Calstro Hospice Inc.

“Based on observation, interview, and record review, the agency failed to ensure a designated registered nurse (RN) was responsible for coordination of patient care and ensuring continuous assessment of patient needs for one of four sampled patients (Patient 2) when, the Case Manager (RN 2) failed to coordinate care activities, identify barriers to care (refusals to be repositioned), or update family when Patient 2’s existing pressure sores worsened and two new pressure sores appeared. This failure resulted in unmet care needs, unaddressed barriers to care, and further deterioration of Patient 2’s pressure sores due to lack of coordinated oversight, continuous assessment, and timely communication with the family. Findings: During a review of Patient 2’s face sheet (basic information about the patient), undated, the face sheet indicated a start of care date of May 3, 2026, with a benefit period from May 3, 2026, through July 1, 2026 (Benefit Period Eight). The face sheet indicated Patient 2 had a terminal diagnosis of hypertensive heart disease with heart failure (high blood pressure that causes heart damage, meaning the heart cannot pump enough blood to meet the body’s needs). During a review of Patient 2’s “Skin Assessment,” dated May 3, 2026, the “Skin Assessment,” indicated Patient 2 had three pressure related wounds:a. Wound 1: Unstageable (dead, hardened skin tissue covers the wound base. Because the depth cannot be seen, a stage or severity rating cannot be assigned) pressure sore on the mid upper sacrum (the lower back right above the tailbone). Size: length 4 cm (centimeters-a unit of measurement), width 4.5 cm, and depth could not be measured.b. Wound 2: Unstageable pressure sore on the right buttock (butt cheek). Size: length 1.5 cm, width 2 cm, and depth could not be measured.c. Wound 3: DTI (Deep Tissue Injury—purple or maroon intact skin due to damage underneath from pressure) on the left buttock. Size: length 1 cm, width 1 cm, and depth could not be measured. During a review of Patient 2’s “Skin Assessment,” dated May 26, 2026, performed by Registered Nurse 2 (RN 2) the “Skin Assessment” indicated, worsening of Patient 2’s pressure related wounds upon admission and two additional pressure related wounds:a. Wound 1: Unstageable pressure sore on the mid upper sacrum. A stage two (an open, shallow wound or blister where the top layers of skin are lost) wound next to it was now part of the sacrum sore. Size: length 6.5 cm, width 5.5 cm, and depth 0.2 cm (an increase of length by 2.5 cm, width by 1 cm, and depth by 0.2 cm in 23 days).b. Wound 2: Unstageable pressure sore on the right buttock. Size: length 2.5 cm, width 2 cm, and depth 0.1 cm (an increase of length by 1 cm, width by 0 cm, and depth by 0.1 cm in 23 days).c. Wound 3: The stage two left buttocks wound was now part of Wound 1.d. Wound 4: Right foot, great toe; no stage or measurements were written down. (Wound 4 was not present at the start of care.)e. Wound 5: Right ankle stage three (a deep wound open to the fat layer underneath) pressure sore. Size: length 5 cm, width 5 cm, and depth 0.2 cm. (Wound 5 was not present at the start of care.) During a review of Patient 2’s Interdisciplinary Group (IDG—the hospice care team) Meeting Note dated June 16, 2026, the note indicated RN 2 and the Medical Director (MD) attended. The note further indicated: “Last 2 Weeks: … Patient continues to decline functionally and remains fully bed bound. … Patient is alert and oriented to person, place, and date, with intermittent confusion regarding time. She is blind [both eyes] but is able to verbalize needs effectively. … Patient requires assistance with [ADL activities of daily living], retaining only the ability to feed herself. … Over the past two weeks, Patient has demonstrated worsening skin integrity with multiple wounds requiring physician review and updated wound care orders. Current wounds include an unstageable sacral wound with eschar, now encompassing a previously adjacent Stage 2 wound; a Stage 2 pressure injury to the right upper buttock; a new Stage 2 pressure injury to the right lateral heel; and an unstageable wound to the right great toe. Pain associated with repositioning and wound care has increased, requiring premedication. … Ongoing Interventions: Skilled nursing assessments for disease progression and symptom management. … Ongoing wound care per physician orders. … Repositioning education and reinforcement to prevent further skin breakdown. … Team Update: … The interdisciplinary team continues to monitor Patient closely due to increasing skin breakdown, pain associated with wound care, and overall functional decline. Physician notified regarding worsening wounds and discomfort associated with dressing changes. New wound care orders obtained and implemented. Facility staff … educated regarding the wound care regimen, pressure relief measures, repositioning schedule, pain management, and monitoring for signs of infection or further deterioration.” The Interdisciplinary Group Meeting Note had no documented evidence to show RN 2 notified the IDG about Patient 2’s refusals to be turned or about using pressure-relieving equipment. During an observation on June 24, 2026, at 11:00 AM, at Patient 2’s Assisted Living Facility (ALF—a facility that helps with everyday tasks like bathing and medication) with RN 2, Patient 2 was lying on her right side on a mattress awake and alert. An alternating pressure mattress (a mattress that pumps air in and out to shift body weight and relieve skin pressure) or a low air loss mattress (a mattress that blows a gentle air flow to keep skin cool and dry) was not observed in Patient 2’s room at the time of the visit. She was awake and able to talk. Patient 2 complained of pain in her right thigh and RN 2 administered Patient 2 pain medication. RN 2 informed Patient 2 he would call the doctor to see if the dose could be increased. During the visit, RN 2 also provided ordered wound care. During an interview on June 24, 2026, at 12:15 PM, with the Care Giver (CG) at Patient 2’s ALF (CG/ALF), the CG/ALF stated she had been a CG for the facility for the past two years. The CG/ALF stated non‑ambulatory patients were repositioned every two hours, provided the patient consented to being repositioned. The CG/ALF stated Patient 2 refused at times to be repositioned. During a telephone interview on June 24, 2026, at 11:22 AM, with the Administrator of Patient 2’s ALF (Admin/ALF), the Admin/ALF stated the facility had staff available 24 hours a day, seven days a week, to provide patient care services. The Admin/ALF stated the staff included Licensed Vocational Nurses (LVNs) for wound dressing changes but only for a stage one pressure sore (intact skin that shows a persistent area of redness over a bony area and does not blanch (turn white) when pressed) or minimally open skin such as a skin tear. The Admin/ALF stated the facility was not licensed to provide skilled nursing services and Patient 2’s wounds were too severe for the facility’s LVN to provide the required care. The Admin/ALF stated it was the hospice agency’s responsibility to care for Patient 2’s wounds. The Admin/ALF stated the ALF’s staff repositioned bed bound (unable to get out of bed on their own and must remain in bed for all daily activities, relying on others for movement and positioning) patients every two hours; however, although Patient 2 was bed bound and too weak to reposition herself, she refused repositioning regularly. The Admin/ALF stated she told her staff to leave Patient 2 in her preferred position because it was a patient’s right to refuse care. During an interview on June 24, 2026, at 12:00 PM with RN 2, RN 2 stated he had been Patient 2’s case manager from May 3, 2026, to June 8, 2026, and RN 3 took over as Patient 2’s case manager on June 9, 2026. RN 2 stated he was aware, Patient 2 did not want to be repositioned since admission; therefore, facility staff did not reposition her every two hours because it would go against Patient 2’s wishes. RN 2 stated he asked Patient 2 why she was refusing to be repositioned, but Patient 2 spoke very little, maybe a word or two, so he did not receive an answer. RN 2 stated he conducted Patient 2’s wound assessment on May 26, 2026, and was aware her wounds had worsened and two more pressure sores had appeared. RN 2 stated he had attended Patient 2’s IDG meetings and discussed her refusals of repositioning, but did not document the discussion or the recommendation, which was to continue instructing the ALF staff to reposition Patient 2 every two hours. RN 2 stated he had tried to call Patient 2’s son but was never able to reach him, so he had not updated the son on the worsening pressure sores. During an interview on June 24, 2026, at 1:34 PM with Patient 2’s son/responsible party, the son/responsible party stated the agency had not informed him that his mother’s pressure sores had worsened or that she had developed additional pressure sores. The son/responsible party stated, “Pressure sores are very bad sores and bad things can happen.” During an interview on June 24, 2026, at 1:52 PM, with the Director of Patient Care Services (DPCS), the DPCS stated that once Patient 2’s pressure sores worsened and increased on May 26, 2026, RN 2 was responsible for updating Patient 2’s plan of care with pressure‑relieving devices. The DPCS stated RN 2 did not clearly communicate the level or severity of Patient 2’s refusals to be repositioned every two hours during the IDG meeting. The DPCS stated if he had communicated this information clearly, she would have arranged a care‑planning meeting to address the issue; however, because she did not understand the severity of the refusals, she did not do so. During an interview on June 25, 2026, at 9:00 AM, with RN 3, RN 3 stated she had taken over as the case manager for Patient 2 on June 9, 2026, while RN 2 continued to assist with Patient 2’s care. RN 3 stated she had not yet attended an IDG meeting for Patient 2, as RN 2 was attending those meetings at this time. RN 3 stated she was not aware Patient 2 had been refusing to be repositioned every two hours during her first visit on June 9, 2026. RN 3 stated, during her visit on June 12, 2026, a staff member at the ALF informed her Patient 2 had been refusing care. RN 3 further stated, Patient 2 had not refused treatments or repositioning from her. RN 3 stated Patient 2 was able to speak clearly and answered questions appropriately. RN 3 stated when Patient 2 was resistive, she was able to talk with her and obtain her cooperation. RN 3 stated, “If put in simple terms, I believe she is able to comprehend and agree to the care and repositioning.” RN 3 stated she did not consider the use of pressure‑relieving devices for Patient 2’s pressure sores. RN 3 stated Patient 2’s pressure sores would not heal solely by changing wound treatment orders; one would have to remove the pressure from the wounds. During an interview on June 25, 2026, at 9:30 AM, with the Physician Designee (PD), the PD stated she was covering the duties of the Medical Director (MD), who was currently out of the country. The PD stated she had not yet attended an IDG meeting for Patient 2; however, she explained that the members of the IDG needed to work together in a coordinated manner and identify a way to relieve the pressure on Patient 2’s wounds. During a review of the agency’s policy titled, “Interdisciplinary Group Plan of Care,” dated May 2022, indicated, “PURPOSE: To ensure the coordination of services for each patient. POLICY: ... The Case Manager will be responsible for coordination of services with the interdisciplinary group from referral to discharge. PROCEDURE: … 3. It will be the responsibility of the Case Manager to facilitate communication about changes in the patient’s status between interdisciplinary group members and the patient’s attending physician. … 5. When the patient requires services from the interdisciplinary group, the Case Manager will be responsible for cooperative care planning to assure goals, interventions, and outcomes are palliative in nature.””

“Based on observation, interview, and record review, the agency failed to revise and document the patients’ plans of care as frequently as the patients’ conditions required for one of four sampled patients (Patient 2) when Patient 2 refused to be repositioned for her existing pressure sores (damage to the skin and underlying soft tissue caused by prolonged, unrelieved pressure) present upon admission and two additional pressure sores that developed after admission.This failure resulted in further worsening of Patient 2’s pressure sores, increased pain and discomfort, delayed healing, and an increased risk of infection. Findings: During a review of Patient 2’s face sheet (basic information about the patient), undated, the face sheet, indicated a start of care date of May 3, 2026, with a benefit period from May 3, 2026, through July 1, 2026 (Benefit Period Eight). The face sheet indicated Patient 2 had a terminal diagnosis of Hypertensive heart disease with heart failure (unmanaged high blood pressure causes heart damage, and the heart cannot pump enough blood to meet the body’s needs).A review of Patient 2’s “Skin Assessment,” dated May 3, 2026, indicated Patient 2 had three pressure related wounds:a. Wound 1: Unstageable (dead, hardened skin tissue covers the wound base. Because the depth cannot be seen, a stage or severity rating cannot be assigned) pressure sore on the mid upper sacrum (the lower back right above the tailbone). Size: length 4 cm (centimeters-a unit of measurement), width 4.5 cm, and depth could not be measured.b. Wound 2: Unstageable pressure sore on the right buttock (butt cheek). Size: length 1.5 cm, width 2 cm, and depth could not be measured.c. Wound 3: DTI (Deep Tissue Injury—purple or maroon intact skin due to damage underneath from pressure) on the left buttock. Size: length 1 cm, width 1 cm, and depth could not be measured.During an observation on June 24, 2026, at 11:00 AM, at Patient 2’s Assisted Living Facility (ALF—a facility that helps with everyday tasks like bathing and medication) with RN 2, Patient 2 was lying on her right side on a mattress awake and alert. An alternating pressure mattress (a mattress that pumps air in and out to shift body weight and relieve skin pressure) or a low air loss mattress (a mattress that blows a gentle air flow to keep skin cool, dry and protected from moisture, friction, and heat—factors that contribute to pressure sores) was not observed in Patient 2’s room at the time of the visit. She was awake and able to talk. Patient 2 complained of pain in her right thigh and RN 2 administered Patient 2’s pain medication. RN 2 informed Patient 2 he would call the doctor to see if the dose could be increased. During the visit RN 2 also provided ordered wound care.During an interview on June 24, 2026, at 12:15 PM, with the Care Giver (CG) at Patient 2’s ALF (CG/ALF), the CG/ALF stated she had been a CG for the facility for the past two years. The CG/ALF stated non‑ambulatory patients were repositioned every two hours, provided the patient consented to being repositioned. The CG/ALF stated Patient 2 refused at times to be repositioned.During a telephone interview on June 24, 2026, at 11:22 AM, with the Administrator of Patient 2’s ALF (Admin/ALF), the Admin/ALF stated the facility had staff available 24 hours a day, seven days a week, to provide patient care services. The Admin/ALF stated the staff included Licensed Vocational Nurses (LVNs) for wound dressing changes but only for a stage one pressure sore (intact skin that shows a persistent area of redness over a bony area and does not blanch (turn white) when pressed) or minimally open skin such as a skin tear. The Admin/ALF stated the facility was not licensed to provide skilled nursing services and Patient 2’s wounds were too severe for the facility’s LVN to provide the required care. The Admin/ALF stated it was the Hospice agency’s responsibility to care for Patient 2’s wounds. The Admin/ALF stated the ALF’s staff repositioned bed bound (unable to get out of bed on their own and must remain in bed for all daily activities, relying on others for movement and positioning) patients every two hours; however, although Patient 2 was bed bound and too weak to reposition herself, she refused repositioning regularly. The Admin/ALF stated she told her staff to leave Patient 2 in her preferred position because it was a patient’s right to refuse care.During a review of Patient 2’s “Skin Assessment,” dated May 26, 2026, performed by RN 2, the “Skin Assessment” indicated, worsening of Patient 2’s pressure related wounds upon admission and two additional pressure related wounds:a. Wound 1: Unstageable pressure sore on the mid upper sacrum. A stage two (an open, shallow wound or blister where the top layers of skin are lost) wound next to it was now part of the sacrum sore. Size: length 6.5 cm, width 5.5 cm, and depth 0.2 cm (an increase of length by 2.5 cm, width by 1 cm, and depth by 0.2 cm in 23 days).b. Wound 2: Unstageable pressure sore on the right buttock. Size: length 2.5 cm, width 2 cm, and depth 0.1 cm (an increase of length by 1 cm, width by 0 cm, and depth by 0.1 cm in 23 days).c. Wound 3: The stage two left buttocks wound was now part of Wound 1.d. Wound 4: Right foot, great toe; no stage or measurements were written down. (Wound 4 was not present at the start of care.)e. Wound 5: Right ankle stage three (a deep wound open to the fat layer underneath) pressure sore. Size: length 5 cm, width 5 cm, and depth 0.2 cm. (Wound 5 was not present at the start of care.)During a review of Patient 2’s plan of care dated from May 3, 2026, to June 24, 2026, indicated no documented evidence to show Patient 2’s plan of care had been updated to address Patient 2’s refusals to be repositioned every two hours. The plan of care also indicated no documented evidence to show further pressure-relieving interventions to include an alternating pressure mattress, or a low‑air‑loss mattress, or a bed cradle (an elevated frame that holds the weight of heavy bedding off the feet and toes, eliminating friction and pressure).During a review of Patient 2’s Interdisciplinary Group (IDG—the hospice care team) Meeting Note, dated June 16, 2026, indicated the meeting was attended by RN 2 and the Medical Director (MD) and the documentation indicated:“Last 2 Weeks: … Patient continues to decline functionally and remains fully bed bound … Patient is alert and oriented to person, place, and date, with intermittent confusion regarding time. She is blind [both eyes] but is able to verbalize needs effectively. … Patient requires assistance with [ADL‑activities of daily living], retaining only the ability to feed herself. … Over the past two weeks, Patient has demonstrated worsening skin integrity with multiple wounds requiring physician review and updated wound care orders. Current wounds include Unstageable sacral wound with eschar, now encompassing a previously adjacent Stage 2 wound; Stage 2 pressure injury to right upper buttock; new Stage 2 pressure injury to right lateral heel; Unstageable wound to right great toe. Pain associated with repositioning and wound care has increased, requiring premedication … Ongoing Interventions: Skilled nursing assessments for disease progression and symptom management. … Ongoing wound care per physician orders: … Repositioning education and reinforcement to prevent further skin breakdown. … Team Update: … Interdisciplinary team continues to monitor Patient closely due to … increasing skin breakdown, pain associated with wound care, and overall functional decline. Physician notified regarding worsening wounds and discomfort associated with dressing changes. New wound care orders obtained and implemented. Facility staff … educated regarding wound care regimen, pressure relief measures, repositioning schedule, pain management, and monitoring for signs of infection or further deterioration.”The Interdisciplinary Group Meeting Note had no documented evidence to show RN 2 notified the IDG of Patient 2’s refusals to be turned or about using pressure-relieving equipment. There was no documented evidence to show interventions to address Patient 2’s refusals to be repositioned every two hours or the use of pressure relieving devices. During an interview on June 24, 2026, at 12:00 PM with RN 2, RN 2 stated he had been Patient 2’s case manager from May 3, 2026, to June 8, 2026, and RN 3 took over as Patient 2’s case manager on June 9, 2026. RN 2 stated he was aware Patient 2 did not want to be repositioned since admission; therefore, facility staff did not reposition her every two hours because it would go against Patient 2’s wishes. RN 2 stated he asked Patient 2 why she was refusing to be repositioned, but Patient 2 spoke very little, maybe a word or two, so he did not receive an answer. RN 2 stated he conducted Patient 2’s wound assessment on May 26, 2026, and was aware her wounds had worsened and two more pressure sores had appeared. RN 2 stated he had not updated Patient 2’s care plan to address her refusals to reposition or the need for pressure relieving equipment.During an interview on June 24, 2026, at 1:52 PM, with the Director of Patient Care Services (DPCS), the DPCS stated once Patient 2’s pressure sores worsened and increased on May 26, 2026, RN 2 was responsible for updating Patient 2’s plan of care with pressure relieving devices. The DPCS stated RN 2 did not clearly communicate the level or severity of Patient 2’s refusals to be repositioned every two hours during the IDG meeting. The DPCS stated if he had communicated this information clearly, she would have arranged a care planning meeting to address the issue; however, because she did not understand the severity of the refusals, she did not do so.During an interview on June 25, 2026, at 9:00 AM, with RN 3, RN 3 stated she had taken over as the case manager for Patient 2 on June 9, 2026, while RN 2 continued to assist with Patient 2’s care. RN 3 stated she had not yet attended an IDG meeting for Patient 2, as RN 2 was attending those meetings at this time. RN 3 stated she was not aware Patient 2 had been refusing to be repositioned every two hours during her first visit on June 9, 2026. RN 3 stated during her visit on June 12, 2026, a staff member at the ALF informed her Patient 2 had been refusing care. RN 3 further stated Patient 2 had not refused treatments or repositioning from her. RN 3 stated Patient 2 was able to speak clearly and answered questions appropriately. RN 3 stated when Patient 2 was resistive, she was able to talk with her and obtain her cooperation. RN 3 stated, “If put in simple terms, I believe she is able to comprehend and agree to the care and repositioning.” RN 3 stated she did not consider the use of pressure relieving devices for Patient 2’s pressure sores. RN 3 stated Patient 2’s pressure sores would not heal solely by changing wound treatment orders; one would have to remove the pressure from the wounds.During a review of the agency’s policy and procedure titled, “The Plan of Care,” dated May 2022, indicated, “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 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. … The plan will focus on identified problems, goals, and interventions. … PROCEDURE: … 7. Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to evaluate progress toward goals. 8. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes. 9. The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group … based on ongoing comprehensive assessments of the patient and family/caregiver. Review of the plan of care will be documented in the clinical record. … 10. Any change in the patient’s condition must result in a change in the plan of care, prior to implementation of the new service.””

“Based on observation, interview, and record review, the agency failed to provide a collaborative and functional Interdisciplinary Group (IDG — a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) for one of four sampled patients (Patient 2) when the Registered Nurse (RN 2) failed to communicate and share critical information regarding Patient 2’s frequent refusals to be repositioned with the incoming Case Manager (RN 3) and the Director of Patient Care Services (DPCS). This failure resulted in uncoordinated care, a lack of interdisciplinary intervention to address barriers to care which led to further deterioration of Patient 2’s skin integrity, worsening of wounds and the development of two more acquired wounds while admitted to the agency. Findings: During a review of Patient 2’s face sheet (basic information about the patient), undated, the face sheet indicated a start of care date of May 3, 2026, with a benefit period from May 3, 2026, through July 1, 2026 (Benefit Period Eight). The face sheet indicated Patient 2 had a terminal diagnosis of Hypertensive heart disease with heart failure (unmanaged high blood pressure causes heart damage, and the heart cannot pump enough blood to meet the body’s needs).A review of Patient 2’s “Skin Assessment,” dated May 3, 2026, the “Skin Assessment” indicated Patient 2 had three pressure related wounds:a. Wound 1: Unstageable (dead, hardened skin tissue covers the wound base. Because the depth cannot be seen, a stage or severity rating cannot be assigned) pressure sore on the mid upper sacrum (the lower back right above the tailbone). Size: length 4 cm (centimeters-a unit of measurement), width 4.5 cm, and depth could not be measured.b. Wound 2: Unstageable pressure sore on the right buttock (butt cheek). Size: length 1.5 cm, width 2 cm, and depth could not be measured.c. Wound 3: DTI (Deep Tissue Injury—purple or maroon intact skin due to damage underneath from pressure) on the left buttock. Size: length 1 cm, width 1 cm, and depth could not be measured.During a review of Patient 2’s “Skin Assessment,” dated May 26, 2026, performed by RN 2, the “Skin Assessment” indicated worsening of Patient 2’s pressure related wounds upon admission and two additional pressure related wounds:a. Wound 1: Unstageable pressure sore on the mid upper sacrum. A stage two (an open, shallow wound or blister where the top layers of skin are lost) wound next to it was now part of the sacrum sore. Size: length 6.5 cm, width 5.5 cm, and depth 0.2 cm (an increase of length by 2.5 cm, width by 1 cm, and depth by 0.2 cm in 23 days).b. Wound 2: Unstageable pressure sore on the right buttock. Size: length 2.5 cm, width 2 cm, and depth 0.1 cm (an increase of length by 1 cm, width by 0 cm, and depth by 0.1 cm in 23 days).c. Wound 3: The stage two left buttocks wound was now part of Wound 1.d. Wound 4: Right foot, great toe; no stage or measurements were written down. (Wound 4 was not present at the start of care.)e. Wound 5: Right ankle stage three (a deep wound open to the fat layer underneath) pressure sore. Size: length 5 cm, width 5 cm, and depth 0.2 cm. (Wound 5 was not present at the start of care.)During an observation on June 24, 2026, at 11:00 AM, at Patient 2’s Assisted Living Facility (ALF—a facility that helps with everyday tasks like bathing and medication) with RN 2, Patient 2 was lying on her right side on a mattress awake and alert. An alternating pressure mattress (a mattress that pumps air in and out to shift body weight and relieve skin pressure) or a low air loss mattress (a mattress that blows a gentle air flow to keep skin cool, dry and protected from moisture, friction, and heat—factors that contribute to pressure sores) was not observed in Patient 2’s room. Patient 2 was awake and able to talk. Patient 2 complained of pain in her right thigh and RN 2 administered Patient 2 pain medication. RN 2 informed Patient 2 he would call the doctor to see if the dose could be increased. During the visit RN 2 provided ordered wound care.During an interview on June 24, 2026, at 12:15 PM, with the Care Giver (CG) at Patient 2’s ALF (CG/ALF), the CG/ALF stated she had been a CG for the facility for the past two years. The CG/ALF stated non‑ambulatory patients were repositioned every two hours, provided the patient consented to being repositioned. The CG/ALF stated Patient 2 refused at times to be repositioned.During a telephone interview on June 24, 2026, at 11:22 AM, with the Administrator of Patient 2’s ALF (Admin/ALF), the Admin/ALF stated the facility had staff available 24 hours a day, seven days a week, to provide patient care services. The Admin/ALF stated the staff included Licensed Vocational Nurses (LVNs) for wound dressing changes but only for a stage one pressure sore (intact skin that shows a persistent area of redness over a bony area and does not blanch (turn white) when pressed) or minimally open skin such as a skin tear. The Admin/ALF stated the facility was not licensed to provide skilled nursing services and Patient 2’s wounds were too severe for the facility’s LVN to provide the required care. The Admin/ALF stated, it was the Hospice agency’s responsibility to care for Patient 2’s wounds. The Admin/ALF stated the ALF’s staff repositioned bed bound (unable to get out of bed on their own and must remain in bed for all daily activities, relying on others for movement and positioning) patients every two hours; however, although Patient 2 was bed bound and too weak to reposition herself, she refused repositioning regularly. The Admin/ALF stated she told her staff to leave Patient 2 in her preferred position because it was a patient’s right to refuse care.During a review of Patient 2’s Interdisciplinary Group (IDG—the hospice care team) Meeting Note dated June 16, 2026, the Interdisciplinary Group Meeting Note indicated attendance by RN 2 and the Medical Director (MD) and the documentation indicated:“Last 2 Weeks: … Patient continues to decline functionally and remains fully bed bound … Patient is alert and oriented to person, place, and date, with intermittent confusion regarding time. She is blind [both eyes] but is able to verbalize needs effectively. … Patient requires assistance with [ADL‑activities of daily living], retaining only the ability to feed herself. … Over the past two weeks, Patient has demonstrated worsening skin integrity with multiple wounds requiring physician review and updated wound care orders. Current wounds include Unstageable sacral wound with eschar, now encompassing a previously adjacent Stage 2 wound; Stage 2 pressure injury to right upper buttock; new Stage 2 pressure injury to right lateral heel; Unstageable wound to right great toe. Pain associated with repositioning and wound care has increased, requiring premedication … Ongoing Interventions: Skilled nursing assessments for disease progression and symptom management. … Ongoing wound care per physician orders: … Repositioning education and reinforcement to prevent further skin breakdown. … Team Update: … Interdisciplinary team continues to monitor Patient closely due to … increasing skin breakdown, pain associated with wound care, and overall functional decline. Physician notified regarding worsening wounds and discomfort associated with dressing changes. New wound care orders obtained and implemented. Facility staff … educated regarding wound care regimen, pressure relief measures, repositioning schedule, pain management, and monitoring for signs of infection or further deterioration.”The Interdisciplinary Group Meeting Note had no documented evidence to show RN 2 notified the IDG of Patient 2’s refusals to be turned or about using pressure-relieving equipment. There was no documented evidence to show interventions to address Patient 2’s refusals to be repositioned every two hours or the use of pressure relieving devices.During an interview on June 24, 2026, at 12:00 PM, with RN 2, RN 2 stated he had been Patient 2’s case manager from May 3, 2026, to June 8, 2026, and RN 3 took over as Patient 2’s case manager on June 9, 2026. RN 2 stated he was aware Patient 2 did not want to be repositioned since admission; therefore, facility staff did not reposition her every two hours because it would go against Patient 2’s wishes. RN 2 stated he asked Patient 2 why she was refusing to be repositioned, but Patient 2 spoke very little, maybe a word or two, so he did not receive an answer. RN 2 stated he conducted Patient 2’s wound assessment on May 26, 2026, and was aware her wounds had worsened and two more pressure sores had appeared. RN 2 stated he had not updated Patient 2’s care plan to address her refusals to reposition or the need for pressure relieving equipment.During an interview on June 24, 2026, at 1:52 PM, with the Director of Patient Care Services (DPCS), the DPCS stated that once Patient 2’s pressure sores worsened and increased on May 26, 2026, RN 2 was responsible for updating Patient 2’s plan of care with pressure relieving devices. The DPCS stated RN 2 did not clearly communicate the level or severity of Patient 2’s refusals to be repositioned every two hours during the IDG meeting. The DPCS stated if he had communicated this information clearly, she would have arranged a care planning meeting to address the issue; however, because she did not understand the severity of the refusals, she did not do so.During an interview on June 25, 2026, at 9:00 AM, with RN 3, RN 3 stated she had taken over as the case manager for Patient 2 on June 9, 2026, while RN 2 continued to assist with Patient 2’s care. RN 3 stated she had not yet attended an IDG meeting for Patient 2, as RN 2 was attending those meetings at this time. RN 3 stated she was not aware Patient 2 had been refusing to be repositioned every two hours during her first visit on June 9, 2026. RN 3 stated during her visit on June 12, 2026, a staff member at the ALF informed her Patient 2 had been refusing care. RN 3 further stated Patient 2 had not refused treatments or repositioning from her. RN 3 stated Patient 2 was able to speak clearly and answered questions appropriately. RN 3 stated when Patient 2 was resistive, she was able to talk with her and obtain her cooperation. RN 3 stated, “If put in simple terms, I believe she is able to comprehend and agree to the care and repositioning.” RN 3 stated she did not consider the use of pressure relieving devices for Patient 2’s pressure sores. RN 3 stated Patient 2’s pressure sores would not heal solely by changing wound treatment orders; one would have to remove the pressure from the wounds.During an interview with the Physician Designee (PD) on June 25, 2026, at 9:30 AM, the PD stated she was covering the duties of the Medical Director (MD), who was currently out of the country. The PD stated she had not yet attended an IDG meeting for Patient 2; however, she explained that the members of the IDG needed to work together in a coordinated manner and identify a way to relieve the pressure on Patient 2’s wounds.During a review of the agency’s policy and procedure titled, “Interdisciplinary Group Plan of Care,” dated May 2022, indicated, “PURPOSE: To ensure the coordination of services for each patient. ... PROCEDURE: … 3. It will be the responsibility of the Case Manager to facilitate communication about changes in the patient’s status between interdisciplinary group members and the patient’s attending physician. 4. [Name of agency] personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. ... 11. Continuity of care will be maintained throughout the patient’s course with hospice. Exchange of information between healthcare providers and contracted providers will be documented in the clinical record. ...””

“Based on interview and record review, the agency failed to follow their policy and procedure titled, “Revocation of Hospice Benefit,” dated May 2022, for one of four sampled patients (Patient 1) when the hospice agency did not obtain a signed revocation of election of hospice care statement (patient-initiated choice to stop receiving Medicare-covered hospice care), place the statement in the clinical record, identify the physician taking over Patient 1’s care, or provide that physician with a copy of the discharge summary.This failure resulted in no documented evidence Patient 1 was aware of the revocation of hospice care and had the potential to cause a breakdown in care coordination by not ensuring Patient 1’s physician received required information at the time of revocation. Findings: During a review of Patient 1’s face sheet (basic information about the patient), undated, the face sheet indicated a start of care date of December 24, 2025, with a benefit period from June 22, 2026, through August 20, 2026 (Benefit Period Eight), and was discharged from the hospice agency to an acute care hospital on June 10, 2026. The face sheet indicated Patient 1 had a terminal diagnosis of Alzheimer`s disease (a brain disorder that slowly and permanently damages memory and thinking and eventually makes it hard to do everyday tasks).During a review of Patient 1’s discharge summary dated June 10, 2026, by a Registered Nurse (RN 1), the discharge summary indicated, “Patient received hospice services until she elected to revoke hospice care. Education provided regarding hospice philosophy, goals of care, and implications of revocation. Revocation processed per protocol. Hospice services were appreciated and delivered in alignment with patient goals until revocation. On [June 10, 2026], [Patient 1] revoked from hospice care to seek aggressive treatment. …” A review of Patient 1’s electronic clinical record from December 24, 2025, to June 23, 2026, was conducted. There was no documented evidence to show a signed revocation of election of hospice care statement, a physician’s discharge order, identification of the physician taking over Patient 1’s care, or that the physician had been provided a copy of Patient 1’s discharge summary.During an interview on June 23, 2026, at 2:55 PM, with the Director of Patient Care Services (DPCS), the DPCS confirmed Patient 1’s clinical record did not contain a signed revocation of election of hospice care statement or a physician’s discharge order. The DPCS stated Patient 1’s receiving physician had not been identified and had not been sent Patient 1’s discharge summary. The DPCS stated the agency’s policy and procedure titled “Revocation of Hospice Benefit,” dated May 2022, was not followed. During an interview on June 23, 2026, at 3:18 PM, with a Registered Nurse (RN 1), RN 1 confirmed he had written Patient 1’s discharge summary. RN 1 stated he had only been seeing Patient 1 for one week prior to Patient 1’s discharge and learned about the discharge to the acute care hospital through the agency’s communication stream including emails, texts, and a communication software application. RN 1 stated he did not know why Patient 1 was sent to the hospital. RN 1 stated a signed revocation of election of hospice care statement was not obtained. RN 1 further stated he did not have any contact with Patient 1 or Patient 1’s family during or after the discharge process.During a review of the agency’s policy and procedure titled “Revocation of Hospice Benefit,” dated May 2022, indicated, “PURPOSE: To ensure that the patient’s right to revoke the Medicare or Medicaid hospice benefit is understood and properly applied. POLICY: A patient and family/caregiver may revoke the election of hospice care at any time. In order to revoke this care, a revocation of election of hospice care statement (NOTR) must be signed and filed in the patient’s clinical record. Revoking the Medicare or Medicaid hospice benefit is the patient’s and family/caregiver’s choice. In revoking these benefits, the individual forfeits coverage for any remaining days in that election period. Any individual can in the future sign onto remaining election periods as long as he/she meets admission criteria. An individual may not designate an effective date earlier than the date the revocation of election of hospice care statement was signed. PROCEDURE: 1. The patient will choose to revoke his/her election of hospice benefit when he/she: A. Elects active treatment, inconsistent with the role of palliative hospice care. B. Moves beyond the geographical service area of the hospice and cannot be transferred to another hospice provider. C. Chooses to withdraw from the program with or without cause. 2. The Case Manager will facilitate the patient’s revocation and assist with a smooth transition to another setting or independent care. 3. The Case Manager will notify the attending physician and interdisciplinary group about the revocation and reason. A discharge summary will be sent to the attending physician. 4. A revocation of election of hospice care statement will be signed by the patient and will document the date, time, and reason for revocation. A copy will be sent to billing and will be retained in the clinical record. The organization will submit the NOTR to the Medicare contractor (MAC) within 5 calendar days of the date on the notice. 5. Relevant information will be documented in the clinical record by the Case Manager and/or Clinical Supervisor. …””

“Based on interview and record review, the agency failed to ensure the discharge summary contained all required elements and was provided to the receiving physician for one of four sampled patients (Patient 1) when Patient 1’s discharge summary did not include: a summary of Patient 1’s stay with treatments, symptoms, and pain management; Patient 1’s current plan of care and latest physician orders; the reason for discharge and the name of the organization to which Patient 1 was being transferred; discharge orders, instructions, medication profile, and allergies; the status and resolution of problems identified at admission and during care; continuing pain and symptom management needs; the overall status of the patient at discharge; or a summary of the care or services provided and ongoing unmet needs. This failure had the potential to cause confusion or delays in Patient 1’s care, make it harder for the receiving physician to understand Patient 1’s needs, and increase the risk that important care needs would not be met during the transition. Findings: During a review of Patient 1’s face sheet (basic information about the patient), undated, the face sheet indicated a start of care date of December 24, 2025, with a benefit period from June 22, 2026, through August 20, 2026 (Benefit Period Eight), and was discharged from the hospice agency to an acute care hospital on June 10, 2026. The face sheet indicated Patient 1 had a terminal diagnosis of Alzheimer`s disease (a brain disorder that slowly and permanently damages memory and thinking and eventually makes it hard to do everyday tasks).During a review of Patient 1’s discharge summary dated June 10, 2026, by a Registered Nurse (RN 1), indicated, “Patient received hospice services until she elected to revoke hospice care. Education provided regarding hospice philosophy, goals of care, and implications of revocation. Revocation processed per protocol. Hospice services were appreciated and delivered in alignment with patient goals until revocation. On [June 10, 2026], [Patient 1] revoked from hospice care to seek aggressive treatment. Hospice services were provided in accordance with patient goals of care and remained appropriate throughout the episode. Skilled nursing assessment, interventions, and professional judgement were required due to ongoing symptom burden, disease progression, and caregiver needs. Episode of care concluded following patient revocation in accordance with hospice protocol.”A review of Patient 1’s electronic clinical record from December 24, 2025, to June 23, 2026, was conducted. There was no documented evidence to show a signed revocation of election of hospice care statement, a physician’s discharge order, identification of the physician taking over Patient 1’s care, or that the physician had been provided a copy of Patient 1’s discharge summary.During an interview on June 23, 2026, at 3:18 PM, with a Registered Nurse (RN 1), RN 1 confirmed he had written Patient 1’s discharge summary. RN 1 stated he had only been seeing Patient 1 for one week prior to Patient 1’s discharge and learned about the discharge to the hospital through the agency’s communication stream, which utilized emails, texts, and a communication software application. RN 1 stated he did not know why Patient 1 was sent to the hospital and did not obtain a signed revocation of election of hospice care statement or have any contact with Patient 1 or Patient 1’s family during or after the discharge process.During an interview on June 23, 2026, at 2:55 PM, with the Director of Patient Care Services (DPCS), the DPCS confirmed Patient 1’s discharge summary did not include a summary of Patient 1’s stay with treatments, symptoms, and pain management; Patient 1’s current plan of care and the latest physician orders; the reason for discharge and the name of the organization to which Patient 1 was being transferred; discharge orders, instructions, medication profile, and allergies; the status and resolution of problems identified at admission and during care; continuing pain and symptom management needs; the overall status of the patient at discharge; or a summary of the care or services provided and ongoing unmet needs. The DPCS further confirmed Patient 1’s receiving physician had not been identified and had not been sent Patient 1’s discharge summary. During a review of the agency’s policy and procedure titled “Discharge Summary,” dated May 2022, indicated, “PURPOSE: To define the requirements for documentation of a discontinuation of a service and when patients are discharged from hospice. POLICY: All patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record. PROCEDURE: 1. Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued, which may include, as appropriate: A. The date of discharge, the date the physician and patient informed of discharge. B. The reason for discharge, including the name of the organization to which the patient is being transferred, if applicable. C. Patient identifying information. D. Contact person receiving report and date and time report given. E. Patient’s physician. F. Diagnoses related to discharge. G. Significant health history. H. Discharge orders, instructions, medication profile and allergies. I. The status of problems identified at admission and during the provision of care. J. The resolution of identified problems. K. Continuing pain and symptom management needs. L. The overall status of the patient at discharge. M. A summary of the care or services provided and ongoing needs that cannot be met. N. The patient’s current plan of care. 0. The patient’s latest physician orders. P. Presence of Advance Directive. Q. End of life decisions. … 4. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service. 5. A copy of the discharge summary will be provided to the patient’s attending physician. If requested, the patient’s clinical records will be provided. 6. Hospice will complete all necessary audits to determine the completeness of the patient’s clinical record within 30 days of the last hospice visit and discharge date. The discharge record will be organized according to policy for clinical records contents and removed from the active files.””

“Upon patient record review, 1 of 20 (Patient #10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #10: During patient visit, noted discrepancies between SNF med profile and hospice med profile. SNF profile includes patient med dosages: Fentanyl Patch (1) 100 mcg/hr. patch and (1) 25 mcg/hr. patch beginning 1/17/26. Hospice has Fentanyl 150 mcg (1) patch transdermal every 72 hrs. effective 1/18/26. SNF med profile has 1/16/26 Hydromorphone 1mg/ml (4) ml q2hrs PRN. Hospice med profile has 1/18/26 (6) ml q 2 hrs. prn. (Hospice staff followed up with facility to reconcile upon discussion.)”

“Upon patient record review, 3 of 20 (Patient #1, 7, 10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: Admitted with Xarelto and Eliquis. IDG Care Plan did not include problems, goals interventions related to bleeding precautions initially. (Med discontinued 1/16 and 1/15/26). Also, patient has Keppra prescribed for seizures with no problems, goals, interventions related to seizure precautions. Patient #7: Patient admitted with Keppra prescribed for seizures,with no problems, goals, interventions related to seizure precautions. Patient #10: Patient has multiple meds prescribed for seizures with no problems, goals, interventions related to seizure precautions.”

“Upon patient record review, 2 of 20 (Patient #4, 9) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #4: Patient admitted with order for oxygen 15 lpm per Oximyzer continuously. IDG problems, goals interventions for respiratory problem, show oxygen at 2lpm. and does not specify rate of prn or continuous. 1/2/26 order to decrease to 4lpm, but no update to flow rate at that time. Patient #9: Patient admitted with fungating tumor of chest. Orders for change in wound treatment 1/7/26 Xeroform to CA Alginate with no update to problems, goals and interventions through 1/20/26 IDG. Updated prior to end of survey.”

“Upon client record review, 3 of 20 (Patient #2, 4, 17) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: 12/13/25 Physician order: May have volunteer evaluation. No documented evidence services provided or declined. Patient #4: 12/14/25 Physician order: May have volunteer evaluation. No documented evidence services provided or declined. Patient # 17: Patient order for oxygen 2lpm via NC. 2/3/25, day of patient death, oxygen was increased by hospice nurse to 5lpm via nasal cannula related to dyspnea, but nurse failed to document order for increase.”

“Upon patient record review, 6 of 20 (Patient #1, 2, 4, 7, 8,10) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: Oxygen prescribed with no oxygen precautions addressed in Aide Care Plan. Xarelto and Eliquis prescribed with no bleeding precautions. Keppra prescribed with no seizure precaution addressed in Aide Care Plan. Patient #2: Oxygen prescribed with no oxygen precautions addressed in Aide Care Plan. Patient#4: Oxygen prescribed with no oxygen precautions addressed in Aide Care Plan. Rate was initially 15 lpm via Oxymizer continuously for sob. 1/2/26 order to decrease to 4 lpm with no update to Aide Care Plan. Patient prescribed Xarelto with no bleeding precaution addressed in Aide Care Plan. Patient t#7: Keppra prescribed with no seizure precautions addressed in Aide Care Plan. Patient #8: Oxygen prescribed with no oxygen precautions addressed in Aide Care Plan. Eliquis prescribed with no bleeding precautions addressed in Aide Care Plan. Patient #10: Oxygen prescribed with no oxygen precautions addressed in Aide Care Plan. Patient has multiple seizure medications prescribed with no seizure precautions addressed in Aide Care Plan.”

“Upon patient client record review, 2 of 20 (Patient #14, 20) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #14: 12/23/25 visit SN removed and replaced Foley catheter. The nurse did not document details including if/how much balloon deflated prior to removal and did not document details of prep/insertion/size of catheter or balloon. Patient #20: Contracted staff providing continuous care, BS, LVN signature not legible and typed name is first name only.”

“Upon patient record review, 2 of 5 (Patients #2 and 3) did not contain evidence that all entries were clear and complete: Patient #2: SOC 07/12/25. This documentation noted that the patient had a deep tissue injury (DTI) to the ‘right’ heel, with accompanying orders for wound care. The LVN made a follow-up visit on 07/13/25, and documented this DTI to be located on the ‘left’ heel. This is unclear documentation. Patient #3: SOC 07/14/25. The record noted that the patient had a left lateral, anterior head hematoma with abrasion, with accompanying orders for daily wound care, and daily use of ice packs. An LVN made a follow-up visit on 07/15/25. The documentation noted the presence, and observation, of this injury site. However, there was no documented description of the site status.”

“Upon patient record review, 7 of 7 (Patient #1,#2,#3,#4,#5,#6,#7) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1,#2,#3,#4,#5,#6,#7:The record indicates LVN made visit in which vital signs were taken, questions asked regarding pain, and regarding if any respiratory issues. There is no evidence of any problems, goals, and to any patient issues in place for prior to LVN visit. Patient#2: The LVN indicates in documentation for tuck in visit on 12/6/24 that patient was experiencing dyspnea and obtained an order for oxygen 3lpm via NC continuous. Prior to RN initial assessment, LVN made a second visit on 2/7 during which LVN documents patient experiencing dyspnea and discomfort. LVN obtained order for additional dose of morphine. The hospice MD then came to facility during this visit and gave an order for facility to give Morphine every 2 hours as needed. There is no evidence of problems, goals, and interventions related to pain or respiratory needs. Patient#4: Per LVN documentation for “tuck in” visit 1/29, the LVN performed wound care cleaning an open wound on coccyx with normal saline, patting dry, and covering with silicone dressing. Documentation for the 1/29 LVN visit also indicates LVN emptied the ileostomy bag. There is no evidence of problems, goals, and interventions related to these needs. Patient#6: The LVN indicates during tuck in visit on 2/3/25 that patient was short of breathe. This was resolved with use of oxygen. There is no evidence of problems, goals, and interventions related to these needs.”

“Upon patient record review, 7 of 7 (Patient #1,#2,#3,#4,#5,#6,#7) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1,#2,#3,#4,#5,#6,#7: The record indicates the order for the LVN visit states “SN x 1 for wellness”. However, this order is not specific to the scope of care for the visit.”

“Upon client record review, 3 of 7 (Patient #4,#6,#7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4,#6,#7: The record indicates LVN made “tuck in” visit at which the LVN completed vital signs, checked for pain and for SOB. There is no evidence of an order of plan of care related to this care. Patient#4: The record indicates LVN made “tuck in” visit at which the LVN completed care to an open wound and emptied ileostomy bag. There is no evidence of an order of plan of care related to these needs.”

“Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There is no evidence the governing body/Administrator is providing oversight of the management of the hospice as evidenced by the agency not following §418.54 Condition of participation: Initial and comprehensive assessment of the patient, § 418.56 Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. Patients were being seen by an LVN and providing hands on care/assessment prior to the RN completing an initial assessment and developing a plan of care.”

“Upon client record review, 4 of 7 (Patient #1,#2,#3,#5) did not have evidence that any changes in the hospice plan of care were discussed with the patient/family and SNF/NF or ICF/IID representatives, and are approved by the hospice before implementation. Patient #1,#2,#3,#5: There is no evidence of of plan of care being discussed with patient/family and the facility, or being approved before implementation or LVN visit being made. Patient#3: LVN visited for “tuck in” 4/22/24 at 630pm. A second LVN made death visit 4/22 at 2300. There is no evidence of a plan of care in place prior to passing of the patient.”