Premier Hospice & Home Care

“Based on interview and record review, the HA failed to notify the Interdisciplinary group (IDG, a designated team of professionals who collaborate to meet the physical, medical, psychosocial, emotional, and spiritual needs of hospice patients and their families) of missed visits according to the HA’s policy and procedure for three of five sampled patients (Patient 2, Patient 4, and Patient 5). This failure had the potential to result in Patient 2, Patient 4 and Patient 5’s delayed symptom management, unmet needs which could negatively impact their dignity and overall quality of life. 1. During a review of Patient 2’s clinical record titled “Patient Profile,” undated, the “Patient Profile” indicated Patient 2 was admitted on 5/15/2025 with terminal diagnosis of Alzheimer’s diseases (a disease characterized by a progressive decline in mental abilities). During a review of Patient 2’s clinical record titled “Plan of Care (POC)”, for the certification period 5/10/2026 to 7/8/2026, the “POC” indicated Patient 2 was to receive hospice aide visits once weekly to provide assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily), hygiene management, and ongoing assistance with changes in condition. During a review of Patient 2’s clinical record titled “View: Aide,” for the certification period 5/10/2026 to 7/8/2026, the “View: Aide” did not contain any information that Patient 2 was seen by a hospice aide for the week of 5/31/2026 to 6/6/2026. During a concurrent interview and record review on 6/15/2026 at 12:36 PM with the Director of Patient Care Services-Designee (DPCS-D), Patient 2’s clinical record for the certification period 5/10/2026 to 7/8/2026 was reviewed. The clinical record did not contain any information that Patient 2 was seen by a hospice aide for the week of 5/31/2026 to 6/6/2026. The DPCS-D was unable to provide documented evidence that the IDG was notified of the missed hospice aide visits for the week of 5/31/2026 to 6/6/2026. The DPCS-D stated that notifying the IDG of a missed visit was necessary to allow the team to arrange for another clinician to provide the required hospice aide services. The DPCS-D stated that Patient 2’s hygiene may have been negatively affected and further stated that personal care services support the patient’s overall comfort and dignity. During a review of HA’s policy and procedure (P&P) titled “Missed Visits”, revised on November 2017, the P&P indicated the following: - If a visit is missed for any reason, the clinician should attempt to reschedule it within the ordered frequency period so that physician-ordered visit frequency is maintained. - If a visit is missed and cannot be rescheduled within the ordered frequency period, the clinician will notify the IDG and clinical supervisor of the missed visit and the reason for the missed visit. - If an aide visit is missed, the aide will notify the case manager and/or clinical supervisors and document the missed visit in the clinical record. Findings: 2. During a review of Patient 4’s clinical record titled “Patient Profile”, undated, the “Patient Profile” indicated Patient 4 was admitted on 11/25/2025 with terminal diagnosis of heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a concurrent interview and record review on 6/15/2026 at 11:38 AM with the DPCS D, Patient 4’s clinical record titled “Plan of Care” (POC), for the certification period 5/24/2026 to 7/27/2026 was reviewed. The POC indicated that Patient 4 was to be seen by a licensed vocational nurse (LVN) three times per week to monitor and assess the patient’s condition. The DPCS (D) stated that during each LVN home visit, the LVNs also provided wound care to Patient 4’s left leg wound. During a concurrent interview and record review on 6/15/2026 at 11:41 AM with the DPCS D, Patient 4’s clinical record titled “View: Skilled Nursing”, for the certification period of 5/24/2026 to 7/22/2026, was reviewed. The “View: Skilled Nursing” indicate skilled nursing visit was missed on 5/24/2026 and 5/31/2026 by Licensed Vocational Nurse 2 (LVN 2). The DPCS D stated that LVN 2 should notify the IDG, that includes the Medical Director (MD) and DPCS D, of the missed visits and that this communication should have been documented in Patient 4’s clinical record. During a concurrent interview and record review on 6/15/2026 at 11:42 AM with the DPCS D, Patient 4’s clinical record, for the certification period of 5/24/2026 to 7/22/2026 was reviewed. The DPCS D was unable to provide documented evidence that LVN 2 notified the IDG of the missed visits on 5/24/2026 and 5/31/2026. The DPCS D stated maintaining communication with the healthcare team is essential to ensure Patient 4 would not experience delays in care that could lead to worsening of the left leg wound, development of new skin impairments, and result in avoidable pain and poor quality of life. 3. During a review of Patient 5’s clinical record titled “Patient Profile”, undated, the “Patient Profile” indicated Patient 5 was admitted on 8/15/2024 with terminal diagnosis of Alzheimer’s diseases (a disease characterized by a progressive decline in mental abilities). During a concurrent interview and record review on 6/15/2026 at 11:25 AM with the DPCS D, Patient 5’s clinical record titled “Aide Care Plan” for the certification period of 4/7/2026 to 5/26/2026, was reviewed. The “Aide Care Plan” indicated Patient 5 receive hospice aide services once a week to assist with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The DPCS D stated hospice aides provide Patient 5 with a partial shower or bath and personal care/hygiene. During a concurrent interview and record review on 6/15/2026 at 11:27 AM with the DPCS D, Patient 5’s clinical record titled “View: Aide Visit”, for the certification period of 4/7/2026 to 5/26/2026, was reviewed. The “View: Aide Visit” did not contain any information that Patient 5 was seen by a hospice aide for the week of 5/3/2026 to 5/9/2026. The DPCS D stated the hospice aide should attempt to reschedule the home visit, preferably within the same week, and notify the notify the IDG of the missed visit. The DPCS D stated that any communication should have been documented in Patient 5’s clinical record. During a concurrent interview and record review on 6/15/2026 at 11:30 AM with the DPCS D, Patient 5’s clinical record for the certification period of 4/7/2026 to 5/26/2026, was reviewed. The DPCS D was unable to provide documented evidence that the hospice aide notified the IDG of the missed visit for the week of 5/3/2026 to 5/9/2026. The DPCS D stated maintaining communication with the healthcare team is essential to ensure Patient 5 would not experience delays in care that could lead to new skin impairments or decline in quality of life. During a review of HA’s policy and procedure (P&P) titled “Missed Visits”, revised on November 2017, the P&P indicated the following: - If a visit is missed for any reason, the clinician should attempt to reschedule it within the ordered frequency period so that physician-ordered visit frequency is maintained. - If a visit is missed and cannot be rescheduled within the ordered frequency period, the clinician will notify the IDG and clinical supervisor of the missed visit and the reason for the missed visit. - If an aide visit is missed, the aide will notify the case manager and/or clinical supervisors and document the missed visit in the clinical record.”

“Based on interview and record review the HA failed to provide hospice care and services in accordance with the individualized plan of care (POC) for four of five sampled patients (Patient 1, Patient 2, Patient 4 and Patient 5). 1. For Patient 1 and Patient 4, the HA failed to provide skilled nursing services as outlined in the POC. This failure had the potential to result in delayed care and unmet needs for Patient 1 and Patient 4, that could lead to avoidable pain, worsening of skin conditions, and a diminished quality of life. 2. For Patient 2 and Patient 5, the HA failed to provide hospice aide services as outlined in the POC. This failure had the potential to result in unmet needs for Patient 2 and Patient 5, which could negatively impact their dignity, contribute to the development or worsening of skin impairments, and diminish their overall quality of life. 1a. During a review of Patient 1’s clinical record titled “Patient Profile,” (admission record, summary of patient’s basic information) undated, the “Patient Profile” indicated Patient 1 was admitted on 5/13/2026 with terminal diagnosis of hypertensive heart disease without heart failure (structural or functional changes in the heart that result from long-standing high blood pressure, excluding cases where heart failure has already developed). During a concurrent interview and record review on 6/15/2026 at 10:24 AM with the Director of Patient Care Services-Designee (DPCS-D), Patient 1’s clinical record titled “Plan of Care (POC)”, for the certification period 5/13/2026 to 8/10/2026 was reviewed. The “POC” indicated Patient 1 was to receive licensed vocational nurse (LVN) visits twice weekly to provide skilled nursing interventions, support, and ongoing monitoring and assessment of changes in condition. The DPCS D stated LVN visit notes must include patient assessment findings, any changes in condition, a narrative of the visit, and the LVN’s dated signature. During a concurrent interview and record review on 6/15/2026 at 10:30 AM with the DPCS D, Patient 1’s clinical record titled “Skilled Nursing Visit”, for the scheduled LVN visit dated 5/21/2026 was reviewed. The “Skilled Nursing Visit “ indicated the LVN visit was conducted on 5/19/2026 from 6 PM – 7 PM and included an electronic signature dated 5/21/2026. The DPCS- D stated LVN visits were not provided as outlined in the POC and there was no documentation of the second LVN visit for the week of 5/17/2026 to 5/23/2026. The DPCS- D stated that missed visits result in missed opportunities to identify changes in the patient’s condition. During a concurrent interview and record review on 6/15/2026 at 10:52 AM with the DPCS-D, Patient 1’s clinical record titled “Plan of Care (POC)”, for the certification period 5/13/2026 to 8/10/2026 was reviewed. The “POC” indicated pain-management interventions that included assessing and monitoring the patient’s pain level, maintaining pain at or below the patient’s threshold or less than 3 to 4 on a 0-10 pain scale (standardized tool used to assess pain, with 0 being no pain at all and 10 being the absolute worst pain imaginable), educating the patient and caregivers on pain-reduction and prevention techniques, implementing non-pharmacological interventions (measures used to manage symptoms without medications), and administering pain medications. The DPCS-D stated that during the missed LVN visit on 5/21/2026, Patient 1’s pain-management interventions were not provided as outlined in the POC. The DPCS-D stated Patient 1 was at risk of experiencing undertreated pain, potentially resulting in discomfort. During a review of HA’s policy and procedure (P&P) titled “The Plan of Care,” revised on November 2021, the P&P indicated the following: - The individualized plan of care will be established and maintained for each individual admitted to the hospice program. - The care provided to the patient must be in accordance with the plan of care. - The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. 1b. During a review of Patient 4’s clinical record titled “Patient Profile”, undated, the “Patient Profile” indicated Patient 4 was admitted on 11/25/2025 with terminal diagnosis of heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a concurrent interview and record review on 6/15/2026 at 11:38 AM with the DPCS-D, Patient 4’s clinical record titled “Plan of Care (POC)”, for the certification period 5/24/2026 to 7/27/2026 was reviewed. The POC indicated that Patient 4 was to be seen by a licensed vocational nurse (LVN) three times per week to monitor and assess the patient’s condition. The DPCS-D stated that during each LVN home visit, the LVNs also provided wound care to Patient 4’s left leg wound. During a concurrent interview and record review on 6/15/2026 at 11:41 AM with the DPCS-D, Patient 4’s clinical record titled “View: Skilled Nursing”, for the certification period of 5/24/2026 to 7/22/2026, was reviewed. The “View: Skilled Nursing” indicate skilled nursing visit was missed on 5/24/2026 and 5/31/2026 by Licensed Vocational Nurse 2 (LVN 2). The DPCS stated LVN 2 did not follow Patient 5’s POC, which required LVN home visits three times per week. The DPCS-D stated the POC was developed to ensure Patient 4’s needs are met and the healthcare team are providing appropriate interventions and treatment to Patient 4. The DPCS D stated that failure to follow Patient 4’s POC may result in worsening of the patient’s left leg wound and a lack of assessment of the patient’s current condition, which could lead to avoidable pain and negatively impact on Patient 4’s overall quality of life. During a review of HA’s P&P titled “The Plan of Care”, revised on November 2021, the P&P indicated the following: - The individualized plan of care will be established and maintained for each individual admitted to the hospice program. - The care provided to the patient must be in accordance with the plan of care. - The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. 2a. During a review of Patient 2’s clinical record titled “Patient Profile,” undated, the “Patient Profile” indicated Patient 2 was admitted on 5/15/2025 with terminal diagnosis of Alzheimer’s diseases (a disease characterized by a progressive decline in mental abilities). During a review of Patient 2’s clinical record titled “Plan of Care (POC)”, for the certification period 5/10/2026 to 7/8/2026, indicated Patient 2 was to receive hospice aide visits once weekly to provide assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily), hygiene management, and ongoing assistance with changes in condition. During a concurrent interview and record review on 6/15/2026 at 12:36 PM with the DPCS-D, Patient 2’s clinical record titled “View: Aide,” for the certification period 5/10/2026 to 7/8/2026 was reviewed. The “View: Aide” did not contain any information that Patient 2 was seen by a hospice aide for the week of 5/31/2026 to 6/6/2026. The DPCS-D stated hospice aide visits were not provided once a week as outlined in the POC. The DPCS-D stated that Patient 2’s hygiene may have been negatively affected and further stated that personal care services support the patient’s overall comfort and dignity. During a review of HA’s P&P titled “The Plan of Care”, revised on November 2021, the P&P indicated the following: - The individualized plan of care will be established and maintained for each individual admitted to the hospice program. - The care provided to the patient must be in accordance with the plan of care. - The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. 2b. During a review of Patient 5’s clinical record titled “Patient Profile”, undated, the “Patient Profile” indicated Patient 5 was admitted on 8/15/2024 with terminal diagnosis of Alzheimer’s diseases (a disease characterized by a progressive decline in mental abilities). During a concurrent interview and record review on 6/15/2026 at 11:25 AM with the DPCS-D, Patient 5’s clinical record titled “Aide Care Plan” for the certification period of 4/7/2026 to 5/26/2026, was reviewed. The “Aide Care Plan” indicated Patient 5 receive hospice aide services once a week to assist with ADLs. The DPCS-D stated hospice aides provide Patient 5 with a partial shower or bath and personal care/hygiene. During a concurrent interview and record review on 6/15/2026 at 11:27 AM with the DPCS D, Patient 5’s clinical record titled “View: Aide Visit”, for the certification period of 4/7/2026 to 5/26/2026, was reviewed. The “View: Aide Visit” did not contain any information that Patient 5 was seen by a hospice aide for the week of 5/3/2026 to 5/9/2026. The DPCS-D stated the hospice aide did not follow Patient 5’s POC, which required the hospice aide visit once a week. The DPCS stated that hospice aide POC was developed to ensure Patient 5’s personal needs are met. The DPCS D stated that failure to follow Patient 5’s POC may affect the patient’s dignity and increase the risk for developing new skin impairments. During a review of HA’s P&P titled “The Plan of Care”, revised on November 2021, the P&P indicated the following: - The individualized plan of care will be established and maintained for each individual admitted to the hospice program. - The care provided to the patient must be in accordance with the plan of care. - The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) Clinical Records was met as follows: a. The HA failed to ensure that documentation of patient care was completed in the electronic medical record (EMR) within 48 hours of the patient visit for three of eight sampled patients (Patient 1, Patient 2 and Patient 5). This failure had potential to result in compromised timely availability of accurate clinical information in the EMR for Patient 1, Patient 2 and Patient 5, placing the patients at risk of delayed or inappropriate care. (Refer to L672)b. The HA failed to ensure appropriately authenticated and dated entries in the patient clinical record for five of eight patients (Patient 1, Patient 2, Patient 4, Patient 5 and Patient 7) when:b.1. The HA’s Director of Patient Care Services Designee (DPCS Designee) backdated (the practice of marking a document with a date earlier than its actual creation or execution date) the clinical record for Patient 1, Patient 2 and Patient 5. b.2. The Plan of Care (POC) for Patient 1, Patient 2, Patient 4, Patient 5 and Patient 7 were not signed and authenticated by identifiable licensed nurse according to HA’s policies and procedures.These failures resulted in the care team not having timely access to accurate clinical information for Patient 1, Patient 2, Patient 4, Patient 5 and Patient 7, placing the patients at risk for delays in care or care that did not fully reflect their current clinical needs. (Refer to L679) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for clinical records are provided to patients certified to receive hospice benefits.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure patients’ clinical record contained documented evidence of completed patient care rendered in the electronic medical record (EMR) within 48 hours of the patient visit for three of eight sampled patients (Patient 1, Patient 2 and Patient 5). This failure could lead to the lack of coordination of patients’ clinical information and continuity of patient care provided to these certified hospice patients. c. During a review of Patient 5’s clinical record titled “Patient Profile” (admission record, summary of patient’s basic information), the “Patient Profile” indicated Patient 5 was admitted on 5/15/2025, with diagnoses including Alzheimer’s disease and dementia.During a review on 4/23/2026 of Patient 5’s clinical record titled “View: Nursing Visit”, for the certification period of 3/11/2026 to 5/9/20266. The “View: Nursing Visit” indicated the “Registered Nurse (RN) - Skilled Nursing Visit” note dated 3/19/2026, 4/2/2026 and 4/14/2026 did not contain any information.During a concurrent interview and record review on 4/24/2026 at 12:36 PM with the DPCS Designee, Patient 5’s clinical record titled “RN – Skilled Nursing Visit”, dated 3/19/2026, 4/2/2026 and 4/14/2026 was reviewed. The “RN – Skilled Nursing Visit” indicated the DPCS Designee electronically signed the “RN – Skilled Nursing Visit” on the day the visit were completed. The DPCS Designee stated the Patient 5’s “RN – Skilled Nursing Visit” notes were completed on 4/23/2026. The DPCS Designee stated the “RN – Skilled Nursing Visit” did not indicate the note were late entries.During an interview on 4/23/2026 at 12:37 PM with the DPCS Designee, the DPCS Designee stated late entries in Patient 5’s clinical record will have the healthcare team to be unaware of Patient 5’s current needs that may lead to delays in care, unmanaged symptoms, missed interventions, decreased comfort, increased pain, and a less dignified dying process.During an interview on 4/27/2026 at 10:05 AM with the HA’s DPCS Designee, the DPCS Designee stated visit notes should be completed within 48 hours after the visit and should be electronically signed and dated on the date the note was completed.During a review of the HA’s P&P titled, “Entries into The Clinical Record”, dated 2017, the P&P indicated:-Hospice personnel providing direct patient care and supervisory functions will complete documentation within the electronic medical record on the day care is provided to the patient and no later than 48 hours following the patient visit. a. During a review of Patient 1’s clinical record titled “Patient Profile,” (admission record, summary of patient’s basic information) undated, the “Patient Profile” indicated Patient 1 was admitted on 8/15/2024 with terminal diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities). During an interview on 4/24/2026 at 10:23 AM with the HA’s Registered Nurse 1 (RN 1), RN 1 stated that all documentation of patient visits must be completed in the EMR within 48 hours of the visit. During a concurrent interview and record review on 4/24/2026 at 12:43 PM with the HA’s Director of Patient Care Services Designee (DPCS Designee), Patient 1’s clinical record titled, “RN - Skilled Nursing Visit,” dated 3/12/2026, 3/26/2026, and 4/9/2026 were reviewed. The “RN - Skilled Nursing Visit” indicated DPCS Designee signed and dated the clinical records on the date of each scheduled visit. DPCS Designee stated that she actually completed and signed the clinical records on 4/23/2026, not 3/12/2026, 3/26/2026, or 4/9/2026. DPCS Designee stated that the documentation did not indicate “late entry” and that she did not complete documentation in the EMR within 48 hours of each patient visit. During a concurrent interview and record review on 4/24/2026 at 12:43 PM with the HA’s DPCS Designee, Patient 1’s clinical record titled, “RN Recertification,” dated 4/2/2026 was reviewed. The “RN Recertification” indicated DPCS Designee signed and dated the clinical record on 4/2/2026. DPCS Designee stated that she actually completed and signed the clinical record on 4/23/2026, not 4/2/2026. DPCS Designee stated that the documentation did not indicate “late entry” and that she did not complete documentation in the EMR within 48 hours of each patient visit. During an interview on 4/23/2026 at 12:50 PM with the HA’s DPCS Designee, the DPCS Designee stated that late or missing nursing visit documentation in Patient 1’s clinical record could prevent the care team from understanding the patient’s current needs and ensuring an updated plan of care. DPCS Designee stated that this placed Patient 1 at risk of unmet needs, missed interventions, decreased comfort, increased pain, and a less dignified dying process. During an interview on 4/27/2026 at 10:05 AM with the HA’s DPCS Designee, the DPCS Designee stated that the electronic signature date on visit notes must match the date the note was actually completed. The DPCS Designee stated that if the visit note is completed more than 48 hours after the patient visit, it must be labeled as a “late entry.” During a review of the HA’s policy and procedure (P&P) titled, “Entries into The Clinical Record,” dated 2017, the P&P indicated: -Hospice personnel providing direct patient care and supervisory functions will complete documentation within the electronic medical record on the day care is provided to the patient and no later than 48 hours following the patient visit. -Late entries and amendments will be documented stating, “late entry or amendment for visit of (date and time of visit)” and include the date the entry is made, the date and documentation that was originally omitted or amended, and the signature and title of the staff member making the late entry or amendment. -Amendments, corrections or late entries within the electronic medical record must distinctly identify the amendment, correction, or late entry and provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each record modification. b. During a review of Patient 2’s clinical record titled “Patient Profile,” the “Patient Profile” indicated Patient 2 was admitted on 7/22/2024 with terminal diagnosis of Alzheimer’s disease. During an interview on 4/24/2026 at 10:23 AM with the HA’s Registered Nurse 1 (RN 1), RN 1 stated that all documentation of patient visits must be completed in the EMR within 48 hours of the visit. During a concurrent interview and record review on 4/24/2026 at 12:36 PM with the HA’s DPCS Designee, Patient 2’s clinical record titled, “RN - Skilled Nursing Visit,” dated 3/26/2026 and 4/9/2026 were reviewed. The “RN - Skilled Nursing Visit” indicated DPCS Designee signed and dated the clinical records on the date of each scheduled visit. DPCS Designee stated that she actually completed and signed the clinical records on 4/23/2026, not 3/26/2026 or 4/9/2026. DPCS Designee stated that the documentation did not indicate “late entry” and that she did not complete documentation in the EMR within 48 hours of each patient visit. During a concurrent interview and record review on 4/24/2026 at 12:36 PM with the HA’s DPCS Designee, Patient 2’s clinical record titled, “Aide Supervisory Visit,” dated 4/12/2026 was reviewed. The “Aide Supervisory Visit “ indicated DPCS Designee signed and dated the clinical record on 4/12/2026. DPCS Designee stated that she actually completed and signed the clinical record on 4/23/2026, not 4/12/2026. DPCS Designee stated that the documentation did not indicate “late entry” and that she did not complete documentation in the EMR within 48 hours of each patient visit. During a concurrent interview and record review on 4/24/2026 at 12:36 PM with the HA’s DPCS Designee, Patient 2’s clinical record titled, “LVN Supervisory Visit,” dated 4/12/2026 was reviewed. The “LVN Supervisory Visit “ indicated DPCS Designee signed and dated the clinical record on 4/12/2026. DPCS Designee stated that she actually completed and signed the clinical record on 4/23/2026, not 4/12/2026. DPCS Designee stated that the documentation did not indicate “late entry” and that she did not complete documentation in the EMR within 48 hours of each patient visit. During an interview on 4/23/2026 at 12:50 PM with the HA’s DPCS Designee, the DPCS Designee stated that late or missing nursing visit documentation in Patient 2’s clinical record could prevent the care team from understanding the patient’s current needs and ensuring an updated plan of care. DPCS Designee stated that this placed Patient 2 at risk of unmet needs, missed interventions, decreased comfort, increased pain, and a less dignified dying process. During an interview on 4/27/2026 at 10:05 AM with the HA’s DPCS Designee, the DPCS Designee stated that the electronic signature date on visit notes must match the date the note was actually completed. The DPCS Designee stated that if the visit note is completed more than 48 hours after the patient visit, it must be labeled as a “late entry.” During a review of the HA’s P&P titled, “Entries into The Clinical Record,” dated 2017, the P&P indicated: -Hospice personnel providing direct patient care and supervisory functions will complete documentation within the electronic medical record on the day care is provided to the patient and no later than 48 hours following the patient visit. -Late entries and amendments will be documented stating, “late entry or amendment for visit of (date and time of visit)” and include the date the entry is made, the date and documentation that was originally omitted or amended, and the signature and title of the staff member making the late entry or amendment. -Amendments, corrections or late entries within the electronic medical record must distinctly identify the amendment, correction, or late entry and provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each record modification.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure all entries in the patients’ clinical records are authentic, must identify the original content, the modified content, signed, dated, and authorship for each record for five of eight patients (Patient 1, Patient 2, Patient 4, Patient 5 and Patient 7):a. The HA’s Director of Patient Care Services Designee (DPCS Designee) backdated (the practice of marking a document with a date earlier than its actual creation or execution date) the clinical record for Patient 1, Patient 2 and Patient 5. b. The Plan of Care (POC) for Patient 1, Patient 2, Patient 4, Patient 5 and Patient 7 were not signed and authenticated by identifiable licensed nurse according to HA’s policies and procedures.These failures resulted in the care team not having timely access to accurate clinical information for Patient 1, Patient 2, Patient 4, Patient 5 and Patient 7, placing the patients at risk for delays in care or care that did not fully reflect their current clinical needs. a.3. During a review of Patient 5’s clinical record titled “Patient Profile,” the “Patient Profile” indicated Patient 5 was admitted on 5/15/2025, with diagnoses including Alzheimer’s disease and dementia.During a review on 4/23/2026 of Patient 5’s clinical record titled “View: Nursing Visit”, for the certification period of 3/11/2026 to 5/9/20266. The “View: Nursing Visit” indicated the “Registered Nurse (RN) - Skilled Nursing Visit” note dated 3/19/2026, 4/2/2026 and 4/14/2026 did not contain any information.During a concurrent interview and record review on 4/24/2026 at 12:36 PM with the DPCS Designee, Patient 5’s clinical record titled “RN – Skilled Nursing Visit”, dated 3/19/2026, 4/2/2026 and 4/14/2026 was reviewed. The “RN – Skilled Nursing Visit” indicated the DPCS Designee electronically signed the “RN – Skilled Nursing Visit” on the day the visit were completed. The DPCS Designee stated the Patient 5’s “RN – Skilled Nursing Visit” notes were completed on 4/23/2026. The DPCS Designee stated the “RN – Skilled Nursing Visit” did not indicate the note were a late entry.During an interview on 4/23/2026 at 12:37 PM with the DPCS Designee, the DPCS Designee stated Patient 5’s clinical record that were not completed in a timely manner could result in the healthcare team being unaware of Patient 5’s current needs and may lead to delays in care, unmanaged symptoms, missed interventions, decreased comfort, increased pain, and poor quality of life.During a review of the HA’s P&P titled, “Entries into The Clinical Record,” dated 2017, the P&P indicated:-Hospice personnel providing direct patient care and supervisory functions will provide signature authorization of clinical documentation, including the staff member’s name and credentials.-Late entries and amendments will be documented stating, “late entry or amendment for visit of (date and time of visit)” and include the date the entry is made, the date and documentation that was originally omitted or amended, and the signature and title of the staff member making the late entry or amendment.-Amendments, corrections or late entries within the electronic medical record must distinctly identify the amendment, correction, or late entry and provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each record modification. b.3. During a review of Patient 4’s clinical record titled “Patient Profile,” the “Patient Profile” indicated Patient 4 was admitted on 3/20/2025, with diagnoses that included respiratory failure (a condition where the lungs cannot get enough oxygen into the blood) and dementia (a progressive state of decline in mental abilities).During a concurrent interview and record review on 4/24/2026 at 11:26 AM with RN 1, Patient 4’s clinical record titled “Plan of Care”, dated 3/18/2026, the POC was electronically signed and dated by “Premier Admin”. RN 1 stated clinical notes should be signed and dated by a licensed nurse and “Premier Admin” did not identify the responsible nurse who initiated Patient 4’s POC. RN 1 stated the person who initiated Patient 4’s POC should be identifiable to ensure the patient’s condition and needs have clinical oversight and that appropriate interventions are being provided.During an interview on 4/27/2026 at 10:05 AM with the DPCS Designee, the DPCS Designee stated she is not aware who completed Patient 4’s POC. b.4. During a review of Patient 5’s clinical record titled “Patient Profile,” the “Patient Profile” indicated Patient 5 was admitted on 5/15/2025, with diagnoses including Alzheimer’s and dementia.During a concurrent interview and record review on 4/24/2026 at 11:27 AM with RN 1, Patient 4’s clinical record titled “Plan of Care”, dated 3/18/2026 and 4/15/2026, the POC was electronically signed and dated by “Premier Admin”. RN 1 stated clinical notes should be signed and dated by a licensed nurse and “Premier Admin” did not identify the responsible nurse who initiated Patient 5’s POC. RN 1 stated the person who initiated Patient 5’s POC should be identifiable to ensure the patient’s condition and needs have clinical oversight and that appropriate interventions are being provided.During an interview on 4/27/2026 at 10:05 am with the DPCS Designee, the DPCS Designee stated she is not aware who completed Patient 5’s POC. b.5. During a review of Patient 7’s clinical record titled “Patient Profile,” the “Patient Profile” indicated Patient 7 was admitted on 3/5/2026 with diagnosis of Alzheimer’s disease.During a concurrent interview and record review on 4/24/2026 at 11:27 AM with RN 1, Patient 7’s clinical record titled “Plan of Care”, dated 3/18/2026, the POC was electronically signed and dated by “Premier Admin”. RN 1 stated clinical notes should be signed and dated by a licensed nurse and “Premier Admin” did not identify the responsible nurse who initiated Patient 5’s POC. RN 1 stated the person who initiated Patient 7’s POC should be identifiable to ensure the patient’s condition and needs have clinical oversight and that appropriate interventions are being provided.During an interview on 4/27/2026 at 10:05 AM with the DPCS Designee, the DPCS Designee stated she is not aware who completed Patient 7’s POC.During a review of HA’s P&P titled, “Entries into The Clinical Record”, dated November 2017, the P&P indicated Signatures authorization of clinical documentation will include the staff member’s name and credentials, as specified on professional licenses and certification documents.During a review of HA’s P&P titled, “Plan of Care”, dated November 2021, the P&P indicated:-The Case Manager or admitting registered nurse will initiate the development of plan of care.- The plan of care will be reviewed and revised as frequently as deemed necessary by the interdisciplinary group. a.1. During a review of Patient 1’s clinical record “Patient Profile,” (admission record, summary of patient’s basic information) undated, the “Patient Profile” indicated Patient 1 was admitted on 8/15/2024 with terminal diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities). During a review of Patient 1’s electronic medical record (EMR) “Nursing,” (section of the EMR containing nursing visit notes) the “Nursing” section indicated that documentation of “RN - Skilled Nursing Visit,” dated 3/12/2026, 3/26/2026, and 4/9/2026, had a status of “not started”. During a review of Patient 1’s EMR “Nursing,” the “Nursing” section indicated that documentation of “RN Recertification,” dated 4/2/2026, had a status of “not started”. During a concurrent interview and record review on 4/24/2026 at 12:43 PM with the HA’s Director of Patient Care Services Designee (DPCS Designee), Patient 1’s clinical record titled, “RN - Skilled Nursing Visit,” dated 3/12/2026, 3/26/2026, and 4/9/2026 were reviewed. The “RN - Skilled Nursing Visit” indicated DPCS Designee signed and dated the clinical records on the date of each scheduled visit. DPCS Designee stated that she actually completed and signed the clinical records on 4/23/2026, not 3/12/2026, 3/26/2026, or 4/9/2026. During a concurrent interview and record review on 4/24/2026 at 12:43 PM with the HA’s DPCS Designee, Patient 1’s clinical record titled, “RN Recertification,” dated 4/2/2026 was reviewed. The “RN Recertification” indicated DPCS Designee signed and dated the clinical record on 4/2/2026. DPCS Designee stated that she actually completed and signed the clinical record on 4/23/2026, not 4/2/2026. During an interview on 4/23/2026 at 12:50 PM with the HA’s DPCS Designee, the DPCS Designee stated the signature dates listed on Patient 1’s clinical record reflected previous dates and not the date she signed each record. DPCS Designee stated that Patient 1’s physician would not have access to current clinical documentation preventing implementation of new treatment orders. DPCS Designee stated that this placed Patient 1 at risk of unmet needs, missed interventions, decreased comfort, increased pain, and a less dignified dying process. During an interview on 4/27/2026 at 12:17 PM with the HA’s DPCS Designee, the DPCS Designee stated that the electronic charting system (an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff) automatically assigns the visit date as the signature date during authentication, so the author must manually update the signature date if it differs from the visit date. During a review of the HA’s policy and procedure (P&P) titled, “Entries into The Clinical Record,” dated 2017, the P&P indicated: -Hospice personnel providing direct patient care and supervisory functions will provide signature authorization of clinical documentation, including the staff member’s name and credentials. -Late entries and amendments will be documented stating, “late entry or amendment for visit of (date and time of visit)” and include the date the entry is made, the date and documentation that was originally omitted or amended, and the signature and title of the staff member making the late entry or amendment. -Amendments, corrections or late entries within the electronic medical record must distinctly identify the amendment, correction, or late entry and provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each record modification. a.2. During a review of Patient 2’s clinical record titled “Patient Profile,” the “Patient Profile” indicated Patient 2 was admitted on 7/22/2024 with terminal diagnosis of Alzheimer’s disease. During a review of Patient 2’s EMR “Nursing,” the “Nursing” section indicated that documentation of “RN - Skilled Nursing Visit,” dated 3/26/2026 and 4/9/2026, had a status of “not started”. During a review of Patient 2’s EMR “Nursing,” the “Nursing” section indicated that documentation of “LVN Supervisory Visit,” dated 4/12/2026, had a status of “not started”. During a review of Patient 2’s EMR “Aide,” (section of the EMR containing aide visit notes) the “Aide” section indicated that documentation of “Aide Supervisory Visit,” dated 4/12/2026, had a status of “not started”. During a concurrent interview and record review on 4/24/2026 at 12:36 PM with the HA’s DPCS Designee, Patient 2’s clinical record titled, “RN - Skilled Nursing Visit,” dated 3/26/2026 and 4/9/2026 were reviewed. The “RN - Skilled Nursing Visit” indicated DPCS Designee signed and dated the clinical records on the date of each scheduled visit. DPCS Designee stated that she actually completed and signed the clinical records on 4/23/2026, not 3/26/2026, or 4/9/2026. During a concurrent interview and record review on 4/24/2026 at 12:36 PM with the HA’s DPCS Designee, Patient 2’s clinical record titled, “LVN Supervisory Visit,” dated 4/12/2026 was reviewed. The “LVN Supervisory Visit “ indicated DPCS Designee signed and dated the clinical record on 4/12/2026. DPCS Designee stated that she actually completed and signed the clinical record on 4/23/2026, not 4/12/2026. During a concurrent interview and record review on 4/24/2026 at 12:36 PM with the HA’s DPCS Designee, Patient 2’s clinical record titled, “Aide Supervisory Visit,” dated 4/12/2026 was reviewed. The “LVN Supervisory Visit “ indicated DPCS Designee signed and dated the clinical record on 4/12/2026. DPCS Designee stated that she actually completed and signed the clinical record on 4/23/2026, not 4/12/2026. During an interview on 4/23/2026 at 12:50 PM with the HA’s DPCS Designee, the DPCS Designee stated the signature dates listed on Patient 2’s clinical record reflected previous dates and not the date she signed each record. DPCS Designee stated that Patient 2’s physician would not have access to current clinical documentation preventing implementation of new treatment orders. DPCS Designee stated that this placed Patient 2 at risk of unmet needs, missed interventions, decreased comfort, increased pain, and a less dignified dying process. During an interview on 4/27/2026 at 12:17 PM with the HA’s DPCS Designee, the DPCS Designee stated that the electronic charting system automatically assigns the visit date as the signature date during authentication, so the author must manually update the signature date if it differs from the visit date. During a review of the HA’s P&P titled, “Entries into The Clinical Record,” dated 2017, the P&P indicated: -Hospice personnel providing direct patient care and supervisory functions will provide signature authorization of clinical documentation, including the staff member’s name and credentials. -Late entries and amendments will be documented stating, “late entry or amendment for visit of (date and time of visit)” and include the date the entry is made, the date and documentation that was originally omitted or amended, and the signature and title of the staff member making the late entry or amendment. -Amendments, corrections or late entries within the electronic medical record must distinctly identify the amendment, correction, or late entry and provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each record modification. b.1. During a review of Patient 1’s clinical record titled “Patient Profile,” (admission record, summary of patient’s basic information) undated, the “Patient Profile” indicated Patient 1 was admitted on 8/15/2024 with terminal diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities). During a concurrent interview and record review on 4/24/2026 at 11:27 AM with the HA’s Registered Nurse 1 (RN 1), Patient 1’s clinical record titled “Plan of Care (POC),” dated 4/15/2026 was reviewed. The “POC” indicated an electronic signature by “Premier Admin, RN” on 4/15/2026. RN 1 stated that the POC must be signed by a licensed nurse, and the nurse’s name must be listed to identify who initiated and validated the POC. RN 1 stated that using the username “Premier Admin, RN” does not show who actually signed the POC. RN 1 stated proper authentication with a signature and names ensured clinical oversight and appropriate patient care interventions. During a concurrent interview and record review on 4/24/2026 at 12:20 PM with the HA’s Director of Patient Care Services Designee (DPCS Designee) Patient 1’s clinical record titled “Plan of Care (POC),” dated 4/15/2026 was reviewed. The “POC” indicated an electronic signature by “Premier Admin, RN” on 4/15/2026. DPCS Designee stated that she does not know which staff member used the username “Premier Admin, RN” and that including the staff member’s name was necessary to identify who authenticated the POC and to confirm that the individual is a licensed registered nurse. During a review of the HA’s policy and procedure (P&P) titled, “Entries into The Clinical Record,” dated 2017, the P&P indicated signature authorization of clinical documentation will include the staff member’s name and credentials as specified on professional licenses and/or certification documents. During a review of the HA’s P&P titled, “The Plan of Care,” dated November 2021, the P&P indicated: -The Case Manager or admitting Registered Nurse will complete the initial assessment and will initiate the development of the plan of care. -The Case Manager or admitting Registered Nurse will notify the attending physician of the initial assessment findings and recommend services for those needs. Orders for the start of care will be verbally received by the Case Manager or admitting Registered Nurse from the attending physician and documented on the plan of care. -The plan of care will identify the patient’s needs and services to meet those needs. Care provided to the patient will be in accordance with the plan of care. -The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days. During a review of the HA’s Registered Nurse Job Description, dated November 2017, essential Registered Nurse job functions and responsibilities include: -Completion of initial, comprehensive and ongoing assessments of patients and family members to determine hospice needs. -Development of a plan of care that establishes goals, based on nursing diagnosis and incorporated palliative nursing actions. -Assessment and evaluation of patient’s status by participating in revising the plan of care. b.2. During a review of Patient 2’s clinical record titled “Patient Profile,” the “Patient Profile” indicated Patient 2 was admitted on 7/22/2024 with terminal diagnosis of Alzheimer’s disease. During a concurrent interview and record review on 4/24/2026 at 11:27 AM with the HA’s RN 1, Patient 2’s clinical record titled “Plan of Care (POC),” dated 3/18/2026 was reviewed. The “POC” indicated an electronic signature by “Premier Admin” on 3/18/2026. RN 1 stated that the POC must be signed by a licensed nurse, and the nurse’s name must be listed to identify who initiated and validated the POC. RN 1 stated that using the username “Premier Admin” does not show who actually signed the POC. RN 1 stated proper authentication with a signature and names ensured clinical oversight and appropriate patient care interventions. During a concurrent interview and record review on 4/24/2026 at 12:20 PM with the HA’s Director of Patient Care Services Designee (DPCS Designee) Patient 2’s clinical record titled “Plan of Care (POC),” dated 3/18/2026 was reviewed. The “POC” indicated an electronic signature by “Premier Admin” on 3/18/2026. DPCS Designee stated that she does not know which staff member used the username “Premier Admin” and that including the staff member’s name was necessary to identify who authenticated the POC and to confirm that the individual is a licensed registered nurse. During a review of the HA’s P&P titled, “Entries into The Clinical Record,” dated 2017, the P&P indicated signature authorization of clinical documentation will include the staff member’s name and credentials as specified on professional licenses and/or certification documents. During a review of the HA’s P&P titled, “The Plan of Care,” dated November 2021, the P&P indicated: -The Case Manager or admitting Registered Nurse will complete the initial assessment and will initiate the development of the plan of care. -The Case Manager or admitting Registered Nurse will notify the attending physician of the initial assessment findings and recommend services for those needs. Orders for the start of care will be verbally received by the Case Manager or admitting Registered Nurse from the attending physician and documented on the plan of care. -The plan of care will identify the patient’s needs and services to meet those needs. Care provided to the patient will be in accordance with the plan of care. -The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days. During a review of the HA’s Registered Nurse Job Description, dated November 2017, essential Registered Nurse job functions and responsibilities include: -Completion of initial, comprehensive and ongoing assessments of patients and family members to determine hospice needs. -Development of a plan of care that establishes goals, based on nursing diagnosis and incorporated palliative nursing actions. -Assessment and evaluation of patient’s status by participating in revising the plan of care.”

“Based on an interview and record review, the Hospice Agency (HA, a team of healthcare professionals that provides specialized, comfort-focused care for people with terminal illnesses who have roughly six months or less to live), failed to ensure the Condition of Participation (CoP, refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Organization and Administration of Services was met as follows: The HA failed to ensure a governing body (a group of individuals who have responsibility for the overall management and operations, including oversight of the patient care) assumed full responsibility for the management of the day-to-day operations for hospice services when the HA did not hire or have on staff a Director of Patient Care Services (DPCS, a person responsible for the overall direction of hospice clinical services) and/or a DPCS Designee (DPCS-D) to manage the care and services for eleven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 10, Patient 11, Patient 12, and Patient 13) who were receiving hospice services. This deficient practice resulted in the HA not conducting regular Interdisciplinary Group (a group of different health care professionals who work closely together to provide coordinate care for the patient) meetings for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 10, Patient 11, Patient 12, and Patient 13 as per the agency’s protocol increasing the risk for unmanaged symptoms without regular coordinated review of patients plan of care. The deficiency further resulted in the agency not conducting Quality Assurance and Performance Improvement (QAPI-- data driven system used to continuously improve care quality and patient safety) meetings increasing the risk of undetected adverse events, declining quality of care, and poor care coordination (Refer to L651). The cumulative effect of these systemic practices resulted in the failure of the Hospice Agency to deliver statutorily (written law) mandated compliance with Federal regulation for Organization and Administration of Services to ensure the highest quality of care are being provided to patients certified to receive hospice benefits.”

“Based on interview, and record review, the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live), failed to ensure the Condition of Participation (COP - conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people 65 years of age or more and for certain younger people with disabilities]) for Medical Director was met as evidenced by: 1.The HA failed to ensure the medical director and/or physician designee (who is a hospice employee or under contract with the hospice) reviewed patients clinical information to determine hospice (health care that focuses on the palliation of a terminally ill patient’s pain and symptoms and attending to their emotional and spiritual needs at the end of life) care criteria is met and/or provide an initial written certification that the patient had six months or less to live if the illness runs its normal course for four of fourteen sampled patients (Patient 2, Patient 3, Patient 4 and Patient 13) (Refer to L667). 2. The HA failed to ensure the medical director and/or physician designee conducted a review and verified the patient’s clinical information to determine the patient’s need of recertification of terminal illness for continued hospice care and services for nine of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 11, and Patient 12) (Refer to L 668). The cumulative effect of these systemic practices resulted in the failure of the Hospice Agency to deliver statutorily (written law) mandated compliance with Federal regulation for Medical Director to ensure the highest quality of care are being provided to patients certified to receive hospice benefits.”

“Based on observation, interview and record review, the hospice agency (HA, a team of healthcare professionals that provides specialized, comfort-focused care for people with terminal illnesses who have roughly six months or less to live ) failed to ensure the Condition of Participation (CoP, refers to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Patient’s Rights was met as follows: 1. The HA failed to ensure a completed copy of written information regarding advance directive (a legal document that outlines a person’s wishes in the event an individual is unable to communicate decisions regarding healthcare and treatment) policies and descriptions was provided for two of fourteen sampled patients (Patient 5 and Patient 6). This failure had the potential to result in the patient’s family and/or caregivers being unaware of the patient’s healthcare preferences, which may lead to confusion regarding medical decision-making and can result in psychological distress to the patient and or patient’s family or caregivers. (Refer to L503). 2. The HA failed to ensure access to the clinical record for one of 14 sampled patients (Patient 2) when the HA binder (a centralized, accessible resource for caregivers, ensuring 24/7 access to a patient’s plan of care, medication instructions, legal documents, and emergency contact information) was not available and accessible for review in the patient’s home. This failure had the potential for Patient 2 to experience delays in care delivery, medication administration errors, and care inconsistent with the established plan of care, potentially resulting in patient distress, agitation, uncontrolled symptoms, emergency hospitalization, and an undignified and avoidable traumatic death. (Refer to L516).The cumulative effect of these systemic deficient practices resulted in the hospice agency’s failure to maintain compliance with statutorily mandated Patient Rights requirements, thereby failing to ensure the provision of quality care and services to patient.”

“Based on observation, interview and record review, the hospice agency (HA, a team of healthcare professionals that provides specialized, comfort-focused care for people with terminal illnesses who have roughly six months or less to live ) failed to ensure the Condition of Participation (CoP, refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Initial and Comprehensive Assessment of the Patient was met as follows: The Home Health Agency (HA) failed to ensure that an initial assessment was conducted for one of fourteen sampled patients (Patient 13), as the electronic medical record (EMR, a digital version of a patient’s clinical record) did not contain documented evidence that the assessment was completed. This deficient practice had the potential to result in unidentified immediate care needs, risks, and required interventions for Patient 13, potentially resulting in inappropriate care planning, compromised patient safety, and unmet patient needs. (Refer to L522). 2. The HA failed to ensure that the drug profile list (a comprehensive record of a patient’s entire medication regimen used by healthcare professionals to manage care and prevent errors) was reviewed for three of fourteen sampled patients (Patient 1, Patient 2, and Patient 6). This deficient practice had the potential to result in medication administration errors and lack of appropriate medication profile review and care planning, potentially resulting in unsafe medication administration, delayed or inappropriate symptom management, emergency hospitalization, and an undignified and avoidable traumatic death. (Refer to L530). 3. The HA failed to ensure an initial bereavement assessment was conducted for one of fourteen sampled patients (Patient 4) when the EMR did not contain documented evidence that the assessment was conducted. This failure had the potential to result in unrecognized bereavement risk factors and unmet emotional support needs for Patient 4’s family/caregivers, potentially resulting in inappropriate bereavement interventions inconsistent with the plan of care. (Refer to L531). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with Initial and Comprehensive Assessment of the Patient to ensure provision of quality care and services to patients.”

“Based on observation, interview and record review, the hospice agency (HA, a team of healthcare professionals that provides specialized, comfort-focused care for people with terminal illnesses who have roughly six months or less to live ) failed to ensure the Condition of Participation (CoP, refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Interdisciplinary Group (IDG, team members consists of a medical director, nurses, social worker and spiritual chaplain, working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), Care Planning, and Coordination of Services was met as follows: 1). The HA failed to ensure that education and training were provided to the patient/patient’s caregiver related to safety precautions during a seizure (a brief episode of abnormal electrical activity in the brain that can cause changes in behavior, movement, sensation, or consciousness) episode for one of fourteen sampled patients (Patient 6). These failures resulted in the HA’s inability to ensure the patient’s/patient caregiver’s understanding of possible risks, safety precautions, and side effects of medications. (Refer to L544). 2). The HA failed to ensure that a care plan for one of fourteen sampled patients (Patient 6) was formulated to address safety precautions during a seizure episode while on anti-seizure medication. This failure had the potential to result in a lack or delay in delivery of necessary care and services for patients. (Refer to L545). 3). The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss a patients plan of care to be able to provide the best individualized care and support to patients and families) reviewed and revised, in a timely manner, the plan of care (POC- an individualized care planned) for six of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). This failure had potential for patients not to be properly evaluated which could result in them not being provided an individualized focused care. (Refer to L552). 4). The HA failed to ensure that the POC was revised for one of 14 sampled patients (Patient 1) when the POC did not include assessment, monitoring, treatment interventions, and patient specific goals for a stage 4 pressure injury (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). This failure had the potential to result in Patient 1 experiencing worsening tissue damage, delayed healing, increased risk of infection, and unmanaged pain, potentially resulting in distress, agitation, uncontrolled symptoms, emergency hospitalization, and an undignified and avoidable traumatic death. (Refer to L553) 5). The HA failed to implement its own policy and procedure titled “The Plan of Care” by failing to provide home visits to two of 14 sampled patients (Patient 12 and Patient 13) according to the patient’s plan of care. This failure had the potential for medication errors, delayed detection of patient health changes, and unmanaged pain or chronic condition symptoms that could lead to episodes requiring emergency care. (Refer to L555).”

“Based on interviews and record review, the hospice agency (HA, a team of healthcare professionals that provides specialized, comfort-focused care for people with terminal illnesses who have roughly six months or less to live ) failed to ensure the Condition of Participation (CoP, refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Quality assessment and performance improvement (QAPI, is a systematic, data-driven approach to maintaining and enhancing the quality of care and services) was met as follows: The HA failed to develop, implement, and maintain an effective, ongoing, hospice-wide, data-driven Quality Assessment and Performance Improvement (QAPI) program. This deficient practice resulted in the HA’s inability to demonstrate compliance with federal regulations requiring documentary evidence of its quality and performance improvement initiatives. (Refer to L571). The cumulative effect of this systemic practice resulted in the failure of the hospice agency to deliver statutorily mandated compliance with Federal regulation for Quality assessment and performance improvement to ensure the highest quality of care is being provided to patients certified to receive the Medicare hospice benefits.”

“Based on observation, interview and record review, the hospice agency (HA, a team of healthcare professionals that provides specialized, comfort-focused care for people with terminal illnesses who have roughly six months or less to live ) failed to ensure the Condition of Participation (CoP, refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Core Services was met as follows: The HA failed to provide spiritual counseling services to eleven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 10, Patient 11, Patient 12, and Patient 13) and the Patients’ families/caregivers. This failure had the potential to result in Patients and families/caregivers experiencing unmet psychosocial and spiritual needs, potentially resulting in emotional distress and impaired end-of-life adjustment. (Refer to L598). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with Core Services to ensure provision of quality care and services to patients.”

“Based on observation, interviews, and record review, the Hospice Agency (HA, a team of healthcare professionals that provides specialized, comfort-focused care for people with terminal illnesses who have roughly six months or less to live) failed to ensure a completed copy of written information regarding advance directive (a legal document that outlines person’s wishes in the event an individual is unable to express wishes for healthcare and treatment) policies and descriptions were provided for two of fourteen sampled patients (Patient 5 and Patient 6). This failure had the potential to result in the patient’s family and/or caregivers being unaware of the patient’s healthcare preferences, which may result in psychological distress for the patient/patient’s family/caregiver. During a review of Patient 5’s clinical record titled “Patient Profile,” the patient profile indicated Patient 5 was admitted to the HA on 5/15/2025 with a terminal diagnosis of Alzheimer’s disease (a progressive brain disorder that slowly destroys memory and thinking skills), unspecified. During a home visit observation on 1/22/2026, at 10:47 a.m., at Patient 5’s residence, in an Assisted Living (AL, a residential housing for people who need help with daily tasks but do not require the intensive 24 hours/7 days medical care found in a nursing home) setting, with Licensed Vocational Nurse (LVN 2), Patient 5 was observed resting comfortably on her wheelchair. Patient 5 is confused at times, awake and oriented to her name only, follows simple commands, and unable to hold a simple conversation. During an interview on 1/22/2026, at 11:17 a.m., with Patient 5’s daughter (Family Member/FM2), FM2 stated that she is her mother’s (Patient 5) power of attorney (POA, is a legal document that gives one person the authority to make decisions and take actions on behalf of another person). FM2 stated that the HA prepared a pink form that is called POLST (Physician Orders for Life-Sustaining Treatment, is a signed medical order that directs the healthcare providers of detailed treatments a seriously ill or frail person wants during a medical emergency) and she signed it for her mother (Patient 5) sometime around May of 2025. FM2 stated that she does not have a copy of Patient 5’s POLST and it should be in Patient 5’ s HA’s folder. During a concurrent review and interview on 1/22/2026, at 11:55 a.m., of Patient 5’s HA folder with LVN 2, The folder had the name of the agency, inside of the folder was a copy of Patient 5’s plan of care, active medication list signed notice of patient’s rights, but did not indicate a copy of a POLST. During interview with LVN 2, stated she was unaware that Patient 5’s POLST was not in the HA’s folder. LVN 2 stated that Patient 5’s copy of POLST should always be in her HA’S folder and is readily available for reference to determine Patient 5’s code status and what to do if Patient 5’s heartbeat stops. During a review of Patient 6’s clinical record titled “Patient Profile,” the patient profile indicated Patient 6 was admitted to the HA on 3/20/2025 with a terminal diagnosis of acute respiratory failure with hypoxia (a life-threatening condition where the lungs suddenly become unable to get enough oxygen into the bloodstream to meet the body’s need). During a home visit observation on 1/22/2026, at 11:30 a.m., to Patient 6’s residence, in an AL setting, with LVN 2, Patient 6 was observed resting comfortably on her hospital bed. Patient 6 is confused at all times, awake and oriented to her name only, speaks randomly but incoherent, unable to follow simple commands, and unable to hold a simple conversation. During a concurrent review and interview on 1/22/2026, at 12:02 p.m., of Patient 6’s HA folder with LVN 2, The folder had the name of the agency, inside of the folder was a copy of Patient 6’s plan of care, active medication list signed notice of patient’s rights, but did not indicate a copy of a POLST. During interview with LVN 2, stated she was unaware that Patient 6’s POLST was not in the HA’s folder. LVN 2 stated that Patient 6’s copy of POLST should always be in her HA’S folder and is readily available for reference to determine Patient 6’s code status and what to do if Patient 6’s heartbeat stops. During a review of the HA’s policy and procedure (P&P) entitled, “POLST Policy”, dated September 2020, the P&P indicated that the hospice will ensure the POLST is accessible to staff and emergency responders.”

“Based on observation, interview and record review, the Hospice Agency (HA, a team of healthcare professionals that provides specialized, comfort-focused care for people with terminal illnesses who have roughly six months or less to live) failed to ensure access to the clinical record for one of 14 sampled patients (Patient 2) when the HA binder (a centralized, accessible resource for caregivers, ensuring 24/7 access to a patient’s plan of care, medication instructions, legal documents, and emergency contact information) was not available and accessible for review in the patient’s home. This failure had the potential for Patient 2 to experience delays in care delivery, medication administration errors, and care inconsistent with the established plan of care, potentially resulting in distress, agitation, uncontrolled symptoms, emergency hospitalization, and an undignified and avoidable traumatic death. Findings: During a review of Patient 2’s undated clinical record titled “Patient Profile,” (page of the medical chart containing a summary of basic patient information), the “Patient Profile” indicated the HA admitted Patient 2, a 78-year-old male, on 2/25/2025, with a terminal diagnosis of Neurocognitive disorder with Lewy bodies (progressive brain disease causing a decline in thinking, memory, and focus). During Patient 2’s home visit with Licensed Vocational Nurse (LVN) 1 on 1/21/2026 at 10:27 a.m., the HA binder was not made available for review. Patient 2’s Family Member (FM) 1 indicated that the HA binder was misplaced during the 2025 holiday season (the festive period from late November through early January) and that she had been unable to access the HA binder since then. During an interview conducted on 10/21/2026 at 10:55 a.m. with Licensed Vocational Nurse (LVN) 1 stated that she did not access or update the Home Health Agency (HA) binder at each home visit. LVN 1 further stated that documentation regarding her visit dates and visit notes was maintained in the electronic medical record, which was not accessible to the patient or the patient’s family/caregiver. During an interview conducted on 1/26/2026 at 12:15 p.m. with Registered Nurse Case Manager (RNCM) 2, RNCM 2 stated that the HA binder is required to be reviewed and updated by the Registered Nurse (RN), LVN, and Certified Home Health Aide (CHHA) at every visit. RNCM 2 further stated that if the binder was missing and could not be accessed by the patient’s caregiver or HA staff, the HA was responsible for replacing the binder at the next scheduled visit. RNCM 2 explained that access to the HA binder was essential for caregivers to reference the visitation schedule, review assessment notes, track vital signs, and ensure accurate medication administration. RNCM 2 stated that, as a result of the binder not being available, Patient 2 was at risk for medication administration errors, and Family Member (FM) 1 did not have access to Patient 2’s plan of care or other important educational materials maintained in the HA binder. During a review of the HA’s policy and procedure (P&P) titled, “Rights/Responsibilities,” dated November 2021, the P&P indicated the patient will be informed during the initial visit, in advance of furnishing care, of:The hours of care and services and how to obtain care or services after hours.The right to be informed of his/her condition, to participate in all aspects of care including development of their plan of care, and the right to refuse all or part of his/her care to the extent permitted by law.The right to pain management and symptom control.The P&P indicated the family/caregiver are responsible for:Following the organization’s policies and procedures concerning patient care.Understanding and accepting the consequences for outcomes if the care, services, and /or treatment plan are not followed. During a review of the HA’s P&P titled, “The Plan of Care,” dated November 2021, the P&P indicated:A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements for the physician-directed medical orders and the care planning process.As needed, the patient and family/caregiver will receive written instructions regarding treatments or aspects of care that will be the responsibility of the patient and family/caregiver to provide follow through with. During a review of the HA’s P&P titled, “Medication Management,” dated November 2021, the P&P indicated the following:During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. Including using the medication profile to evaluate the use of drugs in the home setting, teach drug purposes, dosages, routes, times, side effects and contraindications, and as a communication tool for other clinicians involved in care.Each patient and/or family/caregiver will receive appropriate written teaching materials for specific medications he/she is receiving.”

“Based on interview and record review, the hospice agency failed to implement its policy and procedure titled “Initial Assessment” by not conducting an initial assessment for one of 14 sampled patients (Patient 13) within 48 hours after the election of hospice care.This failure had the potential to cause adverse consequences, including unmanaged symptoms such as pain, shortness of breath, anxiety, and exposure to medication safety risks that could lead to episodes of emergency care. Findings:During a review of Patient 13’s clinical record titled “Patient Profile,” the record indicated the HA admitted Patient 13 on 2/5/2025, with a terminal diagnosis of Alzheimer’s disease, unspecified (a diagnosis for dementia that is progressive and neurodegenerative but lacks specific details on its subtype, stage, or severity).During a review o Patient 13’s electronical medical record (EMR), (a digital version of patient’s chart used by healthcare providers to document, store, and manage clinical information, including nursing notes, medications, and allergies, it was determined that under he nursing visit documentation section, there was no evidence that a registered nurse completed an initial comprehensive assessment for the benefit periods spanning from 2/5/2025 through 1/20/2026During a telephone interview with Registered Nurse (RN 3) on 1/29/2026 at 12:05 PM, RN 3 confirmed that Patient 13 was under her care. RN 3 stated that she completed an initial comprehensive assessment for Patient 13 on 2/5/2025 on paper but did not upload the assessment to the EMR or electronically sign it on that date because she did not have a code and was unfamiliar with the process. Furthermore, RN 3 acknowledged that she did not provide the agency with copies of the assessments completed during patient visits.RN 3 emphasized the importance of electronically signing patient assessments in the EMR, explaining that an electronic signature serves as a formal attestation that the assessment was completed by the responsible nurse. It also confirms the identity of the person completing the assessment, reducing the risk of falsified or incomplete records. RN 3 stated that signed assessments ensure that clinical decisions are based on verified and accurate information.During a review of the facility’s undated policy and procedure titled “Initial Assessment,” revised in November 2021, it was noted that the policy requires a registered nurse to conduct an initial assessment within 48 hours after the election of hospice care, unless otherwise specified by the physician, patient, or representative to be completed in less than 48 hours.””

“Based on observation, interview, and record review, the Hospice Agency (HA), (a team of healthcare professionals that provides specialized, comfort-focused care for individuals with terminal illnesses who have a life expectancy of approximately six months or less), failed to ensure that the drug profile list (a comprehensive record of a patient’s entire medication regimen used by healthcare professionals to manage care, ensure accuracy, and prevent medication errors) was reviewed and maintained accurately for three of fourteen sampled patients (Patient 1, Patient 2, and Patient 6).This deficient practice resulted in drug profile lists that were inaccurate, incomplete, or not reflective of current physician orders and medications available in the home, as evidenced by the following:The HA failed to ensure that Patient 1’s drug profile list was free from discontinued medications:The following medications remained listed on the drug profile despite limited-duration orders and no evidence of current use:Amoxicillin–potassium clavulanate oral tablet 875/125 milligrams (mg), take one tablet twice daily for infection, quantity dispensed 20 tablets, with a start date of 11/01/2025.Zithromax (azithromycin) Z-Pak oral tablet 250 mg, take 500 mg by mouth daily for five days, with a start date of 06/25/2025.Metronidazole oral tablet 500 mg, take 500 mg three times daily for ten days, with a start date of 06/25/2025. The continued inclusion of discontinued or completed antibiotic therapies created an inaccurate medication profile. The HA failed to ensure that Patient 2’s drug profile list was consistent with physician orders and medications available in the home.A medication bottle for Sinemet controlled release (CR) 25-100 mg, take one tablet three times daily, was present in the home, while the drug profile listed Sinemet 25-100 mg extended release (ER), take one tablet at night.Patient 2 was taking amlodipine besylate 10 mg, half tablet (5 mg) by mouth as needed for systolic blood pressure greater than 190, instead of the drug profile order for amlodipine besylate 10 mg, take one tablet by mouth daily every morning.Linzess oral capsule 290 micrograms (mcg), take one capsule daily as needed for constipation, had an expiration date of January 2025.Docusate sodium oral tablet 100 mg, take one tablet twice daily for constipation, was listed on the drug profile but was not available in the home.Trospium chloride 20 mg tablet, take one tablet twice daily, was present in the home but not included in the drug profile list.A men’s once-daily multivitamin was present in the home but not included in the drug profile list.These findings demonstrated that the medication profile was not accurately reconciled with physician orders or medications available for administration. The HA failed to ensure that medications listed on the drug profile were available for administration for Patient 6.Morphine sulfate tablet 15 mg, 0.5 tablet every two hours as needed for shortness of breath and/or pain, was listed on the drug profile; however, the medication was not available in the patient’s home at the time of review.These failures had the potential to result in medication administration errors, inaccurate medication reconciliation, and lack of appropriate interdisciplinary review and care planning. This placed patients at risk for unsafe medication administration, delayed or inappropriate symptom management, unmanaged pain or respiratory distress, emergency hospitalization, and an undignified and avoidable traumatic death. 1). During a review of Patient 1’s clinical record titled “Patient Profile” (a page of the medical record containing a summary of basic patient information), the record indicated that the hospice agency (HA) admitted Patient 1, a 96-year-old female, on 1/28/2025, with a terminal diagnosis of Alzheimer’s disease (a progressive brain disorder that slowly destroys memory and thinking skills), unspecified. During a review of Patient 1’s clinical record titled “Medication Profile” (a comprehensive record of a patient’s entire medication regimen used by healthcare professionals to manage care and prevent errors), the medication profile included the following medications:Amoxicillin–potassium clavulanate oral tablet 875/125 mg, take one tablet twice daily for infection, quantity dispensed 20 tablets, start date 11/1/2025, with a therapy completion date of 11/10/2025.Zithromax (azithromycin) Z-Pak oral tablet 250 mg, take 500 mg by mouth daily for five days, start date 6/25/2025, with a therapy completion date of 6/29/2025.Metronidazole oral tablet 500 mg, take 500 mg three times daily for ten days, start date 6/25/2025, with a therapy completion date of 7/4/2025.These medications remained listed on the medication profile despite completion of therapy and no evidence that the medications were current orders. During a review of Patient 1’s clinical record titled “Plan of Care Order,” dated 1/13/2026, patient goals included:Minimize negative effects of medication/treatment not related to the hospice diagnosis.Demonstrate understanding of safe medication use.Manage medication issues with patient and family/caregiver verbalizing satisfaction with measures taken to address medication safety concerns. During a concurrent interview and record review on 1/29/2026 at 12:12 p.m. with Licensed Vocational Nurse (LVN) 1, Patient 1’s undated medication profile was reviewed and confirmed to include the above completed antibiotic therapies.The continued inclusion of completed and discontinued medications resulted in an inaccurate medication profile that did not reflect the patient’s current medication regimen. Patient 2 b). During a review of Patient 2’s clinical record titled “IDG Meeting” (a meeting conducted with the interdisciplinary group to review, revise, and document the individualized plan of care at least every 15 calendar days), dated 1/7/2026, patient goals included:Minimize negative effects of medication/treatment not related to the hospice diagnosis.Demonstrate understanding of safe storage and use of medication.Manage medication issues with patient and family/caregiver verbalizing satisfaction with measures taken to address medication safety concerns.Understand proper disposal of unused medications.The IDG documentation indicated that Registered Nurse Case Manager (RNCM) 2 reviewed and ordered Patient 2’s medications on 8/22/2025. During a concurrent observation on 1/21/2026 at 11:03 a.m., LVN 1 was observed conducting medication reconciliation in Patient 2’s home. Patient 2’s Family Member (FM) 1 presented all medications available in the home for review. LVN 1 compared medication bottles with the medication profile list, and the following discrepancies were identified:Patient 2 had Sinemet CR 25/100 mg available and administered three times daily, while the medication profile indicated Sinemet 25/100 mg extended-release tablet to be taken once nightly.Patient 2 was receiving amlodipine besylate 5 mg as needed for systolic blood pressure greater than 190 mmHg, while the medication profile indicated amlodipine besylate 10 mg daily every morning.Linzess oral capsule 290 mcg was present in the home with an expiration date of January 2025, although FM 1 stated the medication was no longer being taken.Docusate sodium 100 mg, ordered twice daily for constipation, was not available in the home.Trospium chloride 20 mg twice daily was present in the home but not listed on the medication profile.Men’s once-daily multivitamin was present in the home but not listed on the medication profile. During interviews conducted on 1/21/2026 at 11:03 a.m., FM 1 stated:The Sinemet label was handwritten with the word “night” to prevent confusion regarding administration time.Amlodipine was administered only when systolic blood pressure exceeded 190 mmHg and not daily as ordered.Linzess was no longer taken.Docusate sodium was not available because the medication had run out. During an interview on 1/21/2026 at 11:33 a.m., LVN 1 stated that an accurate medication profile is essential for interdisciplinary collaboration, allowing clinicians to verify the patient’s prescribed medications. LVN 1 stated that medication labels should match physician medication orders, as mismatches could cause confusion and errors that may result in incorrect dosing. LVN 1 stated that if Sinemet was not administered as ordered, Patient 2 was at risk of experiencing poor symptom management possibly resulting in increased muscle contraction and forgetfulness. LVN 1 further stated that the HA should have provided Patient 2 with a complete and accurate medication profile list.These findings indicated that Patient 2’s medication profile was not current or accurate and did not reflect medications available in the home or medications being administered. c). During a review of Patient 6’s clinical record titled “Patient Profile,” the record indicated Patient 6 was admitted to the HA on 3/20/2025 with a terminal diagnosis of acute respiratory failure with hypoxia (a life-threatening condition in which the lungs are unable to provide adequate oxygen to the bloodstream). During a home visit observation on 1/22/2026 at 11:30 a.m., Patient 6 was observed resting in bed in an Assisted Living setting with LVN 2 present. Patient 6 was observed to be confused at all times, oriented to name only, speaking incoherently, unable to follow simple commands, and unable to maintain conversation. During a concurrent interview and record review on 1/22/2026 at 11:45 a.m., Patient 6’s Medication Profile, dated 1/14/2026 through 3/14/2026, was reviewed with LVN 2. The medication profile listed:Morphine sulfate oral tablet 15 mg, dose 0.5 tablet by mouth every two hours as needed for shortness of breath or pain. The morphine medication was not available in the patient’s residence. LVN 2 confirmed that the morphine tablets had expired and were discarded by the hospice registered nurse during a supervisory visit the prior week. LVN 2 stated she performed medication reconciliation during visits but missed verifying the availability of the morphine medication. LVN 2 stated that it is important for medication reconciliations to be completed so that staff are following the most up to date orders to ensure the availability and expiration of patients’ medications. During an interview on 1/22/2026 at 12:05 p.m., the Assisted Living Medication Technician confirmed that the expired morphine tablets were discarded by the HA’s visiting RN and that a replacement supply had been reordered. During an interview on 1/26/2026 at 12:15 p.m., RNCM 2 stated that medications listed on the medication profile must be available in the home for administration and that medication changes such as discontinuation, new medications, or changes in the frequency or dosage, must be reflected in the medication profile to maintain accuracy. The medication profile listed an ordered medication that was not available for administration, resulting in an inaccurate medication profile and potential delay in symptom management. A review of the HA’s policy and procedure titled “Medication Profile,” dated November 2021, indicated:Patients receiving medications under the HA’s care will have a current and accurate medication profile maintained in the clinical record.Medication profiles will be updated with each medication change to reflect current, new, and discontinued medications.A drug regimen review will be performed during initial and comprehensive assessments to evaluate effectiveness and appropriateness, identify potential interactions, adverse reactions, duplicate therapy, noncompliance issues, omissions, and unclear information.The medication profile will be used as a care planning and teaching guide.Medication profile review will be considered when changing the plan of care.”

“Based on interview and record review, the Hospice Agency (HA, a team of healthcare professionals that provides specialized, comfort-focused care for individuals with terminal illnesses who have a life expectancy of approximately six months or less) failed to ensure that an initial bereavement assessment was conducted for one of fourteen sampled patients (Patient 4). The electronic medical record (EMR, a digital version of a patient’s clinical record) did not contain documented evidence that the initial bereavement assessment was completed. This deficient practice had the potential to result in unrecognized bereavement risk factors and unmet emotional and psychosocial support needs for Patient 4’s family and/or caregivers, potentially resulting in inappropriate or delayed bereavement interventions inconsistent with the established plan of care. Findings: During a review of Patient 4’s undated, clinical record titled, “Patient Profile,” (page of the medical record containing a summary of basic patient information) the “Patient Profile indicated the HA admitted Patient 4, an 82 year old male, on 11/25/2025, with a terminal diagnosis of heart failure (the heart becomes too weak or stiff and cannot pump blood effectively). During a review of Patient 4’s clinical record titled, “Plan of Care Order,” dated 1/29/2026, the “Plan of Care Order” indicated that a Chaplain was to provide spiritual support for the patient and family. During a concurrent interview and record review on 1/28/2026 at 10:44 a.m. with Social Worker (SW) 1, Patient 4’s EMR was reviewed. The EMR did not contain documented evidence that the initial bereavement assessment was conducted. SW 1 stated that as of 1/28/2025 the initial bereavement assessment had not yet been completed. The assessment should have been completed by 11/28/2025, three days after the Patient’s admission. During an interview on 1/28/2026 at 10:44 a.m. with SW 1, SW 1 stated that the initial bereavement assessment was essential to assess patient and family/caregiver psychosocial needs and for the HA to provide services to meet the needs. SW 1 stated that services offered include meal assistance, mental health resources, and bereavement resources. SW 1 stated that without completion of the initial bereavement assessment, Patient 4 and family/caregivers may remain unfamiliar with the social worker’s role in hospice care, and that the HA would be unable to identify and provide patient-specific bereavement resources and support. During a review of the HA’s policy and procedure (P&P) titled, “Bereavement Assessment,” dated November 2021, the P&P indicated that on admission, the social worker or hospice registered nurse will complete an initial bereavement assessment within 3-5 days of hospice admission. During a review of the HA’s Job Description titled, “Medical Social Worker/Social Work Associate,” dated November 2021, the job description indicating the following job functions and responsibilities:Assesses the psychosocial status of patients and families/caregivers related to the patient’s terminal illness and environment.Carries out social evaluations and plans intervention based on evaluation findings.Maintains clinical records on all patients referred to social work.Provides information and referral services to patients and families/caregivers.Participates in the development of the individualized plan of care and attends regularly schedules interdisciplinary group meetings.”

“Based on observation, interview and record review, the hospice agency (HA, a team of healthcare professionals that provides specialized, comfort-focused care for people with terminal illnesses who have roughly six months or less to live ) failed to ensure education and training were provided to the patient/patient’s caregiver related to safety precautions during a seizure (a brief episode of abnormal electrical activity in the brain that can cause changes in behavior, movement, sensation, or consciousness) episode for one of fourteen sampled patients (Patient 6). These failures resulted in the HA’s inability to ensure the patient’s/patient caregiver’s understanding of possible risks, safety precautions, and side effects of medications. During a review of Patient 6’s clinical record titled “Patient Profile,” the patient profile indicated Patient 6 was admitted to the HA on 3/20/2025 with a terminal diagnosis of acute respiratory failure with hypoxia (a life-threatening condition where the lungs suddenly become unable to get enough oxygen into the bloodstream to meet the body’s need). During a home visit observation on 1/22/2026, at 11:30 a.m., to Patient 6’s residence, in an Assisted Living (AL, a residential housing for people who need help with daily tasks but do not require the intensive 24 hours/7 days medical care found in a nursing home) setting, with LVN 2, Patient 6 was observed resting comfortably on her hospital bed. Patient 6 is confused at all times, awake and oriented to her name only, speaks randomly but incoherent, unable to follow simple commands, and unable to hold a simple conversation. During a concurrent interview and record review on 1/22/2026, at 11:45 a.m., Patient 6’s medication profile (dated 1/14/2026–3/14/2026) was reviewed with LVN 2. The review identified the following medication currently being administered: -Levetiracetam Oral tablet 500 milligrams (mg, unit of weight), dose: one (1) tablet, frequency: twice daily, indication: epilepsy (a chronic brain disorder characterized by two or more unprovoked, recurring seizures (a sudden, temporary burst of uncontrolled electrical activity in the brain) caused by sudden, abnormal electrical surges in the brain), instructions: take 1 tablet by mouth twice daily, classification: anti-convulsant (a medication used to prevent, stop, or reduce the frequency and severity of seizures or convulsions). During an interview on 1/22/2026 at 12:11 p.m. with LVN2, LVN 2 stated that she did not provide any teaching or education to Patient 6’s caregivers regarding seizure precautions or what to do if Patient 6 is having a seizure episode. LVN 2 stated that Patient 6 did not have any seizure episodes for a long time, but it is still necessary to provide teachings to patient’s caregivers regarding seizure precautions (a set of safety measures taken to prevent injury and reduce danger for individuals at risk of having a seizure). LVN2 stated that patient teaching must be done at the start of the care and at random, it needs to be documented and needs to provide written education materials if necessary. LVN 2 stated that patient teaching is important to be given to patients and patient’s caregivers to better understand how to respond for a certain situation, to determine the readiness and preparedness.During a review of the HA’s policy and procedure (P&P) entitled, “Patient Education Process”, revised date of November 2021, the P&P indicated that:To provide guidelines for giving specific instruction and information to patients and family/caregivers regarding hospice services.Patients and family/caregivers will receive education in verbal, visual, and written format, as appropriate. The scope of teaching will be determined by the assessed needs, abilities, learning preferences, and readiness to learn of the patient and family/caregiver, as well as by the plan of care. Education will be the responsibility of each interdisciplinary group member.When appropriate, the clinician will use preprinted, hospice-approved patient teaching handouts. When not available, the clinician will, if needed, identify available written or visual materials to aid in the education process.If a patient’s condition prevents him/her from participating in instruction, family/caregivers will receive the information/instruction.”

“Based on observation, interview and record review, the hospice agency (HA, a team of healthcare professionals that provides specialized, comfort-focused care for people with terminal illnesses who have roughly six months or less to live) failed to ensure that a care plan (an individualized, written document outlining the specific medical, emotional, and spiritual support for a patient) for one of fourteen sampled patients (Patient 6) was developed to address safety precautions during a seizure (a brief episode of abnormal electrical activity in the brain that can cause changes in behavior, movement, sensation, or consciousness) episode while on anti-seizure medication. This failure had the potential to result in a lack or delay in delivery of necessary care and services for patients. During a review of Patient 6’s clinical record titled “Patient Profile,” the patient profile indicated Patient 6 was admitted to the HA on 3/20/2025 with a terminal diagnosis of acute respiratory failure with hypoxia (a life-threatening condition where the lungs suddenly become unable to get enough oxygen into the bloodstream to meet the body’s need). During a home visit observation on 1/22/2026, at 11:30 a.m., at Patient 6’s residence, in an Assisted Living (AL, a residential housing for people who need help with daily tasks but do not require the intensive 24 hours/7 days medical care found in a nursing home) setting, with LVN 2, Patient 6 was observed resting comfortably in her hospital bed. Patient 6 was observed to be awake, but confused at all times, and oriented to name only, speaking randomly and incoherently, unable to follow simple commands, and unable to maintain a conversation. During a concurrent interview and record review on 1/22/2026, at 11:45 a.m., Patient 6’s medication profile dated 1/14/2026 through 3/14/2026 was reviewed with LVN 2. The review identified the following medication currently being administered:Levetiracetam Oral tablet 500 milligrams (mg, unit of weight), one tablet twice daily by mouth for epilepsy epilepsy (a chronic brain disorder characterized by two or more unprovoked, recurring seizures (a sudden, temporary burst of uncontrolled electrical activity in the brain) caused by sudden, abnormal electrical surges in the brain),During a concurrent interview and record review on 1/22/2026, at 11:58 a.m., Patient 6’s clinical record titled “IDG (Interdisciplinary Group, where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) Meeting,” dated 1/7/2026 was reviewed with LVN 2. LVN 2 stated that an IDG meeting included the care plans formulated to address the specific issues identified in Patient 6’s care. LVN 2 confirmed and stated that Patient 6’s IDG meeting, dated 1/7/2026, did not include a care plan to address safety precautions during seizure episode while on anti-seizure medication. LVN 2 stated that a care plan should have been developed for Patient 6 to address seizure precautions, as a reference to all healthcare team involved in Patient 6’s care. LVN 2 stated that the care plan has to address potential problems, and for the nursing team to be aware of the goals, interventions and current health status of Patient 6. During a review of the HA’s policy and procedure (P&P) titled, “The Plan of Care” with a revised date of November 2021, the P&P indicated that: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care.”

“Based on interview and record review, the Hospice Agency (HA, a team of healthcare professionals that provides specialized, comfort-focused care for people with terminal illnesses who have roughly six months or less to live) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) reviewed and revised, the plan of care (POC- an individualized care planned) in a timely manner for six of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). This failure had the potential to result in patients not to be properly evaluated which could result in them not being provided individualized focused care. a). During a review of Patient 1’s clinical record titled “Patient Profile,” (page of the medical record containing a summary of basic patient information) the “Patient Profile” indicated the HA admitted Patient 1 on 1/28/2025, with a terminal diagnosis of Alzheimer’s disease (a progressive brain disorder that slowly destroys memory and thinking skills), unspecified. During a review of Patient 1’s electronic medical record (EMR, a digital version of a patient’s clinical record) titled, “IDG Meeting,” (meeting held with the IDG in attendance to review, revise and document the individualized POC as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days) the “IDG Meeting” indicated there was no documented evidence of an IDG/POC meeting being held between 7/3/2025 through 1/6/2026. During a review of Patient 1’s EMR titled, “IDG Meeting” dated 1/7/2026, the “IDG Meeting” indicated that an IDG/POC meeting was held on 1/7/2026 but was not signed by staff members who were in attendance. b). During a review of Patient 2’s clinical record titled “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 2 on 2/25/2025, with a terminal diagnosis of Neurocognitive disorder with Lewy bodies (progressive brain disease causing a decline in thinking, memory, and focus). During a review of Patient 2’s EMR titled, “IDG Meeting,” the “IDG Meeting” indicated there was no documented evidence of an IDG/POC meeting held between 7/3/2025 through 1/6/2026. During a review of Patient 2’s EMR titled, “IDG Meeting” dated 1/7/2026, the “IDG Meeting” indicated that an IDG/POC meeting was held on 1/7/2026 but was not signed by staff members who were in attendance. c). During a review of Patient 3’s clinical record titled “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 3 on 9/1/2023, with a terminal diagnosis of acute combined systolic and diastolic congestive heart failure (inability of the heart to pump blood out for fill properly). During a review of Patient 3’s EMR titled, “IDG Meeting,” the “IDG Meeting” indicated that there was no documented evidence of an IDG/POC meeting held between 7/3/2025 through 1/6/2026. During a review of Patient 3’s EMR titled “IDG Meeting” dated 1/7/2026, the “IDG Meeting” indicated that an IDG/POC meeting was held on 1/7/2026 but was not signed by staff members in attendance. d). During a review of Patient 4’s clinical record titled “Patient Profile,” the “Patient Profile indicated the HA admitted Patient 4 on 11/25/2025, with a terminal diagnosis of heart failure (the heart becomes too weak or stiff and cannot pump blood effectively). During a review of Patient 4’s EMR titled, “IDG Meeting,” the “IDG Meeting” indicated there was no documented evidence of an IDG/POC meeting being held between 11/25/2025 through 1/28/2026. e). During a review of Patient 5’s clinical record titled “Patient Profile,” the patient profile indicated Patient 5 was admitted to the HA on 5/15/2025 with a terminal diagnosis of Alzheimer’s disease (a progressive brain disorder that slowly destroys memory and thinking skills), unspecified. During a review of Patient 5’s EMR titled “IDG Meeting,” the “IDG Meeting” indicated that there was no documented evidence of an IDG/POC meeting being held between 7/14/2025 through 1/28/2026. f). During a review of Patient 6’s clinical record titled “Patient Profile,” the patient profile indicated Patient 6 was admitted to the HA on 3/20/2025 with a terminal diagnosis of acute respiratory failure with hypoxia (a life-threatening condition where the lungs suddenly become unable to get enough oxygen into the bloodstream to meet the body’s need). During a review of Patient 6’s EMR titled “IDG Meeting,” the “IDG Meeting” indicated that there was no documented evidence of an IDG/POC meeting being held between 9/16/2025 through 1/28/2026. During a review of Patient 6’s EMR titled “IDG Meeting,” dated 1/7/2026, the “IDG Meeting” indicated an IDG/POC meeting was held on 1/7/2026 but did not include a signature by the DPCS/ DPCS-D, a registered nurse, or other staff members in attendance. g). During a review of Patient 7’s clinical record titled “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 7 on 7/22/2024, with a terminal diagnosis of Alzheimer’s disease, unspecified During a review of Patient 7’s EMR titled “IDG Meeting,” the “IDG Meeting” indicated that there was no documented evidence of an IDG/POC meeting being held between 7/17/2025 through 1/28/2026. During an interview on 1/26/2026 at 11:38 a.m. with the Registered Nurse/Case Manager (RNCM 1), RNCM 1 stated that it was important for documentation of the IDG meetings to be uploaded into the EMR and to be current, and available for review by the care team to demonstrate communication between the interdisciplinary group regarding patient needs and to ensure those needs are met. During an interview on 1/26/2026 at 1:13 p.m. with the HA’s ADM, the ADM stated that IDG meetings were held to ensure that the medical director, nurses, and social worker were fully informed of the patient’s current health condition, to monitor disease progression and the effectiveness of patient care interventions, to ensure patients receive the appropriate medications and treatments, and to ensure the POC is up to date and implemented. During an interview on 1/27/2026 at 2:48 p.m. with the HA’s LVN AA, the LVN AA stated that all IDG and POC meetings were found in the IDG/POC tab of the EMR. LVN AA stated that meeting attendance was verified through electronic signature at the bottom of each IDG/POC meeting note and if the note was not signed that meant that staff member was not in attendance. LVN AA stated that if the IDG meeting note was not listed under the IDG/POC tab it meant that the IDG meeting did not occur. During a review of the HA’s P&P titled “Interdisciplinary Group Meeting,” revised November 2021, the P&P indicated that: The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires. The meeting will be facilitated by the hospice Clinical Supervisor/Nursing Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available. The procedure includes: Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor. The patient’s plan of care will be updated no less frequently than every 15 days or more frequently if the patient’s condition requires; social, cultural, and physical environments presenting obstacles to effective intervention; integration of alternative therapies into medical regime to assist in effectiveness; and any special needs of the patient. A plan of care update will be completed for each patient and family/caregiver no less frequently than every 15 days utilizing the ongoing comprehensive assessment. An interdisciplinary group meeting plan of care update from will be used for update of the patient and family/caregiver and the attending physician. It will note changes, response to treatment and progress toward targeted outcomes. Patient approaching recertification will be reviewed for the appropriateness of continuation of care based on identifiable criteria and progression of the mental illness.”

“Based on interview and record review, the Hospice Agency (HA, a team of healthcare professionals that provides specialized, comfort-focused care for people with terminal illnesses who have roughly six months or less to live) failed to ensure that the Plan of Care (POC, an individualized written plan of care in accordance with the patient’s needs) was revised for one of 14 sampled patients (Patient 1) to include assessment, monitoring, treatment interventions, and patient-specific goals for a stage 4 pressure injury (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). This failure had the potential to result in Patient 1 experiencing worsening tissue damage, delayed healing, increased risk of infection, and unmanaged pain, potentially resulting in distress, agitation, uncontrolled symptoms, emergency hospitalization, and an undignified and avoidable traumatic death. Findings: During a review of Patient 1’s undated clinical record titled, “Patient Profile,” (page of the medical record containing a summary of basic patient information), the “Patient Profile” indicated the HA admitted Patient 1, a 96-year-old female, on 1/28/2025, with a terminal diagnosis of Alzheimer’s disease (a progressive brain disorder that slowly destroys memory and thinking skills), unspecified. During a review of Patient 1’s clinical record titled “RN Initial Assessment,” dated 1/28/2025, the assessment documentation indicated the presence of Wound 1 located on the sacrum (a large, triangular bone at the base of the spine). The wound was identified as an open pressure injury (localized damage to the skin and/or underlying tissue, usually occurring over a bony prominence) and was documented as Stage 4. The wound measurements were recorded as 2 centimeters (cm) in length, 2 cm in width, and 1 cm in depth. During a review of Patient 1’s clinical record titled, “RN Skilled Nursing Visit,” dated 1/13/2026, the “RN Skilled Nursing Visit” indicated the presence of a buttock wound, increased pain and discomfort during wound care, and the presence of further skin break down. The record indicated that wound care was performed by an Licensed Vocational Nurse (LVN) once a week and all other wound care treatment was performed by Patient 1’s Family Member (FM) 3. During an interview on 1/23/2026 at 1:22 p.m. with Patient 1’s FM 3, FM 3 stated that Patient 1 had a pressure injury in the buttocks region and stated, “It’s big, you used to be able to see the bone.” FM 3 stated that she provided wound care treatment and dressing changes on the days an LVN did not visit and after Patient 1 had a bowel movement. FM 3 stated Patient 1’s pressure injury had not improved since admission to the HA. During a concurrent interview and record review on 1/29/2026 at 12:12 p.m. with LVN 1, Patient 1’s “Plan of Care Order,” dated 1/13/2026, was reviewed. The “Plan of Care Order” did not include assessment, monitoring, treatment interventions, and patient specific goals for the sacrum stage 4 pressure injury. LVN 1 verified that wound care interventions were not included in Patient 1’s POC and stated that the POC should be current and accurate for clinicians to verify and carry out patient care treatments as ordered by the physician. LVN 1 stated that the POC helps ensure patients receive proper care. During an interview on 1/29/2026 at 1:19 p.m. with Registered Nurse (RN) 3, RN 3 stated that an updated POC helped ensure that patients were visited by clinicians at appropriate intervals, that patients received appropriate care according to assessment findings, and to ensure that the patient, the patient’s family, and the HA staff were knowledgeable of the patient’s changing needs. During a review of the HA’s policy and procedure (P&P) titled, “The Plan of Care,” dated November 2021, the P&P indicated the following: The POC will include, but not limited to: diagnosis, patient and family/caregiver needs, reduction of risk factors, safety measures to prevent against abuse, injury or infection, medical supplies necessary to meet patient needs, frequency and types of services, individualized interventions, treatment goals, pain and symptom management interventions, physician orders, physician-directed instruction to patient and family/caregiver, and measurable outcomes. The POC will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. The POC must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregivers’ needs. Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to evaluate progress towards goals. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing assessments, and analysis of patient response to care. Care provided to the patient will be in accordance with the POC. The POC will be reviewed and revised as frequently as necessary, but not less often than every 15 days.”

“Based on interview and record review, the Hospice Agency (HA, a team of healthcare professionals that provides specialized, comfort-focused care for people with terminal illnesses who have roughly six months or less to live) failed to implement its own policy and procedure titled “The Plan of Care” by failing to provide home visits to two of 14 sampled patients (Patient 12 and Patient 13) according to the patient’s plan of care. This failure had the potential to result in medication errors, delayed detection of patient health changes, and unmanaged pain or chronic condition symptoms that could lead to episodes requiring emergency care. Findings:a). During a review of Patient 12’s clinical record titled “Patient Profile,” the record indicated that the HA admitted Patient 12 on 12/8/2025, with a terminal diagnosis of Alzheimer’s disease, unspecified.During a review of Patient 12’s record titled “Plan of Care” for the benefit periods 8/15/2024 through 11/12/2024, and 6/11/2025 through 8/9/2025, the records indicated that the registered nurse (RN) was expected to make at least two home visits per month and additional visits as needed.During a review of Patient 12’s records titled “IDG Meeting” the records indicated that the RN was expected to make at least two home visits per month and additional visits as needed, for IDG meetings held on 11/20/2024; 12/12/2025; 4/23/2025; and 1/72026.During a review of Patient 12’s electronic medical record (EMR, a digital, computer-based version of a patient’s paper chart containing comprehensive medical history, including diagnoses, medications, treatment plans, and lab results), under the section for nursing visits, the record showed that the RN missed home visits for the patient during the following benefit periods:1. 8/15/2024 -11/12/2024: 8/29/2024, 9/12/2024, and 9/26/20242. 11/13/2024 – 2/10/2025: 12/19/2024, 1/2/2025, 1/16/2025, 1/30/2025, and 2/9/20253. 2/11/2025 – 4/11/2025: 2/23/2025, 3/9/2025, 3/23/2025, and 4/6/20254. 4/12/2025 – 6/10/2025: 4/20/2025, 5/18/2025, and 6/1/20255. 6/11/2025 – 8/9/2025: 6/23/2025, 7/7/2025, and 7/21/20256. 8/10/2025 – 10/8/2025: 8/23/2025, 9/5/2025, and 9/19/20257. 10/9/2025 – 12/7/2025: 10/17/2025, 10/31/2025, 11/14/2025, and 11/28/2025b). During a review of Patient 13’s clinical record titled “Patient Profile” the record indicated the HA admitted Patient 13 on 2/5/2025, with a terminal diagnosis of Alzheimer’s disease, unspecified.During a review of Patient 13’s records titled “IDG Meeting” the records indicated that the RN was expected to make at least two home visits per month and additional visits as needed, for IDG meetings held on 2/12/2025; 4/9/2025, and 7/2/2025.During a review of Patient 13’s EMR, under the section for nursing visits, the record showed that the RN missed home visits on 2/19/2025; 2/28/2025; 3/5/2025; 3/19/2025; 3/28/2025; and 4/4/2025, during the benefit period between 2/5/2025 and 4/5/2025. The RN did not complete any home visits from 4/6/2025 through 1/30/2026.During a telephone interview on 1/29/2026, at 12:05 PM, Registered Nurse (RN 3) confirmed that she visits patients every two weeks to ensure the care plan is being met and to make changes if needed. RN 3 stated that she visited her patients twice a month, conducted patient assessments, and recorded them on paper. RN 3 acknowledged that she did not provide the agency with copies of the assessments she completed on paper during home visits and did not upload them to the EMR because she was unfamiliar with the process.RN 3 explained that missed visits could result in the patient not receiving the care they need. She emphasized the importance of electronically signing patient assessments in the EMR, explaining that an electronic signature serves as a formal attestation that the assessment was completed by the responsible clinician. It also confirms the identity of the person completing the assessment, reducing the risk of falsified or incomplete records. Signed assessments ensure that clinical decisions are based on verified and accurate information.During a review of the HA’s undated policy and procedure titled “The Plan of Care” revised in November 2021, indicated that a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group.”

“Based on interviews and record review, the hospice agency (HA, a team of healthcare professionals that provides specialized, comfort-focused care for people with terminal illnesses who have roughly six months or less to live) failed to develop, implement, and maintain an effective, ongoing, hospice-wide, data-driven Quality Assessment and Performance Improvement (QAPI, is a systematic, data-driven approach to maintaining and enhancing the quality of care and services) program. This deficient practice resulted in HA’s inability to demonstrate compliance with federal regulations requiring documentary evidence of its quality and performance improvement initiatives. During a concurrent interview and review on 1/27/2026, at 11:21 a.m., with the HA’s Chief Executive Officer (CEO), the HA’s undated QAPI binder was reviewed. The CEO stated and confirmed that the HA’s QAPI binder contained no documented evidence related to the QAPI program and that the QAPI binder was empty. During an interview on 1/27/2026, at 2:48 p.m. with the HA’s Licensed Vocational Nurse/Administrative Assistant (LVN AA), the LVN AA stated that she was responsible for the HA’s QAPI program. LVN AA stated that the most current QAPI program binder was from 2023, that the 2024 QAPI program electronic file had been lost and could not be recuperated, and that the 2025 QAPI program binder was incomplete. LVN AA stated that she was currently working on the QAPI program for the first quarter of 2025 (January 2025 through March 2025) and that the results of the QAPI program had not been reviewed or presented because the binder was incomplete. LVN AA stated that the results of the QAPI program had not been reviewed by the medical director, the ADM or the governing body. A review of the HA’s P&P titled “Improving Organizational Performance,” revised May 2023, the P&P indicated that the Governing Body (GB) is responsible for ensuring that the performance improvement program is defined, implemented, maintained, and evaluated annually. Senior management is also required to report the results of QAPI activities to the GB on a quarterly basis.”

“Based on interview and record review, the Hospice Agency (HA, a team of healthcare professionals that provides specialized, comfort-focused care for people with terminal illnesses who have roughly six months or less to live) failed to provide spiritual counseling services to 11 of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 10, Patient 11, Patient 12, and Patient 13) and families/caregivers. This failure had the potential to result in Patients and families/caregivers experiencing unmet psychosocial and spiritual needs, potentially resulting in emotional distress and impaired end-of-life adjustment. Findings: During a review of Patient 1’s clinical record titled, “Patient Profile,” (page of the medical record containing a summary of basic patient information) undated, the “Patient Profile” indicated the HA admitted Patient 1 on 1/28/2025, with a terminal diagnosis of Alzheimer’s disease (a progressive brain disorder that slowly destroys memory and thinking skills), unspecified. A review of Patient 2’s undated clinical record titled, “Patient Profile” the “Patient Profile” indicated the HA admitted Patient 2 on 2/25/2025, with a terminal diagnosis of Neurocognitive disorder with Lewy bodies (progressive brain disease causing a decline in thinking, memory, and focus). During a review of Patient 3’s clinical record titled “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 3 on 9/1/2023, with a terminal diagnosis of acute combined systolic and diastolic congestive heart failure (inability of the heart to pump blood out for fill properly). During a review of Patient 4’s clinical record titled “Patient Profile,” the “Patient Profile indicated the HA admitted Patient 4 on 11/25/2025, with a terminal diagnosis of heart failure (the heart becomes too weak or stiff and cannot pump blood effectively). During a review of Patient 5’s clinical record titled “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 5 on 5/15/2025, with a terminal diagnosis of Alzheimer’s disease, unspecified. During a review of Patient 6’s clinical record titled “Patient Profile,” the patient profile indicated Patient 6 was admitted to the HA on 3/20/2025 with a terminal diagnosis of acute respiratory failure with hypoxia (a life-threatening condition where the lungs suddenly become unable to get enough oxygen into the bloodstream to meet the body’s need). During a review of Patient 7’s clinical record titled “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 7 on 7/22/2024, with a terminal diagnosis of Alzheimer’s disease, unspecified. During a review of Patient 10’s clinical record titled “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 10 on 11/5/2025, with a terminal diagnosis of acute on chronic systolic (congestive) heart failure (a critical condition where a patient with a known history of chronic, stable heart failure experiences a sudden, severe worsening of symptoms). During a review of Patient 11’s clinical record titled “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 11 on 11/9/2025, with a terminal diagnosis of Parkinson’s disease with dyskinesia, with fluctuations ( the occurrence of involuntary, erratic, and dance-like movements [twisting, fidgeting, swaying] as a side effect of long-term medication, primarily levodopa, rather than a direct symptom of the disease itself). During a review of Patient 12’s clinical record titled “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 12 on 12/8/2025, with a terminal diagnosis of Alzheimer’s disease, unspecified. During a review of Patient 13’s clinical record titled “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 13 on 2/5/2025, with a terminal diagnosis of Alzheimer’s disease, unspecified. During an interview on 1/20/2026 at 3:01 p.m. with the HA’s Administrator (ADM), the ADM stated that Social Worker (SW) 1 was fulfilling both the Social Worker and Chaplain roles due to low patient census (total number of admitted hospice patients). During an interview on 1/28/2026 at 10:44 a.m. with SW 1, SW 1 stated that he was employed at the HA as a Social Worker and stated that he did not provide Chaplain services to the hospice patient or family/caregivers. SW 1 stated that he was not a certified Chaplain and did not have formal theology education or training related to chaplain services. During a review of the HA’s Job Description titled, “Hospice Chaplain,” dated November 2017, the job description indicating the following:Qualifications: graduate of accredited seminary or school of theology and experience working with death and dying, individuals/family/caregiver. Functions and responsibilities: spiritual assessment of patients and families/caregivers, facilitates the development of the individualized plan of care, provides direct spiritual care to patients and families/caregivers, maintains records of spiritual services utilization, attends the interdisciplinary group meetings, participates in the quality assessment performance improvement program, and provided funeral or memorial services for patients as requested. During a review of the HA’s policy and procedure (P&P) titled, “Spiritual Assessment,” dated November 2021, the P&P indicated that an in-depth spiritual assessment will be completed for each patient/family by the Hospice Chaplain. The assessment will include, but not limited to, evaluation of the following: coping with and adjusting to the patient’s terminal illness and religious and/or spiritual reactions to terminal illness.”

“Based on interview and record review, the Hospice Agency (HA, a team of healthcare professionals that provides specialized, comfort-focused care for people with terminal illnesses who have roughly six months or less to live), failed to ensure a governing body (a group of individuals who have responsibility for the overall management and operations, including oversight of the patient care) assumed full responsibility for the management of the day-to-day operations for hospice services when the HA did not hire or have on staff a Director of Patient Care Services (DPCS, a person responsible for the overall direction of hospice clinical services) and/or a DPCS Designee (DPCS-D) to manage the care and services for eleven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 10, Patient 11, Patient 12, and Patient 13) who were receiving hospice services. This deficient practice resulted in the HA not conducting regular Interdisciplinary Group (a group of different health care professionals who work closely together to provide coordinate care for the patient) meetings for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 10, Patient 11, Patient 12, and Patient 13 as per the agency’s protocol increasing the risk for unmanaged symptoms without regular coordinated review of patients plan of care. The deficiency further resulted in the agency not conducting Quality Assurance and Performance Improvement (QAPI-- data driven system used to continuously improve care quality and patient safety) meetings increasing the risk of undetected adverse events, declining quality of care, and poor care coordination. On 1/28/2026, at 11:08 a.m., the California Department of Public Health (CDPH) called an Immediate Jeopardy (IJ, a situation in which the HA’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient), in the presence of the HA’s Chief of Operations (CEO) and Administrator (ADM), related to the agency’s failure to ensure a governing body assumed full responsibility for the management of the day-to-day operations for hospice services. On 1/29/2026 at 2:06 p.m., the HA was unable to submit an acceptable IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 1/29/2026, at 2:13 p.m., CDPH completed the survey tasks and conducted an exit conference while onsite in the presence of the HA’s CEO and ADM with the IJ situations not removed. Findings: During a review of Patient 1’s “Patient Profile,” (page of the medical record containing a summary of basic patient information) the “Patient Profile” indicated the HA admitted Patient 1 on 1/28/2025, with a terminal (an incurable, progressive disease that cannot be treated to recovery and is expected to result in death, usually within months) diagnosis of Alzheimer’s disease (a progressive brain disorder that slowly destroys memory and thinking skills), unspecified. During a review of Patient 1’s electronic medical record (EMR, a digital version of a patient’s clinical record) titled, Interdisciplinary Group (IDG- a team of different healthcare experts [such as doctors, nurses, social workers, and therapists] who work together to create one unified plan for a patient) Meeting, there was no documented evidence that an IGD meeting was held between 7/3/25 to 1/6/26 for Patient 1. During a review of Patient 1’s “IDG Meeting” dated 1/7/2026, the “IDG Meeting” indicated that an IDG/ Plan of Care (POC) meeting was held on 1/7/2026 but there was no signature by an DPCS/ DPCS-D, a registered nurse, or other staff members in attendance. During a review of Patient 2’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 2 on 2/25/2025, with a terminal diagnosis of Neurocognitive disorder with Lewy bodies (progressive brain disease causing a decline in thinking, memory, and focus). During a review of Patient 2’s “IDG Meeting,” there was no documented evidence that an IGD meeting was held between 7/3/25 to 1/6/26 for Patient 2. During a review of Patient 2’s “IDG Meeting” dated 1/7/2026, the “IDG Meeting” indicated that an IDG/POC meeting was held on 1/7/2026 but there was no signature by an DPCS/ DPCS-D, a registered nurse, or other staff members in attendance. During a review of Patient 3’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 3 on 9/1/2023, with a terminal diagnosis of acute combined systolic and diastolic congestive heart failure (inability of the heart to pump blood out for fill properly). During a review of Patient 3’s “IDG Meeting,” there was no documented evidence that an IGD meeting was held between 7/3/25 to 1/6/26 for Patient 3. During a review of Patient 3’s “IDG Meeting” dated 1/7/2026, the “IDG Meeting” indicated that an IDG/POC meeting was held on 1/7/2026 but there was no signature by an DPCS/ DPCS-D, a registered nurse, or other staff members in attendance. During a review of Patient 4’s “Patient Profile,” the “Patient Profile indicated the HA admitted Patient 4 on 11/25/2025, with a terminal diagnosis of heart failure (the heart becomes too weak or stiff and cannot pump blood effectively). During a review of Patient 4’s “IDG Meeting,” there was no documented evidence that an IGD meeting was held between 11/25/25 to 1/28/26 for Patient 4. During a review of Patient 5’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 5 on 5/15/2025, with a terminal diagnosis of Alzheimer’s disease, unspecified. During a review of Patient 5’s “IDG Meeting,” there was no documented evidence that an IGD meeting was held between 7/14/25 to 1/28/26 for Patient 5. During a review of Patient 6’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 6 on 3/20/2025, with a terminal diagnosis of acute respiratory failure with hypoxia (a life-threatening condition where the lungs suddenly become unable to get enough oxygen into the bloodstream to meet the body’s need). During a review of Patient 6’s “IDG Meeting,” there was no documented evidence that an IGD meeting was held between 9/16/25 to 1/6/26 for Patient 6. During a review of Patient 6’s “IDG Meeting” dated 1/7/2026, the “IDG Meeting” indicated that an IDG/POC meeting was held on 1/7/2026 but there was no signature by an DPCS/ DPCS-D, a registered nurse, or other staff members in attendance. During a review of Patient 7’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 7 on 7/22/2024, with a terminal diagnosis of Alzheimer’s disease, unspecified. During a review of Patient 7’s “IDG Meeting,” there was no documented evidence that an IGD meeting was held between 7/17/25 to 1/28/26 for Patient 7. During a review of Patient 10’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 10 on 11/5/2025, with a terminal diagnosis of acute on chronic systolic (congestive) heart failure (a critical condition where a patient with a known history of chronic, stable heart failure experiences a sudden, severe worsening of symptoms). During a review of Patient 10’s “IDG Meeting,” there was no documented evidence that an IGD meeting was held between 11/5/25 to 1/28/26 for Patient 10. During a review of Patient 11’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 11 on 11/9/2025, with a terminal diagnosis of Parkinson’s disease with dyskinesia, with fluctuations ( the occurrence of involuntary, erratic, and dance-like movements [twisting, fidgeting, swaying] as a side effect of long-term medication, primarily levodopa, rather than a direct symptom of the disease itself). During a review of Patient 11’s “IDG Meeting,” there was no documented evidence that an IGD meeting was held between 8/11/25 to 1/28/26 for Patient 11. During a review of Patient 12’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 12 on 12/8/2025, with a terminal diagnosis of Alzheimer’s disease, unspecified. During a review of Patient 12’s “IDG Meeting,” there was no documented evidence that an IGD meeting was held between 6/11/25 to 1/6/26 for Patient 12. During a review of Patient 12’s “IDG Meeting” dated 1/7/2026, the “IDG Meeting” indicated that an IDG/POC meeting was held on 1/7/2026 but there was no signature by an DPCS/ DPCS-D, a registered nurse, or other staff members in attendance. During a review of Patient 13’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 13 on 2/5/2025, with a terminal diagnosis of Alzheimer’s disease, unspecified. During a review of Patient 13’s “IDG Meeting,” there was no documented evidence that an IGD meeting was held between 4/6/25 to 1/28/26 for Patient 13. During an interview on 1/20/2026 at 10:56 a.m. with the ADM, the ADM stated that she (ADM) was not a licensed clinician. The ADM indicated that the HA had experienced increased levels of staff turnover (the rate at which employees leave an organization are replaced by new hires within a specific period) and that the DPCS and DPCS-D positions were vacant. The ADM stated the DPCS and DPCS-D positions had been vacant since March 2025. The ADM stated the HA had not been able to employ a registered nurse to fulfill the DPCS role and that the HA was not prepared for the recertification survey. During an interview on 1/20/2026 at 11:15 a.m., with the ADM, the ADM stated that Registered Nurse Case Manager 1 (RNCM 1) and Registered Nurse Case Manager 2 (RNCM 2) oversaw the coordination of nursing services for their designated patients. During a review of the facility provided contact information list on 1/22/26 and provided by the ADM, the Contact information for Director of Nursing/ Chief Nursing Officer was documented as not applicable (N/A). During an interview on 1/26/2026 at 11:38 a.m. with RNCM 1, RNCM 1 stated the HA did not have a DPCS or DPCS-D. RNCM 1 stated that she had four patients under her care (Patient 4, Patient 6, Patient 7, and Patient 12). RNCM 1 stated that it is important for documentation of the IDG meetings to be entered into the patient’s medical records, current, for review by the care team to demonstrate communication between the interdisciplinary group regarding patient needs and to ensure those needs are met. During an interview on 1/26/2026 at 12:15 p.m., with RNCM 2, RNCM 2 stated that the HA did not have a DPCS or DPCS-D. RNCM 2 stated that the HA offered her the DPCS role 2 years ago (2024) and she declined. RNCM 2 stated that she had two patients under her care (Patient 1 and Patient 2). RNCM 2 stated that she did not facilitate IDG meetings or oversee quality assurance (QA) tasks. RNCM 2 stated that she only performed the RN role at the HA. During an interview on 1/26/2026 at 1:13 p.m., with the ADM, the ADM stated that the DPCS and DPCS-D positions had been vacant since November 2024 (not March 2025 as previously stated). The ADM stated that in the absence of a DPCS/DPCS-D, RNCM 1 and RNCM 2 oversaw the clinical aspect of patient care for their designated patients. During an interview on 1/26/2026 at 1:13 p.m., with the ADM, the ADM stated that in the past the HA had contracted an outside company to perform QA tasks, such as facilitating IDG meetings and clinical care monitoring. The ADM stated that she was unsure if the contract was current and stated the HA no longer worked with the contracted company. The ADM stated that the ADM and LVN Administrator Assistant (LVN AA) now assumed responsibility for the QA tasks. During an interview on 1/26/2026 at 1:13 p.m., with the ADM, the ADM stated that the DPCS/ DPCS-D roles have not been assigned to a specific person who had the experience and qualifications to perform the role. The ADM stated “we can’t keep up with what we have...we are behind. We can’t keep up.” During an interview on 1/26/2026 at 1:13 p.m., with the ADM, the ADM stated that IDG meetings are held to ensure that the medical director, nurses, and social worker are fully informed of the patient’s current health condition, to monitor disease progression, the effectiveness of patient care interventions, to ensure patients receive the appropriate medications and treatments, and to ensure the POC is up to date and implemented. During an interview on 1/26/2026 at 1:13 p.m., with the ADM, the ADM stated that accurate medical records are to be uploaded into the patient’s EMR within 48 hours of a clinician’s visits to ensure that the care team can reference the medical record, be informed about any changes in conditions or undesired medications/treatment outcomes, and to facilitate care coordination and patient/ family involvement in the treatment plan. The ADM stated, “the chart [medical record] 100 percent needs to be up to date and current so that everyone has a better view of what’s happening with the patient.” The ADM stated that lack of accurate and updated medical records could potentially result in inadequate or missed treatment interventions or medication administration errors. During an interview on 1/27/2026 at 2:48 p.m., with the LVN AA, the LVN AA stated that all IDG and POC meetings are found in each patient’s EMR. LVN AA stated that IGD meeting attendance is verified by electronic signature of each attendee within the meeting note. The LVN AA stated that if note was not signed by a staff member, it meant the staff member did not attend the IGD meeting. LVN AA stated that if the IDG meeting note was not found in the patient’s medical record, it meant that the IDG meeting did not occur. During a review of the HA’s Job Description titled, “Clinical Director/ Director of Patient Care Services,” dated November 2021, the job description indicated the following DPCS essential job functions and responsibilities:Coordinated and oversees all direct and indirect patient services provided by clinical organization personnel.Provides guidance and counseling to coordinators and Clinical Supervisors/Nursing Supervisors to assist them in continually improving all aspects of hospice care services, provided through organization personnel.Assists clinical supervisors/nursing supervisors in managing clinical teams and planning. Provides help in assessment, planning, implementation and evaluation of patient and family/caregiver care to all clinical personnel as indicated. Oversees the maintenance of patient’s clinical records, statistics, reports, and records for purposes of evaluation and reporting of organization activities. Assures proper maintenance of clinical records in compliance with local, state, and federal laws.Assures compliance with all local, state, and federal laws regarding licensure and certification of organization personnel and maintains compliance to the Joint Commission Home Care standards.In the temporary absence (more than twenty [20] consecutive working days) of the Director of Patient Care Services, a Registered Nurse shall be designated, in writing, as responsible for fulfilling the duties of the Director of Patient Care Services. Any vacancy in the DPCS position shall be filled within sixty (60) days of the vacancy and the Department will be notified of the replacement. During a review of the HA’s Job Description titled, “Executive Director/Administrator,” dated November 2017, the job description indicated the following Administrator essential job functions and responsibilities: ensuring adequate and appropriate staffing and ensuring organizational compliance with legal, regulatory and accreditation requirements. During a review of the HA’s Policy and Procedure (P&P) titled “Hospice Nursing Care,” revised November 2021, the P&P indicated that the licensed practical/vocational nurse will supplement the nursing care needs of the patient as provided by the registered nurse by: providing services in accordance with organizational policies and procedures, preparing clinical and progress notes documenting outcomes of interventions, assisting the registered nurse or physician in performing specialized duties related to end-of-life care, assisting the registered nurse in carrying out the plan of care, preparing equipment and materials for treatment adhering to aseptic technique as required, assisting the patient in learning appropriate self-care techniques, assessing patient and family/caregiver response to care, and ensuring communication of information to appropriate team members During a review of the HA’s P&P titled “Interdisciplinary Group Meeting,” revised November 2021, the P&P indicated that:The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires.The meeting will be facilitated by the hospice Clinical Supervisor/Nursing Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available. The procedure includes:Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor.The patient’s plan of care will be updated no less frequently than every 15 days or more frequently if the patient’s condition requires; social, cultural, and physical environments presenting obstacles to effective intervention; integration of alternative therapies into medical regime to assist in effectiveness; and any special needs of the patient.A plan of care update will be completed for each patient and family/caregiver no less frequently than every 15 days utilizing the ongoing comprehensive assessment. An interdisciplinary group meeting plan of care update from will be used for update of the patient and family/caregiver and the attending physician. It will note changes, response to treatment and progress toward targeted outcomes.Patient approaching recertification will be reviewed for the appropriateness of continuation of care based on identifiable criteria and progression of the mental illness. 2. During an interview on 1/20/2026 at 10:56 a.m. with the ADM, the ADM stated that she (ADM) was not a licensed clinician. The ADM indicated that the HA had experienced increased levels of staff turnover and that the DPCS and DPCS-D positions were vacant. The ADM stated the DPCS and DPCS-D positions had been vacant since March 2025. During an interview on 1/26/2026 at 1:13 p.m., with the ADM, the ADM stated that the DPCS and DPCS-D positions had been vacant since November 2024 (not March 2025 as previously stated). During an interview on 1/26/2026 at 1:13 p.m., with the ADM, the ADM stated that in the past the HA had contracted an outside company to perform QA tasks, such as the Quality Assurance and Performance Improvement (QAPI) program. The ADM stated that she was unsure if the contract was current and stated the HA no longer worked with the contracted company. The ADM stated that the ADM and LVN AA now assume responsibility for QA tasks. During a review of HA’s QAPI binder (undated), the HA’s QAPI binder indicated no documented evidence related to the QAPI program and was empty. During an interview on 1/27/2026 at 2:48 p.m., with the LVN AA, LVN AA stated that she was responsible for the HA’s QAPI program. LVN AA stated that the most current QAPI program binder was from 2023. LVN AA stated that that the 2024 QAPI program electronic file had been lost and could not be recuperated, and that the 2025 QAPI program binder was incomplete. LVN AA stated she (LVN AA) was currently working on the QAPI program for the first quarter of 2025 (January 2025 to March 2025) and that the results of the QAPI program had not been reviewed or presented because the binder was incomplete. LVN AA stated the results of the QAPI program had not been reviewed by the medical director, the ADM or the governing body. During a review of the HA’s P&P titled “Improving Organizational Performance,” revised May 2023, the P&P indicated that the Governing Body (GB) is responsible for ensuring that the performance improvement program is defined, implemented, maintained, and evaluated annually. Senior management is also required to report the results of QAPI activities to the GB on a quarterly basis. During a review of the HA’s P&P titled “Hospice Nursing Care,” revised November 2021, the P&P indicated that the licensed practical/vocational nurse will supplement the nursing care needs of the patient as provided by the registered nurse by: providing services in accordance with organizational policies and procedures, preparing clinical and progress notes documenting outcomes of interventions, assisting the registered nurse or physician in performing specialized duties related to end-of-life care, assisting the registered nurse in carrying out the plan of care, preparing equipment and materials for treatment adhering to aseptic technique as required, assisting the patient in learning appropriate self-care techniques, assessing patient and family/caregiver response to care, and ensuring communication of information to appropriate team members.”

“Based on interview and record review, the Hospice Agency (HA, a team of healthcare professionals that provides specialized, comfort-focused care for people with terminal illnesses who have roughly six months or less to live) failed to conduct an Initial Certification of Terminal Illness (CTI, process where the medical director or physician designee reviews the hospice patient’s clinical information and provides a written certification that the patient’s life expectancy is 6 months or less if the illness runs its normal course) and or a Recertification of Terminal Illness (process performed at designated intervals where the medical director or physician designee reviews the hospice patient’s clinical information and provides a written recertification that the patient’s life expectancy is 6 months or less if the illness runs its normal course) prior to the start of care as follows: Initial CTI was not completed for four of fourteen sampled patients (Patient 2, Patient 3, Patient 4 and Patient 13) by the HA’s Medical Director (MD) or physician designee. Recertification of Terminal Illness was not completed prior to the start of care for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 11, and Patient 12) by the HA’s MD or physician designee. These failures placed patients at risk for delays in care and resulted in their enrollment in hospice without proper verification of eligibility, which could have prevented them from receiving necessary care and services to meet their care goals. On 1/29/2026, at 1:48 p.m., the California Department of Public Health (CDPH) called an Immediate Jeopardy (IJ, a situation in which the HA’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient), in the presence of the Chief Executive Officer (CEO) and the Administrator (ADM), related to the agency’s failure to ensure the Medical Director completed a Certification of Terminal Illness for Patient 2,3,4 and 13 the start of care for hospice services. On 1/29/2026 at 2:06 p.m., the HA was unable to submit an acceptable IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 1/29/2026, at 2:13 p.m., CDPH completed the survey tasks and conducted an exit conference while onsite in the presence of the HA’s CEO and ADM with the IJ situations not removed. Findings: During a review of Patient 2’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 2 on 2/25/2025, with a terminal diagnosis of Neurocognitive disorder with Lewy bodies (progressive brain disease causing a decline in thinking, memory, and focus). During a review of Patient 2’s electronic medical record (EMR) titled, “F2F (face to face) Certifying,” (undated), indicated the HA’s Medical Director (MD) or physician designee did not complete an initial CTI for the benefit period dated from 2/25/2025 - 5/25/2025. During a review of Patient 3’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 3 on 9/1/2023, with a terminal diagnosis of acute combined systolic and diastolic congestive heart failure (inability of the heart to pump blood out for fill properly). During a review of Patient 3’s EMR titled, “F2F Certifying,” (undated), indicated the HA’s MD or physician designee did not complete an initial CTI for the benefit period dated from 9/1/2023 - 11/29/2023. During a review of Patient 4’s “Patient Profile,” the “Patient Profile indicated the HA admitted Patient 4 on 11/25/2025, with a terminal diagnosis of heart failure (the heart becomes too weak or stiff and cannot pump blood effectively). During a review of Patient 4’s EMR titled, “F2F Certifying,” (undated), indicated the HA’s MD or physician designee did not complete an initial CTI for the benefit period dated from 11/25/2025 - 1/23/2026. During a review of Patient 13’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 13 on 2/5/2025, with a terminal diagnosis of Alzheimer’s disease, unspecified. During a review of Patient 13’s EMR titled, “F2F Certifying,” (undated), indicated the HA’s MD or physician designee did not complete an initial CTI for the benefit period dated from 2/5/2025 - 1/8/2026. During an interview on 1/27/2025 at 12:02 p.m., with the MD, the MD stated that he (MD), could not remember if he was the person responsible for completing the CTI for the HA’s patients. The MD stated, “I get what [CTI] is... I don’t remember at the top of my head” and stated, “...it should be me obviously, if the patient’s seeing me then yes, I have to recertify them.” During an interview on 1/27/2025 at 12:02 p.m., with the MD, the MD stated that he completed the initial CTI after the start of care (SOC) date for the hospice patient and then stated, “the CTI should be done at the beginning or near the beginning of hospice care.” During an interview on 1/27/2025 at 12:02 p.m., with the MD, the MD stated that the initial CTI is a physician’s evaluation certifying that a patient is terminally ill, had six months or less to live, and was medically eligible to receive hospice services. The MD stated that CTI is required for patients to receive hospice services. The MD stated that without a CTI patients were at risk of experiencing a lapse in hospice care and services or a delay in treatment. The MD stated that if patients experience a delay in care, patients might not receive their pain medication and experience unmedicated pain. During an interview on 1/27/2025 at 2:48 p.m. with the HA’s Licensed Vocational Nurse Administrative Assistant (LVN AA), the LVN AA stated that patient CTIs are found in the patient’s EMR and nowhere else. She (LVN AA) stated that if there is no entry, that means the CTI was not completed. During a review of the HA’s Policy and Procedure (P&P) titled “Certification of Terminal Illness,” revised November 2021, the P&P indicated that at the time of admission to hospice, the hospice Medical Director or the patient’s attending physician will complete a certification narrative that reflects the patient’s individual circumstances based on his/her review of the patient’s medical record or, if applicable, examination of the patient. The hospice Medical Director and the patient’s attending physician will sign the certification of terminal illness and authorization for hospice services forms. The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election statement. During a review of the HA’s P&P titled “Physician Services – Medical Director,” revised November 2021, the P&P indicated the Medical Director shall:Review patient’s medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establish the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care, including written certification of terminal illness.Provide written certification of terminal illness including a short clinical narrative for all subsequent benefit periods and provide a face-to-face encounter visit with patient prior to third hospice benefit period and subsequent benefit periods.”

“Based on interview and record review, the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live)failed to ensure the medical director and/or physician designee conducted a review and verified the patient’s clinical information to determine the patient’s need of recertification of terminal illness for continued hospice care and services for nine of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 11, and Patient 12). This deficient practice resulted in the hospice medical director and/or the designee to certify patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses. The deficient practice also increased the risk of a lapse of hospice care and services, delays in treatment, and experience untreated medical issues. On 1/29/2026, at 1:48 p.m., the California Department of Public Health (CDPH) called an Immediate Jeopardy (IJ, a situation in which the HA’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient), in the presence of Chief Executive Officer (CEO) and the Administrator (ADM), related to the agency’s failure to ensure the Medical Director completed a Recertification of Terminal Illness for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 11, and Patient 12 prior to the start of care for hospice services. On 1/29/2026 at 2:06 p.m., the HA was unable to submit an acceptable IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 1/29/2026, at 2:13 p.m., CDPH completed the survey tasks and conducted an exit conference while onsite in the presence of the HA’s CEO and ADM with the IJ situations not removed. Findings:During a review of Patient 1’s “Patient Profile,” (page of the medical record containing a summary of basic patient information) the “Patient Profile” indicated the HA admitted Patient 1 on 1/28/2025, with a terminal diagnosis of Alzheimer’s disease (a progressive brain disorder that slowly destroys memory and thinking skills), unspecified. During a review of Patient 1’s EMR, titled “F2F (face to face) Certifying,” indicated that the Medical Director (MD) or physician designee did not sign the recertification of terminal illness before the start of care for the following certification periods dated: 1/28/2025 - 3/28/2025, 3/29/2025 - 5/27/2025, 5/28/2025 - 7/26/2025, 7/27/2025 - 9/24/2025, 11/24/2025 - 1/22/2026, and 1/23/2026 - 3/23/2026. During a review of Patient 2’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 2 on 2/25/2025, with a terminal diagnosis of Neurocognitive disorder with Lewy bodies (progressive brain disease causing a decline in thinking, memory, and focus). During a review of Patient 2’s EMR titled, “F2F Certifying,” indicated that the HA’s MD or physician designee did not sign the recertification of terminal illness before the start of care for the following certification periods dated: 5/26/2025 - 8/23/2025, 8/24/2025 - 10/22/2025, 10/23/2025 - 12/21/2025, and 12/22/2025 - 2/19/2026. During a review of Patient 3’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 3 on 9/1/2023, with a terminal diagnosis of acute combined systolic and diastolic congestive heart failure (inability of the heart to pump blood out for fill properly). During a review of Patient 3’s EMR titled, “F2F Certifying,” indicated that the HA’s MD or physician designee did not sign the recertification of terminal illness before the start of care for the following certification periods dated: 2/22/2025 - 4/22/2025, 4/23/2025 - 6/21/2025, 6/22/2025 - 8/20/2025, 8/21/2025 - 10/19/2025, 10/20/2025 - 12/18/2025, and 12/19/2025 - 2/16/2026. During a review of Patient 4’s “Patient Profile,” the “Patient Profile indicated the HA admitted Patient 4 on 11/25/2025, with a terminal diagnosis of heart failure (the heart becomes too weak or stiff and cannot pump blood effectively). During a review of Patient 4’s EMR titled, “F2F Certifying,” indicated that the HA’s MD or physician designee did not sign the recertification of terminal illness before the start of care for the certification period dated 1/24/2026 - 3/24/2026. During a review of Patient 5’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 5 on 5/15/2025, with a terminal diagnosis of Alzheimer’s disease, unspecified. During a review of Patient 5’s EMR, titled “F2F Certifying,” indicated that the HA’s MD or physician designee did not sign the recertification of terminal illness before the start of care for the following certification periods dated: 7/14/2025 - 9/11/2025, 9/12/2025 - 11/10/2025, and 11/11/2025 - 1/9/2026. During a review of Patient 6’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 6 on 3/20/2025, with a terminal diagnosis of acute respiratory failure with hypoxia (a life-threatening condition where the lungs suddenly become unable to get enough oxygen into the bloodstream to meet the body’s need). During a review of Patient 6’s EMR, titled “F2F Certifying,” indicated that the HA’s MD or physician designee did not sign the recertification of terminal illness before the start of care for the following certification periods dated: 6/18/2025-9/15/2025, 9/16/2025 - 11/14/2025, and 11/15/2025 - 1/13/2026. During a review of Patient 7’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 7 on 7/22/2024, with a terminal diagnosis of Alzheimer’s disease, unspecified. During a review of Patient 7’s EMR, titled “F2F Certifying,” indicated that the HA’s MD or physician designee did not sign the recertification of terminal illness before the start of care for the following certification periods dated: 10/20/2024-1/17/2025, 1/18/2025 - 3/18/2025, 3/19/2025 - 5/17/2025, 7/17/2025 - 9/14/2025, and 9/15/2025 - 11/13/2025. During a review of Patient 11’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 11 on 11/9/2025, with a terminal diagnosis of Parkinson’s disease with dyskinesia, with fluctuations ( the occurrence of involuntary, erratic, and dance-like movements [twisting, fidgeting, swaying] as a side effect of long-term medication, primarily levodopa, rather than a direct symptom of the disease itself). During a review of Patient 11’s EMR, titled “F2F Certifying,” indicated that the HA’s MD or physician designee did not sign the recertification of terminal illness before the start of care for the certification period dated 11/9/2025 - 2/6/2026. During a review of Patient 12’s “Patient Profile,” the “Patient Profile” indicated the HA admitted Patient 12 on 12/8/2025, with a terminal diagnosis of Alzheimer’s disease, unspecified. During a review of Patient 12’s EMR, titled “F2F Certifying,” indicated that the HA’s MD or physician designee did not sign the recertification of terminal illness before the start of care for the following certification periods dated: 11/13/2024 - 2/10/2025, 2/11/2025 - 4/11/2025, 4/12/2025 - 6/10/2025, 6/11/2025 - 8/9/2025, 8/10/2025 - 10/8/2025, 10/9/2025 - 12/7/2025, and 12/8/2025 - 2/5/2026. During an interview on 1/27/2025 at 12:02 p.m., with the MD, the MD stated that he (MD) could not remember if he was the person responsible for completing the CTI for the HA’s patients. The MD stated, “I get what [CTI] is... I don’t remember at the top of my head” and stated, “...it should be me obviously, if the patient’s seeing me then yes, I have to recertify them.” During an interview on 1/27/2025 at 12:02 p.m., with the MD, the MD stated that the recertification of terminal illness should be completed before the end of the current benefit to verify that the patient continues to require hospice services for the next certification period. During an interview on 1/27/2025 at 12:02 p.m., with the MD, the MD stated that the recertification of terminal illness was a physician’s evaluation certifying that a patient was terminally ill, had six months or less to live, and was medically eligible to receive hospice services. The MD stated that recertification was required for patients to continue receiving hospice services. The MD stated that without a recertification patients were at risk of experiencing a lapse in hospice care and services or a delay in treatment. The MD stated that if patients experience a delay in care, patients might not receive their pain medication and experience unmedicated pain. During an interview on 1/27/2025 at 2:48 p.m. with the HA’s Licensed Vocational Nurse Administrative Assistant (LVN AA), the LVN AA stated that patient Recertification of Terminal Illness are found in the patient’s EMR and nowhere else. She (LVN AA) stated that if there is no entry, that means the Recertification of Terminal Illness was not completed. During a review of the HA’s Policy and Procedure (P&P) titled “Certification of Terminal Illness,” revised November 2021, the P&P indicated that at the time of admission to hospice, the hospice Medical Director or the patient’s attending physician will complete a certification narrative that reflects the patient’s individual circumstances based on his/her review of the patient’s medical record or, if applicable, examination of the patient. The hospice Medical Director and the patient’s attending physician will sign the certification of terminal illness and authorization for hospice services forms. The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election statement. During a review of the HA’s P&P titled “Physician Services – Medical Director,” revised November 2021, the P&P indicated the Medical Director shall:Review patient’s medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establish the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care, including written certification of terminal illness.Provide written certification of terminal illness including a short clinical narrative for all subsequent benefit periods and provide a face-to-face encounter visit with patient prior to third hospice benefit period and subsequent benefit periods.”