West Coast Healthcare, LLC

“Based on interview and record review, the hospice failed to ensure the grievance was thoroughly investigated as per the hospice’s P&P for four nonsampled patients (Patients A, B, C, and D). This failure created the risk of violating the patient’s rights and not providing quality of care and services to these patients. Findings: The hospice’s P&P titled Resolution of Patient Conflicts, Grievance or Complaints reviewed 9/1/24, showed the hospice will investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregiver. Review of the hospice’s grievance log was conducted on 11/12/25. The grievance log showed the complaints were filed on the following dates:-On 4/15/25, a complaint about the hospice staff who signed in for Patient A but did not provide care.-On 8/2 and 8/28/24, a complaint about the hospice staff who did not communicate well and the needs were not addressed for Patient B.-On 2/8/23, a complaint about the hospice staff who did not manage the skin condition for Patient C.-On 6/16/23, a complaint about the hospice staff related to the visit schedule of the multiple disciplines, the lack of training about DME, and providing for personal care for Patient D. However, review of the hospice’s documents failed to show documented evidence of an interview conducted with the alleged staff. On 11/25/25 at 1258 hours, an interview and concurrent document review was conducted with the Administrator. The Administrator was asked if they investigated the grievance filed. The Administrator was asked if an interview with the alleged staff was conducted. The Administrator replied “yes, I have to.” The Administrator was asked to provide the documents for the staff interview. The Administrator reviewed the grievance log and stated there was none documented. The Administrator was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the comprehensive assessments were completed no later than five calendar days after the election of hospice care for eight of 19 sampled patients (Patients 1, 5, 6, 8, 9, 10, 15, and 17). This failure had the potential for not addressing the care needs for these patients. Findings: XX. Review of Patient 8’s clinical record was initiated on 11/12/25. The clinical record showed the SOC was 6/6/25. The patient was certified for hospice services during the certification periods from 6/6/25 to 9/3/25 and 9/4/25 to 12/2/25. Review of the RN Hospice Start of Care dated 6/6/24, showed the RN had performed an assessment.However, RN 1 failed to assess the patient’s weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.On 11/26/25 at 1017 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS was informed on Patient 8’s missed weight or MAC measurement assessment from the SOC. The DPCS verified she could not find any weight or MAC measurement on Patient 8’s SOC RN visit documentation. XX. Review of Patient 10’s clinical record was initiated on 11/12/25. The clinical record showed the SOC was 12/3/24. The patient was certified for hospice services during certification periods from 12/3/25 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, and 9/29/25 to 11/27/25 and 11/28/25 to 1/26/25. *Review of the RN Hospice Start of Care dated 12/3/24, showed the RN had performed an assessment.However, RN 1 failed to assess the patients weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care. On 11/25/25 at 1442 hours, an interview and a concurrent clinical record review were conducted with the DPCS. The DPCS was asked if weight or MAC measurement should be conducted every SOC visit. The DPCS stated weight or MAC measurement should be measured every SOC visit. The DPCS was informed of the missing weight or MAC measurements and DPCS was further asked if she could find any documentation of weight or MAC measurements from Patient 10’s SOC RN visit. The DPCS verified she could not find any documentation and acknowledged it should have been done. The hospice’s P&P titled Patient Assessments reviewed 9/1/24, showed the hospice will conduct and document in writing a patient specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patients’ need for physical, psychosocial, emotional, and spiritual care. The Interdisciplinary Group/Team (IDG/IDT) in consultation with the patients’ attending physician (if any), will complete the comprehensive assessment no later than five calendar days after the election of hospice benefit. 1. Review of Patient 15’s clinical record was initiated on 11/20/25. The clinical record showed the SOC was 9/9/24. The patient was certified for hospice services during the certification periods from 9/9/24 to 12/7/24, 12/8/24 to 3/7/25, 3/8/25 to 5/6/25, 5/7/25 to 7/5/25, 7/6/25 to 9/3/25, 9/4/25 to 11/2/25 and 11/3/25 to 1/1/26. *Review of the RN Hospice Start of Care dated 9/9/24, showed the RN had performed an assessment.However, there was no documented evidenced the RN 1 assessed the patients weight as part of the completion of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.*Review of the clinical records showed the MSW conducted an initial evaluation dated 9/24/25. However, the MSW failed to performed the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.On 11/25/25 at 1518 hours an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if the height and weight needed to be taken. The Administrator replied, we check the MAC instead of the weight. The Administrator was also asked if the MAC was documented. The Administrator reviewed the clinical records and replied, it was not documented on the notes. The Administrator was further ask as to the timeline of the initial MSW comprehensive assessment. The Administrator replied there was a missed visit on 9/20/25, the evaluation was conducted more than 5 calendar days from the SOC. The Administrator was informed and acknowledged the findings. 2. Review of Patient 17’s clinical record was initiated on 11/20/25. The clinical record showed the SOC was 3/5/25. The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25 and 10/31/25 to 12/29/25. Review of the RN Hospice Start of Care dated 3/5/25, showed the RN 1 had performed an assessment. *However, the RN 1 failed to assess the patients weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.Further review of the RN Hospice Start of Care dated 3/5/25 showed a documentation for a Chaplain referral. *However, review of the clinical records showed the Chaplain 1 conducted the initial evaluation on 4/3/25 which was more than 5 calendar days after the election of hospice care.On 11/20/25 at 1527 hours, an interview and concurrent clinical record review was conducted with the Volunteer Coordinator/ HR/Intake Manager. The Volunteer Coordinator/ HR/Intake Manager was asked if there was other Chaplain evaluation notes after the SOC. The Volunteer Coordinator/ HR/Intake Manager replied, it was the only Chaplain evaluation notes.On 11/25/25 at 1437 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked as to the timeline of the completion of the Chaplain initial evaluation. The Administrator replied, within 5 days from the SOC. The Administrator was informed and acknowledged the findings. 3. Review of Patient 9’s clinical record was initiated on 11/19/25. The clinical record showed the SOC was 1/14/25. The patient was certified for hospice services during the certification periods from 1/14/25 to 4/13/25, 4/14/25 to 6/12/25, 6/13/25 to 8/11/25, 8/12/25 to 10/10/25 and 10/11/25 to 12/925.Review of the RN Hospice Start of Care dated 1/14/25, showed the RN 1 had performed an assessment. Further review of the clinical records showed the MSW conducted an initial evaluation dated 1/24/25. However, the MSW failed to performed the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.On 11/26/25 at 0958 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked as to the timeline of the completion of the MSW initial evaluation. The Administrator reviewed the clinical record and replied, there was a coordination note on 1/20/25 and should be within 5 days if the family was agreeable. The Administrator was informed and acknowledged the findings. 4. Review of Patient 1’s closed clinical record was initiated on 11/14/25. The clinical record showed the SOC was 12/18/24. The patient was certified for hospice services during the certification periods from 12/18/24 to 3/17/25, 3/18/25 to 6/15/25 and 6/16/25 to 8/2/25. The patient passed away on 8/2/25. Review of the RN Hospice Start of Care dated 12/18/24, showed the RN 3 had performed an assessment.However, there was no documented evidenced the RN 3 assessed the patients weight as part of the completion of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.Further review of the RN Hospice Start of Care dated 12/18/24 on the section of “Is the patient /caregiver open to Volunteer services to meet social /family support need” showed “yes, Volunteer Coordinator notified of request”. The reason for the Volunteer services was for errands and emotional support (telephone).However, review of the closed clinical record failed to show a volunteer coordinator visited the patient no later than 5 calendar days after the election of hospice care.On 11/25/25 at 1135 hours, an interview and concurrent closed clinical record review was conducted with the Administrator. The Administrator was asked if there was a documentation of the patients’ weight was taken on the initial comprehensive assessment. The Administrator reviewed the closed clinical record and replied none was documented. The Administrator was also asked if the Volunteer visit was conducted. The Administrator reviewed the closed clinical record and replied, typically the Social Worker will follow up for the volunteer request, MSW saw the patient on 12/20/24 but does not document the need for Volunteer, we don’t have Volunteer at that time. The Administrator was informed and acknowledged the findings. Crossed reference: L-554 5. Review of Patient 6’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 9/25/24. The patient was certified for hospice services during the certification periods from 9/25/24 to 12/23/24, 12/24/24 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, 9/20/25 to 11/18/25 and 11/19/25 to 1/17/25. Review of the RN Hospice Start of Care dated 9/25/24, showed the RN 1 had performed an assessment. However, the RN 1 failed to assess the patients weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.On 11/25/25 at 0909 hours an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if the MAC was documented. The reviewed the clinical record and replied, no. The Administrator was informed and acknowledged the findings. #. Review of Patient 5’s clinical record was initiated on 11/13/25. The clinical record showed the SOC was 3/13/25. The patient was certified for hospice services during the certification periods from 3/13/25 to 6/10/25, 6/11/25 to 9/8/25, 9/9/25 to 11/7/25 and 11/8/25 to 1/6/26. Review of the RN Hospice Start of Care dated 3/13/25, showed the RN 1 had performed an assessment. However, the RN 1 failed to assess the patients weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care On 11/26/25 at 0811 hours an interview and concurrent clinical record review was conducted with the Administrator. The reviewed the clinical record and replied, no. The Administrator was informed and acknowledged the findings. The hospice’s P&P titled Patient Assessments reviewed 9/1/24, showed the hospice will conduct and document in writing a patient specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patients’ need for physical, psychosocial, emotional, and spiritual care. The Interdisciplinary Group/Team (IDG/IDT) in consultation with the patients’ attending physician (if any), will complete the comprehensive assessment no later than five calendar days after the election of hospice benefit. 1. Review of Patient 15’s clinical record was initiated on 11/20/25. The clinical record showed the SOC was 9/9/24. The patient was certified for hospice services during the certification periods from 9/9/24 to 12/7/24, 12/8/24 to 3/7/25, 3/8/25 to 5/6/25, 5/7/25 to 7/5/25, 7/6/25 to 9/3/25, 9/4/25 to 11/2/25, and 11/3/25 to 1/1/26. The Hospice Informed Consent/Election of Hospice Benefit dated 9/9/24, showed hospices services was elected. *Review of the RN Hospice Start of Care dated 9/9/24, showed the RN had performed an assessment.However, there was no documented evidenced RN 1 assessed the patient’s weight as part of the completion of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.*Review of the clinical records showed the MSW conducted an initial evaluation dated 9/24/25. However, the MSW failed to performed the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.On 11/25/25 at 1518 hours an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if the height and weight needed to be taken. The Administrator replied, we check the MAC instead of the weight. The Administrator was also asked if the MAC was documented. The Administrator reviewed the clinical records and stated it was not documented on the notes. The Administrator was asked as to the timeline of the initial MSW comprehensive assessment. The Administrator stated there was a missed visit on 9/20/25 and the evaluation was conducted more than 5 calendar days from the SOC. The Administrator was informed and acknowledged the findings. 2. Review of Patient 17’s clinical record was initiated on 11/20/25. The clinical record showed the SOC was 3/5/25. The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25, and 10/31/25 to 12/29/25.The Authorization & Consent for Treatment dated 3/5/25, showed hospices services was elected. Review of the RN Hospice Start of Care dated 3/5/25, showed RN 1 had performed an assessment. *However, RN 1 failed to assess the patients weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.Further review of the RN Hospice Start of Care dated 3/5/25, showed a documentation for a Chaplain referral. *However, review of the clinical records showed Chaplain 1 conducted the initial evaluation on 4/3/25 which was more than 5 calendar days after the election of hospice care.On 11/20/25 at 1527 hours, an interview and concurrent clinical record review was conducted with the Volunteer Coordinator/ HR/Intake Manager. The Volunteer Coordinator/ HR/Intake Manager was asked if there was other Chaplain evaluation notes after the SOC. The Volunteer Coordinator/ HR/Intake Manager replied, it was the only Chaplain evaluation notes.On 11/25/25 at 1437 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked as to the timeline of the completion of the Chaplain initial evaluation. The Administrator replied, within 5 days from the SOC. The Administrator was informed and acknowledged the findings. 3. Review of Patient 9’s clinical record was initiated on 11/19/25. The clinical record showed the SOC was 1/14/25. The patient was certified for hospice services during the certification periods from 1/14/25 to 4/13/25, 4/14/25 to 6/12/25, 6/13/25 to 8/11/25, 8/12/25 to 10/10/25 and 10/11/25 to 12/9/25.The Hospice Informed Consent/Election of Hospice Benefit dated 1/14/25, showed hospices services was elected. Review of the RN Hospice Start of Care dated 1/14/25, showed RN 1 had performed an assessment. Further review of the clinical records showed the MSW conducted an initial evaluation dated 1/24/25. However, the MSW failed to perform the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.On 11/26/25 at 0958 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked as to the timeline of the completion of the MSW initial evaluation. The Administrator reviewed the clinical record and stated there was a coordination note on 1/20/25 and should be within 5 days if the family was agreeable. The Administrator was informed and acknowledged the findings. 4. Review of Patient 1’s closed clinical record was initiated on 11/14/25. The clinical record showed the SOC was 12/18/24. The patient was certified for hospice services during the certification periods from 12/18/24 to 3/17/25, 3/18/25 to 6/15/25 and 6/16/25 to 8/2/25. The patient expired on 8/2/25. The Hospice Informed Consent/Election of Hospice Benefit dated 12/18/24, showed hospices services was elected. Review of the RN Hospice Start of Care dated 12/18/24, showed the RN 3 had performed an assessment.However, there was no documented evidence RN 3 assessed the patient’s weight as part of the completion of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.Further review of the RN Hospice Start of Care dated 12/18/24, on the section of “Is the patient /caregiver open to Volunteer services to meet social /family support need” showed “yes, Volunteer Coordinator notified of request”. Documentation showed the reason for the volunteer services was for errands and emotional support (telephone).However, review of the closed clinical record failed to show a volunteer coordinator visited the patient no later than 5 calendar days after the election of hospice care.On 11/25/25 at 1135 hours, an interview and concurrent closed clinical record review was conducted with the Administrator. The Administrator was asked if there was a documentation of the patients’ weight was taken on the initial comprehensive assessment. The Administrator reviewed the closed clinical record and replied none was documented. The Administrator was also asked if the Volunteer visit was conducted. The Administrator reviewed the closed clinical record and replied, typically the Social Worker will follow up for the volunteer request, MSW saw the patient on 12/20/24 but does not document the need for Volunteer, we don’t have Volunteer at that time. The Administrator was informed and acknowledged the findings. Crossed reference: L-554 5. Review of Patient 6’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 9/25/24. The patient was certified for hospice services during the certification periods from 9/25/24 to 12/23/24, 12/24/24 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, 9/20/25 to 11/18/25 and 11/19/25 to 1/17/25. The Authorization & Consent for Treatment dated 9/25/24, showed hospices services was elected. Review of the RN Hospice Start of Care dated 9/25/24, showed the RN 1 had performed an assessment. However, the RN 1 failed to assess the patients weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.On 11/25/25 at 0909 hours an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if the MAC was documented. The reviewed the clinical record and replied, no. The Administrator was informed and acknowledged the findings. 6. Review of Patient 5’s clinical record was initiated on 11/13/25. The clinical record showed the SOC was 3/13/25. The patient was certified for hospice services during the certification periods from 3/13/25 to 6/10/25, 6/11/25 to 9/8/25, 9/9/25 to 11/7/25 and 11/8/25 to 1/6/26.The Hospice Informed Consent/Election of Hospice Benefit dated 3/12/25, showed hospices services was elected. Review of the RN Hospice Start of Care dated 3/13/25, showed the RN 1 had performed an assessment. However, the RN 1 failed to assess the patients weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care On 11/26/25 at 0811 hours an interview and concurrent clinical record review was conducted with the Administrator. The reviewed the clinical record and replied, no. The Administrator was informed and acknowledged the findings. 7. Review of Patient 8’s clinical record was initiated on 11/12/25. The clinical record showed the SOC was 6/6/25. The patient was certified for hospice services during the certification periods from 6/6/25 to 9/3/25 and 9/4/25 to 12/2/25.The Authorization & Consent for Treatment dated 6/6/25, showed hospices services was elected. Review of the RN Hospice Start of Care dated 6/6/24, showed the RN had performed an assessment.However, RN 1 failed to assess the patient’s weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.On 11/26/25 at 1017 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS was informed on Patient 8’s missed weight or MAC measurement assessment from the SOC. The DPCS verified she could not find any weight or MAC measurement on Patient 8’s SOC RN visit documentation. 8. Review of Patient 10’s clinical record was initiated on 11/12/25. The clinical record showed the SOC was 12/3/24. The patient was certified for hospice services during certification periods from 12/3/25 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, and 9/29/25 to 11/27/25 and 11/28/25 to 1/26/25.The Hospice Informed Consent/Election of Hospice Benefit dated 12/3/24, showed hospices services was elected. *Review of the RN Hospice Start of Care dated 12/3/24, showed the RN had performed an assessment.However, RN 1 failed to assess the patients weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care. On 11/25/25 at 1442 hours, an interview and a concurrent clinical record review were conducted with the DPCS. The DPCS was asked if weight or MAC measurement should be conducted every SOC visit. The DPCS stated weight or MAC measurement should be measured every SOC visit. The DPCS was informed of the missing weight or MAC measurements and DPCS was further asked if she could find any documentation of weight or MAC measurements from Patient 10’s SOC RN visit. The DPCS verified she could not find any documentation and acknowledged it should have been done.”

“Based on interview and record review, the hospice failed to ensure the comprehensive assessment included the assessment for volunteer need for one of 19 sampled patients (Patient 14). This failure had the potential risk of not identifying and addressing the care needs for this patient.Findings: Review of Patient 14’s clinical record was initiated on 11/19/25. The clinical record showed the SOC was 8/1/24. The patient was certified for hospice services during the certification periods from 8/1/24 to 10/29/24, 10/30/24 to 12/28/24, 12/29/24 to 2/26/25, 2/27/25 to 4/27/25, 4/28/25 to 6/26/25, 6/27/25 to 8/25/25, 8/26/25 to 10/24/25, and 10/25/25 to 12/23/25.However, further review of the clinical record failed to show documented evidence the initial comprehensive assessment included the assessment of the patient’s need for volunteer services.On 11/21/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings.”

“Based on observation, interview, and record review, the hospice failed to include all current medications included specific indications and parameters for its use for one of 19 sampled patients (Patient 5). This failure had the potential for the patients to not receive the appropriate care and necessary services and negatively affect the patients’ well-being. Findings: The hospice’s P&P Titled Medication Management reviewed 9/8/25 showed medication assessments will identify all medications, both prescription and non-prescription the patient is taking and document in the clinical record. Medication monitoring occurs at each scheduled clinical visit and will include gathering appropriate information to develop an accurate medication history and a current medication profile. Medication assessments are continuous and ongoing, occur at every scheduled clinical visit and are documented in the clinical record. 1. Review of Patient 5’s clinical record was initiated on 11/13/25. The clinical record showed the SOC was 3/13/25. The patient was certified for hospice services during the certification periods from 3/13/25 to 6/10/25, 6/11/25 to 9/8/25, 9/9/25 to 11/7/25 and 11/8/25 to 1/6/26. The Medication Profile showed the patients’ medications included the following: -acetaminophen (analgesic) 325 mg two tablets PO Q6H PRN for pain and temperature NTE 3gms in 24H-Betadine (antiseptic) 5% topical spray, QD for wound care-Calcium citrate magnesium and zinc with Vitamin D3 (supplement) one tablet PO BID -Centrum silver women 8 mg Iron -400 mcg -50 mcg (supplement) one tablet PO QD-Dorzolamide- timolol (glaucoma) 2%-0.5% eye drops in a dropperette -ophthalmic one dropperette QD-Glimepiride (antidiabetic) 2 mg tablet one tablet QD-Humalog Kwikpen U-100 (antidiabetic) Insulin 100 unit/ml subcutaneous four times a day-hydrocodone 5mg /acetaminophen 325 mg (pain medication) one tablet orally Q4H PRN-Lantus Solostar U-100 (antidiabetic) Insulin 100 Units/Ml (3ml) subcutaneous pen 11 unit subcutaneous QAM and 4 unit QPM-Latanoprost 0.005% (glaucoma) eye drops -ophthalmic one drop at QHS-Medihoney (honey) 100% (wound care) topical paste - topical as per instructions three times a week-Metformin (antidiabetic) 500 mg one tablet BID-Metoprolol succinate ER (anti hypertension) 50 mg tablet extended release 24H one tablet QD, hold for SBP less than 100 -Miralax (constipation) 17 gram/dose oral powder 17 grams QD-Oxygen Gas inhalation (Shortness of breath) 2-5 Liter PRN -Preservision Areds 2 Plus Multivitamin (vision supplement) 200 mcg-15mcg-5 Mg -11mg capsule -Senna Plus (constipation) 8.5 mg-50 mg tablet one tablet BID-Seroquel (agitation) 25 mg tablet one tablet QAM-Sertraline (agitation) 50 mg tablet QD-Simvastatin (anti cholesterol) 10 mg tablet QHS-Tolterodine Er (over reactive bladder) 4mg capsule Extended release 24H one capsule QD-Trulicity (antidiabetic) 1.5 mg/ 0.5ml subcutaneous pen injector 1.5 mg Weekly every Wednesday-Vitamin C(supplement) 500 mg tablet 0ne tablet QD-Xarelto (blood thinner) 10 mg tablet one tablet QDA joint home visit with RN 1 was conducted on 11/13/25 at 0900 hours, to the B&C facility where Patient 5 resided. Review of the patients’ medications included the following instructions: -Betadine (antiseptic) 5% topical spray, QD for wound care. However, the spray preparation was changed into swab.-Medi honey (honey) 100% (wound care) topical paste - topical as per instructions three times a week. However, the medication was discontinued. -Metoprolol succinate ER (anti hypertension) 50 mg tablet extended release 24H one tablet QD hold for SBP less than 100. However, the instructions when to hold the medications was not included on the medication label.-Trulicity (antidiabetic) 1.5 mg/ 0.5ml subcutaneous pen injector 1.5 mg Weekly every Wednesday. However, the medication was given every Friday instead of every Wednesday as ordered. In addition, the patient was taking Simethicone 80 mg 1/2 tablet Q6H PRN for flatulence. However, the medication was not included in the medication profile. On 11/13/25 at 0957 hours, an interview and concurrent clinical record review was conducted with the RN 1 and the PCG. The RN 1 acknowledged the findings. On 11/26/25 at 0800 hours, the Administrator was informed and acknowledged the findings. xx. Review of Patient 7’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 7/27/24. The patient was certified for hospice during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25. The Medication Profile showed the patients’ medications included the following:-Acetaminophen 500 mg tablet , to take one tablet every 4 hours as needed for pain level 1-3/10 , do not exceed 3 g of acetaminophen in 24 hours from all sources,-Acetaminophen 650 mg rectal suppository, to insert one suppository rectally every 4 hours as needed for temperature greater than 100 F, do not exceed 33 g of acetaminophen in 24 hours from all sources,-Arnicare cream 7%, to apply thin layer on right heel topically at bedtime as needed for right heel pain,-Bisacodyl 10 mg rectal suppository, to insert one rectal suppository daily as needed , for constipation,-Bupropion Hcl Xl 150 mg extended release oral tablet, to take one oral tablet two times daily, indicated for depression, -Diazepam 5 mg oral tablet, to take one tablet at bedtime, for anxiety,-Diclofenac 1% topical gel, to apply 2 inch topically on right heel 3 times daily as needed for right heel pain,-Dulcolax 5 mg tablet delayed release oral tablet, to take one tablet two times daily for bowel movement,-Glipizide 2.5 mg-Metformin 500 mg toral ablet , to take one tablet 2 times daily for diabetes mellitus,-Hyoscyamine 0.125 mg sublingual tablet, to take one tablet every 4 hours as needed for secretions,-Ipratropium 0.5 mg - Albulterol 3 mg(2.5 mg base) 3 ml nebulization solution inhalation, to take 3 mg every 4 hours as needed for cough/ wheezing. However, medication not available during the visit.-Lidocaine Pain relief 4% topical patch, to apply 1 patch daily for 12 hours in 24 hours to affected area for pain,-Lorazepam 0.5 mg oral tablet, to take one tablet every 4 hours as needed for anxiety,-Melatonin 10 mg oral capsule, to take one capsule at bedtime for appetite stimulant, -Milk of Magnesia Concentrated 2,400 mg/10 ml oral suspension, to take 30 ml daily as needed for constipation, -Mirtazepine 30 mg oral tablet, to take one tablet at bedtime for appetite stimulant, -Morphine Concentrate 20 mg/ml oral syringe , to take 5mg orally every 2 hours as needed for pain or shortness of breath, -Nitroglycerin 0.4mg sublingual tablet, to take 1 tablet under the tongue on the first sign of angina episode, may take 1 tablet every 5 minutes as needed, for up to 15 minutes. Note: Do not take more than 3 tablets in 15 minutes,-Ondansetron Hcl 4 mg oral tablet, to take 1 tablet every four hours as needed for nausea or vomiting,-Oxygen Gas for inhalation via nasal cannula for 2-5 liters as needed for shortness of breath,-Pepto-Bismol 262 mg/15 ml oral suspension, to take 30 ml 2 times daily as needed for upset stomach,-Polyethylene Glycol 3350 17 grams, 17 grams to mix with 8 oz of water or juice , to take daily as needed for constipation.-Trazodone 100 mg oral tablet, to take 2 tablets at bedtime for sleep,-Tussin DM 10 mg-100mg/5ml, to take 10 ml every 4 hours as needed for cough.On 11/14/25 at 1320 hours, a hospice home visit observation was conducted on Patient 7 with MSW. At 1335 hours, medication profile was reviewed with MSW. Patient 7’s medications on hospice medication profile printed dated 11/12/25 were checked if all are available. However, Patient 7’s Ipratropium 0.5mg-Albuterol 3mg nebulization solution was not available. Patient 7’s caregiver was also asked if he can find Patient 7’s Ipratropium 0.5mg-Albuterol 3mg nebulization solution medication. Patient 7’s caregiver was not able to find the mentioned medication. Patient 7 was asked if he still takes Ipratropium 0.5mg-Albuterol 3mg nebulization solution medication via inhalation. Patient 7 stated he was still taking it. MSW also could not find the Ipratropium 0.5mg-Albuterol 3mg nebulization solution from Patient 7’s medication tray. The hospice’s P&P Titled Medication Management reviewed 9/8/25, showed medication assessments will identify all medications, both prescription and non-prescription the patient is taking and document in the clinical record. Medication monitoring occurs at each scheduled clinical visit and will include gathering appropriate information to develop an accurate medication history and a current medication profile. Medication assessments are continuous and ongoing, occur at every scheduled clinical visit and are documented in the clinical record. 1. Review of Patient 5’s clinical record was initiated on 11/13/25. The clinical record showed the SOC was 3/13/25. The patient was certified for hospice services during the certification periods from 3/13/25 to 6/10/25, 6/11/25 to 9/8/25, 9/9/25 to 11/7/25, and 11/8/25 to 1/6/26. The Medication Profile showed the patient’s medications included the following: -acetaminophen (analgesic) 325 mg two tablets PO Q6H PRN for pain and temperature notto exceed 3 gms in 24 hours-Betadine (antiseptic) 5% topical spray QD for wound care-calcium citrate magnesium and zinc with vitamin D3 (supplement) one tablet PO BID -Centrum Silver Women 8 mg Iron 400 mcg -50 mcg (supplement) one tablet PO QD-dorzolamide timolol (used to treat glaucoma) 2%-0. 5% eye drops one dropperette QD-glimepiride (antidiabetic) 2 mg tablet one tablet QD-Humalog KwikPen U-100 (antidiabetic) 100 units/ml subcutaneous four times a day-hydrocodone 5 mg/acetaminophen 325 mg (opioid analgesic) one tablet orally Q four hours PRN-Lantus SoloStar U-100 (antidiabetic) 100 units/ml (3ml) subcutaneous 11 units QAM and 4 units QPM-latanoprost 0.005% (used to treat glaucoma) eye drops one drop at QHS-Medihoney 100% (wound dressing) topical as per instructions three times a week-metformin (antidiabetic) 500 mg one tablet BID-metoprolol succinate ER (antihypertension) 50 mg tablet extended release 24 hours one tablet QD, hold for SBP less than 100 -Miralax (lavxative) 17 gram/dose oral powder 17 grams QD-oxygen gas inhalation 2-5 liters PRN -Preservision Areds 2 Plus Multivitamin (supplement) 200 mcg-15mcg-5 Mg -11mg capsule -Senna Plus (laxative) 8.5 mg-50 mg tablet one tablet PO BID-Seroquel (antipsychotic) 25 mg tablet one tablet PO QAM-sertraline (antidepressant) 50 mg tablet PO QD-simvastatin (antilipemic) 10 mg tablet PO QHS-tolterodine Er (used to treat overactive bladder) 4 mg capsule one capsule PoQD-Trulicity (antidiabetic) 1.5 mg/ 0.5ml subcutaneous pen injector 1.5 mg weekly every Wednesday-vitamin C (supplement) 500 mg tablet one tablet QD-Xarelto (anticoagulant) 10 mg one tablet QD A joint home visit with RN 1 was conducted on 11/13/25 at 0900 hours, to the B&C facility where Patient 5 resided. Review of the patient’s medications included the following instructions: -Betadine 5% topical spray QD for wound care. However, the spray preparation was changed into swab.-Medihoney 100% topical as per instructions three times a week. However, the medication was discontinued. -metoprolol succinate ER 50 mg tablet extended release 24 hours one tablet QD, hold for SBP less than 100. However, the instructions when to hold the medication was not included on the medication label.-Trulicity 1.5 mg/ 0.5ml subcutaneous pen injector 1.5 mg weekly every Wednesday. However, the medication was given every Friday instead of every Wednesday as ordered. In addition, the patient was taking simethicone (antiflatulence) 80 mg one half tablet Q six hours PRN for flatulence. However, the medication was not included in the medication profile. On 11/13/25 at 0957 hours, an interview and concurrent clinical record review was conducted with the RN 1 and the PCG. RN 1was informed and acknowledged the findings. On 11/26/25 at 0800 hours, the Administrator was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments included the changes that had occurred since the initial assessment, information on the patient’s progress, and reassessment of the patient’s responses for four of 19 sampled patients (Patient 4, 8, 18, and 19). This failure created the risk of not addressing the care needs for these patients.Findings: Review of the hospice’s P&P titled Plan of Care Process reviewed 9/1/24, showed the update of the comprehensive assessment will be accomplished by the Hospice IDG/IDT, in collaboration with the individual’s attending physician, if any, and will evaluate changes that have taken place since the initial assessment. The interdisciplinary POC will be developed by the IDG/IDT, upon completion of the comprehensive assessment within 15 days from start of care.xx. Review of Patient 4’s closed clinical record was initiated on 11/14/25. The clinical record showed the SOC was 12/23/24. The patient was certified for hospice services during the certification period 12/23/24 to 3/22/25. The patient was discharged from hospice services on 2/4/25.Review of the RN Visit Note Report dated 12/23/24, showed a small abrasion to the left forearm, covered with Tegaderm (used to protect and cover wounds).The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 1/13/25, showed no documented evidence the IDG had discussed the patient’s small abrasion to the left forearm.On 11/21/25 at 1114 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings. XX. Review of Patient 8’s clinical record was initiated on 11/12/25. The clinical record showed the SOC was 6/6/25. The patient was certified for hospice services during the certification periods from 6/6/25 to 9/3/25 and 9/4/25 to 12/2/25. Review of Patient 8’s RN visit note dated 9/22/25 showed Patient 8 was with itchiness and with generalized small apparent bug bites. Review of Patient 8’s SN visit note dated 9/29/25 showed Patient 8 was with abscess on pubic area. *However, there was no documentation from the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/1/25 showing Patient 8’s with itchiness and generalized small apparent bug bites and abscess on pubic area was discussed. On 11/26/25 at 1017 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked to show any documentation discussing update plan of care on Patient 8’s itchiness, generalized small apparent bug bite and abscess on pubic area. The DPCS acknowledged she could not find any documentation and verified the plan of care should have been updated. XX. Review of Patient 18 was initiated on 11/12/25. The clinical record showed the SOC was 2/24/25. The patient was certified for hospice services during certification periods 2/24/25 - 5/24/25, 5/25/25 to 8/22/25, 8/23/25 to 10/21/25 and 10/22/25 to 12/20/25. Review of the RN Visit Note Report dated 10/13/25 showed Patient 18 with facial bruising. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/15/25, showed no documented evidence the IDG had discussed the patient’s facial bruising. On 11/26/25 at 0859 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if she could provide any updated plan of care on Patient 18’s facial bruising. The DPCS verified she could not find any documentation and acknowledge there should have been a plan of care on Patient 18’s facial bruising. XX. Review of 19’s clinical record was initiated on 11/12/25. The clinical record showed the SOC was 5/21/24. The patient was certified for hospice services during certification period periods 5/21/24 to 8/18/24, 8/19/24 to 11/16/24, 11/17/24 to 1/15/25, 1/16/25 to 3/16/25, 3/17/25 to 5/15/25, 5/16/25 to 7/14/25, 7/15/25 to 9/12/25, 9/13/25 to 11/11/25 and 11/12/25 to 1/10/26. Review of Patient 19’s RN visit note dated 11/13/25 showed patient reports new right shoulder pain with movement. However, there was no documentation from the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 11/19/25 showing Patient 19’s new right shoulder pain with movement was discussed. On 11/26/25 at 1532 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked what was the agency’s process if patient had a change of condition. The DPCS stated the licensed nurse should assess the patient, inform the patient/caregiver, inform physician. The DPCS was further asked if there was a need to initiate and develop a care plan. The DPCS stated it is required to initiate and develop a care plan for any change of condition. The DPCS was informed of Patient 19’s change of condition dated 11/13/25 and verified there was no care plan initiated and developed for addressing Patient 19’s new right shoulder pain.”

“Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for 10 of 19 sampled patients (Patients 1, 3, 5, 6, 7, 11, 13, 15, 16, and 17). This failure created the risk of not providing appropriate, consistent, and quality care to the patients. Findings: xx. Review of Patient 3’s closed clinical record was initiated on 11/13/25. The clinical record showed the SOC was 1/25/24. The patient was certified for hospice during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25, and 4/10/25 to 6/2/25. The patient expired on 6/2/25.Review of the physician’s order dated 3/26/25, showed an order for MSW effective 4/13/25 for 1W1 and 1Q2W2 (one visit every other week for two weeks).*However, the MSW had no documented visits for the weeks 4/27/25 to 5/3/25, 5/4/25 to 5/10/25, and 5/11/25 to 5/17/25.On 11/13/25 at 1500 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator stated if the visit was missed for the week, a visit should have been rescheduled or offered a visit for the following week. The Administrator verified and acknowledged the finding.xx. Review of Patient 7’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 7/27/24. The patient was certified for hospice during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25.a.Review of the physician’s order dated 9/5/25, showed an order for HA visits effective 9/21/25 for 2W8 and 1W1.*However, the HA notes for Week 5 (10/12/25 to 10/18/25), showed one HA visit instead of two visits as per the physician’s order.b.Review of the physician’s order dated 10/27/25, showed an order for SN visits effective 10/26/25 for 3WK1, 2WK2, and 1WK1.*However, the SN notes for Week 7 (10/26/25 to 11/1/25) showed two SN visits instead of three visits as per the physician’s order.c.Review of the physician’s order dated 10/9/25, showed an order for MSW visits effective 10/26/25 for 1WK3.*However, the MSW had no documented visits for the week 10/26/25 to 11/1/25 and 11/2/to 11/8/25.On 11/21/25 at 1343 hours, an interview and concurrent clinical record review were conducted with the Administrator and DPCS. The Administrator stated the missed visits were reported, however, there was no documented evidence the missed visits were offered for another day. The Administrator and DPCS verified and acknowledged the findings.xx. Review of Patient 13’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 1/12/23. The patient was certified for hospice during the certification periods from 1/12/23 to 4/11/23, 4/12/23 to 7/10/23, 7/11/23 to 9/8/23, 9/9/23 to 11/7/23, 11/8/23 to 1/6/24, 1/7/24 to 3/6/24, 3/7/24 to 5/5/24, 5/6/24 to 7/4/24, 7/5/24 to 9/2/24, 9/3/24 to 11/1/24, 11/2/24 to 12/31/24, 1/1/25 to 3/1/25, 3/2/25 to 4/30/25, 5/1/25 to 6/29/25, 6/30/25 to 8/28/25, 8/29/25 to 10/27/25 and 10/28/25 to 12/26/25.Review of the physician’s order dated 8/14/25, showed an order may recert patient for next hospice certification period (8/29/25 to 10/27/25). Calendar frequency for SN effective 8/31/25 was 1WK 8.Review of the calendar of actual visits for SN for Week 7 (10/5/25 to 10/11/25) showed SN had two visits, 10/7/25 and 10/8/25.Review of the RN Visit Note Report dated 10/8/25, showed the visit type of SN Hospice PRN visit. In the narrative patient was found on the floor next to the bed on the right side, an unwitnessed fall. On inspection small bump on the right side of forehead measuring 0.8 cm x 1.2 cm. MD was notified and a new order was received for floor mat.*However, review of the physician’s order dated 10/8/25 failed to show an order for the PRN visit.On 11/21/25 at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings.xx. Review of Patient 14’s clinical record was initiated on 11/19/25. The clinical record showed the SOC was 8/1/24. The patient was certified for hospice during the certification periods from 8/1/24 to 10/29/24, 10/30/24 to 12/28/24, 12/29/24 to 2/26/25, 2/27/25 to 4/27/25, 4/28/25 to 6/26/25, 6/27/25 to 8/25/25, 8/26/25 to 10/24/25 and 10/25/25 to 12/23/25.Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report Report dated 8/11/24, showed an HHA frequency effective 8/26/25 to 1WK1 and 2WK8.*However, the HA notes for the following weeks showed one HA visit instead of two visits as per POC.-Week 4 (9/14/25 to 9/20/25), and-Week 5 (9/21/25 to 9/27/25). On 11/21/25 at 1425 hours, an interview and concurrent clinical record review were conducted with the Administrator and DPCS. The Administrator stated the missed visits were reported, however, there was no documented evidence the missed visits were offered for another day. The Administrator and DPCS verified and acknowledged the findings. XX. Review of Patient 16’s clinical record was initiated on 11/12/25. The clinical record showed the SOC was 9/3/25. The patient was certified for hospice services during certification period 9/3/25 to 12/1/25. Review of Patient 16’s physician order dated 9/5/25 showed an order for SN effective 9/3/25 for 2w1, 2w8.*However, there was no documented SN visit for the week of 11/2/25 to 11/8/25. On 11/24/25 at 1304 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if there was any documentation for Patient 16’s SN visit for the week of 11/9/25 to 11/15/25. The DPCS verified she could not find any SN visit documentation within that week. The DPCS was further asked if there was any SN missed visit documentation and an any documentation that offer of SN visit within that week. The DPCS verified it was missed visit and acknowledged she could not find any documentation of any SN visit or follow up visit was offered. XX. Review of Patient 18 was initiated on 11/12/25. The clinical record showed the SOC was 2/24/25. The patient was certified for hospice services during certification periods 2/24/25 - 5/24/25, 5/25/25 to 8/22/25, 8/23/25 to 10/21/25 and 10/22/25 to 12/20/25. Review of Patient 18’s MD order dated 10/7/25 showed an order for HA visit effective 10/22/25 1w1, 2w8.*However, the HA notes for Week 3 (11/9/25 to 11/15/25), showed one HA visit instead of two visits as per the physician’s order. On 11/26/25 at 0859 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if there was another HA visit documentation aside from 11/14/25 for Patient 18. The DPCS stated 11/10/25 was a missed HA visit. The DPCS was further asked for any documentation that a follow up visit was offered. The DPCS verified there was no documentation of a follow up HA visit was offered. The hospice’s P&P titled Plan of Care Process reviewed 9/1/24 showed to ensure that the care provided is in accordance with the written plan of care (POC), appropriately planned, and delivered in a timely manner to meet the patients ‘s and family’s specific needs. #. Review of Patient 15’s clinical record was initiated on 11/20/25. The clinical record showed the SOC was 9/9/24. The patient was certified for hospice services during the certification periods from 9/9/24 to 12/7/24, 12/8/24 to 3/7/25, 3/8/25 to 5/6/25, 5/7/25 to 7/5/25, 7/6/25 to 9/3/25, 9/4/25 to 11/2/25 and 11/3/25 to 1/1/26. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3, 9/17, 10/1, 10/15 and 10/29/25 showed the patients current problem list. The list included an evaluation of patient/family mental coping and emotional stability. Review of the Nursing Visit notes dated 9/26 and 10/22/25 showed the RN 2 had performed an assessment. The assessment included a section for the patients spiritual, psychosocial, social and emotional status. However, the RN 2 failed to follow the POC as the assessment for the patients spiritual, psychosocial, social and emotional were left blank. On 11/25/25 at 1524 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if the SN needed to complete the assessment. The Administrator replied yes. The Administrator was also asked if the care plan was followed. The Administrator reviewed the clinical records and acknowledged the findings. #. Review of Patient 11’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 2/18/25. The patient was certified for hospice services during the certification periods from 2/18/25 to 5/18/25, 5/19/25 to 8/16/25, 8/17/25 to 10/15/25 and 10/16/25 to 12/14/25. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 8/20, 9/3, 9/17, 10/15, 10/29 and 11/15/25 showed the patients current problem list. The list included an evaluation of patient/family mental coping and emotional stability. Review of the Nursing Visit notes dated 10/7 and 10/29/25 showed the SN had performed an assessment. The assessment included a section for the patients spiritual, psychosocial, social and emotional status. However, the RN 2 failed to follow the POC as the assessment for the patients spiritual, psychosocial, social and emotional were left blank. On 11/26/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. #. Review of Patient 17’s clinical record was initiated on 11/20/25. The clinical record showed the SOC was 3/5/25. The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25 and 10/31/25 to 12/29/25. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3, 9/17, 10/1, 10/15, 10/29 and 11/15/25 showed the patients current problem list. The list included an evaluation of patient/family mental coping and emotional stability. Review of the Nursing Visit notes dated 9/29, 10/6, 10/13, 10/20 and 10/27 and 10/29/25 showed the SN had performed an assessment. The assessment included a section for the patients spiritual, psychosocial, social and emotional status. However, the SN failed to follow the POC as the sections for the assessment of the patients spiritual, psychosocial, social and emotional were left blank.On 11/25/25 at 1445 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. #. Review of Patient 1’s closed clinical record was initiated on 11/14/25. The clinical record showed the SOC was 12/18/24. The patient was certified for hospice services during the certification periods from 12/18/24 to 3/17/25, 3/18/25 to 6/15/25 and 6/16/25 to 8/2/25. The patient passed away on 8/2/25. *The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 7/16/25 cited SN visit 1 time a week. The POC included a wound care order. The order showed to “cleanse Stage 2 -3 scattered decub to sacrum with dermal cleanser, pat dry with gauze, apply Medi-honey then cover with Mepilex or Duoderm lite. Change weekly and as needed if moist, soiled or dislodge. Caregiver may provide care”.Review of the Visit Note Report dated 7/22, 7/29/25 showed the RN 4 performed a wound assessment and treatment to the patients Stage 3 pressure injury to the sacrum. The wound treatment showed “cleanse healing stage 2-3 decub to sacrum with soap and water. Strict pressure relief. May apply Medi-honey with repositioning and leave open to air”. However, the wound treatment provided was inconsistent with the POC.*The Physicians Order dated 6/1/25 showed a recertification order. The order includes the Chaplain visits cited 1W1, 2Q2W2, 1Q3Wk3, 1Q2W2.Review of the closed clinical record showed a missed visit documentation of Chaplain 2 for Weeks 1, 2 and 3. However, there was no documented evidenced of the Chaplain visit was conducted on Week 5 (from 7/13 to 7/19/25) as ordered by the physician. On 11/25/25 at 1335 hours, an interview and concurrent closed clinical record review was conducted with the Administrator. The Administrator was asked if it was a missed visit. The Administrator reviewed the closed clinical record and replied, there should be a Chaplain visit on Week 5 but there was none. The Administrator was also asked if there was a communication note related to the Chaplain missed visit. The Administrator replied, “We’ll look for the record. The Administrator was further asked if the wound treatment was followed as ordered in the POC. The Administrator reviewed the closed clinical record and replied, no. The Administrator was informed and acknowledged the findings. #. Review of Patient 6’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 9/25/24. The patient was certified for hospice services during the certification periods from 9/25/24 to 12/23/24, 12/24/24 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, 9/20/25 to 11/18/25 and 11/19/25 to 1/17/25.Review of the Physicians’ Order dated 9/5/25. showed the recertification order. The Order included a Chaplain visit one time per month for spiritual support.However, review of the clinical record failed to show documented evidenced of the Chaplain had visited the patient for the month of October as ordered. On 11/25/25 at 0909 hours an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if there was a visit conducted by the Chaplain for the month of October. The Administrator reviewed the clinical record and replied, no, it should be a PRN visit, it’s a clinical error. The Administrator was informed and acknowledged the findings. #. Review of Patient 5’s clinical record was initiated on 11/13/25. The clinical record showed the SOC was 3/13/25. The patient was certified for hospice services during the certification periods from 3/13/25 to 6/10/25, 6/11/25 to 9/8/25, 9/9/25 to 11/7/25 and 11/8/25 to 1/6/26.The Physicians Order dated 9/15/25, showed a wound care order. The order was for “nystatin 100,000 units /gram powder, apply to peri wound of sacral ulcer mix with Calmoseptine to be apply every dressing change for three weeks due to redness”.Review of the Visit Note Report for example dated 9/17, 9/24, 9/26 and 10/1/25 on the section of narrative showed the SN had performed wound assessment and treatment to the patients pressure injury to the sacral coccyx area. The treatment showed cleanse wound with wound cleanser patted dry apply tetracycline followed by Medihoney covered with alginate and foam dressing. However, the SN failed to follow the physicians order for the treatment of the patients pressure injury to the sacral/coccyx area. On 11/26/25 at 0811 hours an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if the wound care treatment for nystatin and calmoseptine was provided. The Administrator reviewed the clinical record and replied, none documented. The Administrator was informed and acknowledged the findings. The hospice’s P&P titled Plan of Care Process reviewed 9/1/24, showed to ensure that the care provided is in accordance with the written plan of care (POC), appropriately planned, and delivered in a timely manner to meet the patient’s and family’s specific needs. 1. Review of Patient 15’s clinical record was initiated on 11/20/25. The clinical record showed the SOC was 9/9/24. The patient was certified for hospice services during the certification periods from 9/9/24 to 12/7/24, 12/8/24 to 3/7/25, 3/8/25 to 5/6/25, 5/7/25 to 7/5/25, 7/6/25 to 9/3/25, 9/4/25 to 11/2/25, and 11/3/25 to 1/1/26. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3, 9/17, 10/1, 10/15, and 10/29/25, showed the patient’s current problem list. The list included an evaluation of patient/family mental coping and emotional stability. Review of the Nursing Visit notes dated 9/26 and 10/22/25, showed RN 2 had performed an assessment. The assessment included a section for the patient’s spiritual, psychosocial, social, and emotional status. However, RN 2 failed to follow the POC as the assessment for the patient’s spiritual, psychosocial, social and emotional were left blank. On 11/25/25 at 1524 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if the SN needed to complete the assessment. The Administrator stated yes. The Administrator was also asked if the care plan was followed. The Administrator reviewed the clinical record and acknowledged the findings. 2. Review of Patient 11’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 2/18/25. The patient was certified for hospice services during the certification periods from 2/18/25 to 5/18/25, 5/19/25 to 8/16/25, 8/17/25 to 10/15/25, and 10/16/25 to 12/14/25. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 8/20, 9/3, 9/17, 10/15, 10/29, and 11/15/25, showed the patient’s current problem list. The list included an evaluation of patient/family mental coping and emotional stability. Review of the Nursing Visit notes dated 10/7 and 10/29/25, showed the SN had performed an assessment. The assessment included a section for the patients spiritual, psychosocial, social, and emotional status. However, RN 2 failed to follow the POC as the assessment for the patients spiritual, psychosocial, social and emotional were left blank. On 11/26/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the finding. 3. Review of Patient 17’s clinical record was initiated on 11/20/25. The clinical record showed the SOC was 3/5/25. The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25, and 10/31/25 to 12/29/25. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3, 9/17, 10/1, 10/15, 10/29, and 11/15/25, showed the patient’s current problem list. The list included an evaluation of patient/family mental coping and emotional stability. Review of the Nursing Visit notes dated 9/29, 10/6, 10/13, 10/20, 10/27, and 10/29/25, showed the SN had performed an assessment. The assessment included a section for the patients spiritual, psychosocial, social and emotional status. However, the SN failed to follow the POC as the sections for the assessment of the patient’s spiritual, psychosocial, social and emotional were left blank.On 11/25/25 at 1445 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. 4. Review of Patient 1’s closed clinical record was initiated on 11/14/25. The clinical record showed the SOC was 12/18/24. The patient was certified for hospice services during the certification periods from 12/18/24 to 3/17/25, 3/18/25 to 6/15/25, and 6/16/25 to 8/2/25. The patient expired on 8/2/25. *The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 7/16/25, cited SN visit one time a week. The POC included a wound care order. The order showed to “cleanse Stage 2 -3 scattered decub to sacrum with dermal cleanser, pat dry with gauze, apply Medi-honey then cover with Mepilex or Duoderm lite. Change weekly and as needed if moist, soiled or dislodge. Caregiver may provide care.”Review of the Visit Note Report dated 7/22 and 7/29/25, showed RN 4 performed a wound assessment and treatment to patient’s Stage 3 sacrum pressure injury. The wound treatment showed, “cleanse healing stage 2-3 decub to sacrum with soap and water. Strict pressure relief. May apply Medi-honey with repositioning and leave open to air.” However, the wound treatment provided was inconsistent with the POC.*The Physician’s Order dated 6/1/25, showed the recertification order included Chaplain visits 1W1 (one time a week for one week), 2Q2W2 (two times every two weeks for two weeks), 1Q3W3, and 1Q2W2.Review of the closed clinical record showed a missed visit documentation of Chaplain 2 for Weeks 1, 2, and 3. However, there was no documented evidenced the Chaplain visit was conducted on Week 5 (7/13/25 to 7/19/25) as ordered by the physician. On 11/25/25 at 1335 hours, an interview and concurrent closed clinical record review was conducted with the Administrator. The Administrator was asked if it was a missed visit. The Administrator reviewed the closed clinical record and stated there should be a Chaplain visit for Week 5 but there was none. The Administrator was also asked if there was a communication note related to the Chaplain missed visit. The Administrator replied, “We’ll look for the record.” The Administrator was further asked if the wound treatment was followed as ordered in the POC. The Administrator reviewed the closed clinical record and stated no. The Administrator was informed and acknowledged the findings. 5. Review of Patient 6’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 9/25/24. The patient was certified for hospice services during the certification periods from 9/25/24 to 12/23/24, 12/24/24 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, 9/20/25 to 11/18/25, and 11/19/25 to 1/17/25.Review of the Physicians’ Order dated 9/5/25. showed the recertification order included a Chaplain visit one time per month for spiritual support.However, review of the clinical record failed to show documented evidence of Chaplain visited the patient for the month of October as ordered. On 11/25/25 at 0909 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if there was a visit conducted by the Chaplain for the month of October. The Administrator reviewed the clinical record and stated no, it should be a PRN visit, and it was a clinical error. The Administrator was informed and acknowledged the findings. 6. Review of Patient 5’s clinical record was initiated on 11/13/25. The clinical record showed the SOC was 3/13/25. The patient was certified for hospice services during the certification periods from 3/13/25 to 6/10/25, 6/11/25 to 9/8/25, 9/9/25 to 11/7/25, and 11/8/25 to 1/6/26.The Physician’s Order dated 9/15/25, showed a wound care order as follows: “nystatin 100,000 units /gram powder, apply to peri wound of sacral ulcer mix with Calmoseptine to be apply every dressing change for three weeks due to redness.”Review of the Visit Note Report on the section of narrative dated 9/17, 9/24, 9/26, and 10/1/25, showed the SN performed wound assessment and treatment to the patient’s sacral coccyx area pressure injury. Documentation showed the treatment included wound cleansed with wound cleanser, patted dry, applied tetracycline (antibiotic), followed by Medihoney (used for wound care), and covered with alginate (wound dressing) and foam dressing. However, the SN failed to follow the physician’s order for the treatment of the patient’s sacral/coccyx area pressure injury. On 11/26/25 at 0811 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if the wound care treatment for nystatin (antifungal) and Calmoseptine (moisture barrier) were provided. The Administrator reviewed the clinical record and stated there was none documented. The Administrator was informed and acknowledged the findings. 7. Review of Patient 16’s clinical record was initiated on 11/12/25. The clinical record showed the SOC was 9/3/25. The patient was certified for hospice services during certification period 9/3/25 to 12/1/25.Review of the physician’s order dated 9/5/25, showed an order for SN visits 2W1 and 2W8, effective 9/3/25.*However, there was no documented SN visit for the week of 11/2/25 to 11/8/25.On 11/24/25 at 1304 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if there was any documentation for Patient 16’s SN visit for the week of 11/2/25 to 11/8/25. The DPCS verified she could not find any SN visit documentation within that week. The DPCS was further asked if there was any SN missed visit documentation and any documentation that offer of the SN visit within that week. The DPCS verified it was missed visit. The DPCS acknowledged she could not find any documentation of any SN visit or follow up visit that was offered.8. Review of Patient 3’s closed clinical record was initiated on 11/13/25. The clinical record showed the SOC was 1/25/24. The patient was certified for hospice during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25, and 4/10/25 to 6/2/25. The patient expired on 6/2/25.Review of the physician’s order dated 3/26/25, showed an order for MSW visits 1W1 and 1Q2W2 effective 4/13/25*However, the MSW had no documented evidence of visits for the weeks 4/27/25 to 5/3/25, 5/4/25 to 5/10/25, and 5/11/25 to 5/17/25.On 11/13/25 at 1500 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator stated if the visit was missed for the week, a visit should have been rescheduled or offered a visit for the following week. The Administrator verified and acknowledged the finding.9. Review of Patient 7’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 7/27/24. The patient was certified for hospice during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25.a. Review of the physician’s order dated 10/27/25, showed an order for SN visits W1, 2W2, and 1W1, effective 10/26/25*However, the SN notes for Week 7 (10/26/25 to 11/1/25) showed two SN visits instead of three visits as per the physician’s order.b. Review of the physician’s order dated 10/9/25, showed an order for MSW visits 1W3, effective 10/26/25*However, there was no documented evidence the MSW had visits for the weeks of 10/26/25 to 11/1/25, and 11/2/25 to 11/8/25.On 11/21/25 at 1343 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The Administrator stated the missed visits were reported; however, there was no documented evidence the missed visits were offered for another day. The Administrator and DPCS verified and acknowledged the findings.10. Review of Patient 13’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 1/12/23. The patient was certified for hospice during the certification periods from 1/12/23 to 4/11/23, 4/12/23 to 7/10/23, 7/11/23 to 9/8/23, 9/9/23 to 11/7/23, 11/8/23 to 1/6/24, 1/7/24 to 3/6/24, 3/7/24 to 5/5/24, 5/6/24 to 7/4/24, 7/5/24 to 9/2/24, 9/3/24 to 11/1/24, 11/2/24 to 12/31/24, 1/1/25 to 3/1/25, 3/2/25 to 4/30/25, 5/1/25 to 6/29/25, 6/30/25 to 8/28/25, 8/29/25 to 10/27/25, and 10/28/25 to 12/26/25.Review of the physician’s order dated 8/14/25, showed an order may recertify the patient for the next hospice certification period (8/29/25 to 10/27/25). Documentation showed the calendar frequency for the SN was 1W8 effective 8/31/25.Review of the calendar of actual visits for the SN for Week 7 (10/5/25 to 10/11/25) showed the SN had two visits which were on 10/7/25 and 10/8/25.Review of the RN Visit Note Report dated 10/8/25, showed the visit type was SN Hospice PRN visit. Documentation showed the patient was found on the floor next to the bed on the right side and an unwitnessed fall. Documentation showed on inspection a small bump on the right side of the forehead. Documentation showed the physician was notified and a new order was received for a floor mat.*However, review of the physician’s order dated 10/8/25, failed to show an order for the PRN visit.On 11/21/25 at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings.”

“Based on record review and interview, the hospice failed to ensure the written POCs were developed to reflect the patient and family goals and interventions based on the problems identified for six of 19 sampled patients (Patients 3, 5, 6, 7, 13, and 17). This failure created the risk of not addressing the care needs for these patients.Findings: xx. Review of Patient 3’s closed clinical record was initiated on 11/13/25. The clinical record showed the SOC was 1/25/24. The patient was certified for hospice during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25 and 4/10/25 to 6/2/25. Patient expired on 6/2/25.a.Review of the RN Visit Note Report dated 5/2/25, showed in the narrative that patient stated she returned to bed as her buttocks was burning, applied calmoseptine (provide relief to skin irritants) to coccyx/buttocks for skin protection.The physician’s order dated 5/11/25, showed apply a thin layer of calmoseptine to buttocks two times a day for skin protection.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s skin impairment.b.Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report showed a documentation that patient was found on the floor next to the bed on 5/20/21.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s fall.c.Review of the of the RN Visit Note Report dated 5/30/25, showed in the narrative that patient appears to be transitioning, agitated and trying to get out of bed.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s change of condition.On 11/21/25 at 0833 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator verified and acknowledged the findings.xx. Review of Patient 7’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 7/27/24. The patient was certified for hospice during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25 and 9/20/25 to 11/18/25.a.Review of the RN Visit Note Report dated 10/20/25, showed in the narrative that patient reported occasional episodes of shortness of breath. The physician’s order dated 10/21/25, showed the to administer oxygen at 2-5 liters per minute for shortness of breath via nasal cannula; and*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 7’s shortness of breath.b.Review of the RN Visit Note Report dated 10/23/25, showed in the narrative that patient reported feeling more depressed than before.The physician’s order dated 10/23/25, showed an increase in Bupropion hydrochloride (medication used as an antidepressant) 150 mg 24 hour tablet to two times daily.Furthermore, the physician’s order dated 10/23/25, showed the changes in the following orders:-Diazepam (medication for relieving anxiety disorders) 5 mg tablet at bedtime for anti-anxiety;-melatonin (short-term aid for various sleep issues) 10 mg capsule at bedtime for sleeping aid.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 7’s problem related to depression, anxiety and sleeplessness.On 11/21/25 at 1343 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The Administrator and DPCS verified and acknowledged the findings.xx. Review of Patient 13’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 1/12/23. The patient was certified for hospice during the certification periods from 1/12/23 to 4/11/23, 4/12/23 to 7/10/23, 7/11/23 to 9/8/23, 9/9/23 to 11/7/23, 11/8/23 to 1/6/24, 1/7/24 to 3/6/24, 3/7/24 to 5/5/24, 5/6/24 to 7/4/24, 7/5/24 to 9/2/24, 9/3/24 to 11/1/24, 11/2/24 to 12/31/24, 1/1/25 to 3/1/25, 3/2/25 to 4/30/25, 5/1/25 to 6/29/25, 6/30/25 to 8/28/25, 8/29/25 to 10/27/25 and 10/28/25 to 12/26/25.a.Review of the RN Visit Note Report dated 9/23/25 showed wound care was provided to Patient 13’s right nipple, cleansed wound with saline and patted dry. Right nipple exposed to air.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 13’s problem related to the wound in the right nipple.Review of the RN Visit Note Report dated 10/8/25, showed in the narrative patient was found on the floor next to the bed on the right side, an unwitnessed fall. On inspection small bump on the right side of forehead measuring 0.8 cm x 1.2 cm.Furthermore, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/13/25, showed the recent fall on 10/8/25 was discussed in the IDG. However, in the plan of care updates/IDG recommendation, showed no plan of care updates.There was no documented evidence the IDG had developed an individualized POC to address Patient 13’s fall.On 11/21/25 at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings. The hospice’s P&P titled Plan of Care Process reviewed 9/1/24 showed the hospice will develop an individualized POC for each patient. The POC must reflect patient and family goals and intervention based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. #. Review of Patient 17’s clinical record was initiated on 11/20/25. The clinical record showed the SOC was 3/5/25. The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25 and 10/31/25 to 12/29/25. Review of the RN Hospice Recert Assessment dated 8/18/25, showed the RN 1 had performed an assessment. The assessment showed the patients primary diagnosis of hypertensive heart disease. The patient was assessed to have + 2 edema to the left foot, ankle and calf. However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 8/20/25, failed to show documented evidenced of an individualized POC was developed to address the patients + 2 edema to the left foot, ankle and calf. Further review of the Visit Note Report on the following dates showed:-on 9/5 and 9/8/25 = +1 edema to the right and left foot and calf, +2 edema to the right and left ankle,-on 9/11/25 = +1 edema to the right and left foot and calf, +2 edema to the right and left ankle and +1 edema to the right and left thigh.However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3 and 9/17/25 failed to show documented evidenced of an individualized POC was developed to address the patients edema to the bilateral lower extremities. On 11/25/25 at 1445 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if a care plan was developed to address the patients edema. The Administrator reviewed the clinical record and replied, no, was not develop. The Administrator was informed and acknowledged the findings. #. Review of Patient 6’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 9/25/24. The patient was certified for hospice services during the certification periods from 9/25/24 to 12/23/24, 12/24/24 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, 9/20/25 to 11/18/25 and 11/19/25 to 1/17/25. *Review of the Physicians Order dated 9/26/25, showed an order for Bactrim DS take one tablet BID for 7 days for UTI.Further review of the Physicians Order dated 10/6/25, showed an order for Cephalexin 250 mg QD for prophylactic prevention of UTI.However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/1 and 10/15/25 failed to show documented evidenced of an individualized POC was developed to address the patients UTI. *Review of the Physicians Order dated 10/23/25, showed an order for Seroquel 25 mg QHS for insomnia.However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/29/25 failed to show documented evidenced of an individualized POC was developed to address the patients insomnia. On 11/25/25 at 0909 hours an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if a care plan was developed to address the patients UTI and insomnia. The Administrator reviewed the clinical record and replied, no, was not develop. The Administrator was informed and acknowledged the findings. #. Review of Patient 5’s clinical record was initiated on 11/13/25. The clinical record showed the SOC was 3/13/25. The patient was certified for hospice services during the certification periods from 3/13/25 to 6/10/25, 6/11/25 to 9/8/25, 9/9/25 to 11/7/25 and 11/8/25 to 1/6/26.The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/17, 10/1, 1015, 10/29 and 11/2/25 on the section of medication list showed the patient was on oral hypoglycemics and insulin injection.However, the IDG failed to developed an individualized care plan to address the patients diabetes. On 11/26/25 at 0811 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if a care plan related to diabetes was developed. The Administrator reviewed the clinical record and replied it was missed. The Administrator was informed and acknowledged the findings. The hospice’s P&P titled Plan of Care Process reviewed 9/1/24, showed the hospice will develop an individualized POC for each patient. The POC must reflect patient and family goals and intervention based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. 1. Review of Patient 17’s clinical record was initiated on 11/20/25. The clinical record showed the SOC was 3/5/25. The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25, and 10/31/25 to 12/29/25. Review of the RN Hospice Recert Assessment dated 8/18/25, showed RN 1 had performed an assessment. The assessment showed the patient’s primary diagnosis of hypertensive heart disease. The patient was assessed to have 2+ edema (scale to rate the severity of edema 0=no edema 4+=severe edema) on the left foot, ankle, and calf. However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 8/20/25, failed to show documented evidence of an individualized POC was developed to address the patients 2+ edema on the left foot, ankle, and calf. Further review of the Visit Note Report on the following dates showed:-On 9/5 and 9/8/25, 1+ edema on the right and left foot and calf and 2+ edema to the right and left ankle,-On 9/11/25, 1+ edema on the right and left foot and calf, 2+ edema to the right and left ankle, and 1+ edema on the right and left thigh.However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3 and 9/17/25, failed to show documented evidence of an individualized POC was developed to address the patient’s edema on the bilateral lower extremities. On 11/25/25 at 1445 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if a care plan was developed to address the patient’s edema. The Administrator reviewed the clinical record and stated no and was not developed. The Administrator was informed and acknowledged the findings. 2. Review of Patient 6’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 9/25/24. The patient was certified for hospice services during the certification periods from 9/25/24 to 12/23/24, 12/24/24 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, 9/20/25 to 11/18/25, and 11/19/25 to 1/17/25. *Review of the Physicians Order dated 9/26/25, showed an order for Bactrim DS (anitibiotic) one tablet BID for seven days for UTI.Further review of the Physicians Order dated 10/6/25, showed an order for cephalexin (antibiotic) 250 mg QD for prophylactic prevention of UTI.However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/1 and 10/15/25, failed to show documented evidenced of an individualized POC was developed to address the patient’s UTI. *Review of the Physicians Order dated 10/23/25, showed an order for Seroquel (antipsychotic) 25 mg QHS for insomnia.However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/29/25, failed to show documented evidenced of an individualized POC was developed to address the patient’s insomnia. On 11/25/25 at 0909 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if a care plan was developed to address the patient’s UTI and insomnia. The Administrator reviewed the clinical record and stated no and was not developed. The Administrator was informed and acknowledged the findings. 3. Review of Patient 5’s clinical record was initiated on 11/13/25. The clinical record showed the SOC was 3/13/25. The patient was certified for hospice services during the certification periods from 3/13/25 to 6/10/25, 6/11/25 to 9/8/25, 9/9/25 to 11/7/25, and 11/8/25 to 1/6/26.The Hospice IDG Comprehensive Assessment and Plan of Care Update Report on the section of medication list dated 9/17, 10/1, 10/15, 10/29, and 11/2/25 showed the patient was on oral hypoglycemics and insulin injection.However, the IDG failed to developed an individualized care plan to address the patient’s diabetes. On 11/26/25 at 0811 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if a care plan related to diabetes was developed. The Administrator reviewed the clinical record and stated it was missed. The Administrator was informed and acknowledged the findings. 4. Review of Patient 3’s closed clinical record was initiated on 11/13/25. The clinical record showed the SOC was 1/25/24. The patient was certified for hospice during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25, and 4/10/25 to 6/2/25. Patient expired on 6/2/25.a. Review of the RN Visit Note Report dated 5/2/25, showed the patient stated she returned to bed as her buttocks was burning, applied Calmoseptine (moisture barrier) to the coccyx/buttocks for skin protection.The physician’s order dated 5/11/25, showed to apply a thin layer of Calmoseptine to buttocks two times a day for skin protection.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s skin impairment.b.Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 5/21/25, showed a documentation the patient was found on the floor next to the bed on “5/20.”*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s fall.c. Review of the of the RN Visit Note Report dated 5/30/25, showed the patient appeared to be transitioning, agitated, and trying to get out of bed.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s change of condition.On 11/21/25 at 0833 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator verified and acknowledged the findings.5. Review of Patient 7’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 7/27/24. The patient was certified for hospice during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25.a. Review of the RN Visit Note Report dated 10/20/25, showed the patient reported occasional episodes of shortness of breath. The physician’s order dated 10/21/25, showed to administer oxygen at 2-5 liters per minute for shortness of breath via nasal cannula.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 7’s shortness of breath.b. Review of the RN Visit Note Report dated 10/23/25, showed in the narrative that patient reported feeling more depressed than before.The physician’s order dated 10/23/25, showed an increase in Bupropion hydrochloride (medication used as an antidepressant) 150 mg 24 hour tablet to two times daily.Furthermore, the physician’s order dated 10/23/25, showed the changes in the following orders:-Diazepam (medication for relieving anxiety disorders) 5 mg tablet at bedtime for anti-anxiety;-melatonin (short-term aid for various sleep issues) 10 mg capsule at bedtime for sleeping aid.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 7’s problem related to depression, anxiety and sleeplessness.On 11/21/25 at 1343 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The Administrator and DPCS verified and acknowledged the findings.6. Review of Patient 13’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 1/12/23. The patient was certified for hospice during the certification periods from 1/12/23 to 4/11/23, 4/12/23 to 7/10/23, 7/11/23 to 9/8/23, 9/9/23 to 11/7/23, 11/8/23 to 1/6/24, 1/7/24 to 3/6/24, 3/7/24 to 5/5/24, 5/6/24 to 7/4/24, 7/5/24 to 9/2/24, 9/3/24 to 11/1/24, 11/2/24 to 12/31/24, 1/1/25 to 3/1/25, 3/2/25 to 4/30/25, 5/1/25 to 6/29/25, 6/30/25 to 8/28/25, 8/29/25 to 10/27/25 and 10/28/25 to 12/26/25.a. Review of the RN Visit Note Report dated 9/23/25 showed wound care was provided to Patient 13’s right nipple, cleansed wound with saline and patted dry. Right nipple exposed to air.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 13’s problem related to the wound in the right nipple.Review of the RN Visit Note Report dated 10/8/25, showed in the narrative patient was found on the floor next to the bed on the right side, an unwitnessed fall. On inspection small bump on the right side of forehead measuring 0.8 cm x 1.2 cm.Furthermore, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/13/25, showed the recent fall on 10/8/25 was discussed in the IDG. However, in the plan of care updates/IDG recommendation, showed no plan of care updates.There was no documented evidence the IDG had developed an individualized POC to address Patient 13’s fall.On 11/21/25 at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings.”

“Based on record review and interview, the hospice failed to ensure the POCs included measurable outcome for 12 of 19 sampled patients (Patients 1, 3, 4, 5, 6, 7, 9, 11,13, 14, 15 and 17). This failure had the potential risk of not evaluating the POC and providing appropriate care and services to these patients.Findings: #.Review of Patient 3’s closed clinical record was initiated on 11/13/25. The clinical record showed the SOC was 1/25/24. The patient was certified for hospice during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25 and 4/10/25 to 6/2/25. Patient expired on 6/2/25.The Hospice POC Report, showed the patient’s identified problems. The goal was established for the identified problem. However, the goal listed was not measurable and specific to the patient’s needs.For example, the goal for altered cardiac/circulatory system was that cardiac exacerbations are identified promptly and interventions initiated. However, there was no documented evidence of the measurable outcome as to what cardiac exacerbations would be related to the cardiac/circulatory system.Another example was the goal for altered comfort was that patient verbalizes decrease in pain or has decrease in non-verbal signs and symptoms of pain. However, there was no documented evidence of the measurable outcome as to what non-verbal signs and symptoms of pain would be related to altered comfort.On 11/21/25 at 0833 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator verified and acknowledged the findings.xx.Review of Patient 4’s closed clinical record was initiated on 11/14/25. The clinical record showed the SOC was 12/23/24. The patient was certified for hospice services during the certification period 12/23/24 to 3/22/25, The patient was discharged from hospice service on 2/4/25.The Hospice POC Report, showed the patient’s identified problems. The goal was established for the identified problem. However, the goal listed was not measurable and specific to the patient’s needs.a.The goal for need for observation and assessment of altered comfort was that patient verbalizes decrease in pain or has decrease in non-verbal signs and symptoms of pain. However, there was no documented evidence of the measurable outcome as to what non-verbal signs and symptoms of pain would be related to altered comfort.b.The goal for need for observation and assessment of sensory/neurological status was that patient tolerates assessment of sensory/neurological status. However, there was no documented evidence of the measurable outcome as to what kind of assessment would be tolerated by the patient related to sensory/neurological status.c.The goal for altered home safety was the patient/caregiver verbalizes understanding of proper safety measures related to fall awareness. However, there was no documented evidence as to what proper safety measures were related to home safety.On 11/21/25 at 1114 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings.xx. Review of Patient 7’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 7/27/24. The patient was certified for hospice during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25 and 9/20/25 to 11/18/25.The Hospice POC Report, showed the patient’s identified problems. The goal was established for the identified problem. However, the goal listed was not measurable and specific to the patient’s needs.For example, the goal for need for observation and assessment of cardiac/circulatory system was that cardiac exacerbations are identified promptly and interventions initiated. However, there was no documented evidence of the measurable outcome as to what cardiac exacerbations would be related to the cardiac/circulatory system.On 11/21/25 at 1343 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The Administrator and DPCS verified and acknowledged the findings.xx. Review of Patient 13’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 1/12/23. The patient was certified for hospice during the certification periods from 1/12/23 to 4/11/23, 4/12/23 to 7/10/23, 7/11/23 to 9/8/23, 9/9/23 to 11/7/23, 11/8/23 to 1/6/24, 1/7/24 to 3/6/24, 3/7/24 to 5/5/24, 5/6/24 to 7/4/24, 7/5/24 to 9/2/24, 9/3/24 to 11/1/24, 11/2/24 to 12/31/24, 1/1/25 to 3/1/25, 3/2/25 to 4/30/25, 5/1/25 to 6/29/25, 6/30/25 to 8/28/25, 8/29/25 to 10/27/25 and 10/28/25 to 12/26/25.The Hospice POC Report, showed the patient’s identified problems. The goal was established for the identified problem. However, the goal listed was not measurable and specific to the patient’s needs.For example, the goal for observation and assessment of skin was patient will be free from exacerbations of integumentary status. However, there was no documented evidence of the measurable outcome as to what exacerbations would be related to integumentary status.Another example would be the goal altered home safety was patient/caregivers verbalizes understanding of proper safety measures related to fall awareness. However, there was no documented evidence of the measurable outcome as to what safety measures are in relation to fall awareness. On 11/21/25 at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings.xx. Review of Patient 14’s clinical record was initiated on 11/19/25. The clinical record showed the SOC was 8/1/24. The patient was certified for hospice during the certification periods from 8/1/24 to 10/29/24, 10/30/24 to 12/28/24, 12/29/24 to 2/26/25, 2/27/25 to 4/27/25, 4/28/25 to 6/26/25, 6/27/25 to 8/25/25, 8/26/25 to 10/24/25 and 10/25/25 to 12/23/25.The Hospice POC Report, showed the patient’s identified problems. The goal was established for the identified problem. However, the goal listed was not measurable and specific to the patient’s needs.For example, the goal for observation and assessment of altered comfort was patient will verbalize decreased in pain or has decreased non-verbal signs and symptoms of pain as a result of pharmacologic pain control regimen. However, there was no documented evidence of the measurable outcome of what the non-verbal signs and symptoms of pain are in relation to patient’s altered comfort.For example, the goal for need for observation and assessment of cardiac/circulatory system was that cardiac exacerbations are identified promptly and interventions initiated. However, there was no documented evidence of the measurable outcome as to what cardiac exacerbations would be related to the cardiac/circulatory system.On 11/21/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings. The hospice’s P&P titled Plan of Care Process reviewed 9/1/24 showed to ensure that the care provided is in accordance with the written plan of care (POC), appropriately planned, and delivered in a timely manner to meet the patients ‘s and family’s specific needs. The POC incudes, but not limited to measurable outcomes anticipated from implementing and coordinating the POC. Review of the clinical records for Patients 1, 3, 4, 5, 6, 7, 9, 11, 13,14, 15 and 17 showed no documented evidence the POCs included measurable outcomes. For example:1. Review of Patient 15’s clinical record was initiated on 11/20/25. The clinical record showed the SOC was 9/9/24. The patient was certified for hospice services during the certification periods from 9/9/24 to 12/7/24, 12/8/24 to 3/7/25, 3/8/25 to 5/6/25, 5/7/25 to 7/5/25, 7/6/25 to 9/3/25, 9/4/25 to 11/2/25 and 11/3/25 to 1/1/26. The Hospice POC Report, showed the patient’s identified problems. The goal was established for the identified problem. However, the goal listed was not measurable and specific to the patient’s needs for example:-the goal for altered comfort was that patient verbalizes decrease in pain or has decrease in non-verbal signs and symptoms of pain and verbalizes adequate pain control. However, there was no documented evidence of the measurable outcome as to what an adequate and non-verbal signs and symptoms of pain would be related to altered comfort.-the goal for altered cardiac/circulatory system was that cardiac exacerbations are identified promptly and interventions initiated. However, there was no documented evidence of the measurable outcome as to what cardiac exacerbations would be related to the cardiac/circulatory system.-the goal for altered respiratory status was to verbalize comfort with respiratory status. However, there was no documented evidence of the measurable outcome as to what a comfortable respiratory status.-the goal for altered gastrointestinal status and constipation related to opioid use and or other GI problem was for the control of patients constipation, verbalizes proper nutrition and fluid intake to maintain proper bowel management. However, there was no documented evidence of the measurable outcome as to what a controlled constipation, proper nutrition and proper bowel management was.On 11/25/25 at 1518 hours an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patients’ POCs no less frequently than every 15 calendar days for three of 19 sampled patients (Patients 4, 9, and 17). This failure had the potential for not providing appropriate, consistent, and quality care to these patients.Findings: The hospice’s P&P titled Interdisciplinary Group Roles and Responsibilities last reviewed 9/1/24 showed the IDG/IDT meetings will be held during the course of patient care to monitor and evaluate the patient’s interdisciplinary POC progress, at least every 15 days , or more frequently warranted by the patient’s condition.xx.Review of Patient 4’s closed clinical record was initiated on 11/14/25. The clinical record showed the SOC was 12/23/24. The patient was certified for hospice services during the certification period 12/23/24 to 3/22/25, The patient was discharged from hospice service on 2/4/25.Review of the clinical record showed the POC/IDG was conducted on 12/30/24 and 1/13/25.However, the following POC/IDG was conducted on 1/29/25, which was more than 15 calendar days as per the hospice’s P&P.On 11/21/25 at 1114 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings. The hospice’s P&P titled Plan of Care Process reviewed 9/1/24 showed the hospice will review and revise patient care in accordance with the changes in the patients response to care and changes that have occurred regarding diagnosis, treatment, medications, precautions and limitations. #. Review of Patient 17’s clinical record was initiated on 11/20/25. The clinical record showed the SOC was 3/5/25. The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25 and 10/31/25 to 12/29/25. Review of the RN Hospice Recert Assessment dated 8/18/25, showed the RN 1 had performed an assessment. The assessment showed the patients primary diagnosis of hypertensive heart disease. The patient was assessed to have + 2 edema to the left foot, ankle and calf. However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 8/20/25, failed to show documented evidenced of the IDG had reviewed/revised the POC to address the patients + 2 edema to the left foot, ankle and calf. Further review of the Visit Note Report on the following dates showed:-on 9/5 and 9/8/25 = +1 edema to the right and left foot and calf, +2 edema to the right and left ankle,-on 9/11/25 = +1 edema to the right and left foot and calf, +2 edema to the right and left ankle and +1 edema to the right and left thigh.However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3 and 9/17/25 failed to show documented evidenced of the IDG had reviewed/revised the POC to address the the patients edema to the bilateral lower extremities. On 11/25/25 at 1445 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if the patients edema was discussed in the IDG. The Administrator reviewed the clinical record and replied, no, was not discussed and updated. The Administrator was informed and acknowledged the findings. crossed ref. L-545 #. Review of Patient 9’s clinical record was initiated on 11/19/25. The clinical record showed the SOC was 1/14/25. The patient was certified for hospice services during the certification periods from 1/14/25 to 4/13/25, 4/14/25 to 6/12/25, 6/13/25 to 8/11/25, 8/12/25 to 10/10/25 and 10/11/25 to 12/925.Review of the Visit Note Report dated 9/16/25, on the section of narrative to address significant changes in condition showed the PCG reported the patient passing out pebble like stools. MD made aware and received a new orders to increase Colace 250 mg BID and Senna 8.6 mg BID. Hold for loose stools.However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/17/25 failed to show documented evidenced of the IDG had reviewed and revised the care plan to address the patients episode of passing out of pebble stools. Moreover, there was no documented evidence of the IDG discussed the new orders to increase Colace 250 mg BID and Senna 8.6 mg BID as written on the SN visit notes. On 11/26/25 at 0958 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if the patients stool softeners/medications were discussed in the IDG. The Administrator reviewed the clinical record and replied, the MD ordered date for the medications was 9/18/25, hence it was not discussed on 9/17 IDG but on 10/1/25 IDG. The Administrator was also asked if the POC/IDG dated 9/17/25 was revised to show the episode of the reported passing out of pebble like stools. The Administrator reviewed the clinical records and replied no. The Administrator was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the revised POCs included the patients’ progress towards goals specified in the POCs for five of 19 sampled patients (Patients 3, 4, 7, 13, and 14). This failure created the risk of not providing the necessary care and services to meet the care needs for these patients.Findings: 1. Review of Patient 3’s closed clinical record was initiated on 11/13/25. The clinical record showed the SOC was 1/25/24. The patient was certified for hospice services during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25, and 4/10/25 to 6/2/25. The patient expired on 6/2/25. The Hospice POC Report showed the patient’s identified problems. For example:-On 1/25/24, a care plan problem was added for observation and assessment of cardiac/circulatory system.-On 8/6/24, a care plan problem was added for altered comfort. Both care plan problem goals were established for the identified problems. However, there was no documented evidence the revised POC included the patient’s progress towards the goal for the care plan problem identified. On 11/21/25 at 0833 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and verified the finding. 2. Review of Patient 4’s closed clinical record was initiated on 11/14/25. The clinical record showed the SOC was 12/23/24. The patient was certified for hospice services during the certification period 12/23/24 to 3/22/25. The patient was discharged from hospice on 2/4/25. The Hospice POC Report showed the patient’s identified problems. For example:-On 12/23/24, a care plan problem was added for observation and assessment of altered comfort and observation and assessment of sensory/neurological status.-On 12/25/24, a care plan problem was added for altered home safety.The care plan problem goals were established for the identified problems. However, there was no documented evidence the revised POC included the patient’s progress towards the goal for the care plan problem identified. On 11/21/25 at 1114 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They were informed and verified the finding. 3. Review of Patient 7’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 7/27/24. The patient was certified for hospice services during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25. The Hospice POC Report, showed the patient’s identified problems. For example:-On 7/24/24, a care plan problem was added for a need for observation and assessment of cardiac/circulatory system.-On 7/27/24, a care plan problem was added for a need to assessment of nutrition/hydration.The care plan problem’s goals were established for the identified problems. However, there was no documented evidence the revised POC included the patient’s progress towards the goal for the care plan problem identified. On 11/21/25 at 1343 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They were informed and verified the finding. 4. Review of Patient 13’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 1/12/23. The patient was certified for hospice services during the certification periods from 1/12/23 to 4/11/23, 4/12/23 to 7/10/23, 7/11/23 to 9/8/23, 9/9/23 to 11/7/23, 11/8/23 to 1/6/24, 1/7/24 to 3/6/24, 3/7/24 to 5/5/24, 5/6/24 to 7/4/24, 7/5/24 to 9/2/24, 9/3/24 to 11/1/24, 11/2/24 to 12/31/24, 1/1/25 to 3/1/25, 3/2/25 to 4/30/25, 5/1/25 to 6/29/25, 6/30/25 to 8/28/25, 8/29/25 to 10/27/25, and 10/28/25 to 12/26/25. The Hospice POC Report, showed the patient’s identified problems. For example:-On 1/12/23, a care plan problem was added for altered home safety.-On 1/11/24, a care plan problem was added for observation and assessment of skin.The care plan problem’s goals were established for the identified problems. However, there was no documented evidence the revised POC included the patient’s progress towards the goal for the care plan problem identified. On 11/21/25 at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They were informed and verified the finding. 5. Review of Patient 14’s clinical record was initiated on 11/19/25. The clinical record showed the SOC was 8/1/24. The patient was certified for hospice services during the certification periods from 8/1/24 to 10/29/24, 10/30/24 to 12/28/24, 12/29/24 to 2/26/25, 2/27/25 to 4/27/25, 4/28/25 to 6/26/25, 6/27/25 to 8/25/25, 8/26/25 to 10/24/25, and 10/25/25 to 12/23/25. The Hospice POC Report, showed the patient’s identified problems. For example:-On 8/1/24, a care plan problem was added for observation and assessment of altered comfort.-On 8/1/24, a care plan problem was added for observation and assessment of cardiac/circulatory system.The care plan problem’s goals were established for the identified problems. However, there was no documented evidence the revised POC included the patient’s progress towards the goal for the care plan problem identified. On 11/21/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They were informed and verified the finding.”

“Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing and supervising the care and services provided for two of 19 sampled patients (Patients 1 and 13). This failure created the risk of not addressing the care needs for these patients.Findings: Review of the hospice’s P&P titled Interdisciplinary Group Roles and Responsibilities last reviewed 9/1/24, showed the IDG/IDT responsibilities will include but not limited to:a. Participation in the establishment of the plan of care with the patient and/or family and the primary physician;b .Provision and supervision of hospice care and continuity of services;c. Periodic reviews and updates of the plan of care for each patient receiving hospice care.xx. Review of Patient 13’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 1/12/23. The patient was certified for hospice during the certification periods from 1/12/23 to 4/11/23, 4/12/23 to 7/10/23, 7/11/23 to 9/8/23, 9/9/23 to 11/7/23, 11/8/23 to 1/6/24, 1/7/24 to 3/6/24, 3/7/24 to 5/5/24, 5/6/24 to 7/4/24, 7/5/24 to 9/2/24, 9/3/24 to 11/1/24, 11/2/24 to 12/31/24, 1/1/25 to 3/1/25, 3/2/25 to 4/30/25, 5/1/25 to 6/29/25, 6/30/25 to 8/28/25, 8/29/25 to 10/27/25, and 10/28/25 to 12/26/25. Review of the SN Visit Note Report dated 9/23/25, showed a wound care was provided to Patient 13’s right nipple. The wound was cleansed with saline and patted dry. However, there was no documented evidence to show the patient’s status was reported to the physician. On 11/21/25 at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They were informed and verified the finding. #. Review of Patient 1’s closed clinical record was initiated on 11/14/25. The clinical record showed the SOC was 12/18/24. The patient was certified for hospice services during the certification periods from 12/18/24 to 3/17/25, 3/18/25 to 6/15/25 and 6/16/25 to 8/2/25. The patient passed away on 8/2/25. Review of the RN Hospice Start of Care dated 12/18/24, showed the RN 3 had performed an assessment. The assessment included a question for Volunteer needs. The question was “ Is the patient /caregiver open to Volunteer services to meet social /family support need”. The RN 1 documented “yes, Volunteer coordinator notified of request”. The reason for the Volunteer services was for errands and emotional support (telephone).However, review of the closed clinical record failed to show documented evidenced of the request for the Volunteer services was coordinated with the Volunteer Coordinator. On 11/25/25 at 1135 hours, an interview and concurrent closed clinical record review was conducted with the Administrator. The Administrator was asked if the Volunteer visit was conducted. The Administrator reviewed the closed clinical record and replied, typically the Social Worker will follow up for the volunteer request, MSW saw the patient on 12/20/24 but does not document the need for Volunteer, we don’t have Volunteer at that time. The Administrator was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for 10 of 19 sampled patients (Patients 1, 3, 5, 6, 7, 11, 13, 15, 16, and 17). This failure created the risk of not providing appropriate, consistent, and quality care to the patients. Findings: The hospice’s P&P titled Plan of Care Process reviewed 9/1/24, showed to ensure that the care provided is in accordance with the written plan of care (POC), appropriately planned, and delivered in a timely manner to meet the patient’s and family’s specific needs. 1. Review of Patient 15’s clinical record was initiated on 11/20/25. The clinical record showed the SOC was 9/9/24. The patient was certified for hospice services during the certification periods from 9/9/24 to 12/7/24, 12/8/24 to 3/7/25, 3/8/25 to 5/6/25, 5/7/25 to 7/5/25, 7/6/25 to 9/3/25, 9/4/25 to 11/2/25, and 11/3/25 to 1/1/26. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3, 9/17, 10/1, 10/15, and 10/29/25, showed the patient’s current problem list. The list included an evaluation of patient/family mental coping and emotional stability. Review of the Nursing Visit notes dated 9/26 and 10/22/25, showed RN 2 had performed an assessment. The assessment included a section for the patient’s spiritual, psychosocial, social, and emotional status. However, RN 2 failed to follow the POC as the assessment for the patient’s spiritual, psychosocial, social and emotional were left blank. On 11/25/25 at 1524 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if the SN needed to complete the assessment. The Administrator stated yes. The Administrator was also asked if the care plan was followed. The Administrator reviewed the clinical record and acknowledged the findings. 2. Review of Patient 11’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 2/18/25. The patient was certified for hospice services during the certification periods from 2/18/25 to 5/18/25, 5/19/25 to 8/16/25, 8/17/25 to 10/15/25, and 10/16/25 to 12/14/25. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 8/20, 9/3, 9/17, 10/15, 10/29, and 11/15/25, showed the patient’s current problem list. The list included an evaluation of patient/family mental coping and emotional stability. Review of the Nursing Visit notes dated 10/7 and 10/29/25, showed the SN had performed an assessment. The assessment included a section for the patients spiritual, psychosocial, social, and emotional status. However, RN 2 failed to follow the POC as the assessment for the patients spiritual, psychosocial, social and emotional were left blank. On 11/26/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the finding. 3. Review of Patient 17’s clinical record was initiated on 11/20/25. The clinical record showed the SOC was 3/5/25. The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25, and 10/31/25 to 12/29/25. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3, 9/17, 10/1, 10/15, 10/29, and 11/15/25, showed the patient’s current problem list. The list included an evaluation of patient/family mental coping and emotional stability. Review of the Nursing Visit notes dated 9/29, 10/6, 10/13, 10/20, 10/27, and 10/29/25, showed the SN had performed an assessment. The assessment included a section for the patients spiritual, psychosocial, social and emotional status. However, the SN failed to follow the POC as the sections for the assessment of the patient’s spiritual, psychosocial, social and emotional were left blank.On 11/25/25 at 1445 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. 4. Review of Patient 1’s closed clinical record was initiated on 11/14/25. The clinical record showed the SOC was 12/18/24. The patient was certified for hospice services during the certification periods from 12/18/24 to 3/17/25, 3/18/25 to 6/15/25, and 6/16/25 to 8/2/25. The patient expired on 8/2/25. *The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 7/16/25, cited SN visit one time a week. The POC included a wound care order. The order showed to “cleanse Stage 2 -3 scattered decub to sacrum with dermal cleanser, pat dry with gauze, apply Medi-honey then cover with Mepilex or Duoderm lite. Change weekly and as needed if moist, soiled or dislodge. Caregiver may provide care.”Review of the Visit Note Report dated 7/22 and 7/29/25, showed RN 4 performed a wound assessment and treatment to patient’s Stage 3 sacrum pressure injury. The wound treatment showed, “cleanse healing stage 2-3 decub to sacrum with soap and water. Strict pressure relief. May apply Medi-honey with repositioning and leave open to air.” However, the wound treatment provided was inconsistent with the POC.*The Physician’s Order dated 6/1/25, showed the recertification order included Chaplain visits 1W1 (one time a week for one week), 2Q2W2 (two times every two weeks for two weeks), 1Q3W3, and 1Q2W2.Review of the closed clinical record showed a missed visit documentation of Chaplain 2 for Weeks 1, 2, and 3. However, there was no documented evidenced the Chaplain visit was conducted on Week 5 (7/13/25 to 7/19/25) as ordered by the physician. On 11/25/25 at 1335 hours, an interview and concurrent closed clinical record review was conducted with the Administrator. The Administrator was asked if it was a missed visit. The Administrator reviewed the closed clinical record and stated there should be a Chaplain visit for Week 5 but there was none. The Administrator was also asked if there was a communication note related to the Chaplain missed visit. The Administrator replied, “We’ll look for the record.” The Administrator was further asked if the wound treatment was followed as ordered in the POC. The Administrator reviewed the closed clinical record and stated no. The Administrator was informed and acknowledged the findings. 5. Review of Patient 6’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 9/25/24. The patient was certified for hospice services during the certification periods from 9/25/24 to 12/23/24, 12/24/24 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, 9/20/25 to 11/18/25, and 11/19/25 to 1/17/25.Review of the Physicians’ Order dated 9/5/25. showed the recertification order included a Chaplain visit one time per month for spiritual support.However, review of the clinical record failed to show documented evidence of Chaplain visited the patient for the month of October as ordered. On 11/25/25 at 0909 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if there was a visit conducted by the Chaplain for the month of October. The Administrator reviewed the clinical record and stated no, it should be a PRN visit, and it was a clinical error. The Administrator was informed and acknowledged the findings. 6. Review of Patient 5’s clinical record was initiated on 11/13/25. The clinical record showed the SOC was 3/13/25. The patient was certified for hospice services during the certification periods from 3/13/25 to 6/10/25, 6/11/25 to 9/8/25, 9/9/25 to 11/7/25, and 11/8/25 to 1/6/26.The Physician’s Order dated 9/15/25, showed a wound care order as follows: “nystatin 100,000 units /gram powder, apply to peri wound of sacral ulcer mix with Calmoseptine to be apply every dressing change for three weeks due to redness.”Review of the Visit Note Report on the section of narrative dated 9/17, 9/24, 9/26, and 10/1/25, showed the SN performed wound assessment and treatment to the patient’s sacral coccyx area pressure injury. Documentation showed the treatment included wound cleansed with wound cleanser, patted dry, applied tetracycline (antibiotic), followed by Medihoney (used for wound care), and covered with alginate (wound dressing) and foam dressing. However, the SN failed to follow the physician’s order for the treatment of the patient’s sacral/coccyx area pressure injury. On 11/26/25 at 0811 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if the wound care treatment for nystatin (antifungal) and Calmoseptine (moisture barrier) were provided. The Administrator reviewed the clinical record and stated there was none documented. The Administrator was informed and acknowledged the findings. 7. Review of Patient 16’s clinical record was initiated on 11/12/25. The clinical record showed the SOC was 9/3/25. The patient was certified for hospice services during certification period 9/3/25 to 12/1/25.Review of the physician’s order dated 9/5/25, showed an order for SN visits 2W1 and 2W8, effective 9/3/25.*However, there was no documented SN visit for the week of 11/2/25 to 11/8/25.On 11/24/25 at 1304 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if there was any documentation for Patient 16’s SN visit for the week of 11/2/25 to 11/8/25. The DPCS verified she could not find any SN visit documentation within that week. The DPCS was further asked if there was any SN missed visit documentation and any documentation that offer of the SN visit within that week. The DPCS verified it was missed visit. The DPCS acknowledged she could not find any documentation of any SN visit or follow up visit that was offered.8. Review of Patient 3’s closed clinical record was initiated on 11/13/25. The clinical record showed the SOC was 1/25/24. The patient was certified for hospice services during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25, and 4/10/25 to 6/2/25. The patient expired on 6/2/25.Review of the physician’s order dated 3/26/25, showed an order for MSW visits 1W1 and 1Q2W2 effective 4/13/25*However, the MSW had no documented evidence of visits for the weeks 4/27/25 to 5/3/25, 5/4/25 to 5/10/25, and 5/11/25 to 5/17/25.On 11/13/25 at 1500 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator stated if the visit was missed for the week, a visit should have been rescheduled or offered a visit for the following week. The Administrator verified and acknowledged the finding.9. Review of Patient 7’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 7/27/24. The patient was certified for hospice services during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25.a. Review of the physician’s order dated 10/27/25, showed an order for SN visits W1, 2W2, and 1W1, effective 10/26/25*However, the SN notes for Week 7 (10/26/25 to 11/1/25) showed two SN visits instead of three visits as per the physician’s order.b. Review of the physician’s order dated 10/9/25, showed an order for MSW visits 1W3, effective 10/26/25*However, there was no documented evidence the MSW had visits for the weeks of 10/26/25 to 11/1/25, and 11/2/25 to 11/8/25.On 11/21/25 at 1343 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The Administrator stated the missed visits were reported; however, there was no documented evidence the missed visits were offered for another day. The Administrator and DPCS verified and acknowledged the findings.10. Review of Patient 13’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 1/12/23. The patient was certified for hospice services during the certification periods from 1/12/23 to 4/11/23, 4/12/23 to 7/10/23, 7/11/23 to 9/8/23, 9/9/23 to 11/7/23, 11/8/23 to 1/6/24, 1/7/24 to 3/6/24, 3/7/24 to 5/5/24, 5/6/24 to 7/4/24, 7/5/24 to 9/2/24, 9/3/24 to 11/1/24, 11/2/24 to 12/31/24, 1/1/25 to 3/1/25, 3/2/25 to 4/30/25, 5/1/25 to 6/29/25, 6/30/25 to 8/28/25, 8/29/25 to 10/27/25, and 10/28/25 to 12/26/25.Review of the physician’s order dated 8/14/25, showed an order may recertify the patient for the next hospice certification period (8/29/25 to 10/27/25). Documentation showed the calendar frequency for the SN was 1W8 effective 8/31/25.Review of the calendar of actual visits for the SN for Week 7 (10/5/25 to 10/11/25) showed the SN had two visits which were on 10/7/25 and 10/8/25.Review of the RN Visit Note Report dated 10/8/25, showed the visit type was SN Hospice PRN visit. Documentation showed the patient was found on the floor next to the bed on the right side and an unwitnessed fall. Documentation showed on inspection a small bump on the right side of the forehead. Documentation showed the physician was notified and a new order was received for a floor mat.*However, review of the physician’s order dated 10/8/25, failed to show an order for the PRN visit.On 11/21/25 at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the RN provided timely supervision to the LVNs to assess the quality of care and services provided for one of 19 sampled patients (Patient 7). This failure had the potential of not providing the appropriate, consistent, and quality care to the patient.Findings: Review of Patient 7’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 7/27/24. The patient was certified for hospice services during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25. Review of the SN visit notes dated 10/3 and 11/6/25, showed the LVN conducted the visits; however, there was no documented evidence to show the RN had conducted the supervisory visit. On 11/21/25 at 1343 hours, an interview and concurrent clinical record review were conducted with the Administrator and DPCS. The Administrator and DPCS were informed and verified the finding.”

“Based on interview and record review, the hospice failed to implement the bereavement program as per the hospice’s P&P to address the needs of the bereaved family members for two of three sampled deceased patients (Patient 2 and 3). This failure created the increased risk of not addressing the bereavement needs of the bereaved family members.Findings: The hospice’s P&P titled Bereavement Program Policy and Procedure reviewed 10/1/24, showed the hospice will define and implement a structured, compliant and compassionate Bereavement Program that provides emotional, psychosocial, spiritual, and educational support to the family and caregivers of hospice patients for at least 12 months following the patient’s death. Bereavement procedure includes the Post-Death Bereavement Risk Assessment completed within agency defined timeframe (commonly one to four weeks after death), using a standardized tool. The Bereavement Plan of Care will be developed for each bereaved individual that includes: risk level, identified needs and problems, goals, planned interventions and contact schedule. The Bereavement Intervention includes condolence letters, phone calls, and home visits among others. xx. Review of Patient 3’s closed clinical record was initiated on 11/13/25. The clinical record showed the SOC was 1/25/24. The patient was certified for hospice during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25, and 4/10/25 to 6/2/25. The patient expired on 6/2/25. There was no documented evidence of a post-death bereavement risk assessment was completed by the hospice after one to four weeks after the patient’s death as per the hospice’s P&P. There was no documented evidence a bereavement plan of care was completed by the Bereavement Coordinator after the patient’s death as per the hospice’s P&P. There was no documented evidence that condolence letters nor phone calls were provided to the bereaved family as per the hospice’s P&P. On 11/21/25 at 0833 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and verified the findings. 2. . Review of Patient 2 ’s closed clinical record was initiated on 11/12/25. The clinical record showed the SOC was 2/5/25. The patient was certified for hospice during the certification periods from 2/5/25 - 5/5/25 and 5/6/25 - 8/3/25. Patient expired on 8/3/25.There was no documented evidence of a post-death bereavement risk assessment was completed by the hospice after one to four weeks after the patient’s death as per hospice’s P&P.There was no documented evidence that condolence letters nor phone calls were provided to the bereaved family as per hospice’s P&P.On 11/26/25 at 0855 hours, an interview and a concurrent clinical record review was conducted with the DPCS. The DPCS was asked to show any documentation on Patient 2’s bereavement process one to four weeks after the patient’s death dated 8/3/25 and if there were any documentation of condolence letters or phone calls provided to the bereaved family. The DPCS verified she was not able to find any documentation related on bereavement process for Patient 2’s family and caregivers.”

“Based on interview and record review, the hospice failed to ensure the HAs provided HA services in accordance with the POC for nine of 19 sampled patients (Patients 5, 6, 7, 9, 11, 14, 15, 17, and 18). This failure had the potential for not providing the appropriate, consistent, and quality care to the patients. Findings: Review of the clinical records for Patients 5, 6, 7, 9, 11, 14, 15, 17, and 18 showed the HA did not follow the POC. For example: 1. Review of Patient 15’s clinical record was initiated on 11/20/25. The clinical record showed the SOC was 9/9/24. The patient was certified for hospice services during the certification periods from 9/9/24 to 12/7/24, 12/8/24 to 3/7/25, 3/8/25 to 5/6/25, 5/7/25 to 7/5/25, 7/6/25 to 9/3/25, 9/4/25 to 11/2/25, and 11/3/25 to 1/1/26. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3/25, cited HA visits 1W1, 2W8 effective 9/4/25. Review of the Aide Care Plan Report for the certification periods from 9/4/25 to 11/2/25 and 11/3/25 to 1/1/26, showed the HA to provide ADL services including to shampoo in bed one time a week. However, review of the HA visit notes dated 9/5, 9/9, 9/12, 9/16, 9/19, 9/23, 9/26, 9/30,10/3, 10/7, 10/10,10/14, 10/17, 10/21, 10/24, 10/28, 10/31, 11/7, 11/11, 11/14 and 11/18/25, showed the HA provided shampoo in bed every visit instead of one time a week as per the POC. On 11/25/25 at 1418 hours, an interview with concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. 2. Review of Patient 11’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 2/18/25. The patient was certified for hospice services during the certification periods from 2/18/25 to 5/18/25, 5/19/25 to 8/16/25, 8/17/25 to 10/15/25, and 10/16/25 to 12/14/25. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/15/25, cited HA visits 1W1, 2W8 effective 10/16/25. Review of the Aide Care Plan Report for the certification periods from 8/17/25 to 10/15/25 and 10/16/25 to 12/14/25, showed the HA to provide ADL services including shampoo in bed one time a week. However, review of HA visit notes dated 8/19, 8/21, 8/26, 8/28, 9/2, 9/6/,9/9, 9/11, 9/16, 9/18, 9/23, 9/25, 9/30, 10/2, 10/7, 10/9, 10/16, 10/21, 10/23, 10/28, 10/30, 11/4, 11/6, 11/11, and 11/13/25, showed the HA provided shampoo in bed every visit instead of one time a week as per the POC. On 11/26/25 at 1030 hours, an interview with concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. 3. Review of Patient 17’s clinical record was initiated on 11/20/25. The clinical record showed the SOC was 3/5/25. The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25, and 10/31/25 to 12/29/25. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 8/20/25, cited HA visits 3W9 effective 9/1/25. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/29/25, cited HA visits 2W8, 1W1 effective 11/2/25. Review of the Aide Care Plan Report for the certification periods from 9/1/25 to 10/30/25 and 10/31/25 to 12/29/25, showed the HA to ADL services including to shampoo in bed one time a week. However, review of the HA visit notes dated 9/1, 9/3, 9/4, 9/8, 9/10, 9/11, 9/15, 9/17, 9/18, 9/22, 9/24, 9/25, 9/29,0/1,10/2,10/6, 10/8,10/9, 10/13,10/15, 10/16, 10/20, 10/22, 10/23, 10/27, 10/29, 10/30, 11/3, 11/6, 11/13, 11/17, and 11/19/25 showed the HA provided shampoo in bed every visit instead of one time a week as per the POC. On 11/25/25 at 1437 hours, an interview with concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the RN provided timely supervision to the HAs to assess the quality of care and services provided to nine of 19 sampled patients (Patients 5, 6, 7, 9, 11, 14, 15, 17, and 18). This failure had the potential of not providing the appropriate, consistent, and quality care to the patients.Findings: xx. Review of Patient 7’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 7/27/24. The patient was certified for hospice during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/17/25, showed frequency of the HHA effective 9/21/25 was 2W8 and 1W1. Review of the HA notes showed HA 1 conducted the visits on 9/30, 10/2, 10/7, 10/9, 10/16, 10/21, 10/23, 10/28, and 10/30/25. However, there was no documented evidence the RN conducted HA supervision every 14 days. On 11/21/25 at 1343 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The Administrator and DPCS were informed and verified the finding. Review of the clinical records for Patients 5, 6, 7, 9, 11, 15 and 17 showed the HA failed to follow the written care plan as ordered. For example: The hospice’s P&P titled Employee Supervision reviewed 12/6/24 showed the purpose was to establish employee supervision practices in accordance with the applicable federal and state laws and regulations. The policy showed supervision will be performed within the time frame defined by the policy. The procedure includes a registered nurse (RN) must make an on-site visit to the patients home no less frequently than every14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the Hospice Interdisciplinary Group/Team (DG/IDT) meet the patients needs. The hospice aide does not have to be present during the visit. 1. Review of Patient 15’s clinical record was initiated on 11/20/25. The clinical record showed the SOC was 9/9/24. The patient was certified for hospice services during the certification periods from 9/9/24 to 12/7/24, 12/8/24 to 3/7/25, 3/8/25 to 5/6/25, 5/7/25 to 7/5/25, 7/6/25 to 9/3/25, 9/4/25 to 11/2/25 and 11/3/25 to 1/1/26. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3/25, cited HHA visit 1WK1, 2WK8 effective 9/4/25.Review of the clinical record during the certification period 9/4/25 to 11/2/25, showed HA 1 conducted the visits on 9/5, 9/9, 9/12, 9/16, 9/19, 9/23, 9/26, 9/30,10/3, 10/7, 10/10,10/14, 10/17, 10/21, 10/24, 10/28, 10/31/25. Further review of the clinical records for the certification period 9/4/25 to 11/2/25, showed the RN had performed HA supervisory visit on 9/10, 10/5 and 10/15/25. However, the RN supervisory visit was not conducted every 14 days as per P&P.On 11/25/25 at 1524 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked as to the frequency of HA supervisory visit. The Administrator replied every 14 days. The Administrator reviewed the clinical records and acknowledged the findings. 2. Review of Patient 11’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 2/18/25. The patient was certified for hospice services during the certification periods from 2/18/25 to 5/18/25, 5/19/25 to 8/16/25, 8/17/25 to 10/15/25 and 10/16/25 to 12/14/25. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/15/25 cited HHA visit 1W1, 2W8 effective 10/16/25.Review of the clinical record during the certification period from 10/16/25 to 12/14/25 showed HA 4 conducted the visits on 10/16, 10/21, 10/23, 10/28, 10/30, 11/4, 11/6, 11/11 and 11/13/25.Further review of the clinical records for the certification period 10/16/25 to 12/14/25, showed the RN had performed HA supervisory visit on 11/6 and 11/14/25. However, the RN supervisory visit was not conducted every 14 days as per P&P.On 11/26/25 at 1030 hours, an interview with concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. #. Review of Patient 17’s clinical record was initiated on 11/20/25. The clinical record showed the SOC was 3/5/25. The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25 and 10/31/25 to 12/29/25. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 8/20/25 cited HHA visit 3W9 effective 9/1/25. In addition, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/29/25 cited HHA visit 2W8, 1W1 effective 11/2/25.Review of the Aide hospice visit notes dated 9/1, 9/3, 9/4, 9/8, 9/10, 9/11, 9/15, 9/17, 9/18, 9/22, 9/24, 9/25, 9/29,0/1,10/2,10/6, 10/8,10/9, 10/13,10/15, 10/16, 10/20, 10/22, 10/23, 10/27, 10/29, 10/30, 11/3, 11/6, 11/13, 11/17 and 11/19/25. Review of the clinical record for the certification period 9/1/25 to 10/30/25 and 10/31/25 to 12/29/25 showed an RN had performed supervisory visits on 9/3, 9/15 and 11/10/25. However, the RN supervisory visit was not conducted every 14 days as per P&P. On 11/25/25 at 1437 hours, an interview with concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the volunteers provided day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff. This failure created the risk of not addressing the patients’ needs.Findings: Review of the hospice’s volunteer program was conducted on 11/20/25. The hospice’s documents showed no documented evidence the volunteers provided day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff for the years of 2024 and 2025. On 11/20/25 at 1506 hours, an interview and concurrent hospice document review was conducted with the Volunteer Coordinator. The Volunteer Coordinator stated the hospice did not have volunteers since January 2024. On 11/21/25 at 1600 hours, the Administrator and DPCS were informed and verified the finding.”

“Based on interview and record review, the hospice Administrator failed to be responsible for the day-to-day operations of the organization and maintain the administrative responsibility related to completion of tuberculosis screening for one of 10 employee files reviewed (Chaplain 2); and timely submission of clinical records. This failure had the potential for spread of infection and not maintaining the complete medical records.Findings: Review of the hospice’s P&P titled Timelines reviewed 9/1/24 showed, the hospice will ensure timely provision of care to meet patient’s needs incompliance with federal and state law requirements. The hospice will establish staff responsibilities for acceptable timeframes for completion and submission of medical record information including, but not limited to : visit notes and assessments, physician orders, certifications and recertifications, transfer and discharges. XX. Review of Patient 18 was initiated on 11/12/25. The clinical record showed the SOC was 2/24/25. The patient was certified for hospice services during certification periods 2/24/25 - 5/24/25, 5/25/25 to 8/22/25, 8/23/25 to 10/21/25 and 10/22/25 to 12/20/25. Review of the physician’s order dated 10/7/25, showed an order for SN effective 10/26/25 1w8.The agency’s electronic system showed SN visit was conducted on 11/18/25 for week 4, 11/16/25 to 11/22/25. However, there was no documentation of SN visit. On 11/26/25 at 0859 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was asked if she could provide SN visit documentation dated 11/18/25. The DPCS stated there was SN visit and verified the licensed nurse was not able to submit the SN visit documentation in a timely manner within 24- 48 hours. The DPCS further acknowledged SN visits documentation should be submitted within 24-48 hours. Review of the hospice’s P&P titled Job Description/Performance Evaluation reviewed 10/1/24 showed the Administrators’ primary function is to assume overall responsibility and authority for the administrative and leadership functions, supervision of the organizational plan, and responsibility for ongoing communication with the Governing Body and the interdisciplinary Group/Team (IDG/IDT), as well as the hospice staff. The essential functions include to organize and directs the hospice’s ongoing functions and ensures the hospice, including any multiple location(s), are in compliance with all applicable federal, state, and local laws and regulatory agencies related to health and safety of patients and ensures that the organization employs or contracts with qualified personnel. According to Standards of Quality Hospice Care 2005 Section 6.3 (a) (1) (2):-All persons providing physician, nursing or home health aide services shall have a health examination by a physician, nurse practitioner or physician’s assistant six months prior to employment or within 14 days of the date of employment. The initial health examination shall include a tuberculosis screening. Review of the employee file was initiated on 11/21/25 with the Volunteer Coordinator/HR/Intake Manager.Review of the Chaplain 2 personnel file showed the hiring date of 6/14/23. The file showed the physical examination and tuberculosis screening was completed on 10/27/22. However, the TB testing was conducted more than six months prior to employment.On 11/21/25 at 1344 hours an interview and concurrent document review was conducted with the Volunteer Coordinator/HR/Intake Manager. The Volunteer Coordinator/HR/Intake Manager was informed and acknowledged the finding.On 11/25/25 at 1247 hours, an interview and concurrent document review was conducted with the Administrator. The Administrator was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the clinical records were complete and accurate for six of 19 sampled patients (Patients 3, 4, 7, 10, 14, and 16). This failure had the potential risk of substandard care provided to the patients as their clinical information were not accurate and complete. Review of the hospice’s P&P titled Timelines last reviewed 9/1/24, showed the hospice will ensure timely provision of care to meet patient’s needs in compliance with all federal and state laws and regulations. The hospice will establish staff responsibilities for acceptable timeframes for completion and submission of clinical record information including visit notes, assessments, physician orders, certifications and recertification, transfers and discharges. Physician signatures are obtained on any updated IDG/IDT POC. #. Review of Patient 3’s closed clinical record was initiated on 11/13/25. The clinical record showed the SOC was 1/25/24. The patient was certified for hospice during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25, and 4/10/25 to 6/2/25. The patient expired on 6/2/25.a. The MD Ordered and Approved Medications dated 3/26/25, included the following medications:-acetaminophen (analgesic) 500 mg tablet two times daily for chronic pain.-acetaminophen 500 mg tablet every four hours as needed for moderate pain.However, the RN Visit Note Report dated 4/19/25, showed the patient did not have pain and was not currently on pain management which was inconsistent with the physician’s order. b. The MD Ordered and Approved Medications dated 3/26/25, showed to administer oxygen for inhalation at 2 to 4 liters per minute as needed for shortness of breath.However, the RN Visit Note Report dated 4/26/25, showed there was no equipment available. Also, on the section if oxygen safely stored, the SN documented not applicable which were inconsistent with the physician’s order. c. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 4/9/25, showed the physician electronically signed on 8/1/25, which was more than 30 days of the updated IDG/IDT POC. On 11/21/25 at 0833 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The DPCS confirmed that physician signatures should be obtained within 30 days. The Administrator and DPCS were informed and verified the finding. xx. Review of Patient 4’s closed clinical record was initiated on 11/14/25. The clinical record showed the SOC was 12/23/24. The patient was certified for hospice services during the certification period 12/23/24 to 3/22/25. The patient was discharged from hospice on 2/4/25. a. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 1/29/25 and 2/12/25, showed the physician electronically signed on 8/1/25, which was more than 30 days of the updated IDG/IDT POC. On 11/21/25 at 1141 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The DPCS confirmed that physician signature should be obtained within 30 days. The Administrator and DPCS were informed and verified and the finding. xx. Review of Patient 7’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 7/27/24. The patient was certified for hospice during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25. a. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/17/25 and 10/1/25, showed the physician electronically signed on 11/12/25, which was more than 30 days of the updated IDG/IDT POC. b. Review of the calendar showed an actual SN visit on 11/10/25 and 11/13/25. However, there was no visit note completed. c. Review of the calendar showed an actual HA visit on 11/13/25. However, there was no visit note completed. On 11/21/25 at 1343 hours, an interview and concurrent clinical record review were conducted with the Administrator and DPCS. The DPCS confirmed that physician signatures should be obtained within 30 days from the date of the clinical record. Furthermore, visit notes should be completed with 24 hours of actual visit. The Administrator and DPCS were informed and verified the findings. xx. Review of Patient 14’s clinical record was initiated on 11/19/25. The clinical record showed the SOC was 8/1/24. The patient was certified for hospice during the certification periods from 8/1/24 to 10/29/24, 10/30/24 to 12/28/24, 12/29/24 to 2/26/25, 2/27/25 to 4/27/25, 4/28/25 to 6/26/25, 6/27/25 to 8/25/25, 8/26/25 to 10/24/25, and 10/25/25 to 12/23/25. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/8/25 and 9/22/25, showed the physician electronically signed on 11/5/25, which was not within the 30 days of any updated IDG/IDT POC. On 11/21/25 at 1425 hours, an interview and concurrent clinical record review were conducted with the Administrator and DPCS. The DPCS confirmed that physician signature should be obtained within 30 days. The Administrator and DPCS were informed and verified the finding. XX. Review of Patient 10’s physical copy of Nursing Visit Note dated 10/29/25 showed, goal of visit was for assessment and education. However, Patient 10’s Nursing Visit Note showed blank documentation on the following sections: a. The Emergency Preparedness Assessment section that showed assessment for mobility status: if patient is ambulatory, non ambulatory, wheelchair, chairbound or bedbound; assessment on special needs: if patient is electricity dependent, communication challenges, language barriers, intellectual disabilities, special dietary needs, essential medications, etc. b. The Coordination of Care/Professional Management Education that showed assessment on review with patient/ caregiver/ physician; if coordinated care with IDG, physician, orders received, plan of care updated. On 11/24/25 at 1442 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS was informed on Patient 2’s Nursing Visit Note dated 10/29/25, showed no assessment on Emergency Preparedness and Coordination of Care/Professional Management Education and was asked if it should have been completed. The DPCS verified it should have been completed. XX. Review of Patient 16’s clinical record was initiated on 11/12/25. The clinical record showed the SOC was 9/3/25. The patient was certified for hospice services during certification period 9/3/25 to 12/1/25. Review of the Patient 16’s RN visit notes showed the following:-dated 9/19/25 , 10/7/25, and 10/21/25 showed no documentation on MAC measurement.-dated 9/3/25 showed Patient 16’s genitourinary assessment indicated Patient 16 was with Nephrostomy tube. Patient 16’s narrative documentation showed Patient 16 was with Right arm PICC line, nephrostomy tube x 2, colostomy and with IV antibiotics x 2 for pseudomonas and MRSA. -dated 9/5/25, Patient 16’s assessment on type of ostomy showed Patient 16 was with colostomy. Patient 16’s narrative documentation showed Patient 16 was with right nephrostomy.-dated 9/9/25, Patient 16’s assessment on type of ostomy showed colostomy. Patient16’s narrative documentation showed Patient 16 was with PICC line dressing to right arm changed and on antibiotic therapy. -dated 9/16/25, Patient 16’s assessment on type of ostomy showed Patient 16 was with colostomy. Patient 16’s narrative documentation showed Patient 16 was with PICC line dressing changed, on IV antibiotic therapy.-dated 9/19/25, Patient 16’s assessment on type of ostomy showed Patient was with colostomy. Patient 16’s narrative documentation showed Patient 16 was with PICC line removed per patient request , IV antibiotics completed.-dated 9/30/25, Patient 16’s genitourinary assessment showed Patient 16 was with nephrostomy tube and type of ostomy showed colostomy. Patient 16’s narrative documentation showed Patient 16 was on antibiotic prophylaxis.-dated 10/7/25, Patient 16’s narrative documentation showed Patient 16 was with colostomy and with nephrostomy tubing.-dated 10/14/25, 10/21/25, 10/28/25, and 11/11/25, Patient 16’s genitourinary assessment showed Patient 16 was with nephrostomy tube and type of ostomy showed colostomy.*However, there was no documentation showing interventions provided or goals met on Patient 16’s colostomy, nephrostomy, antibiotic therapy and PICC line care and there was no specific, detailed assessment documentation on Patient 16’s PICC line site and care. On 11/24/25 at 1304 hours, an interview and concurrent clinical record review was conducted with DPCS. The DPCS was asked what was the agency protocol for any missed visits. The DPCS stated the patient should be offered another visit. The DPCS was further asked for any documentation of any SN visit for the week of 11/2/25 to 11/8/25. The DPCS verified it was missed and acknowledged she could not find any documentation to show an attempted visit was arranged for Patient 16. The DCPS was also asked how frequent licensed nurses should conduct MAC measurements. The DCPS stated the MAC measurement should be measured every 14 days. The DCPS was informed on Patient 16’s missed MAC measurements and DCPS verified the MAC measurements should have been done. Additionally, the DPCS asked if there was any specific documentation she could show that interventions provided or were the goals met regarding Patient 16’s colostomy, nephrostomy, antibiotic therapy, PICC line care as well as if there were any documentation of detailed PICC line assessment conducted from the above-mentioned dates . The DPCS verified she could not find any specific documentation regarding interventions were provided or if goals were met regarding Patient 16’s colostomy, nephrostomy, antibiotic therapy, PICC line care and further verified she could not find any specific, detailed documentation of PICC line assessment from above dates mentioned. Review of the hospice’s P&P titled Timelines last reviewed 9/1/24, showed the hospice will ensure timely provision of care to meet patient’s needs in compliance with all federal and state laws and regulations. The hospice will establish staff responsibilities for acceptable timeframes for completion and submission of clinical record information including visit notes, assessments, physician orders, certifications and recertification, transfers and discharges. Physician signatures are obtained on any updated IDG/IDT POC. 1. Review of Patient 3’s closed clinical record was initiated on 11/13/25. The clinical record showed the SOC was 1/25/24. The patient was certified for hospice during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25, and 4/10/25 to 6/2/25. The patient expired on 6/2/25.a. The MD Ordered and Approved Medications dated 3/26/25, included the following medications:-acetaminophen (analgesic) 500 mg tablet two times daily for chronic pain.-acetaminophen 500 mg tablet every four hours as needed for moderate pain.However, the RN Visit Note Report dated 4/19/25, showed the patient did not have pain and was not currently on pain management which was inconsistent with the physician’s order. b. The MD Ordered and Approved Medications dated 3/26/25, showed to administer oxygen for inhalation at 2 to 4 liters per minute as needed for shortness of breath.However, the RN Visit Note Report dated 4/26/25, showed there was no equipment available. Also, on the section if oxygen was safely stored, the SN documented not applicable which was inconsistent with the physician’s order. c. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 4/9/25, showed the physician electronically signed on 8/1/25, which was more than 30 days of the updated IDG/IDT POC. On 11/21/25 at 0833 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The DPCS confirmed that physician signatures should be obtained within 30 days. The Administrator and DPCS were informed and verified the finding. 2. Review of Patient 4’s closed clinical record was initiated on 11/14/25. The clinical record showed the SOC was 12/23/24. The patient was certified for hospice services during the certification period 12/23/24 to 3/22/25. The patient was discharged from hospice on 2/4/25. a. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 1/29/25 and 2/12/25, showed the physician electronically signed on 8/1/25, which was more than 30 days of the updated IDG/IDT POC. On 11/21/25 at 1141 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The DPCS confirmed that physician signature should be obtained within 30 days. The Administrator and DPCS were informed and verified and the finding. 3. Review of Patient 7’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 7/27/24. The patient was certified for hospice during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25. a. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/17/25 and 10/1/25, showed the physician electronically signed on 11/12/25, which was more than 30 days of the updated IDG/IDT POC. b. Review of the calendar showed an actual SN visit on 11/10/25 and 11/13/25. However, there was no visit note completed. c. Review of the calendar showed an actual HA visit on 11/13/25. However, there was no visit note completed. On 11/21/25 at 1343 hours, an interview and concurrent clinical record review were conducted with the Administrator and DPCS. The DPCS confirmed that physician signatures should be obtained within 30 days from the date of the clinical record. Furthermore, visit notes should be completed with 24 hours of actual visit. The Administrator and DPCS were informed and verified the findings. 4. Review of Patient 14’s clinical record was initiated on 11/19/25. The clinical record showed the SOC was 8/1/24. The patient was certified for hospice during the certification periods from 8/1/24 to 10/29/24, 10/30/24 to 12/28/24, 12/29/24 to 2/26/25, 2/27/25 to 4/27/25, 4/28/25 to 6/26/25, 6/27/25 to 8/25/25, 8/26/25 to 10/24/25, and 10/25/25 to 12/23/25. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/8/25 and 9/22/25, showed the physician electronically signed on 11/5/25, which was not within the 30 days of any updated IDG/IDT POC. On 11/21/25 at 1425 hours, an interview and concurrent clinical record review were conducted with the Administrator and DPCS. The DPCS confirmed that physician signature should be obtained within 30 days. The Administrator and DPCS were informed and verified the finding. 5. Review of Patient 10’s Nursing Visit Note dated 10/29/25, showed the goal of visit was for assessment and education. However, Patient 10’s Nursing Visit Note showed the following sections were left blank: The Emergency Preparedness Assessment section which included the assessment for mobility status: if patient is ambulatory, non ambulatory, wheelchair, chairbound or bedbound; assessment on special needs: if patient is electricity dependent, communication challenges, language barriers, intellectual disabilities, special dietary needs, essential medications, etc. The Coordination of Care/Professional Management Education which included the review with patient/ caregiver/ physician; if coordinated care with IDG, physician, orders received, plan of care updated. On 11/24/25 at 1442 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS was informed on the findings and was asked if it should have been completed. The DPCS verified it should have been completed. 6. Review of Patient 16’s clinical record was initiated on 11/12/25. The clinical record showed the SOC was 9/3/25. The patient was certified for hospice services during certification period 9/3/25 to 12/1/25. Review of the Patient 16’s RN visit notes showed the following:-Dated 9/19, 10/7, and 10/21/25, failed to show documented evidence the patient’s MAC was measured.-Dated 9/3/25, showed Patient 16 had nephrostomy tube, PICC line on the right arm, and colostomy. Patient 16 was on IV antibiotics for pseudomonas and MRSA.-Dated 9/5/25, Patient 16 had colostomy and right nephrostomy.-Dated 9/9 and 9/16/25, Patient 16 had colostomy, PICC line dressing to the right arm was changed, and on antibiotic therapy.-Dated 9/19/25, Patient 16 had colostomy, PICC line was removed as per the patient’s request, IV antibiotic was completed.-Dated 9/30/25, Patient 16 had nephrostomy tube and colostomy; and on antibiotic prophylaxis.-Dated 10/7/25, Patient 16’s narrative documentation showed Patient 16 was with colostomy and with nephrostomy tubing.-dated 10/14/25, 10/21/25, 10/28/25, and 11/11/25, Patient 16’s genitourinary assessment showed Patient 16 was with nephrostomy tube and type of ostomy showed colostomy.*However, there was no documentation showing interventions provided or goals met on Patient 16’s colostomy, nephrostomy, antibiotic therapy and PICC line care and there was no specific, detailed assessment documentation on Patient 16’s PICC line site and care. On 11/24/25 at 1304 hours, an interview and concurrent clinical record review was conducted with DPCS. The DPCS was asked what was the agency protocol for any missed visits. The DPCS stated the patient should be offered another visit. The DPCS was further asked for any documentation of any SN visit for the week of 11/2/25 to 11/8/25. The DPCS verified it was missed and acknowledged she could not find any documentation to show an attempted visit was arranged for Patient 16. The DCPS was also asked how frequent licensed nurses should conduct MAC measurements. The DCPS stated the MAC measurement should be measured every 14 days. The DCPS was informed on Patient 16’s missed MAC measurements and DCPS verified the MAC measurements should have been done. Additionally, the DPCS asked if there was any specific documentation she could show that interventions provided or were the goals met regarding Patient 16’s colostomy, nephrostomy, antibiotic therapy, PICC line care as well as if there were any documentation of detailed PICC line assessment conducted from the above-mentioned dates . The DPCS verified she could not find any specific documentation regarding interventions were provided or if goals were met regarding Patient 16’s colostomy, nephrostomy, antibiotic therapy, PICC line care and further verified she could not find any specific, detailed documentation of PICC line assessment from above dates mentioned.”

“Based on interview and record review, the hospice failed to authenticate the entries made into the clinical records of four of 19 sampled patients (Patients 3, 4, and 13). This failure had the potential to not have verified patient information.Findings: Review of the hospice’s P&P titled Authorization and Authentication of Medical Record Entries last reviewed 9/1/24, showed all medical record entries whether paper, electronic or combination format will be made by appropriate staff and authenticated as true and accurate by the author of the entry. Each medical record entry will be dated and signed with the complete name and title and/or credential of the person making the entry. 1. Review of Patient 3’s closed clinical record was initiated on 11/13/25. The clinical record showed the SOC was 1/25/24. The patient was certified for hospice services during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25 and 4/10/25 to 6/2/25. The patient expired on 6/2/25. a. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 4/9/25, failed to show the electronic signature of the hospice physician. b. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 4/23 and 5/21/25, failed to show the date when the physician signed the report. On 11/21/25 at 0833 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They were informed and verified the findings. 2. Review of Patient 4’s closed clinical record was initiated on 11/14/25. The clinical record showed the SOC was 12/23/24. The patient was certified for hospice services during the certification period 12/23/24 to 3/22/25. The patient was discharged from the hospice on 2/4/25. a. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 12/30/24, failed to show the electronic signature of the hospice physician. b. Review of the Hospice IDG Comprehensive Assessment and Plan of care Update Report dated 1/13/25, failed to show the date when the physician signed the report. On 11/21/25 at 1114 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They were informed and verified the findings. 3. Review of Patient 13’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 1/12/23. The patient was certified for hospice services during the certification periods from 1/12/23 to 4/11/23, 4/12/23 to 7/10/23, 7/11/23 to 9/8/23, 9/9/23 to 11/7/23, 11/8/23 to 1/6/24, 1/7/24 to 3/6/24, 3/7/24 to 5/5/24, 5/6/24 to 7/4/24, 7/5/24 to 9/2/24, 9/3/24 to 11/1/24, 11/2/24 to 12/31/24, 1/1/25 to 3/1/25, 3/2/25 to 4/30/25, 5/1/25 to 6/29/25, 6/30/25 to 8/28/25, 8/29/25 to 10/27/25 and 10/28/25 to 12/26/25. a. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/13/25, failed to show the date when the physician signed the report. b. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 11/5/25, failed to show electronic signature of the hospice physician and pastor/counselor. On 11/21/25 at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They were informed and verified the findings.”