Nova Home Hospice Inc.

“Based on interview and record review, the agency failed to arrange and implement an alternate office or command post site to ensure business operations will continue during an actual emergency, which is necessary for supporting the care continuation, in a universe of 12 patients, when staff members provided differing information regarding the agency’s Emergency Preparedness Plan for the designated alternate office site during emergency event.This failure had the potential to disrupt the agency’s ability to maintain continuous care, placing the agency’s patients at risk, and compromising their safety and quality of care during an emergency event. During an interview February 2, 2026, at 4:50 PM, with Director of Patient Care Services (DPCS 1), the DPCS 1 stated the last time the agency’s Emergency Preparedness Plan in-service (training) provided to the staff was on January 2026. DPCS 1 further stated she was not sure where the alternate office site would be during an emergency, but guessed it might be in the “trash bin area” outside the agency office or at [name of store] shopping center.During an interview on February 3, 2026, at 11:50 AM, with Hospice Aid 1 (HA 1), HA 1 stated she was not sure when the agency’s Emergency Preparedness Plan in-services was given. HA 1 further stated it might have been “two months ago,” around December 2025 and she was not sure about the alternate office site in case of an emergency event. During an interview on February 3, 2026, at 5:00 PM, with a License Vocational Nurse 1 (LVN 1), LVN 1 stated she received in-service material for Emergency Preparedness Plan “last night”, and stated she did not remember being told where the alternate office site would be during emergencies.During a concurrent interview and record review, on February 5, 2026, at 11:50 AM, with the Administrator (Admin), the Admin reviewed the agency’s policy and procedure (P&P) titled, “Emergency Management Plan,” revised April 2020, which indicated, “… To establish a plan which will allow for continuation of services in the event of a disaster, natural or man-made, affecting the organization or the community and to ensure the safe management of staff while securing patient and employee records. Procedures. 7. An alternate site will be designated in the event the office must be evacuated or is not accessible due to the emergency. Any clinical and financial records or blank documentation forms necessary for care during the emergency will be maintained off-site in the event they cannot be retrieved from the office…When an Emergency declared... 13... D. In the event tie office building is determined to be unsafe, the Executive director/Administrator or designee will communicate the location to which all personnel are to report for work... ” The Admin stated he and the agency consultant were responsible for the agency’s Emergency Preparedness Plan. The Admin confirmed that he did not have documentation to show the designated alternate office site/command post had been arranged and provided to all staff to maintain essential functions during emergency event. Furthermore, he stated the agency did not follow the policy.”

“Based on interview and record review, the agency failed to ensure that the current patient roster contained the required acuity level (a system of classifying patients according to the urgency of their medical needs during an emergency situation) for each patient, was readily available to support continuity of care during an emergency in accordance with the agency’s policy.This failure had the potential to impact on the agency’s ability to adequately assess and address the needs of the patients to implement immediate intervention during emergencies, compromising the safety and well-being of nine patients at risk. A review of the agency’s “Emergency Operation Plan” (EOP) binder for the period from January 1, 2025, through January 31, 2026, indicated that a patient roster with required acuity levels was not readily available to ensure adequate support for maintaining continuity of care during an emergency.During a concurrent interview and record review on February 5, 2026, at 10:30 AM, with the Administrator (Admin) and Director of Patient Care Services (DPCS), the Admin stated that he was responsible for the agency’s Emergency Preparedness Plan including updating the patient roster. Upon reviewing the agency’s EOP binder, the Admin was unable to provide an explanation as to why the patient roster, containing the required acuity levels, was not implemented in accordance with the agency’s policy.During a sequent concurrent interview and record review on February 5, 2026, at 11:40 AM, with the Admin and DPCS. Both Admin and DPCS reviewed the agency’s policy and procedure titled, “Emergency Management Plan”, revised April, 2020, which indicated, “To establish a plan which will allow for continuation of services in the event of a disaster, natural or man-made, affecting the organization or the community and to ensure the safe management of staff while securing patient and employee records. Procedures…. 12. The agency maintains a hard copy of a current patient list including contact information and categories identified for each patient in the event there is a power failure…. EMERGENCY SUPERVISOR TASKS… Calling orders - Administrator will notify the above leaders/supervisors when disaster/emergency alert is activated…Each month, all emergency supervisors will get an updated copy of emergency list and copy of patient acuity, staff roster and keep it at home for reference if the emergency occurs after hours, or if the agency is damaged or destroyed, so that when the Administrator activated the EOP the supervisors are all prepared…”. The Admin stated he was not aware the patient roster needed to be updated monthly as per the agency’s P&P. The Admin further stated the agency did not follow the policy.”

“Based on interview and record review, the hospice failed to follow its own policy when initial bereavement assessment (tools used to identify the social, spiritual, and cultural factors impacting the family’s ability to cope) was not completed for three out of fourteen sampled patients (Patients 1, 5, and 6). This failure had the potential to prevent the hospice from providing life-safety interventions and emotional support essential to the family’s wellbeing after a loss. 1. A review of Patient 1’s face sheet (document that gives a summary of patient’s information) indicated a start of care date of July 14, 2023, with a certification period (a specific timeframe during which a patient is eligible to receive hospice [medical care for people who are expected to live six months or less] services) of December 8, 2025, through February 27, 2026. Patient 1 had primary diagnoses that included unspecified Alzheimer`s disease (a decline in mental function including memory, language, problem-solving and hypertension (blood pressure that is higher than normal). During a concurrent record review and interview on February 5, 2026, at 12:30 PM with the Administrator (Admin), the Admin reviewed Patient 1’s electronic clinical records, and indicated that Nursing Comprehensive Assessment (a thorough, patient-centered evaluation conducted to identify the physical, psychosocial, emotional, and spiritual needs of a patient) was completed on July 14, 2023, and the initial bereavement assessment was missing. The Admin confirmed the assessment was not present in Patient 1’s electronic medical records. Admin was unsure why the initial bereavement assessment was not done timely. 2. A review of Patient 5’s face sheet indicated a start of care date of June 30, 2023, with a certification period of December 16, 2025, through February 13, 2026. Patient 5 had primary diagnoses that included unspecified Alzheimer`s disease.During a concurrent record review and interview on February 5, 2026, at 12:40 PM, with the Admin, the Admin reviewed Patient 5’s electronic clinical records and indicated that the Nursing Comprehensive Assessment was completed on June 30, 2023, and the initial bereavement assessment was missing. The Admin confirmed the assessment was not present in the electronic medical record. Admin was unsure why the initial bereavement assessment was not done timely 3. A review of Patient 5’s face sheet indicated a start of care date of September 13, 2023, with a certification period of December 31, 2025, through February 28, 2026. Patient 6 had primary diagnoses that included unspecified Alzheimer`s disease.During a concurrent record review and interview on February 5, 2026, at 12:45 PM, with the Admin, the Admin reviewed Patient 5’s electronic clinical record and indicated that the Nursing Comprehensive Assessment was completed on September 13, 2023, and the initial bereavement assessment was missing. The Admin confirmed the assessment was not present in Patient 5’s electronic medical record. Admin was unsure why the initial bereavement assessment was not done timely.During an interview on February 5, 2026, at 1:00 PM, with the Spiritual Care Coordinator (SC- a trained professional responsible for providing spiritual care to patients in hospice care settings), the SC confirmed the initial bereavement assessment was not performed from admission for Patient 1, 5, and 6. Furthermore, the SC stated that the initial assessment is important to identify risk as early as possible, making sure the family is not alone, and has the support they need to get through their loss safely.During a follow up interview on February 5, 2026, at 1:05 PM, with the SC, the SC stated he was not aware that the Initial Bereavement Assessment for Patients 1, 5, and 6 had been done because he was not in the role during their admission. Furthermore, he stated that since these patients were still active, it was his responsibility to review the charts of Patients 1, 5, and 6 and make sure that the required assessments were completed, which he did not do.During a concurrent interview and record review on February 5, 2026, at 1:20 PM , the Admin and SC reviewed the agency’s policy and procedure (P&P) titled “Bereavement Service” revised April 2020, which indicated, “PURPOSE. To ensure that appropriate and coordinated bereavement services are provided to family/caregivers. POLICY. [Name of facility] will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for up to one year following the death of the patient. Services will be provided by personnel who have received training and have experience dealing with grief…. The program will provide bereavement services to the family/caregivers of hospice patients, before and after the patient’s death, in accordance with the plan of care. The purpose of these services will be to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing pathological grief reactions that may interfere with the eventual resolution and integration of their losses. …”. The Admin stated the agency did not follow the policy.”

“Based on observation, interview, and record review, the facility failed to ensure patient medical supplies were properly maintained to reduce the spread of microorganisms (small organisms that can cause illness, such as bacteria and viruses), when seven boxes (total of 210 pieces) of foley catheter (a flexible tube that is put through the urinary opening and into your bladder) and six foley catheter insertion trays (all necessary items for foley catheter insertion and exchange) were found expired in the supply cabinet, available for use by the nurses. This failure had the potential to result in the spread of microorganisms to 22 immunocompromised (weak immune system) vulnerable patients, placing their health and safety at risk. During an interview on the home visit on February 3, 2026, at 5:15 PM, with the Licensed Vocational Nurse 1 (LVN 1), the LVN 1 stated foley insertion trays or foley catheters were gathered from the hospice agency office.During a facility tour observation conducted on February 5, 2026, at 10:40 AM, with the Staffing Director of Patient Care Services (DPCS), seven boxes (total of 210 pieces) of foley catheter were found expired in the supply cabinet. Four boxes (120 pieces) with an expiration date of October 2024, and three boxes (90 pieces) with an expiration date of April 2025.During a further observation on February 5, 2026, at 10:45 AM, with the DPCS, six foley catheter insertion trays were found expired in the supply cabinet with an expiration date of April 30, 2024.During an interview on February 5, 2026, at 10:55 AM, with the DPCS, she stated that she was responsible for the agency’s clinical supplies, including checking and confirming their expiration dates. Furthermore, the DPCS acknowledged that she should have removed all expired supplies to ensure patient safety and maintain infection control but admitted that she had not done so.During a follow-up interview on February 5, 2026, at 11:00 AM with the Administrator (Admin), the Admin stated that the agency does not have a specific written policy regarding expired supplies. The agency’s best practice is to maintain an active stock and remove all expired items. The Administrator stated that the DPCS is responsible for overseeing this practice, and she had not done so.”

“Based on observation, interview, and record review, the agency failed to ensure nursing services were provided in accordance with accepted standards of practice related to medication management and maintenance of home clinical records for two of fourteen sampled patients (Patient 1 and 2) when:1. For Patient 1, the home clinical record did not include the Plan of Care (a customized plan detailing the medical, physical, emotional, and spiritual care for a terminally ill patient, designed to maximize comfort and quality of life) and a current medication profile (MP - a record of all medications a patient is currently taking), and two medications were observed to be past their expiration dates but remained available for use.2. For Patient 2, one medication was observed to be past their expiration dates but remained available for use.These failures had the potential to result in ineffective drug therapy, significant side effects and noncompliance with drug therapy and insufficient nursing oversight, which could place Patients 1 and 2 at risk and compromising their safety and well-being. 1. A review of Patient 1’s face sheet (document that gives a summary of patient’s information) indicated a start of care date of July 14, 2023, with a certification period (a specific timeframe during which a patient is eligible to receive hospice [medical care for people who are expected to live six months or less] services) of December 8, 2025, to February 27, 2026. Patient 1 had primary diagnoses which included unspecified Alzheimer`s disease (a decline in mental function including memory, language, problem-solving) and hypertension (blood pressure that is higher than normal).During a home visit on February 2, 2026, at 4:30 PM, with the Director of Patient Care Services/Administrator (DPCS), in the presence of Patient 1 and Patient 1’s wife, a review of Patient 1’s home clinical record binder and the surrounding area was conducted. Patient 1’s current care plan including the most recent MP were not found in the binder or anywhere in the house. Both DPCS and Patient 1’s wife confirmed that these documents were not available.During a concurrent observation and interview in a home visit on February 2, 2026, at 4:35 PM, with the DPCS, Patient 1’s actual medication bottles available at home were compared with Patient 1’s most current MP. The DPCS examined a bottle of Haloperidol (a prescription antipsychotic [medications work by altering brain chemistry] medication. In hospice, it is used to treat terminal delirium, severe agitation in end-stage Alzheimer`s). indicated “Drug Exp 07/26/24” [Drug Expired July 26, 2024 (medication had been expired for one year, six months, and 7 days)]. Patient 1’s MP indicated “Haloperidol 5 mg (milligram-a unit of measure) tablets … take three times a day as needed for agitation.” Patient 1’s wife stated, “I didn’t [did not] notice that the medication was expired because my husband [Patient1] doesn’t [does not] take it very often.”During a concurrent observation and interview in a home visit on February 2, 2026, at 4:40 PM, with the DPCS, the DPCS examined a bottle of Lorazepam (a medication to treat anxiety) medication. In hospice care to manage distressing symptoms during the final stages of life), indicated “Drug Exp 4/5/24” [Drug Expired April 5, 2025 (medication had been expired ten months)]. Patient 1’s MP indicated “Lorazepam 0.5 mg tablets … take daily at bedtime for anxiety.” Patient 1’s wife stated, “I didn’t [did not] notice that the medication was expired.”During an interview on February 2, 2026, at 4:45 PM, with Patient 1’s wife, Patient 1’s wife stated, “He [Patient 1] had been taking both Haloperidol and Lorazepam since he started with hospice. His doctor is aware of it.” 2. A review of Patient 2’s face sheet indicated a start of care date of September 26, 2024, with a certification period of January 19, 2026, to March 19, 2026. Patient 2 had primary diagnoses that included Alzheimer`s disease late onset and hypertension.During a concurrent observation and interview in a home visit on February 3, 2026, at 11:30 AM, with Hospice Aid 1 (HA 1) and in the presence of Patient 2’s daughter an observation of Patient 2’s actual medication bottles available in the home were compared with Patient 2’s most current Medication Profile (MP). An inspection of a bottle of Lactulose (a prescribed medication to treat constipation [difficulty pooing]), indicated “Drug Exp 12/31/25” [Drug Expired December 31, 2025 (medication had been expired 35 days)]. Patient 2’s MP indicated “Lactulose 20 g/30ml (gram-a unit of measure/milliliter-a unit of measure) solution (liquid form) … three times a day for constipation.” Patient 2’s daughter stated, “I didn’t [did not] notice that the medication was expired.”During an interview on February 5, 2026, at 1:30 PM, with the DPCS. The DPCS stated that the visiting nurse and case manager are responsible for reviewing and updating the MP during their visits. The printed MP should have been updated accordingly. Furthermore, the DPCS stated, “The visiting nurse or case manager should have included the process of checking all home medications for correct orders, expiration dates, and reordering medication as needed. I do not know why it was not done.”During a concurrent interview and record review on February 5, 2026, at 1:40 PM, the DPCS reviewed the agency’s policy and procedure (P&P) titled “Comprehensive Assessment,” revised April 2020, which indicated, “POLICY. Each patient admitted by Hospice will have an appropriate initial assessment and comprehensive. Procedure… Each patient’s comprehensive assessment includes a review of all medications the patient is currently taking (prescription, non-prescription, herbs, home remedies, other alternative treatments, etc.) to identify: assessment performed and documented. • Drug effectiveness. • Side effects. • Actual or potential drug interactions. • Noncompliance with medications. • Duplicate therapy. • Ineffective therapy. • Potential adverse effects. • Medication reactions. • Drug therapy associated with lab monitoring… “. The DPCS stated the agency did not follow the policy.During a concurrent interview and record review on February 5, 2026, at 1:45 PM, the DPCS reviewed the agency’s P&P titled “Medication Profile,” revised April 2020, which indicated, “PURPOSE To define the use of the medication profile in evaluating a patient’s current medication regimen. POLICY Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. PROCEDURE… 2. The admitting nurse will initiate a medication profile to document the current medication regiment… 5. 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. …”. The DPCS stated the agency did not follow the policy. During a concurrent interview and record review on February 5, 2026, at 1:50 PM, the DPCS reviewed the agency’s P&P titled “Plan of Care,” revised April 2020, which indicated, “PURPOSETo ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. POLICY. 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.…PROCEDURE. 1. The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care… 9. The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, …. Review of the plan of care will be documented in the clinical record... 11. … 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 or follow through….” The DPCS stated the agency did not follow the policy.”

“Based on record review and interview, the agency’s Administrator failed to assume full legal authority and responsibility to ensure their State license (the document permitting the operation of a health facility and the authority to perform services within the scope of these regulations) was current and valid under applicable state law, when the State license posted in the facility was expired since January 13, 2026 (Expired for 23 days). This failure had the potential to bypass the state oversight and legal safeguards designed to ensure safety and wellbeing for the universe of 12 active patients and their families. During a concurrent observation, interview, and record review on February 2, 2026, at 10:38 AM, with the Administrator (Admin) in the hallway, the agency’s State license was observed to be displayed on the wall by the lobby area. The license had an effective date of January 14, 2024, and an expiration date of January 13, 2026, indicating it had been expired for 23 days. The Admin reviewed and confirmed that the facility’s State license was expired. The Admin stated that he is responsible for ensuring the agency’s compliance with regulations.During a concurrent record review and interview on February 2, 2026, at 2:00 PM, the Admin provided a copy of a check written to the State Department dated January 26, 2026, and indicated the agency attempt to renew its license 13 days after the January 13th expiration. The Admin acknowledged the delay in the renewal process.A review of the agency’s Policy and Procedure (P&P) titled “Job Description. Job Title/Position: Executive Director/Administrator, “ revised October 2010, indicated, “JOB DESCRIPTION SUMMARY… The Executive Director/Administrator is responsible for the overall direction of the hospice services. … ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES. 1. Operational planning and budgeting. 2. Ensuring organizational compliance with legal, regulatory and accreditation requirements ...”During a concurrent interview and record review on February 5, 2026, at 9:30 AM, with the Admin, the Admin reviewed the agency’s P&P titled “Regulatory Compliance” revised April 2020. The P&P indicated, “PURPOSE. To ensure compliance with local, state, federal, and other regulatory bodies. POLICY. The organization will maintain evidence of regulatory compliance, including but not limited to: 1. Current state license…” The Admin stated it is his responsibility to ensure that the facility’s license remains active and does not expire. The Admin further stated that this was not done.”