Vision Viejo Hospice Services

“Based on interview and record review, the hospice failed to ensure the emergency preparedness plan was reviewed and updated at least annually. This failure created the potential risk of not providing the necessary care and services to the patients of the hospice during emergency events. Findings: Review of the hospice’s P&P on emergency preparedness program was initiated on 6/18/25. The P&P titled Emergency Management Plan revised 4/2021, showed the emergency preparedness plan will be reviewed and revised annually. * However, review of the hospice documents failed to show documented evidenced the hospice staff reviewed and revised the emergency plan annually. On 6/20/25 at 0850 hours, an interview and concurrent record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was asked if the emergency plan was reviewed and revised annually. The Administrator/LVN/Volunteer Coordinator replied no. The Administrator/LVN/Volunteer Coordinator stated it was reviewed and revised in the year of 2022. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the finding.”

“Based on record review and interview, the hospice failed to ensure the emergency preparedness communication plan included the means in the event of an evacuation to release patient information. This failure created the potential risk of not providing appropriate, consistent, and quality care to the patients during the emergency events. Findings: Review of the hospice’s P&P on emergency preparedness program was initiated on 6/18/25. The P&P titled Emergency Preparedness Plan dated 4/2021, included the hospice’s communication plan. * However, the communication plan failed to include the means in the event of an evacuation to release patient information. On 6/20/25 at 0850 hours, an interview and concurrent record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings.”

“Based on record review and interview, the hospice failed to ensure the initial training in emergency preparedness was provided to all new and existing staff, individuals providing services under arrangement, and volunteers consistent with their expected role at least annually. In addition, the hospice failed to ensure the staff demonstrated knowledge of emergency procedures. These failures created the potential risk of the hospices’ staff not knowing what to do in case of an emergency event. Findings: Review of the hospice’s emergency preparedness program was initiated on 6/18/25. The hospice’s Emergency Operation Plan included the training program. The training program showed the hospice will provide initial training in emergency preparedness to all new and existing staff, individuals providing services under arrangement, and volunteers consistent with their expected role was provided at least annually and demonstrate staff knowledge of emergency procedures. * However, there was no documented evidence of the initial trainings provided to all new and existing staff, individuals providing services under arrangement, and volunteers consistent with their expected role was provided at least annually; and demonstrated staff knowledge of emergency procedures. On 6/20/25 at 0850 hours, an interview and concurrent record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was asked if the emergency preparedness trainings were provided at least annually. The Administrator/LVN/Volunteer Coordinator reviewed the emergency preparedness documents and stated there was no training provided and documented for all the staff annually. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the finding.”

“Based on record review and interview, the hospice failed to ensure the emergency preparedness testing exercises were provided and conducted annually for the years of 2021, 2022, and 2023. This failure created the potential risk of the hospice’s staff not knowing what to do in case of emergency. Review of the hospices’ emergency preparedness program was initiated on 6/18/25. The hospice’s Emergency Operation Plan included the testing program. The testing program showed the hospice will conduct emergency preparedness testing at least annually.* However, there was no documented evidence the testing exercises were conducted for the years of 2021, 2022, and 2023.On 6/19/25 at 0800 hours, an interview was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator stated the testing exercises were conducted on 12/22/20 and 9/2024. She stated there were no testing exercises for the years of 2021, 2022, and 2023.On 6/20/25 at 0850 hours, an interview and concurrent record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the comprehensive assessments were completed no later than five calendar days after the election of hospice care for two of 14 sampled patients (Patients 2 and 13). This failure created the potential risk of not addressing the care needs for these patients. Findings: Review of the hospice’s P&P titled Comprehensive Assessment revised 04/2021 showed a comprehensive patient assessment will be performed by the interdisciplinary group no later than five calendar days after the election of hospice care in consultation with attending physician.1. Review of Patient 2’s clinical record was initiated on was initiated on 6/11/25. The clinical record showed the SOC was on 9/17/24. The patient was certified for hospice services during the certification periods from 3/16/25 to 5/14/25 and 5/15/25 to 7/13/25.Review of Visit Note-Psychosocial Assessment dated 9/25/24, showed documentation the Medical Social Worker assessed for living arrangement, advanced directives, financial and legal considerations, patient/caregiver functional limitations, patient’s appearance and cognition, mood/affect/behavior, psychological/substance abuse, safety consideration, support system, and bereavement risk assessment.*However, the comprehensive psychosocial assessment was completed later than five calendar days after the election of hospice care.On 6/20/25 at 0954 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. 1.Review of Patient 13’s closed clinical record was initiated on 6/13/25. The clinical record showed the SOC was 12/23/24. The patient was certified for hospice service during the periods from 12/23/24 to 3/22/25 and 3/23/25 to 6/20/25. The patient expired on 4/20/25.Review of the Physician Order- Admit to Hospice dated 12/23/25 showed an order for SW - Social Services. The order included the Social Services assessment within five days of admission (12/23 to 12/26/24).Review of the closed clinical record showed the MSW conducted the telehealth visit on 12/29/24. However, the MSW visit was more than five calendar days after the election of hospice benefit as per P&P.On 6/20/25 at 1405 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/ Volunteer Coordinator was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the comprehensive assessment identified the imminence of death for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9,10, 11, 12, 13 and 14). This failure created the risk of not appropriately addressing the care needs for these patients. Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9,10, 11, 12, 13 and 14 was conducted and did not identify the imminence of death. For example:1. Review of Patient 1’s clinical record was initiated on 6/10/25. The clinical record showed the SOC was 10/8/23. The patient was certified for hospice services during the certification periods from 3/31/25 to 5/29/25 and 5/30/25 to 7/28/25.2. Review of Patient 8’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was 2/21/25. The patient was certified for hospice services during the certification periods from 2/21/25 to 5/2/25 and 5/30/25 to 7/31/25.3. Review of Patient 12’s clinical record was initiated on 6/17/25. The clinical record showed the SOC was 12/30/24. The patient was certified for hospice services during the certification period from 6/27/24 to 8/25/24. The patient revoked hospice on 8/25/24. 4. Review of Patient 5’s clinical record was initiated on 6/11/25. The clinical record showed the SOC was 1/16/25. The patient was certified for hospice services during the certification periods from 1/6/25 to 4/15/25 and 4/16/25 to 7/14/25. 5. Review of Patient 11’s clinical record was initiated on 6/18/25. The clinical record showed the SOC was 1/22/25. The patient was certified for hospice services during the certification periods from 1/22/25 to 4/21/25 and 4/22/25 to 6/20/25. The patient passed away on 5/18/25. * However, the initial comprehensive assessments did not identify the imminence of death for the above clinical records. On 6/20/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings.”

“Based on observation, interview, and record review, the hospice failed to include all current medications’ side effects and actual or potential drug interaction in the comprehensive assessments; ensure the medication profile was reviewed and updated to reflect the current medications; and include specific indications and parameters for its use for two of 14 sampled patients (Patients 1 and 2). These failures created the potential for the patients to not receive the appropriate care and necessary services and negatively affect the patients’ well-being. Findings: #. Review of Patient 2’s clinical record was initiated on was initiated on 6/11/25. The clinical record showed the SOC was on 9/17/24. The patient was certified for hospice services during the certification periods from 3/16/25 to 5/14/25 and 5/15/25 to 7/13/25.Review of the IDG Meeting Notes/POC dated 3/24, 4/7, 4/21, 5/5, and 5/19/25, showed active medications orders included the following:- acetaminophen (pain medication) 500 mg tablet, take one tablet by mouth every 4 hours as needed for pain- Roxanol (opioid pain medication) liquid 0.25 ml20 every 4 hours as needed for severe pain or severe shortness of breath*The IDG Meeting Notes for the dates listed above showed medication profile was reviewed. However, the medication list showed no specific instructions for what severity of pain to administer acetaminophen for example mild or moderate pain. In addition, the Roxanol order did not show an administration route or what the complete dosage for 0.25 ml. On 6/20/25 at 1003 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. Review of the hospice’s P&P titled Medication Profile revised 4/2021 showed patients receiving the medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and or discontinued medications. Deviations in taking medications as ordered will be documented in the clinical notes, and the physician will be notified. 1. Review of Patient 1’s clinical record was initiated on 6/10/25. The clinical record showed the SOC was 10/8/23. The patient was certified for hospice services during the certification periods from 3/31/25 to 5/29/25 and 5/30/25 to 7/28/25. A joint home visit with LVN 1 was conducted on 6/11/25 at 0900 hours, to the B&C facility where Patient 1 resided. Review of the Patient Medication Profile (for Home) included the following:-Acetaminophen (analgesic) 325 mg tablet take two tablets every 6 hours as needed by mouth for mild pain and temperature above 100 degrees Fahrenheit. However, the instructions on the patients bubble pack failed to include the indication for the temperature above 100 degrees Fahrenheit. -Robitussin Cough and Chest Congestion DM max liquid (cough and congestion) take 15 ml twice a day as needed by mouth. However, the instructions on the patient bottle was to take 15 ml three times a day as needed instead of two times a day as ordered. In addition, the medication expiration date was 6/11/25.-Miralax 20 ml liquid (constipation) take 8 oz of Miralax powder mix daily as needed for constipation. However, the instructions on the bottle was to drink every day instead of daily as needed. On 6/11/25 at 0953 hours, an interview and concurrent clinical record review was conducted with the LVN 1. The LVN 1 was informed and acknowledged the findings. On 6/20/25 at 1145 hours, the above findings were shared with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments were completed no less than every 15 days and included the changes that had occurred since the initial assessment, information on the patient’s progress, and reassessment of the patient’s responses for four of 14 sampled patients (Patients 1, 3, 8, and 11). This failure created the potential risk of not addressing the care needs to these patients. Findings: Review of the hospice’s P&P title Comprehensive Assessment revised 4/2021 showed during the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient’s clinical record. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patient’s condition requires but at a minimum every 15 days. The interdisciplinary group is required to only updated those sections that require updating. If no changes are needed, then that must be documented. If there has been a change in the patient’s condition/status, then the comprehensive assessment must be updated. #. Review of Patient 3’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was on 3/21/25. The patient was certified for hospice services during the certification periods from 3/21/25 to 6/18/25.Review of the Communication Note dated 5/5/25, showed the patient became very lethargic and 911 was called. Paramedics reported to the hospice nurse the patient was having episode of hypoglycemia (low blood sugar level in the blood) and was given Gluco Tabs (fast-acting chewable tablets containing glucose used to treat mild to moderate hypoglycemia in people with diabetes).Review of the IDG Meeting Note/POC dated 5/19/25, showed did not show documentation evidence a care plan problem was developed to address the patient’s risk for episodes of hypoglycemia, use of diabetic medications or diagnosis of diabetes. In addition, there was no documented evidence to show the IDG had discussed the patient’s episode of hypoglycemia.On 6/20/25 at 1015 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. #. Review of Patient 10’s closed clinical record was initiated on 6/13/25. The clinical record showed the SOC was on 11/11/24. The patient was certified for hospice services during the certification period from 11/11/24 to 2/8/25 and 2/9/25 to 4/9/25. The patient expired on 2/9/25.a. Review of the Physician Admitting Orders dated 9/25/24, showed an order for SN-Nursing Services for 1x weekly visits and 7 prn SN visits for symptom management and wound dressing change from 9/25/24-9/28/24 and SN- Nursing Services for 1x weekly visits and 7 prn SN visits for symptom management and wound dressing change from 9/29/24 to ongoing.Further review of the clinical record showed for week 11/17 to 11/23/24, there was no documented evidence a SN visit was conducted as per the physician’s order. In addition, the IDG Meeting Note/POC dated 12/2/24, did not show documented evidence the IDG discussed the SN missed visit.On 6/20/25 at 1104 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. b. Review of the Physician Admitting Orders dated 9/25/24, showed an order for CHHA -Aid Services for 2x weekly visits from 9/25/24-9/28/24 and CHHA- Aide Services for 2x weekly visits from 9/29/24 to ongoing.Further review of the clinical records showed the HA conducted three visits a week instead of two visits per week as per the physician’s order of the following week:- From 11/11 to 11/16/24- From 11/17 to 11/23/24- From 12/1 to 12/7/24- From 12/8 to 12/14/24- From 12/22 to 12/28/24- From 12/29/24 to 1/4/25- From 1/5 to 1/11/25- From 1/19 to 1/25/25-From 1/26 to 2/1/25- From 2/2 to 2/8/25Review of the IDG Meeting Note/POC dated 11/18, 12/2, 12/16, and 12/30/24, 1/13 and 1/27/25, did not show documented evidence the IDG discussed the patient’s need for one extra HA visit from the physician’s order.On 6/20/25 at 1108 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. 1. Review of Patient 1’s clinical record was initiated on 6/10/25. The clinical record showed the SOC was 10/8/23. The patient was certified for hospice services during the certification periods from 3/31/25 to 5/29/25 and 5/30/25 to 7/28/25.Review of the SN visit notes dated 4/2/25, showed the SN had performed an Skin Assessment. The documentation showed the patient was assessed to have a traumatic wound to the toe with a measurement of Width - 2.5 cm, Length = 3 cm, Depth= 0.1. Review of the clinical record showed the the IDG had reviewed the POC every 14 days. However, there was no documented evidence the IDG had updated the comprehensive assessments to include the changes that had occurred regarding the patient’s traumatic wound to the toe. On 6/20/25 at 1151 hours, an interview and an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Coordinator was asked if the physician was notified of the patients traumatic wound to the toe. The Administrator/LVN/Volunteer Coordinator replied, no, there was no mention of the physician notification on the note. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings.2. Review of Patient 8’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was 2/21/25. The patient was certified for hospice service during the certification periods from 2/21/25 to 5/2/25 and 5/3/25 to 7/31/25.Review of the SN visit notes dated 4/30, 5/8, 5/14, 5/22, 5/28, 6/5/25, showed the SN had performed Skin Assessment. The Skin Assessment showed patient had “other” type of lesion on the chest/front, color = brown, width 1.0 cm, length= 1.0 cm. However, review of the IDG Meeting Note/ POC dated 5/5, 5/19 and 6/2/25 failed to show documented evidenced of the IDG had updated the comprehensive assessment to address the patients “other” type of lesion on the chest/front. On 6/20/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 3. Review of Patient 11’s closed clinical record was initiated on 6/18/25. The clinical record showed the SOC was 1/22/25. The patient was certified for hospice service during the certification periods from 1/22/25 to 4/21/25 and 4/22/25 to 6/20/25. The patient expired on 5/18/25. Review of the SN note dated 3/11, 3/17 and 3/20//25, showed the patient was assessed to have an abrasion to the right back. The assessment showed color = red; width= 1.0 cm; Length= 1.5 cm.Review of the SN notes dated 4/1/25 showed the SN documented the patients skin integrity as intact.However, review of the IDG Meeting Note/POC failed to show documented evidenced of the IDG had updated the comprehensive assessment related to the patients abrasion to the back.On 6/20/25 at 1121 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. Review of the hospice’s P&P titled Comprehensive Assessment revised 4/2021, showed during the comprehensive patient assessment, all baseline data and other relevant information will be documented through interview and observation in the patient’s clinical record. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patient’s condition requires but at a minimum every 15 days. The interdisciplinary group is required to only update those sections that require updating. If no changes are needed, then that must be documented. If there has been a change in the patient’s condition/status, then the comprehensive assessment must be updated. 1. Review of Patient 3’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was on 3/21/25. The patient was certified for hospice services during the certification period from 3/21/25 to 6/18/25.Review of the Communication Note dated 5/5/25, showed the patient became very lethargic and 911 was called. Paramedics reported to the hospice nurse the patient was having episode of hypoglycemia (low blood sugar level in the blood) and was given Gluco Tabs (fast-acting chewable tablets containing glucose used to treat mild to moderate hypoglycemia in people with diabetes).Review of the IDG Meeting Note/POC dated 5/19/25, no documented evidence to show the IDG had discussed the patient’s episode of hypoglycemia.On 6/20/25 at 1015 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. 2. Review of Patient 1’s clinical record was initiated on 6/10/25. The clinical record showed the SOC was 10/8/23. The patient was certified for hospice services during the certification periods from 3/31/25 to 5/29/25 and 5/30/25 to 7/28/25.Review of the SN visit notes dated 4/2/25, showed the SN performed a skin assessment. Documentation showed the patient was assessed to have a traumatic wound to the toe with a measurement of 3 cm (length) x 2.5 cm (width) x 0.1 cm (depth)Review of the clinical record showed the the IDG had reviewed the POC every 14 days. However, there was no documented evidence the IDG had updated the comprehensive assessment to include the changes that had occurred regarding the patient’s traumatic toe wound.On 6/20/25 at 1151 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Coordinator was asked if the physician was notified of the patients traumatic toe wound. The Administrator/LVN/Volunteer Coordinator replied no. The Administrator/LVN/Volunteer Coordinator stated there was no mention of the physician notification on the note. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the finding.3. Review of Patient 8’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was 2/21/25. The patient was certified for hospice service during the certification periods from 2/21/25 to 5/2/25 and 5/3/25 to 7/31/25.Review of the SN visit notes dated 4/30, 5/8, 5/14, 5/22, 5/28, and 6/5/25, showed the SN performed skin assessment. The Skin Assessment showed patient had “other” type of lesion on the chest/front. Documentation showed the color was brown and the measurement was 1.0 cm (length) and 1.0 cm (width).However, review of the IDG Meeting Note/ POC dated 5/5, 5/19, and 6/2/25, failed to show documented evidenced the IDG updated the comprehensive assessment to address the patients “other” type of lesion on the chest/front. On 6/20/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 4. Review of Patient 11’s closed clinical record was initiated on 6/18/25. The clinical record showed the SOC was 1/22/25. The patient was certified for hospice service during the certification periods from 1/22/25 to 4/21/25 and 4/22/25 to 6/20/25. The patient expired on 5/18/25. Review of the SN note dated 3/11, 3/17, and 3/20/25, showed the patient was assessed to have a right back abrasion. The assessment showed the color was red. Documentation showed the measurement was 1.5 cm (length) and 1 cm (width).Review of the SN notes dated 4/1/25, showed the SN documented the patients skin integrity was intact.However, the IDG Meeting Note/POC dated 4/7/25, failed to show documented evidenced the IDG updated the comprehensive assessment related to the patient’s abrasion on the back as per the SN note dated 4/1/25.On 6/20/25 at 1121 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings.”

“Based on record review and interview, the hospice failed to ensure care and services were provided in accordance with the POC for three of 14 sampled patients (Patients 5, 10, and 13). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. Findings: Review of the hospice’s P&P titled The Plan of Care revised 4/2021 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted in the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs, goals, and outcome achievement. #. Review of Patient 10’s closed clinical record was initiated on 6/13/25. The clinical record showed the SOC was on 11/11/24. The patient was certified for hospice services during the certification period from 11/11/24 to 2/8/25 and 2/9/25 to 4/9/25. The patient expired on 2/9/25.a. Review of the Physician Admitting Orders dated 9/25/24, showed an order for SN-Nursing Services for 1x weekly visits and 7 prn SN visits for symptom management and wound dressing change from 9/25/24-9/28/24 and SN- Nursing Services for 1x weekly visits and 7 prn SN visits for symptom management and wound dressing change from 9/29/24 to ongoing.Further review of the clinical record showed for week 11/17 to 11/23/24, there was no documented evidence a SN visit was conducted as per the physician’s order.On 6/20/25 at 1104 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. b. Review of the Physician Admitting Orders dated 9/25/24, showed an order for CHHA -Aid Services for 2x weekly visits from 9/25/24-9/28/24 and CHHA- Aide Services for 2x weekly visits from 9/29/24 to ongoing.Further review of the clinical records showed the HA conducted three visits a week instead of two visits per week as per the physician’s order of the following week:- From 11/11 to 11/16/24- From 11/17 to 11/23/24- From 12/1 to 12/7/24- From 12/8 to 12/14/24- From 12/22 to 12/28/24- From 12/29/24 to 1/4/25- From 1/5 to 1/11/25- From 1/19 to 1/25/25-From 1/26 to 2/1/25- From 2/2 to 2/8/25On 6/20/25 at 1108 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. 1. Review of Patient 5’s clinical record was initiated on 6/11/25. The clinical record showed the SOC was 1/16/25. The patient was certified for hospice service during the certification periods from 1/16/25 to 4/15/25 and 4/16/25 to 7/14/25.a. Review of the Volunteer Documentation- Direct Patient Care dated 1/22 and 1/25/25 showed the Volunteer 1 visited the patient. However, review of the Physicians Order - Admit to Hospice dated 1/16/25, failed to show documented evidenced of the physicians order for the Volunteer visit. *Review of the IDG Meeting Note/POC dated 1/27/25 showed the scope and frequency of services. The services included Volunteer cited 1 to 2x weekly start date 1/26/25.Review of the clinical record showed the Volunteer visited the patient once a week during Weeks 1 to 7. However review of the clinical record failed to show documented evidenced of a Volunteer visit was conducted on Week 8 (3/2 to 3/8/25) as ordered on the IDG meeting dated 1/27/25.b. Review of the Plan of Care - Active cited for SN visit 1x weekly, 7PRN for symptom management. The POC also showed a care plan related to altered skin integrity/ redness to buttocks - 4/9/25 open. The intervention included to assess skin every SN visit.Review of the RN 1 visit notes dated 4/23/25 showed the patient was assessed to have a Stage 2 pressure injury to the right buttocks. The assessment includes the following: color= red, width = 0.7 cm, length = 0.8 cm and depth = 0.2 cm.Review of the SN visit notes dated 4/30 and 5/7/25 showed the SN had visited the patient.However, the SN failed to show documented evidenced of the SN had performed wound assessment as part of the skin assessment as ordered in the POC. On 6/20/25 at 0952 hours, an interview and an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings.2. Review of Patient 4’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was 10/20/23. The patient was certified for hospice service during the certification period from 4/12/25 to 6/10/25. Review of the Plan of Care - Active cited for SN visit 1x weekly, 7PRN for symptom management. The POC also showed a care plan related to altered skin integrity related to impaired nutritional intake and immobility. The intervention included to assess skin every SN visit.Review of Visit Note - RN - Nursing Note dated 4/29/25 showed the RN 1 performed an assessment. The patient was assessed to have a Stage 2 pressure injury to the left buttock. Review of the Skin Assessment for the Stage 2 pressure injury to the left buttocks showed on the following:-Week 4 (4/27 to 5/3) showed an SN visit on 4/29/25 - new assessment: color= pink; width = 1.0 cm; length = 0.5 cm and depth = 0.1 cm.-Week 5 (5/4 to 5/10) showed an SN visit on 5/7/25 re -assessment: color= pink; width = 1.0 cm; length = 0.5 cm and depth = 0.1 cm.-Week 7 (5/18 to 5/24) showed an SN visit on 5/21/25 re -assessment: color= pink; width = 1.0 cm; length = 0.5 cm and depth = 0.1 cm.-Week 8 (5/25 to 5/31) showed an SN visit on 5/27/25 re -assessment: color= pink; width = 0.5 cm; length = 0.3 cm and depth = 0.1 cm and-Week 9 ( 6/1 to 6/7) showed an SN visit on 6/6/25 re -assessment: color= pink; width = 0.5 cm; length = 0.3 cm and depth = 0.1 cm.Review of the clinical record showed on Week 6 (5/11 to 5/17), the SN visit the patient on 5/13/25.However the SN failed to perform wound assessment as ordered on the POC.On 6/20/25 at 0916 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was asked if the wound assessment should be included on the every SN visit. The Administrator/LVN/Volunteer Coordinator replied, yes, it should be included as part of the skin assessment. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings.3. Review of Patient 13’s closed clinical record was initiated on 6/13/25. The clinical record showed the SOC was 12/23/24. The patient was certified for hospice service during the periods from 12/23/24 to 3/22/25 and 3/23/25 to 6/20/25. The patient expired on 4/20/25.*Review of the Physician Order - Admit to Hospice dated 12/23/24 showed an order for scope and frequency of services. The services included CHHA cited 3x weekly 12/29/24 ongoing. Review of the closed clinical record showed the CHHA visited the patient three times weekly as ordered. However, on Week 3, the CHHA visited the patient two times instead of three times as ordered by the physician. *Review of the IDG Meeting dated 12/30/25 showed an order for scope and frequency of services. The services included SC - Chaplain services cited 1x monthly start 12/29/24. Review of the closed clinical record showed the Chaplain visited the patient on 12/28, 2/22 and 3/24/25 as ordered. However, there was no documented evidenced of a Chaplain visit was conducted for the month of January as ordered. On 6/20/25 at 1405 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/ Volunteer Coordinator was informed and acknowledged the findings. The hospice’s P&P titled The Plan of Care revised 4/2021, showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted in the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs, goals, and outcome achievement. 1. Review of Patient 10’s closed clinical record was initiated on 6/13/25. The clinical record showed the SOC was on 11/11/24. The patient was certified for hospice services during the certification periods from 11/11/24 to 2/8/25 and 2/9/25 to 4/9/25. The patient expired on 2/9/25.a. Review of the Physician Admitting Orders dated 9/25/24, showed the following:-SN-Nursing Services for 1x weekly visit and 7 prn SN visit for symptom management and wound dressing change from 9/25/24 to 9/28/24.-SN- Nursing Services for 1x weekly visit and 7 prn SN visit for symptom management and wound dressing change from 9/29/24 to ongoing.Further review of the clinical record for week 11/17/24 to 11/23/24, showed there was no documented evidence a SN visit was conducted instead of one times a week as per the POC.On 6/20/25 at 1104 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. b. Review of the Physician Admitting Orders dated 9/25/24, showed an order for CHHA -Aid Services for 2x weekly visits from 9/25/24 to 9/28/24 and CHHA- Aide Services for 2x weekly visits from 9/29/24 to ongoing.Further review of the clinical records showed the HA conducted three visits a week instead of two visits per week as per the physician’s order of the following week:- From 11/11/24 to 11/16/24- From 11/17/24 to 11/23/24- From 12/1/24 to 12/7/24- From 12/8/24 to 12/14/24- From 12/22/24 to 12/28/24- From 12/29/24 to 1/4/25- From 1/5/25 to 1/11/25- From 1/19/25 to 1/25/25-From 1/26/25 to 2/1/25- From 2/2 to 2/8/25On 6/20/25 at 1108 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. 2. Review of Patient 5’s clinical record was initiated on 6/11/25. The clinical record showed the SOC was 1/16/25. The patient was certified for hospice service during the certification periods from 1/16/25 to 4/15/25 and 4/16/25 to 7/14/25.a. Review of the Volunteer Documentation- Direct Patient Care dated 1/22 and 1/25/25 showed Volunteer 1 visited the patient. * However, the Physicians Order - Admit to Hospice dated 1/16/25, showed no documented evidenced of the physician’s order for the volunteer visit. Review of the IDG Meeting Note/POC dated 1/27/25, showed volunteer visits 1 to 2x weekly with a start date of 1/26/25.Review of the clinical record showed the volunteer visited the patient one time a week during Weeks 1 to 7. * However, there was no documented evidenced of a volunteer visit was conducted on Week 8 (3/2/25 to 3/8/25) as per IDG meeting Note/POC dated 1/27/25.b. The IDG Meeting Note dated 4/21/25, showed SN visit 1x weekly and 7 PRN for symptom and pain management. The IDG Meeting Note included a care plan problem dated 4/9/25, for altered skin integrity/redness to buttocks. The intervention included to assess skin every SN visit.The RN 1 visit notes dated 4/23/25, showed the patient was assessed to have a Stage 2 right buttock pressure injury. The assessment showed the color was red and had a measurement of 0.8 cm (length) x0.7 cm (width) x 0.2 cm (depth).The SN visit notes dated 4/30 and 5/7/25, showed the SN visited the patient.However, there was no documented evidenced the SN performed wound assessment as part of the skin assessment as per the POC. On 6/20/25 at 0952 hours, an interview and an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 3. Review of Patient 4’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was 10/20/23. The patient was certified for hospice services during the certification period from 4/12/25 to 6/10/25. The IDG Meeting Note dated 4/21/25, showed SN visit 1x weekly and 7 PRN for symptom management. The IDG Meeting Note included a care plan problem dated 6/4/24, for altered skin integrity related to impaired nutritional intake and immobility. The intervention included to assess skin integrity every visit.The Visit Note - RN - Nursing Note dated 4/29/25, showed RN 1 assessed the patient to have a Stage 2 left buttock pressure injury.The Skin Assessment for the Stage 2 left buttock pressure injury showed the following:-Week 4 (4/27 to 5/3) showed an SN visit on 4/29/25 - new assessment: color= pink; width = 1.0 cm; length = 0.5 cm and depth = 0.1 cm.-Week 5 (5/4 to 5/10) showed an SN visit on 5/7/25 re -assessment: color= pink; width = 1.0 cm; length = 0.5 cm and depth = 0.1 cm.-Week 7 (5/18 to 5/24) showed an SN visit on 5/21/25 re -assessment: color= pink; width = 1.0 cm; length = 0.5 cm and depth = 0.1 cm.-Week 8 (5/25 to 5/31) showed an SN visit on 5/27/25 re -assessment: color= pink; width = 0.5 cm; length = 0.3 cm and depth = 0.1 cm and-Week 9 ( 6/1 to 6/7) showed an SN visit on 6/6/25 re -assessment: color= pink; width = 0.5 cm; length = 0.3 cm and depth = 0.1 cm.Review of the clinical record showed on Week 6 (5/11 to 5/17), the SN visit the patient on 5/13/25.However the SN failed to perform wound assessment as ordered on the POC.On 6/20/25 at 0916 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was asked if the wound assessment should be included on the every SN visit. The Administrator/LVN/Volunteer Coordinator replied, yes, it should be included as part of the skin assessment. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 4. Review of Patient 13’s closed clinical record was initiated on 6/13/25. The clinical record showed the SOC was 12/23/24. The patient was certified for hospice service during the periods from 12/23/24 to 3/22/25 and 3/23/25 to 6/20/25. The patient expired on 4/20/25.*Review of the Physician Order - Admit to Hospice dated 12/23/24 showed an order for scope and frequency of services. The services included CHHA cited 3x weekly 12/29/24 ongoing. Review of the closed clinical record showed the CHHA visited the patient three times weekly as ordered. However, on Week 3, the CHHA visited the patient two times instead of three times as ordered by the physician. *Review of the IDG Meeting dated 12/30/25 showed an order for scope and frequency of services. The services included SC - Chaplain services cited 1x monthly start 12/29/24. Review of the closed clinical record showed the Chaplain visited the patient on 12/28, 2/22 and 3/24/25 as ordered. However, there was no documented evidenced of a Chaplain visit was conducted for the month of January as ordered. On 6/20/25 at 1405 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/ Volunteer Coordinator was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for four of 14 sampled patients (Patients 1, 3, 7, and 8). This failure created the potential risk to cause an inconsistent delivery of care which can result in the decline or lack of improvement of the patients’ health conditions.Findings: 1. Review of Patient 1’s clinical record was initiated on 6/10/25. The clinical record showed the SOC was 10/8/23. The patient was certified for hospice services during the certification periods from 3/31/25 to 5/29/25 and 5/30/25 to 7/28/25.The Visit Note- Comprehensive Recertification Assessment dated 3/26/25, showed the RN 1 had performed body system assessment. The assessment included the goals and intermediate interventions for the altered nutrition. The RN 1 documented the patient was diabetic and on anti diabetic medications -Rybelsus.However, review of the IDG Meeting Note/POC dated 4/7/25 failed to show documented evidenced the IDG had developed an individualized care plan to address the patients diabetes and the anti diabetic medication - Rybelsus. In addition, the Visit Note- Comprehensive Recertification Assessment dated 5/21/25, showed the RN 1 had performed body system assessment. The assessment included the goals and intermediate interventions for the altered nutrition. The RN 1 documented the following: Is the patient diabetic = Yes; How often the blood sugar checked: as needed only for signs and symptoms of hyper/hypoglycemia. Review of the IDG Meeting Note/POC dated 6/2/25 showed the patients identified problems and goals included alteration in nutrition. However, the IDG failed to developed an individualized care plan to address the patients diabetes and the blood sugar check for the signs and symptoms of hyper/hypoglycemia.On 6/20/25 at 1135 hours, an interview and an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Coordinator was asked if a care plan was develop to address the patients diabetes. The Administrator/LVN/Volunteer Coordinator replied, yes, we should but did not see a care plan. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings.2. Review of Patient 8’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was 2/21/25. The patient was certified for hospice service during the certification periods from 2/21/25 to 5/2/25 and 5/3/25 to 7/31/25.Review of the SN visit notes dated 4/30, 5/8, 5/14, 5/22, 5/28, 6/5/25, showed the SN had performed Skin Assessment. The Skin Assessment showed patient had other type of wound on the chest/front, color = brown, width 1.0 cm, length= 1.0 cm. However, review of the IDG Meeting Note/POC dated 5/5, 5/19 and 6/2/25 failed to documented evidenced of the IDG had develop an individualized care plan to address the patients wound on the chest/front. On 6/20/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. Review of the hospice’s P&P titled Revised/Updated Plan of Care (undated) showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of they physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessment performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days.#. Review of Patient 7’s clinical record was initiated on 6/13/25. The clinical record showed the SOC was on 12/28/23. The patient was certified for hospice services during the certification periods from 4/21/25 to 6/19/25.a. Review of the IDG Meeting Note/POC dated 5/5/25, showed a traumatic leg wound.Review of the Skin Assessments dated 5/2/25, showed a new assessment for a leg/front traumatic wound.*However, there was no documented evidence the IDG had developed an individual POC to address Patient 7’s traumatic leg wound.On 6/20/25 at 0927 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. b. Review of the Visit Note- RN – Nursing Note date 5/1/25, showed under the nutrition section, Patient 7 was on a soft diet and nectar thick liquid fluid consistency. In addition, under narrative section showed, Family Member 1 “reports that within the last week, he noted saliva pooling in the patient’s throat.” Family Member 1 “reports that patient starts coughing and as if choking from own saliva.” *However, there was no documented evidence the IDG had developed an individual POC to address Patient 7’s risk for aspiration or choking.On 6/20/25 at 0912 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. #. Review of Patient 3’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was on 3/21/25. The patient was certified for hospice services during the certification periods from 3/21/25 to 6/18/25.a. A joint home visit with HA 3 was conducted on 6/12/25 at 0914 hours, to Patient 3’s home. Medication reconciliation was conducted with HA 3 and Family Member 2. The following was identified:-atorvastatin (medication to lower high cholesterol) medication bottle label showed an expiration date of 5/20/25,-Plavix (medication to prevent blood clot) medication bottle label showed an expiration date of 12/8/23,-losartan potassium (medication to lower the blood pressure level) medication bottle label showed an expiration date of 12/8/23,-Mobic (medication to relieve pain) medication bottle label showed an expiration date of 2/19/25, and-metformin (medication to help lower blood sugar level) medication bottle label showed an expiration date of 6/8/24. Family Member 2 was informed of the expiration date in the label of the mentioned medication bottles. Family Member 2 stated she transferred the new tablets or capsules from the new medication to the old medication bottles because the old medication bottles were nice and good. HA 3 was informed and acknowledged the finding.*However, there was no documented evidence the IDG had developed an individual POC to address Family Member 2’s ways of storing Patient 3’s medication in old medication bottles with labels that showed expired dates.On 6/20/25 at 1011 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. b. Review of the IDG Meeting Note/POC dated 3/24, 4/17, 4/21, 5/5, 5/19, and 6/12/25, showed Patient 3 was taking metformin for diabetes.*However, there was no documented evidence the IDG had developed an individual POC to address Patient 3’s used of metformin and diagnosis for diabetes.On 6/20/25 at 1015 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding.”

“Based on interview and record review, the hospice failed to ensure the revised POCs included the visit frequency of the services provided for four of 14 sampled patients (Patients 6, 7, 9, and 14). This failure created the potential risk of not providing the necessary services for these patients.Findings: 2. Review of Patient 9’s clinical record was initiated on 6/17/25. The clinical record showed the SOC was 7/15/24 for palliative services. Review of the Plan of Care Items -Active showed the scope and frequency of the services. The services includes SN cited 1x monthly and 5 PRN. The POC also cited SW - Social Worker 0 x monthly and 2 PRN.However, POC failed to include the reason for the PRN visits of SN and SW as per P&P.On 6/20/25 at 1348 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/ Volunteer Coordinator was informed and acknowledged the findings. Review of the hospice’s P&P titled The Plan of Care revised 4/2021 showed the plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs, goals, and outcome achievement. 1. Review of Patient 7’s clinical record was initiated on 6/13/25. The clinical record showed the SOC was on 12/28/23. The patient was certified for hospice services during the certification periods from 4/21/25 to 6/19/25.Review of the IDG Meeting Note/POC dated 4/21, 5/5, 5/19, and 6/2/25, showed the orders for the MSW to visit 2x prn. *However, the documentation failed to include the indication for the MSW prn visits. On 6/20/25 at 1021 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated there should had been an indication for the MSW prn visit such as for emotional support. The DPCS was informed and acknowledged the above finding. 2. Review of Patient 6’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was on 12/14/24. The patient was certified for hospice services during the certification periods from 3/14/25 to 6/11/25 and 6/12/25 to 8/10/25.Review of the IDG Meeting Note/POC dated 3/24, 4/7, 4/21, 5/5, 5/19. And 6/2/25, showed the orders for the Volunteer visit frequency was 1-2x weekly.Review of the Frequency Order dated 2/2/25, showed Volunteer visit 1x prn for social support.However, the IDG Meeting Note/POC failed to include revision of the volunteer frequency visits to reflect the current order of volunteer visit of 1x prn for social support.On 6/20/25 at 1021 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. 3. Review of Patient 14’s closed clinical record was initiated on 6/17/25. The clinical record showed the SOC was on 12/11/24. The patient was certified for hospice services during the certification period from 12/11/24 to 3/10/25 and 3/11/25 to 6/8/25. The patient was discharged and revoked hospice services on 4/2/25.Review of the IDG Meeting Note/POC dated 12/16/24, showed the MSW visits were declined but services will be available if needed to provide psychosocial support.However, review of the IDG Meeting Note/POC dated 12/23, 12/30, 1/13, 1/27, 2/10, 2/24, 3/10, and 3/24/25 failed to include revision of the MDS frequency visits to reflect MSW services were declined.On 6/20/25 at 1206 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding.”

“Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12, and 14). This failure created the potential risk of not evaluating the POC and providing appropriate care and services to these patients. Findings: The hospice’s P&P titled The Plan of Care revised 4/2021 showed the plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort, and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs, goals, and outcome achievement. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 showed no documented evidence the POCs included measurable outcomes. For example:1. Review of Patient 1’s clinical record was initiated on 6/10/25. The clinical record showed the SOC was 10/8/23. The patient was certified for hospice services during the certification periods from 3/31/25 to 5/29/25 and 5/30/25 to 7/28/25.The Plan of Care Items - Active showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:-The goal for alteration in comfort/symptoms related to progression of disease process was to increase comfort/satisfaction from pain/discomfort by non verbal communication within the benefit period. However, there was no documented evidence as to what an increase comfort/satisfaction from pain/discomfort was.-The goal for alteration in respiratory status related to aspiration risk was to have an optimum level of oxygen within the benefit period. However, there was no documented evidence as to what optimum oxygen level was.-The goal for alteration in nutritional status related to dysphagia and disease process was to have adequate food and fluids as tolerated or desired within the benefit period. However, there was no documented evidence as to what an adequate food and fluids as tolerated was.-The goals for alteration in bladder elimination related to chronic UTI symptoms was to have an elimination needs met at an acceptable level and to have an optimum skin integrity maintained due to incontinence. However, there was no documented evidence as to what an acceptable level of elimination and optimum skin integrity was.On 6/20/25 at 1135 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 2. Review of Patient 8’s clinical record was initiated on 6/10/25. The clinical record showed the SOC was 2/21/25. The patient was certified for hospice services during the certification period from 2/21/25 to 5/2/25 and 5/3/25 to 7/31/25. The Plan of Care Items - Active, showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:-The goal for alteration in comfort/symptoms related to COPD, disease process was to have increase comfort/satisfaction from pain/discomfort as exhibited by verbal and non verbal communication within the benefit period. However, there was no documented evidence as to what an increase comfort/satisfaction from pain/discomfort was.-The goals for alteration in circulatory status related to 41% oxygen saturation level on the extremities as evidenced by moderate cyanosis on the right foot and mild cyanosis on both hands was to have an optimum peripheral circulation. However, there was no documented evidence as to what an optimum peripheral circulation was.-The goal for alteration in respiratory status related to disease process was to have an optimum level of oxygen within the benefit period. However, there was no documented evidence as to what optimum oxygen level was.-The goal for alteration in nutritional status related to disease process was to have adequate food and fluids as tolerated or desired. However, there was no documented evidence as to what an adequate food and fluids as tolerated was.-The goals for alteration in bladder elimination related to chronic UTI symptoms was to have an elimination needs met at an acceptable level and to have an optimum skin integrity maintained due to incontinence. However, there was no documented evidence as to what an acceptable level of elimination and optimum skin integrity was.On 6/20/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patients’ POCs no less frequently than every 15 calendar days for five of 14 sampled patients (Patients 1, 4, 5, 10, and 11). This failure created the potential risk for not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 1’s clinical record was initiated on 6/10/25. The clinical record showed the SOC was 10/8/23. The patient was certified for hospice services during the certification periods from 3/31/25 to 5/29/25 and 5/30/25 to 7/28/25.a. The Visit Note- Comprehensive Recertification Assessment dated 3/26/25, showed the RN 1 had performed body system assessment. The assessment included the goals and intermediate interventions for the altered nutrition. The RN 1 documented the patient was diabetic and on anti diabetic medications - Rybelsus.However, review of the IDG Meeting notes dated 4/7, 4/21, 5/5 and 5/19/15 failed to show documented evidenced of the IDG had reviewed and revised the care plan to address the patients diabetes and the use of oral hypoglycemics - Rybelsus.In addition, the Visit Note- Comprehensive Recertification Assessment dated 5/21/25, showed the RN 1 had performed body system assessment. The assessment included the goals and intermediate interventions for the altered nutrition. The RN 1 documented the following: Is the patient diabetic = Yes; How often the blood sugar checked: as needed only for signs and symptoms of hyper/hypoglycemia. However, review of the IDG Meeting Note/POC dated 6/2/25 failed to show documented evidenced of the IDG had reviewed and revised the care plan to address the patients diabetes and the as needed blood sugar check for the signs and symptoms of hypo/hyperglycemia. b. Review of the SN visit notes dated 4/2/25, showed the SN had performed an Skin Assessment. The documentation showed the patient was assessed to have a traumatic wound to the toe with a measurement of Width - 2.5 cm, Length = 3 cm, Depth= 0.1. Review of the IDG Meeting notes dated 4/7/25 showed the a care plan for altered skin integrity. However, there was no documented evidenced of the IDG had revised the care plan to address the patients traumatic wound to the toe. On 6/20/25 at 1151 hours, an interview and an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Coordinator was asked if a care plan was revised to address the patients diabetes and the traumatic wound to the toe. The Administrator/LVN/Volunteer Coordinator replied, no, the POC was not revised. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings.2. Review of Patient 5’s clinical record was initiated on 6/11/25. The clinical record showed the SOC was 1/16/25. The patient was certified for hospice service during the certification periods from 1/16/25 to 4/15/25 and 4/16/25 to 7/14/25.a. Review of the IDG Meeting Note/POC dated 1/27/25 showed the scope and frequency of services. The services included Volunteer cited 1 to 2x weekly start date 1/26/25.Review of the clinical record showed the Volunteer visited the patient once a week during Weeks 1 to 7 as ordered.Further review of the clinical record to showed a Volunteer missed visit on Week 8 (3/2 to 3/8/25). However, review of the IDG Meeting Notes dated 3/10/25 failed to show documented evidenced of the IDG discussed the volunteer missed visit on Week 8 (3/2 to 3/8/25).*Review of the IDG Meeting Note/POC dated 1/27/25 showed the scope and frequency of services. The services included Volunteer cited 1 to 2x weekly start date 1/26/25.Review of the Communication Note dated 3/13/25 showed a the Volunteer 1 reported the PCG no longer wants a visit from the Volunteer.Review of the IDG Meeting Note/POC dated 3/24/25 showed a care plan for volunteer services. The care plan includes the goals and intervention for the volunteer services.However, review of the IDG Meeting Note/POC dated 3/24, 4/7, 4/21, 5/5, 5/19 and 6/2/25 failed to show documented evidenced of the care plan was revised to address the PCG request of no longer visits from the Volunteer. b. Review of the RN 1 Visit notes dated 5/21/25 on the section of narrative note showed the patient was assessed to have a slight redness to the bilateral buttocks and the Stage 2 pressure injury to the right buttocks was resolved.Review of the IDG Meeting Note/POC dated 6/2/25 showed a care plan related to altered skin integrity. The care plan included the goals and intervention to address the patients open wound to the right buttocks.However, the IDG Meeting dated 6/2/25 failed to show documented evidenced of the care plan was revised to reflect the slight redness to the bilateral buttocks and the Stage 2 pressure injury to the right buttocks was resolved.On 6/20/25 at 1022 hours, an interview and an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings.3. Review of Patient 4’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was 10/20/23. The patient was certified for hospice service during the certification periods from 4/12/25 to 6/10/25 and 6/11/25 to 8/9/25. Review of Visit Note - RN - Nursing Note dated 4/29/25 showed the RN 1 performed an assessment. The patient was assessed to have a Stage 2 pressure injury to the left buttock. Further, review of the Skin Assessment dated 4/29/25 showed a new assessment for the Stage 2 pressure injury to the left buttock; color= pink; width = 1.0 cm; length = 0.5 cm and depth = 0.1 cm.Review of the IDG Meeting Note/POC dated 5/5, 5/19 and 6/2/25, showed a care plan goals and intervention related to altered skin integrity. However, the IDG failed to revised the care plan to address the new assessment of the Stage 2 pressure injury to the left buttocks.On 6/20/25 at 0916 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings.4. Review of Patient 11’s closed clinical record was initiated on 6/18/25. The clinical record showed the SOC was 1/22/25. The patient was certified for hospice service during the certification periods from 1/22/25 to 4/21/25 and 4/22/25 to 6/20/25. The patient expired on 5/18/25.Review of the SN note dated 3/11, 3/17 and 3/20//25, showed the patient was assessed to have an abrasion to the right back. The assessment showed color = red; width= 1.0 cm; Length= 1.5 cm.Review of the SN notes dated 3/26/25 on the section of narrative notes showed the patients abrasion to the mid back was healed.Further review of the SN visit notes dated 4/1/25 on the section of skin integrity showed the patient skin was intact.Review of the IDG Meeting Note/POC dated 4/7/25, showed a care plan goals and intervention related to altered skin integrity. However, the IDG failed to revised the care plan to address the healed abrasion to the patients back. On 6/20/25 at 1121 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. Review of the hospice’s P&P titled Revised/Updated Plan of Care (undated) showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of they physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessment performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. #. Review of Patient 10’s closed clinical record was initiated on 6/13/25. The clinical record showed the SOC was on 11/11/24. The patient was certified for hospice services during the certification period from 11/11/24 to 2/8/25 and 2/9/25 to 4/9/25. The patient expired on 2/9/25.Review of the IDG Meeting Note/POC dated 11/18, 12/2, 12/16, and 12/30/24, 1/13, and 1/27/25, showed under active orders Dulcolax (medication for constipation) 10 mg suppository daily prn. *However, the documentation failed to show evidence of the IDG reviewed and revised to reflect the indication for the Dulcolax medication.On 6/20/25 at 1149 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. b. Review of the Physician Admitting Orders dated 9/25/24, showed an order for CHHA -Aid Services for 2x weekly visits from 9/25/24-9/28/24 and CHHA- Aide Services for 2x weekly visits from 9/29/24 to ongoing.Review of the CHHA Visit Notes showed the HA conducted three visit a week instead of two visits per week as per the physician’s order of the following week:- From 11/11 to 11/16/24- From 11/17 to 11/23/24- From 12/1 to 12/7/24- From 12/8 to 12/14/24- From 12/22 to 12/28/24- From 12/29/24 to 1/4/25- From 1/5 to 1/11/25- From 1/19 to 1/25/25-From 1/26 to 2/1/25- From 2/2 to 2/8/25 *However, review of the IDG Meeting Note/POC dated 11/18, 12/2, 12/16, and 12/30/24, 1/13, and 1/27/25, showed CHHA -Aid Services for 2x weekly, was not updated to reflect the HA’s extra one day visit per week for the weeks listed above, as per the hospice’s P&P.On 6/20/25 at 1108 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding.”

“Based on interview and record review, the hospice failed to ensure the revised POCs included the patients’ progress towards the goals specified in the POCs for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14). This failure had the potential for not addressing the care needs for these patients. Findings: 3. Review of Patient 12’s closed clinical record was initiated on was initiated on 6/17/25. The clinical record showed the SOC was on 12/30/23. The patient was certified for hospice services during the certification periods from 6/27/24 to 8/25/24. The patient revoked hospice on 8/25/24.The IDG Meeting Note/POC review dated 7/1, 7/15, 7/29, 8/12 and 8/26/24, showed the hospice identified patient care problems included altered comfort, altered neuro status, altered circulatory status, altered respiratory status, altered self care, altered self-care and psycho-social adjustment/coping. The goals were established for these identified problems. Documentation showed the status of these care plan problems were open.* However, there was no documented evidence the POCs included the patient’s progress towards the goals for each of the care plan problem identified. In addition, review of the SN visit notes dated 7/2, 7/8, 7/16, 7/22, 7/30, 8/5, 8/13 and 8/19/25 showed there was a question for progress towards goal for each care plan problem and was either coded as “yes or N/A.” However, the progress towards goal for each care plan problem was not discussed or documented in the IDG Meeting Notes.On 6/20/25 at 1048 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/ LVN/Volunteer Coordinator was informed and acknowledged the above findings.4. Review of Patient 13’s closed clinical record was initiated on was initiated on 6/13/25. The clinical record showed the SOC was on 12/23/24. The patient was certified for hospice services during the certification periods from 12/23/24 to 3/22/25 and 3/23/25 to 6/20/25. The patient expired on 4/20/25.The IDG Meeting Note/POC review dated 12/30,1/13, 1/27, 2/10, 3/24, 4/7, 4/21/25 showed the hospice identified patient care problems included knowledge and training, safety: potential for harm, altered comfort, altered neuro status, altered elimination, altered skin integrity, altered self-care, psycho-social adjustment/coping, spiritual services, and bereavement. The goals were established for these identified problems. Documentation showed the status of these care plan problems were open.* However, there was no documented evidence the POCs included the patient’s progress towards the goals for each of the care plan problem identified. In addition, review of the SN visit notes dated 12/23, 12/31, 1/8, 1/15, 1/21, 1/29, 2/12, 2/19, 3/20, 4/2, 4/8 and 4/16/25 showed there was a question for progress towards goal for each care plan problem and was either coded as “yes or N/A.” However, the progress towards goal for each care plan problem was not discussed or documented in the IDG Meeting Notes.On 6/20/25 at 1405 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/ LVN/Volunteer Coordinator was informed and acknowledged the above findings. Review of the hospice’s P&P titled The Plan of Care revised 4/2021 showed the plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs, goals, and outcome achievement. Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to be evaluated toward goals. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14, showed no documented evidence the revised POCs included the patients’ progress towards goals. For example:1. Review of Patient 2’s clinical record was initiated on was initiated on 6/11/25. The clinical record showed the SOC was on 9/17/24. The patient was certified for hospice services during the certification periods from 3/16/25 to 5/14/25 and 5/15/25 to 7/13/25.The IDG Meeting Note/POC review dated 3/24, 4/7, 4/21, 5/5, 5/19, and 6/2/25, showed the hospice identified patient care problems included knowledge and training, safety: potential for harm, altered comfort, altered neuro status, altered elimination, altered skin integrity, altered self-care, psycho-social adjustment/coping, spiritual services, and bereavement. The goals were established for these identified problems. Documentation showed the status of these care plan problems were open.* However, there was no documented evidence the POCs included the patient’s progress towards the goals for each of the care plan problem identified. In addition, review of the SN visit notes showed there was a question for progress towards goal for each care plan problem and was either coded as “yes or N/A.” However, the progress towards goal for each care plan problem was not discussed or documented in the IDG Meeting Note/POC.On 6/20/25 at 0958 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. 2. Review of Patient 3’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was on 3/21/25. The patient was certified for hospice services during the certification periods from 3/21/25 to 6/18/25.The IDG Meeting Note/POC review dated 3/24, 4/7, 4/21, 5/5, 5/19, and 6/2/25, showed the hospice identified patient care problems included knowledge and training, safety: potential for harm, altered comfort, altered neuro status, altered bowel status altered circulatory status, altered respiratory status, altered elimination, altered skin integrity, altered self-care, psycho-social adjustment/coping, and spiritual services. The goals were established for these identified problems. Documentation showed the status of these care plan problems were open.* However, there was no documented evidence the POCs included the patient’s progress towards the goals for each of the care plan problem identified. In addition, review of the SN visit notes showed there was a question for progress towards goal for each care plan problem and was either coded as “yes or N/A.” However, the progress towards goal for each care plan problem was not discussed or documented in the IDG Meeting Note/POC.On 6/20/25 at 1021 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding.”

“Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing, coordinating, and supervising the care and services provided for five of 14 sampled patients (Patients 1, 5, 7, 8, and 11). This failure had the potential risk of not addressing the care needs for these patients. Findings: Review of the hospice’s P&P titled Care/Services Coordination revised 4/2021 showed timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient, and relevant to the care/services provided. The clinician/technician will be responsible for facilitating communications about the changes in the patient’s status among the assigned personnel. Organization personnel will communicate in a timely manner via telephone, one-on-one meetings, case conferences, and home visits. Documentation of all communications will be included in the clinical record on a communication note, case conference summary, or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication.Review of the hospice’s P&P titled Monitoring Patient’s Response/Reporting to Physician revised 4/2021 showed the patient physician and/or the hospice Medical Director will be contacted on the same day when any of the following occur: change in the patient’s condition… #. Review of Patient 7’s clinical record was initiated on 6/13/25. The clinical record showed the SOC was on 12/28/23. The patient was certified for hospice services during the certification periods from 4/21/25 to 6/19/25.Review of the Visit Note- Rn- Nursing Note dated 5/1/25, showed under the narrative notes, “Patient’s wound on the left side of his forehead continue to have bloody drainage whenever dressing is removed. Family Member 1 covers the wound with a gauze pad and tape.*However, there was no documented evidence the physician was notified of the change of condition on the same day of the visit as per the hospice’s P&P. In addition, there was no documented evidence RN 1 had coordinated with the IDG regarding the patient’s change of condition related to the continued bloody drainage of the Patient 7’s forehead.On 6/20/25 at 0923 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. The DPCS was asked if Patient 7’s continued bloody drainage to his forehead considered a change of condition. The DPCS replied “yes” and stated the physician should had been notified by the nurse and verified treatment orders. 1. Review of Patient 8’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was 2/21/25. The patient was certified for hospice service during the certification periods from 2/21/25 to 5/2/25 and 5/3/25 to 7/31/25.a. Review of the Plan of Care Items - Active showed the scope and frequency of the services. The services included SC cited 1X monthly dated 2/24/25 and ongoing.Review the Visit Note - Spiritual Assessment dated 2/24/25, showed the SC had performed the initial visit assessment.Further review of the clinical record showed the SC had left a voicemail for the PCG on 3/14, 4/14/25 for the follow up appointment. Moreover, review of the SC note dated 4/22/25 showed, PCG declined visits and will call SC to know when to visit. However, review of the clinical record failed to show documented evidenced the SC had coordinated the visit for the month of May as per POC. In addition, review of the IDG Meeting Note/POC dated 5/5, 5/19 and 6/2/25 failed to show documented evidenced of the IDG had discussed the SC visit frequency. b. Review of the Plan of Care Items - Active showed the scope and frequency of the services. The services included SN cited 1x monthly and 6 PRN beginning 2/23/25 for symptoms management. Review of the SN visit notes dated 4/30, 5/8, 5/14, 5/22, 5/28, 6/5/25, showed the SN had performed Skin Assessment. The Skin Assessment showed patient had “other” type of lesion on the chest/front, color = brown, width 1.0 cm, length= 1.0 cm. However, review of the clinical record failed to show documented evidenced of the physician was notified of the patients “other” type of lesion on the chest/front. On 6/20/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 2. Review of Patient 5’s clinical record was initiated on 6/11/25. The clinical record showed the SOC was 1/16/25. The patient was certified for hospice service during the certification periods from 1/16/25 to 4/15/25 and 4/16/25 to 7/14/25.Review of the IDG Meeting Note/POC dated 1/27/25 showed the scope and frequency of services. The services included Volunteer cited 1 to 2x weekly start date 1/26/25.Review of the Communication Note dated 3/13/25 showed a the Volunteer 1 reported the PCG no longer wants a visit from the Volunteer.However, review of the clinical record showed a Volunteer visit was conducted on 3/24/25 after the PCG had reported no longer wants a visit. On 6/20/25 at 0952 hours, an interview and an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was asked if the volunteer visit was discontinued. The Administrator/LVN/Volunteer Coordinator replied, no, it was not discontinued on the care plan during IDG meeting. The Administrator/LVN/Volunteer Coordinator was further asked as to who needs to coordinate with the volunteer related to the cancellation of the visit. The Administrator/LVN/Volunteer Coordinator replied, I am and should have notified the volunteer. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings.3. Review of Patient 11’s closed clinical record was initiated on 6/18/25. The clinical record showed the SOC was 1/22/25. The patient was certified for hospice service during the certification periods from 1/22/25 to 4/21/25 and 4/22/25 to 6/20/25. The patient expired on 5/18/25.Review of the SN note dated 3/11/25, showed the patient was assessed to have an abrasion to the right back. The assessment showed color = red; width= 1.0 cm; Length= 1.5 cm.Further review of the SN notes under the section of coordination, showed the coordinated with family and patient. However, there was no documented evidenced of the physician was notified of the new assessed abrasion to the back. On 6/20/25 at 1121 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 4. Review of Patient 1’s clinical record was initiated on 6/10/25. The clinical record showed the SOC was 10/8/23. The patient was certified for hospice services during the certification periods from 3/31/25 to 5/29/25 and 5/30/25 to 7/28/25.Review of the SN visit notes dated 4/2/25, showed the SN had performed an Skin Assessment. The documentation showed the patient was assessed to have a traumatic wound to the toe with a measurement of Width - 2.5 cm, Length = 3 cm, Depth= 0.1. However, review of the SN visit note dated 4/2/25 failed to show documented evidenced of the physician was notified of the patients traumatic wound to the toe.On 6/20/25 at 1151 hours, an interview and an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Coordinator was asked if the physician was notified of the patients traumatic wound to the toe. The Administrator/LVN/Volunteer Coordinator replied, no, there was no mention of the physician notification on the note. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. Review of the hospice’s P&P titled Care/Services Coordination revised 4/2021, showed timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient, and relevant to the care/services provided. The clinician/technician will be responsible for facilitating communications about the changes in the patient’s status among the assigned personnel. Organization personnel will communicate in a timely manner via telephone, one-on-one meetings, case conferences, and home visits. Documentation of all communications will be included in the clinical record on a communication note, case conference summary, or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication. Review of the hospice’s P&P titled Monitoring Patient’s Response/Reporting to Physician revised 4/2021, showed the patient’s physician and/or the hospice Medical Director will be contacted on the same day when any change in the patient’s condition. 1. Review of Patient 7’s clinical record was initiated on 6/13/25. The clinical record showed the SOC was on 12/28/23. The patient was certified for hospice services during the certification period from 4/21/25 to 6/19/25. Review of the SN note dated 5/1/25, showed patient’s wound on the left side of his forehead continued to have bloody drainage whenever dressing was removed. The family member covered the wound with a gauze pad and tape. *However, there was no documented evidence the physician was notified of the change of condition on the same day of the visit as per the hospice’s P&P. In addition, there was no documented evidence the SN had coordinated with the IDG regarding the patient’s change of condition related to the continued bloody drainage of the Patient 7’s forehead. On 6/20/25 at 0923 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. The DPCS was asked if Patient 7’s continued bloody drainage to his forehead considered a change of condition. The DPCS replied yes and stated the physician should had been notified by the nurse and verified treatment orders. 2. Review of Patient 8’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was 2/21/25. The patient was certified for hospice service during the certification periods from 2/21/25 to 5/2/25 and 5/3/25 to 7/31/25.a. Review of the Plan of Care Items - Active cited SC visits 1X monthly on 2/24/25 and ongoing. Review the Visit Note - Spiritual Assessment dated 2/24/25, showed the SC had performed the initial visit assessment. Documentation showed the SC had left a voicemails for the PCG on 3/14 and 4/14/25 for the follow up appointment. Moreover, review of the SC note dated 4/22/25 showed, PCG declined visits and will call SC to know when to visit. However, review of the clinical record failed to show documented evidenced the SC had coordinated the visit for the month of May as per POC. In addition, review of the IDG Meeting Note/POC dated 5/5, 5/19 and 6/2/25 failed to show documented evidenced of the IDG had discussed the SC visit frequency. b. Review of the Plan of Care Items - Active cited SN visits 1x monthly and 6 PRN beginning 2/23/25 for symptoms management. Review of the SN visit notes dated 4/30, 5/8, 5/14, 5/22, 5/28, 6/5/25, showed the SN had performed Skin Assessment. The Skin Assessment showed patient had “other” type of lesion on the chest/front, color = brown, width 1.0 cm, length= 1.0 cm. However, review of the clinical record failed to show documented evidenced of the physician was notified of the patients “other” type of lesion on the chest/front. On 6/20/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 3. Review of Patient 5’s clinical record was initiated on 6/11/25. The clinical record showed the SOC was 1/16/25. The patient was certified for hospice service during the certification periods from 1/16/25 to 4/15/25 and 4/16/25 to 7/14/25.Review of the IDG Meeting Note/POC dated 1/27/25 showed the scope and frequency of services. The services included Volunteer cited 1 to 2x weekly start date 1/26/25.Review of the Communication Note dated 3/13/25 showed a the Volunteer 1 reported the PCG no longer wants a visit from the Volunteer.However, review of the clinical record showed a Volunteer visit was conducted on 3/24/25 after the PCG had reported no longer wants a visit. On 6/20/25 at 0952 hours, an interview and an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was asked if the volunteer visit was discontinued. The Administrator/LVN/Volunteer Coordinator replied, no, it was not discontinued on the care plan during IDG meeting. The Administrator/LVN/Volunteer Coordinator was further asked as to who needs to coordinate with the volunteer related to the cancellation of the visit. The Administrator/LVN/Volunteer Coordinator replied, I am and should have notified the volunteer. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 4. Review of Patient 11’s closed clinical record was initiated on 6/18/25. The clinical record showed the SOC was 1/22/25. The patient was certified for hospice service during the certification periods from 1/22/25 to 4/21/25 and 4/22/25 to 6/20/25. The patient expired on 5/18/25.Review of the SN note dated 3/11/25, showed the patient was assessed to have an abrasion to the right back. The assessment showed color = red; width= 1.0 cm; Length= 1.5 cm.Further review of the SN notes under the section of coordination, showed the coordinated with family and patient. However, there was no documented evidenced of the physician was notified of the new assessed abrasion to the back. On 6/20/25 at 1121 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 5. Review of Patient 1’s clinical record was initiated on 6/10/25. The clinical record showed the SOC was 10/8/23. The patient was certified for hospice services during the certification periods from 3/31/25 to 5/29/25 and 5/30/25 to 7/28/25.Review of the SN visit notes dated 4/2/25, showed the SN had performed an Skin Assessment. The documentation showed the patient was assessed to have a traumatic wound to the toe with a measurement of Width - 2.5 cm, Length = 3 cm, Depth= 0.1. However, review of the SN visit note dated 4/2/25 failed to show documented evidenced of the physician was notified of the patients traumatic wound to the toe.On 6/20/25 at 1151 hours, an interview and an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Coordinator was asked if the physician was notified of the patients traumatic wound to the toe. The Administrator/LVN/Volunteer Coordinator replied, no, there was no mention of the physician notification on the note. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings.”

“Based on record review and interview, the hospice failed to ensure care and services were provided in accordance with the POC for three of 14 sampled patients (Patients 5, 10, and 13). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. The hospice’s P&P titled The Plan of Care revised 4/2021 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted in the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs, goals, and outcome achievement. 1. Review of Patient 10’s closed clinical record was initiated on 6/13/25. The clinical record showed the SOC was on 11/11/24. The patient was certified for hospice services during the certification periods from 11/11/24 to 2/8/25 and 2/9/25 to 4/9/25. The patient had expired on 2/9/25.Review of the Physician Admitting Orders dated 9/25/24, showed the following orders:-SN-Nursing Services 1x weekly visit and 7 PRN visits for symptom management and wound dressing change from 9/25/24 to 9/28/24, and from 9/29/24 to ongoing.Further review of the clinical record for Week 2 (11/17/24 to 11/23/24), showed no documented evidence a SN visit was conducted instead of one time a week as per the physician’s order.On 6/20/25 at 1104 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. 2. Review of Patient 5’s clinical record was initiated on 6/11/25. The clinical record showed the SOC was 1/16/25. The patient was certified for hospice services during the certification periods from 1/16/25 to 4/15/25 and 4/16/25 to 7/14/25.a. The Volunteer Documentation- Direct Patient Care dated 1/22 and 1/25/25, showed Volunteer 1 visited the patient. * However, the Physicians Order - Admit to Hospice dated 1/16/25, showed no documented evidence of the physician’s order for the volunteer visits on 1/22 and 1/25/25.b, Review of the IDG Meeting Note dated 1/27/25, showed volunteer visits 1 to 2x weekly with a start date of 1/26/25.Review of the clinical record showed the volunteer visited the patient one time a week during Weeks 1 to 7. * However, there was no documented evidence of a volunteer visit conducted on Week 8 (3/2/25 to 3/8/25) as per the IDG Meeting Note.On 6/20/25 at 0952 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 3. Review of Patient 13’s closed clinical record was initiated on 6/13/25. The clinical record showed the SOC was 12/23/24. The patient was certified for hospice services during the periods from 12/23/24 to 3/22/25 and 3/23/25 to 6/20/25. The patient had expired on 4/20/25.The IDG Meeting Note dated 12/30/25, showed an order for Chaplain services 1x monthly to start on 12/29/24. Review of the closed clinical record showed the Chaplain visited the patient on 12/28, 2/22, and 3/24/25, as ordered. * However, there was no documented evidence of the Chaplain visit conducted for the month of January 2025 as per the IDG Meeting Note. On 6/20/25 at 1405 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/ Volunteer Coordinator was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to document the reason for conducting the PIPs and measurable progress achieved on their projects. This failure had the potential risk of not effectively evaluating the outcomes of the PIPs to improve the care and services provided by the hospice’s staff. Findings: Review of the hospice’s P&P titled Sample Quality Assessment and Performance Improvement (QAPI) Plan revised 4/2021 showed the purpose of the Hospice QAPI Plan is to provide a strategy for the systematic organization-wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high value, effective, and efficient services in accordance with its mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations. The objectives includes the following:- To show measurable improvement in indicators that demonstrate an improvement in palliative outcomes and end-of life support systems- To measure, analyze, and track quality indicators, including adverse events, to enable the assessment of processes of care, hospice services and operations- To collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement- To conduct PIP aimed at performance improvement and to track performance to ensure that it is sustained- To document QAPI activities including reasons for Performance Improvement Projects and progress achieved on these projectsThe QAPI Plan is operated through a committee structure. The QAPI Coordinator ensures that leadership priorities for improvement are evaluated. In addition, the QAPI Coordinator examines results from ongoing quality control activities to identify trends that will need follow-up action by the QAPI Committee. A formal evaluation of all QAPI will occur annually. A written report will be completed by the QAPI Coordinator. After review by the directors of each department, the report will be presented to the Governing Body. The report will include a summary of all activities included as part of the QAPI Plan. The Governing Body will measure the effectiveness of the QAPI Plan based on the established objectives. The Governing Body will provide input into the identification and prioritization of future improvement activities. Review of the hospice’s QAPI program and meeting minutes for 2023, 2024, and 2025 was conducted on 6/19/25, and showed the following: a. Review of the 2024, 2024, and 2025 QAPI Quarterly Meeting Minutes showed the following same topics were discussed during the meetings:- The previous quarter meeting follow up- Continuity of care: chart review- Infection Control- Pain Management: HIS Report- Perception of Care- Grievance and Concerns- Infection/ Incident Reports- Employee File Audit The Quarterly Meeting Minutes showed the sections for discussion, recommendation, decisions/goals, scheduled actions and responsible person. For example, for the 2025 1st Quarter (January-March) QAPI Meeting Minutes, showed under the topic of Infection Control, a discussion for consistent monitoring of six surveillance report, a recommendation to each infection be measured as they are reported, a decision to root cause analysis based on reported data, a schedule action to provide ongoing in-service to patients, family, and all staff regarding infection precautions and to continue to track trend based on collected data, and responsible personnel as the DPCS and QA Manager. There were evidence of data collected on the number of cases of infection, number of admission/discharges, number of chart audits, number of falls, etc. However, the QAPI program and quarterly meeting minutes for 2023, 2024, and 2025 did not specify the PIPs the hospice were working on, reasons for conducting these projects, and measurable progress achieved on these projects. b. Review of the Quarterly 2024 QAPI Meeting Minutes failed to show documented evidence the 4th Quarter QAPI meeting was conducted. c. Review of the Quarterly 2023 and 2024 QAPI Meeting Minutes failed to show documented evidence of the attendees for the 3rd Quarter of 2023 and 1st to 3rd Quarters of 2024 QAPI. d. Review of the QAPI program for 2023 and 2024 failed to documented evidence of an evaluation of all QAPI annually as per the hospice’s P&P.On 6/19/25 at 1300 hours, an interview and concurrent document review was conducted with the Administrator/LVN/Volunteer Coordinator. When the Administrator/LVN/Volunteer Coordinator was asked what QAPI project the hospice was working on, she replied the QAPI projects were pain management, infection control, medication orders, late submissions of documentation, and MSW and Chaplain’s frequency visits. The Administrator/LVN/Volunteer Coordinator was informed the QAPI program and meeting minutes for 2023, 2024, and 2025 did not specify these PIPs. The Administrator/LVN/ Volunteer Coordinator was informed and acknowledged the above findings.”

“Based on observation, interview, and record review, the hospice failed to ensure the standard precautions to prevent the transmission of infections and communicable diseases were implemented for one of 14 sampled seven patients (Patient 2). This failure had the potential for spread of infections. Findings: According to the CDC recommendation, washing hands before and after using gloves to prevent the spread of germs. If soap and water are not available, you can use an alcohol-based hand sanitizer that contains at least 60% alcohol. Gloves are not a substitute for hand hygiene. Review of the hospice’s P&P titled Infection Control Precautions revised 11/2017 showed organization personnel will adhere to the following precautions and will instruct patients and family/caregivers in infection control precautions, as appropriate to the patient’s care needs. Hand hygiene will be performed to prevent cross-contamination between the patient and personnel. Review of Patient 2’s clinical record was initiated on was initiated on 6/11/25. The clinical record showed the SOC was on 9/17/24. The patient was certified for hospice services during the certification periods from 3/16/25 to 5/14/25 and 5/15/25 to 7/13/25.A joint home visit with RN 1 was conducted on 6/11/25 at 0925 hours, to Patient 2’s home. RN 1 was observed performing a head to toe physical assessment to Patient 2; however, RN 1 did not perform hand hygiene prior to setting up her equipment such as the blood pressure cuff, thermometer, and pulse oximeter and prior to donning gloves to provide care to Patient 2. RN 1 placed the pulse oximeter to Patient 2’s right index finger. Then, RN 1 removed her gloves after checking Patient 2’s bowel sounds with her stethoscope. RN 1 donned new gloves prior to measuring Patient 2’s arm circumference with a measuring tape. RN 1 did not perform hand hygiene prior to donning new gloves. RN 1 removed her used gloves again. When RN 1 finished all her care task to Patient 2, RN 1 did not perform hand hygiene. On 6/11/25 at 0950 hours, an interview was conducted with RN 1. RN 1 was informed and acknowledged the above finding. RN 1 stated she felt nervous and should had washed her hands prior to providing patient care, when removing gloves, and after patient’s care. On 6/20/25 at 1005 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding.”

“Based on interview and record review, the hospice failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention control, and investigation of infectious and communicable disease. This failure had the potential risk of the spread of infections and not improving the infection control program. Findings: Review of the hospice’s P&P titled Infection Control Plan revised 4/2021, showed the hospice is committed to reducing the risk of acquisition and transmission of health care associated infections. Recognized prevention and control mechanisms will be implemented for planning, surveillance, identification, prevention/controls, and reporting procedures. To determine the effectiveness of the infection control plan, the hospice will measure, assess, improve, and redesign (as appropriate) the surveillance, identification, prevention, and control function annually through its performance improvement program. Review of the hospice’s P&P titled Evaluating and Maintaining Records of Infections Among Patients revised 4/2021 showed the following:- All patients with a new, actual, or suspected infection will have a patient infection report within 24 hours of discovery. If trends are discovered, target surveillance or problem-oriented surveillance may be initiated for specific high-risk patient populations if high volume, problem-prone areas are identified.- The Infection Identification-Patient Report Form is completed when any of the following occur:a. A new, actual, or suspected infection is clinically observed by home health personnel.b. Culture is ordered and performed, and the results are positive.c. A new antibiotic is ordered.d. A patient is admitted to a hospital due to an actual or suspected infection.e. A patient unanticipated death due to an actual or suspected infection.f. A reportable, communicable infection is identified.g. Patient has temperatures greater than 101 degrees Fh. Patient has conjunctivitis.- The Case Manager or the nurse caring for the patient in his/her absence should complete the Infection Identification Patient Report within 24 hours of discovering the infection.- Each section of the report should be completed in its entirety.- If patient was admitted to home care from a hospital and a new infection was identified by the clinician within the first 48 hours of service, the source of the suspected infection may be nosocomial.- After completion, the original form will be sent to the Performance Improvement Coordinator, and a copy will be submitted to the appropriate personnel for follow-up.- The Performance Improvement Coordinator summarizes, trends, and analyzes the reports. The break down and summary may include, but will not be limited to:a. Number of infection typesb. Sources of infectionc. Diagnosesd. Age/sex of patientse. Family/caregiverf. Pathogens, if identifiedg. Follow-up takenh. Orders/medications- The Performance Improvement Coordinator, in conjunction with the Clinical Supervisor, will investigate possible causal factors and recommend appropriate action to contain the transmission of the infection. Actions may include implementing target or problem surveillance to aid in identifying causal factors and appropriate recommendations.- A report on infections will be given at each Performance Improvement Committee meeting. A summary will be forwarded to the IDG. - Information from the summary, analysis, and discussion will be used as part of the organization’s risk analysis and annual evaluation of the organization’s infection prevention and control activities. Review of the QAPI and infection control documents for 2023, 2024, and 2025 was conducted on 6/19/25, and showed the following:a. The Quarterly Infection Control Report, QAPI Meeting Minutes Report, and the data collected were inconsistent.-Review of the 1st Quarter 2023 (January-March) Infection Control Report showed there were two UTIs, one soft tissue infection, and 10 other infections with a total of 13 cases of infection. However, the Data Visit Notes Infection Report showed there were two UTIs, one soft tissue infection, and eight other cases of infections with a total of 11 cases of infection. In addition, the 1st Quarter 2023 QAPI Meeting Minutes Report showed under the topic of infection control, there were six surveillances within the quarter with mostly respiratory and influenza with no complications. -Review of the 4th Quarter 2023 (October-December) Data Visit Notes Infection Report showed there were two UTIs, one influenza-like symptoms, and one cellulitis of the left leg with a total of four cases of infection. However, there was no documented evidence the 4th Quarter 2023 Infection Control Report was completed. In addition, review of the 4th Quarter 2023 QAPI Meeting Minutes Reports showed under the topic of infection control, there were five surveillances within the quarter. -Review of the 1st Quarter 2024 Infection Control Report showed there were two UTIs, one URI, and one lower respiratory tract infection with a total of four cases of infection. However, the Data Visit Notes Infection Report showed there were two UTIs and one flu-like symptoms with a total of three cases of infection. In addition, review of the 1st Quarter 2024 QAPI Meeting Minutes showed under the topic of infection control, there were three surveillance report within the quarter for two UTIs and one respiratory infection with a total of three cases of infection. b. Review of the 4th Quarter 2024 of Data Visit Note Infection Control showed nine UTIs and two influenza-like symptoms with a total of 11 cases of infection. However, there was no documented evidence the 4th Quarter 2024 Infection Control Report was completed and QAPI meeting was conducted. c. Review of the 1st Quarter 2025 Data Visit Note Infection Report showed two UTIs, two influenza-like symptoms, and two lower respiratory tract infections with a total of six cases of infection. However, there was no documented evidence the 1st Quarter 2025 Infection Control Report was completed. In addition, review of the 1st Quarter 2025 QAPI Meeting Minutes Report showed under the topic of infection control, there were six surveillances within the quarter which were mostly respiratory and influenza without complications. d. Review of the Infection Control documents for 2023, 2024, and 2025 failed to show documented evidence the infection control data were analyzed and investigated to determine the causes and prevent the prevalence of infection. In addition, the QAPI program failed to show documented evidence the effectiveness of the actions or recommendations implemented were evaluated and the need for revision of actions or recommendations to reach the outcome goal for the infection control were discussed. On 6/20/25 at 1323 hours, an interview and concurrent facility document review was conducted with the Administrator/LVN/ Volunteer Coordinator. The Administrator/LVN/ Volunteer Coordinator was informed and acknowledged the above findings.”

“Based on interview and record review, the hospice failed to implement the bereavement program for two of two sampled patients (Patients 11 and 13) as per the hospice’s P&P. This failure had the potential risk of not addressing the bereavement needs of the bereaved family members. Findings: The hospice’s P&P titled Bereavement Services (undated) showed the hospice will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for up to one (1) year following the death of the patient. After the bereavement risk assessment is completed, a plan shall be developed to address bereavement/grief issues and shall be implemented as needed. After a death has occurred the bereavement assessment will be updated and the family/caregiver needs will be discussed at the next interdisciplinary group meeting. Within (2) weeks after death of a patient, a sympathy card will be sent to the bereaved. 1.Review of the closed clinical record for Patient 11 was initiated on 6/18/25. The clinical record showed the SOC was 1/22/25. The patient was certified for hospice services during the certification periods from 1/22/25 to 4/21/25 and 4/22/25 to 6/20/25. The patient had expired on 5/18/25. Review of the clinical record showed the bereavement assessment was completed on 5/22/25, and bereavement plan of care was developed. Review of the Contact Info and Task showed the first call to the bereaved family member was made on 5/21/25; and the first letter was sent on 6/17/25. However, there was no documented evidence a sympathy card was sent to the bereaved family two weeks after death as per the hospice’s P&P. 2. Review of the closed clinical record for Patient 13 was initiated on 6/13/25. The clinical record showed the SOC was 12/23/24. The patient was certified for hospice services during the certification periods from 12/23/24 to 3/22/25 and 3/23/25 to 6/20/25. The patient had expired on 4/20/25. Review of the clinical record showed the bereavement assessment was completed on 4/25/25, and bereavement plan of care was developed. Review of the Contact Info and Task showed the first letter was sent on 5/20/25. However, there was no documented evidence a sympathy card was sent to the bereaved family 2 weeks after death as per the hospice’s P&P. On 6/20/25 at 1121 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/ LVN/ Volunteer Coordinator was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure HAs 1 and 2 were provided with at least the 12 hours of in-service training during each 12-month period. This failure had the potential of not updating with the current practices for these HAs. Findings: Review of the hospice’s P&P titled Hospice Aide Training 4/2021 showed the organization will provide performance reviews (at least annually) and in-service education (12 hours per year) to ensure competence of hospice aides. The performance review will address each of the area of the competency evaluation. The in-services will be provided by a qualified instructor and may occur while an aide is providing care to patients. Documentation will be made in the personnel files. Review of the personnel files was conducted on 6/18/25. HAs 1 and 2’s personnel files did not include documented evidence of the HA’s in-service education completed hours as per the hospice’s P&P. Review of the HA’s in-service binder was conducted on 6/18/25. The following was identified: - The binder showed the 2023 monthly sign-in sheet forms of in-service trainings provided to the HAs including HAs 1 and 2 conducted on 1/9, 1/23, 3/6, 4/24, 5/8, 5/22, 7/10, 7/31, 9/4, and 10/9/23, with the different topics such as the medical procedures, patient care, and administration’s agendas. The monthly in-service documentation showed the time for the in-service trainings were from 1400 to 1500 hours. However, the total number of hours of in-service trainings for HAs 1 and 2 were 10 hours instead of 12 hours as per the hospice’s P&P. - The binder showed the 2024 monthly sign-in sheet forms of in-service trainings provided to the HAs including HAs 1 and 2 conducted on 1/2, 1/15, 4/8, 5/ 6, 5/20, 6/17, 7/1, 8/12, 9/9, 9/23, and 11/29/24, with the different topics such as the medical procedures, patient care, and administration’s agendas. The monthly in-service documentation showed the time for the in-service trainings were from 1400- 1500 hours. However, the total number of hours of in-service trainings for HAs 1 and 2 were 11 hours instead of 12 hours as per the hospice’s P&P. On 6/18/25 at 1555 hours, a follow-up interview and concurrent document review was conducted with the Administrator/LVN/ Volunteer Coordinator. The Administrator/LVN/ Volunteer Coordinator was informed and acknowledged the above findings.”

“Based on interview and record review, the hospice failed to ensure the HA in-service training was supervised by a registered nurse in the classroom and the supervised practical training was performed by the RN. This failure had the potential for the HAs to be incorrectly trained. Findings: Review of the hospice’s P&P titled Hospice Aide Training revised 4/2021 showed the organization will provide performance reviews (at least annually) and in-service education (12 hours per year) to ensure competence of hospice aides. The performance review address each of the areas of the competency evaluation. The in-services will be provided by a qualified instructor and may occur while an aide is providing care to patients. Review of the HA’s in-service training binder was conducted on 6/18/25. The binder showed the monthly sign-in sheet forms for HA in-service trainings conducted on 1/20, 2/10, 2/24, 3/24, 4/7, 4/25, 5/5, and 6/2/25, with different topics such as patient care, infection practices, and administration’s agendas.* However, there was no documented evidence who had supervised and conducted the in-service education/training to the HAs. On 6/18/25 at 1515 hours, an interview and concurrent hospice document review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding.”

“Based on interview and record review, the hospice failed to ensure the HAs provided services in accordance with the POCs for two of 14 sampled patient (Patients 10 and 13). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 10’s closed clinical record was initiated on 6/13/25. The clinical record showed the SOC was on 11/11/24. The patient was certified for hospice services during the certification periods from 11/11/24 to 2/8/25 and 2/9/25 to 4/9/25. The patient had expired on 2/9/25. Review of the physician’s order dated 9/25/24, showed an order for “CHHA -Aid” services 2x weekly visits from 9/25/24 to 9/28/24 and from 9/29/24 to ongoing. * However, further review of the clinical record showed the HA conducted three visits a week instead of two visits per week as per the physician’s order on the following week:- From 11/11/24 to 11/16/24- From 11/17/24 to 11/23/24- From 12/1/24 to 12/7/24- From 12/8/24 to 12/14/24- From 12/22/24 to 12/28/24- From 12/29/24 to 1/4/25- From 1/5/25 to 1/11/25- From 1/19/25 to 1/25/25-From 1/26/25 to 2/1/25- From 2/2 to 2/8/25 On 6/20/25 at 1108 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. 2. Review of Patient 13’s closed clinical record was initiated on 6/13/25. The clinical record showed the SOC was 12/23/24. The patient was certified for hospice services during the periods from 12/23/24 to 3/22/25 and 3/23/25 to 6/20/25. The patient had expired on 4/20/25.Review of the physician’s order dated 12/23/24, showed an order for “CHHA-Aid” services 3x weekly from12/29/24 to ongoing. * However, for Week 3 (1/5/25 to 1/11/25), the HA visited the patient two times instead of three times per week as ordered by the physicianOn 6/20/25 at 1405 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/ Volunteer Coordinator was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the volunteers provided at a minimum, equals to 5% of the total patient care hours of all paid hospice employees and contracted staff. This failure had the potential of not providing the adequate volunteer services.Findings: Review of the hospice’s P&P titled Volunteer Services revised 11/2017 showed the Volunteer Coordinator will track the use of volunteers, the cost saving achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel. Review of the hospice’s volunteer programs for the years of 2023, 2024, and 2025 was conducted on 6/18/25. The following was identified:- The Utilization of Volunteer Service and Cost Saving Report for April 2025 showed 116 hours of total direct patient care hours. The documentation showed the volunteer hours provided was 0% of the total patient care hours of all paid hospice employees and contracted staff. On 6/18/25 at 1350 hours, an interview and concurrent hospice document review was conducted with the Administrator/ LVN/Volunteer Coordinator. The Administrator/ LVN/Volunteer Coordinator was informed and acknowledged the above finding.”

“Based on interview and record review, the hospice Administrator failed to be responsible for the day-to-day operations of the organization and maintain the administrative and supervisory responsibility for all care provided as evidenced by:-The written agreement for one of eight contractors (Contractor 1) failed to include the required elements related to bereavement follow-up.-The comprehensive assessment of pressure injury was not followed as per the hospice’s P&P.-The personnel performance evaluation, physical examination/health screening, and TB testing were not performed annually as per the state regulation.-The personnel orientation was not completed as per the hospice’s P&P.-The palliative care program P&P did not specify frequency of the IDG meetings. These failures had the potential to negatively impact the hospice’s operational performance. Findings: The hospices’ agency P&P titled Comprehensive Assessment undated showed the procedure for wound assessment. The wound assessment included drainage, odor and the surrounding skin for redness, inflammation or signs of breakdown. The documentation guidelines included the treatment and condition of the wound (each visit), appearance of the wound bed, wound measurements (at least weekly), inflammation or erythema of the skin around the wound, estimated amount of drainage, stage the wound weekly and compare the progress with the goals of therapy.1. Review of Patient 5’s clinical record was initiated on 6/11/25. The clinical record showed the SOC was 1/16/25. The patient was certified for hospice service during the certification periods from 1/16/25 to 4/15/25 and 4/16/25 to 7/14/25.Review of the RN 1 visit notes dated 4/23/25 showed the patient was assessed to have a Stage 2 pressure injury to the right buttocks. The assessment includes the following: color= red, width = 0.7 cm, length = 0.8 cm and depth = 0.2 cm.Further review of the LVN1 visit notes dated 5/14/25 showed the patient was assessed to have a Stage 2 pressure injury to the right buttocks. The assessment includes the following: color= red, width = 0.7 cm, length = 0.8 cm and depth = 0.2 cm.However, the assessment for the stage 2 pressure injury failed to include drainage, odor and the surrounding skin for redness as per P&P.In addition, review of the SN visit notes dated 4/30 and 5/7/25 failed to show documented evidenced of the SN had performed assessment for the patients Stage 2 pressure injury to the right buttocks as per P&P. On 6/20/25 at 0952 hours, an interview and an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings.2. Review of Patient 4’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was 10/20/23. The patient was certified for hospice service during the certification periods from 4/12/25 to 6/10/25 and 6/11/25 to 8/9/25. Review of the Plan of Care - Active cited for SN visit 1x weekly, 7PRN for symptom management. The POC also showed a care plan related to altered skin integrity related to impaired nutritional intake and immobility. The intervention included to assess skin every SN visit.Review of Visit Note - RN - Nursing Note dated 4/29/25 showed the RN 1 performed an assessment. The patient was assessed to have a Stage 2 pressure injury to the left buttock. Review of the Skin Assessment for the Stage 2 pressure injury to the left buttocks showed on the following:-Week 4 (4/27 to 5/3) showed an SN visit on 4/29/25 - new assessment: color= pink; width = 1.0 cm; length = 0.5 cm and depth = 0.1 cm.-Week 5 (5/4 to 5/10) showed an SN visit on 5/7/25 re -assessment: color= pink; width = 1.0 cm; length = 0.5 cm and depth = 0.1 cm.-Week 7 (5/18 to 5/24) showed an SN visit on 5/21/25 re -assessment: color= pink; width = 1.0 cm; length = 0.5 cm and depth = 0.1 cm.-Week 8 (5/25 to 5/31) showed an SN visit on 5/27/25 re -assessment: color= pink; width = 0.5 cm; length = 0.3 cm and depth = 0.1 cm and-Week 9 ( 6/1 to 6/7) showed an SN visit on 6/6/25 re -assessment: color= pink; width = 0.5 cm; length = 0.3 cm and depth = 0.1 cm.However, the assessment for the stage 2 pressure injury failed to include drainage, odor and the surrounding skin for redness as per P&P.In addition, review of the clinical record showed on Week 6 (5/11 to 5/17), the SN visit the patient on 5/13/25. However the SN failed to perform wound assessment as per P&P.On 6/20/25 at 0916 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings.3a. The hospice P&P titled Performance Evaluation revised 4/2021, showed the performance evaluations will be completed (and dated) on all personnel annually, based on personnel’s annual evaluation and the personnel orientation checklist will be completed for all new personnel. The new personnel will sign and date when the orientation has been completed.Review of the hospice’s personnel file was initiated on 5/19/25. The personnel file showed the following:-the MSW personnel file showed the hiring date was 5/28/24. However, the orientation checklist was not available on the file as per P&P.-the Volunteer 2 personnel file showed the hiring date was 12/31/23. The orientation checklist was provided. However, the Volunteer 2 failed to sign and date the orientation as per P&P.-the RN 1 personnel file showed the hiring date was 12/18/19. However, the performance evaluation for the year 2024 was not completed as per P&P.-the LVN 1 personnel file showed the hiring date was 5/15/18. However, the performance evaluation for the year 2024 was not completed as per P&P.-the Bereavement Program Director personnel file showed the hiring date was 7/18/22. However, the performance evaluation for the year 2024 was not completed as per P&P.-the DPCS personnel file showed the hiring date was 10/15. However, the performance evaluation for the year 2024 was not completed as per P&P.b. According to Standards of Quality Hospice Care 2005 Section 6.3 (a) (1) (2): All persons providing physician, nursing or home health aide services shall have a health examination by a physician, nurse practitioner or physician’s assistant six months prior to employment or within 14 days of the date of employment. Each examination shall include confirmation by the person performing the examination that the employee is physically and medically qualified to perform the duties to be assigned, and that employee has no health condition that would create a hazard to patients. The initial health examination shall include a tuberculosis screening screening. Tuberculosis screening shall occur annually thereafter.The hospices’ P&P titled Selection/Hiring of Personnel undated showed a current physical and TB test/chest X-ray must be received prior to the first day of employment.-the Volunteer 1 personnel file showed the hiring date was 10/22/24. However, there was no documented evidenced of the TB test was provided prior to the date of hire.-the DPCS personnel file showed the hiring date was 10/1/15. However, there was no documented evidenced of the annual TB test and physical examination was provided for the year 2024. -the Administrator/LVN/Volunteer Coordinator personnel file showed the hiring date was 8/1/15. However, there was no documented evidenced of the annual TB test was provided for the year 2024. -the the LVN 2 personnel file showed the hiring date was 4/20/18. However, there was no documented evidenced of the physical examination for the year 2024 was provided. On 9/19/25 at 1532 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings.4. Review of the Palliative Plan of Care revised January 2022, showed the plan of care will be reviewed and updated on a regular basis in accordance with the palliative care program policies. This plan will focus on identified problems, goals, interventions and identification of measurable outcomes. The procedure includes the plan of care will be reviewed , evaluated and revised as frequently as deemed necessary, by the members of the interdisciplinary team, with input from the attending physician, the patient, and the family/caregiver. Revisions date will be noted on the plan of care.Review of the hospices’ P&P titled Interdisciplinary Care revised January 2022, showed the interdisciplinary team conducts regular patient care conferences with its members and other program staff members as needed to discuss patient - centered goals of care, disease prognosis, and advance care planning with input from the patient and family. The interdisciplinary group (in collaboration with the attending physician, if any) will conduct assessments, develop and update the plan of care, and reviews the effectiveness of care routinely in accordance with the Palliative Care Program policies and procedures.Review of Patient 9’s clinical record was initiated on 6/17/25. The clinical record showed the SOC was 7/15/24 for palliative services. Review of the Visit Note - Comprehensive Nursing Assessment dated 7/15/24, showed the DPCS performed the initial comprehensive assessment. The comprehensive assessment includes goals and intervention for the identified body system alterations. The Plan of Care Items - Active showed the care plan goals and intervention opened on the following dates:-on 7/15/24 includes the alteration in comfort related to arthritic pain; circulatory status related to disease process, elimination related to constipation; psychosocial adjustments/coping,-on 7/19/24 spiritual services and -on 10/31/24-respiratory status related to symptoms of upper respiratory infection.However, review of the clinical record failed to show documented evidenced of the IDG meeting was conducted to review the effectiveness care plan goals and intervention as per P&P.In addition, review of the hospices’ P&P showed the timeline for the IDG will be conducted regularly. However, there was no specific timeline written on the P&P as to what a “regular” frequency means.On 9/19/25 at 1348 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was asked if they performed IDG for the comprehensive assessments and revisions of the plan of care for the patient. The Administrator/LVN/Volunteer Coordinator replied, we don’t have IDGs for the palliative patient. The Administrator/LVN/Volunteer Coordinator was also asked about the process if there was a change in patient condition. The Administrator/LVN/Volunteer Coordinator replied, the nurse will call and will notify the physician. The Administrator/LVN/Volunteer Coordinator was further asked about the P&P related to “regular “ IDG timeline. The Administrator/LVN/Volunteer Coordinator replied, assuming it’s monthly because the patient was being seen monthly. The Administrator/LVN/Volunteer Coordinator was also asked if the timeline for IDG meeting was specific. The Administrator/LVN/Volunteer Coordinator replied, it should be specific but not written on the P&P. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. Review of the hospice’s P&P titled Executive Director/Administrator revised 4/2021 showed the Executive Director/Administrator is responsible for the overall direction of the hospice services. He/she is responsible for the employment of qualified personnel; is responsible for the provision of hospice services, directly, and the delegation to and coordination of hospice personnel evaluations; is responsible for establishing the standards of care to comply with federal and state regulations and guidelines. The Executive Director/Administrator establishes, implements, and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy. According to Standards of Quality Hospice Care, 2005 Section (B) Contractual Services, when program services are not provided directly by employees there shall be a written agreement defining the nature and scope of services provided. The agreement shall address, but not be limited to: roles and responsibilities of the program and the contracted individual or organization in the following: patient/family admission process, interdisciplinary team conferences, discharge planning, bereavement follow-up, and term of the agreement and the conditions for its renewal or termination. 1. Review of the written agreement between the hospice and Contractor 1 as the Medical Director was initiated on 6/19/25. The written agreement was effective 10/1/23. However, the written agreement with Contractor 1 did not show documented evidence of statement to include the roles and responsibilities of the contractor regarding the bereavement follow-up.On 6/18/25 at 1522 hours, an interview and concurrent hospice document review was conducted with the Administrator/ LVN/Volunteer Coordinator. The Administrator/ LVN/Volunteer Coordinator was informed and acknowledged the above finding.”

“Based on interview and record review, the hospice failed to complete skills competency assessment annually as per the hospice’s P&P. This failure had the potential risk for substandard healthcare outcomes to the patients receiving hospice services. Findings: The hospice’s P&P titled Scope of the Program/Process Methodology revised 4/2021 showed the hospice establishes and annually re-evaluates its job specific “competency based checklist” which reflects the duties commonly required in the performance of clinical positions. The hospice will establish and annually evaluates a group of specific skills related to patient care responsibilities and complexity of care provided by staff. Review of 11 personnel files was conducted on 6/19/25. HA 2’s personnel file showed the hiring date was 3/15/17; however, the skills competency evaluation for the year of 2024 was not completed as per the hospice’s P&P. On 6/19/25 at 1532 hours, an interview and concurrent personnel file review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed ensure the clinical records were complete and accurate for eight of 14 sampled patients (Patients 1, 4, 5, 6, 8, 10, 11, and 14). This failure had the potential risk of substandard care provided to the patients as their clinical information were not accurate and complete. Findings: #. Review of Patient 6’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was on 12/14/24. The patient was certified for hospice services during the certification periods from 3/14/25 to 6/11/25 and 6/12/25 to 8/10/25.a. Review of the IDG Meeting Note/POC dated 5/19/25, showed under the skin assessment impairment number 1 as blister to thigh and impairment number 2 as traumatic wound to thigh. However, under the care plan problem number 5 as skin tear to posterior thigh. *The wound type and location were inconsistent.On 6/20/25 at 1041 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. b. Review of the Visit Note- RN Nursing Notes dated 4/3, 4/17, 5/1, and 5/15/25, showed under Supervisory Visit question coded as “no.” However, the nurse’s narrative documentation showed “SN visited patient today for CHHA, LVN supervisory visit, and routine care follow up.” *The documentation for supervisory visit question and narrative notes about supervisory visit were inconsistent.On 6/20/25 at 1119 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. The DPCS stated the nurse probably click the answer as a “no” incorrectly in the supervisory visit question, and the following questions were automatically coded “n/a” after clicking “no” as an answer. #. Review of Patient 10’s closed clinical record was initiated on 6/13/25. The clinical record showed the SOC was on 11/11/24. The patient was certified for hospice services during the certification period from 11/11/24 to 2/8/25 and 2/9/25 to 4/9/25. The patient expired on 2/9/25.Review of the Skin Assessment dated 11/25, 12/11, and 12/23/24, 1/1, 1/13, and 1/27/25, showed arterial wound to heel/medial and three different sites of toes. The documentation showed unstageable stage with slough and/or eschar.On 6/20/25 at 1124 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS stated arterial wounds are not supposed to be stage like pressure injuries. The DPCS further stated the nurse probably used the wrong verbiage. The DPCS stated the documentation was inaccurate. The DPCS was informed and acknowledged the above finding. #. Review of Patient 14’s closed clinical record was initiated on 6/17/25. The clinical record showed the SOC was on 12/11/24. The patient was certified for hospice services during the certification period from 12/11/24 to 3/10/25 and 3/11/25 to 6/8/25. The patient was discharged and revoked hospice services on 4/2/25.Review of Visit Note- RN Nursing Note dated 3/19/25, showed under the narrative notes, “Patient reports she was started on oral antibiotic.”*However, further review clinical records, did not show documented evidence the patient was taking any oral antibiotics.On 6/20/25 at 1200 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS stated it was probably a documentation error. The DPCS was informed and acknowledged the above finding. The hospice’s P&P titled Contents of Clinical Record revised 4/2021 showed a clinical record will be maintained for each patient receiving care. The clinical record will accurately document the care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel.1.Review of Patient 8’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was 2/21/25. The patient was certified for hospice service during the certification periods from 2/21/25 to 5/2/25 and 5/3/25 to 7/31/25.Review of the IDG Meeting Note/POC dated 3/10/25, on the section of scope and frequency of services includes SW - Social Services cited 0 x monthly and 1 PRN for psychosocial support.Further review of the IDG Meeting Note/POC dated 3/10/25 on the section of narrative notes, showed the MSW will visit the patient monthly and 1 PRN for psychosocial support. However, the MSW visit frequency was inconsistent. On 6/20/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the finding. 2. Review of Patient 5’s clinical record was initiated on 6/11/25. The clinical record showed the SOC was 1/16/25. The patient was certified for hospice service during the certification periods from 1/16/25 to 4/15/25 and 4/16/25 to 7/14/25.a. Review of the Volunteer Documentation - Direct Patient Care dated 1/25/25 showed the Volunteer 1 visited the patient. However, the Volunteer 1 electronically signed the visit note on 1/22/25 which was inconsistent with the visit date. b. Review of the Visit Note - Comprehensive Nursing Assessment dated 1/16/25, showed the RN 2 had performed body system assessment. The patient skin was assessed as intact. Further review of the SN visit notes dated 1/22, 1/0, 2/5, 2/12, 2/19, 2/26, 3/5, 3/12, 3/19, 3/26 and 4/2/25, showed the patients skin assessment was documented as intact.However, review of the IDG Meeting Notes dated 1/27, 2/10, 2/24 and 3/10/25 on the section of Skin Assessment showed the patient was documented to have a Stage 2 pressure injury to the buttocks which was inconsistent. On 6/20/25 at 0952 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was asked if the patient had a stage 2 pressure injury to the buttocks. The Administrator/LVN/Volunteer Coordinator reviewed the clinical records and replied, the patient does not have a pressure injury upon admission. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. c. Review of the RN 1 visit note dated 4/23/25 showed the patient was assessed to have a Stage 2 pressure injury to the buttocks.Review of the LVN 1 visit notes dated 4/30/24 showed the LVN 1 performed a skin integrity assessment. However, the LVN 1 documented the patients skin integrity was intact which was inaccurate.Further review of the LVN 1 visit note dated 5/14/25 on the section of the Skin Assessment showed the LVN 1 documented the patients Stage 2 pressure injury to the buttocks. The Stage 2 pressure injury was assessed for color= red, width=0.7 cm; length= 0.8 cm and depth= 0.2 cm. However, on the section of skin integrity, the LVN 1 documented the patients skin as intact which was inconsistent. On 6/20/25 at 1022 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 3. Review of Patient 4’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was 10/20/23. The patient was certified for hospice service during the certification periods from 4/12/25 to 6/10/25 and 6/11/25 to 8/9/25. Review of the Skin assessment dated 5/7, 5/21 and 6/6, showed the patient was assessed to have a Stage 2 pressure injury to the left buttocks.However, on the section of skin integrity, the SN documented the patient skin is intact which was inconsistent. On 6/20/25 at 0916 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 4. Review of Patient 11’s closed clinical record was initiated on 6/18/25. The clinical record showed the SOC was 1/22/25. The patient was certified for hospice service during the certification periods from 1/22/25 to 4/21/25 and 4/22/25 to 6/20/25. The patient expired on 5/18/25.Review of the SN note dated 3/11, 3/17 and 3/20//25, showed the patient was assessed to have an abrasion to the right back. The assessment showed color = red; width= 1.0 cm; Length= 1.5 cm.However, review of the SN notes dated 3/12, 3/17 and 3/26/25 showed the SN documented the patients skin integrity as intact which was inaccurate.Further review of the SN visit notes dated 3/26/25 showed the SN re-assessed the patients abrasion to the right back. The assessment showed color = pink; width= 1.0 cm; Length= 1.5. However, the SN documented: site clear, intact and no impairment noted which was inconsistent.On 6/20/25 at 1121 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 5. Review of Patient 1’s clinical record was initiated on 6/10/25. The clinical record showed the SOC was 10/8/23. The patient was certified for hospice services during the certification periods from 3/31/25 to 5/29/25 and 5/30/25 to 7/28/25.Review of the SN visit notes dated 4/2/25, showed the SN had performed an Skin Assessment. The documentation showed the patient was assessed to have a traumatic wound to the toe with a measurement of Width - 2.5 cm, Length = 3 cm, Depth= 0.1. However, review of the SN visit note dated 4/2/25 failed to show documented evidenced of the laterality of the patients traumatic wound to the toe.On 6/20/25 at 1151 hours, an interview and an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Coordinator was asked if the physician was notified of the patients traumatic wound to the toe. The Administrator/LVN/Volunteer Coordinator replied, no, there was no mention of the physician notification on the note. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. The hospice’s P&P titled Contents of Clinical Record revised 4/2021, showed a clinical record will be maintained for each patient receiving care. The clinical record will accurately document the care provided and results in detail; and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. 1. Review of Patient 8’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was 2/21/25. The patient was certified for hospice service during the certification periods from 2/21/25 to 5/2/25 and 5/3/25 to 7/31/25. Review of the IDG Meeting Note/POC dated 3/10/25, on the section of scope and frequency of services, cited Social Services no monthly visit, 1 PRN for psychosocial support. However, on the narrative section showed MSW will visit the patient monthly and 1 PRN for psychosocial support. On 6/20/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the finding. 2. Review of Patient 5’s clinical record was initiated on 6/11/25. The clinical record showed the SOC was 1/16/25. The patient was certified for hospice service during the certification periods from 1/16/25 to 4/15/25 and 4/16/25 to 7/14/25. a. Review of the Volunteer Documentation - Direct Patient Care dated 1/25/25, showed Volunteer 1 visited Patient 5. However, Volunteer 1 electronically signed the visit note on 1/22/25 which was inconsistent with the visit date. b. Review of the Visit Note - Comprehensive Nursing Assessment dated 1/16/25, showed the RN 2 had performed body system assessment. The patient skin was assessed as intact. Further review of the SN visit notes dated 1/22, 1/0, 2/5, 2/12, 2/19, 2/26, 3/5, 3/12, 3/19, 3/26 and 4/2/25, showed the patients skin assessment was documented as intact.However, review of the IDG Meeting Notes dated 1/27, 2/10, 2/24 and 3/10/25 on the section of Skin Assessment showed the patient was documented to have a Stage 2 pressure injury to the buttocks which was inconsistent. On 6/20/25 at 0952 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was asked if the patient had a stage 2 pressure injury to the buttocks. The Administrator/LVN/Volunteer Coordinator reviewed the clinical records and replied, the patient does not have a pressure injury upon admission. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. c. Review of the RN 1 visit note dated 4/23/25 showed the patient was assessed to have a Stage 2 pressure injury to the buttocks.Review of the LVN 1 visit notes dated 4/30/24 showed the LVN 1 performed a skin integrity assessment. However, the LVN 1 documented the patients skin integrity was intact which was inaccurate.Further review of the LVN 1 visit note dated 5/14/25 on the section of the Skin Assessment showed the LVN 1 documented the patients Stage 2 pressure injury to the buttocks. The Stage 2 pressure injury was assessed for color= red, width=0.7 cm; length= 0.8 cm and depth= 0.2 cm. However, on the section of skin integrity, the LVN 1 documented the patients skin as intact which was inconsistent. On 6/20/25 at 1022 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 3. Review of Patient 4’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was 10/20/23. The patient was certified for hospice service during the certification periods from 4/12/25 to 6/10/25 and 6/11/25 to 8/9/25. Review of the Skin assessment dated 5/7, 5/21 and 6/6, showed the patient was assessed to have a Stage 2 pressure injury to the left buttocks.However, on the section of skin integrity, the SN documented the patient skin is intact which was inconsistent. On 6/20/25 at 0916 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 4. Review of Patient 11’s closed clinical record was initiated on 6/18/25. The clinical record showed the SOC was 1/22/25. The patient was certified for hospice service during the certification periods from 1/22/25 to 4/21/25 and 4/22/25 to 6/20/25. The patient expired on 5/18/25.Review of the SN note dated 3/11, 3/17 and 3/20//25, showed the patient was assessed to have an abrasion to the right back. The assessment showed color = red; width= 1.0 cm; Length= 1.5 cm.However, review of the SN notes dated 3/12, 3/17 and 3/26/25 showed the SN documented the patients skin integrity as intact which was inaccurate.Further review of the SN visit notes dated 3/26/25 showed the SN re-assessed the patients abrasion to the right back. The assessment showed color = pink; width= 1.0 cm; Length= 1.5. However, the SN documented: site clear, intact and no impairment noted which was inconsistent.On 6/20/25 at 1121 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 5. Review of Patient 1’s clinical record was initiated on 6/10/25. The clinical record showed the SOC was 10/8/23. The patient was certified for hospice services during the certification periods from 3/31/25 to 5/29/25 and 5/30/25 to 7/28/25.Review of the SN visit notes dated 4/2/25, showed the SN had performed an Skin Assessment. The documentation showed the patient was assessed to have a traumatic wound to the toe with a measurement of Width - 2.5 cm, Length = 3 cm, Depth= 0.1. However, review of the SN visit note dated 4/2/25 failed to show documented evidenced of the laterality of the patients traumatic wound to the toe.On 6/20/25 at 1151 hours, an interview and an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Coordinator was asked if the physician was notified of the patients traumatic wound to the toe. The Administrator/LVN/Volunteer Coordinator replied, no, there was no mention of the physician notification on the note. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 6. Review of Patient 6’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was on 12/14/24. The patient was certified for hospice services during the certification periods from 3/14/25 to 6/11/25 and 6/12/25 to 8/10/25.a. Review of the IDG Meeting Note/POC dated 5/19/25, showed under the skin assessment impairment number 1 as blister to thigh and impairment number 2 as traumatic wound to thigh. However, under the care plan problem number 5 as skin tear to posterior thigh. *The wound type and location were inconsistent.On 6/20/25 at 1041 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. b. Review of the Visit Note- RN Nursing Notes dated 4/3, 4/17, 5/1, and 5/15/25, showed under Supervisory Visit question coded as “no.” However, the nurse’s narrative documentation showed “SN visited patient today for CHHA, LVN supervisory visit, and routine care follow up.” *The documentation for supervisory visit question and narrative notes about supervisory visit were inconsistent.On 6/20/25 at 1119 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. The DPCS stated the nurse probably click the answer as a “no” incorrectly in the supervisory visit question, and the following questions were automatically coded “n/a” after clicking “no” as an answer. 7. Review of Patient 10’s closed clinical record was initiated on 6/13/25. The clinical record showed the SOC was on 11/11/24. The patient was certified for hospice services during the certification period from 11/11/24 to 2/8/25 and 2/9/25 to 4/9/25. The patient expired on 2/9/25.Review of the Skin Assessment dated 11/25, 12/11, and 12/23/24, 1/1, 1/13, and 1/27/25, showed arterial wound to heel/medial and three different sites of toes. The documentation showed unstageable stage with slough and/or eschar.On 6/20/25 at 1124 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS stated arterial wounds are not supposed to be stage like pressure injuries. The DPCS further stated the nurse probably used the wrong verbiage. The DPCS stated the documentation was inaccurate. The DPCS was informed and acknowledged the above finding. 8. Review of Patient 14’s closed clinical record was initiated on 6/17/25. The clinical record showed the SOC was on 12/11/24. The patient was certified for hospice services during the certification period from 12/11/24 to 3/10/25 and 3/11/25 to 6/8/25. The patient was discharged and revoked hospice services on 4/2/25.Review of Visit Note- RN Nursing Note dated 3/19/25, showed under the narrative notes, “Patient reports she was started on oral antibiotic.”*However, further review clinical records, did not show documented evidence the patient was taking any oral antibiotics.On 6/20/25 at 1200 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS stated it was probably a documentation error. The DPCS was informed and acknowledged the above finding.”

“Based on interview and record review, the hospice failed to ensure the clinical records were authenticated and dated timely in accordance with the hospice’s P&P for 10 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 10, and 13). This failure had the potential risk of substandard care provided to these patients as their clinical information were not completed timely.Findings: #. Review of the hospice’s P&P titled Interdisciplinary Group Meeting revised 4/2021 showed members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor.Review of Patient 7’s clinical record was initiated on 6/13/25. The clinical record showed the SOC was on 12/28/23. The patient was certified for hospice services during the certification periods from 4/21/25 to 6/19/25.a. Review of the IDG Meeting Note/POC dated 6/2/25, showed an IDG meeting was conducted and documentation showed POC was discussed. *However, there was no documented evidence of signatures of the IDG meeting attendees.On 6/20/25 at 0855 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. The DPCS stated the IDG committees should sign the documents during or after the IDG meeting.b. Review of the CHHA visit notes showed the following:- On 4/17/25 showed a CHHA visit. However, HA 1’s documentation was electronically signed on 4/30/25.- On 4/22/25 showed a CHHA visit. However, HA 1’s documentation was electronically signed on 4/30/25.- On 4/24/25 showed a CHHA visit. However, HA 1’s documentation was electronically signed on 4/30/25.- On 5/8/25 showed a CHHA visit. However, HA 1’s documentation was electronically signed on 5/12/25.- On 6/3/25 showed a CHHA visit. However, HA 1’s documentation was electronically signed on 6/7/25.*However, HA 1 electronically signed the visit notes documentation more than 72 hours instead of within 72 hours from the visit date as per the hospice’s P&P. On 6/20/25 at 0917 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. The DPCS stated documentation should be signed and completed within 72 hours. #. Review of Patient 2’s clinical record was initiated on was initiated on 6/11/25. The clinical record showed the SOC was on 9/17/24. The patient was certified for hospice services during the certification periods from 3/16/25 to 5/14/25 and 5/15/25 to 7/13/25.Review of the Visit Note- Psychosocial Assessment dated 9/25/24, showed the Medical Social Worker conducted a visit. *However, the Medical Social Worker electronically signed her documentation on 9/30/25, which was more than 72 hours instead of within 72 hours of the visit date as per the hospice’s P&P.On 6/20/25 at 0954 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. #. Review of Patient 3’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was on 3/21/25. The patient was certified for hospice services during the certification periods from 3/21/25 to 6/18/25.Review of the CHHA visit notes showed the following:- On 4/16/25 showed a CHHA visit. However, HA 2’s documentation was electronically signed on 4/30/25.- On 4/18/25 showed a CHHA visit. However, HA 2’s documentation was electronically signed on 4/30/25.- On 4/21/25 showed a CHHA visit. However, HA 2’s documentation was electronically signed on 4/30/25.- On 4/23/25 showed a CHHA visit. However, HA 2’s documentation was electronically signed on 4/30/25.- On 4/25/25 showed a CHHA visit. However, HA 2’s documentation was electronically signed on 4/30/25.- On 5/3/25 showed a CHHA visit. However, HA 2’s documentation was electronically signed on 5/8/25.*However, HA 2 electronically signed the visit notes documentation more than 72 hours instead of within 72 hours from the visit date as per the hospice’s P&P. On 6/20/25 at 1022 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. #. Review of Patient 6’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was on 12/14/24. The patient was certified for hospice services during the certification periods from 3/14/25 to 6/11/25 and 6/12/25 to 8/10/25.a. Review of the Visit Note- Comprehensive Nursing Assessment dated 12/14/24, showed RN 2 conducted a visit. *However, RN 2 electronically signed her documentation on 12/24/24, which was more than 72 hours instead of within 72 hours of the visit date as per the hospice’s P&P.On 6/20/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. b. Review of the CHHA visit notes showed the following:- On 3/18/25 showed a CHHA visit. However, HA 2’s documentation was electronically signed on 3/25/25.- On 4/1/25 showed a CHHA visit. However, HA 2’s documentation was electronically signed on 4/14/25.- On 4/21/25 showed a CHHA visit. However, HA 2’s documentation was electronically signed on 4/30/25.- On 4/8/25 showed a CHHA visit. However, HA 2’s documentation was electronically signed on 4/15/25.- On 4/19/25 showed a CHHA visit. However, HA 2’s documentation was electronically signed on 4/30/25.- On 4/22/25 showed a CHHA visit. However, HA 2’s documentation was electronically signed on 4/30/25.- On 4/26/25 showed a CHHA visit. However, HA 2’s documentation was electronically signed on 4/30/25.- On 5/3/25 showed a CHHA visit. However, HA 2’s documentation was electronically signed on 5/8/25.- On 5/10/25 showed a CHHA visit. However, HA 2’s documentation was electronically signed on 5/14/25.- On 5/17/25 showed a CHHA visit. However, HA 2’s documentation was electronically signed on 5/21/25.- On 5/22/25 showed a CHHA visit. However, HA 2’s documentation was electronically signed on 5/28/25.*However, HA 2 electronically signed the visit notes documentation more than 72 hours instead of within 72 hours from the visit date as per the hospice’s P&P. On 6/20/25 at 1023 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. #. Review of Patient 10’s closed clinical record was initiated on 6/13/25. The clinical record showed the SOC was on 11/11/24. The patient was certified for hospice services during the certification period from 11/11/24 to 2/8/25 and 2/9/25 to 4/9/25. The patient expired on 2/9/25.Review of the Visit Note- RN Nursing Note dated 11/25/24, showed RN 1 conducted a visit. *However, RN 1 electronically signed her documentation on 12/2/24, which was more than 72 hours instead of within 72 hours of the visit date as per the hospice’s P&P.On 6/20/25 at 1119 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. Review of the hospice’s P&P titled Contents of the Clinical Record revised 04/2021 showed documentation will include signed and dated clinical notes (all clinical notes must be submitted within 72 hours from the visits).1.Review of Patient 1’s clinical record was initiated on 6/10/25. The clinical record showed the SOC was 10/8/23. The patient was certified for hospice service during the certification periods from 3/31/25 to 5/22/25 and 5/30/25 to 7/28/25.Review of the HA 1’s visit notes showed the following:-on 4/8/25 showed an HA 1 visit. However, the HA 1 electronically signed on 4/14/25,-on 4/12/25 showed an HA 1 visit. However, the HA 1 electronically signed on 4/16/25,-on 4/12/25 showed an HA 1 visit. However, the HA 1 electronically signed on 4/30/25,-on 4/24/25 showed an HA 1visit. However, the HA 1 electronically signed on 4/30/25 and-on 5/8/25 showed an HA 1 visit. However, the HA 1 electronically signed on 5/23/25. However, the HA 1 electronically signed the visit notes more than 72 hours from the visit date as per P&P. On 6/20/25 at 1151 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was asked as to the timeline of the completion and submission of the SN visit notes. The Administrator/LVN/Volunteer Coordinator replied. should be within 72 hours from the visit date. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 2. Review of Patient 8’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was 2/21/25. The patient was certified for hospice service during the certification periods from 2/21/25 to 5/2/25 and 5/3/25 to 7/31/25.Review of the Certification of Terminal Illness for the certification periods from 2/2/25 to 5/2/25 showed a Verbal Order from the hospice physician was received and electronically signed by the RN on 2/21/25.However, the Medical Director electronically signed the CTI verbal order on 5/20/25 which was more than 72 hours from the verbal orders. Review of the HA 2’s visit notes showed the HA 2 visited the patient on the 4/19, 4/22 and 4/26/25. However, the HA 2 electronically signed the visit notes more than 72 hours from the visit date as per P&P. On 6/20/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 3. Review of Patient 5’s clinical record was initiated on 6/11/25. The clinical record showed the SOC was 1/16/25. The patient was certified for hospice service during the certification periods from 1/16/25 to 4/15/25 and 4/16/25 to 7/14/25.a. Review of the HA 2’s visit notes for the certification periods from 1/16/25 to 4/15/25 showed the following:-on 1/18, 1/25 and 1/28/25 showed an HA 2 visit. However, the HA 2 electronically signed on 1/31/25,-on 2/1, 2/4 and 2/8/25 showed an HA 2 visit. However, the HA 2 electronically signed on 2/13/25,-on 2/15/25 showed an HA 2 visit. However, the HA 2 electronically signed on 2/20/25,-on 3/1/25 showed an HA 2 visit. However, the HA 2 electronically signed on 3/17/25,-on 3/4/25 showed an HA 2 visit. However, the HA 2 electronically signed on 3/12/25,-on 3/18/25 showed an HA 2 visit. However, the HA 2 electronically signed on 3/25/25,-on 3/25/25 showed an HA 2 visit. However, the HA 2 electronically signed on 3/28/25,-on 4/1/ and 4/5/25 showed an HA 2 visit. However, the HA 2 electronically signed on 4/14/25 and-on 4/5/25 showed an HA 2 visit. However, the HA 2 electronically signed on 3/12/25.In addition, review of the HA 2’s visit notes for the certification periods from 4/16/25 to 7/14/25 showed the following:-on 4/19, 1/25 and 4/22/25 showed an HA 2 visit. However, the HA 2 electronically signed on 4/30/25,-on 4/26/25 showed an HA 2 visit. However, the HA 2 electronically signed on 5/1/25,-on 5/1/25 showed an HA 2 visit. However, the HA 2 electronically signed on 5/8/25,-on 5/7 and 5/10/25 showed an HA 2 visit. However, the HA 2 electronically signed on 5/29/25,-on 5/15/25 showed an HA 2 visit. However, the HA 2 electronically signed on 5/19/25,-on 5/17, 5/22, 5/24/25 showed an HA 2 visit. However, the HA 2 electronically signed on 5/28/25,However, The HA 2 electronically signed the visit notes more than 72 hours from the visit date as per P&P. b. Review of the Volunteer Documentation - Direct Patient Care dated 3/13/25 showed the Volunteer 1 visited the patient. However, the Volunteer 1 electronically signed the visit note on 3/19/25 which was more than 72 hours from the visit date as per P&P.On 6/20/25 at 0952 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the finding.On 6/20/25 at 0952 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings.4. Review of Patient 4’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was 10/20/23. The patient was certified for hospice service during the periods from 4/12/25 to 6/10/25 and 6/11/25 to 8/9/25. Review of the HA 2’s note showed an HA visit on 4/21/25. However, the HA 2 electronically signed on 4/30/25 more than 72 hours from the visit as per P&P. On 6/20/25 at 0916 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings.5. Review of Patient 13’s clinical record was initiated on 6/13/25. The clinical record showed the SOC was 12/23/24. The patient was certified for hospice service during the periods from 12/23/24 to 3/22/25 and 3/23/25 to 6/20/25. The patient expired on 4/20/25.Review of the HA 1’s note showed an HA visit on 4/8, 4/10 and 4/12/25. However, the HA 1 electronically signed on 4/16/25 more than 72 hours from the visit as per P&P. Further review of the HA 1’s visit note dated 4/19/25, showed the HA electronically signed the note on 4/30/25 more than 72 hours from the visit as per P&P.On 6/20/25 at 1405 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/ Volunteer Coordinator was informed and acknowledged the findings. Review of the hospice’s P&P titled Contents of the Clinical Record revised 04/2021 showed documentation will include signed and dated clinical notes (all clinical notes must be submitted within 72 hours from the visits).1. Review of Patient 1’s clinical record was initiated on 6/10/25. The clinical record showed the SOC was 10/8/23. The patient was certified for hospice service during the certification periods from 3/31/25 to 5/22/25 and 5/30/25 to 7/28/25.Review of HA 1’s visit notes showed the following: -on 4/8/25, HA 1 had conducted the visit. However, HA 1 electronically signed the visit note on 4/14/25.-on 4/12/25, HA 1 had conducted a visit. However, HA 1 electronically signed the visit note on 4/16/25.-on 4/12/25, HA 1 had conducted a visit. However, HA 1 electronically signed the visit note on 4/30/25.-on 4/24/2, HA 1 had conducted a visit. However, HA 1 electronically signed the visit note on 4/30/25. -on 5/8/25, HA 1 had conducted a visit. However, HA 1 electronically signed the visit note on 5/23/25. On 6/20/25 at 1151 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was asked as to the timeline of the completion and submission of the SN visit notes. The Administrator/LVN/Volunteer Coordinator replied it should be within 72 hours from the visit date. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 2. Review of Patient 8’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was 2/21/25. The patient was certified for hospice service during the certification periods from 2/21/25 to 5/2/25 and 5/3/25 to 7/31/25.Review of the Certification of Terminal Illness for the certification period from 2/2/25 to 5/2/25, showed a verbal order from the hospice physician was received and electronically signed by the RN on 2/21/25.However, the Medical Director electronically signed the CTI verbal order on 5/20/25, which was more than 72 hours from the verbal orders. Review of HA 2’s visit notes showed HA 2 visited the patient on 4/19, 4/22 and 4/26/25. However, HA 2 did not electronically signed the visit notes within 72 hours from the visit date as per the hospice’s P&P. On 6/20/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 3. Review of Patient 5’s clinical record was initiated on 6/11/25. The clinical record showed the SOC was 1/16/25. The patient was certified for hospice service during the certification periods from 1/16/25 to 4/15/25 and 4/16/25 to 7/14/25.a. Review of HA 2’s visit notes for the certification period from 1/16/25 to 4/15/25, showed the following:-on 1/18, 1/25, and 1/28/25, HA 2 had conducted the visits. However, HA 2 electronically signed the visit notes on 1/31/25.-on 2/1, 2/4 and 2/8/25, HA 2 had conducted the visits. However, HA 2 electronically signed the visit notes on 2/13/25.-on 2/15/25, HA 2 had conducted a visit. However, HA 2 electronically signed the visit note on 2/20/25.-on 3/1/25, HA 2 had conducted a visit. However, HA 2 electronically signed the visit note on 3/17/25.-on 3/4/25, HA 2 had conducted a visit. However, HA 2 electronically signed the visit note on 3/12/25.-on 3/18/25, HA 2 had conducted a visit. However, HA 2 electronically signed the visit note on 3/25/25.-on 3/25/25, HA 2 had conducted a visit. However, HA 2 electronically signed the visit note on 3/28/25,-on 4/1 and 4/5/25, HA 2 had conducted a visit. However, HA 2 electronically signed the visit note on 4/14/25.-on 4/5/25, HA 2 had conducted a visit. However, HA 2 electronically signed the visit note on 3/12/25.In addition, review of HA 2’s visit notes for the certification periods from 4/16/25 to 7/14/25, showed the following:-on 4/19, 1/25, and 4/22/25, HA 2 had conducted the visits. However, HA 2 electronically signed the visit notes on 4/30/25.-on 4/26/25, HA 2 had conducted a visit. However, HA 2 electronically signed the visit note on 5/1/25.-on 5/1/25, HA 2 had conducted a visit. However, HA 2 electronically signed the visit note on 5/8/25.-on 5/7 and 5/10/25, HA 2 had conducted the visits. However, HA 2 electronically signed the visit notes on 5/29/25.-on 5/15/25, HA 2 had conducted a visit. However, HA 2 electronically signed the visit note on 5/19/25.-on 5/17, 5/22, and 5/24/25, HA 2 had conducted the visits. However, HA 2 electronically signed the visit notes on 5/28/25.b. Review of the Volunteer Documentation - Direct Patient Care dated 3/13/25, showed Volunteer 1 had visited the patient. However, the Volunteer 1 electronically signed the visit note on 3/19/25, which was not withing 72 hours from the visit date as per the hospice’s P&P.On 6/20/25 at 0952 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the finding. 4. Review of Patient 4’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was 10/20/23. The patient was certified for hospice service during the periods from 4/12/25 to 6/10/25 and 6/11/25 to 8/9/25. Review of HA 2’s note showed an HA visit on 4/21/25. However, HA 2 electronically signed on 4/30/25, not within 72 hours from the visit as per the hospice’s P&P. On 6/20/25 at 0916 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/Volunteer Coordinator was informed and acknowledged the findings. 5. Review of Patient 13’s clinical record was initiated on 6/13/25. The clinical record showed the SOC was 12/23/24. The patient was certified for hospice service during the periods from 12/23/24 to 3/22/25 and 3/23/25 to 6/20/25. The patient had expired on 4/20/25.Review of HA 1’s notes showed the HA visits on 4/8, 4/10 and 4/12/25. However, HA 1 electronically signed on 4/16/25, more than 72 hours from the visit as per the hospice’s P&P. Further review of the HA 1’s visit note dated 4/19/25, showed the HA electronically signed the note on 4/30/25, not within 72 hours from the visit as per the hospice’s P&P.On 6/20/25 at 1405 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/ Volunteer Coordinator was informed and acknowledged the findings. 6. Review of the hospice’s P&P titled Interdisciplinary Group Meeting revised 4/2021 showed members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor.Review of Patient 7’s clinical record was initiated on 6/13/25. The clinical record showed the SOC was on 12/28/23. The patient was certified for hospice services during the certification periods from 4/21/25 to 6/19/25.a. Review of the IDG Meeting Note/POC dated 6/2/25, showed an IDG meeting was conducted and documentation showed the POC was discussed. However, there was no documented evidence of signatures of the IDG meeting attendees.On 6/20/25 at 0855 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. The DPCS stated the IDG committees should sign the documents during or after the IDG meeting.b. Review of the CHHA visit notes showed the following:- On 4/17/25, the HA visit was conducted by HA 1. However, HA 1’s documentation was electronically signed on 4/30/25.- On 4/22/25, the HA visit was conducted by HA 1. However, HA 1’s documentation was electronically signed on 4/30/25.- On 4/24/25, the HA visit was conducted by HA 1. However, HA 1’s documentation was electronically signed on 4/30/25.- On 5/8/25, the HA visit was conducted by HA 1. However, HA 1’s documentation was electronically signed on 5/12/25.- On 6/3/25, the HA visit was conducted by HA 1. However, HA 1’s documentation was electronically signed on 6/7/25.HA 1 did not completed the visit noted within 72 hours from the visit date as per the hospice’s P&P. On 6/20/25 at 0917 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. The DPCS stated documentation should be signed and completed within 72 hours. 7. Review of Patient 2’s clinical record was initiated on was initiated on 6/11/25. The clinical record showed the SOC was on 9/17/24. The patient was certified for hospice services during the certification periods from 3/16/25 to 5/14/25 and 5/15/25 to 7/13/25.Review of the Visit Note- Psychosocial Assessment dated 9/25/24, showed the Medical Social Worker conducted a visit. However, the Medical Social Worker electronically signed her documentation on 9/30/25, not within 72 hours of the visit date as per the hospice’s P&P.On 6/20/25 at 0954 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. 8. Review of Patient 3’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was on 3/21/25. The patient was certified for hospice services during the certification periods from 3/21/25 to 6/18/25.Review of the CHHA visit notes showed the following:- On 4/16/25, HA 2 had conducted a HA visit. However, HA 2’s documentation was electronically signed on 4/30/25.- On 4/18/25, HA 2 had conducted a HA visit. However, HA 2’s documentation was electronically signed on 4/30/25.- On 4/21/25, HA 2 had conducted a HA visit. However, HA 2’s documentation was electronically signed on 4/30/25.- On 4/23/25, HA 2 had conducted a HA visit. However, HA 2’s documentation was electronically signed on 4/30/25.- On 4/25/25, HA 2 had conducted a HA visit. However, HA 2’s documentation was electronically signed on 4/30/25.- On 5/3/25, HA 2 had conducted a HA visit. However, HA 2’s documentation was electronically signed on 5/8/25.HA 2 did not electronically signed the visit notes within 72 hours from the visit dates as per the hospice’s P&P. On 6/20/25 at 1022 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. 9. Review of Patient 6’s clinical record was initiated on 6/12/25. The clinical record showed the SOC was on 12/14/24. The patient was certified for hospice services during the certification periods from 3/14/25 to 6/11/25 and 6/12/25 to 8/10/25.a. Review of the Visit Note- Comprehensive Nursing Assessment dated 12/14/24, showed RN 2 had conducted a visit. However, RN 2 electronically signed her documentation on 12/24/24, not within 72 hours of the visit date as per the hospice’s P&P.On 6/20/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. b. Review of the HA visit notes showed the following:- On 3/18/25, HA 2 had conducted a visit. However, HA 2’s documentation was electronically signed on 3/25/25.- On 4/1/25, HA 2 had conducted a visit. However, HA 2’s documentation was electronically signed on 4/14/25.- On 4/21/25, HA 2 had conducted a visit. However, HA 2’s documentation was electronically signed on 4/30/25.- On 4/8/25, HA 2 had conducted a visit. However, HA 2’s documentation was electronically signed on 4/15/25.- On 4/19/25, HA 2 had conducted a visit. However, HA 2’s documentation was electronically signed on 4/30/25.- On 4/22/25, HA 2 had conducted a visit. However, HA 2’s documentation was electronically signed on 4/30/25.- On 4/26/25, HA 2 had conducted a visit. However, HA 2’s documentation was electronically signed on 4/30/25.- On 5/3/25, HA 2 had conducted a visit. However, HA 2’s documentation was electronically signed on 5/8/25.- On 5/10/25, HA 2 had conducted a visit. However, HA 2’s documentation was electronically signed on 5/14/25.- On 5/17/25, HA 2 had conducted a visit. However, HA 2’s documentation was electronically signed on 5/21/25.- On 5/22/25, HA 2 had conducted a visit. However, HA 2’s documentation was electronically signed on 5/28/25.HA 2 did not electronically signed the visit notes within 72 hours from the visit dates as per the hospice’s P&P. On 6/20/25 at 1023 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding. 10. Review of Patient 10’s closed clinical record was initiated on 6/13/25. The clinical record showed the SOC was on 11/11/24. The patient was certified for hospice services during the certification periods from 11/11/24 to 2/8/25 and 2/9/25 to 4/9/25. The patient expired on 2/9/25.Review of the Visit Note- RN Nursing Note dated 11/25/24, showed RN 1 conducted a visit. *However, RN 1 electronically signed her documentation on 12/2/24, which was more than 72 hours instead of within 72 hours of the visit date as per the hospice’s P&P.On 6/20/25 at 1119 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the above finding.”

“Based on interview and record review, the hospice failed to ensure the controlled medications were properly disposed as per the hospice’s P&P for one of 14 sampled patient (Patients 11). This failure had the potential for drug diversion and contaminating the water supply system. Findings: The hospices’ P&P titled Home Use and Disposal of Controlled Substances undated showed controlled drugs will be accounted for on a narcotic count record, which will be maintained as part of the clinical record.1.Review of the closed clinical record for Patient 11 was initiated on 6/18/25. The clinical record showed the SOC was 1/22/25. The patient was certified for hospice services during the certification period from 1/22/25 to 4/21/25 and 4/22/25 to 6/20/25. The patient had expired on 5/18/25.The Patient Medication Profile showed the list of active medications to include comfort kit. The comfort kit included morphine sulfate 100 mg/5ml liquid concentrate 0.5 ml SL Q four hours PRN for pain/SOB, and lorazepam intensol 2 mg/ml liquid 0.5 ml PO/SL Q four hours for anxiety, agitation, restlessness. The Visit Note -Discharge Packet was completed on 5/18/25. Review of the Death Report/Disposal of Controlled Drugs dated 5/18/25, showed the section for the disposal of controlled dugs. The document showed morphine 0.5 ml (#10 ml) was disposed of.However, there was no documented evidence the lorazepam was accounted for as per the hospice’s P&P. On 6/20/25 at 1111 hours, an interview and concurrent closed record review was conducted with the Administrator/LVN/Volunteer Coordinator. The Administrator/LVN/ Volunteer Coordinator was asked regarding the status of lorazepam as part of the comfort kit. The Administrator/LVN/ Volunteer Coordinator replied it was empty but it was not documented. The Administrator/LVN/ Volunteer Coordinator was informed and acknowledged the findings.”