Angels Hospice Corporation

“Based on observation, interview, and record review, the agency failed to protect the privacy and security of patient health information for one (1) of the nineteen sampled patients (Patient 3) when a Licensed Vocational Nurse 1 (LVN 1) used his personal cell phone to take a picture of Patient 3’s wound and send it to the agency without using a secure mobile phone application required to safeguard Patient 3’s health information. This failure resulted in Patient 3’s personal health information being put at risk by not keeping health records confidential, and using personal equipment not being monitored and secured by the agency. Findings: During a review of Patient 3’s face sheet (contains demographic and medical information), undated, Patient 3’s face sheet indicated Patient 3 had a start of care date of June 2, 2026, with a certification period of June 2, 2026, to August 30, 2026. Patient 3 had diagnosis that included senile degeneration of brain (severe mental decline and brain cell loss in older adults) and left lower leg and knee chronic (long lasting) wounds. During a home visit observation on August 18, 2026, at 11:30 AM, with LVN 1, LVN 1 took photos of Patient 3’s left lower leg and knee chronic wounds with his personal cell phone. During a subsequent interview with LVN 1, LVN 1 verified and confirmed he uses his personal cell phone to send and receive Patient 3’s confidential information to the agency without using a secure app. LVN 1 further stated the agency has never provided any secure app to send or receive patients’ confidential information. During an interview on August 20, 2026, at 11:30 AM, with the Director of Patient Care Services (DPCS), the DPCS confirmed the agency does not use any secure app to send or receive patient’s confidential information. The DPCS further stated the agency staff use their personal cell phones to send and receive patient confidential information. During a concurrent interview and record review on August 20,2026, at 11:45 AM, with the DPCS, the facility’s policy and procedure (P&P), titled” RIGHTS AND RESPONSIBILITES, dated April 2020, was reviewed. The P&P indicated, “...The right to privacy, security, and respect of property.” The DPCS stated the agency did not follow their P&P for “Rights and Responsibilities” for patients by sending patients confidential information on personal cell phone messaging service.”

“Based on observation, interview, and record review, the agency failed to ensure standard precautions were followed to prevent the transmission of infections and communicable diseases for 19 of 19 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19) when: 1. Stored medical supplies were available for patient use had passed their expiration date. 2. A Licensed Vocation Nurse (LVN) did not follow clean bag technique (an infection control method used by home healthcare professionals to prevent the spread of germs between the patient’s home and the outside environment) while providing care for Patient 3. This failure had the potential to put the agency’s patients at risk for cross contamination (the process by which bacteria or other microorganism are unintentionally transferred from one substance or object to another) of infectious microorganisms. Findings: During a facility tour on August 17, 2026, at 10:05 AM, in the medical supplies room, the following medical supplies were found to be expired and were available to use: 1.A box of 20 (brand name) particulate Respirator N-95 Masks (a disposable, tight fitting respiratory device that blocks at least 95 percent of airborne particles) with an expiration date of December 2025 (expired 230 days). 2.One (1) Pack of Bandage Flexible Fabric 80 meter sterile (a germ free soft medical covering used to protect wounds, absorb fluids and prevent infection) with an expiration date of January 2021 (expired 2024 days). 3. Three (3) Day Emergency Backpack (a portable collection of basic survival items designed to sustain person for at least days during an evacuation or disaster) with an expiration date of August 2023 (expired 1082 days). During an interview with the administrator (ADMIN), on August 17, 2026, at 10:05 AM, the ADMIN verified that all medical supplies were expired and should have been discarded. During a concurrent interview and record review on August 20, 2026, at 11:15 AM, with the Director of Patient Care Services (DPCS), the agency’s policy and procedure (P&P) titled, “STORAGE, HANDLING, AND ACCESS TO SUPPLIES AND GASES”, dated December 2021, was reviewed. The P&P indicated, “procedure-2. Medical Supplies Room (MSR) used for storage should be checked on a scheduled & /or in accordance with the manufacturer guide on proper handling and product disposable by a supervisor or designee.” The DPCS stated the medical supplies should have been checked regularly, and expired items should have been discarded. The DPCS further stated the agency did not follow the infection prevention control policy. 2. During a review of Patient 3’s face sheet (contains demographic and medical information), undated, indicated Patient 3 had a start of care date of June 2, 2026, with a certification period of June 2, 2026, to August 30, 2026. Patient 3 had diagnosis that included senile degeneration of brain (severe mental decline and brain cell loss in older adults) and left lower leg and knee chronic wounds. During a home visit observation on August 18, 2026, at 11:00 AM, with LVN 1, and in the presence of Patient 3, LVN 1 did not use clean bag procedure before and after giving care to Patient 3, to prevent cross examination. LVN 1 placed his bag on Patient 3 bedside table without use of protective barrier for bag placement. During an Interview on August 18, 2026, at 11:45 AM, with LVN 1, LVN 1 stated he should have performed clean bag procedure, he should have used barrier/paper towel for bedside table to prevent cross contamination, he forgot to do that, he was focused on the patient and the task he was performing. During an Interview on August 20, 2026, at 11:30 AM, with Director of Patient Care Services (DPCS), the DPCS stated staff were supposed to use a barrier for them to put their bag and belongings and/or equipment on when in the Patient’s home. The DPCS further started LVN should have washed/ used alcohol rub to perform hand hygiene and should have not placed his bag on patient’s bedside table without using protective barrier to prevent cross examination. During a concurrent interview and record review with the DPCS, on August 20, 2026, at 11:35 AM, the agency’s policy and procedure (P&P) titled, “BAG TECHNIQUE”, dated July 2022, was reviewed. The P&P indicated, “PURPOSE- To describe the procedure for maintaining a clean nursing bag/computer bag and preventing cross-contamination…PROCEDURE-Bag Technique-1. The bag will be placed on a clean surface (i.e. a surface that can be easily disinfected) in the car and in the home…5. When a visit is completed, reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solutions, hands will be washed, and equipment and supplies will be returned to the bag…7. If paper towels/newspapers have been used as protective barrier for bag placement in the Patients home, they will be discarded”. The DPCS stated the agency staff did not follow the infection prevention control policy.”

“Based on interview and record review, the hospice failed to ensure the Medical Director (MD) provided a complete and valid initial certification of terminal illness (CTI--an official medical document signed by physicians stating that a patient is terminally ill and has a life expectancy of six months or less if the disease runs its normal course) for eight of nineteen sampled patients (Patients 2, 3, 6, 7, 14, 16, 17, and 19), when: 1. The MD failed to ensure the initial CTIs for benefit period one (the initial 90-day block of care requiring a signed terminal prognosis of six months or less from both the hospice Medical Director and the patient’s attending physician) were complete and valid, in that the certifications lacked the required attending physician (AP) signature for Patients 2, 3, 6, 7, 16, 17, and 19. 2. The MD failed to review the clinical information and provide a signed CTI establishing a current terminal prognosis for Patient 14 upon transfer and admission to the hospice. These failures had the potential to cause Patients 2, 3, 6, 7, 16, 17, and 19 to be admitted to hospice inappropriately, resulting in the patients forgoing necessary curative treatments too soon and not being given the opportunity to pursue care aimed at improving or stabilizing their condition, because a complete and valid certification of terminal illness had not been established. In addition, Patient 14 had the potential to continue receiving hospice care without a current terminal prognosis established by the MD, and to have services billed, when eligibility for the benefit period had not been verified. Findings: 1a. A review of Patient 2’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of July 1, 2025, with a benefit period of July 1, 2025 to September 28, 2025 (Benefit Period one). Patient 2 had a primary diagnosis of senile degeneration of brain (a progressive decline in cognitive function, including memory and reasoning, associated with old age). A review of Patient 2’s Hospice evaluation order, dated July 1, 2025, indicated MD 1’s signature. A review of Patient 2’s physician’s progress notes, dated January 2, 2025, indicated AP 1’s signature. A review of Patient 2’s “Physician’s Certification for Hospice Benefit [CTI],” (designated for the Medical Director–MD–to fill out and sign) for the period of July 1, 2025, to September 28, 2025 (Benefit Period one) indicated MD 3’s signature dated July 9, 2025. A review of Patient 2’s “Physician’s Certification for Hospice Benefit [CTI],” (designated for the Attending Physician–AP–to fill out and sign) for the period of July 1, 2025, to September 28, 2025 (Benefit Period one) indicated MD 1’s signature dated July 3, 2025. During an interview with MD 1 on August 19, 2026, at 12:03 PM, MD 1 stated he had provided Patient 2’s hospice evaluation order because he assumed Patient 2 did not have an attending physician to provide the hospice evaluation order. MD 1 stated he was aware of the regulatory requirement for two physician signatures (the MD’s and the AP’s) during a patient’s first benefit period, but MD 1 was not aware he was providing the second signature as the AP, stating, “I thought I was signing as the MD.” MD 1 stated the agency should have contacted AP 1 for his signature on the CTI but did not. A review of Patient 2’s claims for payment indicated a claim dated August 3, 2026, had been submitted for services provided. 1b. A review of Patient 3’s face sheet, undated, indicated a start of care date of June 2, 2026, with a benefit period of June 2, 2026, to August 30, 2026 (Benefit Period one). Patient 3 had a primary diagnosis of senile degeneration of brain. A review of Patient 3’s Hospice evaluation order, dated May 27, 2026, indicated AP 2’s signature. A review of Patient 3’s “Physician’s Certification for Hospice Benefit [CTI],” (designated for the Medical Director–MD–to fill out and sign) for the period of June 2, 2026, to August 30, 2026 (Benefit Period one) indicated MD 2’s signature dated June 2, 2026. A review of Patient 3’s “Physician’s Certification for Hospice Benefit [CTI],” (designated for the Attending Physician–AP–to fill out and sign) for the period of June 2, 2026, to August 30, 2026 (Benefit Period one) indicated MD 1’s signature dated June 2, 2026. During an interview with MD 1 on August 19, 2026, at 12:16 PM, MD 1 confirmed AP 2 had provided Patient 3’s Hospice evaluation order. MD 1 stated he was aware of the regulatory requirement for two physician signatures (the MD’s and the AP’s) during a patient’s first benefit period, but MD 1 was not aware he was providing the second signature as the AP, stating, “I thought I was signing as the MD.” MD 1 stated the agency should have contacted AP 2 for his signature on the CTI but did not. A review of Patient 3’s claims for payment indicated a claim dated August 4, 2026, had been submitted for services provided. 1c. A review of Patient 6’s face sheet, undated, indicated a start of care date of July 29, 2026, with a benefit period of July 29, 2026, to October 26, 2026 (Benefit Period one). Patient 6 had a primary diagnosis of diastolic congestive heart failure (the heart’s left ventricle becomes stiff and cannot fill properly with blood, causing fluid to back up in the lungs and body). A review of Patient 6’s Hospice evaluation order, dated July 27, 2026, indicated AP 3’s signature. A review of Patient 6’s “Physician’s Certification for Hospice Benefit [CTI],” (designated for the Medical Director–MD–to fill out and sign) for the period of July 29, 2026, to October 26, 2026 (Benefit Period one) indicated MD 1’s signature dated August 5, 2026. A review of Patient 6’s “Physician’s Certification for Hospice Benefit [CTI]” (designated for the Attending Physician—AP—to complete and sign) for the period of July 29, 2026, to October 26, 2026 (Benefit Period one) indicated AP 4 was to sign; however, the certification contained no signature. During an interview with MD 1 on August 19, 2026, at 12:19 PM, MD 1 confirmed AP 3 had provided Patient 6’s Hospice evaluation order. MD 1 stated he was aware of the regulatory requirement for two physician signatures (the MD’s and the AP’s) during a patient’s first benefit period. MD 1 confirmed AP 4 had not signed Patient 6’s CTI and stated the agency should have secured either AP 3’s or AP 4’s signature but did not. A review of Patient 6’s claims for payment indicated a claim for services provided was pending. 1d. A review of Patient 7’s face sheet, undated, indicated a start of care date of June 6, 2026, with a benefit period of June 6, 2026, to September 3, 2026 (Benefit Period one). Patient 7 had a primary diagnosis of Alzheimer`s disease (a progressive brain disorder that slowly destroys memory, thinking, and reasoning skills, eventually interfering with a person’s ability to carry out daily activities). A review of Patient 7’s Hospice evaluation order, dated June 5, 2026, indicated AP 5’s signature. A review of Patient 7’s “Physician’s Certification for Hospice Benefit [CTI],” (designated for the Medical Director–MD–to fill out and sign) for the period of June 6, 2026, to September 3, 2026 (Benefit Period one) indicated MD 2’s signature dated June 24, 2026. A review of Patient 7’s “Physician’s Certification for Hospice Benefit [CTI],” (designated for the Attending Physician–AP–to fill out and sign) for the period of June 6, 2026, to September 3, 2026 (Benefit Period one) indicated MD 1’s signature dated June 6, 2026. During an interview with MD 1 on August 19, 2026, at 12:20 PM, MD 1 confirmed AP 5 had provided Patient 7’s Hospice evaluation order. MD 1 stated he was aware of the regulatory requirement for two physician signatures (the MD’s and the AP’s) during a patient’s first benefit period, but MD 1 was not aware he was providing the second signature as the AP, stating, “I thought I was signing as the MD.” MD 1 stated the agency should have contacted AP 5 for his signature on the CTI but did not. A review of Patient 7’s claims for payment indicated a claim dated August 11, 2026, had been submitted for services provided. 1e. A review of Patient 16’s face sheet, undated, indicated a start of care date of April 9, 2026, with a benefit period of April 9, 2026, to July 7, 2026 (Benefit Period one). Patient 16 had a primary diagnosis of atherosclerotic heart disease of native coronary artery (a condition in which the heart’s own coronary arteries become narrowed or hardened by a buildup of plaque, reducing blood flow to the heart muscle), Patient 16 expired on May 17, 2026. A review of Patient 16’s Hospice evaluation order, dated April 7, 2026, indicated a Nurse Practitioner’s (NP) signature. A review of Patient 16’s “Annual Wellness Visit,” dated April 2, 2026, indicated AP 6’s clinical evaluation and signature. A review of Patient 16’s “Physician’s Certification for Hospice Benefit [CTI],” (designated for the Medical Director–MD–to fill out and sign) for the period of April 9, 2026, to July 7, 2026 (Benefit Period one) indicated MD 1’s signature dated April 14, 2026. A review of Patient 16’s “Physician’s Certification for Hospice Benefit [CTI],” (designated for the Attending Physician–AP–to fill out and sign) for the period of April 9, 2026, to July 7, 2026 (Benefit Period one) indicated MD 2’s signature dated April 9, 2026. During an interview with MD 1 on August 19, 2026, at 12:31 PM, MD 1 confirmed an NP had provided Patient 16’s Hospice evaluation order, and that Patient 16’s wellness visit, dated April 2, 2026, identified AP 6, while MD 2 had provided the second signature on the CTI as the AP. MD 1 stated he was aware of the regulatory requirement for two physician signatures (the MD’s and the AP’s) during a patient’s first benefit period, and acknowledged the agency should have contacted AP 6 for the second signature on Patient 16’s CTI but did not. A review of Patient 16’s claims for payment indicated a claim dated May 1, 2026, had been submitted for services provided. 1f. A review of Patient 17’s face sheet, undated, indicated a start of care date of June 12, 2026, with a benefit period of June 12, 2026, to September 9, 2026 (Benefit Period one). Patient 17 had a primary diagnosis of Alzheimer`s disease. Patient 17 expired on July 5, 2026. A review of Patient 17’s Hospice evaluation order, dated June 9, 2026, indicated AP 7’s signature. A review of Patient 17’s “Physician’s Certification for Hospice Benefit [CTI],” (designated for the Medical Director–MD–to fill out and sign) for the period of June 12, 2026, to September 9, 2026 (Benefit Period one) indicated MD 1’s signature dated June 24, 2026. A review of Patient 17’s “Physician’s Certification for Hospice Benefit [CTI],” (designated for the Attending Physician–AP–to fill out and sign) for the period of June 12, 2026, to September 9, 2026 (Benefit Period one) indicated MD 2’s signature dated June 12, 2026. During an interview with MD 1 on August 19, 2026, at 12:34 PM, MD 1 confirmed AP 7 had provided Patient 17’s Hospice evaluation order, while MD 2 had provided the second signature on the CTI as the AP. MD 1 stated he was aware of the regulatory requirement for two physician signatures (the MD’s and the AP’s) during a patient’s first benefit period, and acknowledged the agency should have contacted AP 7 for the second signature on Patient 17’s CTI but did not. A review of Patient 17’s claims for payment indicated a claim dated July 13, 2026, had been submitted for services provided. 1g. A review of Patient 19’s face sheet, undated, indicated a start of care date of March 25, 2026, with a benefit period of March 25, 2026, to June 22, 2026 (Benefit Period one). Patient 19 had a primary diagnosis of senile degeneration of brain. Patient 19 was discharged on May 18, 2026. A review of Patient 19’s Hospice evaluation order, dated March 24, 2026, indicated AP 8’s signature. A review of Patient 19’s “Physician’s Certification for Hospice Benefit [CTI],” (designated for the Medical Director–MD–to fill out and sign) for the period of March 25, 2026, to June 22, 2026 (Benefit Period one) indicated MD 1’s signature dated April 1, 2026. A review of Patient 19’s “Physician’s Certification for Hospice Benefit [CTI],” (designated for the Attending Physician–AP–to fill out and sign) for the period of March 25, 2026, to June 22, 2026 (Benefit Period one) indicated MD 2’s signature dated March 25, 2026. During an interview with MD 1 on August 19, 2026, at 12:40 PM, MD 1 confirmed AP 8 had provided Patient 19’s Hospice evaluation order, while MD 2 had provided the second signature on the CTI as the AP. MD 1 stated he was aware of the regulatory requirement for two physician signatures (the MD’s and the AP’s) during a patient’s first benefit period, and acknowledged the agency should have contacted AP 8 for the second signature on Patient 19’s CTI but did not. A review of Patient 19’s claims for payment indicated a claim dated April 6, 2026, had been submitted for services provided. 2. A review of Patient 14’s face sheet, undated, indicated a start of care date of July 23, 2026, with a benefit period of July 23, 2026, to October 20, 2026 (Benefit Period two). Patient 14 had a primary diagnosis of senile degeneration of brain. A review was conducted of Patient 14’s CTIs from July 23, 2026, to August 19, 2026. There was no documented evidence to show MD 1 had provided and signed a CTI for Patient 14. A review was conducted of Patient 14’s physician’s orders from July 23, 2026, to August 19, 2026. There was no documented evidence to show a physician’s order for Patient 14’s Hospice evaluation. During an interview with the Administrator Designee (AD) and Director of Patient Care Services (DPCS) on August 19, 2026, at 10:20 AM, the AD stated Patient 14 had transferred from another hospice, and she thought the transfer form Patient 14’s daughter and son signed served as the physician’s hospice evaluation order. The AD stated she thought the CTI from the previous hospice was all that was needed because Patient 14 was still within her second benefit period. The DPCS confirmed there was no physician’s order for a hospice evaluation and that MD 1 had not provided and signed a CTI for Patient 14. During an interview with MD 1 on August 19, 2026, at 12:21 PM, MD 1 confirmed there was no physician’s order for a hospice evaluation and that he had not provided and signed a CTI for Patient 14. MD 1 stated the agency should not rely on a CTI provided by a different hospice agency because patients’ conditions are constantly changing and evolving, and he needed to evaluate Patient 14’s current prognosis. MD 1 stated the agency should have evaluated Patient 14 and provided a current CTI but did not. A review of Patient 14’s claims for payment indicated a claim dated August 11, 2026, had been submitted for services provided. A review of the agency’s policy and procedure titled “Certification of Terminal Illness,” dated June 2022, indicated, “PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver choose hospice care, the hospice Medical Director and the patient’s attending physician, if any, will certify the patient’s terminal illness. …” A review of the agency’s policy and procedure titled “Intake Process,” dated April 2020, indicated, “PURPOSE: To establish the process for acceptance and entry of patients into hospice. … PROCEDURE: … D. If the referral call is not from a physician, the physician (or other authorized licensed independent practitioner) will be contacted to confirm service needs, as well as the patient’s medical prognosis and supporting documentation, and to obtain verbal orders. …””

“The hospice agency failed to ensure the Condition of Participation L 536 418.56: Interdisciplinary group, care planning, and coordination of services was in compliance as follows: Based on interview and record review, the agency failed to provide a higher level of care after identifying caregivers at a Board and Care Facility (B&C-a care home for patients who need assistance with daily activities like eating, medication management, toileting, and personal grooming) did not provide repositioning every two hours or incontinence care for one of three sample patients (Patient 1) when Patient 1 was immobile and unable to reposition herself to relieve pressure on her skin. (Refer to L 539) The cumulative effect of these systemic practices resulted in Patient 1 developing multiple wounds: a stage IV pressure ulcer (an open wound with full thickness skin loss and extensive destruction; tissue necrosis (dead tissue) and damage to muscle and bone) to the sacrum (triangular bone at the base of the spine), a deep tissue injury ( DTI-a pressure-related injury to tissues under intact skin) to left buttock, a stage II pressure ulcer (an open wound with partial thickness skin loss. The ulcer is superficial [on top] and presents clinically as an abrasion, blister, or shallow crater] to the right buttock, DTIs to bilateral [both] heels, due to these worsening wounds Patient 1 was hospitalized with wound infections, pain and required surgical debridement (the mechanical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue).”

“The agency failed to ensure the Condition of Participation: L 648 418.100 Organization and administration of services was in compliance when: Based on interview, and record review, the Governing Body (GB) failed to operate and manage the agency from October 22, 2022, to March 20, 2024, when the agency failed to provide a higher level of care after identifying caregivers at a Board and Care Facility (B&C-a care home for patients who need assistance with daily activities like eating, medication management, toileting, and personal grooming) did not provide repositioning every two hours or incontinence care for one of three sample patients (Patient 1) when Patient 1 was immobile and unable to reposition herself to relieve pressure on her skin. (Refer to L 651) The cumulative effect of these systemic practices resulted in Patient 1 developing multiple wounds: a stage IV pressure ulcer (an open wound with full thickness skin loss and extensive destruction; tissue necrosis (dead tissue) and damage to muscle and bone) to the sacrum (triangular bone at the base of the spine), a deep tissue injury ( DTI-a pressure-related injury to tissues under intact skin) to left buttock, a stage II pressure ulcer (an open wound with partial thickness skin loss. The ulcer is superficial [on top] and presents clinically as an abrasion, blister, or shallow crater] to the right buttock, DTIs to bilateral [both] heels, due to these worsening wounds Patient 1 was hospitalized with wound infections, pain and required surgical debridement (the mechanical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue).”

“Based on interview and record review, the agency failed to provide a higher level of care after identifying caregivers at a Board and Care Facility (B&C-a care home for patients who need assistance with daily activities like eating, medication management, toileting, and personal grooming) did not provide repositioning every two hours or incontinence care for one of three sample patients (Patient 1) when Patient 1 was immobile and unable to reposition herself to relieve pressure on her skin. This failure resulted in Patient 1 developing multiple wounds: a stage IV pressure ulcer (an open wound with full thickness skin loss and extensive destruction; tissue necrosis (dead tissue) and damage to muscle and bone) to the sacrum (triangular bone at the base of the spine), a deep tissue injury ( DTI-a pressure-related injury to tissues under intact skin) to left buttock, a stage II pressure ulcer (an open wound with partial thickness skin loss. The ulcer is superficial [on top] and presents clinically as an abrasion, blister, or shallow crater] to the right buttock, DTIs to bilateral [both] heels, due to these worsening wounds Patient 1 was hospitalized with wound infections, pain and required surgical debridement (the mechanical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue). An unannounced visit was made to the facility on March 11, 2024, at 10:26 AM, to investigate a complaint regarding an allegation of abuse and neglect of Patient 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 October 22, 2022, with a benefit period of December 21, 2022, to March 20, 2023 (Second benefit period). Patient 1 had diagnoses that included ovarian cancer. Patient 1 was discharged to the hospital on March 2, 2023, for worsening pressure sores and pain and died at the hospital on March 14, 2023. During an interview with a Registered Nurse Compliance Officer (CO) on March 11, 2024, at 3:04 PM, the CO stated the issues with Patient 1 occurred a year ago and the Director of Patient Care Services (DPCS 1) and the Registered Nurse Case Manager (RNCM 1) involved in Patient 1s care and management were no longer employed by the agency. The CO stated she became involved in Patient 1s case on January 27, 2023 and continually monitored the care and services Patient 1 received. The CO stated the facility where Patient 1 lived was a residential Board and Care (B&C) with six to eight beds. The CO stated the staff were responsible for residential care such as assistance with Activities of Daily Living (ADLs-an individual’s daily self-care activities). The CO stated the staff had 24 hour a day responsibility for the patients but there was no requirement for the staff to stay awake during the nighttime hours and the staff typically went to bed themselves once the patients were settled in. The CO stated the staff were expected to respond if a patient cried out in the night. The CO stated staff went to bed about 10 PM and then awoke around 5 AM to begin morning cares. The CO stated it was understood by the agencys staff who provided and directed Patient 1s care that Patient 1 was not being repositioned every two hours and incontinence care was not provided during this nighttime period. The CO stated the staff who provided and directed Patient 1s care knew Patient 1 was immobile and could not reposition herself. The CO stated the agency did not seek or offer a higher level of care “;because the patient was already in decline.” The CO stated, “We are not trying to heal a wound during the last stages of life.” A review of Patient 1s initial admission assessment dated October 22, 2022, by a Registered Nurse (RN 1), and recertification assessment dated December 16, 2022, by a Registered Nurse Case Manager (RNCM 1), indicated Patient 1s residence was the B&C Facility. Patient 1 had no wounds, and a Braden Scale (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient’s risk for developing pressure ulcers) assessment under “;mobility” indicated “;completely immobile” (does not make even slight changes in body or extremity position without assistance). During a review of a Skilled Nursing (SN) visit note dated February 13, 2023, by a Licensed Vocational Nurse (LVN 2), indicated, “;... Noted new DTI [deep tissue injury] on Lt [left] heel noted with localized area of persistent non-blanchable deep maroon, purple discoloration, skin intact; blanchable redness on Rt [right] heel, skin intact. New DTI on sacrococcyx [tailbone] area and left buttock with deep purple discoloration, see picture for illustration, pain noted on movement manifested by moaning and groaning. ...” During a review of a Skilled Nursing (SN) visit note dated February 15, 2023, by LVN 2, indicated, “;Integumentary – Skin: (DTI on left heel, central posterior [the back side] coccyx [tailbone], and rt buttock) DTI on left heel, central posterior. coccyx, and rt buttock – Moderate. ... She continues to have weakness and requires max assistance with ... ADLs, she is mainly bedbound. ...” During an interview with LVN 2 on March 11, 2024, at 2:41 PM, LVN 2 stated she had visited Patient 1 on February 13, 2023, and February 15, 2023. LVN 2 stated Patient 1 could not reposition herself. LVN 2 stated she did not know if the B&C repositioned Patient 1 every two hours during the nighttime hours. A review of a SN visit note dated February 20, 2023, by a Licensed Vocational Nurse (LVN 3), indicated, “;Upon arrival, [the Medical Director-MD 1] was at the site and saw the patient. ...Body assessment was done and noted an existing sacrococcyx pressure ulcer wound stage 3 [an open wound with full thickness skin loss involving damage or necrosis [death] of subcutaneous [underlying] tissue. The ulcer presents clinically as a deep crater] to left buttock and has opened today per pcg [primary caregiver] report. Wound bed with dark adherence slough [dead tissue] 75% [percent] and 25% granulating [new tissue filling wound] tissue irregular in shape, surrounding area with bruising. ...Pt continues to have weakness and requires max assistance with ... ADLs. ...” A review of a SN visit note dated February 27, 2023, by a Licensed Vocational Nurse (LVN 3), indicated, “;...Patient appears weak, pale, and confused. ...Stage 3 sacral pressure ulcer appears increasing in size from previous visits. Wound bed with full thickness tissue loss, darker yellow slough 50% adhering to wound bed with 50% granulating tissue to left buttock. Right buttock with appearance of stage II (an open wound with partial thickness skin loss. The ulcer is superficial [on top] and presents clinically as an abrasion, blister, or shallow crater] with discoloration with surrounding tissue, stage II to sacral area above the right buttocks, beefy red in color. ...patient noted constant moaning with facial grimacing during the entire wound care. ...” During an interview LVN 3 on March 11, 2024, at 3:29 PM, LVN 3 stated he had visited Patient 1 on February 20, 2023, and February 27, 2023. LVN 3 stated Patient 1 could not reposition herself. LVN 3 stated he did not know if the B&C repositioned Patient 1 every two hours during the nighttime hours. A review of a communication note dated March 2, 2023, by a Medical Social Worker (MSW 1), indicated, “;MSW [MSW 1] received a text message from son [name of Patient 1s son] at 1:40 am stating that he reached out to the office requesting IV [intravenous] hydration. Son stated [patients] pressure wounds and dehydration are not a natural cause of death. Son also stated that Fentanyl [a pain medication] and Morphine [a pain medication] are not natural causes of death. MSW [MSW 1] received another text message at 5:52 am stating that he [Patient 1s son] made the decision to revoke hospice care in order for [Patient 1] to receive emergency medical assistance. At 8:55 am MSW [MSW 1] received a text message stating Ok. I probably surprised everyone. I can’t in good faith or conscience sit on the sidelines with this. I made this decision on my own.” A review of a communication note dated March 20, 2023, by the CO, indicated, “;Received request from pt’s [Patient 1s son] son [name of Patient 1s son] stating he wants “to speak with someone in charge” re [regarding] his mothers pressure ulcers. ... Ulcers developed [approximately] 14 days before [name of Patient 1s son] had pt [Patient 1] sent to acute care hospital for aggressive treatment that he previously stated he did not want. Pt [Patient 1] was at high risk for ulcers d/t [due to] poor nutrition/intake and pt [Patient 1] being dependent upon staff to reposition her. Her [Patient 1] home facility is a Board & Care facility where staff sleep at night when [patients] sleep. It is possible that [Patient 1] was not repositioned nor incontinence issues addressed during sleeping hours, thereby increasing potential for skin breakdown risks. However, the [patients] general status is declining which contributes significantly to the risks. ...” A review of the Acute Care Hospital (ACH) “;ED [Emergency Department] Note-Physician,” dated March 2, 2023, indicated, “;Chief Complaint: Bed sores, History of Present Illness: ... Per report this is a 79-year-old lady with dementia [a group of conditions causing memory loss and impaired judgment], ovarian cancer, chronic pain on opioids [a class of pain medication], and on home oxygen who resides at a boarding care. Her son [name of son] lives several hours away. He states that patient has known chronic sacral decubiti that recently in the last couple weeks were noted to be worsening to a stage III, so a wound care nurse company was called out to provide wound care at the board-and-care where she lives. Son states the caregiver [name of caregiver] at the board and care had previously been doing an excellent job. He states that these nurses have been involved in caring for the patient for roughly 5 [five] to 7 [seven] days. Son states he received a phone call from [name of caregiver] stating that the patient was looking more uncomfortable, moaning, and that they were having difficulty controlling her pain and also expressed concern that the wound care nurse was not able to care for this wound properly. ... The son does state that initially she was on hydrocodone [a pain medication] for pain although he is not sure if this was pain from the cancer or the decubiti. ... He states when he received a call from [name of the caregiver] the caregiver who asked what he wanted to do about these care concerns, and he called 911 to have her brought into the emergency department. ... Physical Exam: ... General: Patient is on the gurney, moaning. When asked where she is in pain she states butt. Wails and cries out when touched or moved. ... Reexamination/Reevaluation: ... Patient is having pain and crying out when touched or moved but she does seem to understand and is redirectable. ... Decubitus ulcer looks fairly extensive and malodorous [foul smelling]. I feel this needs to be evaluated by a wound specialist. It could be infected or need some debridement. ...” A review of the Acute Care Hospital (ACH) physicians order dated March 2, 2023, indicated, “;Order: Admit to Inpatient per ED [Emergency Department], Reason: Wound, edema [swelling], elevated trop [troponin-a protein found in the cells of the heart muscle-elevated levels can indicate heart damage], agitation.” A review of the Acute Care Hospital (ACH) physicians order dated March 3, 2023, indicated, “;Order: Turn Patient, Order Comment: Order entered secondary to turn patient every 2 [two] hour[s] documentation.” A review of the Acute Care Hospital (ACH) “;Wound Care Note,” dated March 2, 2023, indicated, “;... Wound care consult requested for altered skin in the sacrococcyx. On assessment, noted to have full thickness stage IV with tan non-viable [not capable of living] tissue with palpable [able to touch] bone. Malodor [foul smell] noted and undermining, periwound [around the wound] noted to be ischemic [inadequate blood supply] and denuded [stripped]. Left buttock noted to have DTPI [deep tissue pressure injury] with maroon and purple discoloration. Recommendations provided and reported to RN [Registered Nurse]. Recommended to obtain surgical consult. Dakins [Dakin solution is a strong topical antiseptic used to clean infected wounds, and ulcers] soaked gauze is recommended for infection and malodor. Ordered C200 low air loss [a mattress designed to prevent and treat pressure wounds] for support surface, continuing offloading [removing pressure] bilateral [both] heels with heel suspension boots. Continue turning and repositioning patient. ... Turn and reposition every 2 [two] hours. ...” A review of the Acute Care Hospital (ACH) Physician Progress Notes, dated March 4, 2023, indicated, “;Procedure Performed: Excisional [cutting] Debridement [removal of damaged tissue] of Buttocks Wound (involving skin, soft tissue, muscle and bone, [seven by four by three centimeters-a unit of measurement]. Pre-Procedure exam: Buttocks: [four by seven centimeters] decubitus ulcer [pressure ulcer], stage 4, fibrinous [stringy] exudative [oozing out] material and necrotic [dead or dying] appearing. Post-Procedure Exam: Description of Procedure: ... Using an 11 blade, I gently debrided any necrotic appearing and fibrinous exudative material, the ulceration involved skin, soft tissue, muscle and went to sacrum [triangular bone at the base of the spine]. The wound measured [four by three by seven centimeters]. I was able to debride some of the wound, however fibrinous exudative material and necrosis was extensive. ...” A review of the Acute Care Hospital (ACH) physicians order dated March 4, 2023, indicated, “;levofloxacin (Levaquin) [an antibiotic] 250 mg [milligrams-a unit of measurement] = [equals] 50 ml [milliliters-a unit of measurement], IV Soln [intravenous solution], IV Piggback, Q24H [every 24 hours], Indication: Skin/Soft Tissue infection, ...” A review of the Acute Care Hospital (ACH) “;Notification of Death,” dated March 14, 2023, indicated, “;Date/Time of Death: 03/14/2023 [March 14, 2023] 01:20 PDT [AM-Pacific Daylight Time].” A review of the Acute Care Hospital (ACH) “;Discharge Summary,” dated March 31, 2023, indicated, “;Patient is a 79-year-old lady with dementia, ovarian cancer, chronic pain on opioids, and on home oxygen was sent from boarding care due to worsening chronic sacral decubiti reported by HH [home health] nurse. Apparently pts son [name of patients son] lives several hours away received a call from her caregivers about patients wound getting worse and being uncomfortable so 911 was called. ... general surgeon consult requested and pt underwent bedside debridement. ... Patients son declined feeding tube as patient was not eating and after much discussion with the son, he requested comfort care and was started on morphine [a pain medication] and referred to inpatient hospice. Patient was discharged from hospital and admitted to inpatient hospice care under [name of hospice agency] and shortly expired. ...Final Dx [diagnoses]: Cardiopulmonary arrest [the heart stops beating], Seizure breakthrough, Worsening sacral decubitus ulcer s/p [status post] bedside debridement, ...” During an interview with the Medical Director (MD 1), Administrator (Admin), Director of Patient Care Services (DPCS 2) and the Compliance Officer (CO) on March 20, 2024, at 12:15 PM, MD 1 stated he visited Patient 1 on February 20, 2023. MD 1 stated Patient 1 was so weak he had to assist her to turn to assess her sacral wound. MD 1 stated he did not ask the staff if they were repositioning Patient 1 every two hours throughout the day and night. MD 1 stated he did not know the B&C did not reposition or provide incontinence care throughout the nighttime hours. MD 1 stated prolonged pressure will cause skin breakdown and prolonged pressure on an ulcer will cause the ulcer to worsen. MD 1 stated Patient 1 was at high risk for skin breakdown due to her diagnoses, but it was not unavoidable if proper care was given. MD 1 stated the Registered Nurse Case Manager (RNCM 1) should have discussed the repositioning issue in the Interdisciplinary Group (IDG) meetings so it could have been addressed early before the skin breakdown occurred but had not. MD 1 stated continuous care (continuous home care is meant to include predominately nursing care, covered for at least 8 hours, and up to 24 hours in a 24-hour period, beginning and ending at midnight) could have been initiated so the hospice clinical staff could reposition Patient 1 every two hours and provide incontinence care. MD 1 stated this way the Medical Social Worker (MSW 1) could have secured General Inpatient (GIP) services (General inpatient care (GIP) is available to all hospice beneficiaries who are in need of pain control or symptom management that cannot be provided in any other setting. Skilled nursing care may be needed by a patient whose home support has broken down if this breakdown makes it no longer feasible to furnish needed care in the home setting) from one of our five contracted Skilled Nursing Facilities (SNF) and the SNF could reposition Patient 1 every two hours and provide incontinence care 24 hours a day. MD 1 stated these were services the agency could have provided to Patient 1 allowing time for MSW 1 to find a facility with a higher level of care for Patient 1 to live. MD 1 stated the agency did not make these services available to Patient 1. A review of the agencys policy and procedure titled, “;Interdisciplinary Group Coordination of Care,” dated April 2020, indicated, “;Policy: [name of agency] will utilize a case management system to guide an interdisciplinary group to provide comprehensive, coordinated hospice care to patients and family/caregivers. It will be the responsibility of the Clinical Supervisor/Nursing Supervisor to assign a Case Manager who is a registered nurse (RN). The Case Manager will be responsible for coordination of services with the interdisciplinary group from referral to discharge. The type and scope of services provided by the interdisciplinary group will be based upon the comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions. The exact combination of services and level of care will be unique to each patient and family/caregiver unit, and it will change as the needs of the patient and family/caregiver evolve over the course of their involvement with hospice. The interdisciplinary group will maintain responsibility for the provision and coordination of care, regardless of the setting where care is provided to it patients.” A review of the agencys policy and procedure titled, “;Continuous Care Services,” dated April 2020, indicated, “;Policy: Continuous care will be available to patients receiving Medicare and Medicaid hospice benefits, or as other payers allow. Continuous care level of care must be provided a minimum of eight (8) hours to 24 hours a day during short periods in which an individual patient and family/caregiver require continuous nursing care to achieve palliation, to manage acute medical symptoms, and to maintain the patient in his/her residence.” A review of the agencys policy and procedure titled, “;Admission for General Inpatient Services,” dated April 2020, indicated, “;Policy: General inpatient care will be provided as specified under the Medicare, Medicaid, and specific private insurance hospice benefits. Inpatient care may be recommended in other circumstances not related to the terminal illness ...General Guidelines: 1. One (1) or more of the following clinical criteria must be present in order for the patient to be considered appropriate for admission for general inpatient care. Admission decisions are made on an individual basis after evaluation by the hospice interdisciplinary group and in consultation with the patients attending physician. ...1. Symptoms fail to respond to home management, ...5. Open lesions requiring frequent professional care (decubiti, malignant ulcerations, ...severe abrasions...at least b.i.d. [twice a day] dressing changes) beyond the capability of the primary caregiver. 8. Other presenting problems will be identified and evaluated on an individual basis...””

“Based on interview, and record review, the Governing Body (GB) failed to operate and manage the agency from October 22, 2022, to March 20, 2024, when the agency failed to provide a higher level of care after identifying caregivers at a Board and Care Facility (B&C-a care home for patients who need assistance with daily activities like eating, medication management, toileting, and personal grooming) did not provide repositioning every two hours or incontinence care for one of three sample patients (Patient 1) when Patient 1 was immobile and unable to reposition herself to relieve pressure on her skin. This failure resulted in Patient 1 developing multiple wounds: a stage IV pressure ulcer (an open wound with full thickness skin loss and extensive destruction; tissue necrosis (dead tissue) and damage to muscle and bone) to the sacrum (triangular bone at the base of the spine), a deep tissue injury ( DTI-a pressure-related injury to tissues under intact skin) to left buttock, a stage II pressure ulcer (an open wound with partial thickness skin loss. The ulcer is superficial [on top] and presents clinically as an abrasion, blister, or shallow crater] to the right buttock, DTIs to bilateral [both] heels, due to these worsening wounds Patient 1 was hospitalized with wound infections, pain and required surgical debridement (the mechanical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue). An unannounced visit was made to the facility on March 11, 2024, at 10:26 AM, to investigate a complaint regarding an allegation of abuse and neglect of Patient 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 October 22, 2022, with a benefit period of December 21, 2022, to March 20, 2023 (Second benefit period). Patient 1 had diagnoses that included ovarian cancer. Patient 1 was discharged to the hospital on March 2, 2023, for worsening pressure sores and pain and died at the hospital on March 14, 2023. During an interview with a Registered Nurse Compliance Officer (CO) on March 11, 2024, at 3:04 PM, the CO stated the issues with Patient 1 occurred a year ago and the Director of Patient Care Services (DPCS 1) and the Registered Nurse Case Manager (RNCM 1) involved in Patient 1s care and management were no longer employed by the agency. The CO stated she became involved in Patient 1s case on January 27, 2023 and continually monitored the care and services Patient 1 received. The CO stated the facility where Patient 1 lived was a residential Board and Care (B&C) with six to eight beds. The CO stated the staff were responsible for residential care such as assistance with Activities of Daily Living (ADLs-an individual’s daily self-care activities). The CO stated the staff had 24 hour a day responsibility for the patients but there was no requirement for the staff to stay awake during the nighttime hours and the staff typically went to bed themselves once the patients were settled in. The CO stated the staff were expected to respond if a patient cried out in the night. The CO stated staff went to bed about 10 PM and then awoke around 5 AM to begin morning cares. The CO stated it was understood by the agencys staff who provided and directed Patient 1s care that Patient 1 was not being repositioned every two hours and incontinence care was not provided during this nighttime period. The CO stated the staff who provided and directed Patient 1s care knew Patient 1 was immobile and could not reposition herself. The CO stated the agency did not seek or offer a higher level of care “;because the patient was already in decline.” The CO stated, “We are not trying to heal a wound during the last stages of life.” A review of Patient 1s initial admission assessment dated October 22, 2022, by a Registered Nurse (RN 1), and recertification assessment dated December 16, 2022, by a Registered Nurse Case Manager (RNCM 1), indicated Patient 1s residence was the B&C Facility. Patient 1 had no wounds, and a Braden Scale (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient’s risk for developing pressure ulcers) assessment under “;mobility” indicated “;completely immobile” (does not make even slight changes in body or extremity position without assistance). During a review of a Skilled Nursing (SN) visit note dated February 13, 2023, by a Licensed Vocational Nurse (LVN 2), indicated, “;... Noted new DTI [deep tissue injury] on Lt [left] heel noted with localized area of persistent non-blanchable deep maroon, purple discoloration, skin intact; blanchable redness on Rt [right] heel, skin intact. New DTI on sacrococcyx [tailbone] area and left buttock with deep purple discoloration, see picture for illustration, pain noted on movement manifested by moaning and groaning. ...” During a review of a Skilled Nursing (SN) visit note dated February 15, 2023, by LVN 2, indicated, “;Integumentary – Skin: (DTI on left heel, central posterior [the back side] coccyx [tailbone], and rt buttock) DTI on left heel, central posterior. coccyx, and rt buttock – Moderate. ... She continues to have weakness and requires max assistance with ... ADLs, she is mainly bedbound. ...” During an interview with LVN 2 on March 11, 2024, at 2:41 PM, LVN 2 stated she had visited Patient 1 on February 13, 2023, and February 15, 2023. LVN 2 stated Patient 1 could not reposition herself. LVN 2 stated she did not know if the B&C repositioned Patient 1 every two hours during the nighttime hours. A review of a SN visit note dated February 20, 2023, by a Licensed Vocational Nurse (LVN 3), indicated, “;Upon arrival, [the Medical Director-MD 1] was at the site and saw the patient. ...Body assessment was done and noted an existing sacrococcyx pressure ulcer wound stage 3 [an open wound with full thickness skin loss involving damage or necrosis [death] of subcutaneous [underlying] tissue. The ulcer presents clinically as a deep crater] to left buttock and has opened today per pcg [primary caregiver] report. Wound bed with dark adherence slough [dead tissue] 75% [percent] and 25% granulating [new tissue filling wound] tissue irregular in shape, surrounding area with bruising. ...Pt continues to have weakness and requires max assistance with ... ADLs. ...” A review of a SN visit note dated February 27, 2023, by a Licensed Vocational Nurse (LVN 3), indicated, “;...Patient appears weak, pale, and confused. ...Stage 3 sacral pressure ulcer appears increasing in size from previous visits. Wound bed with full thickness tissue loss, darker yellow slough 50% adhering to wound bed with 50% granulating tissue to left buttock. Right buttock with appearance of stage II (an open wound with partial thickness skin loss. The ulcer is superficial [on top] and presents clinically as an abrasion, blister, or shallow crater] with discoloration with surrounding tissue, stage II to sacral area above the right buttocks, beefy red in color. ...patient noted constant moaning with facial grimacing during the entire wound care. ...” During an interview LVN 3 on March 11, 2024, at 3:29 PM, LVN 3 stated he had visited Patient 1 on February 20, 2023, and February 27, 2023. LVN 3 stated Patient 1 could not reposition herself. LVN 3 stated he did not know if the B&C repositioned Patient 1 every two hours during the nighttime hours. A review of a communication note dated March 2, 2023, by a Medical Social Worker (MSW 1), indicated, “;MSW [MSW 1] received a text message from son [name of Patient 1s son] at 1:40 am stating that he reached out to the office requesting IV [intravenous] hydration. Son stated [patients] pressure wounds and dehydration are not a natural cause of death. Son also stated that Fentanyl [a pain medication] and Morphine [a pain medication] are not natural causes of death. MSW [MSW 1] received another text message at 5:52 am stating that he [Patient 1s son] made the decision to revoke hospice care in order for [Patient 1] to receive emergency medical assistance. At 8:55 am MSW [MSW 1] received a text message stating Ok. I probably surprised everyone. I can’t in good faith or conscience sit on the sidelines with this. I made this decision on my own.” A review of a communication note dated March 20, 2023, by the CO, indicated, “;Received request from pt’s [Patient 1s son] son [name of Patient 1s son] stating he wants “to speak with someone in charge” re [regarding] his mothers pressure ulcers. ... Ulcers developed [approximately] 14 days before [name of Patient 1s son] had pt [Patient 1] sent to acute care hospital for aggressive treatment that he previously stated he did not want. Pt [Patient 1] was at high risk for ulcers d/t [due to] poor nutrition/intake and pt [Patient 1] being dependent upon staff to reposition her. Her [Patient 1] home facility is a Board & Care facility where staff sleep at night when [patients] sleep. It is possible that [Patient 1] was not repositioned nor incontinence issues addressed during sleeping hours, thereby increasing potential for skin breakdown risks. However, the [patients] general status is declining which contributes significantly to the risks. ...” A review of the Acute Care Hospital (ACH) “;ED [Emergency Department] Note-Physician,” dated March 2, 2023, indicated, “;Chief Complaint: Bed sores, History of Present Illness: ... Per report this is a 79-year-old lady with dementia [a group of conditions causing memory loss and impaired judgment], ovarian cancer, chronic pain on opioids [a class of pain medication], and on home oxygen who resides at a boarding care. Her son [name of son] lives several hours away. He states that patient has known chronic sacral decubiti that recently in the last couple weeks were noted to be worsening to a stage III, so a wound care nurse company was called out to provide wound care at the board-and-care where she lives. Son states the caregiver [name of caregiver] at the board and care had previously been doing an excellent job. He states that these nurses have been involved in caring for the patient for roughly 5 [five] to 7 [seven] days. Son states he received a phone call from [name of caregiver] stating that the patient was looking more uncomfortable, moaning, and that they were having difficulty controlling her pain and also expressed concern that the wound care nurse was not able to care for this wound properly. ... The son does state that initially she was on hydrocodone [a pain medication] for pain although he is not sure if this was pain from the cancer or the decubiti. ... He states when he received a call from [name of the caregiver] the caregiver who asked what he wanted to do about these care concerns, and he called 911 to have her brought into the emergency department. ... Physical Exam: ... General: Patient is on the gurney, moaning. When asked where she is in pain she states butt. Wails and cries out when touched or moved. ... Reexamination/Reevaluation: ... Patient is having pain and crying out when touched or moved but she does seem to understand and is redirectable. ... Decubitus ulcer looks fairly extensive and malodorous [foul smelling]. I feel this needs to be evaluated by a wound specialist. It could be infected or need some debridement. ...” A review of the Acute Care Hospital (ACH) physicians order dated March 2, 2023, indicated, “;Order: Admit to Inpatient per ED [Emergency Department], Reason: Wound, edema [swelling], elevated trop [troponin-a protein found in the cells of the heart muscle-elevated levels can indicate heart damage], agitation.” A review of the Acute Care Hospital (ACH) physicians order dated March 3, 2023, indicated, “;Order: Turn Patient, Order Comment: Order entered secondary to turn patient every 2 [two] hour[s] documentation.” A review of the Acute Care Hospital (ACH) “;Wound Care Note,” dated March 2, 2023, indicated, “;... Wound care consult requested for altered skin in the sacrococcyx. On assessment, noted to have full thickness stage IV with tan non-viable [not capable of living] tissue with palpable [able to touch] bone. Malodor [foul smell] noted and undermining, periwound [around the wound] noted to be ischemic [inadequate blood supply] and denuded [stripped]. Left buttock noted to have DTPI [deep tissue pressure injury] with maroon and purple discoloration. Recommendations provided and reported to RN [Registered Nurse]. Recommended to obtain surgical consult. Dakins [Dakin solution is a strong topical antiseptic used to clean infected wounds, and ulcers] soaked gauze is recommended for infection and malodor. Ordered C200 low air loss [a mattress designed to prevent and treat pressure wounds] for support surface, continuing offloading [removing pressure] bilateral [both] heels with heel suspension boots. Continue turning and repositioning patient. ... Turn and reposition every 2 [two] hours. ...” A review of the Acute Care Hospital (ACH) Physician Progress Notes, dated March 4, 2023, indicated, “;Procedure Performed: Excisional [cutting] Debridement [removal of damaged tissue] of Buttocks Wound (involving skin, soft tissue, muscle and bone, [seven by four by three centimeters-a unit of measurement]. Pre-Procedure exam: Buttocks: [four by seven centimeters] decubitus ulcer [pressure ulcer], stage 4, fibrinous [stringy] exudative [oozing out] material and necrotic [dead or dying] appearing. Post-Procedure Exam: Description of Procedure: ... Using an 11 blade, I gently debrided any necrotic appearing and fibrinous exudative material, the ulceration involved skin, soft tissue, muscle and went to sacrum [triangular bone at the base of the spine]. The wound measured [four by three by seven centimeters]. I was able to debride some of the wound, however fibrinous exudative material and necrosis was extensive. ...” A review of the Acute Care Hospital (ACH) physicians order dated March 4, 2023, indicated, “;levofloxacin (Levaquin) [an antibiotic] 250 mg [milligrams-a unit of measurement] = [equals] 50 ml [milliliters-a unit of measurement], IV Soln [intravenous solution], IV Piggback, Q24H [every 24 hours], Indication: Skin/Soft Tissue infection, ...” A review of the Acute Care Hospital (ACH) “;Notification of Death,” dated March 14, 2023, indicated, “;Date/Time of Death: 03/14/2023 [March 14, 2023] 01:20 PDT [AM-Pacific Daylight Time].” A review of the Acute Care Hospital (ACH) “;Discharge Summary,” dated March 31, 2023, indicated, “;Patient is a 79-year-old lady with dementia, ovarian cancer, chronic pain on opioids, and on home oxygen was sent from boarding care due to worsening chronic sacral decubiti reported by HH [home health] nurse. Apparently pts son [name of patients son] lives several hours away received a call from her caregivers about patients wound getting worse and being uncomfortable so 911 was called. ... general surgeon consult requested and pt underwent bedside debridement. ... Patients son declined feeding tube as patient was not eating and after much discussion with the son, he requested comfort care and was started on morphine [a pain medication] and referred to inpatient hospice. Patient was discharged from hospital and admitted to inpatient hospice care under [name of hospice agency] and shortly expired. ...Final Dx [diagnoses]: Cardiopulmonary arrest [the heart stops beating], Seizure breakthrough, Worsening sacral decubitus ulcer s/p [status post] bedside debridement, ...” During an interview with the Medical Director (MD 1), Administrator (Admin), Director of Patient Care Services (DPCS 2) and the Compliance Officer (CO) on March 20, 2024, at 12:15 PM, MD 1 stated he visited Patient 1 on February 20, 2023. MD 1 stated Patient 1 was so weak he had to assist her to turn to assess her sacral wound. MD 1 stated he did not ask the staff if they were repositioning Patient 1 every two hours throughout the day and night. MD 1 stated he did not know the B&C did not reposition or provide incontinence care throughout the nighttime hours. MD 1 stated prolonged pressure will cause skin breakdown and prolonged pressure on an ulcer will cause the ulcer to worsen. MD 1 stated Patient 1 was at high risk for skin breakdown due to her diagnoses, but it was not unavoidable if proper care was given. MD 1 stated the Registered Nurse Case Manager (RNCM 1) should have discussed the repositioning issue in the Interdisciplinary Group (IDG) meetings so it could have been addressed early before the skin breakdown occurred but had not. MD 1 stated continuous care (continuous home care is meant to include predominately nursing care, covered for at least 8 hours, and up to 24 hours in a 24-hour period, beginning and ending at midnight) could have been initiated so the hospice clinical staff could reposition Patient 1 every two hours and provide incontinence care. MD 1 stated this way the Medical Social Worker (MSW 1) could have secured General Inpatient (GIP) services (General inpatient care (GIP) is available to all hospice beneficiaries who are in need of pain control or symptom management that cannot be provided in any other setting. Skilled nursing care may be needed by a patient whose home support has broken down if this breakdown makes it no longer feasible to furnish needed care in the home setting) from one of our five contracted Skilled Nursing Facilities (SNF) and the SNF could reposition Patient 1 every two hours and provide incontinence care 24 hours a day. MD 1 stated these were services the agency could have provided to Patient 1 allowing time for MSW 1 to find a facility with a higher level of care for Patient 1 to live. MD 1 stated the agency did not make these services available to Patient 1. A review of the agencys policy and procedure titled, “;Interdisciplinary Group Coordination of Care,” dated April 2020, indicated, “;Policy: [name of agency] will utilize a case management system to guide an interdisciplinary group to provide comprehensive, coordinated hospice care to patients and family/caregivers. It will be the responsibility of the Clinical Supervisor/Nursing Supervisor to assign a Case Manager who is a registered nurse (RN). The Case Manager will be responsible for coordination of services with the interdisciplinary group from referral to discharge. The type and scope of services provided by the interdisciplinary group will be based upon the comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions. The exact combination of services and level of care will be unique to each patient and family/caregiver unit, and it will change as the needs of the patient and family/caregiver evolve over the course of their involvement with hospice. The interdisciplinary group will maintain responsibility for the provision and coordination of care, regardless of the setting where care is provided to it patients.” A review of the agencys policy and procedure titled, “;Continuous Care Services,” dated April 2020, indicated, “;Policy: Continuous care will be available to patients receiving Medicare and Medicaid hospice benefits, or as other payers allow. Continuous care level of care must be provided a minimum of eight (8) hours to 24 hours a day during short periods in which an individual patient and family/caregiver require continuous nursing care to achieve palliation, to manage acute medical symptoms, and to maintain the patient in his/her residence.” A review of the agencys policy and procedure titled, “;Admission for General Inpatient Services,” dated April 2020, indicated, “;Policy: General inpatient care will be provided as specified under the Medicare, Medicaid, and specific private insurance hospice benefits. Inpatient care may be recommended in other circumstances not related to the terminal illness ...General Guidelines: 1. One (1) or more of the following clinical criteria must be present in order for the patient to be considered appropriate for admission for general inpatient care. Admission decisions are made on an individual basis after evaluation by the hospice interdisciplinary group and in consultation with the patients attending physician. ...1. Symptoms fail to respond to home management, ...5. Open lesions requiring frequent professional care (decubiti, malignant ulcerations, ...severe abrasions...at least b.i.d. [twice a day] dressing changes) beyond the capability of the primary caregiver. 8. Other presenting problems will be identified and evaluated on an individual basis...” During an interview with the Administrator (Admin), in the presence of the Director of Patient Care Services (DPCS 2), and a Licensed Clinical Social Worker (LCSW) on March 20, 2024, at 2:42 PM, the Admin stated she was a member of the Governing Body (GB) along with MD 1, DPCS 2, LCSW, CO and Chief Operating Officer/Owner (CEO/Owner). The Admin stated the GB 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 Patient 1s need for a higher level of care. The Admin stated the GB had not provided continuous care services or General Inpatient (GIP) services to provide a higher level of care to Patient 1. A review of the agencys policy and procedure titled, “;Governing Body,” dated April 2020, indicated, “;Policy: The Governing Body will assume full legal authority and responsibility for the operation of [name of agency]. The Governing Body of [name of agency] will serve as the governing authority for the hospice program, which will function according to [name of agency] bylaws. ... Procedure: ... 4. The Governing Body will routinely evaluate to what extent the hospice has met the needs of the community for hospice care. Has provided adequate and appropriate care to patients, ...””