June 4, 2024, at 10:35 AM, LVN 1 stated he made an SN visit because Patient 1s wife had called and stated Patient 1 had loose stools, dark colored. LVN 1 stated he saw dark black tar like loose stools (black or tarry stools are due to bleeding in the upper part of the GI (gastrointestinal) tract, such as the esophagus, stomach, or the first part of the small intestine. In this case, blood is darker because it gets digested on its way through the GI tract) on the bedsheets, on the floor of bedroom and floor of bathroom and on and in the toilet. LVN 1 stated he helped clean up Patient 1. LVN 1 stated he texted the Medical Director (MD) directly. LVN 1 stated the MD responded, “;thank you for the update” and I was not given any instruction to give Patient 1 or the family. LVN 1 stated he had made an independent decision to tell Patient 1s wife to take Patient 1 to the acute care hospital if the bleeding started again. LVN 1 stated he had conducted a head-to-toe assessment but did not see any wounds. LVN 1 stated he did not notice a wound on Patient 1s right great toe. During an interview with the MD on June 4, 2024, at 12:15 PM to 12:41 PM, the MD stated he was the Medical Director for the Hospice Agencys Palliative Care Program. The MD stated he had received a text from LVN 1 on May 5, 2024, and he had responded, “;thank you for the update.” The MD stated he had not given LVN 1 any direction to give Patient 1 or the family. The MD stated he did not think the bleeding was an urgent situation at the time but after reviewing Patient 1s previous medical history he should have instructed Patient 1 to go to the acute care hospital. The MD stated it could be difficult for the Hospice Agencys staff to switch between a hospice philosophy (providing comfort care without aggressive treatments) and the philosophy for palliative care (providing comfort care with aggressive treatments). A review of Patient 1s SN visit note dated May 16, 2024, by LVN 3, was conducted. There was no documented evidence to show LVN 3 had identified or assessed Patient 1s right great toe wound identified at the acute care hospital during the May 6, 2024, to May 8, 2024, admission. During an interview with LVN 3 on June 4, 2024, at 11:48 AM, LVN 3 stated Patient 1s wife had told him Patient 1 had been to the acute care hospital the week before (May 6, 2024, to May 11, 2024), but he could not remember the dates. LVN 3 stated he did not remember any specifics about Patient 1s acute care hospital stay and had not reported Patient 1s hospitalization to the Hospice Agencys staff. LVN 3 stated he had not conducted a thorough head-to-toe assessment of Patient 1 and had not noticed a wound to Patient 1s right great toe. A review of Patient 1s SN visit note dated May 17, 2024, by LVN 2, indicated, “;... PRN [as needed] visit [related to] wound care, ... verbal, calm, cooperative, respiration even and unlabored with no SOB [shortness of breath] noted, wife stated ... during patient bath she noticed open area on right great toe, no discharge or pus noted, BLE [bilateral lower extremities] warm to touch, patient denies any fever or chills and no pain or discomfort during visit, [MD] made aware with new order: cleanse open area on right great toe with NS [normal saline], pat dry, apply [wound gel] and cover with dry dressing secure with tape daily and as needed if dislodged or soiled [times]14 days and re-assess. Family/cg may perform wound care. ... May have wound consult. Wound care administered, tolerated well, ... Patient and wife educated on signs and symptoms of infection such as increase pain to site, increased redness, presence of ... pus, fever, chills. If any sign/symptoms of infection noticed to call [PMC-a Professional Medical Corporation] nurse advice line. Patient and wife encourage to wear proper fitting footwear, wife and patient acknowledge understanding, patient and wife encourage to monitor. follow up with podiatrist/ [primary care physician] and call [PMC] If there’s any questions or concerns ...” During an interview with LVN 2 on June 4, 2024, at 10:55 AM, LVN 2 stated he had conducted the SN visit because Patient 1s wife had called the office and informed them of the right great toe wound. During a concurrent interview and record review with the Medical Director (MD) and in the presence of the Administrator (Admin), Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:20 PM, Patients 1s History and Physical (H&P) was reviewed. The MD stated he could not verify Patient 1 had uncontrolled symptoms requiring services from a Palliative Care Program. 2b. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 12, 2024, into the Palliative Care Program. Patient 2 had diagnoses that included post right knee surgery and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). A review of Patient 2s referral order dated April 1, 2024, by a PMC physician (PMC/MD) indicated, “;Evaluate and treat for palliative care program.” During a home visit and interview with Patient 2 on June 5, 2024, at 1:36 PM, Patient 2 was sitting on a couch in the living room and was wearing a short sleeve shirt and short pants. Patient 2s right knee was visible, and a long-healed scar was observed on her right knee. Patient 2 was not using oxygen, not short of breath and did not appear to be in distress. Patient 2 stated she did not know the services the Hospice Agency was providing. Patient 2 stated the PMC told her they would send a nurse to provide services in her home instead of the hospital. Patient 2 stated she was doing very well, and she only had pain with her right knee when she walked and during Physical Therapy. Patient 2 stated she was excited to go back to work in a few weeks. During a concurrent interview and record review with the Medical Director (MD) and in the presence of the Administrator (Admin), Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:42 PM, Patients 2s History and Physical (H&P) was reviewed. The MD stated he could not verify Patient 2 had uncontrolled symptoms requiring services from a Palliative Care Program. 2c. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 24, 2024, into the Palliative Care Program. Patient 3 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), chest pain, diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Patient 3s Acute Care Hospital (ACH) clinical records for a May 1, 2024, to May 3, 2024, hospital admission for chest pain indicated a physicians referral order dated May 2, 2024, which indicated, “;Discharge to home [with] Home Health.” A review of Patient 3s referral order dated May 6, 2024, by a PMC physician (PMC/MD) indicated, “;Evaluate and treat for palliative care program.” During a home visit and interview with Patient 3 on June 5, 2024, at 2:53 PM, Patient 3 was sitting in wheelchair and using her feet propelled herself to the kitchen table. Patient 3 was wearing a short sleeve shirt, long pants, and shoes. A pressure bandage was visualized to her left upper arm. Patient 3 stated the bandage was covering her dialysis access. Patient 3 was not utilizing oxygen, not short of breath and did not appear to be in distress. Patient 3 stated she had been receiving dialysis treatments for two years and was used to it. Patient 3 stated she did not have chest pain or any other pain. Patient 3 stated she was not on oxygen and did not have shortness of breath. Patient 3 stated she did not know what services the agency provided but she would like help with transportation to her doctors appointments, some Physical Therapy so she could walk again and someone to clean her bathroom. During a concurrent interview and record review with the Medical Director (MD) and in the presence of the Administrator (Admin), Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:44 PM, Patients 3s History and Physical (H&P) was reviewed. The MD stated he could not verify Patient 3 had uncontrolled symptoms requiring services from a Palliative Care Program. A review of the agencys policy and procedure titled “;Screening and Assessment,” undated, indicated, “;POLICY STATEMENT: This policy outlines the procedures and guidelines for eliciting and documenting the patient’s preferences and goals for medical care in accordance with core ethical principles. The aim is to promote effective communication, respect patient autonomy, and ensure that medical care aligns with the patient’s values and preferences.” A review of the agencys policy and procedure titled “;Treatment and Ongoing Decision-Making,” undated, indicated, “;POLICY STATEMENT: This policy establishes the framework for developing person-centered goals that form the basis for the plan of care and decisions related to providing, forgoing, and discontinuing treatments within the limits of applicable state and federal laws, current accepted standards of medical care, and professional standards of practice. The policy emphasizes ethical principles, the patient’s treatment preferences, and collaboration with families and decision-makers.””

“Based on interview, and record review, the agency failed to ensure the patients’ initial assessment was completed within 48 hours of the physician’s referral date or on the physician-ordered start of care date for three of four sampled patients (Patients 1, 2, and 3). This failure had the potential to cause a delay in the determination of Patients 1, 2, and 3s immediate care and support needs. 1. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, into the Palliative Care Program. Patient 1 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), end stage renal disease (a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant), diabetes mellitus (a disease that results in too much sugar in the blood) and congestive heart failure (a chronic condition in which the heart cannot pump or fill effectively). Patient 1 expired on May 20, 2024. A review of Patient 1s referral order dated February 19, 2024, indicated, “;palliative care.” A review of Patient 1s initial assessment dated March 30, 2024, indicated the initial assessment had been conducted on March 30, 2024. (The initial assessment had been completed 40 days after the physicians referral order) 2. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 12, 2024, into the Palliative Care Program. Patient 2 had diagnoses that included post right knee surgery and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). A review of Patient 2s referral order dated April 1, 2024, by a Professional Medical Corporation (PMC) physician (PMC/MD) indicated, “;Evaluate and treat for palliative care program.” A review of Patient 2s initial assessment dated April 12, 2024, indicated the initial assessment had been conducted on April 12, 2024. (The initial assessment had been completed 11 days after the physicians referral order) 3. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 24, 2024, into the Palliative Care Program. Patient 3 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), chest pain, diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Patient 3s referral order dated May 6, 2024, by a Professional Medical Corporation (PMC) physician (PMC/MD) indicated, “;Evaluate and treat for palliative care program.” A review of Patient 3s initial assessment dated May 24, 2024, indicated the initial assessment had been conducted on May 24, 2024. (The initial assessment had been completed 18 days after the physicians referral order) During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 11:22 AM, Patients 1, 2 and 3s referral orders and initial assessments were reviewed, respectively. The DPCS and CS verified Patients 1, 2, and 3, did not have an initial assessment within 48 hours of the referral to the agency and should have. A review of the agencys policy and procedure titled “;Patient Referral, Admission and Non-Admission,” undated, indicated, “;POLICY: All patients presenting for admission will be assessed to determine [Palliative Care Program] appropriateness. The admission will then be completed in a timely manner, no more than 48 hours from receiving the referral. Information regarding patient referral, admission and non-admissions will be monitored.””

“Based on interview and record review, the agency failed to ensure the patients’ comprehensive assessments were completed within five days after the start of care for four of four sampled patients (Patient 1, 2, 3, and 4) when no spiritual or psychosocial assessments were conducted. This failure had the potential to cause the patient and familys psychosocial, emotional, and spiritual needs to go unmet. 1. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, into the Palliative Care Program. Patient 1 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), end stage renal disease (a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant), diabetes mellitus (a disease that results in too much sugar in the blood) and congestive heart failure (a chronic condition in which the heart cannot pump or fill effectively). Patient 1 expired on May 20, 2024. A review of Patient 1s Spiritual Counselors (SC) visit notes from March 30, 2024, to June 6, 2024 was conducted. There was no documented evidence to show the SC had reached out to Patient 1 or conducted an initial spiritual assessment. A review of Patient 1s Medical Social Workers (MSW) visit notes from March 30, 2024, to June 6, 2024 was conducted. There was no documented evidence to show the MSW had reached out to Patient 1 or conducted an initial psychosocial assessment. 2. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 12, 2024, into the Palliative Care Program. Patient 2 had diagnoses that included post right knee surgery and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). A review of Patient 2s Spiritual Counselors (SC) visit notes from April 12, 2024, to June 6, 2024 was conducted. There was no documented evidence to show the SC had reached out to Patient 2 or conducted an initial spiritual assessment. A review of Patient 2s Medical Social Workers (MSW) visit notes from April 12, 2024, to June 6, 2024 was conducted. There was no documented evidence to show the MSW had reached out to Patient 2 or conducted an initial psychosocial assessment. During a home visit and interview with Patient 2 on June 5, 2024, at 1:36 PM to 1:49 PM, in the presence of a Licensed Vocational Nurse (LVN 4), Patient 2 stated she was very sad over her mothers death on April 18, 2024, and “;I wanted someone to talk to and listen to me.” Patient 2 stated she had reached out to LVN 4 for help. LVN 4 stated she had not offered Patient 2 Spiritual Counseling Services or Medical Social Worker Counseling Services because Patient 2 was a Palliative Care Program patient, and those services were for hospice patients. 3. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 24, 2024, into the Palliative Care Program. Patient 3 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), chest pain, diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Patient 3s Spiritual Counselors (SC) visit notes from May 24, 2024, to June 6, 2024 was conducted. There was no documented evidence to show the SC had reached out to Patient 3 or conducted an initial spiritual assessment. A review of Patient 3s Medical Social Workers (MSW) visit notes from May 24, 2024, to June 6, 2024 was conducted. There was no documented evidence to show the MSW had reached out to Patient 3 or conducted an initial psychosocial assessment. During a home visit and interview with Patient 3 on June 5, 2024, at 2:53 PM to 3:10 PM, in the presence of a Licensed Vocational Nurse (LVN 4), Patient 3 stated she did not know what services the agency provided but she would like help with transportation to her doctors appointments, someone to familiarize her with available community services and someone to clean her bathroom. LVN 4 told Patient 3 she would reach out to her (Patient 3s) professional medical corporation (PMC) for a referral. LVN 4 stated she had not offered Patient 3 Medical Social Worker Services because Patient 3 was a Palliative Care Program patient, and those services were for hospice patients. 4. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 31, 2024, into the Palliative Care Program. Patient 4 had diagnoses that included diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Patient 4s Spiritual Counselors (SC) visit notes from May 31, 2024, to June 6, 2024 was conducted. There was no documented evidence to show the SC had reached out to Patient 4 or conducted an initial spiritual assessment. A review of Patient 4s Medical Social Workers (MSW) visit notes from May 31, 2024, to June 6, 2024 was conducted. There was no documented evidence to show the MSW had reached out to Patient 4 or conducted an initial psychosocial assessment. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, from 12:06 PM to 12:23 PM, Patients 1, 2, 3, and 4s initial spiritual assessments and initial psychosocial assessments were reviewed. The DPCS and CS verified initial spiritual assessments and initial psychosocial assessments were not conducted for Patients 1, 2, 3, and 4. The DPCS and CS stated the agencys Palliative Care Program provided Spiritual Counseling Services and Medical Social Workers Services and the services should have been provided to Patients 1, 2, 3, and 4. A review of the agencys policy and procedure titled “;Comprehensive Assessment,” dated October 2015, indicated, “;PURPOSE: To provide guidelines for the comprehensive assessment. POLICY: A comprehensive patient assessment will be performed by the hospice IDG no later than 5 calendar days after the [Palliative Care Programs start of care date] in consultation with attending physician. PROCEDURE: ... R. The patient’s psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source and adequacy of environmental and other resources, coping mechanisms and the patient’s and family/caregiver’s reaction to illness. ... T. An assessment of the patient’s and family/caregiver’s spiritual orientation, including, as appropriate, any involvement in a religious group such as a church or synagogue or a support group such as Alcoholics Anonymous and spiritual concerns or needs such as despair, suffering, guilt, etc.” A review of the agencys policy and procedure titled “;Screening and Assessment,” undated, indicated, “;POLICY STATEMENT: Our organization recognizes the significance of spiritual care in enhancing the well-being of patients and families facing serious illness. The spiritual assessment process encompasses spiritual screening, spiritual history, and a full spiritual assessment to identify and address spiritual needs, distress, and preferences. All assessments are conducted using standardized tools, ensuring consistency and comprehensive understanding.” A review of the agencys policy and procedure titled “;Screening and Assessment,” undated, indicated, “;POLICY STATEMENT: Our organization recognizes the importance of assessing patient and family social supports, relationships, resources, and the care environment in palliative care. This policy outlines the criteria and processes for the Interdisciplinary Team (IDT) to screen and assess these social factors, aiming to maximize coping and quality of life. ... PROCEDURE: ... 3. Comprehensive Social Assessment: a. Family structure and function, including roles, quality of relationships, communication, and decision-making preferences and patterns, as well as an assessment of those involved if the patient is in the custody of the county or state. b. Patient and family strengths, resiliency, social and cultural support, and spirituality. c. The availability and ability of a support system to provide respite, assist with errands and chores, and guard against social vulnerability. d. The effect of illness or injury on intimacy and sexual expression, prior experiences with illness, disability and loss, risk of abuse, neglect or exploitation, incarceration, or risk of social isolation. e. Functional limitations that impact activities of daily living (ADLs), instrumental activities of daily living (IADLs), and cognition. f. Changes in patient or family members’ school enrollment, employment or vocational roles, recreational activities, and economic security. g. Identification and documentation if the adult patient or a family member served in the military, and whether the patient or family member may be eligible for VA benefits. h. Living arrangements and perceived impact of the living environment on patient and family quality of life, including safety issues. 1. Patient and family perceptions about caregiving needs, including caregiver availability and capacity. J. The need for adaptive equipment, home modifications, or transportation. k. financial vulnerability (eg, ability to pay rent or mortgage and other bills). I. Ability to access prescription and over-the-counter medications for any reason, including functional or financial issues. m. Nutritional needs and food insecurity n. Advance care planning and legal concerns (see Section 8: Ethical and Legal Aspects of Care) o. Patient and caregiver ability to read and understand information from health and social service providers, insurance companies, and the IDT, as well as the ability of the patient family to ask questions and advocate for their needs. p. The ability of the patient and/or family to adhere to medication or treatment regimens. q. Patient and family willingness and ability to engage or accept resources and referrals. r. The family’s needs, resources, resiliency, and capacity to provide care.””

“Based on observation, interview, and record review, the agency failed to ensure the comprehensive assessment identified and addressed the physical and safety needs of two of four sampled patients (Patients 3 and 4) when: 1. Patient 3’s left great toe wound was not identified or assessed during the admission assessment. 2. Patient 4’s three falls in May 2024, and Patient 4s fear of falling were not identified or assessed. Patient 4’s inability to raise arms past his upper chest was not identified or assessed. This failure caused Patient 3 not to receive wound care for 12 days and Patient 4 not to receive care to address the inability of Patient 4 to raise his arms past his upper chest for six days. In addition, this failure had the potential to cause Patient 4 to fall again and suffer injuries. 1. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 24, 2024, into the Palliative Care Program. Patient 3 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), chest pain, diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a home visit and interview with Patient 3 on June 5, 2024, at 3:13 PM, in the presence of a Licensed Vocational Nurse (LVN 4), LVN 4 removed Patient 3s left foot shoe and sock. A wound was identified to the lower left great toe. The wound was the size of a nickel with a crater and raised edges. A small amount of fluid was oozing from the crater. Patient 3 stated she had the wound at admission to the agency. Patient 3 stated she had the wound on and off for about two years. Patient 3 stated she was supposed to get an orthotic device (braces, splints, and shoe inserts) for her shoe to help heal the wound, but she had not received one. A review of Patient 3s initial admission assessment dated May 24, 2024, was conducted. There was no documented evidence to show Patient 3s left great toe wound had been identified or assessed. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, from 12:06 PM to 12:23 PM, Patient 3s initial admission assessment dated May 24, 2024, was reviewed. The DPCS and CS verified Patient 3s left great toe wound had not been identified or assessed and should have been. 2. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 31, 2024, into the Palliative Care Program. Patient 4 had diagnoses that included diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a home visit and interview with Patient 4 and Patient 4s wife on June 5, 2024, from 10:05 AM to 10:33 AM, in the presence of a Licensed Vocational Nurse (LVN 5), Patient 4s wife stated Patient 4 fell all the time and he (Patient 4) had fallen three times in May 2024. Patient 4s wife stated Patient 4 fell when he transferred from his chair to his walker and from his walker to his chair, bed, and toilet. Patient 4s wife stated she had a hard time helping her husband transfer and ambulate because she was not very strong herself. Patient 4 stated he had a hard time using his walker because he could only raise is arms this much. Patient 4 demonstrated his physical limitation by raising his arms and showing they would not raise past his upper chest. Patient 4 stated it was too painful to raise his arms any further. Patient 4 stated he had back surgery a while ago where his lumbar vertebrae (lower back above tailbone) had been fused and he thought he probably needed more back surgery due to the problem of raising his arms. Patient 4 stated the walker he used was not stable enough to compensate for his arm raising limitation. Patient 4 stated he was so afraid to fall, so he rarely left his chair unless it was necessary. A review of Patient 4s initial admission assessment dated May 31, 2024, was conducted. There was no documented evidence to show Patient 4s repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest had been identified and assessed. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 11:49 AM, Patient 4s initial admission assessment dated May 31, 2024, was reviewed. The DPCS and CS verified Patient 4s repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest had not been identified and assessed and should have been. A review of the agencys policy and procedure titled “;Screening and Assessment,” undated, indicated, “;POLICY STATEMENT: Our organization is committed to ensuring a thorough assessment of physical symptoms and their impact on well-being, quality of life, and functional status for patients with serious illnesses. This policy outlines the criteria and processes for the Interdisciplinary Team (IDT) to conduct comprehensive symptom assessments, utilizing validated tools, considering patient preferences, and addressing challenges related to communication or cognitive impairment. ... PROCEDURE: ... 2. Comprehensive Symptom Assessment: Attention will be given to assessing various aspects of symptoms, including onset, quality, severity, provoking and relieving factors, response to prior treatment, level of burden, impact on functionality and quality of life, and the meaning of distressing symptoms. The IDT will consider the patient’s goals of care during the assessment process. The assessment will include a. Assessment of symptoms including pain, dyspnea, constipation, other physical symptoms b. Assessment of functional status c. Assessment of patient’s and family’s psychosocial status d. Assessment of cultural, spiritual, and religious beliefs e. Assessment of psychological symptoms including anxiety, stress, grief, and coping; standardized scales are used when appropriate f. psychiatric symptoms including depression, anxiety, and suicidal ideation.””

“Based on interview, and record review, the agency failed to ensure the comprehensive assessment was updated by the agency’s interdisciplinary group (in collaboration with the individuals attending physician) and considered changes that took place since the initial assessment for one of four sampled patients (Patient 1) when: 1a. Patient 1’s right great toe wound was not identified or assessed by the visiting Licensed Vocational Nurses. 1b. No re-admission assessment was conducted after Patient 1’s hospitalization from May 6, 2024, to May 8, 2024. 1c. No discharge summary for Patient 1 was documented and no discharge order for Patient 1 was obtained. This failure caused Patient 1 to suffer a delay in wound care, no re-assessment of care needs following an acute care hospital admission, caused Patient 1s attending physicians to be unaware of the medical condition and death of Patient 1 at discharge, and no physician oversight for Patient 1s discharge from the Palliative Care Program. 1a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, into the Palliative Care Program. Patient 1 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), end stage renal disease (a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant), diabetes mellitus (a disease that results in too much sugar in the blood) and congestive heart failure (a chronic condition in which the heart cannot pump or fill effectively). Patient 1 expired on May 20, 2024. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated on May 5, 2024, Patient 1 began bleeding from his rectum with bloody diarrhea. Patient 1s wife stated she called the Hospice Agency, and a nurse (Licensed Vocational Nurse (LVN 1) came out and helped clean Patient 1, “;the blood was everywhere!” Patient 1s wife stated the nurse called the doctor and she (Patient 1s wife) was told it was not recommended for Patient 1 to go to the acute care hospital unless he started bleeding again. Patient 1s wife stated she took Patient 1 to his dialysis appointment the next day May 6, 2024, and told the dialysis nurse about the bleeding episode. Patient 1s wife stated the dialysis nurse told her dialysis could not be done on a patient who had been bleeding and to go to the acute care hospital immediately. Patient 1s wife stated she took Patient 1 to the acute care hospital where Patient 1 was admitted on May 6, 2024, through May 8, 2024, and received two units of blood and a wound was identified on his right great toe. Patient 1s wife stated she told the Hospice Agencys nurse (Licensed Vocational Nurse (LVN 3) on May 16, 2024, about the acute care hospital admission, two units of blood and wound identification but nothing was done. Patient 1s wife stated she called the Hospice Agency on May 17, 2024, and asked for Patient 1s wound to be cared for. Patient 1s wife stated a nurse came out (Licensed Vocational Nurse (LVN 2) and applied a dressing to Patient 1s right great toe but there was no referral to a wound specialist because of Patient 1s diabetes mellitus diagnosis. A review of Patient 1s Acute Care Hospitals (ACH) clinical records dated May 6, 2024, to May 8, 2024, indicated Patient 1 had been admitted on May 6, 2024, and discharged on May 8, 2024. Patient 1s “;Progress Note, Nursing-Wound Care Follow Up,” dated May 8, 2024, indicated, “;Reconsulted for great toe wound. WOUND # 2 [number two], Location: right great toe, Type of Wound: blood blister on diabetic foot, unknown origin, Pressure Injury Stage: n/a [not applicable] Size: 1 [one] CM [centimeter-a unit of measurement] X [by] 2 [two] CM X 0 [zero] CM, Tunneling or Undermining: none noted, Wound Appearance: blood blister under toenail Peri [around] wound: consistent with rest of skin, Edges: adherent, intact Drainage: none noted Odor: none noted, Pain Tolerance: PATIENT TOLERATED TREATMENT, Cleansed: [antiseptic] Dressing: OTA [open to air] ...” A review of Patient 1s Skilled Nursing (SN) visit notes from April 4, 2024, to May 16, 2024, were reviewed. There was no documented evidence to show a right great toe wound had been identified or assessed. A review of Patient 1s SN visit note dated May 16, 2024, by LVN 3, was conducted. There was no documented evidence to show LVN 3 had identified or assessed Patient 1s right great toe wound identified at the acute care hospital during the May 6, 2024, to May 8, 2024, admission. During an interview with LVN 3 on June 4, 2024, at 11:48 AM, LVN 3 stated Patient 1s wife had told him Patient 1 had been to the acute care hospital the week before, but he could not remember the dates. LVN 3 stated he did not remember any specifics about Patient 1s acute care hospital stay and had not reported Patient 1s hospitalization to the Hospice Agencys staff. LVN 3 stated he had not conducted a thorough head-to-toe assessment of Patient 1 and had not noticed a wound to Patient 1s right great toe. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, from 12:06 PM to 12:23 PM, Patient 1s Skilled Nursing (SN) visit notes from April 4, 2024, to May 16, 2024, were reviewed. The DPCS and CS verified Patient 1s right great toe wound had not been identified or assessed and should have been. 1b. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated on May 5, 2024, Patient 1 began bleeding from his rectum with bloody diarrhea. Patient 1s wife stated she called the Hospice Agency, and a nurse (Licensed Vocational Nurse (LVN 1) came out and helped clean Patient 1, “;the blood was everywhere!” Patient 1s wife stated the nurse called the doctor and she (Patient 1s wife) was told it was not recommended for Patient 1 to go to the acute care hospital unless he started bleeding again. Patient 1s wife stated she took Patient 1 to his dialysis appointment the next day May 6, 2024, and told the dialysis nurse about the bleeding episode. Patient 1s wife stated the dialysis nurse told her dialysis could not be done on a patient who had been bleeding and to go to the acute care hospital immediately. Patient 1s wife stated she took Patient 1 to the acute care hospital where Patient 1 was admitted on May 6, 2024, through May 8, 2024, and received two units of blood and a wound was identified on his right great toe. Patient 1s wife stated she told the Hospice Agencys nurse (Licensed Vocational Nurse (LVN 3) on May 16, 2024, about the acute care hospital admission, two units of blood and wound identification but nothing was done. A review of Patient 1s Acute Care Hospitals (ACH) clinical records dated May 6, 2024, to May 8, 2024, indicated Patient 1 had been admitted on May 6, 2024, and discharged on May 8, 2024. Patient 1s ACHs clinical records indicated Patient 1 had received two units of blood and wound care to his right great toe. A review of Patient 1s Comprehensive Assessments from May 8, 2024, to May 21, 2024, was conducted. There was no documented evidence to show Patient 1 had received a reassessment after discharge from the ACH. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, from 12:06 PM to 12:23 PM, Patient 1s Comprehensive Assessments from May 8, 2024, to May 21, 2024, were reviewed. The DPCS and CS verified Patient 1 did not receive a reassessment after discharge from the ACH and should have. 1c. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated Patient 1 died on May 20, 2024, 51 days after starting on the Hospice Agencys Palliative Care Program. Patient 1s wife stated the (PMC-a Professional Medical Corporation), and the Hospice Agency did not provide the aggressive care and services Patient 1 wanted to prolong and improve his life to the extent possible. A review of the agencys Palliative Care Programs discharge roster indicated Patient 1 had been discharged from the agency on May 21, 2024, due to death. A review of Patient 1s physicians orders from May 19, 2024, to June 6, 2024, was conducted. There was no documented evidence to show a discharge order had been obtained. A review of Patient 1s discharge summaries from May 19, 2024, to June 6, 2024, was conducted. There was no documented evidence to show a discharge summary had been documented. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, from 12:06 PM to 12:23 PM, Patient 1s physicians orders from May 19, 2024, to June 6, 2024, and discharge summaries from May 19, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified Patient 1 did not have a discharge order or discharge summary and should have. A review of the agencys policy and procedure titled “;Ongoing Comprehensive Assessments,” dated October 2012, indicated, “;PURPOSE: To provide guidelines for further assessment of patients during ongoing care. POLICY: The scope and intensity of ongoing [Palliative Care Program] patient assessments will be determined by the patient’s prognosis, diagnoses, condition, desire for care, response to previous care, and the care setting. PROCEDURE: 1. During each home visit, the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. ... 2. The nurse will assess the patient on each visit, for: A. Pain, including the origin, location, duration, severity, and relief measures. B. Secondary symptoms related to the terminal illness such as nausea, vomiting, and respiratory distress, and the patient’s response to medications and other interventions. C. Factors that alleviate or exacerbate physical symptoms. D. Current treatment related to the identified symptoms and the patient’s response. E. Vital signs appropriate to the patient’s condition. F. Breath sounds. G. Skin integrity. H. Bowel sounds, elimination (urinary and bowel). I. Mental status. J. Appetite/diet, nutritional status. K. Functional status. L. Safety/home environment. M. Patient and family/caregiver support. N. Spiritual issues. 0. Additional psychosocial issues. P. Progress toward [Palliative Care Program] goals and patient needs and problems. Q. Compliance with treatments and medication regimen. R. The need for an alternative setting or level of care. 3. Ongoing comprehensive assessment should focus on: A. Patient’s and family/caregiver’s response to care. B. Changes in patient condition, level of deterioration. C. Changes in patient diagnoses/prognosis. D. Changes in patient’s care environment or support systems. E. Change in patient’s and family/caregiver’s perceived needs. 4. Based on the 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. 5. Based upon the findings of the assessment, additional orders will be generated and forwarded to the physician (or other authorized licensed independent practitioner) for signature(s). 6. The physician will be notified to verify any changes in medications, including over-the&shy; counter medications, and treatment/interventions that require physician approval. ...””

“Based on interview and record review, the agency failed to ensure the Interdisciplinary Group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) members supervised and provided care and services to meet the physical, medical, psychosocial, emotional, and spiritual needs for four of four sampled patients (Patients 1, 2, 3, and 4) when: 1a. An admission order was not obtained for Patient 1. 1b. Patient 1’s gastrointestinal (GI) bleeding episode on May 5, 2024, was not discussed or addressed by the IDG. 1c. Patient 1’s hospital admission from May 6, 2024, to May 8, 2024, where Patient 1 received two units of blood was not discussed or addressed by the IDG. 1d. Patient 1’s right great toe wound identified at the hospital on May 8, 2024, was not discussed or addressed by the IDG. 1e. Patient 1’s death on May 20, 2024, and discharge on May 21, 2024, was not discussed or addressed by the IDG. 2. There was no documented evidence to show the IDG evaluated, discussed, or provided general oversight for Patient 2s care. 3. Patient 3’s left great toe wound was not discussed or addressed by the IDG. 4. Patient 4’s three falls in May or patients fear of falling was not discussed or assessed by the IDG. Patient 4’s inability to raise arms past his upper chest was not discussed or assessed by the IDG. This failure caused Patient 1 to be admitted to the Palliative Care Program without a physicians order, and a potential to cause Patient 1 to suffer additional GI bleeds and delayed healing or worsening of Patient 1s right great toe wound. This failure caused the IDG to be unaware of the circumstances surrounding Patient 1s death. This failure had the potential to cause Patient 2 not to achieve her desired goals of care and delayed healing or worsening of Patient 3s left great toe wound. In addition, this failure had the potential to cause Patient 4 to suffer additional falls with injuries and his arm raising restriction to worsen. 1a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, into the Palliative Care Program. Patient 1 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), end stage renal disease (a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant), diabetes mellitus (a disease that results in too much sugar in the blood) and congestive heart failure (a chronic condition in which the heart cannot pump or fill effectively). Patient 1 expired on May 20, 2024. A review of Patient 1s physicians orders from March 30, 2024, to June 6, 2024, was conducted. There was no documented evidence to show an admission order for Patient 1. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:10 PM, Patient 1s physicians orders from March 30, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified Patient 1s did not have an admission order and should have. 1b. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated on May 5, 2024, Patient 1 began bleeding from his rectum with bloody diarrhea. Patient 1s wife stated she called the Hospice Agency, and a nurse (Licensed Vocational Nurse (LVN 1)) came out and helped clean Patient 1, “;the blood was everywhere!” Patient 1s wife stated the nurse called the doctor and she (Patient 1s wife) was told it was not recommended for Patient 1 to go to the acute care hospital unless he started bleeding again. A review of Patient 1s SN visit note, dated May 5, 2024, by LVN 1, indicated, “;The patient was seen today for a PRN [as needed] visit due to experiencing bloody, loose stools. The patients wife reported multiple episodes since 3 [three] a.m., with the last occurring around 11:30 a.m. Upon examination, the patient was found sitting on the toilet, awake, alert, and oriented, denying any pain. The patient is on continuous oxygen without respiratory distress and is currently not experiencing further episodes of loose stools or bleeding. The patient managed to walk from the toilet to the bed for cleaning, with no external hemorrhoids detected. The abdomen is soft, non-distended, and non-tender. The patient denies dizziness but feels slightly weaker. Dialysis is scheduled for the following day. ... The wife has been instructed to monitor for additional episodes of bloody stools or any changes in condition ... The physician has been informed, and there are no new orders at this time. The wife will consult with the primary medical doctor for additional guidance and is aware that, should excessive bleeding continue, it is imperative to contact emergency services immediately. ...” During an interview with LVN 1 on June 4, 2024, at 10:35 AM, LVN 1 stated he made an SN visit because Patient 1s wife had called and stated Patient 1 had loose stools, dark colored. LVN 1 stated he saw dark black tar like loose stools (black or tarry stools are due to bleeding in the upper part of the GI (gastrointestinal) tract, such as the esophagus, stomach, or the first part of the small intestine. In this case, blood is darker because it gets digested on its way through the GI tract) on the bedsheets, on the floor of bedroom and floor of bathroom and on and in the toilet. LVN 1 stated he helped clean up Patient 1. LVN 1 stated he texted the Medical Director (MD) directly. LVN 1 stated the MD responded, “;thank you for the update” and I was not given any instruction to give Patient 1 or the family. LVN 1 stated he had made an independent decision to tell Patient 1s wife to take Patient 1 to the acute care hospital if the bleeding started again. During an interview with the MD on June 4, 2024, at 12:15 PM to 12:41 PM, the MD stated he was the Medical Director for the Hospice Agencys Palliative Care Program. The MD stated he had received a text from LVN 1 on May 5, 2024, and he had responded, “;thank you for the update.” The MD stated he had not given LVN 1 any direction to give Patient 1 or the family. The MD stated he did not think the bleeding was an urgent situation at the time but after reviewing Patient 1s previous medical history he should have instructed Patient 1 to go to the acute care hospital. A review of Patient 1s IDG meeting notes from May 5, 2024, to June 6, 2024, was conducted. There was no documented evidence to show acknowledgment of Patient 1s change in medical condition, response to treatment or progress to targeted outcomes. There was no documented evidence to show a problem-solving discussion, new interventions, or update to Patient 1s plan of care. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:10 PM, Patient 1s IDG meeting notes from May 5, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show acknowledgment of Patient 1s change in medical condition, response to treatment or progress to targeted outcomes. The DPCS and CS stated there was no documented evidence to show a problem-solving discussion, new interventions, or update to Patient 1s plan of care. 1c. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated on May 5, 2024, Patient 1 began bleeding from his rectum with bloody diarrhea. Patient 1s wife stated she called the Hospice Agency, and a nurse (Licensed Vocational Nurse (LVN 1)) came out and helped clean Patient 1, “;the blood was everywhere!” Patient 1s wife stated the nurse called the doctor and she (Patient 1s wife) was told it was not recommended for Patient 1 to go to the acute care hospital unless he started bleeding again. Patient 1s wife stated she took Patient 1 to his dialysis appointment the next day May 6, 2024, and told the dialysis nurse about the bleeding episode. Patient 1s wife stated the dialysis nurse told her dialysis could not be done on a patient who had been bleeding and to go to the acute care hospital immediately. Patient 1s wife stated she took Patient 1 to the acute care hospital where Patient 1 was admitted on May 6, 2024, through May 8, 2024, and received two units of blood and a wound was identified on his right great toe. Patient 1s wife stated she told the Hospice Agencys nurse (Licensed Vocational Nurse (LVN 3)) on May 16, 2024, about the acute care hospital admission, two units of blood and wound identification but nothing was done. A review of Patient 1s Acute Care Hospitals (ACH) clinical records dated May 6, 2024, to May 8, 2024, indicated Patient 1 had been admitted on May 6, 2024, and discharged on May 8, 2024. Patient 1s ACHs clinical records indicated Patient 1 had received two units of blood and wound care to his right great toe. During an interview with LVN 3 on June 4, 2024, at 11:48 AM, LVN 3 stated Patient 1s wife had told him Patient 1 had been to the acute care hospital the week before (May 6, 2024, to May 11, 2024), but he could not remember the dates. LVN 3 stated he did not remember any specifics about Patient 1s acute care hospital stay and had not reported Patient 1s hospitalization to the Hospice Agencys staff. A review of Patient 1s IDG meeting notes from May 5, 2024, to June 6, 2024, was conducted. There was no documented evidence to show acknowledgment of Patient 1s acute care hospital admission, response to treatment or progress to targeted outcomes. There was no documented evidence to show a problem-solving discussion on the acute care hospitalization, new interventions, or update to Patient 1s plan of care post-acute care hospital admission. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:10 PM, Patient 1s IDG meeting notes from May 5, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show acknowledgment of Patient 1s change in medical condition-acute care hospital admission, response to treatment or progress to targeted outcomes. The DPCS and CS stated there was no documented evidence to show a problem-solving discussion on the acute care hospitalization, new interventions, or update to Patient 1s plan of care post-acute care hospital admission. 1d. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated on May 5, 2024, Patient 1 began bleeding from his rectum with bloody diarrhea. Patient 1s wife stated she called the Hospice Agency, and a nurse (Licensed Vocational Nurse (LVN 1)) came out and helped clean Patient 1, “;the blood was everywhere!” Patient 1s wife stated the nurse called the doctor and she (Patient 1s wife) was told it was not recommended for Patient 1 to go to the acute care hospital unless he started bleeding again. Patient 1s wife stated she took Patient 1 to his dialysis appointment the next day May 6, 2024, and told the dialysis nurse about the bleeding episode. Patient 1s wife stated the dialysis nurse told her dialysis could not be done on a patient who had been bleeding and to go to the acute care hospital immediately. Patient 1s wife stated she took Patient 1 to the acute care hospital where Patient 1 was admitted on May 6, 2024, through May 8, 2024, and received two units of blood and a wound was identified on his right great toe. Patient 1s wife stated she told the Hospice Agencys nurse (Licensed Vocational Nurse (LVN 3)) on May 16, 2024, about the acute care hospital admission, two units of blood and wound identification but nothing was done. Patient 1s wife stated she called the Hospice Agency on May 17, 2024, and asked for Patient 1s wound to be cared for. Patient 1s wife stated a nurse came out (Licensed Vocational Nurse (LVN 2)) who applied a dressing to Patient 1s right toe. A review of Patient 1s SN visit note dated May 16, 2024, by LVN 3, was conducted. There was no documented evidence to show LVN 3 had identified or assessed Patient 1s right great toe wound identified at the acute care hospital during the May 6, 2024, to May 8, 2024, admission. During an interview with LVN 3 on June 4, 2024, at 11:48 AM, LVN 3 stated Patient 1s wife had told him Patient 1 had been to the acute care hospital the week before (May 6, 2024, to May 11, 2024), but he could not remember the dates. LVN 3 stated he did not remember any specifics about Patient 1s acute care hospital stay and had not reported Patient 1s hospitalization to the Hospice Agencys staff. LVN 3 stated he had not conducted a thorough head-to-toe assessment of Patient 1 and had not noticed a wound to Patient 1s right great toe. A review of Patient 1s SN visit note dated May 17, 2024, by LVN 2, indicated, “;... PRN [as needed] visit [related to] wound care, ... verbal, calm, cooperative, respiration even and unlabored with no SOB [shortness of breath] noted, wife stated ... during patient bath she noticed open area on right great toe, no discharge or pus noted, BLE [bilateral lower extremities] warm to touch, patient denies any fever or chills and no pain or discomfort during visit, [MD] made aware with new order: cleanse open area on right great toe with NS [normal saline], pat dry, apply [wound gel] and cover with dry dressing secure with tape daily and as needed if dislodged or soiled [times]14 days and re-assess. Family/cg may perform wound care. ... May have wound consult. Wound care administered, tolerated well, ... Patient and wife educated on signs and symptoms of infection such as increase pain to site, increased redness, presence of ... pus, fever, chills. If any sign/symptoms of infection noticed to call [PMC-a Professional Medical Corporation] nurse advice line. Patient and wife encourage to wear proper fitting footwear, wife and patient acknowledge understanding, patient and wife encourage to monitor. follow up with podiatrist/ [primary care physician] and call [PMC] If there’s any questions or concerns ...” During an interview with LVN 2 on June 4, 2024, at 10:55 AM, LVN 2 stated he had conducted the SN visit because Patient 1s wife had called the office and informed them of the right great toe wound. A review of Patient 1s IDG meeting notes from May 5, 2024, to June 6, 2024, was conducted. There was no documented evidence to show acknowledgment of Patient 1s right great toe wound, response to treatment or progress to targeted outcomes. There was no documented evidence to show a problem-solving discussion on the right great toe wound, new interventions, or update to Patient 1s plan of care for the right great toe wound. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:10 PM, Patient 1s IDG meeting notes from May 5, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show acknowledgment of Patient 1s right great toe wound, response to treatment or progress to targeted outcomes. The DPCS and CS stated there was no documented evidence to show a problem-solving discussion on the right great toe wound, new interventions, or update to Patient 1s plan of care for the right great toe wound. 1e. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated Patient 1 died on May 20, 2024, 51 days after starting on the Hospice Agencys Palliative Care Program. Patient 1s wife stated the (PMC-a Professional Medical Corporation), and the Hospice Agency did not provide the aggressive care and services Patient 1 wanted to prolong and improve his life to the extent possible. A review of the agencys Palliative Care Programs discharge roster indicated Patient 1 had been discharged from the agency on May 21, 2024, due to death. A review of Patient 1s physicians orders from May 19, 2024, to June 6, 2024, was conducted. There was no documented evidence to show a discharge order had been obtained. A review of Patient 1s discharge summaries from May 19, 2024, to June 6, 2024, was conducted. There was no documented evidence to show a discharge summary had been documented. A review of Patient 1s IDG meeting notes from May 5, 2024, to June 6, 2024, was conducted. There was no documented evidence to show acknowledgment of Patient 1s death and discharge from the agency. There was no documented evidence to show a problem-solving discussion on the circumstances surrounding Patient 1s death. Patient 1s plan of care did not indicate a discharge plan and there was no update to Patient 1s plan of care regarding the death and discharge. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:10 PM, Patient 1s IDG meeting notes from May 5, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no acknowledgment of Patient 1s death and discharge from the agency. The DPCS and CS stated there was no documented evidence to show a problem-solving discussion on the circumstances surrounding Patient 1s death and Patient 1s plan of care did not indicate a discharge plan. In addition, there was no update to Patient 1s plan of care regarding the death and discharge. 2. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 12, 2024, into the Palliative Care Program. Patient 2 had diagnoses that included post right knee surgery and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). A review of Patient 2s IDG meeting notes from April 12, 2024, to June 6, 2024, was conducted. There was no documented evidence to show a discussion of Patient 2s medical condition, response to treatment or progress to targeted outcomes. There was no documented evidence to show a problem-solving discussion, new interventions, or update to Patient 2s plan of care. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:42 PM, Patient 2s IDG meeting notes from April 12, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show a discussion of Patient 2s medical condition, response to treatment or progress to targeted outcomes. The DPCS and CS stated there was no documented evidence to show a problem-solving discussion, new interventions, or update to Patient 2s plan of care. 3. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 24, 2024, into the Palliative Care Program. Patient 3 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), chest pain, diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a home visit and interview with Patient 3 on June 5, 2024, at 3:13 PM, in the presence of a Licensed Vocational Nurse (LVN 4), LVN 4 removed Patient 3s left foot shoe and sock. A wound was identified to the lower left great toe. The wound was the size of a nickel with a crater and raised edges. A small amount of fluid was oozing from the crater. Patient 3 stated she had the wound at admission to the agency. Patient 3 stated she had the wound on and off for about two years. Patient 3 stated she was supposed to get an orthotic device (braces, splints, and shoe inserts) for her shoe to help heal the wound, but she had not received one. A review of Patient 3s initial admission assessment dated May 24, 2024, was conducted. There was no documented evidence to show Patient 3s left great toe wound had been identified or assessed. A review of Patient 3s IDG meeting notes from May 24, 2024, to June 6, 2024, was conducted. There was no documented evidence to show acknowledgment of Patient 3s left great toe wound, response to treatment or progress to targeted outcomes. There was no documented evidence to show a problem-solving discussion on the left great toe wound, new interventions, or update to Patient 3s plan of care for the left great toe wound. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:44 PM, Patient 3s IDG meeting notes from May 24, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show acknowledgment of Patient 3s left great toe wound, response to treatment or progress to targeted outcomes. The DPCS and CS stated there was no documented evidence to show a problem-solving discussion on the left great toe wound, new interventions, or update to Patient 3s plan of care for the left great toe wound. 4. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 31, 2024, into the Palliative Care Program. Patient 4 had diagnoses that included diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a home visit and interview with Patient 4 and Patient 4s wife on June 5, 2024, from 10:05 AM to 10:33 AM, in the presence of a Licensed Vocational Nurse (LVN 5), Patient 4s wife stated Patient 4 fell all the time and he (Patient 4) had fallen three times in May 2024. Patient 4s wife stated Patient 4 fell when he transferred from his chair to his walker and from his walker to his chair, bed, and toilet. Patient 4s wife stated she had a hard time helping her husband transfer and ambulate because she was not very strong herself. Patient 4 stated he had a hard time using his walker because he could only raise is arms this much. Patient 4 demonstrated his physical limitation by raising his arms and showing they would not raise past his upper chest. Patient 4 stated it was too painful to raise his arms any further. Patient 4 stated he had back surgery a while ago where his lumbar vertebrae (lower back above tailbone) had been fused and he thought he probably needed more back surgery due to the problem of raising his arms. Patient 4 stated the walker he used was not stable enough to compensate for his arm raising limitation. Patient 4 stated he was so afraid to fall, so he rarely left his chair unless it was necessary. A review of Patient 4s initial admission assessment dated May 31, 2024, was conducted. There was no documented evidence to show Patient 4s repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest had been identified and assessed. A review of Patient 4s IDG meeting notes from May 31, 2024, to June 6, 2024, was conducted. There was no documented evidence to show acknowledgment of Patient 4s repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest, response to treatment or progress to targeted outcomes. There was no documented evidence to show a problem-solving discussion on the repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest, new interventions, or update to Patient 4s plan of care for the repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his uppe r chest. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:54 PM, Patient 4s IDG meeting notes from May 31, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show acknowledgment of Patient 4s repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest, response to treatment or progress to targeted outcomes. The DPCS and CS stated there was no documented evidence to show a problem-solving discussion on the repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest, new interventions, or update to Patient 4s plan of care for the repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest. A review of the agencys policy and procedure titled, “;Interdisciplinary Team Structure and Processes,” undated, indicated, “;POLICY STATEMENT: Our organization is dedicated to delivering high-quality palliative care that prioritizes the diverse needs of patients and their families. Guided by the Clinical Practice Guidelines for Quality Palliative Care, this policy outlines the structure and processes of the Interdisciplinary Team (IDT) to ensure comprehensive, patient-centered care. PROCEDURE: 1. Interdisciplinary Team Composition: The core IDT shall include professionals from various disciplines, such as: Physicians, Skilled Nurses, Social workers, Chaplains. The IDT may also include other professionals with credentials, experience, and skills to meet the needs of the patient and family. Each team member’s credentials, experience, and skills shall be considered to meet the specific needs of the patient and family. ... 3. Palliative Care Plan implementation: The IDT shall facilitate the implementation and ongoing refinement of the palliative care plan. Regular communication with all care providers shall be maintained to support patient and family goals. ... 5. Regular IDT Meetings: The IDT shall meet regularly to discuss patient care, IDT functioning, and operational details essential to the provision of quality palliative care. The IDT will meet no less than every 14 days for each patient. However, meeting frequency can be increased based on the needs of the population served, care setting(s), and service model. 6. 24/7 Access to Palliative Care Staff: Patients and families shall have access to palliative care staff 24 hours a day, seven days a week through phone or telehealth applications. 7. Continuity with Community Services: The IDT shall access and ensure continuity with community services for families caring for neonates, children, or adults with a serious illness. ...” A review of the agencys policy and procedure titled, “;Interdisciplinary Group Meeting,” dated April 2015, indicated, “;PURPOSE: To define the process for interdisciplinary group meetings and documenting patient status in the clinical record. POLICY: The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires. The meeting will be facilitated by the hospice Clinical Supervisor/Nursing Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available. The patient and family/caregiver will be informed of the schedule for this meeting, its purpose, and that the discussion is confidential.””

“Based on interview and record review, the agency failed to develop an individualized plan of care for four of four sampled patients (Patients 1, 2, 3, and 4) when: 1a. Patient 1’s a lower gastrointestinal (GI) bleeding episode on May 5, 2024, was not care planned. 1b. Patient 1’s hospital admission from May 6, 2024, to May 8, 2024, where Patient 1 received two units of blood was not care planned. 1c. Patient 1’s right great toe wound identified at the hospital on May 8, 2024, was not care planned. 1d. Patient 1’s plan of care did not include discharge planning. 2. There was no documented evidence to show the IDG evaluated, discussed, or updated Patient 2’s care plan. 3. Patient 3’s dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally) and left great toe wound were not care planned. 4. Patient 4’s three falls in May 2024, and the patient’s fear of falling was not care planned. Patient 4’s inability to raise arms past his upper chest was not care planned. This failure had the potential to cause Patient 1 to suffer additional GI bleeds and delayed healing or worsening of Patient 1s right great toe wound. This failure caused the IDG and attending physician to be unaware of the circumstances surrounding Patient 1s death and the discharge from the program. This failure had the potential to cause Patient 2 not to achieve her desired goals of care. This failure had the potential to cause delayed healing or worsening of Patient 3s left great toe wound and unrecognized complications from dialysis treatments. In addition, this failure had the potential to cause Patient 4 to suffer additional falls with injuries and his arm raising restriction to worsen. 1a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, into the Palliative Care Program. Patient 1 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), end stage renal disease (a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant), diabetes mellitus (a disease that results in too much sugar in the blood) and congestive heart failure (a chronic condition in which the heart cannot pump or fill effectively). Patient 1 expired on May 20, 2024. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated on May 5, 2024, Patient 1 began bleeding from his rectum with bloody diarrhea. Patient 1s wife stated she called the Hospice Agency, and a nurse (Licensed Vocational Nurse (LVN 1)) came out and helped clean Patient 1, “;the blood was everywhere!” Patient 1s wife stated the nurse called the doctor and she (Patient 1s wife) was told it was not recommended for Patient 1 to go to the acute care hospital unless he started bleeding again. A review of Patient 1s SN visit note, dated May 5, 2024, by LVN 1, indicated, “;The patient was seen today for a PRN [as needed] visit due to experiencing bloody, loose stools. The patients wife reported multiple episodes since 3 [three] a.m., with the last occurring around 11:30 a.m. Upon examination, the patient was found sitting on the toilet, awake, alert, and oriented, denying any pain. The patient is on continuous oxygen without respiratory distress and is currently not experiencing further episodes of loose stools or bleeding. The patient managed to walk from the toilet to the bed for cleaning, with no external hemorrhoids detected. The abdomen is soft, non-distended, and non-tender. The patient denies dizziness but feels slightly weaker. Dialysis is scheduled for the following day. ... The wife has been instructed to monitor for additional episodes of bloody stools or any changes in condition ... The physician has been informed, and there are no new orders at this time. The wife will consult with the primary medical doctor for additional guidance and is aware that, should excessive bleeding continue, it is imperative to contact emergency services immediately. ...” During an interview with LVN 1 on June 4, 2024, at 10:35 AM, LVN 1 stated he made an SN visit because Patient 1s wife had called and stated Patient 1 had loose stools, dark colored. LVN 1 stated he saw dark black tar like loose stools (black or tarry stools are due to bleeding in the upper part of the GI (gastrointestinal) tract, such as the esophagus, stomach, or the first part of the small intestine. In this case, blood is darker because it gets digested on its way through the GI tract) on the bedsheets, on the floor of bedroom and floor of bathroom and on and in the toilet. LVN 1 stated he helped clean up Patient 1. LVN 1 stated he texted the Medical Director (MD) directly. LVN 1 stated the MD responded, “;thank you for the update” and I was not given any instruction to give Patient 1 or the family. LVN 1 stated he had made an independent decision to tell Patient 1s wife to take Patient 1 to the acute care hospital if the bleeding started again. During an interview with the MD on June 4, 2024, at 12:15 PM to 12:41 PM, the MD stated he was the Medical Director for the Hospice Agencys Palliative Care Program. The MD stated he had received a text from LVN 1 on May 5, 2024, and he had responded, “;thank you for the update.” The MD stated he had not given LVN 1 any direction to give Patient 1 or the family. The MD stated he did not think the bleeding was an urgent situation at the time but after reviewing Patient 1s previous medical history he should have instructed Patient 1 to go to the acute care hospital. A review of Patient 1s care plans from May 5, 2024, to June 6, 2024, was conducted. There was no documented evidence to show Patient 1s change in medical condition (GI bleed) had been care planned. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:10 PM, Patient 1s care plans from May 5, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show Patient 1s change in medical condition (GI bleed) had been care planned. 1b. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated on May 5, 2024, Patient 1 began bleeding from his rectum with bloody diarrhea. Patient 1s wife stated she called the Hospice Agency, and a nurse (Licensed Vocational Nurse (LVN 1)) came out and helped clean Patient 1, “;the blood was everywhere!” Patient 1s wife stated the nurse called the doctor and she (Patient 1s wife) was told it was not recommended for Patient 1 to go to the acute care hospital unless he started bleeding again. Patient 1s wife stated she took Patient 1 to his dialysis appointment the next day May 6, 2024, and told the dialysis nurse about the bleeding episode. Patient 1s wife stated the dialysis nurse told her dialysis could not be done on a patient who had been bleeding and to go to the acute care hospital immediately. Patient 1s wife stated she took Patient 1 to the acute care hospital where Patient 1 was admitted on May 6, 2024, through May 8, 2024, and received two units of blood and a wound was identified on his right great toe. Patient 1s wife stated she told the Hospice Agencys nurse (Licensed Vocational Nurse (LVN 3)) on May 16, 2024, about the acute care hospital admission, two units of blood and wound identification but nothing was done. A review of Patient 1s Acute Care Hospitals (ACH) clinical records dated May 6, 2024, to May 8, 2024, indicated Patient 1 had been admitted on May 6, 2024, and discharged on May 8, 2024. Patient 1s ACHs clinical records indicated Patient 1 had received two units of blood and wound care to his right great toe. During an interview with LVN 3 on June 4, 2024, at 11:48 AM, LVN 3 stated Patient 1s wife had told him Patient 1 had been to the acute care hospital the week before (May 6, 2024, to May 11, 2024), but he could not remember the dates. LVN 3 stated he did not remember any specifics about Patient 1s acute care hospital stay and had not reported Patient 1s hospitalization to the Hospice Agencys staff. A review of Patient 1s care plans from May 5, 2024, to June 6, 2024, was conducted. There was no documented evidence to show Patient 1s acute care hospital admission had been care planned. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:10 PM, Patient 1s care plans from May 5, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show Patient 1s change in medical condition-acute care hospital admission had been care planned. 1c. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated on May 5, 2024, Patient 1 began bleeding from his rectum with bloody diarrhea. Patient 1s wife stated she called the Hospice Agency, and a nurse (Licensed Vocational Nurse (LVN 1)) came out and helped clean Patient 1, “;the blood was everywhere!” Patient 1s wife stated the nurse called the doctor and she (Patient 1s wife) was told it was not recommended for Patient 1 to go to the acute care hospital unless he started bleeding again. Patient 1s wife stated she took Patient 1 to his dialysis appointment the next day May 6, 2024, and told the dialysis nurse about the bleeding episode. Patient 1s wife stated the dialysis nurse told her dialysis could not be done on a patient who had been bleeding and to go to the acute care hospital immediately. Patient 1s wife stated she took Patient 1 to the acute care hospital where Patient 1 was admitted on May 6, 2024, through May 8, 2024, and received two units of blood and a wound was identified on his right great toe. Patient 1s wife stated she told the Hospice Agencys nurse (Licensed Vocational Nurse (LVN 3)) on May 16, 2024, about the acute care hospital admission, two units of blood and wound identification but nothing was done. Patient 1s wife stated she called the Hospice Agency on May 17, 2024, and asked for Patient 1s wound to be cared for. Patient 1s wife stated a nurse came out (Licensed Vocational Nurse (LVN 2)) who applied a dressing to Patient 1s right toe. A review of Patient 1s SN visit note dated May 16, 2024, by LVN 3, was conducted. There was no documented evidence to show LVN 3 had identified or assessed Patient 1s right great toe wound identified at the acute care hospital during the May 6, 2024, to May 8, 2024, admission. During an interview with LVN 3 on June 4, 2024, at 11:48 AM, LVN 3 stated Patient 1s wife had told him Patient 1 had been to the acute care hospital the week before (May 6, 2024, to May 11, 2024), but he could not remember the dates. LVN 3 stated he did not remember any specifics about Patient 1s acute care hospital stay and had not reported Patient 1s hospitalization to the Hospice Agencys staff. LVN 3 stated he had not conducted a thorough head-to-toe assessment of Patient 1 and had not noticed a wound to Patient 1s right great toe. A review of Patient 1s SN visit note dated May 17, 2024, by LVN 2, indicated, “;... PRN [as needed] visit [related to] wound care, ... verbal, calm, cooperative, respiration even and unlabored with no SOB [shortness of breath] noted, wife stated ... during patient bath she noticed open area on right great toe, no discharge or pus noted, BLE [bilateral lower extremities] warm to touch, patient denies any fever or chills and no pain or discomfort during visit, [MD] made aware with new order: cleanse open area on right great toe with NS [normal saline], pat dry, apply [wound gel] and cover with dry dressing secure with tape daily and as needed if dislodged or soiled [times]14 days and re-assess. Family/cg may perform wound care. ... May have wound consult. Wound care administered, tolerated well, ... Patient and wife educated on signs and symptoms of infection such as increase pain to site, increased redness, presence of ... pus, fever, chills. If any sign/symptoms of infection noticed to call [PMC-a Professional Medical Corporation] nurse advice line. Patient and wife encourage to wear proper fitting footwear, wife and patient acknowledge understanding, patient and wife encourage to monitor. follow up with podiatrist/ [primary care physician] and call [PMC] If there’s any questions or concerns ...” During an interview with LVN 2 on June 4, 2024, at 10:55 AM, LVN 2 stated he had conducted the SN visit because Patient 1s wife had called the office and informed them of the right great toe wound. A review of Patient 1s care plans from May 5, 2024, to June 6, 2024, was conducted. There was no documented evidence to show Patient 1s right great toe wound had been care planned. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:10 PM, Patient 1s care plans from May 5, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show Patient 1s right great toe wound had been care planned. 1d. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated Patient 1 died on May 20, 2024, 51 days after starting on the Hospice Agencys Palliative Care Program. Patient 1s wife stated the (PMC-a Professional Medical Corporation), and the Hospice Agency did not provide the aggressive care and services Patient 1 wanted to prolong and improve his life to the extent possible. A review of the agencys Palliative Care Programs discharge roster indicated Patient 1 had been discharged from the agency on May 21, 2024, due to death. A review of Patient 1s physicians orders from May 19, 2024, to June 6, 2024, was conducted. There was no documented evidence to show a discharge order had been obtained. A review of Patient 1s discharge summaries from May 19, 2024, to June 6, 2024, was conducted. There was no documented evidence to show a discharge summary had been documented. A review of Patient 1s care plans from May 5, 2024, to June 6, 2024, was conducted. There was no documented evidence to show discharge planning or Patient 1s death. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:10 PM, Patient 1s care plans from May 5, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show discharge planning or Patient 1s death. 2. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 12, 2024, into the Palliative Care Program. Patient 2 had diagnoses that included post right knee surgery and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). A review of Patient 2s care plans from April 12, 2024, to June 6, 2024, was conducted. There was no documented evidence to show Patient 2s care plans had been updated to reflect Patient 2s changes in medical condition, response to treatment or progress to targeted outcomes. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:42 PM, Patient 2s care plans from April 12, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show Patient 2s care plans had been updated to reflect Patient 2s changes in medical condition, response to treatment or progress to targeted outcomes. 3. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 24, 2024, into the Palliative Care Program. Patient 3 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), chest pain, diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a home visit and interview with Patient 3 on June 5, 2024, at 3:13 PM, in the presence of a Licensed Vocational Nurse (LVN 4), LVN 4 removed Patient 3s left foot shoe and sock. A wound was identified to the lower left great toe. The wound was the size of a nickel with a crater and raised edges. A small amount of fluid was oozing from the crater. Patient 3 stated she had the wound at admission to the agency. Patient 3 stated she had the wound on and off for about two years. Patient 3 stated she was supposed to get an orthotic device (braces, splints, and shoe inserts) for her shoe to help heal the wound, but she had not received one. A review of Patient 3s initial admission assessment dated May 24, 2024, was conducted. There was no documented evidence to show Patient 3s left great toe wound had been identified or assessed. A review of Patient 3s care plans from May 24, 2024, to June 6, 2024, was conducted. There was no documented evidence to show Patient 3s left great toe wound or dialysis had been care planned. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:44 PM, Patient 3s care plans from May 24, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show Patient 3s left great toe wound or dialysis had been care planned. 4. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 31, 2024, into the Palliative Care Program. Patient 4 had diagnoses that included diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a home visit and interview with Patient 4 and Patient 4s wife on June 5, 2024, from 10:05 AM to 10:33 AM, in the presence of a Licensed Vocational Nurse (LVN 5), Patient 4s wife stated Patient 4 fell all the time and he (Patient 4) had fallen three times in May 2024. Patient 4s wife stated Patient 4 fell when he transferred from his chair to his walker and from his walker to his chair, bed, and toilet. Patient 4s wife stated she had a hard time helping her husband transfer and ambulate because she was not very strong herself. Patient 4 stated he had a hard time using his walker because he could only raise is arms this much. Patient 4 demonstrated his physical limitation by raising his arms and showing they would not raise past his upper chest. Patient 4 stated it was too painful to raise his arms any further. Patient 4 stated he had back surgery a while ago where his lumbar vertebrae (lower back above tailbone) had been fused and he thought he probably needed more back surgery due to the problem of raising his arms. Patient 4 stated the walker he used was not stable enough to compensate for his arm raising limitation. Patient 4 stated he was so afraid to fall, so he rarely left his chair unless it was necessary. A review of Patient 4s initial admission assessment dated May 31, 2024, was conducted. There was no documented evidence to show Patient 4s repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest had been identified and assessed. A review of Patient 4s care plans from May 31, 2024, to June 6, 2024, was conducted. There was no documented evidence to show Patient 4s repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest had been care planned. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:54 PM, Patient 4s care plans from May 31, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show Patient 4s repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest had been care planned. A review of the agencys policy and procedure titled “;Treatment and Ongoing Decision-Making,” undated, indicated, “;POLICY STATEMENT: This policy establishes the framework for developing person-centered goals that form the basis for the plan of care and decisions related to providing, forgoing, and discontinuing treatments within the limits of applicable state and federal laws, current accepted standards of medical care, and professional standards of practice. The policy emphasizes ethical principles, the patient’s treatment preferences, and collaboration with families and decision-makers. PROCEDURE: 1. Development of Person-Centered Plan of Care: The patient’s plan of care reflects ethical principles and the assessment of treatment preferences. The plan of care is accurately documented to reflect the patient’s previously stated goals in terms of providing, forgoing, and discontinuing care. 2. Alignment of Treatments with Patient Goals: The IDT ensures that existing treatments align with the patient’s goals and standard practices of care. The team actively works to prevent medically non-beneficial care. ...” A review of the agencys policy and procedure titled “;Treatment,” undated, indicated, “;POLICY STATEMENT: Our organization is committed to providing comprehensive symptom management and care coordination in palliative care, ensuring that the Interdisciplinary Team (IDT) anticipates and addresses the impact of new symptom interventions on existing treatment regimens. This policy outlines the criteria and processes for the IDT to collaborate, assess, train, and support patients, families, and caregivers, incorporating advanced therapies when needed, and optimizing medication management through reconciliation, justification, and ongoing assessment is dedicated to providing patient-centered palliative care through the development of interdisciplinary care plans that address physical symptoms, maximize functional status, and enhance the quality of life. This policy outlines the criteria and processes for the Interdisciplinary Team (IDT) to actively involve patients and caregivers in care planning, employ evidence-based treatments for distressing symptoms and side effects, and regularly assess the need for and effectiveness of bowel regimens when opioids are prescribed. PROCEDURE: 1. Active 1nvolvement of Patients and Caregivers: a. The IDT encourages and facilitates the active involvement of patients and caregivers in developing the plan of care and managing physical symptoms. b. Patients and families are encouraged and given frequent opportunities to ask questions, seek support, and communicate changes in status, including worsening symptoms and treatment-associated side effects. ... 3. Patient-Centered Care Planning: Interdisciplinary care plans will be developed in the context of the patient’s goals of care, disease, prognosis, functional limitations, culture, and care setting. Plans will be regularly reviewed, at least every 14 days or when there is a significant change and adjusted based on changes in the patient’s health status, goals, or preferences. ...””

“Based on interview and record review, the agency failed to ensure the interdisciplinary group documented the patients or representatives level of understanding, involvement, and agreement with the plan of care for one of four sampled patients (Patient 1) when Patient 1 nor Patient 1’s representative consented to: treatment, a financial agreement, hospitalization, blood transfusion, or receipt of the Notice of Privacy Rights and Advance Directive information. This failure had the potential to cause Patient 1 and Patient 1s representative not to know and agree or disagree with the proposed care, treatment, services, medications, interventions, or procedures. Potential benefits, risks, or side-effects, including potential problems. The likelihood of achieving the goals established. Reasonable alternatives to the proposed treatment. Relevant risks, benefits, and side effects related to alternatives. In addition, Patient 1, and Patient 1s representative had the potential not to know their Privacy Rights or Advance Directive information. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, into the Palliative Care Program. Patient 1 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), end stage renal disease (a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant), diabetes mellitus (a disease that results in too much sugar in the blood) and congestive heart failure (a chronic condition in which the heart cannot pump or fill effectively). Patient 1 expired on May 20, 2024. A review of Patient 1s intake and admission documentation dated March 30, 2024, was conducted. There was no documented evidence to show Patient 1, or Patient 1s representative had received and signed consents for: treatment, a financial agreement, hospitalization, blood transfusion, or receipt of the Notice of Privacy Rights and Advance Directive information. During an interview with the Director of Patient Care Services (DPCS) on June 4, 2024, at 3:13 PM, The DPCS stated she had conducted the admission for Patient 1 and it had been her responsibility to explain and get the consents signed. The DPCS stated she did not have the consents forms with her, so she requested the office send the consents to Patient 1s email for signature. The DPCS stated she did not know the consents had never been sent to Patient 1. A review of the agencys policy and procedure titled “;Informed Consent,” undated, indicated, “;POLICY STATEMENT: In order for each [Palliative Care Program] patient to fully participate in decisions about his or her care treatment, and services, the following procedure will be employed to obtain informed consent. When a patient is determined to lack decision-making capacity their legally authorized representative will be informed, and consent obtained on the patient’s behalf. Informed consent will be obtained for the following decisions: Consent for Treatment, Financial Agreement ... Hospitalization ... Blood transfusion ... PROCEDURE: When any of the above listed care, treatment or services are recommended by the [Palliative Care Program] interdisciplinary team the following procedure will be followed: 1. The proposed treatment will be explained by the attending physician, [Palliative Care Program] physician or [Palliative Care Program] Registered Nurse. The goal is to establish a mutual understanding between the patient and the physician or other practitioner and to allow the patient to fully participate in decisions. 2. The process will include a discussion of the following elements; a. The nature of the proposed care, treatment, services, medications, interventions, or procedures. b. Potential benefits, risks, or side-effects, including potential problems c. The likelihood of achieving the goals established. d. Reasonable alternatives to the proposed treatment e. Relevant risks, benefits, and side effects related to alternatives. 3. A patient signature will be obtained for those documents specifically developed including the ... Consent for Treatment, Financial Agreement, ... Notice of Privacy Rights and Advance Directive information. 4. For other items, the [Palliative Care Program] staff member obtaining the consent will describe the process in a narrative note and document the verbal agreement/consent of the patient. The note will be signed and dated by the appropriate [Palliative Care Program] professional and filed in the medical record.””

“Based on observation, interview, and record review, the Governing Body (GB) failed to operate and manage the agency from March 1, 2022, to June 6, 2024, in a universe of 129 Palliative Care Program patients when: 1. Based on interview, and record review, the agency failed to ensure the patients’ initial assessment was completed within 48 hours of the physician’s referral date or on the physician-ordered start of care date for three of four sampled patients (Patients 1, 2, and 3). This failure had the potential to cause a delay in the determination of Patients 1, 2, and 3s immediate care and support needs. 2. Based on interview and record review, the agency failed to ensure the patients’ comprehensive assessments were completed within five days after the start of care for four of four sampled patients (Patient 1, 2, 3, and 4) when no spiritual or psychosocial assessments were conducted. This failure had the potential to cause the patient and familys psychosocial, emotional, and spiritual needs to go unmet. 3. Based on observation, interview, and record review, the agency failed to ensure the comprehensive assessment identified and addressed the physical and safety needs of two of four sampled patients (Patients 3 and 4) when: a. Patient 3’s left great toe wound was not identified or assessed during the admission assessment. b. Patient 4’s three falls in May or Patient 4s fear of falling was not identified or assessed. Patient 4’s inability to raise arms past his upper chest was not identified or assessed. This failure caused Patient 3 not to receive wound care for 12 days and Patient 4 not to receive care to address the inability of Patient 4 to raise his arms past his upper chest for six days. In addition, this failure had the potential to cause Patient 4 to fall again and suffer injuries. 4. Based on interview, and record review, the agency failed to ensure the comprehensive assessment was updated by the agency’s interdisciplinary group (in collaboration with the individuals attending physician) and considered changes that took place since the initial assessment for one of four sampled patients (Patient 1) when: a. Patient 1’s right great toe wound was not identified or assessed by the visiting Licensed Vocational Nurses. b. No re-admission assessment was conducted after Patient 1’s hospitalization from May 6, 2024, to May 8, 2024. c. No discharge summary for Patient 1 was documented and no discharge order for Patient 1 was obtained. This failure caused Patient 1 to suffer a delay in wound care, no re-assessment of care needs following an acute care hospital admission, caused Patient 1s attending physicians to be unaware of the medical condition and death of Patient 1 at discharge, and no physician oversight for Patient 1s discharge from the Palliative Care Program. 5. Based on interview and record review, the agency failed to ensure the Interdisciplinary Group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) members supervised and provided care and services to meet the physical, medical, psychosocial, emotional, and spiritual needs for four of four sampled patients (Patients 1, 2, 3, and 4) when: a. An admission order was not obtained for Patient 1. b. Patient 1’s gastrointestinal (GI) bleeding episode on May 5, 2024, was not discussed or addressed by the IDG. c. Patient 1’s hospital admission from May 6, 2024, to May 8, 2024, where Patient 1 received two units of blood was not discussed or addressed by the IDG. d. Patient 1’s right great toe wound identified at the hospital on May 8, 2024, was not discussed or addressed by the IDG. e. Patient 1’s death on May 20, 2024, and discharge on May 21, 2024, was not discussed or addressed by the IDG. f. There was no documented evidence to show the IDG evaluated, discussed, or provided general oversight for Patient 2s care. g. Patient 3’s left great toe wound was not discussed or addressed by the IDG. h. Patient 4’s three falls in May or patients fear of falling was not discussed or assessed by the IDG. Patient 4’s inability to raise arms past his upper chest was not discussed or assessed by the IDG. This failure caused Patient 1 to be admitted to the Palliative Care Program without a physicians order, and a potential to cause Patient 1 to suffer additional GI bleeds and delayed healing or worsening of Patient 1s right great toe wound. This failure caused the IDG to be unaware of the circumstances surrounding Patient 1s death. This failure had the potential to cause Patient 2 not to achieve her desired goals of care and delayed healing or worsening of Patient 3s left great toe wound. In addition, this failure had the potential to cause Patient 4 to suffer additional falls with injuries and his arm raising restriction to worsen. 6. Based on interview and record review, the agency failed to develop an individualized plan of care for four of four sampled patients (Patients 1, 2, 3, and 4) when: a. Patient 1’s a lower gastrointestinal (GI) bleeding episode on May 5, 2024, was not care planned. b. Patient 1’s hospital admission from May 6, 2024, to May 8, 2024, where Patient 1 received two units of blood was not care planned. c. Patient 1’s right great toe wound identified at the hospital on May 8, 2024, was not care planned. d. Patient 1’s plan of care did not include discharge planning. e. There was no documented evidence to show the IDG evaluated, discussed, or updated Patient 2’s care plan. f. Patient 3’s dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally) and left great toe wound were not care planned. g. Patient 4’s three falls in May 2024, and the patient’s fear of falling was not care planned. Patient 4’s inability to raise arms past his upper chest was not care planned. This failure had the potential to cause Patient 1 to suffer additional GI bleeds and delayed healing or worsening of Patient 1s right great toe wound. This failure caused the IDG and attending physician to be unaware of the circumstances surrounding Patient 1s death and the discharge from the program. This failure had the potential to cause Patient 2 not to achieve her desired goals of care. This failure had the potential to cause delayed healing or worsening of Patient 3s left great toe wound and unrecognized complications from dialysis treatments. In addition, this failure had the potential to cause Patient 4 to suffer additional falls with injuries and his arm raising restriction to worsen. 7. Based on interview and record review, the agency failed to ensure the interdisciplinary group documented the patients or representatives level of understanding, involvement, and agreement with the plan of care for one of four sampled patients (Patient 1) when Patient 1 nor Patient 1’s representative consented to: treatment, a financial agreement, hospitalization, blood transfusion, or receipt of the Notice of Privacy Rights and Advance Directive information. This failure had the potential to cause Patient 1 and Patient 1s representative not to know and agree or disagree with the proposed care, treatment, services, medications, interventions, or procedures. Potential benefits, risks, or side-effects, including potential problems. The likelihood of achieving the goals established. Reasonable alternatives to the proposed treatment. Relevant risks, benefits, and side effects related to alternatives. In addition, Patient 1, and Patient 1s representative had the potential not to know their Privacy Rights or Advance Directive information. 8a. Based on interview, and record review, the agency failed to operate and furnish services in compliance with State Law (California Code, Health, and Safety Code (HSC) § 1747.3), in a universe of 129 Palliative Care Program patients, when the agency: a. Failed to provide the California Department of Public Health Licensing and Certification Division (CDPH L&C) the date the agency intended to begin providing a Palliative Care Program. b. Failed to provide CDPH L&C the State form “HS 200 [a State licensing application].” c. Failed to provide CDPH L&C the Federal form “CMS 417 [a Federal certification application].” d. Failed to provide CDPH L&C information for the period of time in the prior calendar year during which the agency provided palliative care through the Online reporting portal, including but not limited to, all of the following: i. The number of nonhospice patients who received palliative care. ii. The number of patients enrolled in hospice. iv. The primary diagnoses of the patients for which the agency provided palliative care. v. The numbers and types of providers hired during the previous 12 months. vi. The numbers and types of providers who left employment during the previous 12 months. e. Complaints received by the agency during the previous 12 months that related to all the following: i. Events that caused or were likely to cause serious injury, harm, impairment, or death. ii. Events or incidents that negatively impacted a patient’s mental, physical, or psychosocial status and were of such consequence to the patient’s well-being that a rapid response was required. iii. Delays in patient care for hospice and nonhospice patients who received palliative care pursuant to this section. f. Failed to provide the qualifications of staff. g. Failed to be approved by CDPH L&C to provide palliative care. h. Failed to provide CDPH L&C all information the agency provided to the Office of Statewide Health Planning and Development. 8b. Based on observation, interview, and record review, the agency failed to ensure patients met the criteria to be admitted into the agencys Palliative Care Program (a program which helps patients facing chronic or quality of life-limiting illnesses, with the relief of uncontrolled symptoms, pain and stress without focusing on the patients regaining their independence, or becoming as self-sufficient as possible) instead of a Home Health Program (a program which helps patients get better from an illness or injury, regain their independence, and become as self-sufficient as possible) for three of four sampled patients (Patients 1, 2, and 3) when: i. Patient 1 had been admitted to the agencys Palliative Care Program after recently starting dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally) treatments and had diagnoses that included end stage renal disease (a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant), diabetes mellitus (a disease that results in too much sugar in the blood) and congestive heart failure (a chronic condition in which the heart cannot pump or fill effectively). Patient 1s wife stated Patient 1 had been on oxygen but was not short of breath and Patient 1 did not have pain. Patient 1s wife stated Patient 1 wanted to be monitored while adjusting to the new dialysis treatments and help with managing his diabetes mellitus. Patient 1s wife stated Patient 1 wanted every treatment done to help him become as functional and independent as possible. ii. Patient 2 had been admitted to the agencys Palliative Care Program after right knee surgery and had a diagnosis of osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). Patient 2 stated she had some right knee pain due to the surgery but otherwise everything was fine. Patient 2 stated she was excited to go back to work in a few weeks. iii. Patient 3 had been admitted to the agencys Palliative Care Program after a hospital stay for chest pain. Patient 3 was receiving dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally) treatments and had diagnoses that included chest pain, diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Patient 3 stated she had been receiving dialysis treatments for two years and was used to it. Patient 3 stated she did not have chest pain or any other pain. Patient 3 stated she was not on oxygen and did not have shortness of breath. Patient 3 stated she did not know what services the agency provided but she would like help with transportation to her doctors appointments, some Physical Therapy so she could walk again and someone to clean her bathroom. The cumulative effect of these systemic practices resulted in the agency operating an unlicensed and unapproved Palliative Care Program without governmental oversight. In addition, the agency admitted Patients 1, 2, and 3 into a Palliative Care Program with the potential to cause Patients 1, 2, and 3 not to receive the care and services needed for them to achieve their highest level of functioning and independence. 1a.A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, into the Palliative Care Program. Patient 1 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), end stage renal disease (a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant), diabetes mellitus (a disease that results in too much sugar in the blood) and congestive heart failure (a chronic condition in which the heart cannot pump or fill effectively). Patient 1 expired on May 20, 2024. A review of Patient 1s referral order dated February 19, 2024, indicated, “;palliative care.” A review of Patient 1s initial assessment dated March 30, 2024, indicated the initial assessment had been conducted on March 30, 2024. (The initial assessment had been completed 40 days after the physicians referral order) 1b. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 12, 2024, into the Palliative Care Program. Patient 2 had diagnoses that included post right knee surgery and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). A review of Patient 2s referral order dated April 1, 2024, by a PMC physician (PMC/MD) indicated, “;Evaluate and treat for palliative care program.” A review of Patient 2s initial assessment dated April 12, 2024, indicated the initial assessment had been conducted on April 12, 2024. (The initial assessment had been completed 11 days after the physicians referral order) 1c. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 24, 2024, into the Palliative Care Program. Patient 3 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), chest pain, diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Patient 3s referral order dated May 6, 2024, by a PMC physician (PMC/MD) indicated, “;Evaluate and treat for palliative care program.” A review of Patient 3s initial assessment dated May 24, 2024, indicated the initial assessment had been conducted on May 24, 2024. (The initial assessment had been completed 18 days after the physicians referral order) During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 11:22 AM, Patients 1, 2 and 3s referral orders and initial assessments were reviewed, respectively. The DPCS and CS verified Patients 1, 2, and 3, did not have an initial assessment within 48 hours of the referral to the agency and should have. A review of the agencys policy and procedure titled “;Patient Referral, Admission and Non-Admission,” undated, indicated, “;POLICY: All patients presenting for admission will be assessed to determine [Palliative Care Program] appropriateness. The admission will then be completed in a timely manner, no more than 48 hours from receiving the referral. Information regarding patient referral, admission and non-admissions will be monitored.” 2a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, into the Palliative Care Program. Patient 1 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), end stage renal disease (a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant), diabetes mellitus (a disease that results in too much sugar in the blood) and congestive heart failure (a chronic condition in which the heart cannot pump or fill effectively). Patient 1 expired on May 20, 2024. A review of Patient 1s Spiritual Counselors (SC) visit notes from March 30, 2024, to June 6, 2024, was conducted. There was no documented evidence to show the SC had reached out to Patient 1 or conducted an initial spiritual assessment. A review of Patient 1s Medical Social Workers (MSW) visit notes from March 30, 2024, to June 6, 2024, was conducted. There was no documented evidence to show the MSW had reached out to Patient 1 or conducted an initial psychosocial assessment. 2b. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 12, 2024, into the Palliative Care Program. Patient 2 had diagnoses that included post right knee surgery and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). A review of Patient 2s Spiritual Counselors (SC) visit notes from April 12, 2024, to June 6, 2024, was conducted. There was no documented evidence to show the SC had reached out to Patient 2 or conducted an initial spiritual assessment. A review of Patient 2s Medical Social Workers (MSW) visit notes from April 12, 2024, to June 6, 2024, was conducted. There was no documented evidence to show the MSW had reached out to Patient 2 or conducted an initial psychosocial assessment. During a home visit and interview with Patient 2 on June 5, 2024, at 1:36 PM to 1:49 PM, in the presence of a Licensed Vocational Nurse (LVN 4), Patient 2 stated she was very sad over her mothers death on April 18, 2024, and “;I wanted someone to talk to and listen to me.” Patient 2 stated she had reached out to LVN 4 for help. LVN 4 stated she had not offered Patient 2 Spiritual Counseling Services or Medical Social Worker Counseling Services because Patient 2 was a Palliative Care Program patient, and those services were for hospice patients. 2c. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 24, 2024, into the Palliative Care Program. Patient 3 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), chest pain, diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Patient 3s Spiritual Counselors (SC) visit notes from May 24, 2024, to June 6, 2024, was conducted. There was no documented evidence to show the SC had reached out to Patient 3 or conducted an initial spiritual assessment. A review of Patient 3s Medical Social Workers (MSW) visit notes from May 24, 2024, to June 6, 2024, was conducted. There was no documented evidence to show the MSW had reached out to Patient 3 or conducted an initial psychosocial assessment. During a home visit and interview with Patient 3 on June 5, 2024, at 2:53 PM to 3:10 PM, in the presence of a Licensed Vocational Nurse (LVN 4), Patient 3 stated she did not know what services the agency provided but she would like help with transportation to her doctors appointments, someone to familiarize her with available community services and someone to clean her bathroom. LVN 4 told Patient 3 she would reach out to her (Patient 3s) professional medical corporation (PMC) for a referral. LVN 4 stated she had not offered Patient 3 Medical Social Worker Services because Patient 3 was a Palliative Care Program patient, and those services were for hospice patients. 2d. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 31, 2024, into the Palliative Care Program. Patient 4 had diagnoses that included diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Patient 4s Spiritual Counselors (SC) visit notes from May 31, 2024, to June 6, 2024, was conducted. There was no documented evidence to show the SC had reached out to Patient 4 or conducted an initial spiritual assessment. A review of Patient 4s Medical Social Workers (MSW) visit notes from May 31, 2024, to June 6, 2024, was conducted. There was no documented evidence to show the MSW had reached out to Patient 4 or conducted an initial psychosocial assessment. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, from 12:06 PM to 12:23 PM, Patients 1, 2, 3, and 4s initial spiritual assessments and initial psychosocial assessments were reviewed. The DPCS and CS verified initial spiritual assessments and initial psychosocial assessments were not conducted for Patients 1, 2, 3, and 4. The DPCS and CS stated the agencys Palliative Care Program provided Spiritual Counseling Services and Medical Social Workers Services and the services should have been provided to Patients 1, 2, 3, and 4. A review of the agencys policy and procedure titled “;Comprehensive Assessment,” dated October 2015, indicated, “;PURPOSE: To provide guidelines for the comprehensive assessment. POLICY: A comprehensive patient assessment will be performed by the hospice IDG no later than 5 calendar days after the [Palliative Care Programs start of care date] in consultation with attending physician. PROCEDURE: ... R. The patient’s psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source and adequacy of environmental and other resources, coping mechanisms and the patient’s and family/caregiver’s reaction to illness. ... T. An assessment of the patient’s and family/caregiver’s spiritual orientation, including, as appropriate, any involvement in a religious group such as a church or synagogue or a support group such as Alcoholics Anonymous and spiritual concerns or needs such as despair, suffering, guilt, etc.” A review of the agencys policy and procedure titled “;Screening and Assessment,” undated, indicated, “;POLICY STATEMENT: Our organization recognizes the significance of spiritual care in enhancing the well-being of patients and families facing serious illness. The spiritual assessment process encompasses spiritual screening, spiritual history, and a full spiritual assessment to identify and address spiritual needs, distress, and preferences. All assessments are conducted using standardized tools, ensuring consistency and comprehensive understanding.” A review of the agencys policy and procedure titled “;Screening and Assessment,” undated, indicated, “;POLICY STATEMENT: Our organization recognizes the importance of assessing patient and family social supports, relationships, resources, and the care environment in palliative care. This policy outlines the criteria and processes for the Interdisciplinary Team (IDT) to screen and assess these social factors, aiming to maximize coping and quality of life. ... PROCEDURE: ... 3. Comprehensive Social Assessment: a. Family structure and function, including roles, quality of relationships, communication, and decision-making preferences and patterns, as well as an assessment of those involved if the patient is in the custody of the county or state. b. Patient and family strengths, resiliency, social and cultural support, and spirituality. c. The availability and ability of a support system to provide respite, assist with errands and chores, and guard against social vulnerability. d. The effect of illness or injury on intimacy and sexual expression, prior experiences with illness, disability and loss, risk of abuse, neglect or exploitation, incarceration, or risk of social isolation. e. Functional limitations that impact activities of daily living (ADLs), instrumental activities of daily living (IADLs), and cognition. f. Changes in patient or family members’ school enrollment, employment or vocational roles, recreational activities, and economic security. g. Identification and documentation if the adult patient or a family member served in the military, and whether the patient or family member may be eligible for VA benefits. h. Living arrangements and perceived impact of the living environment on patient and family quality of life, including safety issues. 1. Patient and family perceptions about caregiving needs, including caregiver availability and capacity. J. The need for adaptive equipment, home modifications, or transportation. k. financial vulnerability (eg, ability to pay rent or mortgage and other bills). I. Ability to access prescription and over-the-counter medications for any reason, including functional or financial issues. m. Nutritional needs and food insecurity n. Advance care planning and legal concerns (see Section 8: Ethical and Legal Aspects of Care) o. Patient and caregiver ability to read and understand information from health and social service providers, insurance companies, and the IDT, as well as the ability of the patient family to ask questions and advocate for their needs. p. The ability of the patient and/or family to adhere to medication or treatment regimens. q. Patient and family willingness and ability to engage or accept resources and referrals. r. The family’s needs, resources, resiliency, and capacity to provide care.” 3a. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 24, 2024, into the Palliative Care Program. Patient 3 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), chest pain, diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a home visit and interview with Patient 3 on June 5, 2024, at 3:13 PM, in the presence of a Licensed Vocational Nurse (LVN 4), LVN 4 removed Patient 3s left foot shoe and sock. A wound was identified to the lower left great toe. The wound was the size of a nickel with a crater and raised edges. A small amount of fluid was oozing from the crater. Patient 3 stated she had the wound at admission to the agency. Patient 3 stated she had the wound on and off for about two years. Patient 3 stated she was supposed to get an orthotic device (braces, splints, and shoe inserts) for her shoe to help heal the wound, but she had not received one. A review of Patient 3s initial admission assessment dated May 24, 2024, was conducted. There was no documented evidence to show Patient 3s left great toe wound had been identified or assessed. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, from 12:06 PM to 12:23 PM, Patient 3s initial admission assessment dated May 24, 2024, was reviewed. The DPCS and CS verified Patient 3s left great toe wound had not been identified or assessed and should have been. 3b. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 31, 2024, into the Palliative Care Program. Patient 4 had diagnoses that included diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a home visit and interview with Patient 4 and Patient 4s wife on June 5, 2024, from 10:05 AM to 10:33 AM, in the presence of a Licensed Vocational Nurse (LVN 5), Patient 4s wife stated Patient 4 fell all the time and he (Patient 4) had fallen three times in May 2024. Patient 4s wife stated Patient 4 fell when he transferred from his chair to his walker and from his walker to his chair, bed, and toilet. Patient 4s wife stated she had a hard time helping her husband transfer and ambulate because she was not very strong herself. Patient 4 stated he had a hard time using his walker because he could only raise is arms this much. Patient 4 demonstrated his physical limitation by raising his arms and showing they would not raise past his upper chest. Patient 4 stated it was too painful to raise his arms any further. Patient 4 stated he had back surgery a while ago where his lumbar vertebrae (lower back above tailbone) had been fused and he thought he probably needed more back surgery due to the problem of raising his arms. Patient 4 stated the walker he used was not stable enough to compensate for his arm raising limitation. Patient 4 stated he was so afraid to fall, so he rarely left his chair unless it was necessary. A review of Patient 4s initial admission assessment dated May 31, 2024, was conducted. There was no documented evidence to show Patient 4s repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest had been identified and assessed. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 11:49 AM, Patient 4s initial admission assessment dated May 31, 2024, was reviewed. The DPCS and CS verified Patient 4s repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest had not been identified and assessed and should have been. A review of the agencys policy and procedure titled “;Screening and Assessment,” undated, indicated, “;POLICY STATEMENT: Our organization is committed to ensuring a thorough assessment of physical symptoms and their impact on well-being, quality of life, and functional status for patients with serious illnesses. This policy outlines the criteria and processes for the Interdisciplinary Team (IDT) to conduct comprehensive symptom assessments, utilizing validated tools, considering patient preferences, and addressing challenges related to communication or cognitive impairment. ... PROCEDURE: ... 2. Comprehensive Symptom Assessment: Attention will be given to assessing various aspects of symptoms, including onset, quality, severity, provoking and relieving factors, response to prior treatment, level of burden, impact on functionality and quality of life, and the meaning of distressing symptoms. The IDT will consider the patient’s goals of care during the assessment process. The assessment will include a. Assessment of symptoms including pain, dyspnea, constipation, other physical symptoms b. Assessment of functional status c. Assessment of patient’s and family’s psychosocial status d. Assessment of cultural, spiritual, and religious beliefs e. Assessment of psychological symptoms including anxiety, stress, grief, and coping; standardized scales are used when appropriate f. psychiatric symptoms including depression, anxiety, and suicidal ideation.” 4a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, into the Palliative Care Program. Patient 1 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), end stage renal disease (a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant), diabetes mellitus (a disease that results in too much sugar in the blood) and congestive heart failure (a chronic condition in which the heart cannot pump or fill effectively). Patient 1 expired on May 20, 2024. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated on May 5, 2024, Patient 1 began bleeding from his rectum with bloody diarrhea. Patient 1s wife stated she called the Hospice Agency, and a nurse (Licensed Vocational Nurse (LVN 1)) came out and helped clean Patient 1, “;the blood was everywhere!” Patient 1s wife stated the nurse called the doctor and she (Patient 1s wife) was told it was not recommended for Patient 1 to go to the acute care hospital unless he started bleeding again. Patient 1&rs quo;s wife stated she took Patient 1 to his dialysis appointment the next day May 6, 2024, and told the dialysis nurse about the bleeding episode. Patient 1s wife stated the dialysis nurse told her dialysis could not be done on a patient who had been bleeding and to go to the acute care hospital immediately. Patient 1s wife stated she took Patient 1 to the acute care hospital where Patient 1 was admitted on May 6, 2024, through May 8, 2024, and received two units of blood and a wound was identified on his right great toe. Patient 1s wife stated she told the Hospice Agencys nurse (Licensed Vocational Nurse (LVN 3)) on May 16, 2024, about the acute care hospital admission, two units of blood and wound identification but nothing was done. Patient 1s wife stated she called the Hospice Agency on May 17, 2024, and asked for Patient 1s wound to be cared for. Patient 1s wife stated a nurse came out (Licensed Vocational Nurse (LVN 2)) and applied a dressing to Patient 1s right great toe but there was no referral to a wound specialist because of Patient 1s diabetes mellitus diagnosis. A review of Patient 1s Acute Care Hospitals (ACH) clinical records dated May 6, 2024, to May 8, 2024, indicated Patient 1 had been admitted on May 6, 2024, and discharged on May 8, 2024. Patient 1s “;Progress Note, Nursing-Wound Care Follow Up,” dated May 8, 2024, indicated, “;Reconsulted for great toe wound. WOUND # 2 [number two], Location: right great toe, Type of Wound: blood blister on diabetic foot, unknown origin, Pressure Injury Stage: n/a [not applicable] Size: 1 [one] CM [centimeter-a unit of measurement] X [by] 2 [two] CM X 0 [zero] CM, Tunneling or Undermining: none noted, Wound Appearance: blood blister under toenail Peri [around] wound: consistent with rest of skin, Edges: adherent, intact Drainage: none noted Odor: none noted, Pain Tolerance: PATIENT TOLERATED TREATMENT, Cleansed: [antiseptic] Dressing: OTA [open to air] ...” A review of Patient 1s Skilled Nursing (SN) visit notes from April 4, 2024, to May 16, 2024, were reviewed. There was no documented evidence to show a right great toe wound had been identified or assessed. A review of Patient 1s SN visit note dated May 16, 2024, by LVN 3, was conducted. There was no documented evidence to show LVN 3 had identified or assessed Patient 1s right great toe wound identified at the acute care hospital during the May 6, 2024, to May 8, 2024, admission. During an interview with LVN 3 on June 4, 2024, at 11:48 AM, LVN 3 stated Patient 1s wife had told him Patient 1 had been to the acute care hospital the week before, but he could not remember the dates. LVN 3 stated he did not remember any specifics about Patient 1s acute care hospital stay and had not reported Patient 1s hospitalization to the Hospice Agencys staff. LVN 3 stated he had not conducted a thorough head-to-toe assessment of Patient 1 and had not noticed a wound to Patient 1s right great toe. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, from 12:06 PM to 12:23 PM, Patient 1s Skilled Nursing (SN) visit notes from April 4, 2024, to May 16, 2024, were reviewed. The DPCS and CS verified Patient 1s right great toe wound had not been identified or assessed and should have been. 4b. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated on May 5, 2024, Patient 1 began bleeding from his rectum with bloody diarrhea. Patient 1s wife stated she called the Hospice Agency, and a nurse (Licensed Vocational Nurse (LVN 1)) came out and helped clean Patient 1, “;the blood was everywhere!” Patient 1s wife stated the nurse called the doctor and she (Patient 1s wife) was told it was not recommended for Patient 1 to go to the acute care hospital unless he started bleeding again. Patient 1s wife stated she took Patient 1 to his dialysis appointment the next day May 6, 2024, and told the dialysis nurse about the bleeding episode. Patient 1s wife stated the dialysis nurse told her dialysis could not be done on a patient who had been bleeding and to go to the acute care hospital immediately. Patient 1s wife stated she took Patient 1 to the acute care hospital where Patient 1 was admitted on May 6, 2024, through May 8, 2024, and received two units of blood and a wound was identified on his right great toe. Patient 1s wife stated she told the Hospice Agencys nurse (Licensed Vocational Nurse (LVN 3)) on May 16, 2024, about the acute care hospital admission, two units of blood and wound identification but nothing was done. A review of Patient 1s Acute Care Hospitals (ACH) clinical records dated May 6, 2024, to May 8, 2024, indicated Patient 1 had been admitted on May 6, 2024, and discharged on May 8, 2024. Patient 1s ACHs clinical records indicated Patient 1 had received two units of blood and wound care to his right great toe. A review of Patient 1s Comprehensive Assessments from May 8, 2024, to May 21, 2024, was conducted. There was no documented evidence to show Patient 1 had received a reassessment after discharge from the ACH. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, from 12:06 PM to 12:23 PM, Patient 1s Comprehensive Assessments from May 8, 2024, to May 21, 2024, were reviewed. The DPCS and CS verified Patient 1 did not receive a reassessment after discharge from the ACH and should have. 4c. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated Patient 1 died on May 20, 2024, 51 days after starting on the Hospice Agencys Palliative Care Program. Patient 1s wife stated the (PMC-a Professional Medical Corporation), and the Hospice Agency did not provide the aggressive care and services Patient 1 wanted to prolong and improve his life to the extent possible. A review of the agencys Palliative Care Programs discharge roster indicated Patient 1 had been discharged from the agency on May 21, 2024, due to death. A review of Patient 1s physicians orders from May 19, 2024, to June 6, 2024, was conducted. There was no documented evidence to show a discharge order had been obtained. A review of Patient 1s discharge summaries from May 19, 2024, to June 6, 2024, was conducted. There was no documented evidence to show a discharge summary had been documented. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, from 12:06 PM to 12:23 PM, Patient 1s physicians orders from May 19, 2024, to June 6, 2024, and discharge summaries from May 19, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified Patient 1 did not have a discharge order or discharge summary and should have. A review of the agencys policy and procedure titled “;Ongoing Comprehensive Assessments,” dated October 2012, indicated, “;PURPOSE: To provide guidelines for further assessment of patients during ongoing care. POLICY: The scope and intensity of ongoing [Palliative Care Program] patient assessments will be determined by the patient’s prognosis, diagnoses, condition, desire for care, response to previous care, and the care setting. PROCEDURE: 1. During each home visit, the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. ... 2. The nurse will assess the patient on each visit, for: A. Pain, including the origin, location, duration, severity, and relief measures. B. Secondary symptoms related to the terminal illness such as nausea, vomiting, and respiratory distress, and the patient’s response to medications and other interventions. C. Factors that alleviate or exacerbate physical symptoms. D. Current treatment related to the identified symptoms and the patient’s response. E. Vital signs appropriate to the patient’s condition. F. Breath sounds. G. Skin integrity. H. Bowel sounds, elimination (urinary and bowel). I. Mental status. J. Appetite/diet, nutritional status. K. Functional status. L. Safety/home environment. M. Patient and family/caregiver support. N. Spiritual issues. 0. Additional psychosocial issues. P. Progress toward [Palliative Care Program] goals and patient needs and problems. Q. Compliance with treatments and medication regimen. R. The need for an alternative setting or level of care. 3. Ongoing comprehensive assessment should focus on: A. Patient’s and family/caregiver’s response to care. B. Changes in patient condition, level of deterioration. C. Changes in patient diagnoses/prognosis. D. Changes in patient’s care environment or support systems. E. Change in patient’s and family/caregiver’s perceived needs. 4. Based on the 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. 5. Based upon the findings of the assessment, additional orders will be generated and forwarded to the physician (or other authorized licensed independent practitioner) for signature(s). 6. The physician will be notified to verify any changes in medications, including over-the&shy; counter medications, and treatment/interventions that require physician approval. ...” 5a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, into the Palliative Care Program. Patient 1 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), end stage renal disease (a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant), diabetes mellitus (a disease that results in too much sugar in the blood) and congestive heart failure (a chronic condition in which the heart cannot pump or fill effectively). Patient 1 expired on May 20, 2024. A review of Patient 1s physicians orders from March 30, 2024, to June 6, 2024, was conducted. There was no documented evidence to show an admission order for Patient 1. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:10 PM, Patient 1s physicians orders from March 30, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified Patient 1s did not have an admission order and should have. 5b. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated on May 5, 2024, Patient 1 began bleeding from his rectum with bloody diarrhea. Patient 1s wife stated she called the Hospice Agency, and a nurse (Licensed Vocational Nurse (LVN 1)) came out and helped clean Patient 1, “;the blood was everywhere!” Patient 1s wife stated the nurse called the doctor and she (Patient 1s wife) was told it was not recommended for Patient 1 to go to the acute care hospital unless he started bleeding again. A review of Patient 1s SN visit note, dated May 5, 2024, by LVN 1, indicated, “;The patient was seen today for a PRN [as needed] visit due to experiencing bloody, loose stools. The patients wife reported multiple episodes since 3 [three] a.m., with the last occurring around 11:30 a.m. Upon examination, the patient was found sitting on the toilet, awake, alert, and oriented, denying any pain. The patient is on continuous oxygen without respiratory distress and is currently not experiencing further episodes of loose stools or bleeding. The patient managed to walk from the toilet to the bed for cleaning, with no external hemorrhoids detected. The abdomen is soft, non-distended, and non-tender. The patient denies dizziness but feels slightly weaker. Dialysis is scheduled for the following day. ... The wife has been instructed to monitor for additional episodes of bloody stools or any changes in condition ... The physician has been informed, and there are no new orders at this time. The wife will consult with the primary medical doctor for additional guidance and is aware that, should excessive bleeding continue, it is imperative to contact emergency services immediately. ...” During an interview with LVN 1 on June 4, 2024, at 10:35 AM, LVN 1 stated he made an SN visit because Patient 1s wife had called and stated Patient 1 had loose stools, dark colored. LVN 1 stated he saw dark black tar like loose stools (black or tarry stools are due to bleeding in the upper part of the GI (gastrointestinal) tract, such as the esophagus, stomach, or the first part of the small intestine. In this case, blood is darker because it gets digested on its way through the GI tract) on the bedsheets, on the floor of bedroom and floor of bathroom and on and in the toilet. LVN 1 stated he helped clean up Patient 1. LVN 1 stated he texted the Medical Director (MD) directly. LVN 1 stated the MD responded, “;thank you for the update” and I was not given any instruction to give Patient 1 or the family. LVN 1 stated he had made an independent decision to tell Patient 1s wife to take Patient 1 to the acute care hospital if the bleeding started again. During an interview with the MD on June 4, 2024, at 12:15 PM to 12:41 PM, the MD stated he was the Medical Director for the Hospice Agencys Palliative Care Program. The MD stated he had received a text from LVN 1 on May 5, 2024, and he had responded, “;thank you for the update.” The MD stated he had not given LVN 1 any direction to give Patient 1 or the family. The MD stated he did not think the bleeding was an urgent situation at the time but after reviewing Patient 1s previous medical history he should have instructed Patient 1 to go to the acute care hospital. A review of Patient 1s IDG meeting notes from May 5, 2024, to June 6, 2024, was conducted. There was no documented evidence to show acknowledgment of Patient 1s change in medical condition, response to treatment or progress to targeted outcomes. There was no documented evidence to show a problem-solving discussion, new interventions, or update to Patient 1s plan of care. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:10 PM, Patient 1s IDG meeting notes from May 5, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show acknowledgment of Patient 1s change in medical condition, response to treatment or progress to targeted outcomes. The DPCS and CS stated there was no documented evidence to show a problem-solving discussion, new interventions, or update to Patient 1s plan of care. 5c. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated on May 5, 2024, Patient 1 began bleeding from his rectum with bloody diarrhea. Patient 1s wife stated she called the Hospice Agency, and a nurse (Licensed Vocational Nurse (LVN 1)) came out and helped clean Patient 1, “;the blood was everywhere!” Patient 1s wife stated the nurse called the doctor and she (Patient 1s wife) was told it was not recommended for Patient 1 to go to the acute care hospital unless he started bleeding again. Patient 1s wife stated she took Patient 1 to his dialysis appointment the next day May 6, 2024, and told the dialysis nurse about the bleeding episode. Patient 1s wife stated the dialysis nurse told her dialysis could not be done on a patient who had been bleeding and to go to the acute care hospital immediately. Patient 1s wife stated she took Patient 1 to the acute care hospital where Patient 1 was admitted on May 6, 2024, through May 8, 2024, and received two units of blood and a wound was identified on his right great toe. Patient 1s wife stated she told the Hospice Agencys nurse (Licensed Vocational Nurse (LVN 3)) on May 16, 2024, about the acute care hospital admission, two units of blood and wound identification but nothing was done. A review of Patient 1s Acute Care Hospitals (ACH) clinical records dated May 6, 2024, to May 8, 2024, indicated Patient 1 had been admitted on May 6, 2024, and discharged on May 8, 2024. Patient 1s ACHs clinical records indicated Patient 1 had received two units of blood and wound care to his right great toe. During an interview with LVN 3 on June 4, 2024, at 11:48 AM, LVN 3 stated Patient 1s wife had told him Patient 1 had been to the acute care hospital the week before (May 6, 2024, to May 11, 2024), but he could not remember the dates. LVN 3 stated he did not remember any specifics about Patient 1s acute care hospital stay and had not reported Patient 1s hospitalization to the Hospice Agencys staff. A review of Patient 1s IDG meeting notes from May 5, 2024, to June 6, 2024, was conducted. There was no documented evidence to show acknowledgment of Patient 1s acute care hospital admission, response to treatment or progress to targeted outcomes. There was no documented evidence to show a problem-solving discussion on the acute care hospitalization, new interventions, or update to Patient 1s plan of care post-acute care hospital admission. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:10 PM, Patient 1s IDG meeting notes from May 5, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show acknowledgment of Patient 1s change in medical condition-acute care hospital admission, response to treatment or progress to targeted outcomes. The DPCS and CS stated there was no documented evidence to show a problem-solving discussion on the acute care hospitalization, new interventions, or update to Patient 1s plan of care post-acute care hospital admission. 5d. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated on May 5, 2024, Patient 1 began bleeding from his rectum with bloody diarrhea. Patient 1s wife stated she called the Hospice Agency, and a nurse (Licensed Vocational Nurse (LVN 1)) came out and helped clean Patient 1, “;the blood was everywhere!” Patient 1s wife stated the nurse called the doctor and she (Patient 1s wife) was told it was not recommended for Patient 1 to go to the acute care hospital unless he started bleeding again. Patient 1s wife stated she took Patient 1 to his dialysis appointment the next day May 6, 2024, and told the dialysis nurse about the bleeding episode. Patient 1s wife stated the dialysis nurse told her dialysis could not be done on a patient who had been bleeding and to go to the acute care hospital immediately. Patient 1s wife stated she took Patient 1 to the acute care hospital where Patient 1 was admitted on May 6, 2024, through May 8, 2024, and received two units of blood and a wound was identified on his right great toe. Patient 1s wife stated she told the Hospice Agencys nurse (Licensed Vocational Nurse (LVN 3)) on May 16, 2024, about the acute care hospital admission, two units of blood and wound identification but nothing was done. Patient 1s wife stated she called the Hospice Agency on May 17, 2024, and asked for Patient 1s wound to be cared for. Patient 1s wife stated a nurse came out (Licensed Vocational Nurse (LVN 2)) who applied a dressing to Patient 1s right toe. A review of Patient 1s SN visit note dated May 16, 2024, by LVN 3, was conducted. There was no documented evidence to show LVN 3 had identified or assessed Patient 1s right great toe wound identified at the acute care hospital during the May 6, 2024, to May 8, 2024, admission. During an interview with LVN 3 on June 4, 2024, at 11:48 AM, LVN 3 stated Patient 1s wife had told him Patient 1 had been to the acute care hospital the week before (May 6, 2024, to May 11, 2024), but he could not remember the dates. LVN 3 stated he did not remember any specifics about Patient 1s acute care hospital stay and had not reported Patient 1s hospitalization to the Hospice Agencys staff. LVN 3 stated he had not conducted a thorough head-to-toe assessment of Patient 1 and had not noticed a wound to Patient 1s right great toe. A review of Patient 1s SN visit note dated May 17, 2024, by LVN 2, indicated, “;... PRN [as needed] visit [related to] wound care, ... verbal, calm, cooperative, respiration even and unlabored with no SOB [shortness of breath] noted, wife stated ... during patient bath she noticed open area on right great toe, no discharge or pus noted, BLE [bilateral lower extremities] warm to touch, patient denies any fever or chills and no pain or discomfort during visit, [MD] made aware with new order: cleanse open area on right great toe with NS [normal saline], pat dry, apply [wound gel] and cover with dry dressing secure with tape daily and as needed if dislodged or soiled [times]14 days and re-assess. Family/cg may perform wound care. ... May have wound consult. Wound care administered, tolerated well, ... Patient and wife educated on signs and symptoms of infection such as increase pain to site, increased redness, presence of ... pus, fever, chills. If any sign/symptoms of infection noticed to call [PMC-a Professional Medical Corporation] nurse advice line. Patient and wife encourage to wear proper fitting footwear, wife and patient acknowledge understanding, patient and wife encourage to monitor. follow up with podiatrist/ [primary care physician] and call [PMC] If there’s any questions or concerns ...” During an interview with LVN 2 on June 4, 2024, at 10:55 AM, LVN 2 stated he had conducted the SN visit because Patient 1s wife had called the office and informed them of the right great toe wound. A review of Patient 1s IDG meeting notes from May 5, 2024, to June 6, 2024, was conducted. There was no documented evidence to show acknowledgment of Patient 1s right great toe wound, response to treatment or progress to targeted outcomes. There was no documented evidence to show a problem-solving discussion on the right great toe wound, new interventions, or update to Patient 1s plan of care for the right great toe wound. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:10 PM, Patient 1s IDG meeting notes from May 5, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show acknowledgment of Patient 1s right great toe wound, response to treatment or progress to targeted outcomes. The DPCS and CS stated there was no documented evidence to show a problem-solving discussion on the right great toe wound, new interventions, or update to Patient 1s plan of care for the right great toe wound. 5e. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated Patient 1 died on May 20, 2024, 51 days after starting on the Hospice Agencys Palliative Care Program. Patient 1s wife stated the (PMC-a Professional Medical Corporation), and the Hospice Agency did not provide the aggressive care and services Patient 1 wanted to prolong and improve his life to the extent possible. A review of the agencys Palliative Care Programs discharge roster indicated Patient 1 had been discharged from the agency on May 21, 2024, due to death. A review of Patient 1s physicians orders from May 19, 2024, to June 6, 2024, was conducted. There was no documented evidence to show a discharge order had been obtained. A review of Patient 1s discharge summaries from May 19, 2024, to June 6, 2024, was conducted. There was no documented evidence to show a discharge summary had been documented. A review of Patient 1s IDG meeting notes from May 5, 2024, to June 6, 2024, was conducted. There was no documented evidence to show acknowledgment of Patient 1s death and discharge from the agency. There was no documented evidence to show a problem-solving discussion on the circumstances surrounding Patient 1s death. Patient 1s plan of care did not indicate a discharge plan and there was no update to Patient 1s plan of care regarding the death and discharge. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:10 PM, Patient 1s IDG meeting notes from May 5, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no acknowledgment of Patient 1s death and discharge from the agency. The DPCS and CS stated there was no documented evidence to show a problem-solving discussion on the circumstances surrounding Patient 1s death and Patient 1s plan of care did not indicate a discharge plan. In addition, there was no update to Patient 1s plan of care regarding the death and discharge. 5f. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 12, 2024, into the Palliative Care Program. Patient 2 had diagnoses that included post right knee surgery and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). A review of Patient 2s IDG meeting notes from April 12, 2024, to June 6, 2024, was conducted. There was no documented evidence to show a discussion of Patient 2s medical condition, response to treatment or progress to targeted outcomes. There was no documented evidence to show a problem-solving discussion, new interventions, or update to Patient 2s plan of care. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:42 PM, Patient 2s IDG meeting notes from April 12, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show a discussion of Patient 2s medical condition, response to treatment or progress to targeted outcomes. The DPCS and CS stated there was no documented evidence to show a problem-solving discussion, new interventions, or update to Patient 2s plan of care. 5g. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 24, 2024, into the Palliative Care Program. Patient 3 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), chest pain, diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a home visit and interview with Patient 3 on June 5, 2024, at 3:13 PM, in the presence of a Licensed Vocational Nurse (LVN 4), LVN 4 removed Patient 3s left foot shoe and sock. A wound was identified to the lower left great toe. The wound was the size of a nickel with a crater and raised edges. A small amount of fluid was oozing from the crater. Patient 3 stated she had the wound at admission to the agency. Patient 3 stated she had the wound on and off for about two years. Patient 3 stated she was supposed to get an orthotic device (braces, splints, and shoe inserts) for her shoe to help heal the wound, but she had not received one. A review of Patient 3s initial admission assessment dated May 24, 2024, was conducted. There was no documented evidence to show Patient 3s left great toe wound had been identified or assessed. A review of Patient 3s IDG meeting notes from May 24, 2024, to June 6, 2024, was conducted. There was no documented evidence to show acknowledgment of Patient 3s left great toe wound, response to treatment or progress to targeted outcomes. There was no documented evidence to show a problem-solving discussion on the left great toe wound, new interventions, or update to Patient 3s plan of care for the left great toe wound. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:44 PM, Patient 3s IDG meeting notes from May 24, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show acknowledgment of Patient 3s left great toe wound, response to treatment or progress to targeted outcomes. The DPCS and CS stated there was no documented evidence to show a problem-solving discussion on the left great toe wound, new interventions, or update to Patient 3s plan of care for the left great toe wound. 5h. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 31, 2024, into the Palliative Care Program. Patient 4 had diagnoses that included diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a home visit and interview with Patient 4 and Patient 4s wife on June 5, 2024, from 10:05 AM to 10:33 AM, in the presence of a Licensed Vocational Nurse (LVN 5), Patient 4s wife stated Patient 4 fell all the time and he (Patient 4) had fallen three times in May 2024. Patient 4s wife stated Patient 4 fell when he transferred from his chair to his walker and from his walker to his chair, bed, and toilet. Patient 4s wife stated she had a hard time helping her husband transfer and ambulate because she was not very strong herself. Patient 4 stated he had a hard time using his walker because he could only raise is arms this much. Patient 4 demonstrated his physical limitation by raising his arms and showing they would not raise past his upper chest. Patient 4 stated it was too painful to raise his arms any further. Patient 4 stated he had back surgery a while ago where his lumbar vertebrae (lower back above tailbone) had been fused and he thought he probably needed more back surgery due to the problem of raising his arms. Patient 4 stated the walker he used was not stable enough to compensate for his arm raising limitation. Patient 4 stated he was so afraid to fall, so he rarely left his chair unless it was necessary. A review of Patient 4s initial admission assessment dated May 31, 2024, was conducted. There was no documented evidence to show Patient 4s repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest had been identified and assessed. A review of Patient 4s IDG meeting notes from May 31, 2024, to June 6, 2024, was conducted. There was no documented evidence to show acknowledgment of Patient 4s repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest, response to treatment or progress to targeted outcomes. There was no documented evidence to show a problem-solving discussion on the repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest, new interventions, or update to Patient 4s plan of care for the repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:54 PM, Patient 4s IDG meeting notes from May 31, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show acknowledgment of Patient 4s repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest, response to treatment or progress to targeted outcomes. The DPCS and CS stated there was no documented evidence to show a problem-solving discussion on the repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest, new interventions, or update to Patient 4s plan of care for the repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest. A review of the agencys policy and procedure titled, “;Interdisciplinary Team Structure and Processes,” undated, indicated, “;POLICY STATEMENT: Our organization is dedicated to delivering high-quality palliative care that prioritizes the diverse needs of patients and their families. Guided by the Clinical Practice Guidelines for Quality Palliative Care, this policy outlines the structure and processes of the Interdisciplinary Team (IDT) to ensure comprehensive, patient-centered care. PROCEDURE: 1. Interdisciplinary Team Composition: The core IDT shall include professionals from various disciplines, such as: Physicians, Skilled Nurses, Social workers, Chaplains. The IDT may also include other professionals with credentials, experience, and skills to meet the needs of the patient and family. Each team member’s credentials, experience, and skills shall be considered to meet the specific needs of the patient and family. ... 3. Palliative Care Plan implementation: The IDT shall facilitate the implementation and ongoing refinement of the palliative care plan. Regular communication with all care providers shall be maintained to support patient and family goals. ... 5. Regular IDT Meetings: The IDT shall meet regularly to discuss patient care, IDT functioning, and operational details essential to the provision of quality palliative care. The IDT will meet no less than every 14 days for each patient. However, meeting frequency can be increased based on the needs of the population served, care setting(s), and service model. 6. 24/7 Access to Palliative Care Staff: Patients and families shall have access to palliative care staff 24 hours a day, seven days a week through phone or telehealth applications. 7. Continuity with Community Services: The IDT shall access and ensure continuity with community services for families caring for neonates, children, or adults with a serious illness. ...” A review of the agencys policy and procedure titled, “;Interdisciplinary Group Meeting,” dated April 2015, indicated, “;PURPOSE: To define the process for interdisciplinary group meetings and documenting patient status in the clinical record. POLICY: The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires. The meeting will be facilitated by the hospice Clinical Supervisor/Nursing Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available. The patient and family/caregiver will be informed of the schedule for this meeting, its purpose, and that the discussion is confidential.” 6a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, into the Palliative Care Program. Patient 1 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), end stage renal disease (a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant), diabetes mellitus (a disease that results in too much sugar in the blood) and congestive heart failure (a chronic condition in which the heart cannot pump or fill effectively). Patient 1 expired on May 20, 2024. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated on May 5, 2024, Patient 1 began bleeding from his rectum with bloody diarrhea. Patient 1s wife stated she called the Hospice Agency, and a nurse (Licensed Vocational Nurse (LVN 1)) came out and helped clean Patient 1, “;the blood was everywhere!” Patient 1s wife stated the nurse called the doctor and she (Patient 1s wife) was told it was not recommended for Patient 1 to go to the acute care hospital unless he started bleeding again. A review of Patient 1s SN visit note, dated May 5, 2024, by LVN 1, indicated, “;The patient was seen today for a PRN [as needed] visit due to experiencing bloody, loose stools. The patients wife reported multiple episodes since 3 [three] a.m., with the last occurring around 11:30 a.m. Upon examination, the patient was found sitting on the toilet, awake, alert, and oriented, denying any pain. The patient is on continuous oxygen without respiratory distress and is currently not experiencing further episodes of loose stools or bleeding. The patient managed to walk from the toilet to the bed for cleaning, with no external hemorrhoids detected. The abdomen is soft, non-distended, and non-tender. The patient denies dizziness but feels slightly weaker. Dialysis is scheduled for the following day. ... The wife has been instructed to monitor for additional episodes of bloody stools or any changes in condition ... The physician has been informed, and there are no new orders at this time. The wife will consult with the primary medical doctor for additional guidance and is aware that, should excessive bleeding continue, it is imperative to contact emergency services immediately. ...” During an interview with LVN 1 on June 4, 2024, at 10:35 AM, LVN 1 stated he made an SN visit because Patient 1s wife had called and stated Patient 1 had loose stools, dark colored. LVN 1 stated he saw dark black tar like loose stools (black or tarry stools are due to bleeding in the upper part of the GI (gastrointestinal) tract, such as the esophagus, stomach, or the first part of the small intestine. In this case, blood is darker because it gets digested on its way through the GI tract) on the bedsheets, on the floor of bedroom and floor of bathroom and on and in the toilet. LVN 1 stated he helped clean up Patient 1. LVN 1 stated he texted the Medical Director (MD) directly. LVN 1 stated the MD responded, “;thank you for the update” and I was not given any instruction to give Patient 1 or the family. LVN 1 stated he had made an independent decision to tell Patient 1s wife to take Patient 1 to the acute care hospital if the bleeding started again. During an interview with the MD on June 4, 2024, at 12:15 PM to 12:41 PM, the MD stated he was the Medical Director for the Hospice Agencys Palliative Care Program. The MD stated he had received a text from LVN 1 on May 5, 2024, and he had responded, “;thank you for the update.” The MD stated he had not given LVN 1 any direction to give Patient 1 or the family. The MD stated he did not think the bleeding was an urgent situation at the time but after reviewing Patient 1s previous medical history he should have instructed Patient 1 to go to the acute care hospital. A review of Patient 1s care plans from May 5, 2024, to June 6, 2024, was conducted. There was no documented evidence to show Patient 1s change in medical condition (GI bleed) had been care planned. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:10 PM, Patient 1s care plans from May 5, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show Patient 1s change in medical condition (GI bleed) had been care planned. 6b. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated on May 5, 2024, Patient 1 began bleeding from his rectum with bloody diarrhea. Patient 1s wife stated she called the Hospice Agency, and a nurse (Licensed Vocational Nurse (LVN 1)) came out and helped clean Patient 1, “;the blood was everywhere!” Patient 1s wife stated the nurse called the doctor and she (Patient 1s wife) was told it was not recommended for Patient 1 to go to the acute care hospital unless he started bleeding again. Patient 1s wife stated she took Patient 1 to his dialysis appointment the next day May 6, 2024, and told the dialysis nurse about the bleeding episode. Patient 1s wife stated the dialysis nurse told her dialysis could not be done on a patient who had been bleeding and to go to the acute care hospital immediately. Patient 1s wife stated she took Patient 1 to the acute care hospital where Patient 1 was admitted on May 6, 2024, through May 8, 2024, and received two units of blood and a wound was identified on his right great toe. Patient 1s wife stated she told the Hospice Agencys nurse (Licensed Vocational Nurse (LVN 3)) on May 16, 2024, about the acute care hospital admission, two units of blood and wound identification but nothing was done. A review of Patient 1s Acute Care Hospitals (ACH) clinical records dated May 6, 2024, to May 8, 2024, indicated Patient 1 had been admitted on May 6, 2024, and discharged on May 8, 2024. Patient 1s ACHs clinical records indicated Patient 1 had received two units of blood and wound care to his right great toe. During an interview with LVN 3 on June 4, 2024, at 11:48 AM, LVN 3 stated Patient 1s wife had told him Patient 1 had been to the acute care hospital the week before (May 6, 2024, to May 11, 2024), but he could not remember the dates. LVN 3 stated he did not remember any specifics about Patient 1s acute care hospital stay and had not reported Patient 1s hospitalization to the Hospice Agencys staff. A review of Patient 1s care plans from May 5, 2024, to June 6, 2024, was conducted. There was no documented evidence to show Patient 1s acute care hospital admission had been care planned. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:10 PM, Patient 1s care plans from May 5, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show Patient 1s change in medical condition-acute care hospital admission had been care planned. 6c. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated on May 5, 2024, Patient 1 began bleeding from his rectum with bloody diarrhea. Patient 1s wife stated she called the Hospice Agency, and a nurse (Licensed Vocational Nurse (LVN 1)) came out and helped clean Patient 1, “;the blood was everywhere!” Patient 1s wife stated the nurse called the doctor and she (Patient 1s wife) was told it was not recommended for Patient 1 to go to the acute care hospital unless he started bleeding again. Patient 1s wife stated she took Patient 1 to his dialysis appointment the next day May 6, 2024, and told the dialysis nurse about the bleeding episode. Patient 1s wife stated the dialysis nurse told her dialysis could not be done on a patient who had been bleeding and to go to the acute care hospital immediately. Patient 1s wife stated she took Patient 1 to the acute care hospital where Patient 1 was admitted on May 6, 2024, through May 8, 2024, and received two units of blood and a wound was identified on his right great toe. Patient 1s wife stated she told the Hospice Agencys nurse (Licensed Vocational Nurse (LVN 3)) on May 16, 2024, about the acute care hospital admission, two units of blood and wound identification but nothing was done. Patient 1s wife stated she called the Hospice Agency on May 17, 2024, and asked for Patient 1s wound to be cared for. Patient 1s wife stated a nurse came out (Licensed Vocational Nurse (LVN 2)) who applied a dressing to Patient 1s right toe. A review of Patient 1s SN visit note dated May 16, 2024, by LVN 3, was conducted. There was no documented evidence to show LVN 3 had identified or assessed Patient 1s right great toe wound identified at the acute care hospital during the May 6, 2024, to May 8, 2024, admission. During an interview with LVN 3 on June 4, 2024, at 11:48 AM, LVN 3 stated Patient 1s wife had told him Patient 1 had been to the acute care hospital the week before (May 6, 2024, to May 11, 2024), but he could not remember the dates. LVN 3 stated he did not remember any specifics about Patient 1s acute care hospital stay and had not reported Patient 1s hospitalization to the Hospice Agencys staff. LVN 3 stated he had not conducted a thorough head-to-toe assessment of Patient 1 and had not noticed a wound to Patient 1s right great toe. A review of Patient 1s SN visit note dated May 17, 2024, by LVN 2, indicated, “;... PRN [as needed] visit [related to] wound care, ... verbal, calm, cooperative, respiration even and unlabored with no SOB [shortness of breath] noted, wife stated ... during patient bath she noticed open area on right great toe, no discharge or pus noted, BLE [bilateral lower extremities] warm to touch, patient denies any fever or chills and no pain or discomfort during visit, [MD] made aware with new order: cleanse open area on right great toe with NS [normal saline], pat dry, apply [wound gel] and cover with dry dressing secure with tape daily and as needed if dislodged or soiled [times]14 days and re-assess. Family/cg may perform wound care. ... May have wound consult. Wound care administered, tolerated well, ... Patient and wife educated on signs and symptoms of infection such as increase pain to site, increased redness, presence of ... pus, fever, chills. If any sign/symptoms of infection noticed to call [PMC-a Professional Medical Corporation] nurse advice line. Patient and wife encourage to wear proper fitting footwear, wife and patient acknowledge understanding, patient and wife encourage to monitor. follow up with podiatrist/ [primary care physician] and call [PMC] If there’s any questions or concerns ...” During an interview with LVN 2 on June 4, 2024, at 10:55 AM, LVN 2 stated he had conducted the SN visit because Patient 1s wife had called the office and informed them of the right great toe wound. A review of Patient 1s care plans from May 5, 2024, to June 6, 2024, was conducted. There was no documented evidence to show Patient 1s right great toe wound had been care planned. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:10 PM, Patient 1s care plans from May 5, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show Patient 1s right great toe wound had been care planned. 6d. During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated Patient 1 died on May 20, 2024, 51 days after starting on the Hospice Agencys Palliative Care Program. Patient 1s wife stated the (PMC-a Professional Medical Corporation), and the Hospice Agency did not provide the aggressive care and services Patient 1 wanted to prolong and improve his life to the extent possible. A review of the agencys Palliative Care Programs discharge roster indicated Patient 1 had been discharged from the agency on May 21, 2024, due to death. A review of Patient 1s physicians orders from May 19, 2024, to June 6, 2024, was conducted. There was no documented evidence to show a discharge order had been obtained. A review of Patient 1s discharge summaries from May 19, 2024, to June 6, 2024, was conducted. There was no documented evidence to show a discharge summary had been documented. A review of Patient 1s care plans from May 5, 2024, to June 6, 2024, was conducted. There was no documented evidence to show discharge planning or Patient 1s death. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:10 PM, Patient 1s care plans from May 5, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show discharge planning or Patient 1s death. 6e. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 12, 2024, into the Palliative Care Program. Patient 2 had diagnoses that included post right knee surgery and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). A review of Patient 2s care plans from April 12, 2024, to June 6, 2024, was conducted. There was no documented evidence to show Patient 2s care plans had been updated to reflect Patient 2s changes in medical condition, response to treatment or progress to targeted outcomes. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:42 PM, Patient 2s care plans from April 12, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show Patient 2s care plans had been updated to reflect Patient 2s changes in medical condition, response to treatment or progress to targeted outcomes. 6f. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 24, 2024, into the Palliative Care Program. Patient 3 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), chest pain, diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a home visit and interview with Patient 3 on June 5, 2024, at 3:13 PM, in the presence of a Licensed Vocational Nurse (LVN 4), LVN 4 removed Patient 3s left foot shoe and sock. A wound was identified to the lower left great toe. The wound was the size of a nickel with a crater and raised edges. A small amount of fluid was oozing from the crater. Patient 3 stated she had the wound at admission to the agency. Patient 3 stated she had the wound on and off for about two years. Patient 3 stated she was supposed to get an orthotic device (braces, splints, and shoe inserts) for her shoe to help heal the wound, but she had not received one. A review of Patient 3s initial admission assessment dated May 24, 2024, was conducted. There was no documented evidence to show Patient 3s left great toe wound had been identified or assessed. A review of Patient 3s care plans from May 24, 2024, to June 6, 2024, was conducted. There was no documented evidence to show Patient 3s left great toe wound or dialysis had been care planned. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:44 PM, Patient 3s care plans from May 24, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show Patient 3s left great toe wound or dialysis had been care planned. 6g. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 31, 2024, into the Palliative Care Program. Patient 4 had diagnoses that included diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a home visit and interview with Patient 4 and Patient 4s wife on June 5, 2024, from 10:05 AM to 10:33 AM, in the presence of a Licensed Vocational Nurse (LVN 5), Patient 4s wife stated Patient 4 fell all the time and he (Patient 4) had fallen three times in May 2024. Patient 4s wife stated Patient 4 fell when he transferred from his chair to his walker and from his walker to his chair, bed, and toilet. Patient 4s wife stated she had a hard time helping her husband transfer and ambulate because she was not very strong herself. Patient 4 stated he had a hard time using his walker because he could only raise is arms this much. Patient 4 demonstrated his physical limitation by raising his arms and showing they would not raise past his upper chest. Patient 4 stated it was too painful to raise his arms any further. Patient 4 stated he had back surgery a while ago where his lumbar vertebrae (lower back above tailbone) had been fused and he thought he probably needed more back surgery due to the problem of raising his arms. Patient 4 stated the walker he used was not stable enough to compensate for his arm raising limitation. Patient 4 stated he was so afraid to fall, so he rarely left his chair unless it was necessary. A review of Patient 4s initial admission assessment dated May 31, 2024, was conducted. There was no documented evidence to show Patient 4s repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest had been identified and assessed. A review of Patient 4s care plans from May 31, 2024, to June 6, 2024, was conducted. There was no documented evidence to show Patient 4s repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest had been care planned. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:54 PM, Patient 4s care plans from May 31, 2024, to June 6, 2024, were reviewed. The DPCS and CS verified there was no documented evidence to show Patient 4s repeated falls in May 2024, Patient 4s fear of falling again and Patient 4s inability to raise his arms past his upper chest had been care planned. A review of the agencys policy and procedure titled “;Treatment and Ongoing Decision-Making,” undated, indicated, “;POLICY STATEMENT: This policy establishes the framework for developing person-centered goals that form the basis for the plan of care and decisions related to providing, forgoing, and discontinuing treatments within the limits of applicable state and federal laws, current accepted standards of medical care, and professional standards of practice. The policy emphasizes ethical principles, the patient’s treatment preferences, and collaboration with families and decision-makers. PROCEDURE: 1. Development of Person-Centered Plan of Care: The patient’s plan of care reflects ethical principles and the assessment of treatment preferences. The plan of care is accurately documented to reflect the patient’s previously stated goals in terms of providing, forgoing, and discontinuing care. 2. Alignment of Treatments with Patient Goals: The IDT ensures that existing treatments align with the patient’s goals and standard practices of care. The team actively works to prevent medically non-beneficial care. ...” A review of the agencys policy and procedure titled “;Treatment,” undated, indicated, “;POLICY STATEMENT: Our organization is committed to providing comprehensive symptom management and care coordination in palliative care, ensuring that the Interdisciplinary Team (IDT) anticipates and addresses the impact of new symptom interventions on existing treatment regimens. This policy outlines the criteria and processes for the IDT to collaborate, assess, train, and support patients, families, and caregivers, incorporating advanced therapies when needed, and optimizing medication management through reconciliation, justification, and ongoing assessment is dedicated to providing patient-centered palliative care through the development of interdisciplinary care plans that address physical symptoms, maximize functional status, and enhance the quality of life. This policy outlines the criteria and processes for the Interdisciplinary Team (IDT) to actively involve patients and caregivers in care planning, employ evidence-based treatments for distressing symptoms and side effects, and regularly assess the need for and effectiveness of bowel regimens when opioids are prescribed. PROCEDURE: 1. Active 1nvolvement of Patients and Caregivers: a. The IDT encourages and facilitates the active involvement of patients and caregivers in developing the plan of care and managing physical symptoms. b. Patients and families are encouraged and given frequent opportunities to ask questions, seek support, and communicate changes in status, including worsening symptoms and treatment-associated side effects. ... 3. Patient-Centered Care Planning: Interdisciplinary care plans will be developed in the context of the patient’s goals of care, disease, prognosis, functional limitations, culture, and care setting. Plans will be regularly reviewed, at least every 14 days or when there is a significant change and adjusted based on changes in the patient’s health status, goals, or preferences. ...” 7. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, into the Palliative Care Program. Patient 1 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), end stage renal disease (a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant), diabetes mellitus (a disease that results in too much sugar in the blood) and congestive heart failure (a chronic condition in which the heart cannot pump or fill effectively). Patient 1 expired on May 20, 2024. A review of Patient 1s intake and admission documentation dated March 30, 2024, was conducted. There was no documented evidence to show Patient 1, or Patient 1s representative had received and signed consents for: treatment, a financial agreement, hospitalization, blood transfusion, or receipt of the Notice of Privacy Rights and Advance Directive information. During an interview with the Director of Patient Care Services (DPCS) on June 4, 2024, at 3:13 PM, The DPCS stated she had conducted the admission for Patient 1 and it had been her responsibility to explain and get the consents signed. The DPCS stated she did not have the consents forms with her, so she requested the office send the consents to Patient 1s email for signature. The DPCS stated she did not know the consents had never been sent to Patient 1. A review of the agencys policy and procedure titled “;Informed Consent,” undated, indicated, “;POLICY STATEMENT: In order for each [Palliative Care Program] patient to fully participate in decisions about his or her care treatment, and services, the following procedure will be employed to obtain informed consent. When a patient is determined to lack decision-making capacity their legally authorized representative will be informed, and consent obtained on the patient’s behalf. Informed consent will be obtained for the following decisions: Consent for Treatment, Financial Agreement ... Hospitalization ... Blood transfusion ... PROCEDURE: When any of the above listed care, treatment or services are recommended by the [Palliative Care Program] interdisciplinary team the following procedure will be followed: 1. The proposed treatment will be explained by the attending physician, [Palliative Care Program] physician or [Palliative Care Program] Registered Nurse. The goal is to establish a mutual understanding between the patient and the physician or other practitioner and to allow the patient to fully participate in decisions. 2. The process will include a discussion of the following elements; a. The nature of the proposed care, treatment, services, medications, interventions, or procedures. b. Potential benefits, risks, or side-effects, including potential problems c. The likelihood of achieving the goals established. d. Reasonable alternatives to the proposed treatment e. Relevant risks, benefits, and side effects related to alternatives. 3. A patient signature will be obtained for those documents specifically developed including the ... Consent for Treatment, Financial Agreement, ... Notice of Privacy Rights and Advance Directive information. 4. For other items, the [Palliative Care Program] staff member obtaining the consent will describe the process in a narrative note and document the verbal agreement/consent of the patient. The note will be signed and dated by the appropriate [Palliative Care Program] professional and filed in the medical record.” 8a. During an interview with the Administrator (Admin) on June 6, 2024, at 4:07 PM, the Admin stated he was the sole owner and Governing Body (GB) member of the agency. The Admin stated he had started the agencys Palliative Care Program on March 1, 2022, when he had signed a contract with a Professional Medical Corporation (PMC) to provide palliative care services to the PMCs patients. The Admin stated he operated the agencys Palliative Care Program under the umbrella of the Hospice Agency. The Admin stated all the employees who provided care and services to the patients of the Hospice Agency, also provided care and services to the patients enrolled in the agencys Palliative Care Program. A review of a contract titled “;Ancillary Services Agreement Between [name of a professional medical corporation-PMC] a California professional medical corporation and [name of the Hospice Agency],” dated March 1, 2022, indicated, “;Provider [Hospice Agency] is a provider for Palliative care services.” A review of the agencys “;State of California Department of Public Health License,” effective date of February 28, 2024, and an expiration date of February 27, 2026, was conducted. There was no documented evidence to show the agencys Palliative Care Program had been added to the license. During a concurrent interview and record review with the Admin on June 6, 2024, at 4:07 PM, the State Law (California Code, Health, and Safety Code (HSC) § 1747.3), was reviewed. The Admin verified the following: a. The Admin failed to provide the California Department of Public Health Licensing and Certification Division (CDPH L&C) the date the agency intended to begin providing a Palliative Care Program. b. The Admin failed to provide CDPH L&C the State form “HS 200 [a State licensing application].” c. The Admin failed to provide CDPH L&C the Federal form “CMS 417 [a Federal certification application].” d. The Admin failed to provide CDPH L&C information for the period of time in the prior calendar year during which the agency provided palliative care through the Online reporting portal, including but not limited to, all of the following: i. The number of nonhospice patients who received palliative care. ii. The number of patients enrolled in hospice. iv. The primary diagnoses of the patients for which the agency provided palliative care. v. The numbers and types of providers hired during the previous 12 months. vi. The numbers and types of providers who left employment during the previous 12 months. e. The Admin failed to report the complaints received by the agency during the previous 12 months that related to all the following: i. Events that caused or were likely to cause serious injury, harm, impairment, or death. ii. Events or incidents that negatively impacted a patient’s mental, physical, or psychosocial status and were of such consequence to the patient’s well-being that a rapid response was required. iii. Delays in patient care for hospice and nonhospice patients who received palliative care pursuant to this section. f. The Admin failed to report the qualifications of staff. g. The agency was not approved by CDPH L&C to provide a Palliative Care Program. h. The Admin failed to provide CDPH L&C all information the agency provided to the Office of Statewide Health Planning and Development. A review of the agencys policy and procedure titled, “;Legal Considerations,” undated, indicated, “;POLICY STATEMENT: This policy establishes guidelines to ensure that the provision of palliative care within our organization complies with federal, state, and local regulations and laws. Clinicians are required to be knowledgeable about legal and regulatory requirements related to patient care, disclosure of medical information, decision-making, advance care planning, and other relevant aspects of palliative care.” A review of the California Code, Health and Safety Code - HSC § 1747.3, dated January 1, 2018, to January 1, 2027, indicated, “;(a) Notwithstanding any other law, beginning January 1, 2018, a licensee pursuant to this chapter may provide any interdisciplinary hospice services described in this chapter, including, but not limited to, palliative care, to a patient with a serious illness as determined by the physician and surgeon in charge of the care of the patient, including, among other kinds of patients, a patient who continues to receive curative treatment from other licensed health care professionals. (b) A licensee that elects to provide palliative care pursuant to this section shall provide the department with the date the licensee intends to begin providing the palliative care no less than 45 days before that date and all of the following: (1) The completed relevant portions of a form HS 200, or a successor form, as determined by the department. (2) A complete federal form CMS 417, or a successor form, as determined by the department. (c)(1) The department shall not require the documents submitted pursuant to subdivision (b) to be approved prior to the licensee providing palliative care pursuant to this section. (2) The department shall not charge an application fee to provide any care or services pursuant to this section. (d)(1) On or before April 30, 2022, and each April thereafter until April 30, 2025, a licensee shall provide the department with information for the period of time in the prior calendar year during which the licensee provided palliative care pursuant to this section through the department’s online reporting portal, including, but not limited to, all of the following: (A) The number of nonhospice patients who received palliative care pursuant to this section. (B) The number of patients enrolled in hospice. (C) The primary diagnoses of the patients for which the licensee provided palliative care pursuant to this section. (D) The numbers and types of providers hired during the previous 12 months. (E) The numbers and types of providers who left employment during the previous 12 months. (F) Complaints received by the licensee during the previous 12 months that related to all the following: (i) Events that caused or were likely to cause serious injury, harm, impairment, or death. (ii) Events or incidents that negatively impacted a patient’s mental, physical, or psychosocial status and were of such consequence to the patient’s well-being that a rapid response was required. (iii) Delays in patient care for hospice and nonhospice patients who received palliative care pursuant to this section. (iv) Qualifications of staff. (2) A licensee that has been approved by the department to provide palliative care pursuant to this section that has either provided the department with the date the licensee intends to begin providing palliative care pursuant to this section, or has notified the department of its cessation of palliative care provision pursuant to subdivision (g), shall report to the department pursuant to paragraph (1) regardless of whether the licensee provided palliative care pursuant to this section during the prior calendar year. (e) During the period of time a licensee provides palliative care pursuant to this section, the licensee shall simultaneously submit to the department all information the licensee provides to the Office of Statewide Health Planning and Development. (f) Notwithstanding the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), the department may implement, interpret, or make specific the provisions of this section by means of all-facility letters, or similar instructions, without taking regulatory action. (g) If the licensee ceases to provide palliative care services pursuant to this section on or before January 1, 2027, the licensee shall submit to the department the same documents as required in subdivision (b). (h) The provisions of this section shall not be applicable to a hospice facility established pursuant to subdivision (n) of Section 1250, or Section 1339.30 or 1339.40. (i) This section shall not be deemed to modify the provision of hospice care required pursuant to Section 1368.2. (j) On or before January 15, 2026, the department shall convene a stakeholder meeting to discuss the results of the information collected pursuant to this section. The department may, at its discretion, use electronic means, such as a webinar, to convene the stakeholder meeting. (k) For purposes of this section, “;serious illness” shall mean a condition that may result in death, regardless of the estimated length of the patient’s remaining period of life. (l) This section shall remain in effect only until January 1, 2027, and as of that date is repealed.” 8b(i). A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, into the Palliative Care Program. Patient 1 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), end stage renal disease (a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant), diabetes mellitus (a disease that results in too much sugar in the blood) and congestive heart failure (a chronic condition in which the heart cannot pump or fill effectively). Patient 1 expired on May 20, 2024. A review of Patient 1s referral order dated February 19, 2024, indicated, “;palliative care.” During an interview with Patient 1s wife on June 3, 2024, at 10:51 AM, Patient 1s wife stated Patient 1s Medical Group (PMC-a Professional Medical Corporation) referred Patient 1 to the Hospice Agency for their Palliative Care Program. Patient 1s wife stated the PMC told her the Hospice Agency was the gate keeper for Patient 1s care and she had to approve all care, services and trips to the acute care hospital through the Hospice Agency. Patient 1s wife stated Patient 1 had been on oxygen, but he was not short of breath and Patient 1 did not have pain. Patient 1s wife stated Patient 1 wanted to be monitored while adjusting to the new dialysis treatments and help with managing his diabetes mellitus. Patient 1s wife stated Patient 1 wanted every treatment done to help him become as functional and independent as possible. Patient 1s wife stated on May 5, 2024, Patient 1 began bleeding from his rectum with bloody diarrhea. Patient 1s wife stated she called the Hospice Agency, and a nurse (Licensed Vocational Nurse (LVN 1)) came out and helped clean Patient 1, “;the blood was everywhere!” Patient 1s wife stated the nurse called the doctor and she (Patient 1s wife) was told it was not recommended for Patient 1 to go to the acute care hospital unless he started bleeding again. Patient 1s wife stated she took Patient 1 to his dialysis appointment the next day May 6, 2024, and told the dialysis nurse about the bleeding episode. Patient 1s wife stated the dialysis nurse told her dialysis could not be done on a patient who had been bleeding and to go to the acute care hospital immediately. Patient 1s wife stated she took Patient 1 to the acute care hospital where Patient 1 was admitted on May 6, 2024, through May 8, 2024, and received two units of blood and a wound was identified on his right great toe. Patient 1s wife stated she told the Hospice Agencys nurse (Licensed Vocational Nurse (LVN 3)) on May 16, 2024, about the acute care hospital admission, two units of blood and wound identification but nothing was done. Patient 1s wife stated she called the Hospice Agency on May 17, 2024, and asked for Patient 1s wound to be cared for. Patient 1s wife stated a nurse came out (Licensed Vocational Nurse (LVN 2)) who applied a dressing to Patient 1s right toe. Patient 1s wife stated she felt Patient 1 was treated like a Hospice patient, not a patient who wanted everything done to get better. Patient 1s wife stated Patient 1 died on May 20, 2024, 51 days after starting on the Hospice Agencys Palliative Care Program. Patient 1s wife stated the PMC, and the Hospice Agency did not provide the aggressive care and services Patient 1 wanted to prolong and improve his life to the extent possible. A review of Patient 1s Skilled Nursing (SN) visit notes from April 4, 2024, to May 17, 2024, were reviewed. There was no documented evidence to show Patient 1 had shortness of breath or pain. A review of Patient 1s SN visit note, dated May 5, 2024, by LVN 1, indicated, “;The patient was seen today for a PRN [as needed] visit due to experiencing bloody, loose stools. The patients wife reported multiple episodes since 3 [three] a.m., with the last occurring around 11:30 a.m. Upon examination, the patient was found sitting on the toilet, awake, alert, and oriented, denying any pain. The patient is on continuous oxygen without respiratory distress and is currently not experiencing further episodes of loose stools or bleeding. The patient managed to walk from the toilet to the bed for cleaning, with no external hemorrhoids detected. The abdomen is soft, non-distended, and non-tender. The patient denies dizziness but feels slightly weaker. Dialysis is scheduled for the following day. ... The wife has been instructed to monitor for additional episodes of bloody stools or any changes in condition ... The physician has been informed, and there are no new orders at this time. The wife will consult with the primary medical doctor for additional guidance and is aware that, should excessive bleeding continue, it is imperative to contact emergency services immediately. ...” A review of Patient 1s Acute Care Hospitals (ACH) clinical records dated May 6, 2024, to May 8, 2024, indicated Patient 1 had been admitted on May 6, 2024, and discharged on May 8, 2024. Patient 1s ACHs clinical records indicated Patient 1 had received two units of blood and wound care to his right great toe. During an interview with LVN 1 on June 4, 2024, at 10:35 AM, LVN 1 stated he made an SN visit because Patient 1s wife had called and stated Patient 1 had loose stools, dark colored. LVN 1 stated he saw dark black tar like loose stools (black or tarry stools are due to bleeding in the upper part of the GI (gastrointestinal) tract, such as the esophagus, stomach, or the first part of the small intestine. In this case, blood is darker because it gets digested on its way through the GI tract) on the bedsheets, on the floor of bedroom and floor of bathroom and on and in the toilet. LVN 1 stated he helped clean up Patient 1. LVN 1 stated he texted the Medical Director (MD) directly. LVN 1 stated the MD responded, “;thank you for the update” and I was not given any instruction to give Patient 1 or the family. LVN 1 stated he had made an independent decision to tell Patient 1s wife to take Patient 1 to the acute care hospital if the bleeding started again. LVN 1 stated he had conducted a head-to-toe assessment but did not see any wounds. LVN 1 stated he did not notice a wound on Patient 1s right great toe. During an interview with the MD on June 4, 2024, at 12:15 PM to 12:41 PM, the MD stated he was the Medical Director for the Hospice Agencys Palliative Care Program. The MD stated he had received a text from LVN 1 on May 5, 2024, and he had responded, “;thank you for the update.” The MD stated he had not given LVN 1 any direction to give Patient 1 or the family. The MD stated he did not think the bleeding was an urgent situation at the time but after reviewing Patient 1s previous medical history he should have instructed Patient 1 to go to the acute care hospital. The MD stated it could be difficult for the Hospice Agencys staff to switch between a hospice philosophy (providing comfort care without aggressive treatments) and the philosophy for palliative care (providing comfort care with aggressive treatments). A review of Patient 1s SN visit note dated May 16, 2024, by LVN 3, was conducted. There was no documented evidence to show LVN 3 had identified or assessed Patient 1s right great toe wound identified at the acute care hospital during the May 6, 2024, to May 8, 2024, admission. During an interview with LVN 3 on June 4, 2024, at 11:48 AM, LVN 3 stated Patient 1s wife had told him Patient 1 had been to the acute care hospital the week before (May 6, 2024, to May 11, 2024), but he could not remember the dates. LVN 3 stated he did not remember any specifics about Patient 1s acute care hospital stay and had not reported Patient 1s hospitalization to the Hospice Agencys staff. LVN 3 stated he had not conducted a thorough head-to-toe assessment of Patient 1 and had not noticed a wound to Patient 1s right great toe. A review of Patient 1s SN visit note dated May 17, 2024, by LVN 2, indicated, “;... PRN [as needed] visit [related to] wound care, ... verbal, calm, cooperative, respiration even and unlabored with no SOB [shortness of breath] noted, wife stated ... during patient bath she noticed open area on right great toe, no discharge or pus noted, BLE [bilateral lower extremities] warm to touch, patient denies any fever or chills and no pain or discomfort during visit, [MD] made aware with new order: cleanse open area on right great toe with NS [normal saline], pat dry, apply [wound gel] and cover with dry dressing secure with tape daily and as needed if dislodged or soiled [times]14 days and re-assess. Family/cg may perform wound care. ... May have wound consult. Wound care administered, tolerated well, ... Patient and wife educated on signs and symptoms of infection such as increase pain to site, increased redness, presence of ... pus, fever, chills. If any sign/symptoms of infection noticed to call [PMC-a Professional Medical Corporation] nurse advice line. Patient and wife encourage to wear proper fitting footwear, wife and patient acknowledge understanding, patient and wife encourage to monitor. follow up with podiatrist/ [primary care physician] and call [PMC] If there’s any questions or concerns ...” During an interview with LVN 2 on June 4, 2024, at 10:55 AM, LVN 2 stated he had conducted the SN visit because Patient 1s wife had called the office and informed them of the right great toe wound. During a concurrent interview and record review with the Medical Director (MD) and in the presence of the Administrator (Admin), Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:20 PM, Patients 1s History and Physical (H&P) was reviewed. The MD stated he could not verify Patient 1 had uncontrolled symptoms requiring services from a Palliative Care Program. 8b(ii). A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 12, 2024, into the Palliative Care Program. Patient 2 had diagnoses that included post right knee surgery and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). A review of Patient 2s referral order dated April 1, 2024, by a PMC physician (PMC/MD) indicated, “;Evaluate and treat for palliative care program.” During a home visit and interview with Patient 2 on June 5, 2024, at 1:36 PM, Patient 2 was sitting on a couch in the living room and was wearing a short sleeve shirt and short pants. Patient 2s right knee was visible, and a long-healed scar was observed on her right knee. Patient 2 was not using oxygen, not short of breath and did not appear to be in distress. Patient 2 stated she did not know the services the Hospice Agency was providing. Patient 2 stated the PMC told her they would send a nurse to provide services in her home instead of the hospital. Patient 2 stated she was doing very well, and she only had pain with her right knee when she walked and during Physical Therapy. Patient 2 stated she was excited to go back to work in a few weeks. During a concurrent interview and record review with the Medical Director (MD) and in the presence of the Administrator (Admin), Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:42 PM, Patients 2s History and Physical (H&P) was reviewed. The MD stated he could not verify Patient 2 had uncontrolled symptoms requiring services from a Palliative Care Program. 8b(iii). A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of May 24, 2024, into the Palliative Care Program. Patient 3 had diagnoses that included dialysis (a process of removing excess water and cleaning the blood in people whose kidneys can no longer perform these functions naturally), chest pain, diabetes mellitus (a disease that results in too much sugar in the blood), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Patient 3s Acute Care Hospital (ACH) clinical records for a May 1, 2024, to May 3, 2024, hospital admission for chest pain indicated a physicians referral order dated May 2, 2024, which indicated, “;Discharge to home [with] Home Health.” A review of Patient 3s referral order dated May 6, 2024, by a PMC physician (PMC/MD) indicated, “;Evaluate and treat for palliative care program.” During a home visit and interview with Patient 3 on June 5, 2024, at 2:53 PM, Patient 3 was sitting in wheelchair and using her feet propelled herself to the kitchen table. Patient 3 was wearing a short sleeve shirt, long pants, and shoes. A pressure bandage was visualized to her left upper arm. Patient 3 stated the bandage was covering her dialysis access. Patient 3 was not utilizing oxygen, not short of breath and did not appear to be in distress. Patient 3 stated she had been receiving dialysis treatments for two years and was used to it. Patient 3 stated she did not have chest pain or any other pain. Patient 3 stated she was not on oxygen and did not have shortness of breath. Patient 3 stated she did not know what services the agency provided but she would like help with transportation to her doctors appointments, some Physical Therapy so she could walk again and someone to clean her bathroom. During a concurrent interview and record review with the Medical Director (MD) and in the presence of the Administrator (Admin), Director of Patient Care Services (DPCS) and a Clinical Supervisor (CS) on June 6, 2024, at 3:44 PM, Patients 3s History and Physical (H&P) was reviewed. The MD stated he could not verify Patient 3 had uncontrolled symptoms requiring services from a Palliative Care Program. A review of the agencys policy and procedure titled “;Screening and Assessment,” undated, indicated, “;POLICY STATEMENT: This policy outlines the procedures and guidelines for eliciting and documenting the patient’s preferences and goals for medical care in accordance with core ethical principles. The aim is to promote effective communication, respect patient autonomy, and ensure that medical care aligns with the patient’s values and preferences.” A review of the agencys policy and procedure titled “;Treatment and Ongoing Decision-Making,” undated, indicated, “;POLICY STATEMENT: This policy establishes the framework for developing person-centered goals that form the basis for the plan of care and decisions related to providing, forgoing, and discontinuing treatments within the limits of applicable state and federal laws, current accepted standards of medical care, and professional standards of practice. The policy emphasizes ethical principles, the patient’s treatment preferences, and collaboration with families and decision-makers.” During an interview with the Administrator (Admin) on June 6, 2024, from 3:16 PM to 4:07 PM, the Admin stated he was the sole owner and member of the Governing Body (GB). The Admin stated he assumed full legal authority and responsibility for the operation of the agency, and for the quality of care and services provided. The Admin stated the GB had not identified that: a. The patients’ initial assessments were not being completed within 48 hours of the physician’s referral date or on the physician-ordered start of care date. b. The patients’ comprehensive assessments were not being completed within five days after the start of care. c. The comprehensive assessment had not identified and addressed Patient 3’s left great toe wound or Patient 4’s three falls in May 2024, Patient 4s fear of falling or Patient 4’s inability to raise arms past his upper chest. d. The comprehensive assessment was not being updated by the agency’s interdisciplinary group to address Patient 1’s right great toe wound, a re-admission assessment for Patient 1’s hospitalization from May 6, 2024, to May 8, 2024, and Patient 1s discharge summary and discharge order. e. The Interdisciplinary Group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) members did not supervise and provide care and services when: an admission order was not obtained for Patient 1, Patient 1’s gastrointestinal (GI) bleeding episode on May 5, 2024, was not discussed or addressed, Patient 1’s hospital admission from May 6, 2024, to May 8, 2024, where Patient 1 received two units of blood was not discussed or addressed. Patient 1’s right great toe wound identified at the hospital on May 8, 2024, was not discussed or addressed, Patient 1’s death on May 20, 2024, and discharge on May 21, 2024, was not discussed or addressed, the IDG had not evaluated, discussed or provided general oversight for Patient 2s care, Patient 3’s left great toe wound was not discussed or addressed and Patient 4’s three falls in May or patients fear of falling and Patient 4’s inability to raise arms past his upper chest was not discussed or assessed. f. The IDG failed to develop and update an individualized plan of care for Patients 1, 2, 3, and 4. g. Patient 1 and Patient 1s representative had not been provided treatment consents. h. The agency failed to operate and furnish services in compliance with State Law (California Code, Health, and Safety Code (HSC) § 1747.3). i. The agency failed to ensure patients met the criteria to be admitted into the agencys Palliative Care Program. A review of the agencys policy and procedure titled “;Authority/Responsibility,” undated, indicated, “;POLICY STATEMENT: The Governing Body assumes full legal authority and responsibility for the management of the Community-Based Palliative Care Program (“Program”), the provision of all services, its fiscal operations, and continuous quality assessment and performance improvement. The governing body creates, maintains and supports a culture of safety and quality throughout the organization.””