Vida Hospice Services, Inc.

“Based on observation, interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients with 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, care planning, and coordination of services was met as follows: 1.The HA failed to implement the plan of care for one of four sampled patients (Patient 17), who was awaiting possible pacemaker (small electronic device implanted in the body to regulate abnormal heart rhythms) placement, so that Patient 17 received the services necessary to meet the patient-specific needs by failing to: A. Ensure Patient 17 and Patient 17’s caregivers (Primary Care Giver 1 [PCG 1] ) followed the manufacturer’s guidelines for laundering the garment of Patient 17’s wearable defibrillator (non-invasive, vest-like device that continuously monitors heart rhythm and automatically delivers an electric shock to correct any life-threatening rapid and abnormal heart rhythm) so that Patient 17 would not be without the wearable defibrillator for an extended period of time of approximately 21 hours to align with Patient 17’s physician’s order to wear the patient’s prescribed wearable defibrillator at all times, except when bathing or changing the garment, as ordered on 8/29/2025 and indicated on the plan of care. B. Ensure that the Patient 17 and Patient 17’s caregivers (Primary Care PCG 1 and Primary Care Giver 2 [PCG 2]) first obtained Patient 17’s blood pressure (BP, Blood pressure is the amount of force your blood uses to get through your arteries) and heart rate (HR, number of times the heart beats per minute) readings prior to administering carvedilol 3.125 milligrams (mg-unit of measure) and losartan 25 mg orally in order to verify compliance with the physician’s order parameters (specific measurable instructions set by the physician for administering a medication or treatment) to: Hold the carvedilol if systolic blood pressure (SBP- the top number in a blood pressure reading, measuring the force in your arteries when your heart beats and pushes blood out, indicating the pressure when the heart muscle contracts) is below 110 millimeters of mercury (mmHg, unit of measurement of pressure) and heart rate is below 60 beats per minute (BPM). Hold losartan if SBP is below 100 mmHg and diastolic blood pressure (DBP) less than 60 mmHg. C. Ensure the HA licensed nurses clarified Patient 17’s physician order for Lasix (medication to lower BP and reduce fluid buildup in the body) to include the medication’s indication (valid reason that indicates when to use the medication). These failures resulted in Patient 17 being without the prescribed wearable defibrillator on 1/7/2026 to 1/8/2026 for a total of approximately 21 hours placing Patient 17 at an increased risk of serious harm, hospitalization, and death related to potential undetected, untreated life-threatening arrhythmias (abnormal heartbeats); and increased the risk for Patient 17 to experience hypotension (low BP), weakness or fatigue; and shortness of breath that could lead to serious harm, hospitalization, and death (Refer to L549). 2. The HA failed to coordinate care between the HA and the cardiologist (MD 2, a non-hospice physician, who specializes in the study and treatment of heart diseases and abnormalities) of one of four sampled patients (Patient 17), who was awaiting possible pacemaker (small electronic device implanted in the body to regulate abnormal heart rhythms) placement by failing to: Clarify order for LifeVest (wearable defibrillator, non-invasive, vest-like device that continuously monitors heart rhythm and automatically delivers an electric shock to correct any life-threatening rapid and abnormal heart rhythm). Obtain a copy of Patient 17’s “MD 2 Progress Notes,” dated 9/17/2025, to incorporate in Patient 17’s plan of care. Follow up and document Patient 17’s missed and cancelled appointments with MD 2, including appointments cancelled by MD 2 and missed appointments due to Patient 17’s transportation issues or personal reasons. Notify MD 2 that Patient 17 wearable defibrillator delivered an electrical shock to Patient 17 to correct abnormal heart rhythm. This failure had the potential to cause worsening of Patient 17’s heart condition due to the delay in the delivery of care and services related to the lack of continuity of care. (Refer to L558). 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 interdisciplinary group, care planning, and coordination of services to ensure the highest quality of care are being provided to patients certified to receive hospice benefits.”

“Based on observation, interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients with six months or less to live), failed to implement the plan of care for one of four sampled patients (Patient 17), who was awaiting possible pacemaker (small electronic device implanted in the body to regulate abnormal heart rhythms) placement so that Patient 17 received the services necessary to meet the patient-specific needs by failing to: 1.Ensure Patient 17 and Patient 17’s caregivers (Primary Care Giver 1 [PCG 1] ) followed the manufacturer’s guidelines for laundering the garment of Patient 17’s wearable defibrillator (non-invasive, vest-like device that continuously monitors heart rhythm and automatically delivers an electric shock to correct any life-threatening rapid and abnormal heart rhythm) so that Patient 17 would not be without the wearable defibrillator for an extended period of time of approximately 21 hours to align with Patient 17’s physician’s order to wear the patient’s prescribed wearable defibrillator at all times, except when bathing or changing the garment, as ordered on 8/29/2025 and indicated on the plan of care. 2. Ensure that the Patient 17 and Patient 17’s caregivers (Primary Care PCG 1 and Primary Care Giver 2 [PCG 2]) first obtained Patient 17’s blood pressure (BP, Blood pressure is the amount of force your blood uses to get through your arteries) and heart rate (HR, number of times the heart beats per minute) readings prior to administering carvedilol 3.125 milligrams (mg-unit of measure) and losartan 25 mg orally in order to verify compliance with the physician’s order parameters (specific measurable instructions set by the physician for administering a medication or treatment) to:Hold the carvedilol if systolic blood pressure (SBP- the top number in a blood pressure reading, measuring the force in your arteries when your heart beats and pushes blood out, indicating the pressure when the heart muscle contracts) is below 110 millimeters of mercury (mmHg, unit of measurement of pressure) and heart rate is below 60 beats per minute (BPM)Hold losartan if SBP is below 100 mmHg and diastolic blood pressure (DBP) less than 60 mmHg. 3. Ensure the HA licensed nurses clarified Patient 17’s physician order for Lasix (medication to lower BP and reduce fluid buildup in the body) to include the medication’s indication (valid reason that indicates when to use the medication). These failures resulted in Patient 17 being without the prescribed wearable defibrillator on 1/7/2026 to 1/8/2026 for a total of approximately 21 hours placing Patient 17 at an increased risk of serious harm, hospitalization, and death related to potential undetected, untreated life-threatening arrhythmias (abnormal heartbeats); and increased the risk for Patient 17 to experience hypotension (low BP), weakness or fatigue; and shortness of breath that could lead to serious harm, hospitalization, and death. On 1/12/2026 at 12:49 p.m., while onsite at the agency, the Department called an Immediate Jeopardy (IJ, a situation in which the facility’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 Executive Officer (CEO), Director of Patient Care Services/Administrator (DPCS/ADM), and Case Manager (CM), related to the HA’s failure to implement the plan of care to ensure Patient 17, who was awaiting possible pacemaker placement, received the services necessary to meet the patient-specific needs. On 1/12/2026 the HA was unable to submit an IJ Removal Plan (IJRP, a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation). On 1/12/2026 at 4:15 p.m., the Department completed the survey task and conducted an exit conference while onsite with the HA’s CEO, ADM/DPCS, and Case Manager with the IJ situation not removed. Findings: 1. During a review of Patient 17’s medical record, titled “Personal Information,” the “Personal Information” indicated Patient 17 had a start of care (SOC- the date on which a patient begins receiving hospice care) date of 8/29/2025 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, lung disease that cause ongoing inflammation and narrowing of the airways, leading to difficulty breathing) with secondary diagnoses that included pulmonary hypertension ( high pressure of the blood against the arteries in the lungs and the right side of the heart), Atrial Fibrillation (a-fib, irregular and very rapid heart rhythm), and Cardiogenic shock (medical emergency resulting from the inadequate blood flow to the body’s organs due to the dysfunction of the heart). During a review of Patient 17’s medical record, titled “Current Treatment/Medication/Durable Medical Equipment (DME, medical tools and devices designed for long-term, repeated use to help manage a medical condition at home) List,” the “Current Treatment /Medication/DME List” indicated: Order Start Date: 8/29/2025 – wearable defibrillator Note: Turn on wearable defibrillator by inserting battery. Always have the garment on before inserting the battery. Wash it every one to two days. Do not use bleach or fabric softener. Wear the wearable defibrillator all the time and remove only to bathe or change the garment. During a review of Patient 17’s medical record, titled “Plan of Care /Interdisciplinary Group Review (POC/IDG, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors),” dated 1/2/2026, the “POC/IDG Review” included the following: The goal for the cardiovascular (refers to the heart and blood vessels) problem was to keep the wearable defibrillator equipment reliable to serve its purpose and keep Patient 17 safe with the proper maintenance of the wearable defibrillator. The interventions included making sure the equipment was well-maintained as patient’s caregiver follows instructions on its proper maintenance. During an observation, while on a joint home visit at Patient 17’s room in the patient’s current residence on 1/8/2026 at 11:05 a.m. with the Director of Patient Care Services (DPCS), Patient 17 was observed not wearing the prescribed wearable defibrillator. During an interview on 1/8/2026 at 11:50 a.m. with the DPCS, the DPCS stated Patient 17 did not have wearable defibrillator because Patient 17’s wearable defibrillator was washed and being air-dried and was not dry at this time. The DPCS was unable to state how long Patient 17 could safely be without the wearable defibrillator. The DPCS stated Patient 17 was only provided with one garment for Patient 17’s wearable defibrillator (no additional garment for back-up). During an interview on 1/8/2026 at 12:19 p.m., Patient 17 stated she (Patient 17) was not wearing her wearable defibrillator because the wearable defibrillator needed to be washed by PCG 1. Patient 17 stated PCG 1 removed Patient 17’s wearable defibrillator the night before on 1/7/2026. During an interview with PCG 1 on 1/8/2026 at 12:45 p.m., PCG 1 stated that Patient 17’s wearable defibrillator was not available because PCG 1 took Patient 17’s wearable defibrillator home (different place of residence) on 1/7/206 to wash and dry. PCG stated that as of the morning of 1/8/2026, Patient 17’s wearable defibrillator was not yet ready to be worn because the garment was not yet dry as it was still being air-dried at PCG 1’s home. During an interview on 1/8/2026 at 12:55 p.m., the DPCS stated that not following Patient 17’s physician’s order for Patient 17 to wear the wearable defibrillator at all times placed Patient 17 at an increased risk for untreated abnormal arrhythmias, hospitalization, and death. During an interview on 1/9/2026 at 12:03 p.m., the DPCS stated she did not know the type of Patient 17’s wearable defibrillator and did not have a copy of the wearable defibrillator’s manufacturer guidelines to indicate the recommended procedures for washing and drying the wearable defibrillator. The DPCS stated she did not provide specific instructions on how to wash the wearable defibrillator to Patient 17’s caregivers (PCG 1). During a review of Patient 17’s wearable defibrillator manual, dated 2021, the manual indicated the following:Launder the garment every one to two days. Do not wash the electrode belt (device that applies electrical impulses to the skin to stimulate underlying muscles or monitor electrical activity in the body), monitor, or any other accessories.Wash the garment by itself. Do not wash with other laundry.The garment may be hand-washed or machine washed using normal wash cycle and warm water.Use a clothes dryer to dry the garment. Set the clothes dryer to a warm or medium setting. Do not use the high heat setting. 2. During a review of Patient 17’s medical record, titled “Current Treatment/Medication/Durable Medical Equipment (DME) List,” the “Current Treatment /Medication/DME List” indicated:Order Start Date: 8/29/2025 - Carvedilol 3.125 mg 1 tablet orally twice a day with meals. Hold if SBP is less than 110 mmHg and pulse less than 60 BPM. Order Start Date: 10/13/2025 - Losartan potassium 25 mg 1 tablet orally once daily During a review of Nurse Practitioner (NP) 1’s note for Patient 17, titled “Face-to-Face (F2F) Visit Note,” dated 10/12/2025, NP 1’s “F2F Visit Note” indicated the plan was to order losartan 25 mg 1 tablet orally daily and hold the medication if SBP is less than 100 mmHg and DBP is less than 60 mmHg. During a review of Patient 17’s medical record, titled “Plan of Care (POC)/Interdisciplinary Group (IDG) Review,” dated 1/2/2026, the “POC/IDG Review” included the following: The goal for the cardiovascular (refers to the heart and blood vessels) problem was to ensure the BP is maintained within normal limits. The interventions included assessing/monitoring patient’s cardiac status every visit, assessing/monitoring effectiveness of current and new medications/treatments, and instructing patient and patient’s caregiver/s regarding new medication/treatment order and side effects. During an interview and concurrent record review of Patient 17’s home hospice binder, medication list, and medication bottles on 1/8/2026 at 11:50 a.m. with the DPCS, the DPCS stated she instructed PCG 1 to call the HA if Patient 17’s BP and HR readings were outside the order parameters as indicated on the physician’s orders. However, the DPCS stated there was no documented evidence of HA’s monitoring of Patient 17’s BP and HR readings prior to the administration of multiple BP medications. During an interview on 1/8/2026 at 12:10 p.m., PCG 1 stated she was not present to administer Patient 17’s medications in the morning (same day), so PCG 2 placed all of Patient 17’s medications on the bedside table. PCG 1 stated PCG 2 gave all the medications listed on the medication list, including the carvedilol, Lasix, and losartan but did not take the BP and HR prior to the medication administration. PCG 1 stated PCG 2 did not explain what each medication was for because Patient 17 knew all her medications. PCG 1 stated PCG 1 and PCG 2 did not document Patient 17’s daily BP and HR readings as they would usually get an “error” message on the BP monitor (device used to measure and monitor BP and HR, especially in the home setting). During an interview on 1/8/2026 at 12:19 p.m., Patient 17 stated on 1/8/2026 (same day), in the morning, PCG 2 placed a cup containing her daily pills on her chest and she took all the medications but could not identify all the medications. Patient 17 stated PCG 1 was not present during medication administration on 1/8/2026 in the morning. Patient 17 stated she, PCG 1, and PCG 2 did not obtain or attempted to obtain her BP and HR prior to taking all her morning medications on 1/8/2026. Patient 17 stated the HA licensed nurse did not explain during the home visits the indication of each medication. During an interview on 1/8/2026 at 12:55 PM, the DPCS stated she did not specifically instruct Patient 17, PCG 1, and PCG 2 to obtain and document Patient 17’s BP and HR prior to administering the blood pressure medications. The DPCS stated not following Patient 17’s physician’s orders for BP medications and the order parameters for BP and HR placed Patient 17 at an increased risk for hypotension, hospitalization, and death. During an interview and a concurrent review of Patient 17’s clinical records on 1/9/2026 at 12:03 PM with the DPCS, Patient 17’s Registered Nurse (RN) Visit Note, dated 11/4/2025, 11/11/2025, 11/18/2025, 12/2/2025, 12/9/2025, 12/16/2025, 12/23/2025, and 12/30/2025 were reviewed. The DPCS stated the HA licensed nurses must educate Patient 17, PCG 1, and/or PCG 2 to obtain and document Patient 17’s BP and HR to ensure Patient 17’s BP and HR trends and Patient 17’s compliance with the medication orders were monitored. The DPCS stated there was no documented evidence that any patient education was provided to obtain and document the BP readings and HR prior to administering blood pressure medications for Patient 17. 3. During a review of Patient 17’s medical record, titled “Current Treatment/Medication/Durable Medical Equipment (DME) List,” the “Current Treatment /Medication/DME List” indicated:-Order Start Date: 10/13/2025 - Lasix 40 mg 1 tablet orally once a day as needed (PRN). During a review of Patient 17’s medical record, titled “Plan of Care (POC)/Interdisciplinary Group (IDG) Review,” dated 1/2/2026, the “POC/IDG Review” included the following: The goal for the cardiovascular (refers to the heart and blood vessels) problem was to ensure the BP is maintained within normal limits.The interventions included assessing/monitoring patient’s cardiac status every visit, assessing/monitoring effectiveness of current and new medications/treatments, and instructing patient and patient’s caregiver/s on signs and symptoms of impending exacerbation and how to manage. During an interview and concurrent record review of Patient 17’s home hospice binder, medication list, and medication bottles on 1/8/2026 at 11:50 a.m. with the DPCS, Patient 17’s physician order for PRN Lasix and Lasix medication bottle did not include the indication for use of Lasix. The DPCS stated Patient 17’s PRN Lasix was ordered by the physician for Patient 17’s edema (swelling). The DPCS stated Patient 17’s medication order and medication bottle must include the indication for the PRN Lasix to prevent confusion when to administer the Lasix. The DPCS stated Patient 17 had no swelling noted on or reported swelling as of 1/8/2026 at 11:05 a.m. During an interview on 1/8/2026 at 12:19 p.m., Patient 17 stated she was not aware that she took Lasix on 1/8/2025 because Patient 17 did not want to take Lasix because it constantly made her urinate. Patient 17 stated she did not have any generalized swelling in her body. During a review of the HA’s policy and procedures (P&P 1), titled “The Plan of Care,” dated 10/2025, P&P 1 indicated the following:The plan of care must identify the patient’s needs and services to meet those needs. Care decisions and services to be provided must 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.Care provided to the patient must be in accordance with the care plan.The written plan of care must contain, but not limited to:DME and medical supplies necessary to meet patient needs.Patient and caregiver educational needs and assessment of their ability to learn and understand teaching and their ability to safely self-administer drugs and biologicals.All PRN medications must include clear administration parameters, monitoring criteria, and patient/caregiver teaching documentation.”

“Based on observation, interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients with six months or less to live) failed to coordinate care between the HA and the cardiologist (MD 2, a non-hospice physician, who specializes in the study and treatment of heart diseases and abnormalities) of one of four sampled patients (Patient 17), who was awaiting possible pacemaker (small electronic device implanted in the body to regulate abnormal heart rhythms) placement by failing to: 1.Clarify order for LifeVest (wearable defibrillator, non-invasive, vest-like device that continuously monitors heart rhythm and automatically delivers an electric shock to correct any life-threatening rapid and abnormal heart rhythm). 2. Obtain a copy of Patient 17’s “MD 2 Progress Notes,” dated 9/17/2025, to incorporate in Patient 17’s plan of care. 3. Follow up and document Patient 17’s missed and cancelled appointments with MD 2, including appointments cancelled by MD 2 and missed appointments due to Patient 17’s transportation issues or personal reasons. 4. Notify MD 2 that Patient 17 wearable defibrillator delivered an electrical shock to Patient 17 to correct abnormal heart rhythm. This failure had the potential to cause worsening of Patient 17’s heart condition due to the delay in the delivery of care and services related to the lack of continuity of care. Findings:During a review of Patient 17’s medical record, titled “Personal Information,” the “Personal Information” indicated Patient 17 had a start of care (SOC) date of 8/29/2025 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, lung disease that cause ongoing inflammation and narrowing of the airways, leading to difficulty breathing) with secondary diagnoses that included pulmonary hypertension (HTN, high pressure of the blood against the arteries in the lungs and the right side of the heart), heart failure (HF), atrial fibrillation (a-fib, irregular and very rapid heart rhythm), and cardiogenic shock (medical emergency resulting from the inadequate blood flow to the body’s organs due to the dysfunction of the heart). During a review of Patient 17’s medical record, titled “Current Treatment/Medication/Durable Medical Equipment (DME, medical tools and devices designed for long-term, repeated use to help manage a medical condition at home) List,” the “Current Treatment /Medication/DME List” indicated: -Order Start Date: 8/29/2025 – LifeVest (wearable defibrillator, non-invasive, vest-like device that continuously monitors heart rhythm and automatically delivers an electric shock to correct any life-threatening rapid and abnormal heart rhythm) Note: Turn on LifeVest by inserting battery. Always have the garment on before inserting the battery. Wash it every 1-2 days. Do not use bleach or fabric softener. Wear it all the time. Remove it only to bathe or change the garment. During a concurrent observation and interview, while on a joint home visit at Patient 17’s room in her current residence on 1/8/2026 at 11:05 a.m. with the Director of Patient Care Services (DPCS), Patient 17’s HR was 57 BPM. Patient 17 was observed alert and oriented, verbal with pauses in between sentences due to mild to moderate shortness of breath with oxygen saturation (amount of oxygen in the blood) at 93% while on 3 liters of oxygen per minute (L/min) flow rate (amount of oxygen delivered) via nasal cannula (soft, flexible tube with prongs that fit into the nostrils to deliver supplemental oxygen). Patient 17 was observed with generalized weakness, requiring moderate to maximum assistance with the activities of daily living (ADLs), with no generalized swelling noted. Patient 17 was observed not wearing the wearable defibrillator as ordered by the physician. Patient 17 stated she did not know the plan regarding Patient 17’s wearable defibrillator because MD 2’s clinic cancelled several of Patient 17’s previous appointments. Patient 17 stated the most recent appointment on 1/7/2026 (the day prior) was cancelled, because Patient 17’s health insurance coverage changed when the new year started.During a concurrent interview on 1/8/2026 at 12:45 p.m. with the DPCS and PCG 1, the DPCS stated Patient 17 needed to wear the wearable defibrillator before finalizing the plan to implant Patient 17’s pacemaker. PCG 1 stated Patient 17 called the LifeVest hotline the other day and was told by the LifeVest representative that Patient 17 did not need the wearable defibrillator anymore. PCG 1 stated she informed Patient 17 that a physician’s order was still needed for Patient 17 to discontinue wearing the wearable defibrillator. PCG 1 and the DPCS stated there was no physician’s order for Patient 17 to discontinue wearing the wearable defibrillator. The DPCS stated the HA staff did not communicate with MD 2 regarding discontinuing the LifeVest order.During an interview on 1/8/2026 at 12:55 p.m., the DPCS stated the HA did not have the name and contact information of MD 2 on Patient 17’s health records. The DPCS stated there was no documented evidence of any communication regarding the plan for Patient 17’s LifeVest order and the missed MD 2 appointments.During an interview on 1/9/2026 at 10:25 AM, the DPCS stated Patient 17 directly communicated with MD 2’s office to schedule Patient 17’s own appointments with MD 2. The DPCS stated she instructed Patient 17 to report to the HA the plan regarding Patient 17’s wearable defibrillator. The DPCS stated the HA would only coordinate care with MD 2 if a decision to place a pacemaker was finalized. During an interview on 1/9/2026 at 4:16 PM, the DPCS stated PCG 1 did not report to HA any incidents of the wearable defibrillator delivering an electrical shock to Patient 17. The DPCS stated if an electrical shock was delivered by the LifeVest on Patient 17, the HA nurse must notify HA’s Medical Director, MD 2, and the LifeVest hotline to determine the next actions or interventions.During a concurrent interview and record review of Patient 17’s clinical records from outside the HA on 1/12/2026 at 10:56 AM, MD 2 Progress Notes, dated 9/17/2025, was reviewed. The DPCS stated Patient 17 was last seen on 9/17/2025 by MD 2. The DPCS stated MD 2 did not specifically indicate the plan for Patient 17’s LifeVest order and/or pacemaker placement. The DPCS stated MD 2 indicated a plan for follow-up for echocardiogram (echo, a non-invasive test that uses sound waves to create detailed pictures of the heart, showing its structure, chambers, valves, and blood flow to help diagnose heart problems) to evaluate Patient 17’s ejection fraction (EF, a measure of how much blood is pumped out by the main chamber of the heart with each beat) and Holter monitor (small, wearable device that continuously records the heart’s electrical activity for at least 24-48 hours) to evaluate for Patient 17’s atrial flutter (abnormal heart rhythm wherein the heart’s upper chambers beat very fast in an organized pattern) in 3 weeks and to follow up as needed. During an interview on 1/12/2026 at 11:06 AM, the DPCS stated she asked PCG 1 regarding the electrical shock delivered to Patient 17 while under hospice care. The DPCS stated PCG 1 stated she did not report the incident to the HA because she (PCG 1) did not know the wearable defibrillator delivered an electrical shock to Patient 17. The DPCS stated when PCG 1 heard Patient 17 state “I was shocked!” she immediately came to Patient 17’s room to assess Patient 17. The DPCS stated PCG 1 said Patient 17 “looked fine” so PCG 1 “did not think it was an electrical shock but more like an alarm.” The DPCS stated PCG 1 must report all “electrical shocks” delivered to Patient 17 to ensure all staff were aware of what was happening to Patient 17. During a concurrent interview and record review of Patient 17’s clinical records on 1/12/2026 at 11:16 AM, Patient 17’s assessments, visit notes, and communication log were reviewed. The DPCS stated that according to MD 2 clinic staff, Patient 17 had eight (8) scheduled appointments on file with the following notes: 9/17/2025 – Patient 17 was seen by MD 2. 9/22/2025 – Patient 17 cancelled due to “transportation” issues. 9/29/2025 - Patient 17 cancelled due to “transportation” issues. 10/8/2025 - Patient 17 cancelled due to “transportation” issues. 10/15/2025 - Patient 17 cancelled due to “transportation” issues. 11/19/2025 – Appointment cancelled by MD 2’s clinic with no specified reason. 12/10/2025 – Appointment cancelled by MD 2’s clinic with no specified reason. 1/7/2026 – Appointment cancelled by MD 2’s clinic due to insurance issues, pending authorization for Patient 17 to continue care with MD 2. The DCPS stated that the HA “overlooked” the need to request any notes from the MD 2 visit to determine the plan for pacemaker placement and LifeVest order. The DPCS stated the HA nurse informed Patient 17 that the HA could assist with transportation for Patient 17’s scheduled appointments with MD 2. However, the DPCS stated there was no documented evidence that the HA followed up with the missed visits, discussed with Patient 17 the importance of the MD 2 visits, assisted Patient 17 in obtaining transportation, and/or obtained/attempted to obtain any MD 2 notes. The DPCS stated it was important to communicate with MD 2 and/or MD 2 clinic to coordinate Patient 17’s care and ensure the HA and MD 2 were aware of Patient 17’s plan of care with regard to the LifeVest order and pacemaker placement. During a review of the HA’s policy and procedures (P&P 1), titled “Care/Service Coordination,” dated 4/2020, P&P 1 indicated the following:The purpose of P&P 1 was to ensure the coordination of services for each patient and to minimize the potential for missed, conflicting, or duplicated services.Timely and ongoing communication is the responsibility of each team member and must be appropriate to the needs and abilities of the patient and relevant to the care/services provided. The clinician/technician must be responsible for facilitating communication about changes in the patient’s status among the assigned personnel.Organization personnel must communicate changes in a timely manner via telephone, one-on-one meetings, case conferences, and home visits. Documentation of all communications must be included in the clinical record on a communication note, case conference summary, or clinical note. Documentation must include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication.When the patient requires more than one service from the organization, the Case Manager must be responsible for cooperative care planning in order to assure that goals, actions, and the interrelationship of services are not duplicated and to minimize the potential for missed or conflicting services.Written evidence of care coordination may be found in the plan of care/service, case conference summary forms, clinical notes in the patient’s clinical record or interdisciplinary group meeting notes.”

“Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient’s Rights and Responsibilities in a language and manner that the patient understands. Patient 3: There is evidence in the patient record that the admission documents/consents are signed by Board and Care staff with no documented evidence of legal authority. There is a POA signed after admission on 9-4-25 by the Board and Care staff and the patient with clear documentation in the nursing assessment that the patient is unable to sign her own legal documents.”

“Upon patient record review, 1 of 5 (Patient #3) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient 3: There is evidence in the patient record that the admission documents/consents are signed by Board and Care staff with no documented evidence of legal authority. There is a POA signed after admission on 9-4-25 by the Board and Care staff and the patient with clear documentation in the nursing assessment that the patient is unable to sign her own legal documents.”

“Upon patient record review, 1 of 5 (Patient #3) did not have evidence that the hospice obtained the patient’s or representative’s signature confirming that they received a copy of the Patient’s Rights and Responsibilities. Patient 3: There is evidence in the patient record that the admission documents/consents are signed by Board and Care staff with no documented evidence of legal authority. There is a POA signed after admission on 9-4-25 by the Board and Care staff and the patient with clear documentation in the nursing assessment that the patient is unable to sign her own legal documents.”

“Upon observation, there was no evidence the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice. Patient 3: There is evidence in the patient record that the admission documents/consents are signed by Board and Care staff with no documented evidence of legal authority. There is a POA signed after admission on 9-4-25 by the Board and Care staff and the patient with clear documentation in the nursing assessment that the patient is unable to sign her own legal documents.”

“Upon patient record review, 1 of 5 (Patient #3) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient’s rights to the extent allowed by state law. Patient 3: Admission documents/Consents are signed by Board and Care staff with no documented evidence of legal authority. There is a POA signed after admission on 9-4-25 by the Board and Care staff and the patient who has Alzheimer’s and clear documentation with the nursing assessment that the patient is unable to sign her own legal documents.”

“Upon patient record review, 1 of 5 (Patient #3) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient 3:There is evidence in the patient record that the admission documents/consents are signed by Board and Care staff with no documented evidence of legal authority. There is a POA signed after admission on 9-4-25 by the Board and Care staff and the patient with clear documentation in the nursing assessment that the patient is unable to sign her own legal documents.”

“Upon client record review, 1 of 5 (Patient #3) did not have evidence that the plan of care included IDG’s documentation of the patient’s or families level of understanding, involvement and agreement with the plan of care. Patient 3: There is evidence in the patient record that the admission documents/consents are signed by Board and Care staff with no documented evidence of legal authority. There is a POA signed after admission on 9-4-25 by the Board and Care staff and the patient with clear documentation in the nursing assessment that the patient is unable to sign her own legal documents.”

“Upon patient record review, 1 of 5 (Patient #3) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient 3: There is evidence in the patient record that the admission documents/consents are signed by Board and Care staff with no documented evidence of legal authority. There is a POA signed after admission on 9-4-25 by the Board and Care staff and the patient with clear documentation in the nursing assessment that the patient is unable to sign her own legal documents.”

“Upon contract review, 1 of 1 (no contract) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient’s plan of care Unable to abate due to no dialysis contract.”

“Upon client record review, 1 of 5 (Patient #3) did not have evidence that the patient/family receive instruction in the safe use of durable medical equipment and supplies. The hospice may use persons under contract to ensure patient/family are educated. The patient and family can demonstrate the appropriate use of durable medical equipment to the satisfaction of the hospice staff. Patient 3: Admission documents/Consents are signed by Board and Care staff with no documented evidence of legal authority. There is a POA signed after admission on 9-4-25 by the patient who has Alzheimer’s and clear documentation with the nursing assessment that the patient is unable to sign her own consents.”

“Upon patient record review, 1 of 14 (Patient #4) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #4: Readmitted 7/4/25 status post laparotomy and colostomy revision, with orders for incision and colostomy care. 7/23/25 visit patient had pain 9/10. SN observed what she referred to as a “boil” right anal/gluteal fold, that was painful to touch. Had Norco hour prior with partial relief of 7/10. Patient identified pain threshold on this visit is 3. No evidence physician was consulted. No follow up intervention or calls noted. Patient discharged/hospitalized 7/25/25.”

“Upon patient record review, 1 of 14 (Patient #3) 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 #3: During home visit and review of medications, patient verbalizes she is taking different frequency of insulin doses than listed on hospice agency’s current medication profile. Humalog insulin frequency is 3/day on medication profile and patient states she only takes 2 doses/day r/t hypoglycemic episodes. Lantus listed as 2/day on medication profile and patient states she takes ac every meal, ranging 2-3 doses/day, depending on how many meals she eats. Patient not sure date of these changes but “has been a while”.”

“Upon patient record review, 3 of 14 (Patient #5, 6, 13) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #5: Initial bereavement assessment identifies “Twinkle” with facility as primary bereavement contact. MSW initial assessment noted patient has a son who is involved in her care. No documented evidence of bereavement counselor’s attempts to notify and/or assess his bereavement needs. Patient #6: Initial bereavement assessment Angie caregiver, facility staff. MSW initial assessment noted patient has son and sister involved in care. BC/SC documents that patient has a support system that is healthy. No documented evidence of bereavement counselor’s attempts to notify and/or assess family members’ bereavement needs. Patient #13: Initial bereavement assessment with Angie caregiver, facility staff. However, patient has daughter who signed POLST. There is no documented evidence of bereavement counselor’s attempt to notify and/or assess daughter’s bereavement needs.”

“Upon patient record review, 4 of 14 (Patient #1, 2, 3, 4) 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: Patient has Xarelto prescribed since SOC, with no related problems, goals, interventions for bleeding precautions. Patient #2: Initial RN assessment states patient has constipation with order obtained for disposal rectal enema and bladder leakage with order for feminine pads, but there are no related problem, goals, interventions. Clopidogrel prescribed since SOC with no related problems, goals, interventions bleeding precautions. Patient #3:Clopidogrel prescribed since SOC with no related problems, goals, interventions for bleeding precautions. Patient #4: Patient readmitted with abdominal incision and wound care order. There were no related problems, goals and interventions. Eliquis/Apixaban blood thinner prescribed with no related problems, goals, interventions for bleeding precautions.”

“Upon patient record review, 2 of 14 (Patient #13,14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #13: DOS 2/25/25-3/14/25. There was no documented post death bereavement assessment update and no documented efforts to make contact and/or refusal of bereavement services. There was documented evidence of letters sent at intervals. Patient #14: DOS 8/28/24-12/20/24. There was documented post death bereavement assessment 12/20/24 with narrative note stating “SC will contact bereaved when necessary or needed and the bereaved will receive letters from hospice.” There was no documented evidence of any follow up contact or letters/resources sent and no documented refusal of bereavement services”

“Upon personnel record review, 1 of 13 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #5: Competency for shampoo does not specify all three types of shampoo are demonstrated.”

“Upon patient record review, 5 of 14 (Patient #2,3,4,5,9) 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 #2, 5: Assigned tasks include Encourage fluids if not contraindicated, leaving decision making to aide. This needs to be more specific. Patient #3: SOC 2/19/25. 2/19/25 Hospice Aide assignment says patient declined service with no tasks assigned. Note for 2/28 says start next week and subsequent MD order 3/2/25 Hospice Aide 2x/wk. There was no Hospice Aide Assignment sheet update with tasks assignments until 5/13/25, when Hospice Aide Assignment updated with start date of 5/13/25. However, Hospice Aide visits documented as provided 2/week beginning 3/4/25. Patient on Clopidogrel anticoagulant, but bleeding precautions is blank on 5/13/25 Hospice Aide assignment. Patient #4: Patient on Apixaban blood thinner, but bleeding precautions is blank on Hospice Aide assignment sheet. Patient #9: Oxygen 2-5 lpm ordered. Hospice Aide assignment sheet oxygen section is blank.”

“Upon patient record review 1 of 14 (Patient #3) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #3: 2/19/25 Hospice Aide assignment says patient declined service with no tasks assigned. 5/13/25 Hospice Aide Assignment updated with start date of 5/13/25, but Hospice Aide visits began 3/4/25 and continued 2x weekly thru May 8 before Assignment sheet implemented. (2) Hospice Aide visits documented 7/3/25 with no order for additional visit. Staff reports there was a change of staff and both aides inadvertently made visits same day.”

“Upon contract review, 1 of 5 (No Dialysis Contract) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient’s plan of care Upon review, there is no documented evidence of hospice contract with dialysis center. Upon clinical record review for Patient #3, the patient receives Dialysis 3 days/week. The record does not have evidence of hospice IDG/Medical Director’s determination that the dialysis is unrelated (and/or related) to the hospice diagnosis/prognosis.”

“Upon patient client record review, 4 of 14 (Patient #2,4,6,14) did not have evidence that each patient record contains Advance Directives. Patient #4: RN initial assessment documents patient is alert and oriented to time, place, person. MSW initial assessment notes that patient signed her POLST for full code. CTI RN narrative states patient is on full code, but no need to be hooked to ventilator and no chest compression. POLST on file is signed by person identified as care giver, reportedly board and care staff. The POLST Has DNR in section A, but Full Treatment in Section B. Patient #14: Has DNR in section A, but Full Treatment in Section B. Corrected form presented to surveyor before end of survey. Patients #2, 6: DNR/POLST and consents, EOB are signed by Board and Care staff with no documented evidence of legal authority.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency who provides specialized care and support for people with a serious illness who are nearing the end of life) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federally funded healthcare programs) regarding the Patient’s Rights was met as follows: 1. The HA failed to ensure three of 19 sampled patients (Patient 1, Patient 2, and Patient 8) was provided with a copy of the current care plan and an opportunity to participate in developing individualized care plan goals, interventions, and expected outcomes. This failure had the potential to result in Patient 1, Patient 2, Patient 8, and/or their family member/caregiver being unable to be an active participant in his/her care. (Refer to L513). The cumulative effect of this systemic practice resulted in the failure of the hospice agency to deliver statutorily mandated compliance with Federal regulation for Patient’s Rights to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.”

“Based on interview, and record review, the Hospice Agency (HA, agency that provides care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federally funded healthcare programs) for Initial/Comprehensive Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process) of the Patient was met as follows: 1. The HA failed to ensure the Interdisciplinary Group (IDG, a group of health care professionals with various areas of expertise who work together toward the goals of the patients and families) complete the comprehensive assessment no later than five (5) calendar days after hospice election for six of 14 sampled patients (Patient 2, Patient 6,Patient 8,Patient 9, Patient 10, and Patient 13). This failure had the potential to result in the patients and/or caregiver/family not receiving the appropriate assessment and timely support of their needs. (Refer to L523). 2. The HA licensed nurse failed to ensure an accurate comprehensive nursing assessment was conducted for nine of 14 sample patients (Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12) by accurately completing the Local Coverage Determination (LCD, guideline for determining if a patient meets the eligibility requirements for hospice care) for hospice eligibility, based on the patient’s assessment findings and supporting documents in their electronic medical record (EMR, digital version of a patient’s chart within a specific healthcare practice or institution). This failure resulted in the continued certification and/or recertification of patients who were ineligible to receive the hospice benefits. (Refer to L525). 3. The HA failed to complete an initial bereavement assessment, to provide bereavement counseling in accordance with the patient/family’s needs for two of 14 sampled patients (Patient 10 and Patient 11). This failure had the potential to delay the individualized support the family/caregivers required that could impact their ability to cope with the patients’ death. (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 Federal regulation for Initial and Comprehensive Assessment of the patient to ensure the highest quality of care were being provided to patients certified to receive the hospice benefits.”

“Based on observation, interview and record review, the hospice agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federally funded healthcare programs) for Interdisciplinary Group (IDG, team members from different disciplines 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: Based on observation, interview and record review, the hospice agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (CoP-a set of minimum professional standards all hospice agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Interdisciplinary Group (IDG, team members from different disciplines 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 three of 19 sampled patients (Patient 1, Patient 2, and Patient 8) were provided with a copy of the current care plan and an opportunity to participate in developing individualized care plan goals, interventions, and expected outcomes. This failure had the potential to result in patient and/or their family member/caregiver being unable to be an active participant in his/her care. (Refer to L543). 2. The HA failed to ensure that education and training were provided to the patient/patient’s caregiver related to: 1. bleeding precautions while on anti-coagulant medication (medication that is used to prevent and treat blood clots in blood vessels and the heart) for two of 14 sampled patients (Patient 1 and Patient 5). 2. safety precautions during 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 14 sampled patients (Patient 2). 3. oral care after use of steroid inhaler for two of 14 sampled patients (Patient 1 and Patient 3). 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). 3. The HA failed to ensure that the Care plan for three of 14 sampled patients (Patient 1, Patient 2, Patient 5 and Patient 9) was individualized based on their current health status, and personal needs: 1. No care plan for Patient 1, Patient 5 and Patient 9 regarding bleeding precautions while on anti-coagulant medication. 2. No care plan for Patient 2 regarding safety precautions during 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). 4. 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 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 five of 14 sampled patients (Patient1, Patient 5, Patient 8, Patient 9 and Patient 10). This failure placed Patient 1, Patient 5, Patient 8, Patient 9 and Patient 10 at risk of not meeting the hospice and care services needed to address the patients physical, psychosocial, emotional and spiritual needs.(Refer to L552). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure provision of quality care and services to patients.”

“Based on interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (CoP-a set of minimum professional standards all hospice agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Organization and Administration of Services was met as follows: 1.The HA failed to ensure a post bereavement assessment was completed for two of 14 sampled patients (Patient 7 and Patient 14). This deficient practice had the potential to impact a family members’ abilities to cope with the patients’ death. (Refer to L652). 2. The HA failed to ensure written policies and procedures, describing its method(s) of assessment of competency and maintaining a written description of the in-service training provided during the previous 12 months to assess the skills and competence of all its staffs, furnishing care were established. This deficient practice had the potential to affect the professional skills and competence of all its staff towards meeting the patient’s care needs. (Refer to L663). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the Organization and Administration of Services to ensure the highest quality of care were being provided to patients certified to receive the hospice benefits.”

“Based on interview and record review, the Hospice Agency (HA, HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (CoP-a set of minimum professional standards all hospice agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) on Clinical Records was met as follows: 1.The Hospice Agency (HA) failed to maintain an authenticated clinical record based on accepted standards of practice and regulations were followed by failing to: A. 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) meetings were signed by all IDG members for five of 14 sample patients (Patient 1, Patient 5, Patient 8, Patient 9 and Patient 10) . B. Ensure an accurate comprehensive nursing assessment was conducted for nine of 14 sample patients (Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12) by accurately completing the Local Coverage Determination (LCD, guideline for determining if a patient meets the eligibility requirements for hospice care) for hospice eligibility, based on the patient’s assessment findings and supporting documents in their electronic medical record (EMR, digital version of a patient’s chart within a specific healthcare practice or institution). C. Ensure a completed initial bereavement assessment, to provide bereavement counseling in accordance with the patient/family’s needs for two of 14 sampled patients (Patient 10 and Patient 11). These failures resulted in the patients’ medical records not being accurate, complete, signed, and dated by the disciplines delivering services. (Refer to L679). The cumulative effects of these systemic practices resulted in the failure of the hospice to deliver statutorily (written law) mandated compliance with Federal regulations for Clinical Records to ensure patients’ medical records are completed, updated and accurately documented.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency who provides specialized care and support for people with a serious illness who are nearing the end of life) failed to ensure three of 19 sampled patients (Patient 1, Patient 2, and Patient 8) was provided with a copy of the current care plan and an opportunity to participate in developing individualized care plan goals, interventions, and expected outcomes. This failure had the potential to result in Patient 1, Patient 2, Patient 8, and/or their family member/caregiver being unable to be an active participant in his/her care. Findings: 1. During a review of Patient 1’s clinical record titled Personal Information, undated, indicated a start of care (SOC) date of 7/11/2025, with a primary diagnosis of malignant neoplasm (commonly referred to as cancer, a term that encompasses a wide range of diseases characterized by the uncontrolled growth of abnormal cells in the body) of unspecified site of left female breast. During a review of Patient 1’s Plan of Care/Interdisciplinary Group Review (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) form dated 7/11/2025, indicated an order for the frequency of visits for skilled nurse (SN) to one visit per week plus two visits as needed for changes in condition and symptom management. The POC/IDG review form indicated the Master of Social Work (MSW) to visit for initial assessment, then every recertification period for psychosocial (refers to a person’s well-being at the intersection of their internal workings and external experiences, which covers a person’s mental, emotional, social, and spiritual health) needs and support. The POC/IDG review form indicated Spiritual Counselor (SC) to visit for initial assessment, then every recertification plus one as needed per benefit period for spiritual needs and support and hospice aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a joint home visit observation on 8/5/2025, at 12 p.m., with the Director of Patient Care Services (DPCS) at Patient 1’s residence (at a room and board), Patient 1 was observed resting comfortably in her wheelchair. Patient 1 was alert, awake and oriented to her name, time, place and events but spoke random and irrelevant statements unrelated to her care or situation. During a concurrent review of Patient 1’s hospice folder with the DPCS, the folder had the name of the HA, the folder did not have a copy of Patient 1’s Plan of Care. During an interview with the DPCS at 12:11 p.m., the DPCS stated that she did not know if the POC was provided to patients. The DPCS stated that it was important that patients have a copy of POC and the patients and patient’s representative should be involved in formulating the care plan. The DPCS stated the POC should be readily available for patient care references. During an interview with Patient 1’s caregiver (CG) 2, at 12:20 p.m., CG2 stated that she was unsure if copy of Patient 1’s POC was provided to them (Patient 1 and CG 2). CG 2 stated that it would be better if they also have a copy for reference on what individualized care was formulated for Patient 1. b. During a review of Patient 2’s clinical record titled Personal Information, undated, indicated a start of care (SOC) date of 7/14/2025, with a primary diagnosis of cerebrovascular disease (a group of conditions that affect blood flow and blood vessels in the brain), unspecified (no specific location). During a review of Patient 2’s clinical record titled POC/IDG review form dated 7/14/2025, an order of skilled nurse (SN) visit frequency of one visit per week plus two visits as needed for changes in condition and symptom management. The POC/IDG review form indicated the Master of Social Work (MSW) to visit for initial assessment, then every recertification period for psychosocial (a person’s well-being at the intersection of their internal workings and external experiences, which covers a person’s mental, emotional, social, and spiritual health) needs and support. The POC/IDG review form indicated the spiritual counselor (SC) to visit for initial assessment, then every recertification plus one as needed per benefit period for spiritual needs and support. The POC/IDG review form indicated the hospice aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a joint home visit observation on 8/5/2025, at 1 p.m., with the DPCS at Patient 2’s residence (at a room and board). Patient 2’s hospice folder noted with the name of the HA. There was no copy of the plan of care found inside Patient 2’s hospice folder. During an interview with the DPCS on 8/5/2025 at 1:05 p.m., the DPCS stated that she did not know if the POC was provided to patients. The DPCS stated that it was important that patients have a copy of POC since they should be part of the team that formulates the care plan, the patients or their representative should be actively involved in the POC and the POC should be readily available for references. During an interview with Patient 2’s caregiver (CG) 2, at 1:15 p.m., CG2 stated that she was unsure if a copy of Patient 2’s POC was provided to them (Patient 2 and CG2, and that it would be better if they also have a copy of the POC for their reference on what individualized care was formulated for Patient 2. c. During a review of Patient 8’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 4/3/2025 and a primary diagnosis of heart failure (a condition where the heart cannot pump blood effectively enough to meet the body’s needs and can lead to a buildup of fluid in the lungs, legs, and other organs). During a review of Patient 8’s clinical record titled POC/IDG review form dated 8/1/2025, indicated a frequency of skilled nurse (SN) visits of once a week and two as needed per month for changes in condition and symptom management. The POC/IDG form indicated an order for Medical Social Worker (MSW) visits of one initial assessment and then at every recertification and one as needed for psychosocial needs and support. The POC/IDG form indicated an order for spiritual counselor (SC) visits of one initial assessment and then at every recertification and one as needed for spiritual needs and support. During a joint home visit on 8/5/2025 at 11:05 am with the DPCS at Patient 8’s residence (at a room and board), Patient 8 was observed sitting on a reclining couch beside a front wheel walker, awake, alert to name, date of birth, date and location, wearing glasses and able to communicate his needs. When communicating with Patient 8 it was observed Patient 8 was hard of hearing and required people to speak louder or closer to his ears. During a joint home visit observation on 8/5/2025 at 11:50 a.m. with the DPCS at Patient 8’s residence (at a room and board), Patient 8’s HA binder was reviewed. Patient 8’s HA binder indicated the name of the patient, the agency name, agency phone number, the patient’s allergies, copy of signed consent forms and medication list. Patient 8’s HA binder did not include a copy of Patient 8’s plan of care. The DPCS stated she was not sure if the HA provided the patients with a copy of the plan of care upon admission. The DPCS stated it was important to provide patients with a copy of their plan of care, so they can continue to be involved with formulating the POC. During a review of the HA’s policy and procedure, titled “The Plan of Care,” revised date of April 2020, the policy and procedure indicated that 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, agency that provides care and support for people with serious illness and nearing end of life) failed to ensure the Interdisciplinary Group (IDG, a group of health care professionals with various areas of expertise who work together toward the goals of the patients and families) complete the comprehensive assessment no later than five (5) calendar days after hospice election for five of 14 sampled patients (Patient 2, Patient 6, Patient 8, Patient 9, Patient 10, and Patient 12). This failure had the potential to result in the patients and/or caregiver/family not receiving the appropriate assessment and timely support of their needs. Findings: a. During a review of Patient 2’s “Personal Information”, indicated a start of care (SOC) date of 7/14/2025, with a primary diagnosis of cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), unspecified (no specific location). During a review of Patient 2’s Plan of Care/Interdisciplinary Group Review (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) form dated 7/14/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus two visits as needed for changes in condition and symptom management. The POC/IDG review form indicated the Master of Social Work (MSW) to visit for initial assessment, then every recertification period for psychosocial (refers to a person’s well-being at the intersection of their internal workings and external experiences, which covers a person’s mental, emotional, social, and spiritual health) needs and support. The POC/IDG review form indicated the spiritual counselor (SC) to visit for initial assessment, then every recertification plus one as needed per benefit period for spiritual needs and support. The POC/IDG review form indicated the hospice aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a concurrent interview and record review on 8/8/2025 at 11:48 a.m. with the Director of Patient Care Services (DPCS), Patient 2’s audit log (or audit trail, is a chronological record of activities within a computer system or network) from 7/14/2025 to 8/6/2025, via electronic health records were reviewed. The DPCS confirmed and stated that the Master Social Worker (MSW) signed Patient 2’s Psychosocial Assessment (a comprehensive evaluation of an individual’s mental health, social relationships, and overall functioning) on 8/5/2025 for the visit dated 7/17/2025. The DPCS stated it was important for the MSW to complete patient’s psychosocial assessment and to address any issues or concerns regarding the holistic care (means treating the whole person – mind, body, and spirit) to be provided to the patients. The DPCS stated that the clinician who completed the visit for the patient must sign the document within a week or as soon as possible to have it validated. b. During a review of Patient 6’s “Personal Information”, indicated a start of care (SOC) date 4/30/2025 and an end of care (EOC) date of 7/1/2025, with a primary diagnosis of hypothyroidism (a condition in which the thyroid gland [a small organ that sits at the front of the neck] does not produce enough hormone that regulates metabolism, growth, and other bodily functions) During a review of Patient 6’s POC/IDG Review form dated 7/4/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus two visits as needed for changes in condition and symptom management. The POC/IDG review form indicated the Master of Social Work (MSW) to visit for initial assessment, then every recertification period for psychosocial (refers to a person’s well-being at the intersection of their internal workings and external experiences, which covers a person’s mental, emotional, social, and spiritual health) needs and support. The POC/IDG review form indicated the spiritual counselor (SC) to visit for initial assessment, then every recertification plus one visit as needed per benefit period for spiritual needs and support. The POC/IDG review form indicated the hospice aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a concurrent interview and record review on 8/8/2025 at 12:15 p.m. with the DPCS, Patient 6’s clinical record titled “Comprehensive Assessment (a thorough evaluation of a patient’s overall health status, encompassing physical, mental, and social well-being),” dated 4/30/2025 was reviewed. The DPCS confirmed and stated that she signed Patient 6’s Comprehensive Assessment dated 4/30/2025, to close the note on behalf of the licensed staff assigned on 8/4/2025. The DPCS stated she was present during the nurse visit and assessment with Patient 6. The DPCS stated it was important for the visiting nurses to complete patient’s comprehensive assessment and to sign within five (5) days to validate the visit. The DPCS stated she signed to close Patient 6’s comprehensive assessment dated 4/30/2025 since she checks and conducts the quality assurance (a systematic method used to ensure that a service provided to patients meet specified requirements and standards) for the HA and because she had also been present when the assessment was conducted. During a concurrent interview and record review on 8/8/2025 at 12:38 p.m., Patient 6’s audit log from 5/13/2025 to 8/6/2025, via electronic health records were reviewed with the DPCS. The DPCS confirmed and stated that the spiritual chaplain (SC) signed Patient 6’s Bereavement Assessment (a process of evaluating an individual’s unique experience of grief following the death of a loved one or another significant loss) on 8/4/2025 for the visit dated 5/2/2025. The DPCS stated it was important for the SC to complete patient’s bereavement assessment and to address any issues or concerns regarding the holistic care to be provided to the patients. The DPCS stated that the clinician who completed the visit for the patient must sign it within a week or as soon as possible to have it validated. c. During a review of Patient 8’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 4/3/2025 and a primary diagnosis of heart failure (a condition where the heart cannot pump blood effectively enough to meet the body’s needs and can lead to a buildup of fluid in the lungs, legs, and other organs). During a review of Patient 8’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025, indicated a frequency of Skilled Nurse (SN) visits of once a week and two as needed per month for changes in condition and symptom management. The POC/IDG review form indicated the Master Social Worker (MSW) visits of one initial assessment and then at every recertification and one as needed for psychosocial needs and support. The POC/IDG review form indicated the spiritual counselor (SC) visits of one initial assessment and then at every recertification and one as needed for spiritual needs and support. During a review of Patient 8’s clinical record titled Re-cert Assessment dated 7/1/2025, the assessment indicated on the last page under the signature section it was signed by the DPCS on behalf of the assigned staff to close the note and it was dated 8/5/2025. During a concurrent interview and record review on 8/7/2025 at 12:05 p.m. with the DPCS, Patient 8’s EMR was reviewed. Patient 8’s EMR under the section Assessment, indicated a recertification nursing assessment dated 7/1/2025 signed by the DPCS on behalf of the assigned staff and dated 8/5/2025. The DPCS stated and confirmed that Patient 8’s recertification assessment dated 7/1/2025 was not signed by the assigned RN and was signed by herself (DPCS). The DPCS stated she and CM1 review and do QA (Quality Assurance) of clinical notes. The DPCS also stated either herself or CM1 attend the visits of the admission/recertification assessments with the nurses. The DPCS stated the signed date on the assessment of 8/5/2025 does mean the assessment was signed late, as a comprehensive assessment is due within 5 days of the visit. d. During a review of Patient 9’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 9/12/2024 and a primary diagnosis of Chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a review of Patient 9’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025, indicated a frequency of Skilled Nurse (SN) visits of once per week and two as needed visits per month. The POC/IDG indicated Master Social Worker (MSW) visits of one initial assessment and then at every recertification and one as needed for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one as needed for spiritual needs and support. During a review of Patient 9’s clinical record titled Psychosocial Assessment dated 3/7/2025, the assessment’s second page on the signature section indicated an electronic submission for review dated 4/14/2025 by the MSW. During a review of Patient 9’s clinical record titled Spiritual Assessment dated 3/10/2025, the assessment’s second page on the signature section indicated an electronic submission for review dated 3/10/2025 by the Spiritual Counselor 2 (SC2). During a review of Patient 9’s clinical record titled Psychosocial Assessment dated 7/7/2025, th e assessment’s second page in the signature section indicated no documented evidence of an electronic signature or date of submission. During a concurrent interview and record review on 8/7/2025 at 11:29 a.m. with the Case Manager (CM1), Patient 9’s Electronic Medical Record (EMR) was reviewed. Patient 9’s EMR indicated under the section Assessment, a recertification Psychosocial assessment dated 3/7/2025 and 7/7/2025, and an initial Spiritual Assessment dated 3/10/2025. Patient 9’s Psychosocial assessment dated 3/7/2025 indicated under the signature section an electronic submission for review dated 4/14/2025 by the MSW. Patient 9’s recertification Psychosocial assessment dated 7/7/2025 indicated under the signature section no documented evidence of an electronic signature or date of submission by MSW. Patient 9’s initial Spiritual assessment dated 3/10/2025 indicated under the signature section an electronic submission for review dated 3/10/2025 by the SC2. CM1 stated and confirmed comprehensive assessment’s that indicate under the signature section electronic submission means that the clinician has not signed the assessment and only submitted it for review to the HA Quality Assurance (QA), which is her (CM1). CM1 stated and confirmed Patient 9’s psychosocial assessment dated 3/7/2025 was not electronically signed by the MSW and was submitted more than 5 days after the patient’s recertification of care date of 3/11/2025. CM1 stated and confirmed Patient 9’s psychosocial assessment dated 7/7/2025 was not electronically signed by the MSW. CM1 stated and confirmed Patient 9’s Spiritual assessment dated 3/10/2025 did not have documented evidence of an electronic signature by the SC2. CM1 further stated each clinician who did the assessment or home visit has to document their findings and sign the assessment and stated if it is not signed the assessment is considered incomplete and cannot be validated. e. During a review of Patient 10’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 3/26/2025 and a primary diagnosis of Cerebrovascular disease (a group of conditions that affect the blood vessels in the brain and can disrupt blood flow to the brain, leading to damage or death of brain cells). During a review of Patient 10’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025 indicated a frequency of Skilled Nurse (SN) visits of once per week and two visits as needed per month for symptom management and changes in condition. The POC/IDG indicated Master Social Worker (MSW) visits of one initial assessment and then at every recertification and one a needed for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one as needed for spiritual needs and support. During a review of Patient 10’s clinical record titled Spiritual Assessment dated 3/27/2025, the assessment’s second page on the signature section indicated an electronic submission for review dated 3/27/2025 by the Spiritual Counselor 2 (SC2). During a review of Patient 10’s clinical record titled Psychosocial Assessment dated 3/29/2025, the assessment’s second page on the signature section indicated an electronic submission for review dated 4/8/2025 by the MSW. During a review of Patient 10’s clinical record titled Psychosocial Assessment dated 6/12/2025, the assessment’s second page on the signature section indicated an electronic submission for review dated 6/24/2025 by the MSW. During a concurrent interview and record review on 8/7/2025 at 11:35 a.m. with CM1, Patient 10’s EMR was reviewed. Patient 10’s EMR indicated under the section Assessment, an initial Spiritual Assessment dated 3/27/2025, an initial psychosocial assessment dated 3/29/2025 and a recertification psychosocial assessment dated 6/12/2025. Patient 10’s Spiritual Assessment dated 3/27/2025 indicated under the signature section, an electronic submission for review dated 3/27/2025 by the SC2. Patient 10’s Psychosocial assessments dated 3/29/2025 and 6/12/2025 indicated under the signature section, an electronic submission for review by MSW. CM1 stated and confirmed Patient 10’a spiritual assessment dated 3/7/2025, psychosocial assessments dated 3/29/2025 and 6/12/2025 were not signed by the clinician who documented it. CM1 stated an assessment is not considered complete if there is no signature and stated a signature is needed to verify who was the clinician who did the assessment and to also validate the assessment. f. During a review of Patient 12’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 2/19/2025 and a primary diagnosis of Heart Failure (a condition where the heart cannot pump blood effectively enough to meet the body’s needs and can lead to a buildup of fluid in the lungs, legs, and other organs). During a review of Patient 12’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025 indicated a frequency of Skilled Nurse (SN) visits of once per week and two visits as needed per month for changes in condition and symptom management, Master Social Worker (MSW) visits of one initial assessment and then at every recertification and one as needed for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one as needed for spiritual needs and support. During a review of Patient 12’s clinical record titled Re-cert Assessment dated 5/19/2025 the assessment indicated on the last page under the signature section it was signed by the DPCS to close the note on behalf of the staff assigned and dated 7/2/2025. During a concurrent interview and record review on 8/7/2025 at 11:55 a.m. with the DPCS, Patient 12’s EMR was reviewed. Patient 12’s EMR indicated, under the section Assessment nursing, a recertification assessment dated 5/19/2025 that was signed by the DPCS to close the note on behalf of the assigned staff, and it was dated 7/2/2025. The DPCS stated and confirmed that Patient 12’s recertification assessment indicated on the top of the first page the staff assigned was a registered nurse (RN) from the HA, and that the signature was not the RN’s signature but her (DPCS) signature on the assessment. The DPCS stated and confirmed she did sign the assessment to close it after reviewing it but also because she had been present during that assessment of the patient with the RN. DPCS stated every clinician should sign their own assessments and no other discipline like the social worker can sign a nurse’s assessment or vice versa. DPCS stated she or the CM1 review the nurses’ assessments and either she (DPCS) or CM1 will be present during admission or recertification assessments. The DPCS also stated the signed date on Patient 12’s recert assessment is past the 5 days after the initial visit date of 5/19/2025, and it is considered late. During an interview on 8/7/2025 at 10:53 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated all comprehensive assessments are to be completed and submitted within 5 days of SOC. The DPCS stated if an assessment is not signed then it can mean the visit was not done or not done within the time frame. The DPCS stated for example if the nursing comprehensive assessment was submitted without a signature, then it will not validate the visit and it will show the patient was not admitted that day. The DPCS stated each discipline is to sign their own assessment and further stated whatever nurse, or social worker or chaplain completed that home visit must then document the visit and sign the assessment. The DPCS further stated the importance of each discipline signing their own assessment is because they are the only ones that can verify and understand what was documented. The DPCS stated Case Manager (CM1) is the nurse in charge of QA for all patient clinical records. During a phone interview on 8/7/2025 at 2:12 p.m. with Spiritual Counselor 1 (SC1), SC1 stated he has been working with the HA as the spiritual counselor for 6 months. SC1 stated as a spiritual counselor, part of his duties includes documenting and completing the patients’ initial bereavement assessment, post bereavement and spiritual assessment. SC1 stated the initial bereavement assessment and spiritual assessment need to be completed and submitted within 5 days of the patient’s SOC. SC1 stated the initial bereavement assessment can also be completed by the MSW, and who does it all depends on how the workload is divided by the HA office. During a phone interview on 8/7/2025 at 2:23 p.m. with the MSW, the MSW stated part of her responsibilities as the social worker for the HA include home visits, completing the psychosocial assessment and at times the initial bereavement assessment within 5 days of the patient’s SOC. MSW stated she submits her assessments for review to CM1, but the EMR does not allow her to electronically sign her assessments until CM1 reviews and approves it. MSW stated the importance of conducting a psychosocial assessment on a patient is to assess their home situation, the support they have, assess patient and family coping needs and provide resources as needed in the future, assist patients with advanced directives and mortuary information and set up when needed. MSW stated the importance of conducting an initial bereavement assessment is to identify the patient’s primary bereaved, how they are coping and if more support will be needed when patient passes, and also to assess risk level of the bereaved. During a review of the HA’s policy and procedures (P&P 1), titled “Comprehensive Assessment,” revised date of April 2020, P&P 1 indicated the following: The comprehensive patient assessment must be performed by the IDG no later than five (5) calendar days after the election of hospice care in consultation with the attending physician. All baseline data and other relevant information must be documented in the patient’s clinical record including, but is not limited to, the following: Patient and family/caregiver support systems and the care the family/caregiver is available, capable, and willing to provide, including applicable strengths of patient, physical, psychosocial, and/or spiritual resources available. As assessment of the patient’s and family/caregiver’s spiritual orientation, including, as appropriate, any involvement in a religious group such as a church or synagogue or a support group and spiritual concerns or needs such as despair, suffering, guilt, etc.”

“Based on interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) licensed nurse failed to ensure an accurate comprehensive nursing assessment was conducted for seven of 14 sample patients (Patient 2, Patient 3, Patient 4, Patient 5, Patient 9, Patient 10 and Patient 11) by accurately completing the Local Coverage Determination (LCD, guideline for determining if a patient meets the eligibility requirements for hospice care) for hospice eligibility, based on the patient’s assessment findings and supporting documents in their electronic medical record (EMR, digital version of a patient’s chart within a specific healthcare practice or institution). This failure resulted in the incomplete assessment documentation of the patient’s health status, which could have affected their continuity of certification and/or recertification. a. During a review of Patient 2’s “Personal Information”, indicated a start of care (SOC) date of 7/14/2025, with a primary diagnosis of cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), unspecified (no specific location). During a review of Patient 2’s POC (Plan of Care, consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient’s needs)/IDG (Interdisciplinary Group- a team consists of medical director, registered nurse, spiritual chaplain, and social worker, responsible for the holistic care of the hospice beneficiary) Review form dated 7/14/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus two PRN (pro re nata, which means “as needed”) visits for changes in condition and symptom management, the Master of Social Work (MSW) to visit for initial assessment, then every recertification period for psychosocial (refers to a person’s well-being at the intersection of their internal workings and external experiences, which covers a person’s mental, emotional, social, and spiritual health) needs and support, Spiritual Counselor (SC) to visit for initial assessment, then every recertification plus one PRN per benefit period for spiritual needs and support and Hospice Aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a review of Patient 2’s clinical record titled “Comprehensive Nursing Assessment,” dated 7/14/2025, Patient 2’s documented weight was 100 lbs. (pounds, unit of weight) and mid arm circumference (MAC, a measurement of the circumference of the upper am, taken at the midpoint between the shoulder and elbow) of 19 centimeters (cm, unit of weight) from left upper arm. Patient 2’s Comprehensive Nursing Assessment also indicated in the section Narrative and Disease Trajectory, “saw-toothed decline (symptom exacerbations (worsening of a disease, symptom, or problem) and improvement).” Patient 2’s Comprehensive Assessment indicated, under the section Nutrition, if the patient had weight loss greater than 10% in the last 6 months, and licensed staff documented Yes. During a concurrent interview and record review on 8/8/2025 at 12:45 p.m. with the Director of Patient Care Services (DPCS), Patient 2’s pre-admission clinical records titled “History and Physical (refers to a comprehensive assessment of a patient’s health, combining the patient’s medical history with the results of a physical examination),” dated 6/13/2025 and “Discharge Summary (a document that summarizes a patient’s hospital stay, including the reason for admission, treatments received, and recommendations for follow-up care) and Post-Discharge Plan of Care (guide that helps ensure a smooth and safe transition for a patient leaving a healthcare facility to returning home or moving to another care setting like a rehabilitation facility or skilled nursing facility), “ dated 7/10/2025 were reviewed. Patient 2’s History and Physical indicated there was no documented evidence of Patient 2’s weight loss greater than 10% (percent, unit of measurement) in the last 6 months or greater than 7.5 % in the last 3 months. The DPCS confirmed and stated that Patient 2’s previous clinical records prior to the admission to hospice care did not indicate any supporting evidence or objective data regarding weight loss. The DPCS confirmed and stated that Patient 2’s History and Physical records indicated a documented numerical weight of 101 with no specification related to the unit of weight. During a concurrent interview and record review on 8/8/2025 at 12:55 p.m. with the Director of Patient Care Services (DPCS), Patient 2’s clinical record titled “LCD Hospice Eligibility Determination,” dated 7/14/2025, indicated “Patient does not qualify per LCD Guidelines.” Patient 2’s LCD indicated, under section 2. Weight Loss question a. Weight loss greater than 10 % in the last 6 months or greater than 7.5% in the last 3 months? Marked Yes. The DPCS confirmed and stated that she completed the LCD in coordination with the Medical Director. The DPCS stated that she did not notice that LCD was marked incomplete, that is why it made Patient 2 not qualified but subjective (information that comes directly from a patient’s own experience and perspective, including their feelings, symptoms, and perceptions) and objective (factual, measurable, and observable information that is not influenced by personal opinions or feelings) data supported Patient 2’s eligibility to hospice. The DPCS confirmed and stated that the HA has no clinical records to support regarding Patient 2’s weight loss. The DPCS stated that it is important to have clinical records and data to support patient’s diagnosis and symptoms for LCD hospice eligibility. During a concurrent interview and record review on 8/8/2025 at 1:00 p.m. with the DPCS, Patient 2’s clinical records titled “Visit Note RN (Registered Nurse),” dated 7/23/2025, 7/30/2025, 8/5/2025, and 8/6/2025, were reviewed. Patient 2’s Visit Note dated 7/23/2025, 7/30/2025, 8/5/2025, and 8/6/2025 indicated weight under sections vitals and measurements documented 100 lbs. and MAC of 19. The DPCS confirmed and stated that Patient 2’s Visit Note dated 7/23/2025, 7/30/2025, 8/5/2025, and 8/6/2025 indicated same weight value of 100 lbs. and MAC of 19. The DPCS stated that there were no changes in Patient 2’s weight and MAC in Patient 2’s nursing comprehensive assessments and nurse visit notes, DPCS stated that it does not support Patient 2’s weight loss as part of LCD eligibility. DPCS stated the importance of completing patient 2’s assessment and visit note to include current weight is to monitor the patient for any changes in their disease and monitor for decline or improvement in health. b. During a review of Patient 3’s “Personal Information”, indicated a start of care (SOC) date of 3/26/2025, with a primary diagnosis of heart failure (occurs when the heart muscle becomes weakened and cannot pump blood effectively throughout the body) unspecified. During a review of Patient 3’s POC (Plan of Care, consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient’s needs)/IDG (Interdisciplinary Group- a team consists of medical director, registered nurse, spiritual chaplain, and social worker, responsible for the holistic care of the hospice beneficiary) Review form dated 7/14/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus two PRN (pro re nata, which means “as needed”) visits for changes in condition and symptom management, the Master of Social Work (MSW) to visit for initial assessment, then every recertification period for psychosocial (refers to a person’s well-being at the intersection of their internal workings and external experiences, which covers a person’s mental, emotional, social, and spiritual health) needs and support, Spiritual Counselor (SC) to visit for initial assessment, then every recertification plus one PRN per benefit period for spiritual needs and support and Hospice Aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a concurrent interview and record review on 8/8/2025 at 1:00 p.m. with the Director of Patient Care Services (DPCS), Patient 3’s clinical record titled “LCD Hospice Eligibility Determination,” dated 6/16/2025, indicated “Patient does not qualify per LCD Guidelines.” DPCS confirmed and stated that Patient 3’s LCD Hospice Eligibility Determination dated 6/16/2025 had incomplete documentation and questionnaire 2. NYHA (system used to categorize the severity of heart failure based on how much physical activity limits a person) was left unmarked and blank. The DPCS stated that she did not notice that LCD was marked incomplete, that is why it made Patient 3 not qualified but subjective (information that comes directly from a patient’s own experience and perspective, including their feelings, symptoms, and perceptions) and objective (factual, measurable, and observable information that is not influenced by personal opinions or feelings) data supported Patient 3’s eligibility to hospice. The DPCS confirmed and stated that she has no clinical records to support regarding patient 3’s diagnosis of heart failure. The DPCS stated that it is important to have clinical records and data to support patient’s diagnosis and symptoms for LCD hospice eligibility. The DPCS stated and confirmed that Patient 3’s LCD indicated the patient did not qualify for hospice care based on the LCD guidelines. The DPCS stated Patient 3’s LCD is incomplete, and the admitting nurse should have communicated that with the Medical Director 1 (MD1). The DPCS stated patient 3’s LCD at this time indicates patient is not eligible for hospice care. The DPCS stated the importance of completing an LCD for a newly admitted patient to the HA is to verify their eligibility for hospice care, and if they are eligible providing that information in the patient’s EMR so the IDG is aware. c. During a review of Patient 4’s “Personal Information”, indicated a start of care (SOC) date of 7/29/2025, with a primary diagnosis of cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) unspecified. During a concurrent interview and record review on 8/8/2025 at 1:08 p.m. with the DPCS, Patient 4’s clinical record titled “LCD Hospice Eligibility Determination,” dated 7/29/2025, indicated “Patient does not qualify per LCD Guidelines.” DPCS confirmed and stated that Patient 4’s LCD Hospice Eligibility Determination dated 7/29/2025 had incomplete documentation and some questionnaires were left unmarked and blank. The DPCS stated that she did not notice that LCD was incomplete, that is why it made Patient 4 not qualified but subjective and objective data supported Patient 4’s eligibility to hospice. The DPCS confirmed and stated that she h as no clinical records to support Patient 4’s diagnosis. The DPCS stated that it is important to have clinical records and data to support patient’s diagnosis and symptoms for LCD hospice eligibility. The DPCS stated and confirmed that Patient 4’s LCD did indicate the patient did not qualify for hospice care based on the LCD guidelines. The DPCS stated Patient 4’s LCD is incomplete, and the admitting nurse should have communicated that with the Medical Director 1 (MD1). The DPCS stated Patient 4’s LCD at this time indicates not eligible for hospice care. The DPCS stated the importance of completing an LCD for a newly admitted patient to the HA is to verify their eligibility for hospice care, and if they are eligible providing that information in the patient’s EMR so the IDG is aware. The DPCS stated she was just given the role of DPCS recently as the previous DPCS resigned and she has recently started to review nurses’ documentation. The DPCS stated the importance of completing an LCD for a newly admitted patient to the HA is to verify their eligibility for hospice care and provide that information to the IDG. d. During a review of Patient 5’s “Personal Information”, indicated a start of care (SOC) date of 7/29/2025, with a primary diagnosis of cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) unspecified. During a concurrent interview and record review on 8/8/2025 at 1:12 p.m. with the DPCS, Patient 5’s clinical record titled “LCD Hospice Eligibility Determination,” dated 7/29/2025, indicated “Patient does not qualify per LCD Guidelines.” DPCS confirmed and stated that Patient 5’s LCD Hospice Eligibility Determination dated 7/29/2025 had incomplete documentation and some questionnaires were left unmarked and blank. The DPCS stated that she did not notice that LCD was incomplete, that is why it made Patient 5 not qualified but subjective and objective data supported Patient 5’s eligibility to hospice. The DPCS confirmed and stated that she has no clinical records to support Patient 5’s diagnosis. The DPCS stated that it is important to have clinical records and data to support patient’s diagnosis and symptoms for LCD hospice eligibility. The DPCS stated and confirmed that Patient 5’s LCD did indicate the patient did not qualify for hospice care based on the LCD guidelines. The DPCS stated Patient 5’s LCD is incomplete, and the admitting nurse should have communicated that with the Medical Director 1 (MD1). The DPCS stated Patient 5’s LCD at this time indicates patient is not eligible for hospice care. The DPCS stated the importance of completing an LCD for a newly admitted patient to the HA is to verify their eligibility for hospice care, and if they are eligible providing that information in the patient’s EMR so the IDG is aware. The DPCS stated she was just given the role of DPCS recently as the previous DPCS resigned and she has recently started to review nurses’ documentation. The DPCS stated the importance of completing an LCD for a newly admitted patient to the HA is to verify their eligibility for hospice care and provide that information to the IDG. e. During a review of Patient 9’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 9/12/2024 and a primary diagnosis of Chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a review of Patient 9’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025, indicated a frequency of Skilled Nurse (SN) visits of once per week and two as needed (PRN) visits per month, Master of Social Work (MSW) visits of one initial assessment and then at every recertification and one PRN for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one PRN for spiritual needs and support. During a review of Patient 9’s Electronic Medical Record (EMR), the EMR indicated a recertification assessment dated 7/7/2025 with an electronic signature by the DPCS. Patient 9’s recertification assessment indicated that the section LCD eligibility was left blank with no evidence of documentation. During a review of Patient 9’s EMR, the EMR indicated a clinical record titled Physician’s certification for hospice benefit (CTI) for certification #5 for the period of 7/9/2025 to 9/6/2025 documented and electronically signed by the HA Medical Director (MD). Patient 9’s CTI also indicated the attached LCD hospice eligibility determination form dated 7/7/2025 was blank and indicated on the top of the form, patient does not qualify per LCD guidelines. During a review of Patient 9’s EMR, the EMR indicated an uploaded copy of the patient’s History and Physical (H&P) dated 9/7/2024, from a previous hospitalization stay. During a concurrent interview and record review on 8/7/2025 at1:36 p.m. with the DPCS, Patient 9’s EMR was reviewed. Patient 9’s EMR indicated a recertification assessment dated 7/7/2025 electronically signed by the DPCS and was left blank in the section LCD hospice eligibility. Patient 9’s EMR also indicated a clinical record titled CTI for certification #5 for the period of 7/9/2025 to 9/6/2025 electronically signed by the MD, and the attached LCD hospice eligibility determination form dated 7/7/2025 was left blank and indicated patient does not qualify per LCD guidelines. The DPCS stated and confirmed that Patient 9’s recertification assessment that she completed was left blank in the section LCD Eligibility. The DPCS stated she did assess the patient and reviewed his eligibility with the MD, but did not fill out that section of the assessment. The DPCS stated and confirmed that Patient 9’s LCD hospice eligibility determination form dated 7/7/2025 was left blank and not documented on. The DPCS stated it was her responsibility to complete the LCD hospice eligibility form. The DPCS further stated she completed her assessment of the patient, reviewed her findings along with the patient’s history and physical with the MD for the patient’s eligibility for hospice care and stated she forgot to fill out the LCD eligibility form. The DPCS stated the LCD hospice eligibility form and the LCD eligibility section in the recertification assessment must be filled out to its entirety to validate patient’s eligibility for benefits and the IDG care team is aware. The DPCS also stated if it is not filled out then the patient’s hospice eligibility is not validated and assessment not considered complete. f. During a review of Patient 10’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 3/26/2025 and a primary diagnosis of Cerebrovascular disease (a group of conditions that affect the blood vessels in the brain and can disrupt blood flow to the brain, leading to damage or death of brain cells). During a review of Patient 10’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025 indicated a frequency of Skilled Nurse (SN) visits of once per week and two as needed (PRN) visits per month for symptom management and changes in condition, Master of Social Work (MSW) visits of one initial assessment and then at every recertification and one PRN for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one PRN for spiritual needs and support. During a review of Patient 10’s Electronic Medical Record (EMR), the EMR indicated a recertification assessment dated 6/19/2025 with an electronic signature by the DPCS. Patient 10’s recertification assessment indicated that the section LCD eligibility was left blank with no evidence of documentation. During a review of Patient 10’s EMR, the EMR indicated a clinical record titled Physician’s certification for hospice benefit (CTI) for certification #2 for the period of 6/24/2025 to 9/21/2025 documented and electronically signed by the HA MD. Patient 10’s CTI also indicated the attached LCD hospice eligibility determination form dated 6/19/2025 was blank and indicated on the top of the form, patient does not qualify per LCD guidelines. During a review of Patient 10’s EMR, the EMR indicated there was no supporting documentation that included a history and physical (H&P), lab/imaging results, or physician orders. During a concurrent interview and record review on 8/7/2025 at 1:45 p.m. with the DPCS, Patient 10’s EMR was reviewed. Patient 10’s EMR indicated a recertification assessment dated 6/19/2025 electronically signed by the DPCS and was left blank in the section LCD hospice eligibility. Patient 10’s EMR also indicated a clinical record titled CTI for certification #2 for the period of 6/24/2025 to 9/21/2025 electronically signed by the HA MD, and the attached LCD hospice eligibility determination form dated 6/19/2025 was left blank and indicated patient does not qualify per LCD guidelines. The DPCS stated and confirmed that Patient 10’s recertification assessment that she completed was left blank in the section LCD Eligibility. The DPCS stated she did assess the patient and reviewed her assessment findings with the MD, but she (DPCS) forgot tp fill out that section of the assessment. The DPCS also stated and confirmed that Patient 10’s LCD hospice eligibility determination form dated 6/19/2025 was left blank and not documented on. The DPCS stated it was her responsibility to complete the LCD hospice eligibility form when doing her assessment for recertification eligibility. The DPCS further stated she completed her assessment of the patient, reviewed her findings with the MD for the patient’s eligibility for hospice care and stated she also forgot to fill out the LCD eligibility form. The DPCS stated and confirmed that Patient 10’s EMR does not include a copy of the patient’s H&P or labs/images. The DPCS stated the HA has requested that information from Patient 10’s primary physician but have not received it yet. The DPCS stated it is important to have supporting documents like an H&P or labs to provide a better picture of the patient health and support their eligibility for hospice care. The DPCS stated the LCD hospice eligibility form must be filled out to its entirety to validate patient’s eligibility and inform the IDG team of the patient’s condition, to assist them in formulating the individualized plan of care. g. During a review of Patient 11’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 4/3/2025 and a primary diagnosis of Heart Failure (a condition where the heart cannot pump blood effectively enough to meet the body’s needs and can lead to a buildup of fluid in the lungs, legs, and other organs). During a review of Patient 11’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025 indicated a frequency of Skilled Nurse (SN) visits of once per week and two as needed (PRN) visits per month for changes in condition and symptom management, Master of Social Work (MSW) visits of one initial assessment and then at every recertification and one PRN for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one PRN for spiritual needs and support. During a review of Patient 11’s Electronic Medical Record (EMR), the EMR indicated a recertification assessment dated 7/1/2025 with an electronic signature by the DPCS. Patient 11’s recertification assessment indicated that the section LCD eligibility was left blank with no evidence of documentation. During a review of Patient 11’s EMR, the EMR indicated a clinical record titled Physician’s certification for hospice benefit (CTI) for certification #2 for the period of 7/2/2025 to 9/29/2025 documented and electronically signed by the HA MD. Patient 11’s CTI also indicated the attached LCD hospice eligibility determination form dated 7/1/2025 was blank, not filled out, and indicated on the top of the form, patient does not qualify per LCD guidelines. During a review of Patient 11’s EMR, the EMR indicated there was no supporting documentation that included the patient’s history and physical (H&P), lab/imaging results, or physician orders. During a concurrent interview and record review on 8/7/2025 at 1:50 p.m. with the DPCS, Patient 11’s EMR was reviewed. Patient 11’s EMR indicated a recertification assessment dated 7/1/2025 electronically signed by the DPCS and was left blank in the section LCD hospice eligibility. Patient 11’s EMR also indicated a clinical record titled CTI for certification #2 for the period of 7/2/2025 to 9/29/2025 electronically signed by the HA MD, and the attached LCD hospice eligibility determination form dated 7/1/2025 was left blank and indicated patient does not qualify per LCD guidelines. The DPCS stated and confirmed that Patient 11’s recertification assessment was left blank in the section LCD Eligibility. The DPCS stated she did assess the patient, along with the visiting registered nurse, and reviewed the assessment findings with the MD, but she (DPCS) forgot to fill out that section of the assessment. The DPCS also stated and confirmed that Patient 10’s LCD hospice eligibility determination form dated 7/1/2025 was left blank and not documented on. The DPCS stated it was her responsibility to complete the LCD hospice eligibility form and forgot to fill it out. The DPCS stated and confirmed that Patient 11’s EMR does not include a copy of the patient’s H&P or labs/images. The DPCS stated the HA has requested that information from Patient 11’s primary physician office but have not received it yet. The DPCS stated the nursing staff will ask the patient/family for copies of any H&P or lab work but if they do not have it then the HA will contact the primary physicians office to get them. The DPCS stated it is important to have supporting documents like an H&P or labs to help in determining patient’s eligibility for hospice care. The DPCS stated the LCD hospice eligibility form must be filled out to its entirety to validate patient’s eligibility and inform the IDG team of the patient’s condition and how to plan their care. During an interview on 8/8/2025 at 11:30 a.m. with the Medical Director (MD), the MD stated he has been working with the HA for about 1 to 2 years. The MD stated he determines a patient’s hospice eligibility based on their diagnosis, review of medical records from the hospital or their doctors’ office and findings from the admitting nurses’ assessment. The MD stated if the patient or family do not have medical records to provide for review, then the MD will take into account subjective data the patient provides about their health and how they feel and also the objective date the nurse finds during the physical assessment. The MD stated it would be nice and better to have supporting documents to further explain the patient’s health status. The MD stated the admission or recertification assessment and LCD hospice eligibility determination are completed by the admitting registered nurse (RN) and the RN will then report his/her findings to him (MD). The MD further stated it is important to have a patient’s admission/recertification assessment and LCD eligibility determination completed to identify that the patient was looked at, records were reviewed and indicate the trajectory of the patient’s illness. The MD also stated the CTI and LCD determination should correlate and not be in conflict with each. The MD further stated an incomplete assessment and LCD determination is not a good practice from the HA in determining patient’s eligibility. During a review of the HA’s Policy and Procedure (P&P) Titled Admission Criteria and Process with a revised date of April 2020, the P&P indicated the patient’s life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the Local Coverage Determinations (LCDs). The P&P also indicated that a patient’s eligibility criteria will be continually reviewed on an ongoing basis by the IDG to assure appropriateness of hospice care. During a review of the HA’s P&P titled Certification of Terminal Illness with a revised date of April 2020, the P&P indicated that the LCD along with other supporting documentation can be used to provide guidance in determining and documenting terminal prognosis. The P&P also indicated that clinical information and other documentation that supports the medical prognosis must accompany the certification and must be field in the clinical record with the written certification.”

“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 complete and submit an initial bereavement assessment, to provide bereavement counseling in accordance with the patient/family’s needs, within five days of Start of Care (SOC) for two of 14 sampled patients (Patient 10 and Patient 11).This failure had the potential to delay the individualized support the family/caregivers required that could impact their ability to cope with the patients’ death. Findings:a. During a review of Patient 10’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 3/26/2025 and a primary diagnosis of Cerebrovascular disease (a group of conditions that affect the blood vessels in the brain and can disrupt blood flow to the brain, leading to damage or death of brain cells).During a review of Patient 10’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025 indicated a frequency of Skilled Nurse (SN) visits of once per week and two as needed (PRN) visits per month for symptom management and changes in condition, Master of Social Work (MSW) visits of one initial assessment and then at every recertification and one PRN for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one PRN for spiritual needs and support.During a review of Patient 10’s clinical record titled Bereavement Assessment dated 3/29/2025 indicated under the signature section at the bottom of the page, an electronic submission by the MSW dated 4/8/2025.During an interview on 8/7/2025 at 10:53 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated all comprehensive assessments are to be completed and submitted within 5 days of SOC. The DPCS stated if an assessment is not signed then it can mean the visit was not done or not done within the time frame. The DPCS stated for example if the nursing comprehensive assessment was submitted without a signature then it will not validate the visit and it will show the patient was not admitted that day. The DPCS stated each discipline is to sign their own assessment and further stated whatever nurse, or social worker or chaplain completed that home visit must then document the visit and sign the assessment. The DPCS further stated the importance of each discipline signing their own assessment is because they are the only ones that can verify and understand what was documented. The DPCS stated Case Manager (CM1) is the nurse in charge of QA for all patient clinical records.During a concurrent interview and record review on 8/7/2025 at 11:45 a.m. with the CM1, Patient 10’s Electronic Medical Record (EMR) was reviewed. Patient 10’s EMR indicated under the section Bereavement an initial bereavement assessment dated 3/29/2025 indicated it was electronically submitted for review by MSW dated 4/8/2025. The CM1 stated and confirmed Patient 10’s initial bereavement assessment visit was completed on 3/29/2025 and the MSW completed and submitted the assessment on 4/8/2025, 10 days after the SOC. CM1 also stated that the assessment indicated that the MSW submitted the assessment and did not sign the assessment. CM1 stated a completed assessment is when it is fully documented on, signed, dated and submitted. CM1 stated all comprehensive assessments are to be completed and submitted within 5 days of the patient’s SOC. CM1 further stated she oversees quality assurance (QA, a systematic process aimed at ensuring that healthcare services meet or exceed predetermined standards of quality) for all patient clinical records. b. During a review of Patient 11’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 4/3/2025 and a primary diagnosis of Heart Failure (a condition where the heart cannot pump blood effectively enough to meet the body’s needs and can lead to a buildup of fluid in the lungs, legs, and other organs).During a review of Patient 11’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025 indicated a frequency of Skilled Nurse (SN) visits of once per week and two as needed (PRN) visits per month for changes in condition and symptom management, Medical Social Worker (MSW) visits of one initial assessment and then at every recertification and one PRN for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one PRN for spiritual needs and support.During a review of Patient 11’s clinical record titled Bereavement Assessment dated 4/7/2025 indicated under the signature section at the bottom of the page, an electronic submission by the Spiritual Counselor 2 (SC2) dated 4/27/2025.During a concurrent interview and record review on 8/7/2025 at 11:50 a.m. with CM1, Patient 11’s EMR was reviewed. Patient 11’s EMR indicated, under the section Bereavement, an initial bereavement assessment dated 4/7/2025 was electronically submitted by the SC2 dated 4/27/2025. CM1 stated and confirmed Patient 11’s initial bereavement assessment visit was conducted on 4/7/2025 but the SC2 submitted the assessment more than 5 days after patient’s SOC, on 4/27/2025. CM1 also stated and confirmed the initial bereavement assessment was not signed by SC2 which means it is not complete. CM1 stated the staff do have the ability to sign their assessments before submitting for review and SC2 did not sign it before submitting. During a phone interview on 8/7/2025 at 2:12 p.m. with Spiritual Counselor 1 (SC1), SC1 stated he has been working with the HA as the spiritual counselor for 6 months. SC1 stated as a spiritual counselor, part of his duties includes documenting and completing the patients’ initial bereavement assessment, post bereavement and spiritual assessment. SC1 stated the initial bereavement assessment and spiritual assessment need to be completed and submitted within 5 days of the patient’s SOC. SC1 stated the initial bereavement assessment can also be completed by the MSW, and who does it all depends on how the workload is divided by the HA office.During a phone interview on 8/7/2025 at 2:23 p.m. with the MSW, the MSW stated part of her responsibilities as the social worker for the HA include home visits, completing the psychosocial assessment and at times the initial bereavement assessment within 5 days of the patient’s SOC. MSW stated she submits her assessments for review to CM1, but the EMR does not allow her to electronically sign her assessments until CM1 reviews and approves it. MSW stated the importance of conducting a psychosocial assessment on a patient is to assess their home situation, the support they have, assess patient and family coping needs and provide resources as needed in the future, assist patients with advanced directives and mortuary information and set up when needed. MSW stated the importance of conducting an initial bereavement assessment is to identify the patient’s primary bereaved, how they are coping and if more support will be needed when patient passes, and also to assess risk level of the bereaved. During a review of the HA’s Policy and Procedure (P&P) titled Bereavement Assessment with a revised date of April 2020, the P&P indicated on admission the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the bereavement coordinator to review and determine potential needs of the survivors and upon completion all bereavement documentation will be filed.During a review of the HA’s Policy and Procedure (P&P) titled Contents of Clinical Record with a revised date of April 2020, the P&P indicated documentation will include signed and dated clinical notes and each entry in the patient’s clinical record will be dated and signed, including title and credentials, by the person providing the care/service.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency who provides specialized care and support for people with a serious illness who are nearing the end of life) failed to ensure three of 19 sampled patients (Patient 1, Patient 2, and Patient 8) were provided with a copy of the current care plan and an opportunity to participate in developing individualized care plan goals, interventions, and expected outcomes. This failure had the potential to result in Patient 1, Patient 2, Patient 8 and/or their family member/caregiver being unable to be an active participant in his/her care. Findings: a. During a review of Patient 1’s clinical record titled Personal Information, undated, indicated a start of care (SOC) date of 7/11/2025, with a primary diagnosis of malignant neoplasm (commonly referred to as cancer, a term that encompasses a wide range of diseases characterized by the uncontrolled growth of abnormal cells in the body) of unspecified site of left female breast. During a review of Patient 1’s clinical record titled Plan of Care/Interdisciplinary Group Review (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) form dated 7/11/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus two visits as needed for changes in condition and symptom management, the Master of Social Work (MSW) to visit for initial assessment, then every recertification period for psychosocial (refers to a person’s well-being at the intersection of their internal workings and external experiences, which covers a person’s mental, emotional, social, and spiritual health) needs and support, Spiritual Counselor (SC) to visit for initial assessment, then every recertification plus one as needed per benefit period for spiritual needs and support and Hospice Aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a joint home visit observation on 8/5/2025, at 12:00 p.m., with the Director of Patient Care Services (DPCS) at Patient 1’s residence, at a room and board, Patient 1 was observed resting comfortably in her wheelchair. Patient 1 is alert, awake and oriented to her name, time, place and events but speaks random and irrelevant statements unrelated to her care or situation. During a concurrent review of Patient 1’s hospice folder with the DPCS, the folder had the name of the HA, inside of the folder indicated no copy of the Plan of Care. During an interview with the DPCS at 12:11 p.m., DPCS stated that she does not know if the POC was provided to patients. DPCS stated that it is important that patients have a copy of POC since they are part of formulating the care plan, to be actively involved and are readily available for their references during their hospice stay. During the interview with Patient 1’s caregiver (CG) 2, at 12:20 p.m., CG2 stated that she is unsure if copy of Patient 1’s POC was provided to them, stated that it would be better if they would also have a copy for their reference on what individualized care was formulated for the patient (Patient 1). b. During a review of Patient 2’s clinical record titled Personal Information, undated, indicated a start of care (SOC) date of 7/14/2025, with a primary diagnosis of cerebrovascular disease (a group of conditions that affect blood flow and blood vessels in the brain), unspecified (no specific location). During a review of Patient 2’s clinical record titled POC (Plan of Care, consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient’s needs)/IDG (Interdisciplinary Group- a team consists of medical director, registered nurse, spiritual chaplain, and social worker, responsible for the holistic care of the hospice beneficiary) Review form dated 7/14/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus two visits as needed for changes in condition and symptom management, the Master of Social Work (MSW) to visit for initial assessment, then every recertification period for psychosocial (refers to a person’s well-being at the intersection of their internal workings and external experiences, which covers a person’s mental, emotional, social, and spiritual health) needs and support, Spiritual Counselor (SC) to visit for initial assessment, then every recertification plus one visit as needed per benefit period for spiritual needs and support and Hospice Aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a joint home visit observation on 8/5/2025, at 1:00 p.m., with the Director of Patient Care Services (DPCS) at Patient 2’s residence, at a room and board, Patient 2 was observed sleeping comfortably in her bed. During a concurrent review of Patient 2’s hospice folder with the DPCS, the folder had the name of the HA, inside of the folder indicated no copy of the Plan of Care. During an interview with the DPCS at 1:05 p.m., DPCS stated that she does not know if the POC was provided to patients. DPCS stated that it is important that patients have a copy of POC since they are part of formulating the care plan, to be actively involved and are readily available for their references during their hospice stay. During the interview with Patient 2’s caregiver (CG) 2, at 1:15 p.m., CG2 stated that she is unsure if copy of Patient 2’s POC was provided to them, stated that it would be better if they would also have a copy for their reference on what individualized care was formulated for the patient (Patient 2). c. During a review of Patient 8’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 4/3/2025 and a primary diagnosis of Heart failure (a condition where the heart cannot pump blood effectively enough to meet the body’s needs and can lead to a buildup of fluid in the lungs, legs, and other organs). During a review of Patient 8’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025, indicated a frequency of Skilled Nurse (SN) visits of once a week and two visits as needed per month for changes in condition and symptom management, Master Social Worker (MSW) visits of one initial assessment and then at every recertification and one visit as needed for psychosocial needs and support, and spiritual counselor (SC) visits of one initial assessment and then at every recertification and one as needed for spiritual needs and support. During a joint home visit on 8/5/2025 at 11:05am with the Director of Patient Care Services (DPCS) at Patient 8’s residence at a room and board, Patient 8 was observed sitting on a reclining couch aside a front wheel walker, awake, alert to name, date of birth, date and location, wearing glasses and able to communicate his needs. When communicating with Patient 8 it was observed Patient 8 was hard of hearing and required people to speak louder or closer to his ears. During a joint home visit on 8/5/2025 at 11:50 a.m. with the DPCS at Patient 8’s residence at a room and board, Patient 8’s Hospice Agency (HA) binder was reviewed. Patient 8’s HA binder indicated the name of the patient, the agency name, agency phone number, the patient’s allergies, copy of signed consent forms and medication list. Patient 8’s HA binder indicated it did not include a copy of the care plan. The DPCS stated she was not sure if the HA provided the patients with a copy of the plan of care upon admission. The DPCS stated it is important to provide patients with a copy of their plan of care, so it is readily available to them, and they continue to be involved with formulating their care needs. During a review of the HA’s policy and procedure, titled “The Plan of Care,” revised date of April 2020, the policy and procedure indicated that the patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care and be provided instructions regarding treatments or aspects of care that will be the responsibility of the patient and family/caregiver to provide or follow through with.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency who provides specialized care and support for people with a serious illness who are nearing the end of life) failed to ensure that education and training were provided to the patient/patient’s caregiver related to: a. Bleeding precautions while on anti-coagulant medication (medication that is used to prevent and treat blood clots in blood vessels and the heart) for two of 14 sampled patients (Patient 1 and Patient 5). b. Safety precautions during 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 14 sampled patients (Patient 2). c. Oral care after use of steroid oral inhaler ( a type of inhaler by mouth, that delivers medication to the lungs to reduce inflammation) for two of 14 sampled patients (Patient 1 and Patient 3). 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. Findings: a. During a review of Patient 1’s “Personal Information”, indicated a start of care (SOC) date of 7/11/2025, with a primary diagnosis of malignant neoplasm (commonly referred to as cancer, a term that encompasses a wide range of diseases characterized by the uncontrolled growth of abnormal cells in the body) of unspecified site of left female breast. During a review of Patient 1’s Plan of Care/Interdisciplinary Group Review (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) form dated 7/11/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus two visits as needed for changes in condition and symptom management. The POC/IDG review form indicated the Master Social Worker (MSW) to visit for initial assessment, then every recertification period for psychosocial (refers to a person’s well-being at the intersection of their internal workings and external experiences, which covers a person’s mental, emotional, social, and spiritual health) needs and support, spiritual counselor (SC) to visit for initial assessment, then every recertification plus one as needed per benefit period for spiritual needs and support. The POC/IDG review form indicated the hospice aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a joint home visit observation on 8/5/2025, at 12:00 p.m., with the Director of Patient Care Services (DPCS) at Patient 1’s residence, at a room and board, Patient 1 was observed resting comfortably in her wheelchair. Patient 1 is alert, awake and oriented to her name, time, place and events but speaks random and irrelevant statements unrelated to her care or situation. During a concurrent interview, and record review at 12:15 p.m. with the DPCS, Patient 1’s record titled, “Current Treatment/Medication/DME (Durable Medical Equipment) List” printed on 8/4/2025 was reviewed with Patient 1’s current medications that she is taking. The medications reviewed include: Clopidogrel 75 milligram (mg, unit of weight) tablet, take one tablet, oral, once a day for CVA prophylaxis (Cerebrovascular accident or stroke, medication to prevent stroke). Note: Instruct Patient /PCG on bleeding precautions. Trelegy Ellipta (oral inhaler) 100 microgram (msg, unit of weight) – 62.5 mcg-25 mcg/actuation powder for inhalation, inhale 1 puff by mouth every 12 hours for SOB (shortness of breath)/COPD (a group of lung diseases that cause long-term breathing problems). The DPCS stated that Clopidogrel medication was an anticoagulant medication that can cause bleeding, unusual bruising and dark stools. During a concurrent review at 12:20 p.m. with the DPCS, Patient 1’s HA folder was reviewed. The DPCS confirmed and stated that there were no educational materials, or references provided to Patient 1 and Patient 1’s caregiver (G2) regarding what symptoms or side effects to look for while patient is on anticoagulant medication. DPCS stated that when a patient is on a new medication that is high risk, education and teaching need to be provided to patients and caregivers to determine bleeding precautions, what symptoms or side effects to look for like blood in stool, and nosebleed. The DPCS stated that Trelegy Ellipta inhaler is to inhale through mouth, and patient needs to rinse mouth with water without swallowing it after using the medication to help reduce the chance of getting oral thrush (a condition in which the Candida albicans (type of fungus) builds up in the mouth). During an interview at 12:30 p.m. with CG2, CG2 stated that she is a nurse, and she is aware of what to look for when a patient is on anti-coagulant medication and when to report to HA if any bleeding or unusual symptoms occur. CG2 stated that she encourages Patient 1 to rinse her mouth after each use of the Trelegy medication. CG2 stated that she does not remember if visiting nurses provided teachings and education materials regarding use of anticoagulant medication and steroid inhaler. During a concurrent interview and record review on 8/8/2025 at 1:21 p.m. with the DPCS, Patient 1’s clinical record titled “Visit Note RN (Registered Nurse),” dated 7/16/2025, 7/23/2025, and 7/30/25 were reviewed. DPCS confirmed and stated that The Visit Note RN dated 7/16/2025, 7/23/2025, and 7/30/25 did not indicate any documented evidence to validate that visiting nurses provided teachings to Patient 1 and CG2 regarding bleeding precautions while on anti-coagulant medication and oral care after use of steroid inhaler. DPCS2 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. b. During a review of Patient 3’s “Personal Information”, indicated a start of care (SOC) date of 3/26/2025, with a primary diagnosis of heart failure (occurs when the heart muscle becomes weakened and cannot pump blood effectively throughout the body) unspecified. During a review of Patient 3’s POC (Plan of Care, consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient’s needs)/IDG (Interdisciplinary Group- a team consists of medical director, registered nurse, spiritual chaplain, and social worker, responsible for the holistic care of the hospice beneficiary) review form dated 7/14/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus two visits as needed for changes in condition and symptom management. The POC/IDG review form indicated the Master of Social Work (MSW) to visit for initial assessment, then every recertification period for psychosocial (refers to a person’s well-being at the intersection of their internal workings and external experiences, which covers a person’s mental, emotional, social, and spiritual health) needs and support. The POC/IDG form indicated the spiritual counselor (SC) to visit for initial assessment, then every recertification plus one visit as needed per benefit period for spiritual needs and support. The POC/ IDG indicated the hospice aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a concurrent interview, and record review on 8/8/2025 at 1:28 p.m. with the DPCS, Patient 3’s record titled, “Current Treatment/Medication/DME List” printed on 8/4/2025 was reviewed. Patient 3’s Current Treatment/Medication/DME List reviewed include: Advair Diskus (oral inhaler) 250 mcg- 50 mcg/actuation powder for inhalation, inhale 2 puffs by mouth daily for SOB/COPD. DPCS stated that Advair diskus oral inhaler is to inhale through mouth, and patient needs to rinse mouth with water without swallowing it after using the medication to help reduce the chance of getting oral thrush. During a concurrent interview and record review on 8/8/2025 at 1:31 p.m. with the DPCS, Patient 3’s clinical record titled “Recert Assessment,” dated 6/16/2025 and “Visit Note RN (Registered Nurse),” dated 6/30/2025, 7/7/2025, 7/14/2025, 7/21/2025, and 7/28/2025 were reviewed. DPCS confirmed and stated that the Recert Assessment dated 6/16/2025 and The Visit Note RN dated 6/30/2025, 7/7/2025, 7/14/2025, 7/21/2025, and 7/28/2025 did not indicate any documented evidence to validate that visiting nurses provided teachings to Patient 3 and/or Patient 3’s caregiver regarding oral care after use of oral steroid inhaler. DPCS 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. c. During a review of Patient 2’s clinical record titled Personal Information, undated, indicated a start of care (SOC) date of 7/14/2025, with a primary diagnosis of cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), unspecified (no specific location). During a review of Patient 2’s clinical record titled POC (Plan of Care, consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient’s needs)/IDG (Interdisciplinary Group- a team consists of medical director, registered nurse, spiritual chaplain, and social worker, responsible for the holistic care of the hospice beneficiary) Review form dated 7/14/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus two visits as needed for changes in condition and symptom management. The POC/IDG review form indicated the Master of Social Work (MSW) to visit for initial assessment, then every recertification period for psychosocial (refers to a person’s well-being at the intersection of their internal workings and external experiences, which covers a person’s mental, emotional, social, and spiritual health) needs and support. The POC/IDG review form indicated the spiritual counselor (SC) to visit for initial assessment, then every recertification plus one visit as needed per benefit period for spiritual needs and support. The POC/IDG review form indicated the hospice aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a joint home visit observation on 8/5/2025, at 1:00 p.m., with the Director of Patient Care Services (DPCS) at Patient 2’s residence, at a room and board, Patient 2 was observed sleeping comfortably in her bed. During a concurrent interview, and record review at 1:00 p.m. with the DPCS, Patient 2’s record titled, “Current Treatment/Medication/DME (Durable Medical Equipment) List” printed on 8/4/2025 was reviewed with Patient 2’s current medications that she is taking. The medications reviewed include: Lamotrigine (an anticonvulsant medication, drugs used to prevent or treat seizures, a temporary episode of abnormal brain activity that causes sudden changes in behavior, consciousness, or body movements) 100mg, take one tablet twice a day, for seizure. DPCS stated that Lamotrigine medication is an anticonvulsant medication that prevents seizure episodes. During a concurrent review at 1:20 p.m. with the DPCS, Patient 2’s HA folder was reviewed. DPCS confirmed and stated that there were no educational materials, or references provided to Patient 2 and Patient 2’s caregiver (G2) regarding safety precautions during seizure episode. DPCS stated that when a patient is on a new medication and has a history of seizure, education and teaching need to be provided to patients and caregivers regarding what to do during seizure episodes. During an interview at 1:30 p.m. with CG2, CG2 stated that she is a nurse, and she is aware of what to do when a patient is having a seizure and how to prevent Patient 2 from harming during seizure activity. During a concurrent interview and record review on 8/8/2025 at 1:38 p.m. with the DPCS, Patient 2’s clinical record titled “Comprehensive Assessment,” dated 7/14/2025 and “Visit Note RN (Registered Nurse),” dated 7/23/2025, 7/30/2025, 8/5/2025 and 8/6/2025 were reviewed. DPCS confirmed and stated that the Comprehensive Assessment dated 7/14/2025 and The Visit Note RN dated 7/23/2025, 7/30/2025, 8/5/2025 and 8/6/2025 did not indicate any documented evidence to validate that visiting nurses provided teachings to Patient 2 and/or Patient 2’s caregiver regarding safety precautions during seizure episode. DPCS 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. d. During a review of Patient 5’s clinical record titled Personal Information, undated, indicated a start of care (SOC) date of 7/29/2025, with a primary diagnosis of cerebrovascular disease, unspecified. During a review of Patient 5’s POC (Plan of Care, consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient’s needs)/IDG (Interdisciplinary Group- a team consists of medical director, registered nurse, spiritual chaplain, and social worker, responsible for the holistic care of the hospice beneficiary) Review form dated 7/29/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus two visits as needed for changes in condition and symptom management, the Master Social Worker (MSW) to visit for initial assessment, then every recertification period for psychosocial (refers to a person’s well-being at the intersection of their internal workings and external experiences, which covers a person’s mental, emotional, social, and spiritual health) needs and support, Spiritual Counselor (SC) to visit for initial assessment, then every recertification plus one visit as needed per benefit period for spiritual needs and support and Hospice Aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a concurrent interview, and record review on 8/8/2025 at 1:40 p.m. with the DPCS, Patient 5’s record titled, “Current Treatment/Medication/DME List” printed on 8/4/2025 was reviewed. Patient 5’s Current Treatment/Medication/DME List reviewed include: Clopidogrel 75 milligram (mg, unit of weight) tablet, take one tablet, oral, once a day for CVA prophylaxis (Cerebrovascular accident or stroke, medication to prevent stroke). Note: Instruct Patient /PCG on bleeding precautions. DPCS stated that Clopidogrel medication is an anticoagulant medication that can cause bleeding, unusual bruising and dark stools. During a concurrent interview and record review on 8/8/2025 at 1:43 p.m. with the DPCS, Patient 5’s clinical record titled “Comprehensive Nursing Assessment,” dated 7/29/2025 was reviewed. The DPCS Comprehensive Nursing Assessment, dated 7/29/2025 confirmed and stated it did not indicate any documented evidence to validate that visiting nurses provided teachings to Patient 5 and Patient 5’s caregiver regarding bleeding precautions while on anti-coagulant medication. DPCS 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. During a review of the HA’s Policy and Procedure (P&P) titled, “Patient education process,” revised date of April 2020, indicated “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.””

“Based on observation, interview and record review, the hospice agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure that the care plan for four of 14 sampled patients (Patient 1, Patient 2, Patient 5 and Patient 9) was individualized based on their current health status, and personal needs. · Patient 1, Patient 5 and Patient 9 did not have a care plan to addressed bleeding precautions while on anti-coagulant medication (a medication that prevents blood from clotting by stopping existing clots from growing larger and preventing new clots from forming). · Patient 2 did not have a care plan regarding safety precautions during seizure (a sudden burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings and levels of consciousness) episode while on anti-seizure medication (medication to prevent seizure). This failure had the potential to result in a lack or delay in delivery of necessary care and services for Patient 1, Patient 2, Patient 5, and Patient 9. Findings: During a review of Patient 1’s clinical record titled Personal Information undated, indicated a start of care (SOC) date of 7/11/2025, with a primary diagnosis of malignant neoplasm (commonly referred to as cancer, a term that encompasses a wide range of diseases characterized by the uncontrolled growth of abnormal cells in the body) of unspecified site of left female breast. During a review of Patient 1’s clinical record titled Plan of Care/Interdisciplinary Group Review (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) form dated 7/11/2025, indicated the frequency of visits for skilled nurse (SN) was one visit per week plus two visits as needed for changes in condition and symptom management. The POC/IDG review form indicated the Master Social Worker (MSW) to visit for initial assessment, then every recertification period for psychosocial (refers to a person’s well-being at the intersection of their internal workings and external experiences, which covers a person’s mental, emotional, social, and spiritual health) needs and support. The POC/IDG review form indicated spiritual counselor (SC) to visit for initial assessment, then every recertification plus one visit as needed per benefit period for spiritual needs and support. The POC/IDG review form indicated the hospice aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a joint home visit observation on 8/5/2025, at 12p.m., with the Director of Patient Care Services (DPCS) at Patient 1’s residence, at a room and board, Patient 1 was observed resting comfortably in her wheelchair. Patient 1 is alert, awake and oriented to her name, time, place and events but speaks random and irrelevant statements unrelated to her care or situation. During a concurrent interview, and record review at 12:15 p.m. with the DPCS, Patient 1’s record titled, “Current Treatment/Medication/DME (Durable Medical Equipment) List” printed on 8/4/2025 was reviewed with Patient 1’s current medications that she is taking. The medications reviewed include: · Clopidogrel 75 milligram (mg, unit of weight) tablet, take one tablet, oral, once a day for CVA prophylaxis (Cerebrovascular accident or stroke, medication to prevent stroke). Note: Instruct Patient /PCG on bleeding precautions. DPCS stated that Clopidogrel medication is an anticoagulant medication that can cause bleeding, unusual bruising and dark stools. During a concurrent interview and record review on 8/8/2025 at 11:41 a.m. with the DPCS, Patient 1’s electronic health records were reviewed. The DPCS confirmed and stated that Patient 1’s “POC/IDG Review” dated 7/11/2025 and 8/1/2025 did not include a care plan for bleeding precautions while on anti-coagulant medication. DPCS stated that a care plan should have been formulated for Patient 1 while in use of anticoagulant medications. DPCS stated that care plan must address potential problems and for the nursing team to be aware of the goals and interventions and current health status of patient. DPCS stated that patient teaching must be done at the start of the care and at random, stated that it needs to be documented and needs to provide written education materials. b. During a review of Patient 2’s clinical record titled Personal Information, undated, indicated a start of care (SOC) date of 7/14/2025, with a primary diagnosis of cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), unspecified (no specific location). During a review of Patient 2’s clinical record titled POC/IDG Review form dated 7/14/2025, indicated the frequency of visits for skilled nurse (SN) was one visit per week plus two visits as needed for changes in condition and symptom management. The POC/IDG review form indicated the Master of Social Work (MSW) to visit for initial assessment, then every recertification period for psychosocial (refers to a person’s well-being at the intersection of their internal workings and external experiences, which covers a person’s mental, emotional, social, and spiritual health) needs and support. The POC/IDG review form indicated the spiritual counselor (SC) to visit for initial assessment, then every recertification plus one visit as needed per benefit period for spiritual needs and support. The POC/IDG review form indicated the Hospice Aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a joint home visit observation on 8/5/2025, at 1:00 p.m., with the Director of Patient Care Services (DPCS) at Patient 2’s residence, at a room and board, Patient 2 was observed sleeping comfortably in her bed. During a concurrent interview, and record review at 1:00 p.m. with the DPCS, Patient 2’s record titled, “Current Treatment/Medication/DME (Durable Medical Equipment) List” printed on 8/4/2025 was reviewed with Patient 2’s current medications that she is taking. The medications reviewed include: · Lamotrigine (an anticonvulsant medication, drugs used to prevent or treat seizures, a temporary episode of abnormal brain activity that causes sudden changes in behavior, consciousness, or body movements) 100mg, take one tablet twice a day, for seizure. DPCS stated that Lamotrigine medication is an anticonvulsant medication that prevents seizure episodes. CG2 stated that Patient 2 did not have any seizure episode since being admitted to hospice. During a concurrent interview and record review on 8/8/2025 at 11:58 a.m. with the Director of Patient Care Services (DPCS), Patient 2’s electronic health records were reviewed. The DPCS confirmed and stated that Patient 2’s “POC (Plan of Care) Summary,” dated as of 8/4/2025, and “POC/IDG Review” dated 7/14/2025, 7/18/2025, and 8/1/2025 did not include a care plan for safety precautions during seizure episode. DPCS stated that a care plan should have been formulated for Patient 2 since she is currently taking anti-seizure medication and has a medical history of seizure. DPCS stated that care plan must address potential problems and for the nursing team to be aware of the goals and interventions and current health status of patient. DPCS stated that patient teaching must be done at the start of the care and at random, stated that it needs to be documented and needs to provide written education materials c. During a review of Patient 5’s clinical record titled Personal Information, undated, indicated a start of care (SOC) date of 7/29/2025, with a primary diagnosis of cerebrovascular disease, unspecified. During a review of Patient 5’s clinical record titled POC/IDG Review form dated 7/29/2025, indicated the frequency of visits for skilled nurse (SN) was one visit per week plus two visits as needed for changes in condition and symptom management. The POC/IDG review form indicated the Master Social Worker (MSW) to visit for initial assessment, then every recertification period for psychosocial (refers to a person’s well-being at the intersection of their internal workings and external experiences, which covers a person’s mental, emotional, social, and spiritual health) needs and support. The POC/IDG review form indicated the spiritual counselor (SC) to visit for initial assessment, then every recertification plus one visit as needed per benefit period for spiritual needs and support. The POC/IDG review form indicated the Hospice Aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a concurrent interview, and record review on 8/8/2025 at 1:40 p.m. with the DPCS, Patient 5’s record titled, “Current Treatment/Medication/DME List” printed on 8/4/2025 was reviewed. Patient 5’s Current Treatment/Medication/DME List reviewed include: · Clopidogrel 75 milligram (mg, unit of weight) tablet, take one tablet, oral, once a day for CVA prophylaxis (Cerebrovascular accident or stroke, medication to prevent stroke). Note: Instruct Patient /PCG on bleeding precautions. The DPCS stated that Clopidogrel medication was an anticoagulant medication that can cause bleeding, unusual bruising and dark stools. During a concurrent interview and record review on 8/8/2025 at 11:52 a.m. with the DPCS, Patient 5’s electronic health records were reviewed. The DPCS confirmed and stated that Patient 5’s “POC/IDG Review” dated 7/29/2025 did not include a care plan for bleeding precautions while on anti-coagulant medication. The DPCS stated that a care plan should have been formulated for Patient 5 while in use of anticoagulant medications. The DPCS stated that care plan must address potential problems and for the nursing team to be aware of the goals and interventions and current health status of patient. DPCS stated that patient teaching must be done at the start of the care and at random, stated that it needs to be documented and needs to provide written education materials d. During a review of Patient 9’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 9/12/2024 and a primary diagnosis of Chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and a secondary diagnosis of Cerebrovascular disease (group of conditions that affect blood flow to the brain). During a review of Patient 9’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025, indicated a frequency of Skilled Nurse (SN) visits once per week and two as needed visits per month, Master Social Worker (MSW) visits of one initial assessment and then at every recertification and one as needed for psychosocial needs and support. The POC/IDG review form indicated the spiritual counselor (SC) visits of one initial assessment and then at every recertification and one as needed or spiritual needs and support. During a review of Patient 9’s clinical record titled current treatment/ medication/ durable medical equipment (DME) list, undated, indicated medication orders for: Aspirin (drug that reduces pain, fever, inflammation, and blood clotting) 81 milligrams (mg, unit of measurement) enteric coated tablet (a polymer coating that allows the medication to stay intact as it passes through the acid in the stomach), take 1 tablet orally daily in the morning, and Clopidogrel (antiplatelet medication used to prevent blood clots by keeping platelets in the blood from coming together and making clots) 75 mg, take 1 tablet orally daily in the morning. During a concurrent interview and record review on 8/7/2025 10:45 a.m. with the Director of Patient Care Services (DPCS), Patient 9’s clinical record titled Plan of Care/ Interdisciplinary Group (POC/IDG) dated 8/1/2025 was reviewed. Patient 9’s POC/IDG indicated there was no documented care plan for the monitoring and precautions for bleeding due to the use of aspirin and clopidogrel medication. The DPCS stated and confirmed Patient 9’s POC/IDG dated 8/1/2025 did not have documented evidence of a care plan for the monitoring and precautions of bleeding as side effects for the use of the medication’s aspirin and clopidogrel. During a review of the HA Policy and Procedure (P&P) titled The Plan of Care with a revised date of Aril 2020 indicated, the written plan of care will include, but not limited to, patient demographics, diagnosis, reduction in risk factors, safety measures to protect against injury, patient and family/caregiver educational needs and assessment of their ability to learn and understand teaching of medications, drugs and treatments and measurable outcomes anticipated from implementing and coordinating plan of care.”

“Based on interview, and record review, the Hospice Agency (HA, agency who provides specialized care and support for people with a serious illness who are nearing the end of life) failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities),) reviewed and revised the plan of care (POC- an individualized care planned) in a timely manner for five of 14 sampled patients (Patient1, Patient 5, Patient 8, Patient 9 and Patient 10). This failure placed Patient 1, Patient 5, Patient 8, Patient 9 and Patient 10 at risk of not meeting the hospice and care services needed to address the patients physical, psychosocial, emotional and spiritual needs. Findings: a. During a review of Patient 1’s clinical record titled Personal Information, undated, indicated a start of care (SOC) date of 7/11/2025, with a primary diagnosis of malignant neoplasm of unspecified site of left female breast (a cancerous tumor ( grows uncontrollably and can spread to other parts of the body) in the left breast where the exact location within the breast is not specified in the medical documentation, it signifies a malignant growth (cancer) within the breast tissue, but the specific location like the nipple, upper outer quadrant, etc., is not identified). During a concurrent record review and interview on 8/8/2025 at 11:15 a.m., with the Director of Patient Care Services (DPCS), Patient 1’ s clinical record titled “Plan of Care/Interdisciplinary Group Review” (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 8/1/2025 was reviewed. The DPCS confirmed and stated that Patient 1’s POC/IDG Review dated 8/1/2025 had no documented signature of Master of Social Worker (MSW). The DPCS stated that there is no separate sign-in sheet for IDG members during meeting. The DPCS stated the IDG members would only sign electronically when they attended the IDG meetings, there was no separate sign-in sheet. The DPCS stated if the POC/IDG Review was not signed by a particular IDG member, it would mean that IDG members were not present during the meeting to review the patient’s individualized plan of care. b. During a review of Patient 5’s “Personal Information”, indicated a start of care (SOC) date of 7/29/2025, with a primary diagnosis of cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), unspecified. During a concurrent record review and interview on 8/8/2025 at 11:18 a.m., with the DPCS, Patient 5’ s clinical record titled “POC/IDG Review,” dated 7/29/2025 and 8/1/2025 were reviewed. The DPCS confirmed and stated that Patient 5’s POC/IDG Review dated 7/29/2025 and 8/1/2025 had no documented signatures of MSW. The DPCS stated that there is no separate sign-in sheet for IDG members during meetings. The DPCS stated the IDG members would only sign electronically when they attended the IDG meetings, there was no separate sign-in sheet. The DPCS stated if the POC/IDG Review was not signed by a particular IDG member, it would mean that IDG members were not present during the meeting to review the patient’s individualized plan of care. c. During a review of Patient 8’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 4/3/2025 and a primary diagnosis of Heart failure (a condition where the heart cannot pump blood effectively enough to meet the body’s needs and can lead to a buildup of fluid in the lungs, legs, and other organs). During a review of Patient 8’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025, indicated a frequency of Skilled Nurse (SN) visits of once a week and two as needed (PRN) per month for changes in condition and symptom management, Medical Social Worker (MSW) visits of one initial assessment and then at every recertification and one PRN for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one PRN for spiritual needs and support. During a review of Patient 8’s clinical record titled POC/IDG Review dated 8/1/2025 indicated there were documented electronic signatures from the Medical Director (MD), Registered Nurse (RN) and SC1, but there was no documented evidence of a signature under MSW signature from the MSW. During a concurrent interview and record review on 8/7/2025 at 11:15 a.m. with Case Manager 1 (CM1), Patient 8’s clinical record titled POC/IDG Review dated 8/1/2025 was reviewed. Patient 8’s POC/IDG Review dated 8/1/2025 indicated there were documented electronic signatures from the MD, an RN and the Spiritual Counselor 1 (SC1), but there was no documented evidence of a signature under MSW signature from the MSW. CM1 stated and confirmed that Patient 8’s POC/IDG Review dated 8/1/2025 was missing the MSW signature. CM1 stated the IDG members include the MD, DPCS or RN, the MSW and the Chaplain/SC1, and stated all members have to participate in all IDG meetings and document and sign on the POC/IDG. CM1 further stated the importance of all IDG members that attend the meetings document and sign the POC/IDG is to validate their attendance and participation. d. During a review of Patient 9’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 9/12/2024 and a primary diagnosis of Chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a review of Patient 9’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025, indicated a frequency of Skilled Nurse (SN) visits of once per week and two as needed (PRN) visits per month, Medical Social Worker (MSW) visits of one initial assessment and then at every recertification and one PRN for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one PRN for spiritual needs and support. During a review of Patient 9’s Electronic Medical Record (EMR), the EMR under section IDG indicated; POC/IDG Review dated 6/6/2025 indicated there was no documented evidence of the SC1 signature. POC/IDG Review dated 6/20/2025 indicated there was no documented evidence of the SC1 signature. POC/IDG Review dated 7/4/2025 indicated there was no documented evidence of the SC1 and RN signature. POC/IDG Review dated 7/18/2025 indicated there was no documented evidence of the SC1 signature. POC/IDG Review dated 8/1/2025 indicated there was no documented evidence of the SC1 and MSW signature. During a concurrent interview and record review on 8/7/2025 at 11:32 a.m. with CM1, Patient 9’s clinical records titled POC/IDG Review dated 6/6/2025, 6/20/2025, 7/4/2025, 7/18/2025 and 8/1/2025 were reviewed. CM1 stated and confirmed that Patient 9’s POC/IDG Review dated 6/6/2025 did not have signatures from all IDG members and was missing a signature from the SC1. CM1 stated and confirmed Patient 9’s POC/IDG Review dated 6/20/2025 also did not have signatures from all IDG members and was missing the SC1’s signature. CM1 stated and confirmed Patient 9’s POC/IDG Review dated 7/4/2025 did not have all IDG member signatures and was missing a signature from the SC1 and RN. CM1 stated and confirmed Patient 9’s POC/IDG Review dated 7/18/2025 did not include signatures from all IDG members and was also missing a signature from the SC1. CM1 stated and confirmed Patient 9’s POC/IDG Review dated 8/1/2025 did not include all IDG members signatures and was missing the signatures of the MSW and SC1. CM1 further stated the importance of all IDG members documenting and signing the POC/IDG is to validate their attendance and participation. e. During a review of Patient 10’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 3/26/2025 and a primary diagnosis of Cerebrovascular disease (a group of conditions that affect the blood vessels in the brain and can disrupt blood flow to the brain, leading to damage or death of brain cells). During a review of Patient 10’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025 indicated a frequency of Skilled Nurse (SN) visits of once per week and two as needed (PRN) visits per month for symptom management and changes in condition, Medical Social Worker (MSW) visits of one initial assessment and then at every recertification and one PRN for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one PRN for spiritual needs and support. During a review of Patient 10’s clinical record titled POC/IDG Review dated 8/1/2025 indicated there were documented electronic signatures from the MD, SC, and MSW but there was no documented evidence of a signature under RN signature from an RN. During a concurrent interview and record review on 8/7/2025 at 11:40 a.m. with CM1, Patient 10’s clinical record titled POC/IDG Review dated 8/1/2025 was reviewed. Patient 10’s POC/IDG Review dated 8/1/2025 indicated there were documented electronic signatures from the MD, an MSW and the SC1, but there was no documented evidence of a signature under RN signature from an RN. CM1 stated and confirmed that Patient 10’s POC/IDG Review dated 8/1/2025 was missing the RN signature and stated every IDG member should sign the POC/IDG Review. CM1 further stated the importance of all IDG members that attend the meetings document and sign the POC/IDG is to validate their attendance and participation. During an interview on 8/7/2025 at 1:32 p.m. with the DPCS, the DPCS stated all IDG meetings are held every two weeks and mostly done over the phone, either via call or zoom meting. The DPCS stated the IDG members that are required to attend at every meeting include the MD, MSW, SC and DPCS/RN. The DPCS stated the members validation of attendance in the meeting is by documenting in and signing the POC/IDG review. The DPCS stated that is how attendance is validated, the HA doe snot have any other attendance sign in sheet for IDG meetings. During a telephone interview on 8/7/2025 at 2pm with the SC1, the SC1 stated he participates in the IDG meeting that are done every two weeks via phone call. The SC1 stated his participation and attendance of the IDG meeting is verified by his signature on the POC/IDG Review. The SC1 stated if his signature is not on a POC/IDG Review for a patient then it can indicate he was not part of the meeting. During a telephone interview on 8/7/2025 at 2:30 p.m. with the MSW, the MSW stated the HA IDG meets every two weeks on a Friday, and she (MSW) does participate in the meetings every two weeks. MSW stated the IDG meetings are mostly done over the phone, sometimes via zoom call or in person too. The MSW stated her attendance and participation of the IDG meeting can be verified by her documentation and signature on the patient’s POC/IDG Review. MSW was not aware she had missing signatures on patient’s POC/IDG Review. During a review of the agency’s policy and procedure (P&P) titled “Interdisciplinary Group Membership and Responsibilities,” revised date of April 2020, the P & P indicated that the hospice interdisciplinary group responsibilities include but not limited to: B. Participation in the periodic review and updating of the plan of care for each patient receiving hospice services. During a review of the HA’s Policy and Procedure (P&P) titled The Plan of Care with a revised date of April 2020, the P&P indicated the plan of care will be based on the comprehensive (a thorough evaluation of a patient’s physical, psychosocial, emotional, and spiritual needs related to patients terminal illness) and ongoing assessments performed by the members of the interdisciplinary group and will be reviewed on a regular basis but no less than every 15 days, and review of the plan of care will be documented in the clinical record.”

“Based on interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure a post bereavement assessment was completed for two of 14 sampled patients (Patient 7 and Patient 14). This deficient practice had the potential to impact a family members’ abilities to cope with the patients’ death by not adequately assessing the family/caregivers mental and emotional status. Findings: a. During a review of Patient 7’s clinical record titled Personal Information, undated, indicated a start of care (SOC) date of 2/25/2025 and an end of care (EOC) date of 3/14/2025, with a primary diagnosis of chronic obstructive pulmonary disease (COPD, is a group of lung diseases that cause long-term breathing problems). During a review of Patient 7’s clinical record titled POC/IDG Review (Plan of Care/Interdisciplinary Group Review, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), dated 2/25/2025, the POC/IDG Review indicated a goal of bereaved will verbalize understanding regarding hospice bereavement program and express awareness of access to grief counseling services for 13 months, and an intervention which include assess family needs/concerns regarding bereavement, coping measures, anticipated grief reactions and support systems available and to assess caregiver reaction to grief and loss. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 8/8/2025 at 12:35 p.m., Patient 7’s clinical record titled “History of Post-Death Bereavement Assessment” was reviewed. DPCS confirmed and stated that the History of Post – Death Bereavement Assessment was blank and did not indicate documented evidence that a post-bereavement assessment was conducted. The DPCS stated that a post bereavement assessment should be conducted immediately after patient’s death. The DPCS stated that Patient 7 and Patient 14 did not have a post bereavement assessment that should be conducted after death, DPCS stated that it is important to ensure that deceased patient’s family are coping well with the grieving process and to ensure what assistance and resources the HA can provide to them. b. During a review of Patient 14’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 4/13/2025 and an End of Care (EOC) date of 6/2/2025, with a primary diagnosis of Malignant neoplasm of prostate (a cancerous tumor that develops in the prostate gland [a gland below the bladder and in front of the rectum in the male]). During a review of Patient 14’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 5/23/2025 indicated a frequency of Skilled Nurse (SN) visits of once per week and two as needed (PRN) visits per month for changes in condition and symptom management, Medical Social Worker (MSW) visits of one initial assessment and then at every recertification and one PRN for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one PRN for spiritual needs and support. During a review of Patient 14’s Electronic Medical Record (EMR), the EMR indicated under the section History of Post- Death Bereavement Assessment was blank and there was no evidence of a documented or submitted post bereavement assessment. During a concurrent interview and record review on 8/7/2025 at 10:50 a.m. with the DPCS, Patient 14’s EMR was reviewed. Patient 14’s EMR indicated the section History of Post- Death Bereavement Assessment was blank and did not have evidence of a documented or submitted post bereavement assessment. The DPCS stated and confirmed Patient 14’s EMR did not have a documented and submitted post bereavement assessment. The DPCS stated the post bereavement assessment should immediately, within 24 hours, be completed by the bereavement coordinator who is the chaplain/Spiritual Counselor (SC), who is informed by the nurse. The DPCS also stated failure of completing/submitting a patient’s post bereavement assessment is incomplete reporting of the patient’s death because it verifies the patient’s passing as well as the family’s understanding of the passing and assessment of needs. During an interview on 8/7/2025 at 2:15 p.m. with the Spiritual Counselor 1 (SC1), SC1 stated that the post bereavement assessment of a patient is to be completed by the bereavement coordinator, which is him. The SC1 stated that the importance of completing a post bereavement assessment of patient’s family/caregiver is to identify how the family/caregiver is being supported, how their needs are being met and what else is needed to help them cope during a difficult time and do right by the family caregiver. The SC1 stated that a post bereavement assessment should be completed and submitted within 24 hours of the patient’s death. During a review of the HA’s policy and procedure (P&P) titled Bereavement Assessment with a revised date of April 2020 indicated, that the hospice bereavement plan of care will be developed based on an initial assessment of the patient and family/caregiver needs, during care, and at the time of patient’s death as part of the comprehensive assessment.”

“Based on interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure that the HA failed to ensure written policies and procedures, describing its method(s) of assessment of competency and maintaining a written description of the in-service training provided during the previous 12 months to assess the skills and competence of all its staffs, furnishing care were established. This deficient practice had the potential to affect the professional skills and competence of all its staff towards meeting the patient’s care and needs. Findings: During a review of the HA’s record titled Annual Staff In-services binder, the Annual staff In-services binder indicated documented in-services for the months of January to December of the year 2024. The HA binder did not have documented evidence of in-services being conducted since January of 2025. During a concurrent interview and record review on 8/8/2025 at 10:50 a.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), the HA’s record titled Annual Staff In-services binder was reviewed. The ADM/DPCS confirmed and stated that there was no documented evidence that in-services to improve and refresh professional skills and services for all staff members were conducting since January of 2025. The ADM/DPCS stated that they are supposed to conduct training to all staff monthly with different topics to refresh and enhance the skills of all staffs, especially the field nursing staff, to provide better care and services to patients. The ADM/DPCS stated herself and/or the Case Manager 1 (CM1) are in charge of conducting the in-services to the HA staff. During a review of the HA’s policy and procedure (P&P) titled Training/In-service Education, revised date of April 2020, the P&P indicated that the HA will provide training and education to give personnel opportunities to learn new skills and improve/expand existing knowledge, training topics may include information regarding the organization’s professional standards of care/practice, performance improvement monitoring results, updates in patient care techniques/resources, and safety/infection controls requirements.”

“Based on interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure a post bereavement assessment was completed for two of 14 sampled patients (Patient 7 and Patient 14). This deficient practice had the potential to impact a family members’ abilities to cope with the patients’ death by not adequately assessing the family/caregivers mental and emotional status as evidence by an incomplete post bereavement assessment. Findings: a. During a review of Patient 7’s clinical record titled Personal Information, undated, indicated a start of care (SOC) date of 2/25/2025 and an end of care (EOC) date of 3/14/2025, with a primary diagnosis of chronic obstructive pulmonary disease (COPD, is a group of lung diseases that cause long-term breathing problems). During a review of Patient 7’s clinical record titled POC/IDG Review (Plan of Care/Interdisciplinary Group Review, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), dated 2/25/2025, the POC/IDG Review indicated a goal of bereaved will verbalize understanding regarding hospice bereavement program and express awareness of access to grief counseling services for 13 months, and an intervention which include assess family needs/concerns regarding bereavement, coping measures, anticipated grief reactions and support systems available and to assess caregiver reaction to grief and loss. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 8/8/2025 at 12:35 p.m., Patient 7’s clinical record titled “History of Post-Death Bereavement Assessment” was reviewed. DPCS confirmed and stated that the History of Post – Death Bereavement Assessment was blank and did not indicate documented evidence that a post-bereavement assessment was conducted. The DPCS stated that a post bereavement assessment should be conducted immediately after patient’s death. The DPCS stated that Patient 7 and Patient 14 did not have a post bereavement assessment that should be conducted after death, DPCS stated that it is important to ensure that deceased patient’s family are coping well with the grieving process and to ensure what assistance and resources the HA can provide to them. b. During a review of Patient 14’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 4/13/2025 and an End of Care (EOC) date of 6/2/2025, with a primary diagnosis of Malignant neoplasm of prostate (a cancerous tumor that develops in the prostate gland [a gland below the bladder and in front of the rectum in the male]). During a review of Patient 14’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 5/23/2025 indicated a frequency of Skilled Nurse (SN) visits of once per week and two as needed (PRN) visits per month for changes in condition and symptom management, Master of Social Work (MSW) visits of one initial assessment and then at every recertification and one PRN for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one PRN for spiritual needs and support. During a review of Patient 14’s Electronic Medical Record (EMR), the EMR indicated under the section History of Post- Death Bereavement Assessment was blank and there was no evidence of a documented or submitted post bereavement assessment. During a concurrent interview and record review on 8/7/2025 at 10:50 a.m. with the DPCS, Patient 14’s EMR was reviewed. Patient 14’s EMR indicated the section History of Post- Death Bereavement Assessment was blank and did not have evidence of a documented or submitted post bereavement assessment. The DPCS stated and confirmed Patient 14’s EMR did not have a documented and submitted post bereavement assessment. The DPCS stated the post bereavement assessment should immediately be completed by the bereavement coordinator who is the chaplain/Spiritual Counselor (SC). The DPCS also stated failure of completing/submitting a patient’s post bereavement assessment is incomplete reporting of the patient’s death because it verifies the patient’s passing as well as the family’s understanding of the passing and assessment of needs. During an interview on 8/7/2025 at 2:15 p.m. with the Spiritual Counselor 1 (SC1), SC1 stated that the post bereavement assessment of a patient is to be completed by the bereavement coordinator, which is him. The SC1 stated that the importance of completing a post bereavement assessment of patient’s family/caregiver is to identify how the family/caregiver is being supported, how their needs are being met and what else is needed to help them cope during a difficult time and do right by the family caregiver. The SC1 stated that a post bereavement assessment should be completed and submitted within 24 hours of the patient’s death. During a review of the HA’s policy and procedure (P&P) titled Bereavement Assessment with a revised date of April 2020 indicated, that the hospice bereavement plan of care will be developed based on an initial assessment of the patient and family/caregiver needs, during care, and at the time of patient’s death as part of the comprehensive assessment. The P&P also indicated after death occurs the hospice social worker or bereavement coordinator will complete the bereavement follow-up assessment and based on the findings of the assessment, the bereavement coordinator will develop a plan for intervention.”

“Based on interview and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to maintain an authenticated clinical record based on accepted standards of practice and regulations followed by failing to: 1.Ensure the Interdisciplinary Group (IDG, meeting where the Registered Nurse [RN], Master of Social Work [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) meetings were signed by all IDG members for five of 14 sample patients (Patient 1, Patient 5, Patient 8, Patient 9 and Patient 10) . 2. Ensure an accurate comprehensive nursing assessment was conducted for seven of 14 sample patients (Patient 2, Patient 3, Patient 4, Patient 5, Patient 9, Patient 10, and Patient 11) by accurately completing the Local Coverage Determination (LCD, guideline for determining if a patient meets the eligibility requirements for hospice care) for hospice eligibility, based on the patient’s assessment findings and supporting documents in their electronic medical record (EMR, digital version of a patient’s chart within a specific healthcare practice or institution). 3. Ensure a completed initial bereavement assessment, to provide bereavement counseling in accordance with the patient/family’s needs for two of 14 sampled patients (Patient 10 and Patient 11). These failures resulted in the patients’ medical records not being accurate, complete, signed, and dated by the disciplines delivering services. Findings:1.a. During a review of Patient 1’s clinical record titled Personal Information, undated, indicated a start of care (SOC) date of 7/11/2025, with a primary diagnosis of malignant neoplasm of unspecified site of left female breast (a cancerous tumor ( grows uncontrollably and can spread to other parts of the body) in the left breast where the exact location within the breast is not specified in the medical documentation, it signifies a malignant growth (cancer) within the breast tissue, but the specific location like the nipple, upper outer quadrant, etc., is not identified). During a concurrent record review and interview on 8/8/2025 at 11:15 a.m., with the Director of Patient Care Services (DPCS), Patient 1’ s clinical record titled “Plan of Care/Interdisciplinary Group Review” (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 8/1/2025 was reviewed. The DPCS confirmed and stated that Patient 1’s POC/IDG Review dated 8/1/2025 had no documented signature of Master of Social Work (MSW). The DPCS stated that there is no separate sign-in sheet for IDG members during meeting. The DPCS stated the IDG members would only sign electronically when they attended the IDG meetings, there was no separate sign-in sheet. The DPCS stated if the POC/IDG Review was not signed by a particular IDG member, it would mean that IDG members were not present during the meeting to review the patient’s individualized plan of care. b. During a review of Patient 5’s “Personal Information”, indicated a start of care (SOC) date of 7/29/2025, with a primary diagnosis of cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), unspecified. During a concurrent record review and interview on 8/8/2025 at 11:18 a.m., with the DPCS, Patient 5’ s clinical record titled “POC/IDG Review,” dated 7/29/2025 and 8/1/2025 were reviewed. The DPCS confirmed and stated that Patient 5’s POC/IDG Review dated 7/29/2025 and 8/1/2025 had no documented signatures of MSW. The DPCS stated that there is no separate sign-in sheet for IDG members during meetings. The DPCS stated the IDG members would only sign electronically when they attended the IDG meetings, there was no separate sign-in sheet. The DPCS stated if the POC/IDG Review was not signed by a particular IDG member, it would mean that IDG members were not present during the meeting to review the patient’s individualized plan of care. c. During a review of Patient 8’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 4/3/2025 and a primary diagnosis of Heart failure (a condition where the heart cannot pump blood effectively enough to meet the body’s needs and can lead to a buildup of fluid in the lungs, legs, and other organs). During a review of Patient 8’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025, indicated a frequency of Skilled Nurse (SN) visits of once a week and two as needed (PRN) per month for changes in condition and symptom management, MS visits of one initial assessment and then at every recertification and one PRN for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one PRN for spiritual needs and support. During a review of Patient 8’s clinical record titled POC/IDG Review dated 8/1/2025 indicated there were documented electronic signatures from the Medical Director (MD), Registered Nurse (RN) and SC1, but there was no documented evidence of a signature under MSW signature from the MSW. During a concurrent interview and record review on 8/7/2025 at 11:15 a.m. with Case Manager 1 (CM1), Patient 8’s clinical record titled POC/IDG Review dated 8/1/2025 was reviewed. Patient 8’s POC/IDG Review dated 8/1/2025 indicated there were documented electronic signatures from the MD, an RN and the Spiritual Counselor 1 (SC1), but there was no documented evidence of a signature under MSW signature from the MSW. CM1 stated and confirmed that Patient 8’s POC/IDG Review dated 8/1/2025 was missing the MSW signature. CM1 stated the IDG members include the MD, DPCS or RN, the MSW and the Chaplain/SC1, and stated all members have to participate in all IDG meetings and document and sign on the POC/IDG. CM1 further stated the importance of all IDG members that attend the meetings document and sign the POC/IDG is to validate their attendance and participation. d. During a review of Patient 9’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 9/12/2024 and a primary diagnosis of Chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a review of Patient 9’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025, indicated a frequency of Skilled Nurse (SN) visits of once per week and two as needed (PRN) visits per month, MSW visits of one initial assessment and then at every recertification and one PRN for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one PRN for spiritual needs and support. During a review of Patient 9’s Electronic Medical Record (EMR), the EMR under section IDG indicated; POC/IDG Review dated 6/6/2025 indicated there was no documented evidence of the SC1 signature. POC/IDG Review dated 6/20/2025 indicated there was no documented evidence of the SC1 signature. POC/IDG Review dated 7/4/2025 indicated there was no documented evidence of the SC1 and RN signature. POC/IDG Review dated 7/18/2025 indicated there was no documented evidence of the SC1 signature. POC/IDG Review dated 8/1/2025 indicated there was no documented evidence of the SC1 and MSW signature. During a concurrent interview and record review on 8/7/2025 at 11:32 a.m. with CM1, Patient 9’s clinical records titled POC/IDG Review dated 6/6/2025, 6/20/2025, 7/4/2025, 7/18/2025 and 8/1/2025 were reviewed. CM1 stated and confirmed that Patient 9’s POC/IDG Review dated 6/6/2025 did not have signatures from all IDG members and was missing a signature from the SC1. CM1 stated and confirmed Patient 9’s POC/IDG Review dated 6/20/2025 also did not have signatures from all IDG members and was missing the SC1’s signature. CM1 stated and confirmed Patient 9’s POC/IDG Review dated 7/4/2025 did not have all IDG member signatures and was missing a signature from the SC1 and RN. CM1 stated and confirmed Patient 9’s POC/IDG Review dated 7/18/2025 did not include signatures from all IDG members and was also missing a signature from the SC1. CM1 stated and confirmed Patient 9’s POC/IDG Review dated 8/1/2025 did not include all IDG members signatures and was missing the signatures of the MSW and SC1. CM1 further stated the importance of all IDG members documenting and signing the POC/IDG is to validate their attendance and participation. e. During a review of Patient 10’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 3/26/2025 and a primary diagnosis of Cerebrovascular disease (a group of conditions that affect the blood vessels in the brain and can disrupt blood flow to the brain, leading to damage or death of brain cells). During a review of Patient 10’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025 indicated a frequency of Skilled Nurse (SN) visits of once per week and two as needed (PRN) visits per month for symptom management and changes in condition, MSW visits of one initial assessment and then at every recertification and one PRN for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one PRN for spiritual needs and support. During a review of Patient 10’s clinical record titled POC/IDG Review dated 8/1/2025 indicated there were documented electronic signatures from the MD, SC, and MSW but there was no documented evidence of a signature under RN signature from an RN. During a concurrent interview and record review on 8/7/2025 at 11:40 a.m. with CM1, Patient 10’s clinical record titled POC/IDG Review dated 8/1/2025 was reviewed. Patient 10’s POC/IDG Review dated 8/1/2025 indicated there were documented electronic signatures from the MD, an MSW and the SC1, but there was no documented evidence of a signature under RN signature from an RN. CM1 stated and confirmed that Patient 10’s POC/IDG Review dated 8/1/2025 was missing the RN signature and stated every IDG member should sign the POC/IDG Review. CM1 further stated the importance of all IDG members that attend the meetings document and sign the POC/IDG is to validate their attendance and participation. During an interview on 8/7/2025 at 1:32 p.m. with the DPCS, the DPCS stated all IDG meetings are held every two weeks and mostly done over the phone, either via call or zoom meting. The DPCS stated the IDG members that are required to attend at every meeting include the MD, MSW, SC and DPCS/RN. The DPCS stated the members validation of attendance in the meeting is by documenting in and signing the POC/IDG review. The DPCS stated that is how attendance is validated, the HA does not have any other attendance sign in sheet for IDG meetings. During a telephone interview on 8/7/2025 at 2pm with the SC1, the SC1 stated he participates in the IDG meeting that are done every two weeks via phone call. The SC1 stated his participation and attendance of the IDG meeting is verified by his signature on the POC/IDG Review. The SC1 stated if his signature is not on a POC/IDG Review for a patient then it can indicate he was not part of the meeting. During a telephone interview on 8/7/2025 at 2:30 p.m. with the MSW, the MSW stated the HA IDG meets every two weeks on a Friday, and she (MSW) does participate in the meetings every two weeks. MSW stated the IDG meetings are mostly done over the phone, sometimes via zoom call or in person too. The MSW stated her attendance and participation of the IDG meeting can be verified by her documentation and signature on the patient’s POC/IDG Review. MSW was not aware she had missing signatures on patient’s POC/IDG Review. During a review of the agency’s policy and procedure (P&P) titled “Interdisciplinary Group Membership and Responsibilities,” revised date of April 2020, the P & P indicated that the hospice interdisciplinary group responsibilities include but not limited to: B. Participation in the periodic review and updating of the plan of care for each patient receiving hospice services. During a review of the HA’s Policy and Procedure (P&P) titled The Plan of Care with a revised date of April 2020, the P&P indicated the plan of care will be based on the comprehensive and ongoing assessments performed by the members of the interdisciplinary group and will be reviewed on a regular basis but no less than every 15 days, and review of the plan of care will be documented in the clinical record. 2.a. During a review of Patient 2’s “Personal Information”, indicated a start of care (SOC) date of 7/14/2025, with a primary diagnosis of cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), unspecified (no specific location). During a review of Patient 2’s POC (Plan of Care, consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient’s needs)/IDG (Interdisciplinary Group- a team consists of medical director, registered nurse, spiritual chaplain, and social worker, responsible for the holistic care of the hospice beneficiary) Review form dated 7/14/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus two PRN (pro re nata, which means “as needed”) visits for changes in condition and symptom management, the Master of Social Work (MSW) to visit for initial assessment, then every recertification period for psychosocial (refers to a person’s well-being at the intersection of their internal workings and external experiences, which covers a person’s mental, emotional, social, and spiritual health) needs and support, Spiritual Counselor (SC) to visit for initial assessment, then every recertification plus one PRN per benefit period for spiritual needs and support and Hospice Aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a review of Patient 2’s clinical record titled “Comprehensive Nursing Assessment,” dated 7/14/2025, Patient 2’s documented weight was 100 lbs. (pounds, unit of weight) and mid arm circumference (MAC, a measurement of the circumference of the upper am, taken at the midpoint between the shoulder and elbow) of 19 centimeters (cm, unit of weight) from left upper arm. Patient 2’s Comprehensive Nursing Assessment also indicated in the section Narrative and Disease Trajectory, “saw-toothed decline (symptom exacerbations (worsening of a disease, symptom, or problem) and improvement).” Patient 2’s Comprehensive Assessment indicated, under the section Nutrition, if the patient had weight loss greater than 10% in the last 6 months, and licensed staff documented Yes. During a concurrent interview and record review on 8/8/2025 at 12:45 p.m. with the Director of Patient Care Services (DPCS), Patient 2’s pre-admission clinical records titled “History and Physical (refers to a comprehensive assessment of a patient’s health, combining the patient’s medical history with the results of a physical examination),” dated 6/13/2025 and “Discharge Summary (a document that summarizes a patient’s hospital stay, including the reason for admission, treatments received, and recommendations for follow-up care) and Post-Discharge Plan of Care (guide that helps ensure a smooth and safe transition for a patient leaving a healthcare facility to returning home or moving to another care setting like a rehabilitation facility or skilled nursing facility), “ dated 7/10/2025 were reviewed. Patient 2’s History and Physical indicated there was no documented evidence of Patient 2’s weight loss greater than 10% (percent, unit of measurement) in the last 6 months or greater than 7.5 % in the last 3 months. The DPCS confirmed and stated that Patient 2’s previous clinical records prior to the admission to hospice care did not indicate any supporting evidence or objective data regarding weight loss. The DPCS confirmed and stated that Patient 2’s History and Physical records indicated a documented numerical weight of 101 with no specification related to the unit of weight. During a concurrent interview and record review on 8/8/2025 at 12:55 p.m. with the Director of Patient Care Services (DPCS), Patient 2’s clinical record titled “LCD Hospice Eligibility Determination,” dated 7/14/2025, indicated “Patient does not qualify per LCD Guidelines.” Patient 2’s LCD indicated, under section 2. Weight Loss question a. Weight loss greater than 10 % in the last 6 months or greater than 7.5% in the last 3 months? Marked Yes. The DPCS confirmed and stated that she completed the LCD in coordination with the Medical Director. The DPCS stated that she did not notice that LCD was marked incomplete, that is why it made Patient 2 not qualified but subjective (information that comes directly from a patient’s own experience and perspective, including their feelings, symptoms, and perceptions) and objective (factual, measurable, and observable information that is not influenced by personal opinions or feelings) data supported Patient 2’s eligibility to hospice. The DPCS confirmed and stated that the HA has no clinical records to support regarding Patient 2’s weight loss. The DPCS stated that it is important to have clinical records and data to support patient’s diagnosis and symptoms for LCD hospice eligibility. During a concurrent interview and record review on 8/8/2025 at 1:00 p.m. with the DPCS, Patient 2’s clinical records titled “Visit Note RN (Registered Nurse),” dated 7/23/2025, 7/30/2025, 8/5/2025, and 8/6/2025, were reviewed. Patient 2’s Visit Note dated 7/23/2025, 7/30/2025, 8/5/2025, and 8/6/2025 indicated weight under sections vitals and measurements documented 100 lbs. and MAC of 19. The DPCS confirmed and stated that Patient 2’s Visit Note dated 7/23/2025, 7/30/2025, 8/5/2025, and 8/6/2025 indicated same weight value of 100 lbs. and MAC of 19. The DPCS stated that there were no changes in Patient 2’s weight and MAC in Patient 2’s nursing comprehensive assessments and nurse visit notes, DPCS stated that it does not support Patient 2’s weight loss as part of LCD eligibility. DPCS stated the importance of completing patient 2’s assessment and visit note to include current weight is to monitor the patient for any changes in their disease and monitor for decline or improvement in health. b. During a re view of Patient 3’s “Personal Information”, indicated a start of care (SOC) date of 3/26/2025, with a primary diagnosis of heart failure (occurs when the heart muscle becomes weakened and cannot pump blood effectively throughout the body) unspecified. During a review of Patient 3’s POC (Plan of Care, consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient’s needs)/IDG (Interdisciplinary Group- a team consists of medical director, registered nurse, spiritual chaplain, and social worker, responsible for the holistic care of the hospice beneficiary) Review form dated 7/14/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus two PRN (pro re nata, which means “as needed”) visits for changes in condition and symptom management, the Master of Social Work (MSW) to visit for initial assessment, then every recertification period for psychosocial (refers to a person’s well-being at the intersection of their internal workings and external experiences, which covers a person’s mental, emotional, social, and spiritual health) needs and support, Spiritual Counselor (SC) to visit for initial assessment, then every recertification plus one PRN per benefit period for spiritual needs and support and Hospice Aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a concurrent interview and record review on 8/8/2025 at 1:00 p.m. with the Director of Patient Care Services (DPCS), Patient 3’s clinical record titled “LCD Hospice Eligibility Determination,” dated 6/16/2025, indicated “Patient does not qualify per LCD Guidelines.” DPCS confirmed and stated that Patient 3’s LCD Hospice Eligibility Determination dated 6/16/2025 had incomplete documentation and questionnaire 2. NYHA (system used to categorize the severity of heart failure based on how much physical activity limits a person) was left unmarked and blank. The DPCS stated that she did not notice that LCD was marked incomplete, that is why it made Patient 3 not qualified but subjective (information that comes directly from a patient’s own experience and perspective, including their feelings, symptoms, and perceptions) and objective (factual, measurable, and observable information that is not influenced by personal opinions or feelings) data supported Patient 3’s eligibility to hospice. The DPCS confirmed and stated that she has no clinical records to support regarding patient 3’s diagnosis of heart failure. The DPCS stated that it is important to have clinical records and data to support patient’s diagnosis and symptoms for LCD hospice eligibility. The DPCS stated and confirmed that Patient 3’s LCD indicated the patient did not qualify for hospice care based on the LCD guidelines. The DPCS stated Patient 3’s LCD is incomplete, and the admitting nurse should have communicated that with the Medical Director 1 (MD1). The DPCS stated patient 3’s LCD at this time indicates patient is not eligible for hospice care. The DPCS stated the importance of completing an LCD for a newly admitted patient to the HA is to verify their eligibility for hospice care, and if they are eligible providing that information in the patient’s EMR so the IDG is aware. c. During a review of Patient 4’s “Personal Information”, indicated a start of care (SOC) date of 7/29/2025, with a primary diagnosis of cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) unspecified. During a concurrent interview and record review on 8/8/2025 at 1:08 p.m. with the DPCS, Patient 4’s clinical record titled “LCD Hospice Eligibility Determination,” dated 7/29/2025, indicated “Patient does not qualify per LCD Guidelines.” DPCS confirmed and stated that Patient 4’s LCD Hospice Eligibility Determination dated 7/29/2025 had incomplete documentation and some questionnaires were left unmarked and blank. The DPCS stated that she did not notice that LCD was incomplete, that is why it made Patient 4 not qualified but subjective and objective data supported Patient 4’s eligibility to hospice. The DPCS confirmed and stated that she has no clinical records to support Patient 4’s diagnosis. The DPCS stated that it is important to have clinical records and data to support patient’s diagnosis and symptoms for LCD hospice eligibility. The DPCS stated and confirmed that Patient 4’s LCD did indicate the patient did not qualify for hospice care based on the LCD guidelines. The DPCS stated Patient 4’s LCD is incomplete, and the admitting nurse should have communicated that with the Medical Director 1 (MD1). The DPCS stated Patient 4’s LCD at this time indicates not eligible for hospice care. The DPCS stated the importance of completing an LCD for a newly admitted patient to the HA is to verify their eligibility for hospice care, and if they are eligible providing that information in the patient’s EMR so the IDG is aware. The DPCS stated she was just given the role of DPCS recently as the previous DPCS resigned and she has recently started to review nurses’ documentation. The DPCS stated the importance of completing an LCD for a newly admitted patient to the HA is to verify their eligibility for hospice care and provide that information to the IDG. d. During a review of Patient 5’s “Personal Information”, indicated a start of care (SOC) date of 7/29/2025, with a primary diagnosis of cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) unspecified. During a concurrent interview and record review on 8/8/2025 at 1:12 p.m. with the DPCS, Patient 5’s clinical record titled “LCD Hospice Eligibility Determination,” dated 7/29/2025, indicated “Patient does not qualify per LCD Guidelines.” DPCS confirmed and stated that Patient 5’s LCD Hospice Eligibility Determination dated 7/29/2025 had incomplete documentation and some questionnaires were left unmarked and blank. The DPCS stated that she did not notice that LCD was incomplete, that is why it made Patient 5 not qualified but subjective and objective data supported Patient 5’s eligibility to hospice. The DPCS confirmed and stated that she has no clinical records to support Patient 5’s diagnosis. The DPCS stated that it is important to have clinical records and data to support patient’s diagnosis and symptoms for LCD hospice eligibility. The DPCS stated and confirmed that Patient 5’s LCD did indicate the patient did not qualify for hospice care based on the LCD guidelines. The DPCS stated Patient 5’s LCD is incomplete, and the admitting nurse should have communicated that with the Medical Director 1 (MD1). The DPCS stated Patient 5’s LCD at this time indicates patient is not eligible for hospice care. The DPCS stated the importance of completing an LCD for a newly admitted patient to the HA is to verify their eligibility for hospice care, and if they are eligible providing that information in the patient’s EMR so the IDG is aware. The DPCS stated she was just given the role of DPCS recently as the previous DPCS resigned and she has recently started to review nurses’ documentation. The DPCS stated the importance of completing an LCD for a newly admitted patient to the HA is to verify their eligibility for hospice care and provide that information to the IDG. e. During a review of Patient 9’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 9/12/2024 and a primary diagnosis of Chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a review of Patient 9’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025, indicated a frequency of Skilled Nurse (SN) visits of once per week and two as needed (PRN) visits per month, Master of Social Work (MSW) visits of one initial assessment and then at every recertification and one PRN for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one PRN for spiritual needs and support. During a review of Patient 9’s Electronic Medical Record (EMR), the EMR indicated a recertification assessment dated 7/7/2025 with an electronic signature by the DPCS. Patient 9’s recertification assessment indicated that the section LCD eligibility was left blank with no evidence of documentation. During a review of Patient 9’s EMR, the EMR indicated a clinical record titled Physician’s certification for hospice benefit (CTI) for certification #5 for the period of 7/9/2025 to 9/6/2025 documented and electronically signed by the HA Medical Director (MD). Patient 9’s CTI also indicated the attached LCD hospice eligibility determination form dated 7/7/2025 was blank and indicated on the top of the form, patient does not qualify per LCD guidelines. During a review of Patient 9’s EMR, the EMR indicated an uploaded copy of the patient’s History and Physical (H&P) dated 9/7/2024, from a previous hospitalization stay. During a concurrent interview and record review on 8/7/2025 at1:36 p.m. with the DPCS, Patient 9’s EMR was reviewed. Patient 9’s EMR indicated a recertification assessment dated 7/7/2025 electronically signed by the DPCS and was left blank in the section LCD hospice eligibility. Patient 9’s EMR also indicated a clinical record titled CTI for certification #5 for the period of 7/9/2025 to 9/6/2025 electronically signed by the MD, and the attached LCD hospice eligibility determination form dated 7/7/2025 was left blank and indicated patient does not qualify per LCD guidelines. The DPCS stated and confirmed that Patient 9’s recertification assessment that she completed was left blank in the section LCD Eligibility. The DPCS stated she did assess the patient and reviewed his eligibility with the MD, but did not fill out that section of the assessment. The DPCS stated and confirmed that Patient 9’s LCD hospice eligibility determination form dated 7/7/2025 was left blank and not documented on. The DPCS stated it was her responsibility to complete the LCD hospice eligibility form. The DPCS further stated she completed her assessment of the patient, reviewed her findings along with the patient’s history and physical with the MD for the patient’s eligibility for hospice care and stated she forgot to fill out the LCD eligibility form. The DPCS stated the LCD hospice eligibility form and the LCD eligibility section in the recertification assessment must be filled out to its entirety to validate patient’s eligibility for benefits and the IDG care team is aware. The DPCS also stated if it is not filled out then the patient’s hospice eligibility is not validated and assessment not considered complete. f. During a review of Patient 10’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 3/26/2025 and a primary diagnosis of Cerebrovascular disease (a group of conditions that affect the blood vessels in the brain and can disrupt blood flow to the brain, leading to damage or death of brain cells). During a review of Patient 10’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025 indicated a frequency of Skilled Nurse (SN) visits of once per week and two as needed (PRN) visits per month for symptom management and changes in condition, Master of Social Work (MSW) visits of one initial assessment and then at every recertification and one PRN for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one PRN for spiritual needs and support. During a review of Patient 10’s Electronic Medical Record (EMR), the EMR indicated a recertification assessment dated 6/19/2025 with an electronic signature by the DPCS. Patient 10’s recertification assessment indicated that the section LCD eligibility was left blank with no evidence of documentation. During a review of Patient 10’s EMR, the EMR indicated a clinical record titled Physician’s certification for hospice benefit (CTI) for certification #2 for the period of 6/24/2025 to 9/21/2025 documented and electronically signed by the HA MD. Patient 10’s CTI also indicated the attached LCD hospice eligibility determination form dated 6/19/2025 was blank and indicated on the top of the form, patient does not qualify per LCD guidelines. During a review of Patient 10’s EMR, the EMR indicated there was no supporting documentation that included a history and physical (H&P), lab/imaging results, or physician orders. During a concurrent interview and record review on 8/7/2025 at 1:45 p.m. with the DPCS, Patient 10’s EMR was reviewed. Patient 10’s EMR indicated a recertification assessment dated 6/19/2025 electronically signed by the DPCS and was left blank in the section LCD hospice eligibility. Patient 10’s EMR also indicated a clinical record titled CTI for certification #2 for the period of 6/24/2025 to 9/21/2025 electronically signed by the HA MD, and the attached LCD hospice eligibility determination form dated 6/19/2025 was left blank and indicated patient does not qualify per LCD guidelines. The DPCS stated and confirmed that Patient 10’s recertification assessment that she completed was left blank in the section LCD Eligibility. The DPCS stated she did assess the patient and reviewed her assessment findings with the MD, but she (DPCS) forgot tp fill out that section of the assessment. The DPCS also stated and confirmed that Patient 10’s LCD hospice eligibility determination form dated 6/19/2025 was left blank and not documented on. The DPCS stated it was her responsibility to complete the LCD hospice eligibility form when doing her assessment for recertification eligibility. The DPCS further stated she completed her assessment of the patient, reviewed her findings with the MD for the patient’s eligibility for hospice care and stated she also forgot to fill out the LCD eligibility form. The DPCS stated and confirmed that Patient 10’s EMR does not include a copy of the patient’s H&P or labs/images. The DPCS stated the HA has requested that information from Patient 10’s primary physician but have not received it yet. The DPCS stated it is important to have supporting documents like an H&P or labs to provide a better picture of the patient health and support their eligibility for hospice care. The DPCS stated the LCD hospice eligibility form must be filled out to its entirety to validate patient’s eligibility and inform the IDG team of the patient’s condition, to assist them in formulating the individualized plan of care. g. During a review of Patient 11’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 4/3/2025 and a primary diagnosis of Heart Failure (a condition where the heart cannot pump blood effectively enough to meet the body’s needs and can lead to a buildup of fluid in the lungs, legs, and other organs). During a review of Patient 11’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025 indicated a frequency of Skilled Nurse (SN) visits of once per week and two as needed (PRN) visits per month for changes in condition and symptom management, Master of Social Work (MSW) visits of one initial assessment and then at every recertification and one PRN for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one PRN for spiritual needs and support. During a review of Patient 11’s Electronic Medical Record (EMR), the EMR indicated a recertification assessment dated 7/1/2025 with an electronic signature by the DPCS. Patient 11’s recertification assessment indicated that the section LCD eligibility was left blank with no evidence of documentation. During a review of Patient 11’s EMR, the EMR indicated a clinical record titled Physician’s certification for hospice benefit (CTI) for certification #2 for the period of 7/2/2025 to 9/29/2025 documented and electronically signed by the HA MD. Patient 11’s CTI also indicated the attached LCD hospice eligibility determination form dated 7/1/2025 was blank, not filled out, and indicated on the top of the form, patient does not qualify per LCD guidelines. During a review of Patient 11’s EMR, the EMR indicated there was no supporting documentation that included the patient’s history and physical (H&P), lab/imaging results, or physician orders. During a concurrent interview and record review on 8/7/2025 at 1:50 p.m. with the DPCS, Patient 11’s EMR was reviewed. Patient 11’s EMR indicated a recertification assessment dated 7/1/2025 electronically signed by the DPCS and was left blank in the section LCD hospice eligibility. Patient 11’s EMR also indicated a clinical record titled CTI for certification #2 for the period of 7/2/2025 to 9/29/2025 electronically signed by the HA MD, and the attached LCD hospice eligibility determination form dated 7/1/2025 was left blank and indicated patient does not qualify per LCD guidelines. The DPCS stated and confirmed that Patient 11’s recertification assessment was left blank in the section LCD Eligibility. The DPCS stated she did assess the patient, along with the visiting registered nurse, and reviewed the assessment findings with the MD, but she (DPCS) forgot to fill out that section of the assessment. The DPCS also stated and confirmed that Patient 10’s LCD hospice eligibility determination form dated 7/1/2025 was left blank and not documented on. The DPCS stated it was her responsibility to complete the LCD hospice eligibility form and forgot to fill it out. The DPCS stated and confirmed that Patient 11’s EMR does not include a copy of the patient’s H&P or labs/images. The DPCS stated the HA has requested that information from Patient 11’s primary physician office but have not received it yet. The DPCS stated the nursing staff will ask the patient/family for copies of any H&P or lab work but if they do not have it then the HA will contact the primary physicians office to get them. The DPCS stated it is important to have supporting documents like an H&P or labs to help in determining patient’s eligibility for hospice care. The DPCS stated the LCD hospice eligibility form must be filled out to its entirety to validate patient’s eligibility and inform the IDG team of the patient’s condition and how to plan their care. During an interview on 8/8/2025 at 11:30 a.m. with the Medical Director (MD), the MD stated he has been working with the HA for about 1 to 2 years. The MD stated he determines a patient’s hospice eligibility based on their diagnosis, review of medical records from the hospital or their doctors’ office and findings from the admitting nurses’ assessment. The MD stated if the patient or family do not have medical records to provide for review, then the MD will take into account subjective data the patient provides about their health and how they feel and also the objective date the nurse finds during the physical assessment. The MD stated it would be nice and better to have supporting documents to further explain the patient’s health status. The MD stated the admission or recertification assessment and LCD hospice eligibility determination are completed by the admitting registered nurse (RN) and the RN will then report his/her findings to him (MD). The MD further stated it is important to have a patient’s admission/recertification assessment and LCD eligibility determination completed to identify that the patient was looked at, records were reviewed and indicate the trajectory of the patient’s illness. The MD also stated the CTI and LCD determination should correlate and not be in conflict with each. The MD further stated an incomplete assessment and LCD determination is not a good practice from the HA in determining patient’s eligibility. During a review of the HA’s Policy and Procedure (P&P) Titled Admission Criteria and Process with a revised date of April 2020, the P&P indicated the patient’s life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the Local Coverage Determinations (LCDs). The P&P also indicated that a patient’s eligibility criteria will be continually reviewed on an ongoing basis by the IDG to assure appropriateness of hospice care. During a review of the HA’s P&P titled Certification of Terminal Illness with a revised date of April 2020, the P&P indicated that the LCD along with other supporting documentation can be used to provide guidance in determining and documenting terminal prognosis. The P&P also indicated that clinical information and other documentation that supports the medical prognosis must accompany the certification and must be field in the clinical record with the written certification. 3.a. During a review of Patient 10’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 3/26/2025 and a primary diagnosis of Cerebrovascular disease (a group of conditions that affect the blood vessels in the brain and can disrupt blood flow to the brain, leading to damage or death of brain cells).During a review of Patient 10’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025 indicated a frequency of Skilled Nurse (SN) visits of once per week and two as needed (PRN) visits per month for symptom management and changes in condition, Master of Social Work (MSW) visits of one initial assessment and then at every recertification and one PRN for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one PRN for spiritual needs and support. During a review of Patient 10’s clinical record titled Bereavement Assessment dated 3/29/2025 indicated under the signature section at the bottom of the page, an electronic submission by the MSW dated 4/8/2025. During an interview on 8/7/2025 at 10:53 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated all comprehensive assessments are to be completed and submitted within 5 days of SOC. The DPCS stated if an assessment is not signed then it can mean the visit was not done or not done within the time frame. The DPCS stated for example if the nursing comprehensive assessment was submitted without a signature then it will not validate the visit and it will show the patient was not admitted that day. The DPCS stated each discipline is to sign their own assessment and further stated whatever nurse, or social worker or chaplain completed that home visit must then document the visit and sign the assessment. The DPCS further stated the importance of each discipline signing their own assessment is because they are the only ones that can verify and understand what was documented. The DPCS stated Case Manager (CM1) is the nurse in charge of QA for all patient clinical records. During a concurrent interview and record review on 8/7/2025 at 11:45 a.m. with the CM1, Patient 10’s Electronic Medical Record (EMR) was reviewed. Patient 10’s EMR indicated under the section Bereavement an initial bereavement assessment dated 3/29/2025 indicated it was electronically submitted for review by MSW dated 4/8/2025. The CM1 stated and confirmed Patient 10’s initial bereavement assessment visit was completed on 3/29/2025 and the MSW completed and submitted the assessment on 4/8/2025, 10 days after the SOC. CM1 also stated that the assessment indicated that the MSW submitted the assessment and did not sign the assessment. CM1 stated a completed assessment is when it is fully documented on, signed, dated and submitted. CM1 stated all comprehensive assessments are to be completed and submitted within 5 days of the patient’s SOC. CM1 further stated she oversees quality assurance (QA, a systematic process aimed at ensuring that healthcare services meet or exceed predetermined standards of quality) for all patient clinical records. b. During a review of Patient 11’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 4/3/2025 and a primary diagnosis of Heart Failure (a condition where the heart cannot pump blood effectively enough to meet the body’s needs and can lead to a buildup of fluid in the lungs, legs, and other organs). During a review of Patient 11’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 8/1/2025 indicated a frequency of Skilled Nurse (SN) visits of once per week and two as needed (PRN) visits per month for changes in condition and symptom management, Medical Social Worker (MSW) visits of one initial assessment and then at every recertification and one PRN for psychosocial needs and support, and Spiritual Counselor (SC) visits of one initial assessment and then at every recertification and one PRN for spiritual needs and support. During a review of Patient 11’s clinical record titled Bereavement Assessment dated 4/7/2025 indicated under the signature section at the bottom of the page, an electronic submission by the Spiritual Counselor 2 (SC2) dated 4/27/2025. During a concurrent interview and record review on 8/7/2025 at 11:50 a.m. with CM1, Patient 11’s EMR was reviewed. Patient 11’s EMR indicated, under the section Bereavement, an initial bereavement assessment dated 4/7/2025 was electronically submitted by the SC2 dated 4/27/2025. CM1 stated and confirmed Patient 11’s initial bereavement assessment visit was conducted on 4/7/2025 but the SC2 submitted the assessment more than 5 days after patient’s SOC, on 4/27/2025. CM1 also stated and confirmed the initial bereavement assessment was not signed by SC2 which means it is not complete. CM1 stated the staff do have the ability to sign their assessments before submitting for review and SC2 did not sign it before submitting. During a phone interview on 8/7/2025 at 2:12 p.m. with Spiritual Counselor 1 (SC1), SC1 stated he has been working with the HA as the spiritual counselor for 6 months. SC1 stated as a spiritual counselor, part of his duties includes documenting and completing the patients’ initial bereavement assessment, post bereavement and spiritual assessment. SC1 stated the initial bereavement assessment and spiritual assessment need to be completed and submitted within 5 days of the patient’s SOC. SC1 stated the initial bereavement assessment can also be completed by the MSW, and who does it all depends on how the workload is divided by the HA office. During a phone interview on 8/7/2025 at 2:23 p.m. with the MSW, the MSW stated part of her responsibilities as the social worker for the HA include home visits, completing the psychosocial assessment and at times the initial bereavement assessment within 5 days of the patient’s SOC. MSW stated she submits her assessments for review to CM1, but the EMR does not allow her to electronically sign her assessments until CM1 reviews and approves it. MSW stated the importance of conducting a psychosocial assessment on a patient is to assess their home situation, the support they have, assess patient and family coping needs and provide resources as needed in the future, assist patients with advanced directives and mortuary information and set up when needed. MSW stated the importance of conducting an initial bereavement assessment is to identify the patient’s primary bereaved, how they are coping and if more support will be needed when patient passes, and also to assess risk level of the bereaved. During a review of the HA’s Policy and Procedure (P&P) titled Bereavement Assessment with a revised date of April 2020, the P&P indicated on admission the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the bereavement coordinator to review and determine potential needs of the survivors and upon completion all bereavement documentation will be filed. During a review of the HA’s Policy and Procedure (P&P) titled Contents of Clinical Record with a revised date of April 2020, the P&P indicated documentation will include signed and dated clinical notes and each entry in the patient’s clinical record will be dated and signed, including title and credentials, by the person providing the care/service.”