Olympia Hospice Care Inc.

“Based on interviews and record review, the Hospice Agency (HA, healthcare agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (CoP, requirements that healthcare organizations must meet to participate in federal healthcare programs) for Initial & Comprehensive Assessment (thorough evaluation of the patient’s needs that must be addressed to promote comfort and dignity throughout the dying process) of patients was met as follows: a. The HA failed to ensure the comprehensive assessments were complete and accurate for one of 19 sampled patients (Patient 2), who had a diagnosis of type 2 diabetes mellitus (DM II, long-term condition in which the body is unable to maintain normal blood glucose [BG, level of sugar in the blood] levels), to include Patient 2’s baseline BG levels, previous antidiabetic medications (medications to treat DM II), compliance with the diet, and current interventions ordered by the physician to address Patient 2’s DM II.This failure had increased Patient 2’s risks for hyperglycemia (abnormally high BG levels, that can be manifested by blurred vision, confusion, and increased thirst that can lead to coma) due to possible uncontrolled BG levels related to incomplete and/or inaccurate assessments (Refer to L524). b. The HA failed to ensure the comprehensive assessment was complete and accurate to reflect the need for hospice care and services of one of 19 sampled patients (Patient 3). This failure had the potential to result in a decline in the patient’s health condition due to not having proper medical oversight and access to needed medications and medical treatments (Refer to L525). c. The HA failed to ensure the HA licensed nurse conducted and documented complete and accurate ongoing reassessments of the diabetic needs of one of 19 sampled patients (Patient 2) that reflected Patient 2’s BG levels and the effectiveness of Patient 2’s antidiabetic medication. This failure had the potential to result in ineffective drug therapy due to incorrect treatment and services provided related to incomplete and/or inaccurate reassessment of Patient 2’s diabetic needs (Refer to L533). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulation for Initial and Comprehensive Assessment of Patients to ensure the highest quality of care was being provided to patients certified to receive the hospice benefits.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a terminal illness and nearing the end of life) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Interdisciplinary Group (IDG, a collaborative team of healthcare professionals responsible for providing holistic care [care for the patient as a whole person] to hospice patients and their families), Care Planning, Coordination of Services was met as follows: 1.The HA failed to follow and implement the plans of care to completely assess and monitor the port‑a‑Cath catheter site for one of 19 sampled patients (Patient 11). This deficient practice had the potential to result in inaccurate assessments and hinder the agency’s ability to appropriately address the patient’s needs. (Refer to L543). 2. The HA failed to formulate the individualized plans of care based on the current health status and needs of nine of 19 sampled patients (Patients 2, 3, 4, 6, 7, 10, 11, 15, and 16).Patient 2: No individualized care plan to address blood glucose (BG, sugar levels in the blood) monitoring, establish reportable BG parameters, include goals and all interventions to manage diabetes mellitus II (DM II), including Patient 2’s dietary noncompliance.Patient 3: No individualized care plan for bleeding precautions while on anticoagulant medication (warfarin) with a history of falls.Patient 4: No individualized care plan developed upon admission. The “Plan of Care (POC)/Interdisciplinary Group (IDG) Review,” dated 11/26/2025, and “POC/IDG Review,” dated 12/10/2025 did not include problems, goals, or interventions for Patient 4’s plan of care.Patient 6: No individualized care plan for excessive sleeping, increased tremors, and pain.Patient 7: No individualized care plan addressing bleeding precautions while on aspirin and increased risk for injury related to recurrent falls with a total of 9 falls reported within the current year.Patient 10: No individualized care plan addressing safe use of bedside rails to prevent injury.Patient 11: No individualized care plan addressing bleeding precautions while on anticoagulant medication (Eliquis) or potential adverse reactions to opioid medication (Fentanyl).Patient 15: No individualized care plan addressing bleeding precautions while on anticoagulant medication (Eliquis).Patient 16: No individualized care plan addressing assessment, monitoring, and care of a Perma catheter (a specialized, long-term flexible tube surgically placed into a large vein, typically in the neck or chest, to provide constant access to the bloodstream). This failure had the potential to contribute to a decline in patients’ health due to lack of or delays in appropriate care and services. (Refer to L545) 2. The HA failed to ensure the IDG directed, supervised, and coordinated the provision of diabetic care and services for one of 19 sampled patients (Patient 2). This failure had the potential to result in ineffective drug therapy related to inconsistent monitoring of the diet compliance and high BG levels to treat Patient 2’s diabetic needs. (Refer to L554). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure provision of quality care and services to patients certified to receive the hospice benefits.”

“Based on interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (COP- requirements that healthcare organizations must meet to participate in federal healthcare programs) for Clinical Records was met as follows: The HA failed to ensure complete and accurate clinical records for nine of 19 sampled patients (Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 10, Patient 11, Patient 15, and Patient 16) by failing to: a. Ensure Patient 2’s updated comprehensive nursing assessments, visit notes, and individualized plans of care included Patient 2’s BG values, BG parameters to prompt ALF 1 staff to notify the HA nurse, noncompliance to the diet, interventions to manage DM II, and teachings provided to Patient 2 and the ALF 1 staff. b. Ensure Patient 3’s plan of care was individualized to address increased risks for bleeding related to Coumadin use and increased risk of injury related to history of falls. c. Ensure Patient 4’s “POC/IDG Review,” dated 11/26/2025, and “POC/IDG Review,” dated 12/10/2025 was individualized and completed with all problems/goals/interventions listed. d. Ensure Patient 6’s plan of care was individualized to address concerns for excessive sleeping, increased pain (Norco vs. Tramadol), and increased tremors. e. Ensure Patient 7’s plan of care was individualized to address bleeding precautions related to aspirin use and history of falls. f. Ensure Patient 10’s plan of care was individualized to address safe use of bedside rails to prevent injury. g. Ensure Patient 11’s plan of care was individualized to address bleeding precautions while on anticoagulant medication (Eliquis) and potential adverse reactions to opioid medication (Fentanyl). h. Ensure Patient 11’s plan of care (an individualized, written document outlining the specific medical, emotional, and spiritual support for a patient) was followed and implemented to fully reflect the assessment and monitoring of the Port-a-Cath site in the clinical record documentation. i. Ensure Patient 15’s plan of care was individualized to address bleeding precautions while on anticoagulant medication (Eliquis). j. Ensure Patient 16’s plan of care was individualized to address assessment, monitoring, and care of a Perma catheter (a specialized, long-term flexible tube surgically placed into a large vein, typically in the neck or chest, to provide constant access to the bloodstream). These failures had the potential to result in a decline in the patients’ condition due to not receiving the necessary care and services to maintain comfort related to incomplete and inaccurate clinical records patients that could lead to a gap in the continuity of care (Refer to L672). The cumulative effects of these systemic practices resulted in the failure of the hospice to deliver statutorily (written law) mandated compliance with Federal regulations for Clinical Records to ensure patients’ medical records are completed, updated and accurately documented.”

“Based on observation, interviews, and record review, the Hospice Agency (HA, healthcare agency that provides specialized care and support for people with a terminal illness and nearing the end of life) failed to ensure the comprehensive assessments was complete and accurate for three of 19 sampled patients (Patient 2, Patient 11 and Patient 16).For Patient 2, who had a diagnosis of type 2 diabetes mellitus (DM II, long-term condition in which the body is unable to maintain normal blood glucose [BG, level of sugar in the blood] levels, to include the baseline (initial set of data) BG levels, previous antidiabetic medications (medications to treat DM II), and current interventions ordered by the physician to address DM II.For Patient 11, the HA failed to follow and implement the plan of care to completely assess and monitor the port‑a‑Cath catheter (a device used to draw blood and give treatments, including intravenous fluids, blood transfusions, or drugs) site. For Patient 16, The HA failed to conduct a complete and accurate assessment, that reflects the overall status of the Perma catheter (a specialized, long-term flexible tube surgically placed into a large vein, typically in the neck or chest, to provide constant access to the bloodstream).This failure has the potential risks for the patient to manifest signs and symptoms of hyperglycemia (abnormally high BG levels, that can be manifested by blurred vision, confusion, and increased thirst that can lead to diabetic ketoacidosis [DKA, life-threatening complication of DM that leads to the buildup of toxic chemicals in the blood due to the severe lack of insulin]) and/or hypoglycemia (abnormally low BG levels that can be manifested by shakiness, confusion, or sweating that can lead to coma) due to possible uncontrolled BG levels related to incomplete and/or inaccurate assessments that could result to the decline in patients’ health due to lack and/or delay of care and services, complications and/or hospitalization. b. During a review of Patient 11’s undated clinical record, titled “Personal Information,” the “Personal information” indicated Patient 11’s start of care (SOC) date of 3/27/2026 with a primary diagnosis of malignant neoplasm of bladder (a cancerous tumor (mass of abnormal cells that grow uncontrollably, invade nearby tissues, and can spread to other parts of the body) that starts in the bladder lining and has the potential to grow into the bladder wall or spread to other parts of the body), unspecified. During a concurrent observation and interview on 4/24/2026 at 10:15 a.m., conducted during a joint home visit with Registered Nurse (RN) 2 in Patient 11’s room at her residence, Patient 11 was observed resting comfortably in bed and was alert and oriented to person, place, time, and events. Patient 11 reported having a port‑a‑Cath located on her upper right chest and declined RN 2’s skin assessment which includes the port-a-Cath site in my presence. Patient 11 stated that her port‑a‑Cath site was in good condition and that she and her caregivers are knowledgeable about the signs and symptoms of infection or any changes at the port‑a‑Cath site that should be reported to hospice staff. Patient 11 stated that she chose to keep her port‑a‑Cath in place in case she decides to pursue aggressive treatment or requires intravenous (given through vein) hydration or medications. During an interview on 4/26/2026 at 10:35 p.m., Patient 11’s caregiver (CG2) stated that hospice nurses assess Patient 11, including the condition of her port‑a‑cath. CG2 stated that she and the other caregivers are knowledgeable about the signs and symptoms of infection or any changes at the port‑a‑Cath site that should be reported to hospice staff. During an interview and concurrent record review on 4/27/2025 at 10:45 p.m. with the Director of Patient Care Services Designee (DPCSD), Patient 11’s clinical record, titled “POC (Plan of Care)/IDG (Interdisciplinary Group) Review” forms dated 4/1/2026 and 4/15/2026, was reviewed. The DPCSD confirmed and stated that the POC/IDG Review forms dated 4/1/2026 and 4/15/2026 included the following care plan under the “Cardiovascular” section:Presence of a port‑a‑Cath in the right subclavian area.Goals: Patient will remain free from signs and symptoms of infection related to the port‑a‑Cath by the next IDG.Patient/patient’s caregiver (PCG) will verbalize understanding of medication, treatment, care orders, and side effects by the next IDG.Maintain peripheral circulation for patient comfort.Interventions: Assess and monitor cardiac status at every visit.Assess and monitor the port‑a‑Cath site for infection, inflammation, or pain.Educate the patient/family/PCG to notify hospice of any changes.Instruct the patient/PCG regarding new medications, treatments, care orders, and potential side effects.Assess the effectiveness of current and new medications, treatments, and care. During an interview and concurrent record review on 4/27/2025 at 11:38 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 11’s clinical record, including the “Comprehensive Nursing Assessment” dated 3/27/2026 and the “Nursing Updated Assessment” dated 4/17/2026, was reviewed. The DPCSD stated and confirmed that she documented the presence of Patient 11’s port‑a‑Cath in the right subclavian area in the IV (Intravenous, into the vein) assessment section but did not provide a complete assessment that included the characteristics, appearance, and status of the port‑a‑Cath site. The DPCSD stated that a complete assessment of the port‑a‑Cath should include, but is not limited to, the following:Condition of the skin surrounding the port‑a‑CathPresence of redness, swelling, or warmthPresence of drainage, odor, or signs of infectionPatient‑reported pain, discomfort, or tenderness at the siteFunctionality and patency status of the port‑a‑Cath During an interview and concurrent record review on 4/27/2025 at 11:45 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 11’s clinical record, titled “Visit Note RN,” entries dated 4/6/2026, 4/10/2026, 4/13/2026, and 4/20/2026, were reviewed. The DPCSD stated and confirmed that the visiting nurses documented the presence of Patient 11’s port‑a‑Cath in the right subclavian area in the narrative notes but did not provide a complete assessment in accordance with the patient’s plan of care. The DPCSD stated it is important for nurses to follow the care plan to ensure an accurate and comprehensive assessment of the port‑a‑Cath, including monitoring for signs and symptoms of infection, changes in appearance, discomfort, or pain. The DPCSD further stated that incomplete assessments could lead to missed complications and inadequate monitoring of Patient 11’s right subclavian port‑a‑cath. c. During a review of Patient 16’s undated clinical record, titled “Personal Information,” the “Personal information” indicated Patient 16’s start of care (SOC) date of 3/28/2026 with a primary diagnosis of heart disease (condition that affects the heart’s structure or function, making it harder for the heart to pump blood effectively), unspecified and secondary diagnoses that included dependence on renal dialysis (a patient whose kidneys have failed or are not working properly, requiring them to use a machine (hemodialysis) or abdominal catheter (peritoneal dialysis) to clean waste and excess fluid from their). During an interview and concurrent record review on 4/28/2025 at 12:18 p.m. with the DPCS, Patient 16’s clinical record, including the following:“Comprehensive Nursing Assessment,” dated 3/28/2026 was reviewed. The DPCS stated and confirmed that the Comprehensive Nursing Assessment indicated surgical wound (a deliberate cut made in the skin, muscle, or tissue by a healthcare professional during a medical procedure) under Integumentary – Skin section but did not identify the type, characteristics and appearance necessary for assessment. “Skin Assessment,” dated 3/28/2026 was reviewed. The DPCS stated and confirmed that the Skin Assessment indicated “dialysis shunt permcath (a soft, flexible tube placed into a large vein, usually in the neck or chest, to act as a long-term access point for hemodialysis (a treatment that uses a machine and a special filter (dialyzer) to remove waste products, toxins, and excess fluid from the blood when the kidneys can no longer perform these functions))” with status of existing but did not include a nursing documentation for assessment of the appearance, status, and characteristics of it. “Skin Assessment,” dated 4/9/2026 was reviewed. The DPCS stated and confirmed that the Skin Assessment indicated “dialysis shunt permcath” with status of existing but did not include a nursing documentation for assessment of the appearance, status and characteristics of it. “Visit Note RN (Registered Nurse),” dated 4/2/2026, 4/16/2026, 4/21/2026, and 4/23/2026 were reviewed. The DPCS stated and confirmed that the Visit Notes RN identified the presence of Perma Cath but did not include a complete assessment of the status, appearance and characteristics of it. “POC (Plan of Care)/IDG Review” form dated 4/1/2026 and 4/15/2026, was reviewed. The DPCS stated and confirmed that the POC/IDG Review forms did not include an individualized plan of care addressing problems, goals, or interventions related to Patient 11’s presence of Perma catheter. The DPCS stated that it is important for the patient to have an individualized care plan specific to proper assessment and monitoring of the Perma Cath. The DPCS stated that the care plan needs to lead to the foundation of care to assess the appearance, monitor for signs and symptoms of infection, pain, discomfort swelling, placement, dressing appearance and the date the dressing was changed. DPCS stated that although Patient 16’s Perma Cath care and dressing change are managed by the dialysis center, it is still need to have a care plan specifically addressing the continuous assessment and monitoring of it. DPCS stated that it is important for the nurses to have a complete assessment to accurately document the status of the Perma Cath. The DPCS stated that care plan should also include patient and patient caregiver’s teaching related to Perma Cath status. The DPCS stated that if Patient 11 and family decided to discontinue the dialysis treatment, the HA will formulate an individualized care plan for it which also includes management of dressing change. The DPCS stated that identified problems, interventions are implemented to meet those goals, and modifications are made if current interventions are ineffective. The DPCSD further stated that incomplete assessments could lead to missed complications and inadequate monitoring of Patient 15’s presence of permcath. Findings: During a review of Patient 2’s undated clinical record, titled “Personal Information,” the “Personal Information” indicated start of care (SOC) date of 1/27/2026 with a primary diagnosis of hypertensive heart disease with heart failure (serious condition wherein the high pressure of the blood against the arteries causes thickened and weakened heart, limiting its ability to pump blood effectively). The “Personal Information” indicated Patient 2 resided in Assisted Living Facility 1 (ALF 1).During a review of Patient 2’s medical record from Patient 2’s Primary Care Provider (PCP 1, medical professional outside of the HA who serves as the main contact for the patient’s health needs to provide preventative care, treat chronic conditions, and coordinate care with specialists), titled “Subjective Objective Assessment Plan (SOAP, standard medical documentation format used to document patient encounters to ensure organized communication and continuity of care) [Follow Up Encounter] Note,” dated 2/2/2026, the “SOAP (Follow Up Encounter) Note” indicated the following:Patient 2 has other medical diagnoses including, DM II.Patient 2’s BG levels (recommended target BG levels before meals are 80-130 mg/dL and less than 180 mg/dL one to two hours after a meal) range from 166 milligrams (mg, unit of measurement) per deciliter (dL, unit of measurement) – 351 mg/dL with the last hemoglobin A1c (HbA1c, test to measure the average levels of sugar in the blood over the past 2-3 months with the target for diabetic patients less than 7%) of 8.5%.Patient 2 was not compliant with diet recommendations.Patient 2’s DM II medications included:Mounjaro (once weekly injection medication to treat DM II) 2.5 mg/0.5 milliliter (ml, unit of measurement) pen injector – 2.5 mg subcutaneously (inject into the fatty tissue layer below the skin) every 4 weeks for 4 weeksLantus (long-acting man-made insulin used once daily to improve BG control) U-100 insulin 100 units/ml subcutaneous solution – administer 16 units subcutaneously at bedtimeMetformin (medication to treat DM II) hydrochloride 1000 mg tablet by mouth twice daily for DM II.4. The plan for Patient 2 indicated to continue all treatment plans and medications for management of chronic conditions and continue with the current plan of care.During a review of Patient 2’s “Comprehensive Nursing Assessment (HOPE Admission),” dated 2/17/2026, the “Comprehensive Nursing Assessment” indicated Patient 2 had insulin-dependent diabetes mellitus (IDDM) under endocrine assessment (evaluation of endocrine glands that produce chemical messengers through the bloodstream to detect disorders like DM II).During a review of Patient 2’s “Nursing Update Assessment (HUV 1),” dated 2/6/2026, the “Nursing Update Assessment” indicated Patient 2 had IDDM under endocrine assessment.During a review of Patient 2’s “Nursing Update Assessment (HUV 2),” dated 2/20/2026, the “Nursing Update Assessment” indicated Patient 2 had IDDM under endocrine assessment.During a review of Patient 2’s “Plan of Care (POC)/Interdisciplinary Group (IDG) Review,” dated 2/4/2026, the “POC/IDG Review” indicated a physician’s order, dated 1/27/2026, to administer Lantus 100 units/ml 16 units subcutaneously every bedtime for DM II.During a review of Patient 2’s “POC/IDG Review,” dated 2/18/2026, the “POC/IDG Review” indicated a physician’s order, dated 2/11/2026, to discontinue Lantus insulin and start Glipizide (oral medication to treat DM II) 2.5 mg twice a day and hold if BG is below 100 mg/dL. The “POC/IDG Review” also indicated a physician’s order, dated 2/11/2026, to check Patient 2’s BG twice a day before administering Glipizide.During an observation and concurrent interview on 4/24/2026 at 10:05 a.m., during a joint home visit with Registered Nurse 1 (RN 1), in Patient 2’s room, it was observed the patient was alert, awake with some confusion, and sitting in her wheelchair. RN 1 stated Patient 2 has had episodes of diet non-compliance related to eating concentrated sweets brought to ALF 1 by a friend. RN 1 stated Patient 2’s BG levels range from 200s mg/dL – 300s mg/dL.During a concurrent interview and record review of Patient 2’s BG levels obtained by ALF 1 staff on 4/24/2025 at 10:37 a.m., with Medication Technician 1 (MedTech 1) and RN 1, Patient 2’s current physician orders and BG values were reviewed. MedTech 1 stated Patient 2 has a physician’s order to check Patient 2’s BG twice a day before administering Glipizide and administer Glipizide 5 mg twice a day and to hold if BG is below 100 mg/dL. MedTech 1 Patient 2 had episodes of high BG levels above 400 mg/dL and the ALF 1 staff administered Glipizide as ordered. MedTech 1 stated ALF 1 staff did not notify the HA when BG levels were above 400 mg/dL because there was no physician’s order to notify the HA. MedTech 1 stated the HA staff did not specify any parameters for the BG levels to prompt the ALF 1 staff to notify the HA nurses.During a concurrent interview and record review of Patient 2’s clinical records, on 4/24/2026 at 1:55 p.m., with the Director of Patient Care Services (DPCS), Patient 2’s “Comprehensive Nursing Assessment,” dated 1/27/2026, Nursing Updated Assessment (HUV 1), dated 2/6/2026, Nursing Updated Assessment (HUV2), dated 2/20/2026, Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 2/4/2026, and “SOAP (Follow Up Encounter) Note,” dated 2/2/2026, were reviewed. The DPCS stated she was not aware of Patient 2’s BG levels above 400 mg/dL. The DPCS stated the RN assessments were incomplete and inaccurate because there was no documented evidence that RN 1 identified and documented Patient 2’s baseline high BG levels, Patient 2’s noncompliance with the prescribed diet, Patient 2’s previous antidiabetic medications, and/or the inability of Patient 2’s caregivers to administer Lantus insulin as ordered by the physician. The DPCS stated incomplete and inaccurate assessments of Patient 2’s BG levels and DM II medications and their effectiveness could lead increased risks of hypoglycemia or hyperglycemia due to uncontrolled BG levels related to possible incorrect or inconsistent treatments provided.During a telephone interview on 4/28/2026 at 2:09 PM, the Medical Director (MD) stated upon Patient 2’s admission to the HA, MD discontinued the order to administer Lantus insulin to Patient 2 and ordered to start Glipizide 2.5 mg twice a day for Patient 2’s DM II because the HA informed MD that ALF 1 staff was not qualified to administer Lantus injections. The Medical Director stated the Glipizide dose could either be increased or decreased to ensure better BG control depending on the BG values within 1-2 weeks after the start of a particular Glipizide dose. The Medical Director stated he was under the impression that Patient 2’s DM II was “totally controlled.” The Medical Director stated Patient 2’s BG must be checked before breakfast and before administration of any antidiabetic medication/s and 2 hours after dinner. The Medical Director stated the HA nurse must also educate ALF 1 staff to ensure Patient 2 does not have access to “unlimited sweets” to better control Patient 2’s BG levels. The Medical Director stated it was important to keep the BG levels controlled and educate the caregivers to report any BG above 400 mg/dL and/or below 65 mg/dL to prevent unnecessary hospitalizations due to complications, such as DKA.During a review of the HA’s policy and procedures (P&P), titled “Comprehensive Assessment,” dated 4/2020, the P&P indicated the following:A comprehensive assessment must be performed by the IDG no later than 5 days after the election of hospice care in consultation with the attending physician.During the comprehensive patient assessment, all baseline data and other relevant information must be documented, through interview and observation, in the patient’s clinical record, including at least the following information, as relevant:-current treatment and patient response to that treatment-physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patient’s terminal illness-complication and risk factors that affect care planning-patient’s past and present medical and psychosocial history including pertinent diagnosis and any comorbid conditions-review of current and related past medications, including prescription and over-the counter medications, and medication information, including effectiveness of drug therapy-patient and family/caregiver support systems and the care the family/caregiver is available, capable, and willing to provide-specific, individualized patient needs/problems pertinent to the hospice care being provided-patient’s and family/caregiver’s educational needs, abilities, motivation, and readiness to learn”

“Based on interview, and record review, the Hospice Agency (HA, healthcare agency that provides specialized care and support for people with a terminal illness and nearing the end of life) failed to ensure the comprehensive assessment was complete and accurate to reflect the need for hospice care and services of one of 19 sampled patients (Patient 3). This failure had the potential to result in the decline of the patient’s health condition due to the limited access to medically necessary treatment and services, which are not provided by the HA for the terminally ill patients. Findings:During a review of Patient 3’s undated clinical record, titled “Personal Information,” the ‘Personal Information” indicated the start of care (SOC) date of 2/23/2026 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.During a review of Patient 3’s “Comprehensive Nursing Assessment (HOPE Admission),” dated 2/23/2026, the “Comprehensive Nursing Assessment” indicated the principal diagnosis of heart disease was the “evidenced disease likely to contribute to life expectancy of 6 months of less.” The “Comprehensive Nursing Assessment” indicated Patient 3 met the criteria for NYHA class IV level. The “Comprehensive Nursing Assessment” indicated Patient 3 had regular blood pressure at 120/56 and apical pulse at 63 beats per minute but had swelling to both feet. The “Comprehensive Nursing Assessment” indicated Patient 3 had no shortness of breath at rest with clear lung sounds, normal respirations, and 96% oxygen saturation on room air upon assessment of Registered Nurse 5 (RN 5).During a review of Patient 3’s “LCD Hospice Eligibility Determination,” dated 3/23/2026, the “LCD Hospice Eligibility Determination” indicated Patient 3 met the criteria for NYHA Class IV level.During a concurrent interview and record review of Patient 3’s clinical records on 4/28/2026 at 10:22 a.m., with Registered Nurse 1 (RN 1), Patient 3’s GACH 1 note, titled “Documents Review Report,” dated 2/12/2026, PCP 1 note, dated 2/3/2026, “Comprehensive Nursing Assessment,” dated 2/23/2026, and “LCD Hospice Eligibility Determination” were reviewed. The DPCS stated Patient 3 had a diagnosis of hypertensive heart disease without heart failure. RN 1 stated there was no documented evidence Patient 3 had angina pectoris or Patient 3 met NYHA Class IV heart failure. The DPCS stated a complete and accurate assessment was important to ensure Patient 3 was terminally ill and qualified to receive the hospice care and services that are less aggressive and are mainly geared to improve or maintain Patient 3’s comfort.During a telephone interview on 4/28/2026 at 2:09 p.m., the Medical Director stated a patient (in general) who “could not do any work whatsoever or could not tolerate work” and would get shortness of breath after ambulating for a short distance would qualify for NYHA Class IV level heart failure. The Medical Director stated swelling to both lower extremities alone could not confirm heart failure.During a review of the HA’s policy and procedures (P&P), titled “Comprehensive Assessment,” dated 4/2020, the P&P indicated the following:During the comprehensive patient assessment, all baseline data and other relevant information must be documented, through interview and observation, in the patient’s clinical record, including at least the following information, as relevant:-nature and condition causing admission, including the presence or lack of objective data and subjective complaints-physical assessment, including other relevant data related to pertinent physical findings and the patient’s terminal illness-patient’s past and present medical and psychosocial history including pertinent diagnosis and any comorbid conditions-specific, individualized patient needs/problems pertinent to the hospice care being provided”

“Based on observation, interviews, and record review, the Hospice Agency (HA, healthcare agency that provides specialized care and support for people with a terminal illness and nearing the end of life) failed to ensure the HA licensed nurse conducted and documented complete and accurate ongoing reassessments of the diabetic needs of one of 19 sampled patients (Patient 2) that reflected Patient 2’s blood glucose (BG, sugar in the blood) levels and the effectiveness of Patient 2’s antidiabetic medication. This failure had the potential to result in ineffective drug therapy due to incorrect treatment and services provided related to an incomplete and/or inaccurate assessments of Patient 2’s diabetic needs. Findings:During a review of Patient 2’s undated clinical record, titled “Personal Information,” indicated start of care (SOC) date of 1/27/2026 with a primary diagnosis of hypertensive heart disease with heart failure (serious condition wherein the high pressure of the blood against the arteries causes thickened and weakened heart, limiting its ability to pump blood effectively). The “Personal Information” indicated Patient 2 resided in Assisted Living Facility 1 (ALF 1).During a review of Patient 2’s BG levels (recommended target BG levels before meals are 80-130 mg/dL and less than 180 mg/dL one to two hours after a meal) obtained by ALF 1 staff from 1/24/2026 – 4/24/2026, the BG levels were as follows:January 2026 – 97 mg/dL – 363 mg/dLFebruary 2026 – 195 mg/dL – 446 mg/dL (with 3 BG readings above 400 mg/dL)March 2026 – 255 mg/dL – 491 mg/dL (with 4 BG readings above 400 mg/dL)April 2026 – 188 mg/dL – 408 mg/dL (with 2 BG readings above 400 mg/dL)During a review of Patient 2’s HA’s plan of care document provided to ALF 1, titled “Plan of Care (POC)/Interdisciplinary Group (IDG) Review,” dated 4/22/2026, the “POC/IDG Review” indicated Patient 2’s issue of “Insulin Dependent Diabetes Mellitus” with the goals to “assess patient status for ongoing care” and “Patient will be free from signs and symptoms of hypoglycemia (abnormally low BG) or hyperglycemia (abnormally high BG) by next IDG.” The “POC/IDG Review” indicated the interventions included to “instruct patient/patient’s caregiver regarding new medication/treatment order and side effects” and to “monitor/assess effectiveness of current and new medication/treatment.”During an observation and concurrent interview on 4/24/2026 at 10:05 a.m., during a joint home visit with Registered Nurse 1 (RN 1), in Patient 2’s room, it was observed the patient was alert, awake with some confusion, and sitting in her wheelchair. RN 1 stated Patient 2 has had episodes of diet non-compliance related to eating concentrated sweets brought to ALF 1 by a friend. RN 1 stated Patient 2’s BG levels range from 200s mg/dL – 300s mg/dL.During a concurrent interview and record review of Patient 2’s BG levels obtained by ALF 1 staff on 4/24/2025 at 10:37 a.m., with Medication Technician 1 (MedTech 1) and RN 1, Patient 2’s current physician orders and BG values were reviewed. MedTech 1 stated Patient 2 has a physician order to check Patient 2’s BG twice a day before administering Glipizide and to administer Glipizide 5 mg twice a day and to hold if BG is below 100 mg/dL. MedTech 1 Patient 2 has had episodes of high BG levels above 400 mg/dL since Patient 2’s admission to the HA. MedTech 1 stated ALF 1 staff did not notify the HA when BG levels were above 400 mg/dL because there was no physician’s order to notify the HA. MedTech 1 stated the HA staff did not specify any parameters for the BG levels to prompt the ALF 1 staff to notify the HA nurses. During a concurrent interview and record review of Patient 2’s clinical records, on 4/24/2026 at 1:55 p.m., with the Director of Patient Care Services (DPCS), Patient 2’s “Visit Note,” dated 1/28/2026, “Visit Note,” dated 1/30/2026, “Visit Note,” dated 2/2/2026, “Visit Note,” dated 2/4/2026, “Visit Note,” dated 2/13/2026, “Visit Note,” dated 2/27/2026, “Visit Note,” dated 3/6/2026, “Visit Note,” dated 3/13/2026, “Visit Note,” dated 3/20/2026, “Visit Note,” dated 3/27/2026, “Visit Note,” dated 4/3/2026, “Visit Note,” dated 4/10/2026, and “Visit Note,” dated 4/17/2026, were reviewed. The DPCS stated the visit notes indicated Patient 2’s endocrine system (network of glands and organs that produce and release chemicals called hormones directly into the bloodstream to regulate important bodily functions) was “assessed/no issues reported.” The DPCS stated there was no documented evidence that the HA nurse ensured complete and accurate ongoing reassessments of Patient 2’s BG levels, monitored compliance to the prescribed diet, and evaluated the effectiveness of antidiabetic medication ordered. The DPCS stated incomplete and inaccurate assessments of Patient 2’s BG levels and effectiveness of DM II medications could lead increased risks of hypoglycemia or hyperglycemia due to uncontrolled BG levels related to possible incorrect or inconsistent treatments provided.During a telephone interview on 4/28/2026 at 2:09 PM, the Medical Director (MD) stated he was under the impression that Patient 2’s DM II was “totally controlled.” The Medical Director stated after 1-2 weeks of obtaining BG levels, Glipizide could either be increased or decreased to ensure better BG control. The Medical Director stated the HA nurse must also educate ALF 1 staff to ensure Patient 2 does not have access to “unlimited sweets” to better control Patient 2’s BG. The Medical Director stated it was important to keep the BG levels controlled and educate the caregivers to report any BG above 400 mg/dL and/or below 65 mg/dL to prevent unnecessary hospitalizations due to complications, such as diabetic ketoacidosis (DKA, life-threatening complication of DM that leads to the buildup of toxic chemicals in the blood due to the severe lack of insulin).During a review of the HA’s policy and procedures (P&P), titled “Ongoing Assessments,” dated 4/2020, the P&P indicated the following:The scope and intensity of ongoing hospice patient assessments must be determined by the patient’s prognosis, diagnoses, condition, desire for care, response to previous care, and the care setting.During each home visit, the Case Manager or other discipline must evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. Ongoing comprehensive assessments must focus on the patient’s response to care and changes in patient condition, level of deterioration.The nurse must assess each patient on each visit, for:-patient’s response to medications and other interventions-patient’s progress toward hospice goals and patient needs and problems-compliance with treatments and medication regimen4. Based on the assessments, the plan of care—including problems, needs, goals, and outcomes—must be reviewed and updated by the IDG members responsible for the care.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a terminal illness and nearing the end of life) failed to follow and implement the plan of care to completely assess and monitor the port‑a‑Cath catheter (an implanted device used to draw blood and give treatments, including intravenous fluids, blood transfusions, or drugs) site for one of nineteen sampled patients (Patient 11). This deficient practice had the potential to result in inaccurate assessments and hinder the agency’s ability to appropriately address the patient’s needs. During a review of Patient 11’s undated clinical record, titled “Personal Information,” the “Personal information” indicated Patient 11’s start of care (SOC) date of 3/27/2026 with a primary diagnosis of malignant neoplasm of bladder (a cancerous tumor (mass of abnormal cells that grow uncontrollably, invade nearby tissues, and can spread to other parts of the body) that starts in the bladder lining and has the potential to grow into the bladder wall or spread to other parts of the body), unspecified. During a concurrent observation and interview on 4/24/2026 at 10:15 a.m., conducted during a joint home visit with Registered Nurse (RN) 2 in Patient 11’s room at her residence, Patient 11 was observed resting comfortably in bed and was alert and oriented to person, place, time, and events. Patient 11 reported having a port‑a‑Cath located on her upper right chest and declined RN 2’s skin assessment which includes the port-a-Cath site in my presence. Patient 11 stated that her port‑a‑Cath site was in good condition and that she and her caregivers are knowledgeable about the signs and symptoms of infection or any changes at the port‑a‑Cath site that should be reported to hospice staff. Patient 11 stated that she chose to keep her port‑a‑Cath in place in case she decides to pursue aggressive treatment or requires intravenous (given through vein) hydration or medications. During an interview on 4/26/2026 at 10:35 a.m., Patient 11’s caregiver (CG2) stated that hospice nurses assess Patient 11, including the condition of her port‑a‑cath. CG2 stated that she and the other caregivers are knowledgeable about the signs and symptoms of infection or any changes at the port‑a‑Cath site that should be reported to hospice staff. During an interview and concurrent record review on 4/27/2025 at 10:45 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 11’s clinical record, titled “POC (Plan of Care)/IDG (Interdisciplinary Group) Review” forms dated 4/1/2026 and 4/15/2026, was reviewed. The DPCSD confirmed and stated that the POC/IDG Review forms dated 4/1/2026 and 4/15/2026 included the following care plan under the “Cardiovascular” section:Presence of a port‑a‑Cath in the right subclavian area.Goals: Patient will remain free from signs and symptoms of infection related to the port‑a‑Cath by the next IDG.Patient/patient’s caregiver (PCG) will verbalize understanding of medication, treatment, care orders, and side effects by the next IDG.Maintain peripheral circulation for patient comfort.Interventions: Assess and monitor cardiac status at every visit.Assess and monitor the port‑a‑Cath site for infection, inflammation, or pain.Educate the patient/family/PCG to notify hospice of any changes.Instruct the patient/PCG regarding new medications, treatments, care orders, and potential side effects.Assess the effectiveness of current and new medications, treatments, and care. During an interview and concurrent record review on 4/27/2025 at 11:38 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 11’s clinical record, including the “Comprehensive Nursing Assessment” dated 3/27/2026 and the “Nursing Updated Assessment” dated 4/17/2026, was reviewed. The DPCSD stated and confirmed that she documented the presence of Patient 11’s port‑a‑Cath in the right subclavian area in the IV (Intravenous, into the vein) assessment section but did not provide a complete assessment that included the characteristics, appearance, and status of the port‑a‑Cath site. The DPCSD stated that a complete assessment of the port‑a‑Cath should include, but is not limited to, the following:Condition of the skin surrounding the port‑a‑CathPresence of redness, swelling, or warmthPresence of drainage, odor, or signs of infectionPatient‑reported pain, discomfort, or tenderness at the siteFunctionality and patency status of the port‑a‑Cath During an interview and concurrent record review on 4/27/2025 at 11:45 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 11’s clinical record, titled “Visit Note RN,” entries dated 4/6/2026, 4/10/2026, 4/13/2026, and 4/20/2026, were reviewed. The DPCSD stated and confirmed that the visiting nurses documented the presence of Patient 11’s port‑a‑Cath in the right subclavian area in the narrative notes but did not provide a complete assessment in accordance with the patient’s plan of care. The DPCSD stated it is important for nurses to follow the care plan to ensure an accurate and comprehensive assessment of the port‑a‑Cath, including monitoring for signs and symptoms of infection, changes in appearance, discomfort, or pain. The DPCSD further stated that incomplete assessments could lead to missed complications and inadequate monitoring of Patient 11’s right subclavian port‑a‑cath. During a review of the HA’s policy and procedure (P&P) entitled, “The Plan of Care”, revised date of April 2020, the P&P indicated that:written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a terminal illness and nearing the end of life) failed formulate individualized plans of care based on the current health status and needs of nine of 19 sampled patients (Patients 2, 3, 4, 6, 7, 10, 11, 15, and 16).Patient 2: No individualized care plan to address blood glucose (BG, sugar levels in the blood) monitoring, establish reportable BG parameters, include goals and all interventions to manage diabetes mellitus II (DM II), including Patient 2’s dietary noncompliance.Patient 3: No individualized care plan for bleeding precautions while on anticoagulant medication (warfarin) with a history of falls.Patient 4: No individualized care plan developed upon admission. The “Plan of Care (POC)/Interdisciplinary Group (IDG) Review,” dated 11/26/2025, and “POC/IDG Review,” dated 12/10/2025 did not include problems, goals, or interventions for Patient 4’s plan of care.Patient 6: No individualized care plan for excessive sleeping, increased tremors, and pain.Patient 7: No individualized care plan addressing bleeding precautions while on aspirin and increased risk for injury related to recurrent falls with a total of 9 falls reported within the current year.Patient 10: No individualized care plan addressing safe use of bedside rails to prevent injury.Patient 11: No individualized care plan addressing bleeding precautions while on anticoagulant medication (Eliquis) or potential adverse reactions to opioid medication (Fentanyl).Patient 15: No individualized care plan addressing bleeding precautions while on anticoagulant medication (Eliquis).Patient 16: No individualized care plan addressing assessment, monitoring, and care of a Perma catheter (a specialized, long-term flexible tube surgically placed into a large vein, typically in the neck or chest, to provide constant access to the bloodstream).This failure had the potential to contribute to the decline in patients’ health due to lack of or delays in appropriate care and services. f. During a review of Patient 10’s undated clinical record, titled “Personal Information,” the “Personal information” indicated Patient 10’s start of care (SOC) date of 4/18/2026 with a primary diagnosis of unspecified diastolic congestive heart failure (a medical condition which occurs when the heart muscle becomes too stiff or thick to relax properly between beats). During a concurrent observation and interview on 4/23/2026 at 10:12 a.m., conducted during a joint home visit with the Director of Patient Care Services Designee (DPCSD) in Patient 10’s living room, Patient 10 was observed resting comfortably in a hospital bed with safety rails up. Patient 10 was alert and oriented to person, place, time, and events, and was receiving oxygen therapy via nasal cannula connected to an oxygen concentrator set at 2 liters per minute. Patient 10 stated that she and her family requested a hospital bed with side rails to prevent her from falling, especially when turning to her side. She stated she can turn from side to side but loses control when lying on her side, with her leg falling first. Patient 10 further stated she is unable to walk and remains either in bed or in a wheelchair. During an interview on 4/23/2026 at 10:38 a.m., Patient 10’s caregiver (CG1) stated that hospice nurses taught Patient 10 and him on how to use the bed rails safety to prevent injuries. CG1 stated that Patient 10 only uses the bed side rails during sleep, or during perineal (the cleaning of the genital and anal areas (the perineum) to maintain hygiene, prevent infections, and avoid skin breakdown) care. During an interview on 4/23/2026 at 10:38 a.m., Patient 10’s caregiver (CG1) stated that hospice nurses taught both him and Patient 10 how to use the bed rails safely to prevent injuries. CG1 stated that Patient 10 uses bedside rails during perineal (the cleaning of the genital and anal areas (the perineum) care. During an interview and concurrent record review on 4/27/2025 at 10:48 a.m., with the DPCSD, Patient 10’s clinical record, including the “POC (Plan of Care)/IDG (Interdisciplinary Group, consists of Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians that come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) Review form dated 4/22/2026, was reviewed. The DPCSD confirmed that the POC/IDG Review form dated 4/22/2026 did not include an individualized plan of care addressing problems, goals, or interventions related to Patient 10’s safety precautions involving bedside rail use to prevent injury and falls. The DPCSD stated that safety precautions regarding the use of side rails had been provided to Patient 10 and her caregiver; however, it was important to update and individualize Patient 10’s plan of care to ensure all patient problems are identified, goals are established to maintain Patient 10’s overall health and safety, appropriate interventions are implemented to meet those goals, and modifications are made if current interventions are ineffective. During an interview and concurrent record review on 4/27/2025 at 11:28 a.m., with the DPCSD, the “Owner’s Assembly and Operating Manual” for the “Ultra‑Light Plus, Full Electric Low Bed” was reviewed. The DPCSD stated that the manual was provided by the hospice agency’s independent DME (Durable Medical Equipment, any medical equipment used in the home to aid in a better quality of living) supplier. The DPCSD stated and confirmed that the manual indicated the following:Proper patient assessment and monitoring, and proper maintenance and use of equipment are required to reduce the risk of entrapment.The DPCSD stated that proper assessment was completed prior to ordering the patient’s bed and that a care plan should have been developed to address any potential problems that could affect the patient’s safety. g. During a review of Patient 11’s undated clinical record, titled “Personal Information,” the “Personal information” indicated Patient 11’s start of care (SOC) date of 3/27/2026 with a primary diagnosis of malignant neoplasm of bladder (a cancerous tumor (mass of abnormal cells that grow uncontrollably, invade nearby tissues, and can spread to other parts of the body) that starts in the bladder lining and has the potential to grow into the bladder wall or spread to other parts of the body), unspecified. During a review of Patient 11’s clinical record titled, “Current Treatment/Medication/DME,” indicated listed medication which includes: Medication: Eliquis Strength:2.5 milligram (mg, unit of weight) tablet, Dosage: one tablet, Route: oral (by mouth), Frequency: twice daily, Indication: A-fib (a common type of irregular, often rapid heart rhythm caused by misfiring electrical signals, making the heart’s upper chambers quiver instead of beating properly which can cause blood to pool in the heart, increasing the risk of blood clots). Medication: Fentanyl 25 microgram/hour (mcg, unit of weight) transdermal (medication or substances applied directly to the skin) patch, Strength: 25 mcg, Dosage: 1 film, Route: Transdermal, Frequency: Every 72 hours. Rotate sites with every application, Indication: Pain Management. Note: Add a Fentanyl patch 12 for a total of 37 with every dose. Medication: Fentanyl 12 mcg/hr patch, Strength: 12 mcg, Dosage: 1 film, Route: Transdermal, Frequency: Change every 72 hours. Rotate sites with every application, Indication: Pain Management. During an interview and concurrent record review on 4/28/2025 at 10:28 a.m., with the Director of Patient Care Services (DPCS), Patient 11’s clinical record, including the “POC/IDG Review” forms dated 4/1/2026 and 4/15/2026, was reviewed. The DPCS stated and confirmed that the POC/IDG Review forms did not include an individualized plan of care with problems, goals, and interventions addressing Patient 11’s increased risk of bleeding related to the physician‑ordered Eliquis (an anticoagulant used to reduce the body’s ability to form blood clots) and the safe monitoring and proper use of the fentanyl patch (a strong opioid pain medication with risks of overdose and respiratory depression). During an interview on 4/28/2026 at 10:28 a.m., with the DPCS, the DPCS stated that the Fentanyl patch is an opioid transdermal medication used for pain management and is considered a high‑risk medication. The DPCS stated that high‑risk medications like Fentanyl require monitoring for adverse reactions such as overdose and respiratory depression. The DPCS further stated that when a patient is using a Fentanyl patch, the plan of care must include identified problems, interventions, and goals to prevent improper use and unmonitored symptoms that could lead to complications. The DPCS also stated that it is important for the plan of care to include education for the patient and caregiver on symptoms to watch for and when to notify the HA.During an interview on 4/28/2026 at 10:38 a.m., with the DPCS, the DPCS stated that Eliquis is a medication used to prevent blood clots and is considered a high‑risk medication. The DPCS stated that when a patient is taking Eliquis, the plan of care must include bleeding precautions. The DPCS further stated that the plan of care should include assessing and monitoring for signs of bleeding, bruising, and providing education to the patient and caregiver on symptoms to watch for and when to notify the hospice agency. The DPCS stated that unmonitored symptoms could lead to complications such as excessive or internal bleeding.h. During a review of Patient 15’s undated clinical record, titled “Personal Information,” the “Personal information” indicated Patient 15’s start of care (SOC) date of 8/30/2024 with a primary diagnosis of chronic systolic congestive heart failure (a medical condition which occurs when the heart muscle becomes too stiff or thick to relax properly between beats).During a review of Patient 15’s clinical record titled, “Current Treatment/Medication/DME,” indicated listed medication which includes:Medication: Eliquis Strength:2.5 mg tablet, Dosage: one tablet, Route: oral, Frequency: twice a day, Indication: blood thinner.During an interview and concurrent record review on 4/28/2025 at 11:18 a.m., with the DPCS, Patient 15’s clinical record, including the “POC/IDG Review” forms dated 2/18/2026, 3/4/2026, 3/18/2026, 4/1/2026, and 4/15/2026, were reviewed. The DPCS stated and confirmed that the POC/IDG Review forms did not include an individualized plan of care with problems, goals, and interventions addressing Patient 15’s increased risk of bleeding related to the physician‑ordered Eliquis.During an interview on 4/28/2026 at 11:29 a.m., with the DPCS, the DPCS stated that Eliquis is a medication used to prevent blood clots and is considered a high‑risk medication. The DPCS stated that when a patient is taking Eliquis, the plan of care must include bleeding precautions. The DPCS further stated that the plan of care should include assessing and monitoring for signs of bleeding, bruising, and providing education to the patient and caregiver on symptoms to watch for and when to notify the hospice agency. The DPCS stated that unmonitored symptoms could lead to complications such as excessive or internal bleeding. I. During a review of Patient 16’s undated clinical record, titled “Personal Information,” the “Personal information” indicated Patient 16’s start of care (SOC) date of 3/28/2026 with a primary diagnosis of heart disease (condition that affects the heart’s structure or function, making it harder for the heart to pump blood effectively), unspecified and secondary diagnoses that included dependence on renal dialysis (a patient whose kidneys have failed or are not working properly, requiring them to use a machine (hemodialysis) or abdominal catheter (peritoneal dialysis) to clean waste and excess fluid from their). During an interview and concurrent record review on 4/28/2025 at 12:18 p.m. with the DPCS, Patient 16’s clinical record included the following:”Comprehensive Nursing Assessment”, dated 3/28/2026 was reviewed. The DPCS stated and confirmed that the Comprehensive Nursing Assessment indicated surgical wound (a deliberate cut made in the skin, muscle, or tissue by a healthcare professional during a medical procedure) under Integumentary – Skin section but did not identify the type, characteristics and appearance necessary for assessment.“Skin Assessment,” dated 3/28/2026 was reviewed. The DPCS stated and confirmed that the Skin Assessment indicated “dialysis shunt permcath (a soft, flexible tube placed into a large vein, usually in the neck or chest, to act as a long-term access point for hemodialysis (a treatment that uses a machine and a special filter (dialyzer) to remove waste products, toxins, and excess fluid from the blood when the kidneys can no longer perform these functions))” with status of existing but did not include a nursing documentation for assessment of the appearance, status, and characteristics of it. “Skin Assessment,” dated 4/9/2026 was reviewed. The DPCS stated and confirmed that the Skin Assessment indicated “dialysis shunt permcath” with status of existing but did not include a nursing documentation for assessment of the appearance, status and characteristics of it.“Visit Note RN (Registered Nurse),” dated 4/2/2026, 4/16/2026, 4/21/2026, and 4/23/2026 were reviewed. The DPCS stated and confirmed that the Visit Notes RN identified the presence of Perma Cath but did not include a complete assessment of the status, appearance and characteristics of it.“POC (Plan of Care)/IDG Review” form dated 4/1/2026 and 4/15/2026, was reviewed. The DPCS stated and confirmed that the POC/IDG Review forms did not include an individualized plan of care addressing problems, goals, or interventions related to Patient 11’s presence of Perma catheter. The DPCS stated that it is important for the patient to have an individualized care plan specific to proper assessment and monitoring of the Perma Cath. The DPCS stated that the care plan needs to lead to the foundation of care to assess the appearance, monitor for signs and symptoms of infection, pain, discomfort swelling, placement, dressing appearance and the date the dressing was changed. DPCS stated that although Patient 16’s Perma Cath care and dressing change are managed by the dialysis center, it is still need to have a care plan specifically addressing the continuous assessment and monitoring of it. DPCS stated that it is important for the nurses to have a complete assessment to accurately document the status of the Perma Cath. The DPCS stated that care plan should also include patient and patient caregiver’s teaching related to Perma Cath status. The DPCS stated that if Patient 11 and family decided to discontinue the dialysis treatment, the HA will formulate an individualized care plan for it which also includes management of dressing change. The DPCS stated that identified problems, interventions are implemented to meet those goals, and modifications are made if current interventions are ineffective. Findings:a. During a review of Patient 2’s undated clinical record, titled “Personal Information,” the “Personal Information” indicated start of care (SOC) date of 1/27/2026 with a primary diagnosis of hypertensive heart disease with heart failure. The “Personal Information” indicated Patient 2 resided in Assisted Living Facility 1 (ALF 1).During a review of Patient 2’s medical record from Patient 2’s Primary Care Provider (PCP 1, medical professional outside of the HA who serves as main go-to contact for the patient’s health needs to provide preventative care, treat chronic conditions, and coordinate care with specialists), titled “Subjective Objective Assessment Plan (SOAP, standard medical documentation format used to document patient encounters to ensure organized communication and continuity of care) [Follow Up Encounter] Note,” dated 2/2/2026, the “SOAP (Follow Up Encounter) Note” indicated the following:Patient 2 has other medical diagnoses including, DM II.Patient 2’s BG levels range from 166 mg/dL – 351 mg/dL with the last hemoglobin A1c of 8.5.Patient 2 was noncompliant with diet recommendations.Patient 2’s DM II medications included:Mounjaro 2.5 milligrams per 0.5 milliliter subcutaneous pen injector – 2/5 mg subcutaneously every 4 weeks for 4 weeksLantus U-100 insulin 100 units per ml subcutaneous solution – administer 16 units subcutaneously at bedtimeMetformin hydrochloride 1000 mg tablet by mouth twice daily for DM IIDuring a review of Patient 2’s “Comprehensive Nursing Assessment (HOPE Admission),” dated 2/17/2026, the “Comprehensive Nursing Assessment” indicated Patient 2 had insulin-dependent diabetes mellitus (IDDM) under endocrine assessment.During a review of Patient 2’s “Current Treatment/Medication/Durable Medical Equipment (DME) List,” the “Current Treatment/Medication/DME List” indicated a physician’s order, dated 3/11/2026, for Glipizide 5 mg 1 tablet by mouth twice a day for DM II and to hold if BG is below 100 mg/dL.During a review of Patient 2’s BG levels obtained by ALF 1 staff from 1/24/2026 – 4/24/2026, the BG levels were as follows:January 2026 – 97 mg/dL – 363 mg/dLFebruary 2026 – 195 mg/dL – 446 mg/dL (with 3 BG readings above 400 mg/dL)March 2026 – 255 mg/dL – 491 mg/dL (with 4 BG readings above 400 mg/dL)April 2026 – 188 mg/dL – 408 mg/dL (with 2 BG readings above 400 mg/dL)During an observation and concurrent interview on 4/24/2026 at 10:05 a.m., while on a joint home visit with Registered Nurse 1 (RN 1), in Patient 2’s room at ALF 1, Patient 2 was alert, awake with some confusion, and sitting in her wheelchair. RN 1 stated Patient 2 has had episodes of diet noncompliance related to eating concentrated sweets brought to ALF 1 by a friend. RN 1 stated Patient 2’s BG levels range from 200s mg/dL – 300s mg/dL.During a concurrent interview and record review of Patient 2’s BG levels obtained by ALF 1 staff on 4/24/2025 at 10:37 a.m., with Medication Technician 1 (MedTech 1) and RN 1, Patient 2’s current physician orders and BG values were reviewed. MedTech 1 stated Patient 2 has a physician order to check Patient 2’s BG twice a day before administering Glipizide. MedTech 1 stated Patient 2 had a physician’s order for insulin before but did not know why it was discontinued. MedTech 1 stated Patient 2 currently has a physician’s order to administer Glipizide 5 mg twice a day and to hold if BG is below 100 mg/dL. MedTech 1 stated the HA staff did not specify any parameters for the BG levels to prompt the ALF 1 staff to notify the HA nurses. MedTech 1 stated ALF 1 staff did not notify the HA when BG levels were above 400 mg/dL because there was no physician’s order to notify the HA. RN 1 stated he admitted Patient 2 in 1/2026 but he was not aware of the BG levels above 400 mg/dL and the reason why insulin was discontinued.During a concurrent interview and record review of Patient 2’s clinical records, on 4/24/2026 at 1:55 p.m., with the Director of Patient Care Services (DPCS), Patient 2’s “Comprehensive Nursing Assessment,” dated 1/27/2026, Nursing Updated Assessment (HUV 1), dated 2/6/2026, Nursing Updated Assessment (HUV2), dated 2/20/2026, Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 2/4/2026, and “SOAP (Follow Up Encounter) Note,” dated 2/2/2026, were reviewed. The DPCS stated Patient 2’s care plan for endocrine system was not individualized to reflect the current interventions to manage Patient 2’s DM II. The DPCS stated Patient 2’s plan of care did not indicate Patient 2’s noncompliance with the diabetic diet, Glipizide order, and multiple BG levels above 400 mg/dL. The DPCS stated it was important to update the plan of care to closely monitor the BG levels to determine the effectiveness of the interventions or antidiabetic medications ordered and prevent ineffective drug therapy that could place Patient 2 at risk for hypoglycemia or hyperglycemia. The DPCS stated it was important to change the interventions, such as antidiabetic medication/s accordingly, depending on the set goal of the ideal BG level for Patient 2 upon consultation with the Medical Director.During a telephone interview on 4/28/2026 at 2:09 PM, the Medical Director (MD) stated upon Patient 2’s admission to the HA, MD discontinued the order to administer Lantus insulin to Patient 2 and ordered to start Glipizide 2.5 mg twice a day for Patient 2’s DM II because the HA informed MD that ALF 1 was unable to administer Lantus insulin. The Medical Director stated he was under the impression that Patient 2’s DM II was “totally controlled.” The Medical Director stated the Glipizide dose could either be increased or decreased to ensure better BG control depending on the BG values within 1-2 weeks after the start of a particular Glipizide dose. The Medical Director stated Patient 2’s BG must be checked 2 hours before breakfast and before administration of any antidiabetic medication/s and 2 hours after dinner. The Medical Director stated the HA nurse must also educate ALF 1 to ensure Patient 2 does not have access to “unlimited sweets” to better control Patient 2’s BG levels. The Medical Director stated it was important to keep the BG levels controlled and educate the caregivers to report any BG above 400 mg/dL and/or below 65 mg/dL to prevent unnecessary hospitalizations due to complications, such as DKA. b. During a review of Patient 3’s undated clinical record, titled “Personal Information,” the ‘Personal Information” indicated start of care (SOC) date of 2/23/2026 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.During a review of Patient 3’s “Comprehensive Nursing Assessment (HOPE Admission),” dated 2/23/2026, the “Comprehensive Nursing Assessment” indicated Patient 3 has a significant history of recurrent falls with impaired safety awareness and poor short-term memory, contributing to a high fall risk.During a review of Patient 3’s “POC/IDG Review,” dated 4/15/2026, the “POC/IDG Review” indicated a physician’s order, dated 3/9/2026, to administer warfarin sodium 2 mg by mouth daily in the evening for blood blot prevention.During a concurrent interview and record review of Patient 3’s clinical records on 4/28/2026 at 10:22 a.m. with RN 1, Patient 3’s plan of care, visit notes, and assessment notes were reviewed. RN 1 stated “POC/IDG Review,” dated 4/15/2026, did not indicate an individualized plan of care that included problems/goals/interventions to address Patient 3’s increased risks of bleeding related to the physician-ordered warfarin use and increased risk for injury related to the recurrent falls. RN 1 stated it was important to update and individualize Patient 3’s plan of care to ensure all patient problems are identified, goals are set to fix or maintain Patient 3’s health, implement the interventions to meet the goals and revise the interventions, if ineffective. c. During a review of Patient 4’s undated clinical record, titled “Personal Information,” the “Personal Information” indicated SOC date of 11/24/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.During a concurrent interview and record review of Patient 4’s clinical records on 4/28/2026 at 11:05 a.m. with RN 1, Patient 4’s plan of care, visit notes, and assessment notes were reviewed. RN 1 stated the “POC/IDG Review,” dated 11/26/2026 and “POC/IDG Review,” dated 12/10/2026 did not indicate an individualized plan of care that included any problems/goals/interventions. RN 1 stated it was important to update and individualize Patient 4’s plan of care to ensure all patient problems are identified, goals are set to fix or maintain Patient 4’s health, implement the interventions to meet the goals and revise the interventions, if ineffective. d. During a review of Patient 6’s undated clinical record, titled “Personal Information,” the “Personal Information” indicated SOC date of 3/11/2026 with a primary diagnosis of Parkinsonism and severe chronic kidney disease.During a review of Patient 6’s “Comprehensive Nursing Assessment (HOPE Admission),” dated 3/11/2026, the “Comprehensive Nursing Assessment” indicated on Patient 6’s sleep pattern “excessive sleep” with sleep duration lasting between 10-12 hours in a 24-hour period. The “Comprehensive Nursing Assessment” also indicated Patient 6 had no pain observed upon assessment but has had occasional generalized pain with activity that is relieved by non-opioid analgesic and rest.During a review of Patient 6’s “Nursing Updated Assessment (HUV 1),” dated 3/23/2026, the “Nursing Updated Assessment (HUV 1)” indicated on Patient 6’s sleep pattern “excessive sleep” with sleep duration lasting between 10-12 hours in a 24-hour period. The ‘Nursing Updated Assessment (HUV 1)” indicated Patient 6 had no pain upon assessment but has had occasional generalized pain with activity that is relieved by non-opioid analgesic and rest.During a review of Patient 6’s “Nursing Updated Assessment (HUV 2),” dated 3/30/2026, the “Nursing Updated Assessment (HUV 2)” indicated on Patient 6’s sleep pattern “excessive sleep” with sleep duration lasting between 10-12 hours in a 24-hour period. The ‘Nursing Updated Assessment (HUV 2)” indicated Patient 6 had no pain upon assessment but has had occasional generalized pain worse with activity and relieved by opioid analgesic and rest.During a review of Patient 6’s “Visit Note RN,” dated 4/13/2026, the “Visit Note RN” indicated Patient 6 was “noted with increased sleeping hours, skips food occasionally.” The “Visit Note RN” also indicated Patient 6 was noted with “increased tremors due to Parkinson’s and increased pain episodes.” The “Visit Note RN” indicated RN 2 received new orders to change the Parkinson’s medication from three times a day to four times a day and to administer Tramadol three times a day routinely.During a review of Patient 6’s “Visit Note RN,” dated 4/20/2026, the “Visit Note RN” indicated the facility reported Patient 6 “sleeping a lot recently… and skips food often.”During a review of Patient 6’s “Visit Note Short Form,” dated 4/21/2026, the “Visit Note Short Form” indicated the facility reported that Patient 6 was “constantly sleeping and can’t wake up.” The “Visit Note Short Form” indicated when RN 2 conducted a home visit for Patient 6, Patient 6 was sleeping in her bed, was able to wake up but falls back to sleep.During a concurrent interview and review of Patient 6’s clinical records on 4/28/2026 at 11:56 a.m. with RN 2, Patient 6’s visit notes, assessment notes, and care plans were reviewed. RN 2 stated there was no individualized care plan to address increased sleeping, increased pain, and increased tremors. RN 1 stated it was important to update and individualize Patient 6’s plan of care to ensure all patient problems are identified, goals are set to fix or maintain Patient 6’s health, implement the interventions to meet the goals and revise the interventions, if ineffective. e. During a review of Patient 7’s undated clinical record, titled “Personal Information,” the “Personal Information” indicated SOC date of 3/31/2026 with a primary diagnosis of Parkinson’s disease without dyskinesia and secondary diagnoses hypertensive heart disease without heart failure.During a review of Patient 7’s “Comprehensive Nursing Assessment,” dated 3/31/2026, the “Comprehensive Nursing Assessment” indicated Patient 7’s “fall risk remains high, with four documented falls since 3/10/2026 and a total of nine falls reported within the current year.” The “Comprehensive Nursing Assessment” indicated Patient 7 was “now presenting with generalized weakness and inability to ambulate independently, requiring durable medical equipment for mobility and the use of a chair exit alarm to prevent falls.”During a review of Patient 7’s “Current Treatment/Medication/DME List,” it indicated a physician’s order, dated 3/31/2026, to administer Aspirin 81 milligrams chewable tablet orally daily for hypertension.During a concurrent interview and record review of Patient 7’s clinical records on 4/28/2026 at 11:29 a.m. with RN 1, Patient 7’s care plans, assessment notes, and physician orders were reviewed. RN 1 stated there was no documented evidence that Patient 7’s plan of care was individualized to reflect the risks of bleeding related to aspirin use and high risk of falls related to recurrent falls prior to hospice admission and the interventions implemented. RN 1 stated Patient 7’s plan of care must be updated to ensure all interventions are consistently implemented to ensure patient safety due to risks for injury and bleeding. During a review of the HA’s policy and procedures (P&P), titled “The Plan of Care,” dated 4/2020, P&P indicated the following:A written individualized patient and family/caregiver plan of care must be established and maintained for each individual admitted to the hospice program. The individualized plan of care must be reviewed by the rest of the interdisciplinary group within 2 days of start of care.The care provided to the patient must be in accordance with the plan of care.The plan of care must be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and must be reviewed on a regular basis but no less than every 15 days.Any change in the patient’s condition must result in a change in the plan of care, prior to the implementation of the new service.The plan of care must focus on the identified problems, goals, and interventions.Care decisions and services to be provided must be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes.Each patient must be monitored for his/her response to care or services provided against established patient goals and patient outcomes to evaluate progress toward goals.The plan of care must contain, but would not be limited to, the following:-safety measures to protect again abuse, injury, as appropriate-nutritional requirements-DME and medical supplies necessary to meet the patient needs-pain and symptom management interventions-drugs and treatments (including allergies)-physician orders-measurable outcomes anticipated from implementing and coordinating the plan of care”

“Based on observation, interviews, and record review, the Hospice Agency (HA, healthcare agency that provides specialized care and support for people with a terminal illness and nearing the end of life) failed to ensure the interdisciplinary group directed, supervised, and coordinated the provision of diabetic care and services for one of 19 sampled patients (Patient 2).This failure had the potential to result in ineffective drug therapy related to inconsistent monitoring of the diet compliance and high blood glucose (BG) levels to treat Patient 2’s diabetic needs. Findings:During a review of Patient 2’s undated clinical record, titled “Personal Information,” the “Personal Information” indicated start of care (SOC) date of 1/27/2026 with a primary diagnosis of hypertensive heart disease with heart failure. The “Personal Information” indicated Patient 2 resided in Assisted Living Facility 1 (ALF 1).During a review of Patient 2’s medical record from Primary Care Provider (PCP 1), titled “Subjective Objective Assessment Plan (SOAP, standard medical documentation format used to document patient encounters to ensure organized communication and continuity of care) [Follow Up Encounter] Note,” dated 2/2/2026, the “SOAP (Follow Up Encounter) Note” indicated the following:Patient 2 has other medical diagnoses including, but were not limited to, DM II.Patient 2’s BG levels range from 166 mg/dL – 351 mg/dL with the last hemoglobin A1c of 8.5.Patient 2 was noncompliant with diet recommendations.During a review of Patient 2’s “Comprehensive Nursing Assessment (HOPE Admission),” dated 2/17/2026, the “Comprehensive Nursing Assessment” indicated Patient 2 had insulin-dependent diabetes mellitus (IDDM) under endocrine assessment.During a review of Patient 2’s “Current Treatment/Medication/Durable Medical Equipment (DME) List,” the “Current Treatment/Medication/DME List” indicated a physician’s order, dated 3/11/2026, for Glipizide 5 mg 1 tablet by mouth twice a day for DM II and to hold if BG is below 100 mg/dL.During a review of Patient 2’s BG levels obtained by ALF 1 staff from 1/24/2026 – 4/24/2026, the BG levels were as follows:January 2026 – 97 mg/dL – 363 mg/dLFebruary 2026 – 195 mg/dL – 446 mg/dL (with 3 BG readings above 400 mg/dL)March 2026 – 255 mg/dL – 491 mg/dL (with 4 BG readings above 400 mg/dL)April 2026 – 188 mg/dL – 408 mg/dL (with 2 BG readings above 400 mg/dL)During an observation and concurrent interview on 4/24/2026 at 10:05 a.m., while on a joint home visit with Registered Nurse 1 (RN 1), in Patient 2’s room, Patient 2 was alert awake with some confusion, and sitting in her wheelchair. RN 1 stated Patient 2 has had episodes of diet noncompliance related to eating concentrated sweets brought to ALF 1 by a friend. RN 1 stated Patient 2’s BG levels range from 200s mg/dL – 300s mg/dL.During a concurrent interview and record review of Patient 2’s BG levels obtained by ALF 1 staff on 4/24/2025 at 10:37 a.m., with Medication Technician 1 (MedTech 1) and RN 1, Patient 2’s current physician orders and BG values were reviewed. MedTech 1 stated Patient 2 has a physician order to check Patient 2’s BG twice a day before administering Glipizide. MedTech 1 stated Patient 2 has a physician’s order to administer Glipizide 5 mg twice a day and to hold if BG is below 100 mg/dL. MedTech 1 stated ALF 1 staff administered Glipizide as ordered by the physician but did not notify the HA when BG levels were above 400 mg/dL because there was no physician’s order to notify the HA.During a concurrent interview and record review of Patient 2’s HA binder at ALF 1 on 4/24/2026 at 10:54 a.m. with Registered Nurse 1 (RN 1), Patient 2’s “POC/IDG Review,” dated 4/22/2026, was reviewed. RN 1 stated the “POC/IDG Review” indicated the physician order to administer Lantus 100 units/ml 16 units subcutaneously at bedtime was discontinued on 2/11/2026. RN 1 stated he did not know the reason why Lantus insulin was discontinued and Glipizide was started. RN 1 stated the “POC/IDG Review” also indicated to “check blood sugar at bedtimes.” RN 1 stated the “POC/IDG Review” was not updated to include the problems regarding Patient 2’s high BG values and Patient 2’s noncompliance with the diet related to “eating a lot of sweets,” goals, and current interventions. RN 1 stated he was not aware of BG levels above 400 mg/dL. RN 1 stated he could not recall if RN 1 asked the physician to include the parameters for the antidiabetic medication order and if RN 1 educated the ALF 1 staff to report BG levels above 400 mg/dL to the HA.During a concurrent interview and record review of Patient 2’s clinical records, on 4/24/2026 at 1:55 p.m., with the Director of Patient Care Services (DPCS), Patient 2’s “Comprehensive Nursing Assessment,” dated 1/27/2026, Nursing Updated Assessment (HUV 1), dated 2/6/2026, Nursing Updated Assessment (HUV2), dated 2/20/2026, Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 2/4/2026, and “SOAP (Follow Up Encounter) Note,” dated 2/2/2026, were reviewed. The DPCS stated she was not aware that Patient 2 had BG levels above 400 mg/dL. The DPCS stated the BG goal must be between 100 mg/dL – 180 mg/dL to ensure controlled BG levels to provide comfort and prevent diabetic complications, such as blindness, delayed wound healing, pain, and increased risks for infection. The DPCS stated the skilled nurse (SN) must assess during each home visit the BG trends and report to the Medical Director the abnormal values to adjust the dose and/or frequency of the antidiabetic medication as necessary. The DPCS stated the SN must educate the ALF 1 staff (caregivers) to call the HA if BG above 200 mg/dL. The DPCS stated the SN must educate Patient 2 and ALF 1 staff (caregivers) the importance of Patient 2’s compliance with the diet. The DPCS stated if the BG was determined and reported to be above 400 mg/dL, the HA staff must send a SN to evaluate Patient 2 at ALF 1 and report to the Medical Director the BG reading, Patient 2’s condition, and obtain new orders, if any, to lower Patient 2’s BG. The DPCS stated there was no documented evidence that SN provided patient-specific diabetic teachings to ALF 1 staff.During a telephone interview on 4/28/2026 at 2:09 PM, the Medical Director (MD) stated upon Patient 2’s admission to the HA, MD discontinued the order to administer Lantus insulin to Patient 2 and ordered to start Glipizide 2.5 mg twice a day for Patient 2’s DM II because the HA informed MD that ALF 1 was unable to administer Lantus insulin. The Medical Director stated he was under the impression that Patient 2’s DM II was “totally controlled.” The Medical Director stated the Glipizide dose could either be increased or decreased to ensure better BG control depending on the BG values within 1-2 weeks after the start of a particular Glipizide dose. The Medical Director stated Patient 2’s BG must be checked 2 hours before breakfast and before administration of any antidiabetic medication/s and 2 hours after dinner. The Medical Director stated the HA nurse must also educate ALF 1 to closely monitor Patient 2 to ensure Patient 2 does not have access to “unlimited sweets” to better control Patient 2’s BG levels. The Medical Director stated it was important to keep the BG levels controlled and educate the caregivers to report any BG above 400 mg/dL and/or below 65 mg/dL to prevent unnecessary hospitalizations due to complications, such as DKA.During a review of the HA’s policy and procedures (P&P), titled ”Care/Service Coordination,” dated 4/2020, the P&P indicated the following:All personnel must be knowledgeable regarding patient needs, goals of care, and services. All organization personnel involved in patient care/service, including those providing contracted services, must have access to the plan of care/service and all other relevant patient information to ensure coordination and continuity.A registered nurse must be assigned to a patient receiving skilled nursing. The registered nurse is responsible for facilitating communication about changes in the patient’s status among all assigned disciplines.Written evidence of care coordination must be found in the plan of care/service, case conference summary forms, clinical notes in the patient’s clinical record or interdisciplinary group meeting notes.Organization personnel must communicate changes in a timely manner via telephone, one­on-one meetings, case conferences, and home visits. Documentation of all communications must be included in the clinical record on a communication note, case conference summary, or clinical note. Documentation must include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication.”

“Based on observation, interview, and record review, the Hospice Agency (HA, healthcare agency providing care to terminally ill patients who have six months or less to live) failed to ensure patients’ clinical records contained completed individualized plans of care, completed clinical notes, updated plans of care, and comprehensive assessments for nine of 14 sampled patients (Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 10, Patient 11, Patient 15, and Patient 16) by failing to: a. Ensure Patient 2’s updated comprehensive nursing assessments, visit notes, and individualized plans of care included Patient 2’s BG values, BG parameters for Patient 2 to prompt ALF 1 staff to notify the HA nurse, Patient 2’s noncompliance to the physician-prescribed diet, all interventions to manage Patient 2’s DM II, and HA teachings provided to Patient 2 and the ALF 1 staff.b. Ensure Patient 3’s plan of care was individualized to address increased risks for bleeding related to Coumadin use and increased risk of injury related to history of falls.c. Ensure Patient 4’s “POC/IDG Review,” dated 11/26/2025, and “POC/IDG Review,” dated 12/10/2025 was individualized and completed with all problems/goals/interventions listed.d. Ensure Patient 6’s plan of care was individualized to address concerns for excessive sleeping, increased pain (Norco vs. Tramadol), and increased tremors.e. Ensure Patient 7’s plan of care was individualized to address bleeding precautions related to aspirin use and history of falls.f. Ensure Patient 10’s plan of care was individualized to address safe use of bedside rails to prevent injury.g. Ensure Patient 11’s plan of care was individualized to address bleeding precautions while on anticoagulant medication (Eliquis) and potential adverse reactions to opioid medication (Fentanyl). h.Ensure Patient 11’s plan of care (an individualized, written document outlining the specific medical, emotional, and spiritual support for a patient) was followed and implemented to fully reflect the assessment and monitoring of the Port-a-Cath site in the clinical record documentation.\ i. Ensure Patient 15’s plan of care was individualized to address bleeding precautions while on anticoagulant medication (Eliquis).j. Ensure Patient 16’s plan of care was individualized to address assessment, monitoring, and care of a Perma catheter (a specialized, long-term flexible tube surgically placed into a large vein, typically in the neck or chest, to provide constant access to the bloodstream). These failures had the potential to result in a decline in the patients’ condition due to not receiving the necessary care and services to maintain comfort related to incomplete and inaccurate clinical records patients that could lead to a gap in the continuity of care. f. During a review of Patient 10’s undated clinical record, titled “Personal Information,” the “Personal information” indicated Patient 10’s start of care (SOC) date of 4/18/2026 with a primary diagnosis of unspecified diastolic congestive heart failure (a medical condition which occurs when the heart muscle becomes too stiff or thick to relax properly between beats). During a concurrent observation and interview on 4/23/2026 at 10:12 a.m., conducted during a joint home visit with the Director of Patient Care Services Designee (DPCSD) in Patient 10’s living room, Patient 10 was observed resting comfortably in a hospital bed with safety rails up. Patient 10 was alert and oriented to person, place, time, and events, and was receiving oxygen therapy via nasal cannula connected to an oxygen concentrator set at 2 liters per minute. Patient 10 stated that she and her family requested a hospital bed with side rails to prevent her from falling, especially when turning to her side. She stated she can turn from side to side but loses control when lying on her side, with her leg falling first. Patient 10 further stated she is unable to walk and remains either in bed or in a wheelchair. During an interview on 4/23/2026 at 10:38 a.m., Patient 10’s caregiver (CG1) stated that hospice nurses taught Patient 10 and him on how to use the bed rails safety to prevent injuries. CG1 stated that Patient 10 only uses the bed side rails during sleep, or during perineal (the cleaning of the genital and anal areas (the perineum) to maintain hygiene, prevent infections, and avoid skin breakdown) care. During an interview on 4/23/2026 at 10:38 a.m., Patient 10’s caregiver (CG1) stated that hospice nurses taught both him and Patient 10 how to use the bed rails safely to prevent injuries. CG1 stated that Patient 10 uses bedside rails during perineal (the cleaning of the genital and anal areas (the perineum) care. During an interview and concurrent record review on 4/27/2025 at 10:48 a.m., with the DPCSD, Patient 10’s clinical record, including the “POC (Plan of Care)/IDG (Interdisciplinary Group, consists of Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians that come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) Review” form dated 4/22/2026, was reviewed. The DPCSD confirmed that the POC/IDG Review form dated 4/22/2026 did not include an individualized plan of care addressing problems, goals, or interventions related to Patient 10’s safety precautions involving bedside rail use to prevent injury and falls. The DPCSD stated that safety precautions regarding the use of side rails had been provided to Patient 10 and her caregiver; however, it was important to update and individualize Patient 10’s plan of care to ensure all patient problems are identified, goals are established to maintain Patient 10’s overall health and safety, appropriate interventions are implemented to meet those goals, and modifications are made if current interventions are ineffective. During an interview and concurrent record review on 4/27/2025 at 11:28 a.m., with the DPCSD, the “Owner’s Assembly and Operating Manual” for the “Ultra‑Light Plus, Full Electric Low Bed” was reviewed. The DPCSD stated that the manual was provided by the hospice agency’s independent DME (Durable Medical Equipment, any medical equipment used in the home to aid in a better quality of living) supplier. The DPCSD stated and confirmed that the manual indicated the following:Proper patient assessment and monitoring, and proper maintenance and use of equipment are required to reduce the risk of entrapment.The DPCSD stated that proper assessment was completed prior to ordering the patient’s bed and that a care plan should have been developed to address any potential problems that could affect the patient’s safety. g. During a review of Patient 11’s undated clinical record, titled “Personal Information,” the “Personal information” indicated Patient 11’s start of care (SOC) date of 3/27/2026 with a primary diagnosis of malignant neoplasm of bladder (a cancerous tumor (mass of abnormal cells that grow uncontrollably, invade nearby tissues, and can spread to other parts of the body) that starts in the bladder lining and has the potential to grow into the bladder wall or spread to other parts of the body), unspecified. During a review of Patient 11’s clinical record titled, “Current Treatment/Medication/DME,” indicated listed medication which includes: Medication: Eliquis Strength:2.5 milligram (mg, unit of weight) tablet, Dosage: one tablet, Route: oral (by mouth), Frequency: twice daily, Indication: A-fib (a common type of irregular, often rapid heart rhythm caused by misfiring electrical signals, making the heart’s upper chambers quiver instead of beating properly which can cause blood to pool in the heart, increasing the risk of blood clots). Medication: Fentanyl 25 microgram/hour (mcg, unit of weight) transdermal (medication or substances applied directly to the skin) patch, Strength: 25 mcg, Dosage: 1 film, Route: Transdermal, Frequency: Every 72 hours. Rotate sites with every application, Indication: Pain Management. Note: Add a Fentanyl patch 12 for a total of 37 with every dose. Medication: Fentanyl 12 mcg/hr patch, Strength: 12 mcg, Dosage: 1 film, Route: Transdermal, Frequency: Change every 72 hours. Rotate sites with every application, Indication: Pain Management. During an interview and concurrent record review on 4/28/2025 at 10:28 a.m. with the Director of Patient Care Services (DPCS), Patient 11’s clinical record, including the “POC/IDG Review” forms dated 4/1/2026 and 4/15/2026, was reviewed. The DPCS stated and confirmed that the POC/IDG Review forms did not include an individualized plan of care with problems, goals, and interventions addressing Patient 11’s increased risk of bleeding related to the physician‑ordered Eliquis (an anticoagulant used to reduce the body’s ability to form blood clots) and the safe monitoring and proper use of the Fentanyl patch (a strong opioid pain medication with risks of overdose and respiratory depression).During an interview on 4/28/2026 at 10:28 a.m., with the DPCS, the DPCS stated that the Fentanyl patch is an opioid transdermal medication used for pain management and is considered a high‑risk medication. The DPCS stated that high‑risk medications like Fentanyl require monitoring for adverse reactions such as overdose and respiratory depression. The DPCS further stated that when a patient is using a Fentanyl patch, the plan of care must include identified problems, interventions, and goals to prevent improper use and unmonitored symptoms that could lead to complications. The DPCS also stated that it is important for the plan of care to include education for the patient and caregiver on symptoms to watch for and when to notify the HA.During an interview on 4/28/2026 at 10:38 a.m., with the DPCS, the DPCS stated that Eliquis is a medication used to prevent blood clots and is considered a high‑risk medication. The DPCS stated that when a patient is taking Eliquis, the plan of care must include bleeding precautions. The DPCS further stated that the plan of care should include assessing and monitoring for signs of bleeding, bruising, and providing education to the patient and caregiver on symptoms to watch for and when to notify the hospice agency. The DPCS stated that unmonitored symptoms could lead to complications such as excessive or internal bleeding.During an interview and concurrent record review on 4/27/2025 at 10:45 p.m. with the Director of Patient Care Services Designee (DPCSD), Patient 11’s clinical record, titled “POC (Plan of Care)/IDG (Interdisciplinary Group) Review” forms dated 4/1/2026 and 4/15/2026, was reviewed. The DPCSD confirmed and stated that the POC/IDG Review forms dated 4/1/2026 and 4/15/2026 included the following care plan under the “Cardiovascular” section:Presence of a port‑a‑Cath in the right subclavian area.Goals: Patient will remain free from signs and symptoms of infection related to the port‑a‑Cath by the next IDG.Patient/patient’s caregiver (PCG) will verbalize understanding of medication, treatment, care orders, and side effects by the next IDG.Maintain peripheral circulation for patient comfort.Interventions: Assess and monitor cardiac status at every visit.Assess and monitor the port‑a‑Cath site for infection, inflammation, or pain.Educate the patient/family/PCG to notify hospice of any changes.Instruct the patient/PCG regarding new medications, treatments, care orders, and potential side effects.Assess the effectiveness of current and new medications, treatments, and care. During an interview and concurrent record review on 4/27/2025 at 11:38 a.m., with the Director of Patient Care Services Designee (DPCSD), Patient 11’s clinical record, including the “Comprehensive Nursing Assessment” dated 3/27/2026 and the “Nursing Updated Assessment” dated 4/17/2026, was reviewed. The DPCSD stated and confirmed that she documented the presence of Patient 11’s port‑a‑Cath in the right subclavian area in the IV (Intravenous, into the vein) assessment section but did not provide a complete assessment that included the characteristics, appearance, and status of the port‑a‑Cath site. The DPCSD stated that a complete assessment of the port‑a‑Cath should include, but is not limited to, the following:Condition of the skin surrounding the port‑a‑CathPresence of redness, swelling, or warmthPresence of drainage, odor, or signs of infectionPatient‑reported pain, discomfort, or tenderness at the siteFunctionality and patency status of the port‑a‑Cath During an interview and concurrent record review on 4/27/2025 at 11:45 a.m., with the Director of Patient Care Services Designee (DPCSD), Patient 11’s clinical record, titled “Visit Note RN,” entries dated 4/6/2026, 4/10/2026, 4/13/2026, and 4/20/2026, were reviewed. The DPCSD stated and confirmed that the visiting nurses documented the presence of Patient 11’s port‑a‑Cath in the right subclavian area in the narrative notes but did not provide a complete assessment in accordance with the patient’s plan of care. The DPCSD stated it is important for nurses to follow the care plan to ensure an accurate and comprehensive assessment of the port‑a‑Cath, including monitoring for signs and symptoms of infection, changes in appearance, discomfort, or pain. The DPCSD further stated that incomplete assessments could lead to missed complications and inadequate monitoring of Patient 11’s right subclavian port‑a‑cath. h. During a review of Patient 15’s undated clinical record, titled “Personal Information,” the “Personal information” indicated Patient 15’s start of care (SOC) date of 8/30/2024 with a primary diagnosis of chronic systolic congestive heart failure (a medical condition which occurs when the heart muscle becomes too stiff or thick to relax properly between beats).During a review of Patient 15’s clinical record titled, “Current Treatment/Medication/DME,” indicated listed medication which includes:Medication: Eliquis Strength:2.5 mg tablet, Dosage: one tablet, Route: oral, Frequency: twice a day, Indication: blood thinner.During an interview and concurrent record review on 4/28/2025 at 11:18 a.m., with the DPCS, Patient 15’s clinical record, including the “POC/IDG Review” forms dated 2/18/2026, 3/4/2026, 3/18/2026, 4/1/2026, and 4/15/2026, were reviewed. The DPCS stated and confirmed that the POC/IDG Review forms did not include an individualized plan of care with problems, goals, and interventions addressing Patient 11’s increased risk of bleeding related to the physician‑ordered Eliquis.During an interview on 4/28/2026 at 11:29 a.m., with the DPCS, the DPCS stated that Eliquis is a medication used to prevent blood clots and is considered a high‑risk medication. The DPCS stated that when a patient is taking Eliquis, the plan of care must include bleeding precautions. The DPCS further stated that the plan of care should include assessing and monitoring for signs of bleeding, bruising, and providing education to the patient and caregiver on symptoms to watch for and when to notify the hospice agency. The DPCS stated that unmonitored symptoms could lead to complications such as excessive or internal bleeding.I. During a review of Patient 16’s undated clinical record, titled “Personal Information,” the “Personal information” indicated Patient 16’s start of care (SOC) date of 3/28/2026 with a primary diagnosis of heart disease (condition that affects the heart’s structure or function, making it harder for the heart to pump blood effectively), unspecified and secondary diagnoses that included dependence on renal dialysis (a patient whose kidneys have failed or are not working properly, requiring them to use a machine (hemodialysis) or abdominal catheter (peritoneal dialysis) to clean waste and excess fluid from their). During an interview and concurrent record review on 4/28/2025 at 12:18 p.m., with the DPCS, Patient 16’s clinical record, including the following:“Comprehensive Nursing Assessment,” dated 3/28/2026 was reviewed. The DPCS stated and confirmed that the Comprehensive Nursing Assessment indicated surgical wound (a deliberate cut made in the skin, muscle, or tissue by a healthcare professional during a medical procedure) under Integumentary – Skin section but did not identify the type, characteristics and appearance necessary for assessment.“Skin Assessment,” dated 3/28/2026 was reviewed. The DPCS stated and confirmed that the Skin Assessment indicated “dialysis shunt permcath (a soft, flexible tube placed into a large vein, usually in the neck or chest, to act as a long-term access point for hemodialysis (a treatment that uses a machine and a special filter (dialyzer) to remove waste products, toxins, and excess fluid from the blood when the kidneys can no longer perform these functions) with status of existing but did not include a nursing documentation for assessment of the appearance, status, and characteristics of it. “Skin Assessment,” dated 4/9/2026 was reviewed. The DPCS stated and confirmed that the Skin Assessment indicated “dialysis shunt permcath” with status of existing but did not include a nursing documentation for assessment of the appearance, status and characteristics of it.“Visit Note RN (Registered Nurse),” dated 4/2/2026, 4/16/2026, 4/21/2026, and 4/23/2026 were reviewed. The DPCS stated and confirmed that the Visit Notes RN identified the presence of Perma Cath but did not include a complete assessment of the status, appearance and characteristics of it.“POC (Plan of Care)/IDG Review” form dated 4/1/2026 and 4/15/2026, was reviewed. The DPCS stated and confirmed that the POC/IDG Review forms did not include an individualized plan of care addressing problems, goals, or interventions related to Patient 11’s presence of Perma catheter. The DPCS stated that it is important for the patient to have an individualized care plan specific to proper assessment and monitoring of the Perma Cath. The DPCS stated that the care plan needs to lead to the foundation of care to assess the appearance, monitor for signs and symptoms of infection, pain, discomfort swelling, placement, dressing appearance and the date the dressing was changed. DPCS stated that although Patient 16’s Perma Cath care and dressing change are managed by the dialysis center, it is still need to have a care plan specifically addressing the continuous assessment and monitoring of it. DPCS stated that it is important for the nurses to have a complete assessment to accurately document the status of the Perma Cath. The DPCS stated that care plan should also include patient and patient caregiver’s teaching related to Perma Cath status. The DPCS stated that if Patient 11 and family decided to discontinue the dialysis treatment, the HA will formulate an individualized care plan for it which also includes management of dressing change. The DPCS stated that identified problems, interventions are implemented to meet those goals, and modifications are made if current interventions are ineffective. Findings:During a review of Patient 2’s undated clinical record, titled “Personal Information,” the “Personal Information” indicated start of care (SOC) date of 1/27/2026 with a primary diagnosis of hypertensive heart disease with heart failure. The “Personal Information” indicated Patient 2 resided in Assisted Living Facility 1 (ALF 1).During a review of Patient 2’s medical record from Primary Care Provider (PCP 1), titled “Subjective Objective Assessment Plan (SOAP, standard medical documentation format used to document patient encounters to ensure organized communication and continuity of care) [Follow Up Encounter] Note,” dated 2/2/2026, the “SOAP (Follow Up Encounter) Note” indicated the following:Patient 2 has other medical diagnoses including, but were not limited to, DM II.Patient 2’s BG levels range from 166 mg/dL – 351 mg/dL with the last hemoglobin A1c of 8.5.Patient 2 was noncompliant with diet recommendations.During a review of Patient 2’s “Comprehensive Nursing Assessment (HOPE Admission),” dated 2/17/2026, the “Comprehensive Nursing Assessment” indicated Patient 2 had insulin-dependent diabetes mellitus (IDDM) under endocrine assessment.During a review of Patient 2’s “Current Treatment/Medication/Durable Medical Equipment (DME) List,” the “Current Treatment/Medication/DME List” indicated a physician’s order, dated 3/11/2026, for Glipizide 5 mg 1 tablet by mouth twice a day for DM II and to hold if BG is below 100 mg/dL.During a review of Patient 2’s BG levels obtained by ALF 1 staff from 1/24/2026 – 4/24/2026, the BG levels were as follows:January 2026 – 97 mg/dL – 363 mg/dLFebruary 2026 – 195 mg/dL – 446 mg/dL (with 3 BG readings above 400 mg/dL)March 2026 – 255 mg/dL – 491 mg/dL (with 4 BG readings above 400 mg/dL)April 2026 – 188 mg/dL – 408 mg/dL (with 2 BG readings above 400 mg/dL)During an observation and concurrent interview on 4/24/2026 at 10:05 a.m., while on a joint home visit with Registered Nurse 1 (RN 1), in Patient 2’s room, Patient 2 was alert awake with some confusion, and sitting in her wheelchair. RN 1 stated Patient 2 has had episodes of diet noncompliance related to eating concentrated sweets brought to ALF 1 by a friend. RN 1 stated Patient 2’s BG levels range from 200s mg/dL – 300s mg/dL.During a concurrent interview and record review of Patient 2’s BG levels obtained by ALF 1 staff on 4/24/2025 at 10:37 a.m., with Medication Technician 1 (MedTech 1) and RN 1, Patient 2’s current physician orders and BG values were reviewed. MedTech 1 stated Patient 2 has a physician order to check Patient 2’s BG twice a day before administering Glipizide. MedTech 1 stated Patient 2 has a physician’s order to administer Glipizide 5 mg twice a day and to hold if BG is below 100 mg/dL. MedTech 1 stated ALF 1 staff administered Glipizide as ordered by the physician but did not notify the HA when BG levels were above 400 mg/dL because there was no physician’s order to notify the HA.During a concurrent interview and record review of Patient 2’s HA binder at ALF 1 on 4/24/2026 at 10:54 a.m. with Registered Nurse 1 (RN 1), Patient 2’s “POC/IDG Review,” dated 4/22/2026, was reviewed. RN 1 stated the “POC/IDG Review” indicated the physician order to administer Lantus 100 units/ml 16 units subcutaneously at bedtime was discontinued on 2/11/2026. RN 1 stated he did not know the reason why Lantus insulin was discontinued and Glipizide was started. RN 1 stated the “POC/IDG Review” also indicated to “check blood sugar at bedtimes.” RN 1 stated the “POC/IDG Review” was not updated to include the problems regarding Patient 2’s high BG values and Patient 2’s noncompliance with the diet related to “eating a lot of sweets,” goals, and current interventions. RN 1 stated he was not aware of BG levels above 400 mg/dL. RN 1 stated he could not recall if RN 1 asked the physician to include the parameters for the antidiabetic medication order and if RN 1 educated the ALF 1 staff to report BG levels above 400 mg/dL to the HA.During a concurrent interview and record review of Patient 2’s clinical records, on 4/24/2026 at 1:55 p.m., with the Director of Patient Care Services (DPCS), Patient 2’s “Comprehensive Nursing Assessment,” dated 1/27/2026, Nursing Updated Assessment (HUV 1), dated 2/6/2026, Nursing Updated Assessment (HUV2), dated 2/20/2026, Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 2/4/2026, and “SOAP (Follow Up Encounter) Note,” dated 2/2/2026, were reviewed. The DPCS stated she was not aware that Patient 2 had BG levels above 400 mg/dL. The DPCS stated the BG goal must be between 100 mg/dL – 180 mg/dL to ensure controlled BG levels to provide comfort and prevent diabetic complications, such as blindness, delayed wound healing, pain, and increased risks for infection. The DPCS stated the skilled nurse (SN) must assess during each home visit the BG trends and report to the Medical Director the abnormal values to adjust the dose and/or frequency of the antidiabetic medication as necessary. The DPCS stated the SN must educate the ALF 1 staff (caregivers) to call the HA if BG above 200 mg/dL. The DPCS stated the SN must educate Patient 2 and ALF 1 staff (caregivers) the importance of Patient 2’s compliance with the diet. The DPCS stated if the BG was determined and reported to be above 400 mg/dL, the HA staff must send a SN to evaluate Patient 2 at ALF 1 and report to the Medical Director the BG reading, Patient 2’s condition, and obtain new orders, if any, to lower Patient 2’s BG. The DPCS stated there was no documented evidence that SN provided patient-specific diabetic teachings to ALF 1 staff.During a concurrent interview and record review on 4/24/2026 at 1:55 p.m., with the Director of Patient Care Services (DPCS), Patient 2’s clinical records were reviewed. The DCPS stated the following:The DPCS stated she was not aware of Patient 2’s BG levels above 400 mg/dL. The DPCS stated the RN assessments were incomplete and inaccurate because there was no documented evidence that RN 1 identified and documented Patient 2’s baseline high BG levels prior to hospice admission, Patient 2’s noncompliance with the prescribed diet, Patient 2’s previous antidiabetic medications, and/or the inability of Patient 2’s caregivers to administer Lantus insulin as ordered by the physician. The DPCS stated incomplete and inaccurate assessments of Patient 2’s BG levels and DM II medications and their effectiveness could lead increased risks of hypoglycemia or hyperglycemia due to uncontrolled BG levels related to possible incorrect or inconsistent treatments provided.The DPCS stated Patient 2’s care plan for endocrine system was not individualized to reflect the current interventions to manage Patient 2’s DM II. The DPCS stated Patient 2’s plan of care did not indicate Patient 2’s noncompliance with the diabetic diet, Glipizide order, and multiple BG levels above 400 mg/dL. The DPCS stated it was important to update the plan of care to closely monitor the BG levels to determine the effectiveness of the interventions or antidiabetic medications ordered and prevent ineffective drug therapy that could place Patient 2 at risk for hypoglycemia or hyperglycemia. The DPCS stated it was important to change the interventions, such as antidiabetic medication/s accordingly, depending on the set goal of the ideal BG level for Patient 2 upon consultation with the Medical Director.The DPCS stated the visit notes indicated Patient 2’s endocrine system was “assessed/no issues reported.” The DPCS stated there was no documented evidence that the HA nurse ensured complete and accurate ongoing reassessments of Patient 2’s BG levels, compliance to the prescribed diet, and effectiveness of antidiabetic medication ordered. The DPCS stated incomplete and inaccurate assessments of Patient 2’s BG levels and DM II medications and their effectiveness could lead increased risks of hypoglycemia or hyperglycemia due to uncontrolled BG levels related to possible incorrect or inconsistent treatments provided. During a telephone interview on 4/28/2026 at 2:09 PM, the Medical Director (MD) stated upon Patient 2’s admission to the HA, MD discontinued the order to administer Lantus insulin to Patient 2 and ordered to start Glipizide 2.5 mg twice a day for Patient 2’s DM II because the HA informed MD that ALF 1 was unable to administer Lantus insulin. The Medical Director stated he was under the impression that Patient 2’s DM II was “totally controlled.” The Medical Director stated the Glipizide dose could either be increased or decreased to ensure better BG control depending on the BG values within 1-2 weeks after the start of a particular Glipizide dose. The Medical Director stated Patient 2’s BG must be checked 2 hours before breakfast and before administration of any antidiabetic medication/s and 2 hours after dinner. The Medical Director stated the HA nurse must also educate ALF 1 to closely monitor Patient 2 to ensure Patient 2 does not have access to “unlimited sweets” to better control Patient 2’s BG levels. The Medical Director stated it was important to keep the BG levels controlled and educate the caregivers to report any BG above 400 mg/dL and/or below 65 mg/dL to prevent unnecessary hospitalizations due to complications, such as DKA. During a review of Patient 3’s undated clinical record, titled “Personal Information,” the ‘Personal Information” indicated start of care (SOC) date of 2/23/2026 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.During a review of Patient 3’s “Comprehensive Nursing Assessment (HOPE Admission),” dated 2/23/2026, the “Comprehensive Nursing Assessment” indicated Patient 3 has a significant history of recurrent falls with impaired safety awareness and poor short-term memory, contributing to a high fall risk.During a review of Patient 3’s “POC/IDG Review,” dated 4/15/2026, the “POC/IDG Review” indicated a physician’s order, dated 3/9/2026, to administer warfarin sodium 2 mg by mouth daily in the evening for blood blot prevention.During a concurrent interview and record review of Patient 3’s clinical records on 4/28/2026 at 10:22 a.m. with RN 1, Patient 3’s plan of care, visit notes, and assessment notes were reviewed. RN 1 stated “POC/IDG Review,” dated 4/15/2026, did not indicate an individualized plan of care that included problems/goals/interventions to address Patient 3’s increased risks of bleeding related to the physician-ordered warfarin use and increased risk for injury related to the recurrent falls. RN 1 stated it was important to update and individualize Patient 3’s plan of care to ensure all patient problems are identified, goals are set to fix or maintain Patient 3’s health, implement the interventions to meet the goals and revise the interventions, if ineffective. During a review of Patient 4’s undated clinical record, titled “Personal Information,” the “Personal Information” indicated SOC date of 11/24/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.During a concurrent interview and record review of Patient 4’s clinical records on 4/28/2026 at 11:05 a.m. with RN 1, Patient 4’s plan of care, visit notes, and assessment notes were reviewed. RN 1 stated the “POC/IDG Review,” dated 11/26/2026 and “POC/IDG Review,” dated 12/10/2026 did not indicate an individualized plan of care that included any problems/goals/interventions. RN 1 stated it was important to update and individualize Patient 4’s plan of care to ensure all patient problems are identified, goals are set to fix or maintain Patient 4’s health, implement the interventions to meet the goals and revise the interventions, if ineffective. During a review of Patient 6’s undated clinical record, titled “Personal Information,” the “Personal Information” indicated SOC date of 3/11/2026 with a primary diagnosis of Parkinsonism and severe chronic kidney disease.During a review of Patient 6’s “Comprehensive Nursing Assessment (HOPE Admission),” dated 3/11/2026, the “Comprehensive Nursing Assessment” indicated on Patient 6’s sleep pattern “excessive sleep” with sleep duration lasting between 10-12 hours in a 24-hour period. The “Comprehensive Nursing Assessment” also indicated Patient 6 had no pain observed upon assessment but has had occasional generalized pain with activity that is relieved by non-opioid analgesic and rest.During a review of Patient 6’s “Nursing Updated Assessment (HUV 1),” dated 3/23/2026, the “Nursing Updated Assessment (HUV 1)” indicated on Patient 6’s sleep pattern “excessive sleep” with sleep duration lasting between 10-12 hours in a 24-hour period. The ‘Nursing Updated Assessment (HUV 1)” indicated Patient 6 had no pain upon assessment but has had occasional generalized pain with activity that is relieved by non-opioid analgesic and rest.During a review of Patient 6’s “Nursing Updated Assessment (HUV 2),” dated 3/30/2026, the “Nursing Updated Assessment (HUV 2)” indicated on Patient 6’s sleep pattern “excessive sleep” with sleep duration lasting between 10-12 hours in a 24-hour period. The ‘Nursing Updated Assessment (HUV 2)” indicated Patient 6 had no pain upon assessment but has had occasional generalized pain worse with activity and relieved by opioid analgesic and rest.During a review of Patient 6’s “Visit Note RN,” dated 4/13/2026, the “Visit Note RN” indicated Patient 6 was “noted with increased sleeping hours, skips food occasionally.” The “Visit Note RN” also indicated Patient 6 was noted with “increased tremors due to Parkinson’s and increased pain episodes.” The “Visit Note RN” indicated RN 2 received new orders to change the Parkinson’s medication from three times a day to four times a day and to administer Tramadol three times a day routinely.During a review of Patient 6’s “Visit Note RN,” dated 4/20/2026, the “Visit Note RN” indicated the facility reported Patient 6 “sleeping a lot recently… and skips food often.”During a review of Patient 6’s “Visit Note Short Form,” dated 4/21/2026, the “Visit Note Short Form” indicated the facility reported that Patient 6 was “constantly sleeping and can’t wake up.” The “Visit Note Short Form” indicated when RN 2 conducted a home visit for Patient 6, Patient 6 was sleeping in her bed, was able to wake up but falls back to sleep.During a concurrent interview and review of Patient 6’s clinical records on 4/28/2026 at 11:56 a.m. with RN 2, Patient 6’s visit notes, assessment notes, and care plans were reviewed. RN 2 stated there was no individualized care plan to address increased sleeping, increased pain, and increased tremors. RN 1 stated it was important to update and individualize Patient 6’s plan of care to ensure all patient problems are identified, goals are set to fix or maintain Patient 6’s health, implement the interventions to meet the goals and revise the interventions, if ineffective. During a review of Patient 7’s undated clinical record, titled “Personal Information,” the “Personal Information” indicated SOC date of 3/31/2026 with a primary diagnosis of Parkinson’s disease without dyskinesia and secondary diagnoses hypertensive heart disease without heart failure.During a review of Patient 7’s “Comprehensive Nursing Assessment,” dated 3/31/2026, the “Comprehensive Nursing Assessment” indicated Patient 7’s “fall risk remains high, with four documented falls since 3/10/2026 and a total of nine falls reported within the current year.” The “Comprehensive Nursing Assessment” indicated Patient 7 was “now presenting with generalized weakness and inability to ambulate independently, requiring durable medical equipment for mobility and the use of a chair exit alarm to prevent falls.”During a review of Patient 7’s “Current Treatment/Medication/DME List,” it indicated a physician’s order, dated 3/31/2026, to administer Aspirin 81 milligrams chewable tablet orally daily for hypertension.During a concurrent interview and record review of Patient 7’s clinical records on 4/28/2026 at 11:29 a.m. with RN 1, Patient 7’s care plans, assessment notes, and physician orders were reviewed. RN 1 stated there was no documented evidence that Patient 7’s plan of care was individualized to reflect the risks of bleeding related to aspirin use and high risk of falls related to recurrent falls prior to hospice admission and the interventions implemented. RN 1 stated Patient 7’s plan of care must be updated to ensure all interventions are consistently implemented to ensure patient safety due to risks for injury and bleeding. During a review of the HA’s policy and procedures (P&P), titled “Clinical/Service Data Collection,” dated 4/2020, the P&P indicated the following:A clinical/service record must be initiated and maintained for each patient receiving care or services according to organization policies and must included at a minimum:-pertinent medical history-physician orders and evidence of physician oversight activities-changes to the plan of care/service-dates, time, and types of interventions, assessments, and coordination of care/service-patient response to care and services in analyzed and documented as measurable goals-patient and family education-reasons for interruptions in the provision of care and services-current patient status and progress toward goals-outcomes of care/service Entries into the clinical/service record must be clear, concise, and specific statements of fact.The information management system must be designed to assure that data is collected and entered into the record in a systematic manner.”

“Upon personnel record review, 1 of 19 (Personnel # 8) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel # 8: Upon review of the competency assessments for the Aide the following elements were not assessed, 1) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. 2) Appropriate and safe techniques in personal hygiene and grooming that include shampoo, sink, tub, and bed. 3) Recognizing emergencies and knowledge of emergency procedures and their application. 4) The physical, emotional, and developmental needs of, and ways to work with the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property.”

“Upon patient record review, 6 of 19 (Patient # 2, 3, 7, 8, 12, 13) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient # 2: Upon review of the Aide POC dated 10/15/2024, the task of changing bed linens did not contain a frequency. Patient # 3: Upon review of the Aide POC dated 10/31/2024, the task of changing bed linens did not contain a frequency. Patient # 7: Upon review of the Aide POC dated 03/29/2025, the task of changing bed linens did not contain a frequency. Patient # 8: Upon review of the Aide POC dated 02/21/2025, the task of changing bed linens did not contain a frequency. Patient # 12: Upon review of the Aide POC dated 01/07/2025, the task of changing bed linens did not contain a frequency. Patient # 13: Upon review of the Aide POC dated 05/31/2025, the task of changing bed linens did not contain a frequency.”

“Upon patient record review 5 of 19 (Patient # 2, 3, 7, 9, 12) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient # 2: Upon review of the Aide POC 10/14/2024, there was no order for recording bowel movements. Bowel movements were recorded 4/23, 4/25, 4/30, 5/2, 5/7, 5/9, 5/14, 5/26, 5/21, 5/23, 5/28, 6/4/2025. Patient # 3: Upon review of the Aide POC 10/31/2024, there was no order for recording bowel movements. Bowel movements were recorded 4/23, 4/25, 4/30, 5/2, 5/7, 5/9, 5/14, 5/16, 5/21, 5/23, 5/28/2025. Patient # 7: Upon review of the Aide POC 03/29/2025, there was no order for recording bowel movements. Bowel movements were recorded 04/22, 4/24, 4/29, 5/1, 5/6, 5/8, 5/13, 5/15, 5/20, 5/22, 5/27, 5/29/2025. Patient # 9: Upon review of the Aide notes 12/03/2024, the task of changing bed linens was completed without an order and not contained in the Aide POC. Patient # 12: Upon review of the Aide POC 01/07/2025, there was no evidence of orders to record bowel movements. Bowel movements were recorded 4/10, 4/14, 4/17, 4/21, 4/24, 4/28, 5/1, 5/5, 5/8, 5/12, 5/15, 5/19, 5/22, 5/26, 5/29/2025.”

“Upon patient client record review, 13 of 19 (Patient # 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 18, 19) did not have evidence that each patient record contains Advance Directives. Patient #1) Upon review of the patient’s consent the advance directive section of the document was blank. Patient #2) Upon review of the patient’s consent the advance directive section of the document was blank. Patient #3) Upon review of the patient’s consent the advance directive section of the document was blank. Patient #4) Upon review of the patient’s consent the advance directive section of the document was blank. Patient #5) Upon review of the patient’s consent the advance directive section of the document was blank. Patient #6) Upon review of the patient’s consent the advance directive section of the document was blank. Patient #8 Upon review of the patient’s consent the advance directive section of the document was blank. Patient #9) Upon review of the patient’s consent the advance directive section of the document was blank. Patient #10) Upon review of the patient’s consent the advance directive section of the document was blank. Patient #11) Upon review of the patient’s consent the advance directive section of the document was blank. Patient #12) Upon review of the patient’s consent the advance directive section of the document was blank. Patient#18) Upon review of the patient’s consent the advance directive section of the document was blank. Patient #19) Upon review of the patient’s consent the advance directive section of the document was blank.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure that education and training was provided to patient/patient’s caregiver (PCG) on interventions identified in the Plan of Care (POC) for one of ten sampled patients (Patient 24).)This failure had the potential to create the risk of not providing appropriate instructions to address the care needs of the patient. Findings:During a review of Patient 24’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated that Patient 24 start of care (SOC) date was on 2/3/2025 with a primary diagnosis of Parkinsonism, unspecified (a condition that occurs when a person has symptoms and brain dysfunction commonly associated with Parkinson’s disease [a progressive neurological disorder that affects movement, balance, and coordination]). During a review of Patient 24’s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) Review form dated 3/5/2025, the POC/IDG Review form indicated the frequency of visits of the skilled nurse (SN) to two visits per week plus 2 prn (pro re nata, which means “as needed”) visits, and the hospice aide to two visits per week. The spiritual counselor (SC) and the social worker (MSW) was to conduct an evaluation within 5 days from the SOC. The POC/IDG Review form further indicated the skilled nurse would provide the following education and training to Patient 24 and/or PCG during patient home visits:A. Instruct patient/PCG on suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder through a cut in the abdomen) care and maintenance.B. Educate patient/family/PCG on aspiration precautions and G-tube (or gastrostomy tube, a tube inserted through the belly that brings nutrition directly to the stomach) site care. During a joint home visit, on 3/27/2025 at 11:20 a.m. with the registered nurse (RN 2), Patient 24 was observed laying in a hospital bed awake, alert, and nonverbal accompanied by a family member (FM 1). Patient 24 was observed to have a G-tube on his upper abdomen covered with dry dressing and a suprapubic catheter on his right lower abdomen attached to a urine drainage bag. During the visit, RN 2 did not instruct and educate patient or FM 2 on suprapubic catheter care and maintenance, and on G-tube site care. During a concurrent interview and record review, on 3/28/2025 at 11:15 a.m. with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 24’s Visit Note RN dated 3/17/2025, and Visit Note LVN dated 3/13/2025 and 3/20/2025. The DPCS stated and confirmed there were no documented evidence education and training were provided to patient or family on G-tube site care and suprapubic catheter care and maintenance on SN visits dated 3/13/2025, 3/17/2025 and 3/20/2025. The DPCS stated education and training to patient and/or PCG/family should be done on every skilled nursing visit and then documented on the patient clinical record in accordance with the patient plan of care. During a review of the HA’s policy and procedure (P&P), titled The Plan of Care, revised April 2020, the P&P indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.”

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to revise and update the plan of care for one of ten sampled patients (Patient 23), who had a change of condition (a significant alteration in a patient’s health status that deviates from their baseline or previous condition).This deficient practice had the potential to negatively affect the quality of care and services provided to Patient 23. Findings:During a review of Patient 23’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated that Patient 23 start of care (SOC) date was on 7/28/2023 with a primary diagnosis of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery without angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 23’s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) Review form dated 3/05/2025, the POC/IDG Review form indicated the frequency of visits of the skilled nurse (SN) to two visits per week plus 3 prn (pro re nata, which means “as needed”) visits, and the hospice aide to two visits per week. During a review of Patient 23’s Visit Note LVN (licensed vocational nurse) dated 3/20/2025, the Visit Note indicated, “Patient was seen in the recreation room surrounded by other residents… Patient was difficult to arouse, is noted with dyspnea (shortness of breath or difficulty breathing), difficulty with speaking and discoloration on the lips. This nurse obtained an oxygen reading of 69% (normal range for blood oxygen saturation is typically between 95% and 100%), heart rate at 38 bpm (beats per minute, normal resting heart rate for adults is typically between 60 and 100 bpm) and respirations of 24 (normal respiration rate for an adult person at rest range from 12 to 16 breaths per minute).” During a joint home visit, on 3/26/2025 at 11:00 a.m. with the registered nurse (RN 2), Patient 23 was observed laying in a hospital bed awake, alert, oriented to person only and confused, and was on oxygen inhalation via nasal canula (a medical device to provide supplemental oxygen therapy) at 3 liters per minute. During a concurrent interview and record review, on 3/28/2025 at 11:15 a.m. with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 23’s Visit Note LVN dated 3/20/2025 and Plan of Care. The DPCS stated that on 3/20/2025, Patient 23’s oxygen level and heart rate dropped, was short of breath and had a change of condition. The DPCS stated RN 2 notified and obtained new orders from the hospice Medical Director (MD 2) on 3/20/2025 for Patient 23 to remain in bed, to have bed baths only, and to remain on a puree/thickened liquid diet until further notice from MD. However, DPCS stated that she was not able to find documented evidence Patient 23’s plan of care was revised and updated to reflect the patient’s change of condition and address the new orders given by the physician on 3/20/2025. The DPCS stated Patient 23’s plan of care should have been revised to include patient’s new bedbound status and new diet order. During a review of the HA’s policy and procedure (P&P), titled The Plan of Care, revised April 2020, the P&P indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The plan of care will include all services necessary for the palliation, and management of the terminal illness and related conditions. The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver. Any change in patient’s condition must result in a change in the plan of care, prior to implementation of the new service.”

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Organizational Environment was met as follows: 1.The Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to maintain oversight of the contracted (a worker or independent contractor [a self-employed person contracted to perform work for another entity as a non-employee] who is engaged by an employer under a contract for service) Medical Director (HMD); retain professional management responsibility for all hospice services under contract and failed to monitor and exercise control over service provided by personnel under contract. The agency contracted HMD to conduct Medical Director duties. The HMD subcontracted (any worker that is hired by an independent contractor to complete a task) Nurse Practitioner (NP) to conduct the duty of face-to-face evaluation of patients, without the knowledge of the hospice agency. The HA has no records if NP met the credentialing requirements (the process of verifying and assessing the qualifications, education, training, licensure, and professional background of healthcare provider to ensure standards for patient care are met) or if a criminal background check (the process used to verify whether an individual has a criminal history to ensure the patient safety from abuse and protection and prevention of fraud and financial crimes) was completed and cleared to ensure patient safety and protection; and prevention of fraud and financial crimes. This deficient practice would likely compromise the safety of three out of 17 sampled patients (Patient 5, Patient 6, and Patient 7) by exposing Patient 5, Patient 6, and Patient 7 to NP without verification of proper qualifications; verification that NP is cleared of a history of abuse and mistreatment, by increasing the risk for misuse of patient information, and inadequate patient care (conducting an assessment about the patients physical, emotional, and psychological [a wide range of conditions that affect a person’s thoughts, feelings, and behavior] condition to create an accurate care plan is part of patient care). (Refer to L655). The cumulative effects of these systemic practices resulted in the Hospice Agency placing Patient 5, Patient 6, and Patient 7 at increased risk of financial, physical, and emotional harm.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) regarding Patients Rights was met as follows: 1. The HA failed to ensure written information regarding advance directives (a written statement of a person’s wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were properly verified and clearly written in the patients’ clinical records and in the hospice handbook at the patients residence for two out of 17 sampled patients (Patient 7 and Patient 10). (Refer to L503) 2. The HA failed to ensure and manage patients pain and symptom management related to the terminal illness and related conditions in a timely manner for 1 of 17 sampled patients (Patient 17) during the end of life. (Refer to L512) 3. The HA failed to ensure that family members were included in the development and revision of the patients plan of care (a written document that outlines the services and needs of a patient and their family as they approach the end of life) for one of 17 sampled patients (Patient 17). (Refer to L513) The cumulative effects of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with Federal regulation for Patients rights to ensure the highest quality of care were being provided to patients certified to receive the hospice benefits. .”

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Conditions of Participation regarding Initial and Comprehensive Assessment of patients were met as follows: 1. The HA failed to ensure the interdisciplinary group (IDG, composed of a Registered Nurse [RN], Medical Social Worker [MSW], chaplain, physician [MD] who meet regularly to discuss the patients plan of care in order to provide the best individualized care and support patient and families) completed the comprehensive assessment no later than 5 calendar days after election of hospice care for two of 17 sampled patients (Patient 14 and Patient 15) (Refer to L523). 2. The HA failed to ensure that all currently prescribed medications were available and reflected in the physicians orders and all discontinued medications were properly disposed of in a timely manner in accordance with the HAs policy and procedures (P&P) for three of 17 sampled patients (Patient 5, Patient 6, and Patient 7) (Refer to L530). 3. The HA staff failed to ensure four of 17 sampled patients (Patient 5, Patient 11, Patient 14, and Patient 15) received an initial bereavement assessment (Refer to L531). 4. The HA failed to ensure the IDG met and updated the comprehensive assessment at least every 15 days for two out of 17 sampled patients (Patient 5 and Patient 6) to include patients progress toward desired outcomes and reassessment of patients response to care (Refer to L533). The cumulative effect of these systemic practices resulted in the failure of the Hospice to statutorily deliver mandated compliance with the Federal regulations for Initial and Comprehensive Assessments of Patients to ensure highest quality of care are provided to all certified patients receiving the hospice benefits. .”

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition for Participation regarding Care Planning and Coordination of Services for patients was met as follows: 1. The Hospice Agency (HA, a healthcare agency that provides care for terminally ill patients with life expectancy of 6 months or less) failed to ensure the Interdisciplinary Group (IDG, composed of a Registered Nurse [RN], Medical Social Worker [MSW], spiritual counselor [SC], physician [MD] who meet regularly to discuss the patients plan of care in order to provide the best individualized plan of care and support patient and families) provided and supervised the care and services offered by the HA for two of 17 sampled patients (Patient 5 and Patient 6) Refer to L539. 2. The HA failed to ensure the MD, RN, MSW, and pastoral or other counselor served on the IDG and updated the comprehensive assessment at least every 15 days for 17 of 17 sampled patients (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17) (Refer to L541). 3. The HA failed to ensure the IDG developed, implemented, and revised an individualized plan of care for one of 17 sampled patients (Patient 5) (Refer to L552). The cumulative effect of these systemic practices resulted in the Hospice failure to deliver statutorily mandated compliance with the IDG, Care Planning, Coordination of Services, to ensure the highest quality of care are provided to all patients certified to receive the hospice benefits. .”

“Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation regarding Clinical Records was met as follows: 1. Failed to ensure the patient’s clinical record contained the initial and updated plans of care (POC), initial comprehensive, ongoing assessments, visit notes by licensed nurses identifying the Stage 3 pressure sore (full-thickness skin loss due to prolonged pressure on bony prominence) on the sacrococcyx (area at base of the spine) of one of 17 sampled patients (Patient 5). Refer to L672. 2. Failed to ensure the hospice licensed nurses documented the patients responses to the care services and treatment orders provided for the Stage 3 pressure sore (full-thickness skin loss due to prolonged pressure on bony prominence) on the sacrococcyx (area at base of the spine) for one of 17 sampled patients (Patient 5). Refer to L674. 3. Failed to ensure the clinical record contained physician’s orders to treat the Stage 3 pressure sore (full-thickness skin loss due to prolonged pressure on bony prominence) on the sacrococcyx (area at base of the spine) of one of 17 sampled patients (Patient 5). (Refer to L678). 4. Failed to ensure the clinical records were authenticated by the author for 11 of 17 sample selected patients (Patient 1, 2, 3, 4, 5, 6, 7, 10, 12, 16 and 17). Registered Nurse 3 (RN 3), who did not attend regular interdisciplinary group (IDG, group of healthcare professionals from different disciplines that collaborate to develop and implement a comprehensive, individualized care plans to achieve optimal patient outcomes) meetings documented out-of-the ordinary hour entries of the IDG meeting notes on the patients’ electronic health records (eHRs), including in-person IDG meeting notes. (Refer to L679). 5. Failed to ensure all Protected Health Information (PHI, any health information that can identify a patient, including names, addresses, birthdates, medical records) was safeguarded against unauthorized access to the eHRs . The hospice contracted Medical Director shared his HA login (username and password entered to enter a secured computer system or program) with another HA staff, for 15 out of 17 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, and 17) (Refer to L680). The cumulative effect of these systemic practices resulted in the hospice failure to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients’ clinical records are safeguarded from unauthorized access by any individual or hospice staff. .”

“Based on observation, interview and record review, the Hospice Agency (HA- a healthcare agency that provides care for terminally ill patients with life expectancy of 6 months or less) failed to ensure written information regarding advance directives (written statement of a person’s wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were properly verified and clearly written in the patients’ clinical records and the hospice handbook at the patients’ residence for two of 17 sampled patients (Patient 7 and Patient 10). This failure had the potential to result in the violation of the patients’ or responsible party’s rights related to HA not being aware of their choices and wishes regarding medical treatments. a. A review of Patient 7s record titled “;Personal Information”, indicated a start of care(SOC- refers to the comprehensive assessment is the required in-person clinical assessment of the patients physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the hospice agencys services) date on 1/25/2023 with a primary diagnosis of heart disease (refers to a group of conditions that affect the heart and its blood vessels. These conditions can damage the heart muscle, block blood flow to the heart, or disrupt the heart’s rhythm). A joint home visit on 1/29/2025 at 12:19 p.m., was conducted with the Registered Nurse 2 (RN 2) at the residential facility (a housing arrangement that provides individuals a place to live, including meals, personal care assistance and supervision) where Patient 7 was staying. During the home visit observation on 1/29/2025, observed that Patient 7 was alert to name with periods of confusion. Patient 7 was seen sitting on the sofa with her walker in front of her. Patient 7 frequently asks “;Alexa” “;What time is it?”, wears glasses and had a flat affect. Patient 7 is able to follow simple instruction and is verbally responsive to questions and denied pain. RN 2 conducted his visit. During the review of Patient 7s “;Hospice Handbook” on 1/29/2025 at 12:54 p.m., revealed that the front cover indicated the code status “;DNR/Full Code” (DNR-do not resuscitate or no emergency procedures made in an emergency and Full code- requires emergency procedures in emergency). On Patient 7s face sheet indicated “;Full Code”. On concurrent review of Patient 7s document titled “;Physicians order for Life Sustaining Treatment” (POLST- a portable medical order form that documents a patient’s preferences for end-of-life care) indicated Do Not Attempt Resuscitation/DNR with comfort focused treatment only (primary goal of maximizing comfort).During an interview with Registered Nurse 2 (RN 2) on 1/29/2025 at 12:54 p.m., RN 2 stated the durable power of attorney for healthcare (DPOA- primary decision maker for healthcare) was the patients husband (Patient 6). RN 2 stated that the code status for Patient 7 was “;undecided”. RN 2 asked the patients husband what the code status of his wife was and stated “;Shes a DNR”. RN 2 stated that if the code status is not followed, this would negatively affect the patients rights and not following the patients preference for emergency treatment. b. A review of Patient 10s record titled “;Personal Information”, indicated a start of care date on 11/22/2022 with a primary diagnosis of chronic obstructive pulmonary disease (COPD- a group of lung diseases that cause breathing problems). During a record review of Patient 10s POLST indicated to attempt CPR (cardiopulmonary resuscitation- attempt emergency procedures to prolong life) and full treatment (primary goal of prolonging life by all medically effective means) with no artificial means of nutrition, including feeding tubes signed by Patient 10 and the hospice medical director on 11/22/2022. During an interview on 2/3/2025 at 11:20 a.m., with Patient 10s emergency contact (EC), EC stated that the POLST was not updated with the hospice, Patient 10 is now a DNR. EC stated that when he arrived at their residential facility, the patient was really very sick and does not want to go to the hospital. During an interview with the Director of Nursing (DON) on 2/3/2025 at 1:38 p.m., the DON stated she conducted the initial assessment for Patient 7. On concurrent record review of Patient 7s “;Plan of Care (POC) Summary as of 1/28/2025 showed CPR Preference indicated “;undecided” and Code Status “;DNR/Full Code”. DON stated that at the time of admission the patients husband was still undecided on the emergency preference. DON stated that the POLST can be changed as frequently as the family decide to change their end-of-life preference and should be changed and updated in the medical record. A review of the agencys document titled “;Ongoing Assessments” revised 4/2020 indicated the scope and intensity of ongoing hospice patient assessments will be determined by the patient’s prognosis, diagnoses, condition, desire for care, response to previous care, and the care setting. during each home visit, the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. The physician will be notified to verify any changes in medications, including over-the-counter medications, and treatment/interventions that require physician approval. A review of the agencys document titled “;The Plan of Care” revised 4/2020 indicated to ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. 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. The written plan of care will contain but will not be limited to: End-of-life preferences.”

“Based on interview and record review, the Hospice Agency (HA- a healthcare agency that provides care for terminally ill patients with life expectancy of 6 months or less) failed to ensure that family members were notified timely, and patients pain and symptom management were managed in a timely manner for one of 17 sampled patients (Patient 17) during her end of life. This failure resulted in the patient’s and family members’ distress related to HAs inability to notify family members of the care provided and promptly manage the patient’s pain and all other distressing symptoms during the end-of-life. On 1/28/2025, the California Department of Public Health made an unannounced visit to the hospice agency to conduct a complaint validation survey to the hospice agency for Complaint number 112552. A review of Patient 17s “;Personal Information” sheet indicated Patient 17s start of care (SOC- refers to the comprehensive assessment is the required in-person clinical assessment of the patients physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the hospice agencys services) date of 3/14/2023 with the primary medical diagnosis of Alzheimers disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline). During an interview with the Patient 17s family member 1 (FM 1) on 1/31/2025 at 9 a.m., FM 1 stated that she was disappointed with what happened to her mom. FM 1 stated there was no communication with either me or family member 2(FM 2) with the hospice agency. FM 1 stated “;you can talk to my sister (FM 2) we were satisfied until the last week of my mom, you see my mother passed away last 1/3/2025 at the residential home she was in. FM 1 stated that they moved her mom from northern California to southern California so she can be near with FM 2 who was Patient 17’s power of attorney for healthcare. No one called either me or FM 2 for any bereavement calls. FM 1 stated that she knows how hospice works because she worked as a volunteer previously. FM 1 stated no one also called us when the patient passed away. All calls and communication were from the residential home caregivers. During an interview on 1/31/2025 at 11 a.m., with family member 2 (FM 2), FM 2 stated that the residential home recommended this hospice agency to me. No one called me to ask if the patient had a primary care physician. She spoke mostly to the nurse assigned to visit Patient 17 and told her she wasnt happy at all. The agency did not include us in any plan of care and never spoken to a hospice doctor not even once. FM 2 stated that during the week that Patient 17 was transitioning, only 3 times a nurse would come, and the last time was just to pronounce the time of death. During a review of Patient 17s “;History of Visits” revealed that there were only three home visits 12/26/2024, 12/27/2024 and 12/30/2024 conducted and 1/3/2025 was a death visit during the week of 12/26/2024 to 1/3/2025. There was no documented evidence on the “;Communication log” for any communication for the change in condition or report for the decline of the patient in the electronic medical record. During an interview with the Director of Nursing (DON) on 1/31/2025 at 1:04 p.m., DON stated that if any patient in hospice during the period of transition or any changes in condition should be reported to her or the case managers. The DON stated that there should be an increase in home visits or patient can be placed in continuous care to promote comfort to the patient and alleviate stress to the grieving family undergoing such period. There was no documented evidence that a post death bereavement follow-up in the medical record. A review of the agencys document titled “;Scope of Services” revised 4/2020, indicated that Olympia Hospice Care, Inc. provides hospice services that are intended to meet the physical, psychosocial, practical, and spiritual needs of hospice patients and families/caregiver. Olympia Hospice Care, Inc. will operate an office that will provide a safe and adequate location related to space, facilities, and administrative services. Olympia Hospice Care, Inc. will be open from 10:00 a.m. to 4:00 p.m., Monday through Friday, except designated holidays or other days decided by the Executive Director/Administrator. Drugs, biologicals, and core hospice services provided by nurses, social workers, physicians; and bereavement counselors are available 24 hours a day, seven (7) days a week. Other covered services are available on a 24-hour basis to the extent necessary to meet the patient’s needs relating to palliation and treatment of the terminal illness and/or treatment of related conditions. A review of the agencys document titled “;Ongoing Assessments” revised 4/2020, indicated During each home visit, the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. The nurse will assess each patient on each visit, for: A. Pain, including the origin, location, duration, severity, and relief measures B. Secondary symptoms related to the terminal illness such as, nausea, vomiting, and respiratory distress, and patient’s response to medications and other interventions C. Factors that alleviate or exacerbate physical symptoms D. Current treatment related to the identified symptoms and the patient’s response E. Vital signs appropriate to the patient’s condition. Ongoing comprehensive assessments should focus on A. Patient’s response to care B. Changes in patient condition, level of deterioration C. Changes in patient diagnoses/prognosis D. Changes in the patient’s care environment or support systems. A review of the agencys document “;Job Description: Bereavement Coordinator” revised 4/2020, indicated the Bereavement Coordinator is responsible to plan, implement, and maintain a bereavement program to meet the needs of families/caregivers from Hospice for up to one year following the death of the individual hospice patient. Coordinates the assessment and delivery of grief counseling needs and services (one-time, groups, and ongoing follow-up) to ensure timely and appropriate services are provided to family/caregivers. A review of the agencys document “;Job Description: Registered Nurse” revised 4/2020, indicated: The registered nurse plans, organizes and directs hospice care and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individual and families within their homes and communities. Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required.”

“Based on interview and record review, the Hospice Agency (HA- a healthcare agency that provides care for terminally ill patients with life expectancy of 6 months or less) failed to ensure the family members were included in the development and revision of the patients plan of care (written document that outlines the services and needs of a patient and their family as they approach the end of life) for one of 17 sampled patients (Patient 17). This failure resulted in increased distress to the patient and family member related to the HAs inability to coordinate and include family members in the care provided and promptly manage the patient’s pain and all other distressing symptoms during the patients end-of-life. On 1/28/2025, the California Department of Public Health made an unannounced visit to the hospice agency to conduct a complaint validation survey to the hospice agency for Complaint number 112552. A review of Patient 17s “;Personal Information” sheet indicated Patient 17s a start of care (SOC- refers to the comprehensive assessment is the required in-person clinical assessment of the patients physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the hospice agencys services) date of 3/14/2023 with the primary medical diagnosis of Alzheimers disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline). During an interview with the Patient 17s family member 1 (FM 1) on 1/31/2025 at 9 a.m., FM 1 stated that she was disappointed with what happened to her mom. FM 1 stated there was no communication with either me or family member 2(FM 2) with the hospice agency. FM 1 stated “;You can talk to my sister (FM 2) we were satisfied until the last week of my mom, you see my mother passed away last 1/3/2025 at the residential home she was in. FM 1 stated that they moved her mom from Northern California to Southern California so she can be near with FM 2 who was Patient 17’s power of attorney for healthcare. No one called either me or FM 2 for any bereavement calls. FM 1 stated that she knows how hospice works because she worked as a volunteer previously. FM 1 stated no one also called us when the patient passed away. All calls and communication were from the residential home caregivers. During an interview on 1/31/2025 at 11 a.m., with family member 2 (FM 2), FM 2 stated that the residential home recommended this hospice agency to me. No one called me to ask if the patient had a primary care physician. She spoke mostly to the nurse assigned to visit Patient 17 and told her she wasnt happy at all. The agency did not include us in any plan of care and never spoken to a hospice doctor not even once. FM 2 stated that during the week that Patient 17 was transitioning, only 3 times a nurse would come, and the last time was just to pronounce the time of death. During a review of Patient 17s “;History of Visits” revealed that there were only three home visits 12/26/2024, 12/27/2024 and 12/30/2024 conducted and 1/3/2025 was a death visit during the week of 12/26/2024 to 1/3/2025. There was no documented evidence on the “;Communication log” for any communication for the change in condition or report for the decline of the patient in the electronic medical record. During an interview with the Director of Nursing (DON) on 1/31/2025 at 1:04 p.m., DON stated that if any patient in hospice during the period of transition or any changes in condition should be reported to her or the case managers. The DON stated there should be an increase in home visits or patient can be placed in continuous care to promote comfort to the patient and alleviate stress to the grieving family undergoing such period. There was no documented evidence of a post death bereavement follow-up in the medical record. A review of the agencys document titled “;Interdisciplinary Group Membership and Responsibilities” revised 4/2020 indicated the Interdisciplinary Group responsibilities include but are not limited to E. Reporting any unusual change in the patient’s physical, mental, spiritual or emotional status to the primary caregiver(s), the attending physician and the interdisciplinary group. A review of the agencys document titled “;Provision of Care and Record Management” revised 4/2020 indicated documentation will include: Educational needs of patient and family/caregiver, Patient and family education provided, interdisciplinary group meetings and individual patient and family/caregiver case conferences. Attitudes and responses of the patient and family/caregiver to the plan of care and services provided. Each entry will be signed and dated, including title and credentials, by the person providing the care/service. For PRN (as needed) visits, patient visit verification will be required to be submitted with the visit note.”

“Based on interviews and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG, composed of a Registered Nurse [RN], Medical Social Worker [MSW], chaplain, physician [MD] who meet regularly to discuss the patients plan of care in order to provide the best individualized care and support patient and families) complete the comprehensive assessments no later than 5 calendar days after election of hospice care for two of 17 sampled patients (Patient 14 and Patient 15). This failure had the potential to result in the provision of non-individualized care related to the inaccurate or incomplete assessment of the patients. a. During a record review of Patient 14s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC of 1/13/2025 with a primary diagnosis of malignant neoplasm of colon (cancer of the large intestine). During a concurrent interview and record review on 2/3/2025 at 10:28 a.m. with DD, Patient 14s eHR (electronic health record) was reviewed. DD stated there was no documented evidence that a psychosocial assessment was conducted for Patient 14. DD stated a psychosocial assessment was important in assessing the patients coping mechanisms and support groups and identifying if in need of assistance with resources. During a concurrent interview and record review on 2/3/2025 at 11:59 a.m., with MSW, Patient 14s electronic health records were reviewed. MSW stated she called Patient 14s responsible party but the conversation was very brief, and Patient 14s responsible party stated he would call back if Patient 14 “;needed anything.” MSW stated she did not write any notes on the eHRs—including in the Psychosocial Assessment and Communication sections—regarding the encounter. b. During a record review of Patient 15s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC of 1/22/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (narrowing of the blood vessels supplying blood to the heart due to plaque buildup). During a concurrent interview and record review on 2/3/2025 at 10:28 a.m., with DD, Patient 15s eHR was reviewed. DD stated there was no documented evidence that a psychosocial assessment was conducted for Patient 15. During a concurrent interview and record review on 2/3/2025 at 11:59 a.m. with MSW, Patient 15s eHR was reviewed. MSW stated she attempted to speak with Patient 15s responsible party, but MSW was not able to reach her. MSW stated she did not write any notes on Patient 15s eHR—including in the Psychosocial Assessment and Communication sections—regarding the call attempts made. MSW stated it was important to inform the HA if not able to contact the patient or family to ensure all staff were aware of the situation. During a review of the HAs policy and procedures (P&P), titled “;Comprehensive Assessment,” dated 4/2020, the P&P indicated the following: 1. A comprehensive patient assessment must be performed by the IDG no later than 5 calendar days after the election of hospice care in consultation with the attending physician. 2. All baseline data and other relevant information must be documented, through interview and observation, in the patients clinical record, including the following information as relevant: a. Evaluation of the home environment and assessment of emergency preparedness of the patient to include identification of safety or health hazards and presence of adequate living arrangements. b. Patient and family/caregiver support systems and the care the family/caregiver is available, capable, and willing to provide, including applicable strengths of patient, physical, psychosocial, and/or spiritual resources available. c. Patients psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source and adequacy of environment and other resources, coping mechanisms, and the patients and family/caregivers reaction to illness. d. Involvement of family/caregiver, neighbors, and/or other individuals/organizations, including involvement in any support groups.”

“Based on observation, interview, and record review, the Hospice Agency (HA, a healthcare agency that provides care for terminally ill patients with life expectancy of 6 months or less) failed to ensure all currently prescribed medications were available and reflected in the physicians orders and all discontinued medications were properly disposed of in a timely manner in accordance with the HAs policy and procedures (P&P) for three of 17 sampled patients (Patient 5, Patient 6, and Patient 7). These failures had the potential to result in an inconsistent medication administration, medication errors, and adverse drug reactions. a. During a record review of Patient 5s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC date of 10/26/2023 with a primary diagnosis of Alzheimers disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a review of Patient 5s medical record form, titled “;POC Summary,” as of 1/28/2025, the “POC Summary” indicated physicians orders for Zofran orally disintegrating tablet (ODT) 8 milligrams (mg, unit of measurement) 1 tablet every 8 hours as needed for nausea and vomiting and Hyoscyamine Sulfate 0.125 mg ODT 1 tablet every 4 hours as needed for excess oral secretion/congestion. During a concurrent observation and interview while on a joint home visit on 1/29/2025 at 12:10 p.m., with Licensed Vocational Nurse 1 (LVN 1), the following were noted: 1. Two bottles of Zofran ODT. One bottle indicated it contained 4 mg tablets with expiration date 4/2024. The other bottle indicated it contained 8 mg tablets. 2. A bottle of Omeprazole 20 mg delayed-release capsule (CPDR) with a label that indicated fill date 1/7/2025 and Patient 5s name. The physicians orders were not updated to include Omeprazole 20 mg CPDR. 3. Missing bottle of Hyoscyamine Sulfate 0.125 mg orally disintegrating tablets. LVN 1 stated Patient 5 had a physicians order for Zofran ODT 8 mg tablets and Zofran ODT 4 mg tablets must be disposed of due to the potential for medication errors. LVN 1 proceeded with the disposal of Zofran ODT 4 mg per HA protocol. LVN 1 was unable to verify when Patient 5s Omeprazole was ordered and stated she would follow up with the HA to ensure the physicians orders were updated. LVN 1 stated she was not able to reorder Hyoscyamine Sulfate timely to ensure availability of the medication to Patient 5 because the caregivers threw away the bottle, which would prompt her to reorder medications on low supply. During an interview on 2/3/2025 at 3:28 p.m., the Director of Patient Care Services (DPCS) stated the licensed nurse must verify the home medications with the physician orders and report any discrepancies. DPCS stated the licensed nurse must ensure the patient has at least 3 days worth of medication supply per HA policy. b. During a review of Patient 6s document titled “;Personal Information,” it indicated that Patient 6 was admitted on 1/25/2023 with the primary diagnosis of Stage 4 chronic kidney disease (deterioration of the kidneys to function adequately). During a concurrent observation and interview while on a joint home visit on 1/29/2025 at 11:40 a.m., with Registered Nurse 2 (RN2), duplicate physician orders for Coumadin (blood thinner) and other medication discrepancies were noted as follows: 1. Coumadin 6 mg 1 tablet daily in the evening at 5pm 2. Coumadin 7 mg 1 tablet daily in the evening at 5pm 3. Triple antibiotic ointment 400 IU (international units- unit of measurement) daily until wound is healed. Caregiver stated she does not have it in stock and Patient 6 has no wound. 4. Triamcinolone Acetonide 0.125% topical ointment not found in stock. Caregiver stated Pt is not using anymore 5. Macular Assist 15mg Lutein/3mg capsule 1 capsule daily for macular degeneration. Caregiver stated Patient 6 is not taking anymore. c. During a review of Patient 7s document titled “;Personal Information,” it indicated that Patient 7 was admitted on 1/25/2023 with the primary diagnosis of heart disease (a group of conditions that affect the heart and its blood vessels, causing damage to the heart muscle, block blood flow to the heart, or disrupt the heart’s rhythm). During a concurrent observation while on a joint home visit on 1/29/2025 at 12:19 p.m. RN 2, medication discrepancies for Patient 7 were as follows: 1. Pataday 0.2% 1 drop for eye redness. Caregiver stated it was only for 7 days. 2. Losartan 50 mg 1 tablet daily for high blood pressure and arrythmia had a duplicate entry in the medication profile listed as Cozaar 50 mg daily for high blood pressure. 3. Cicopirox 77% topical application as needed. Caregiver stated that patient 7 is not using anymore. 4. Tramadol Hydrochloride 50 mg 1 tablet every 6 hours as needed for pain. Caregiver stated Patient 7 is not taking any more since admission. During an interview on 1/29/2025 at 12:54 p.m., RN 2 stated that RN 2 reviews medication on a regular basis. RN 2 stated RN 2 checks medications as often as RN 2 can. RN 2 stated that RN 2 should check medications comparing it with the stock bottles, updated medication list and the medication list provided at the residential facility. RN 2 stated duplicate entries made in for the Coumadin orders were listed to “;remind” RN 2 of the previous order when RN 2 calls the doctor every two weeks for Patient 6s PT/INR (a blood test to measure how long it takes blood to clot). During an interview on 1/31/2025 at 1:04 p.m., DPCS stated that the visiting nurse should update the medication profile every visit. DON stated the visiting nurse should compare the updated medication list to the bottles in stock at the patients home. DON stated that multiple drug orders should be avoided to not create confusion for the visiting nurse and staff at the residential home. DON stated the visiting nurse should make a mental note or note it separately on a notebook or write it on the nurse’s visit notes to remind the nurse of the previous dose of Coumadin. During a review of the HAs P&P, titled “;Medication Profile” revised 4/2020, the P&P indicated patients receiving medications as administered by the organization must have a current, accurate medication profile in the clinical record. The medication profiles must be updated for each change to reflect current medications, and new and/or discontinued medications.”

“Based on interviews and record review, the Hospice Agency (HA) failed to ensure four of 17 sampled patients (Patient 5, Patient 11, Patient 14, and Patient 15) received an initial bereavement assessment. This failure had the potential for the patients and/or family/caregiver not provided spiritual and emotional support related to the patients’ pending death to be able to cope with the patients’ passing or death. a. During a record review of Patient 5s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC date of 10/26/2023 with a primary diagnosis of Alzheimers disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a concurrent interview and record review on 2/3/2025 at 10:28 a.m., with the Director of Patient Care Services Designee (DD), Patient 5s electronic health record (eHR) was reviewed. DD stated there was no documented evidence that a bereavement assessment was conducted for Patient 5. DD stated it was important to conduct a bereavement assessment within 5 days upon admission to “;assess the risks of the situation for the family during and after the patients terminal illness.” b. During a record review of Patient 11s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC date of 2/1/2023 with a primary diagnosis of Parkinsons disease (progressive neurodegenerative disorder that affects movement, balance, and coordination). During a concurrent interview and record review on 2/3/2025 at 10:28 a.m., with DD, Patient 11s eHR was reviewed. DD stated there was no documented evidence that a bereavement assessment was conducted for Patient 11. c. During a record review of Patient 14s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC of 1/13/2025 with a primary diagnosis of malignant neoplasm of colon (cancer of the large intestine). During a concurrent interview and record review on 2/3/2025 at 10:28 a.m., with DD, Patient 14s eHR was reviewed. DD stated there was no documented evidence that a bereavement assessment was conducted for Patient 14. d. During a record review of Patient 15s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC of 1/22/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (narrowing of the blood vessels supplying blood to the heart due to plaque buildup). During a concurrent interview and record review on 2/3/2025 at 10:28 a.m. with DD, Patient 15s eHR was reviewed. DD stated there was no documented evidence that a bereavement assessment was conducted for Patient 15. During a review of the HAs policy and procedures (P&P), titled “;Comprehensive Assessment,” dated 4/2020, the P&P indicated a bereavement assessment of the needs of the patients family and other individuals must be done and focused on: 1. The nature of the relationship to the patient 2. Circumstances surrounding the illness/prognosis 3. Behaviors prior to and after the illness/prognosis 4. Survivor needs (social, spiritual, and cultural) that may impact coping skills 5. Potential for pathological grief reactions”

“Based on observation, interview and record review, the Hospice Agency (HA, a healthcare agency that provides care for terminally ill patients with life expectancy of 6 months or less) failed to ensure the Interdisciplinary Group (IDG, composed of a Registered Nurse [RN], Medical Social Worker [MSW], spiritual counselor [SC], physician [MD] who meet regularly to discuss the patients plan of care in order to provide the best individualized plan of care and support patient and families) met and updated the comprehensive assessment at least every 15 days for two of 17 sampled patients (Patient 5 and Patient 6) to include patients progress toward desired outcomes and reassessment of patients response to care. This failure had the potential to cause the patients physical decline will not be due to the lack of monitoring of the patients change in condition and progress towards goals. a. During a review of Patient 5s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC date of 10/26/2023 with a primary diagnosis of Alzheimers disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a review of Patient 5s medical form, titled “;Comprehensive Nursing Assessment,” dated 10/26/2023, the “;Comprehensive Nursing Assessment” indicated Patient 5 had an “;open wound on her sacro-coccyx (fused tailbone and sacrum bones) area.” During a review of Patient 5s medical form, titled “;Physician Verbal Orders,” dated 10/26/2023,” the “;Physician Verbal Orders” indicated the treatment order “;Stage 2 coccyx sore (shallow open wound or blister to the tailbone due to prolonged pressure on the skin over a bony prominence): Cleanse with normal saline, pat dry, apply barrier cream until resolves (sore looks pink).” During a review of Patient 5s medical form from Wound Care Specialist 1 (WCS 1), titled “;Progress Report,” dated 10/31/2023, the “;Progress Report” indicated Patient 5 had a Stage 3 pressure sore to the sacro-coccyx (full-thickness skin loss to the sacral area and tailbone due to prolonged pressure on the skin over a bony prominence) with the following measurements: length – 1.68 centimeter (cm, unit of measurement), width – 2.3 cm, and depth – 0.3 cm. During a review of Patient 5s medical form from WCS 1, titled “;Progress Report,” dated 4/24/2024, the “;Progress Report,” indicated Patient 5 had a Stage 3 pressure sore to the sacro-coccyx with the following measurements: length – 1.02 cm, width – 1.06 cm, and depth – 0.5 cm. During a review of Patient 5s medical form from WCS 1, titled “;Progress Report,” dated 10/24/2024, the “;Progress Report,” indicated Patient 5 had a Stage 3 pressure sore to the sacro-coccyx with the following measurements: length – 4.49 cm, width – 3.01 cm, and depth – 1 cm. During a review of Patient 5s medical form from WCS 1, titled “;Progress Report,” dated 1/23/2025, the “;Progress Note” indicated Patient 5 had a Stage 3 pressure sore to the sacro-coccyx with the following measurements: length – 2.66 cm, width – 3.8 cm, and depth – 1.2 cm. During a concurrent observation and interview while on a joint home visit on 1/29/2025 at 12:10 p.m., with Licensed Vocational Nurse 1 (LVN 1), Patient 5 was observed with a foam dressing to the sacrococcyx area. LVN 1 stated Patient 5s caregiver changed the wound dressing in the morning prior to the skilled nursing visit, so LVN 1 did not change the wound dressing at the time. Patient 5s wound care supplies, not labeled with Patient 5s name, were observed inside the bedside nightstand. The wound care ointments included: wound cleanser, Tetracyte (antibiotic) topical spray, Therahoney gel (medical grade honey to assist with wound healing), alginate and foam dressing. During a concurrent review and interview of the Patient 5s home hospice binder, LVN 1 stated there was no evidence of specific wound care orders and plan of care for Patient 5s wound. During a concurrent interview and record review on 1/31/2025 at 11:30 a.m., with the Director of Patient Care Services (DPCS), Patient 5s electronic health record (eHR) was reviewed. The DPCS stated there was no documented evidence of hospice wound care orders entered in Patient 5s eHR. The DPCS stated there was no documented evidence of an individualized plan of care developed and implemented for Patient 5s wound in the eHR. The DPCS stated there was no documented evidence of comprehensive wound care assessments by the licensed nursing during skilled nursing visits. The DPCS stated the Wound Care Specialist was responsible for writing the wound care orders and ordering wound care supplies. The DPCS stated the hospice nurses were in-charge of performing wound care to Patient 5 during skilled nursing visits. The DPCS stated the caregivers and family were responsible for performing wound care on the other days. The DPCS was unable to state Patient 5s current wound care treatments, other interventions to address the long-term wound, and Patient 5s progress towards desired outcomes. The DPCS stated it is important to have hospice wound care orders in Patient 5s eHR to ensure there was “;a specific plan of care to follow” and ensure all hospice licensed nurses consistently implemented the plan. The DPCS stated it was important for the hospice licensed nurses to assess and measure Patient 5s wound and perform wound care every visit to determine if Patient 5s wound care interventions were effective and Patient 5 was progressing towards the goal of improving the wound condition. During a review of the HAs policy and procedures (P&P 1), titled “;Comprehensive Assessment,” dated 4/2020, P&P 1 indicated the following: 1. The comprehensive assessment must be updated by the IDG as frequently as the patients condition requires but at a minimum every 15 days. 2. If there has been a change in the patients condition/status, then the comprehensive assessment must be updated. 3. If no changes are needed, then it must be documented. b. During a review of Patient 6s document titled “;Personal Information,” it indicated that Patient 6 was admitted on 1/25/2023 with the primary diagnosis of Stage 4 chronic kidney disease (deterioration of the kidneys to function adequately). During a review of Patient 6s document titled “;POC Summary” (POC- ongoing comprehensive assessment, a written document that outlines the services and needs of a patient and their family as they approach the end of life), the “;POC Summary” indicated there was no written documented evidence of a plan of care for bleeding secondary to Coumadin therapy. During a concurrent observation while on a joint home visit on 1/29/2025 at 11:40 a.m., with Registered Nurse 2 (RN2), duplicate physician orders for Coumadin (blood thinner) and other medication discrepancies were documented as follows: 1. Coumadin 6 milligrams (mg, unit of measurement of weight) 1 tablet daily in the evening at 5 p.m. 2. Coumadin 7 mg 1 tablet daily in the evening at 5 p.m. During an interview on 1/29/2025 at 12:54 p.m., RN 2 stated that he reviews medication on a regular basis. RN 2 stated, “;I check medications as often as I can.” RN 2 stated that RN 2 should check medications comparing it with the stock bottles, updated medication list and the medication list provided at the residential facility. RN 2 stated that the duplicate entries made for the Coumadin orders were listed to “;remind” RN 2 of the previous order when RN 2 calls the doctor every two weeks for Patient 6s PT/INR (a blood test to measure how long it takes blood to clot). During an interview on 1/31/2025 at 1:04 p.m., the DPCS stated that the visiting nurse should update the medication profile every visit. The DPCS stated the visiting nurse should compare the updated medication list to the bottles in stock at the patients home. The DPCS stated that multiple drug orders should be avoided to not create confusion for the visiting nurse and staff at the residential home. The DPCS stated the visiting nurse should make a mental note or note it separately on a notebook or write it on his visit notes to remind him of the previous dose of Coumadin. The DPCS stated there should be a care plan for bleeding in the eHRs. The DPCS stated there was no documented evidence of a care plan for bleeding in Patient 6s eHRs. The DPCS stated the nurses would not be able to monitor for signs of bleeding for Coumadin therapy if there was no care plan initiated. During a review of the Hospice P&P 2, titled “;The Plan of Care,” dated 4/2020, P&P 2 indicated the plan of care must be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the IDG, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver. Review of the plan of care must be documented in the clinical record. Revision dates must be noted on the plan of care. During a review of Hospice P&P 3, titled “;Ongoing Assessments” dated 4/2020, P&P 3 indicated that during each home visit, the Case Manager or other discipline must evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. P&P 3 indicated that based on the assessments, the plan of care-including problems, needs, goals, and outcomes-must be reviewed and updated by the IDG members responsible for the case. During a review of the Hospice P&P 4, titled “;Medication profile” dated 4/2020, P&P 4 indicated that during subsequent home visits, the medication profile must be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen.”

“Based on observation, interview and record review, the Hospice Agency (HA, a healthcare agency that provides care for terminally ill patients with life expectancy of 6 months or less) failed to ensure the Interdisciplinary Group (IDG, composed of a Registered Nurse [RN], Medical Social Worker [MSW], spiritual counselor [SC], physician [MD] who meet regularly to discuss the patients plan of care in order to provide the best individualized plan of care and support patient and families) provided and supervised care and services offered by the HA for two of 17 sampled patients (Patient 5 and Patient 6). This failure had the potential to cause the patients physical decline due to the IDGs lack of monitoring of the patients change in condition and progress towards goals. a. During a review of Patient 5s medical record form, titled “;Personal Information,” indicated a start of care (SOC) date of 10/26/2023 with a primary diagnosis of Alzheimers disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a review of Patient 5s medical form, titled “;Comprehensive Nursing Assessment,” dated 10/26/2023, indicated Patient 5 had an open wound on her sacrococcyx (fused tailbone and sacrum bones) area. During a review of Patient 5s medical form, titled “;Physician Verbal Orders,” dated 10/26/2023,” the “;Physician Verbal Orders” indicated the treatment order; “;Stage 2 coccyx sore (shallow open wound or blister to the tailbone area due to prolonged pressure on the skin over a bony prominence): Cleanse with normal saline, pat dry, apply barrier cream until resolves (sore looks pink).” During a review of Patient 5s medical form from Wound Care Specialist 1 (WCS 1), titled “;Progress Report,” dated 10/31/2023, “ indicated Patient 5 had a Stage 3 pressure sore to the sacrococcyx (full-thickness skin loss due to prolonged pressure on the skin over the sacrum and tailbone areas) with the following measurements: length – 1.68 centimeter (cm, unit of measurement), width – 2.3 cm, and depth – 0.3 cm. During a review of Patient 5s medical form from WCS 1, titled “;Progress Report,” dated 4/24/2024, the “;Progress Report,” indicated Patient 5 had a Stage 3 pressure sore to the sacrococcyx with the following measurements: length – 1.02 cm, width – 1.06 cm, and depth – 0.5 cm. During a review of Patient 5s medical form from WCS 1, titled “;Progress Report,” dated 10/24/2024, the “;Progress Report,” indicated Patient 5 had a Stage 3 pressure sore to the sacrococcyx with the following measurements: length – 4.49 cm, width – 3.01 cm, and depth – 1 cm. During a review of Patient 5s medical form from WCS 1, titled “;Progress Report,” dated 1/23/2025, the “;Progress Note” indicated Patient 5 had a Stage 3 pressure sore to the sacrococcyx with the following measurements: length – 2.66 cm, width – 3.8 cm, and depth – 1.2 cm. During a concurrent observation and interview on a joint home visit on 1/29/2025 at 12:10 p.m., with Licensed Vocational Nurse 1 (LVN 1), Patient 5 was observed with a foam dressing to the sacrococcyx area. LVN 1 stated Patient 5s caregiver changed the wound dressing in the morning prior to the skilled nursing visit, so LVN 1 did not change the wound dressing at that time. Patient 5s wound care supplies, not labeled with Patient 5s name, were observed inside the bedside nightstand. The wound care ointments included: wound cleanser, Tetracyte (antibiotic) topical spray, Therahoney gel (medical grade honey to assist with wound healing), alginate and foam dressing. However, upon concurrent observation of the Patient 5s home hospice binder, LVN 1 stated there was no evidence of specific wound care orders and plan of care for Patient 5s wound. During a concurrent interview and record review on 1/31/2025 at 11:30 a.m., with the Director of Patient Care Services (DPCS), Patient 5s electronic health record (eHR) were reviewed. The DPCS stated there was no documented evidence of hospice wound care orders entered in Patient 5s eHR. The DPCS stated there was no documented evidence an individualized plan of care was developed and implemented for Patient 5s wound in the eHR. The DPCS stated there was no documented evidence of comprehensive wound care assessments by the licensed nursing during skilled nursing visits. The DPCS stated the Wound Care Specialist was responsible for writing the wound care orders and ordering wound care supplies. The DPCS stated the hospice nurses were in-charge of performing wound care to Patient 5 during skilled nursing visits. The DPCS stated the caregivers and family were responsible for performing wound care on the other days. The DPCS was unable to state Patient 5s current wound care treatments, other interventions to address the long-term wound, and Patient 5s progress towards desired outcomes. The DPCS stated it is important to have hospice wound care orders in Patient 5s eHR to ensure there was “;a specific plan of care to follow” and ensure all hospice licensed nurses consistently implemented the plan. The DPCS stated it was important for the hospice licensed nurses to assess and measure Patient 5s wound and perform wound care every visit to determine if Patient 5s wound care interventions were effective and Patient 5 was progressing towards the goal of improving the wound condition. During a review of the HAs policy and procedures (P&P 1), titled “;Ongoing Assessments,” dated 4/2020, P&P 1 indicated the following: 1. The Case Manager or other discipline must evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. 2. The nurse must assess each patient on each visit for the following, but not limited to: a. Current treatment related to the identified symptoms and the patient response b. Skin integrity c. Progress towards hospice goals and patient needs and problems d. Compliance with treatments and medication regimen 3. Based on the assessments, the plan of care, including problems, needs, goals, and outcomes, must be reviewed and updated by the IDG members responsible for the case. During a review of the HAs P&P 2, dated 4/2020, P&P 2 indicated the following: 1. Each patient must be monitored for his/her response to care or services provided against established patient goals and outcomes to evaluate progress toward goals. 2. Care decisions and services to be provided must be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes. b. During a review of Patient 6s document titled “;Personal Information,” it indicated that Patient 6 was admitted on 1/25/2023 with the primary diagnosis of Stage 4 chronic kidney disease (deterioration of the kidneys to function adequately). During a review of Patient 6s document titled “;POC Summary” (POC- ongoing comprehensive assessment, a written document that outlines the services and needs of a patient and their family as they approach the end of life), the “;POC Summary” indicated there was no written documented evidence of a plan of care for bleeding secondary to Coumadin therapy. During a concurrent observation while on a joint home visit on 1/29/2025 at 11:40 a.m., with Registered Nurse 2 (RN2), duplicate physician orders for Coumadin (blood thinner) and other medication discrepancies were documented as follows: 1. Coumadin 6 milligrams (mg, unit of measurement of weight) 1 tablet daily in the evening at 5 p.m. 2. Coumadin 7 mg 1 tablet daily in the evening at 5 p.m. During an interview on 1/29/2025 at 12:54 p.m., RN 2 stated that RN 2 reviews medication on a regular basis. RN 2 stated, “;I check medications as often as I can.” RN 2 stated that RN 2 should check medications comparing it with the stock bottles, updated medication list and the medication list provided at the residential facility. RN 2 stated that the duplicate entries made for the Coumadin orders were listed to “;remind” RN 2 of the previous order when RN 2 calls the doctor every two weeks for Patient 6s PT/INR (a blood test to measure how long it takes blood to clot). During an interview on 1/31/2025 at 1:04 p.m., the DPCS stated that the visiting nurse should update the medication profile every visit. The DPCS stated the visiting nurse should compare the updated medication list to the bottles in stock at the patients home. The DPCS stated that multiple drug orders should be avoided to not create confusion for the visiting nurse and staff at the residential home. The DPCS stated the visiting nurse should make a mental note or note it separately on a notebook or write it on his visit notes to remind the visiting nurse of the previous dose of Coumadin. The DPCS stated there should be a care plan to monitor signs of bleeding as an adverse effect of Coumadin medication in Patient 6’s eHR. DPCS stated the nurses would not be able to monitor for signs of bleeding for Coumadin therapy if there was no care plan initiated. During a review of the Hospice P&P 2, titled “;The Plan of Care,” dated 4/2020, P&P 2 indicated the plan of care must be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the IDG, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver. Review of the plan of care must be documented in the clinical record. Revision dates must be noted on the plan of care. During a review of the HAs P&P 4, titled “;Medication profile” dated 4/2020, P&P 4 indicated that during subsequent home visits, the medication profile must be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen.”

“Based on interview and record review, the Hospice Agency (HA- a healthcare agency that provides care for terminally ill patients with life expectancy of 6 months or less) failed to ensure all members of the Interdisciplinary Group (IDG, composed of a Registered Nurse [RN], Medical Social Worker [MSW], pastoral or other counselor [SC], physician [MD] who meet regularly to discuss the patients plan of care in order to provide the best individualized plan of care and support patient and families) served on the IDG meetings, updated the comprehensive assessment at least every 15 days, and reviewed and revised the care plan for 15 of 17 sampled patients (Patient 1, 2, 3, 4, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16 and 17). This failure had the potential to cause the decline in the terminally ill patients physical and psychosocial condition due to a delay in the identification of problems and needs, delay of treatment and services, and inadequate monitoring of the patients response to care and progress towards desired outcomes. a. During a review of Patient 1s medical record form, titled “;Personal Information,” it indicated start of care (SOC, admission date) on 9/16/2024 with the diagnosis of malignant neoplasm of the right bronchus of lung (cancer of the lung) During a review of Patient 1s electronic health record (eHR, a digital version of the patients medical record), it indicated no IDG member signed Patient 1s medical record form, titled “;POC/IDG Review,” dated 1/9/2025. The eHR indicated MSW and RN did not sign Patient 1s “;POC/IDG Review,” dated 12/25/2024, 12/11/2024, 11/27/2024, and 11/13/2024. b. A review of Patient 2s medical record form, titled “;Personal Information,” it indicated SOC on 11/6/2024 with the primary diagnosis of malignant neoplasm of connective and soft tissue (cancerous tumor of the muscles, tendons, ligaments, fats and cartilage). During a review of Patient 2s eHR, it indicated the MSW and RN did not sign Patient 2s medical record forms, titled “;POC/IDG Review,” dated 11/6/2024 and 11/13/2024. c. During a review of Patient 3s medical record form, titled “;Personal Information,” it indicated SOC on 4/4/2024 with the primary diagnosis of squamous cell carcinoma of the skin (skin cancer). During a review of Patient 3s eHR, it indicated RN did not sign Patient 3s medical record form, titled “;POC/IDG Review” dated 9/18/2024, 10/4/2024, and 10/16/2024. The eHR indicated RN and MSW did not sign Patient 3s “;POC/IDG Review” dated 11/13/2024. d. During a review of Patient 4s medical record form, titled “;Personal Information,” it indicated SOC on 4/4/2024 with the primary diagnosis of squamous cell carcinoma of the skin. During a review of Patient 4s eHR, it indicated MSW and RN did not sign Patient 4s medical record form, titled “;POC/IDG Review,” dated 11/27/2024, 12/11/2024, 12/25/2024, and 1/6/2025. The eHR indicated MD, MSW, and RN did not sign Patient 4s “;POC/IDG Review” dated 1/22/2025. e. During a review of Patient 5s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC date of 10/26/2023 with a primary diagnosis of Alzheimers disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a review of Patient 5s eHR, it indicated RN and MSW did not sign Patient 5s medical record forms, titled “;POC/IDG Review” dated 1/22/2025, 1/8/2025, and 12/25/2024. f. During a review of Patient 6s medical record form, titled “;Personal Information,” it indicated that SOC on 1/25/2023 with the primary diagnosis of Stage 4 chronic kidney disease (deterioration of the kidneys and inability to function adequately). During a review of Patient 6s eHR, it indicated MSW and RN did not sign Patient 6s medical record form, titled “;POC/IDG Review” dated 11/27/2024, 12/11/2024, 12/25/2024, and 1/6/2025. The eHR indicated the RN did not sign Patient 6s “;POC/IDG Review” dated 1/22/2025. g. During a review of Patient 7s medical record form, titled “;Personal Information,” it indicated SOC on 1/25/2023 with the primary diagnosis of heart disease (group of conditions that affect the heart and its blood vessels, causing damage to the heart muscle, block blood flow to the heart, or disrupt the heart’s rhythm). During a review of Patient 7s eHR, it indicated MSW and RN did not sign Patient 7s medical record form, titled “;POC/IDG Review” dated 11/27/2024, 12/11/2024, 12/25/2024, and 1/6/2025. The eHR indicated RN did not sign Patient 7s “;POC/IDG Review” dated 1/22/2025. h. During a review of Patient 10s medical record form, titled “;Personal Information,” it indicated SOC on 1/25/2023 with the primary diagnosis of chronic obstructive pulmonary disease (COPD, group of disease of the lungs that makes it difficult for the patient to breathe). During a review of Patient 10s eHR, it indicated RN, MSW, and SC did not sign Patient 10s medical record form, titled “;POC/IDG Review” dated 11/27/2024, 12/11/2024, 12/25/2024, 1/8/2025, and 1/22/2025. i. During a review of Patient 11s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC date of 2/1/2023 with a primary diagnosis of Parkinsons disease (progressive neurodegenerative disorder that affects movement, balance, and coordination). During a review of Patient 11s eHR, it indicated MD, RN, MSW, and SC did not sign Patient 11s medical record forms, titled “;POC/IDG Review” dated 12/11/2024, 12/25/2024, 1/8/2025, and 1/22/2025. j. During a review of Patient 12s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC date of 2/20/2023 with a primary diagnosis of atherosclerosis of aorta (buildup of fatty deposits on the inner walls of the main artery of the body). During a review of Patient 12s eHR, it indicated RN, MSW, and SC did not sign Patient 12s medical record forms, titled “;POC/IDG Review” dated 12/25/2024, 1/8/2025, and 1/22/2025. The eHR indicated RN and MSW did not sign Patient 12s POC/IDG Review” dated 12/11/2025. k. During a review of Patient 13s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC date of 1/22/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (narrowing of the blood vessels supplying blood to the heart due to plaque buildup). During a review of Patient 13s eHR, it indicated there was no documented evidence of any IDG meeting or POC review done for Patient 13. l. During a review of Patient 14s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC of 1/13/2025 with a primary diagnosis of malignant neoplasm of colon (cancer of the large intestine). During a review of Patient 14s eHR, it indicated MD, RN, MSW, and SC did not sign Patient 14s medical record forms, titled “;POC/IDG Review” dated 1/14/2025 and 1/22/2025. m. During a record review of Patient 15s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC of 1/22/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery. During a review of Patient 15s eHR, it indicated there was no documented evidence of any IDG meeting or POC review done for Patient 15. n. During a review of Patient 16s medical record form, titled “;Personal Information,” it indicated SOC on 5/13/2022 with the primary diagnosis of Parkinsons disease. During a review of Patient 16s eHR, it indicated MSW, RN, and SC did not sign Patient 16s medical record form, titled “;POC/IDG Review” dated 7/10/2024, 7/24/2024, 8/7/2024, 8/21/2024 and 9/4/2024. o. During a review of Patient 17s medical record form, titled “;Personal Information,” it indicated SOC on 5/13/2022 with the primary diagnosis of Parkinsons disease. During a review of Patient 17s eHR, RN, MSW, and SC did not sign Patient 17s “;POC/IDG Review” dated 11/13/2024, 11/27/2024, 12/11/2024, and 12/25/2024. During a concurrent interview and record review on 1/30/2025 at 2:44 p.m., with the Administrator and the Director of Patient Care Services (DPCS), the IDG meeting notes for the sampled patients were reviewed. The Administrator and DPCS stated that they do their IDG meetings in-person between the office hours of 9 a.m. to 12 p.m. The Administrator and DPCS stated the HA kept separate attendance sheets for IDG meetings, but these attendance sheets were not part of the patients eHR and did not include the patient names and notes as discussed in the IDG meeting. The Administrator stated the DPCS would create the agenda for every IDG meeting. The Administrator stated the IDG would usually discuss the patients who expired first, then the new admissions to create the care plans, then the patients who had a change in condition, and finally, the rest of the patients who need to be discussed or had concerns after their home visits. The Administrator stated the contracted RN who documented the IDG meeting notes for the sampled patients was not present during the IDG meetings. During a review of the Hospice policy and procedures (P&P), titled “;Interdisciplinary Group Membership and Responsibilities,” dated 4/2020, P&P indicated the following: 1. The IDG must collaborate with the patients attending physician to develop an individualized written plan of care (POC). 2. The hospice IDG membership must include, at a minimum, the MD, RN, SW, and pastoral or another counselor. 3. The IDG responsibilities include, but are not limited to, the following: a. Participation in the establishment of the POC for each patient admitted to the hospice. b. Participation in the periodic review and updating of the POC for each patient receiving hospice services. c. Taking a proactive approach in developing/revising the POC by planning ahead for anticipated patient changes and needs. POC decisions must reflect the patient/family preferences rather than be solely a response to a crisis. d. Provision and/or supervision and coordination of hospice care and services. e. Reporting any unusual change in the patients physical, mental, spiritual, or emotional status to the primary caregiver(s), the attending physician, and the IDG. During a review of the Hospice P&P 2, titled “;The Plan of Care,” dated 4/2020, P&P 2 indicated the following: 1. The POC must be initiated at the start of care. 2. The individualized POC must be reviewed by the rest of the IDG within two days of SOC. 3. The care provided to the patient must be in accordance with the POC. The POC must meet the documentation requirements of the physician-directed medical orders and the care planning process. 4. The POC must be based on the initial, comprehensive-and ongoing comprehensive assessments performed by members of the interdisciplinary group and reviewed on a regular basis but no less than every fifteen (15) days. 5. This plan must focus on identified problems, goals, and interventions. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. The patient and family/caregiver must be encouraged to participate in the development of and continued updating of the POC. During a review of the Hospice P&P 3, titled “;Provision of Care and Record Management” dated 4/2020, P&P 3 indicated the following: 1. A clinical record must be maintained for each patient receiving care. The clinical record must contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice IDG members and contract personnel. 2. Documentation must include: POC developed/revised by the IDG based on comprehensive assessments and desired outcomes with time frames. Each entry must be dated and signed, including title and credentials, by the person providing the care/service. During a review of the Hospice P&P 4, titled “;Clinical/Service Data Collection” dated 4/2020, P&P 4 indicated the following: 1. Home Care Personnel providing patient care and supervisory functions have authority to make entries into the clinical/service record. 2. Documentation in the clinical/service record must be timely, detailed, accurate, and reflect the care or services provided. 3. The record format must be reviewed and updated as necessary. 4. Entries to the clinical/service record must be made only by organization personnel and/or by contract personnel who have a written agreement with the organization.”

“Based on observation, interview and record review, the Hospice Agency (HA, a healthcare agency that provides care for terminally ill patients with life expectancy of 6 months or less) failed to ensure the Interdisciplinary Group (IDG, composed of a Registered Nurse [RN], Medical Social Worker [MSW], spiritual counselor [SC], physician [MD] who meet regularly to discuss the patients plan of care in order to provide the best individualized plan of care and support patient and families) developed, implemented, and revised the individualized plan of care for one of 17 sampled patients (Patient 5). This failure had the potential to result in the worsening/decline of Patient 5s wound due to the lack of communication with the IDG team to identify the significant change of the wound, in order to initiate and update the individualized plan of care. a. During a review of Patient 5s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC date of 10/26/2023 with a primary diagnosis of Alzheimers disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a review of Patient 5s medical form, titled “;Comprehensive Nursing Assessment,” dated 10/26/2023, the “;Comprehensive Nursing Assessment” indicated Patient 5 had an “;open wound on her sacrococcyx (fused tailbone and sacrum bones) area.” During a review of Patient 5s medical form, titled “;Physician Verbal Orders,” dated 10/26/2023,” the “;Physician Verbal Orders” indicated the treatment order “;Stage 2 coccyx sore (shallow open wound or blister to the tailbone area due to prolonged pressure on the skin over the bony prominence): Cleanse with normal saline, pat dry, apply barrier cream until resolves (sore looks pink).” During a review of Patient 5s medical form from Wound Care Specialist 1 (WCS 1), titled “;Progress Report,” dated 10/31/2023, the “;Progress Report” indicated Patient 5 had a Stage 3 pressure sore to the sacrococcyx (full-thickness skin loss to the sacral and tailbone areas due to prolonged pressure on the skin over the bony prominence) with the following measurements: length – 1.68 centimeter (cm, unit of measurement), width – 2.3 cm, and depth – 0.3 cm. During a review of Patient 5s medical form from WCS 1, titled “;Progress Report,” dated 4/24/2024, the “;Progress Report,” indicated Patient 5 had a Stage 3 pressure sore to the sacrococcyx with the following measurements: length – 1.02 cm, width – 1.06 cm, and depth – 0.5 cm. During a review of Patient 5s medical form from WCS 1, titled “;Progress Report,” dated 10/24/2024, the “;Progress Report,” indicated Patient 5 had a Stage 3 pressure sore to the sacrococcyx with the following measurements: length – 4.49 cm, width – 3.01 cm, and depth – 1 cm. During a review of Patient 5s medical form from WCS 1, titled “;Progress Report,” dated 1/23/2025, the “;Progress Note” indicated Patient 5 had a Stage 3 pressure sore to the sacrococcyx with the following measurements: length – 2.66 cm, width – 3.8 cm, and depth – 1.2 cm. During a concurrent observation and interview on a joint home visit on 1/29/2025 at 12:10 p.m., with Licensed Vocational Nurse 1 (LVN 1), Patient 5 was observed with a foam dressing to the sacrococcyx area. LVN 1 stated Patient 5s caregiver changed the wound dressing in the morning prior to the skilled nursing visit, so LVN 1 did not change the wound dressing at the time. Patient 5s wound care supplies, not labeled with Patient 5s name, were observed inside the bedside nightstand. The wound care ointments included: wound cleanser, Tetracyte (antibiotic) topical spray, Therahoney gel (medical grade honey to assist with wound healing), alginate and foam dressing. However, upon concurrent observation of the Patient 5s home hospice binder, LVN 1 stated there was no evidence of specific wound care orders and plan of care for Patient 5s wound. During a concurrent interview and record review on 1/31/2025 at 11:30 a.m., with the Director of Patient Care Services (DPCS), Patient 5s electronic health record was reviewed. The DPCS stated there was no documented evidence of hospice wound care orders entered in Patient 5s eHR. The DPCS stated there was no documented evidence of an individualized plan of care developed and implemented for Patient 5s wound in the eHR. The DPCS stated there was no documented evidence of comprehensive wound care assessments by the licensed nursing during skilled nursing visits. The DPCS stated the Wound Care Specialist was responsible for writing the wound care orders and ordering wound care supplies. The DPCS stated the hospice nurses were in-charge of performing wound care to Patient 5 during skilled nursing visits. The DPCS stated the caregivers and family were responsible for performing wound care on the other days. The DPCS was unable to state Patient 5s current wound care treatments, other interventions to address the long-term wound, and Patient 5s progress towards desired outcomes. The DPCS stated it is important to have hospice wound care orders in Patient 5s eHR to ensure there was “;a specific plan of care to follow” and ensure all hospice licensed nurses consistently implemented the plan. The DPCS stated it was important for the hospice licensed nurses to assess and measure Patient 5s wound and perform wound care every visit to determine if Patient 5s wound care interventions were effective and Patient 5 was progressing towards the goal of improving the wound condition. During a review of the HAs policy and procedures (P&P 1), dated 4/2020, P&P 1 indicated the following: 1. A written individualized patient and family/caregiver plan of care that focus on identified problems, goals, and interventions must be established and maintained for each individual admitted to the hospice program. 2. The individualized plan of care must be reviewed by the rest of the IDG within 2 days of start of care. 3. The plan of care must be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the IDG, with input form the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver. Review of the plan of care must be documented in the clinical record. Revision dates must be noted on the plan of care. 4. Any change in the patients condition must result in a change in the plan of care, prior to the implementation of the new service. 5. As needed, the patient and family/caregiver must receive written instructions regarding treatments or aspects of care that must be the responsibility of the patient and family/caregiver to provide or follow through with. 6. The plan of care must meet the documentation requirements of the physician-directed medical orders and the care planning process.”

“Based on interview and record review, the Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to maintain oversight of the contracted (a worker or independent contractor [a self-employed person contracted to perform work for another entity as a non-employee] who is engaged by an employer under a contract for service) Medical Director (HMD); retain professional management responsibility for all hospice services under contract and failed to monitor and exercise control over service provided by personnel under contract. The agency contracted HMD to conduct Medical Director duties. HMD subcontracted Nurse Practitioner (NP) to conduct the duty of face-to-face evaluation of patients, without the knowledge of the hospice agency. The HA has no records if NP met the credentialing requirements (the process of verifying and assessing the qualifications, education, training, licensure, and professional background of healthcare provider to ensure standards for patient care are met) or if a criminal background check (the process used to verify whether an individual has a criminal history to ensure the patient safety from abuse and protection and prevention of fraud and financial crimes) was completed and cleared to ensure patient safety and protection; and prevention of fraud and financial crimes. This deficient practice would likely compromise the safety of three out of 17 sampled patients (Patient 5, Patient 6, and Patient 7) by exposing Patient 5, Patient 6, and Patient 7 to NP without verification of proper qualifications; verification that NP is cleared of a history of abuse and mistreatment, misuse of patient information, and inadequate patient care (conducting an assessment about the patients physical, emotional, and psychological [a wide range of conditions that affect a person’s thoughts, feelings, and behavior] condition to create an accurate care plan is part of patient care). On 2/7/2025 at 4:13 p.m., the Department called an Immediate Jeopardy Situation (IJ, a situation in which the provider’s non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the HAs Director of Nurses (DON), Administrator (ADM), and Administrator Designee (AD) related to failure to maintain oversight of the contracted Medical Director; retain professional management responsibility for all hospice services under contract; and failing to monitor and exercise control over service provided by personnel under contract. The agency contracted the Medical Director to conduct Medical Director duties. The Medical Director subcontracted NP to conduct face-to-face evaluation of patients without the knowledge of the hospice agency. On 2/7/2025, at 6:16 p.m., the HA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 2/7/2025, at 6:50 p.m., the survey team completed the survey tasks and conducted an exit conference, with the DON, ADM, and AD with the IJ situation not removed. 1. A review of Patient 5s “;Personal Information” indicated a start of care (SOC-the day the patient officially begins receiving hospice services) on 10/26/2023 with a terminal diagnosis of Alzheimers disease (a brain disorder that gradually destroys memory and thinking skills). During a record review of Patient 5s NP visit notes dated 12/28/2024, the note indicated that NP visited Patient 5 for the purpose of a recertification assessment (a review of a patient’s medical records and a face-to-face meeting with a hospice professional to determine if the patient still qualifies for hospice care). 2. A review of Patient 6s record titled “;Patient Face Sheet”, indicated a SOC of 1/25/2023 with a primary diagnosis of chronic kidney disease (condition where the kidneys gradually lose their ability to filter waste products from the blood). During a record review of Patient 6s NP visit notes dated 11/10/2024, 9/8/2024, 7/8/2024, and 5/7/2024, the notes indicated that NP visited Patient 6 for the purpose of recertification assessments. 3. A review of Patient 7s record titled “;Patient Face Sheet”, indicated a SOC of 1/25/2023 with a primary diagnosis of end stage heart disease stage 4 (refers to a group of conditions that affect the heart and its blood vessels. These conditions can damage the heart muscle, block blood flow to the heart, or disrupt the heart’s rhythm). During a record review of Patient 7s NP visit notes dated 11/10/2024, 9/8/2024, 7/8/2024, and 5/7/2024, the notes indicated that NP visited Patient 7s for the purpose of recertification assessments During a record review of the facilitys Professional Service Agreement Medical Director dated 5/2/2019, the Professional Service Agreement Medical Director did not specify the use of a subcontractor which also outlined the scope of work, responsibilities, and compliance expectations. During an interview with the HMD on 1/31/2025 at 3:02 pm, HMD stated that NP was not employed by the agency but was employed by him (HMD). During an interview with the DON on 2/3/2025 at 10:51 am, DON stated that NP visited Patients 5,6 and 7. During an interview on 2/6/2025, at 12:25 p.m., the HMD stated that he (HMD) employed NP one year ago to see patients who have been under hospice care longer than 180 days. HMD stated that he (HMD) had verified NPs credentials and experience but did not do a criminal background check because he (HMD) did not feel a criminal background check was needed for NP. During an interview with NP on 2/6/2025, at 1:08 p.m., NP stated that she (NP) has been working for HMD for a year. NP stated that she (NP) assesses the agencys patients (Patient 5, 6, and 7) for the purpose of recertification. NP stated that she (NP) is an independent contractor, and that HMD had subcontracted her (NP). NP stated that after she (NP) sees patients for recertification, she (NP) will provide the notes to HMD. NP stated that HMD will then utilize her (NP) patient visit notes for the Certificate of Terminal Illness (CTI- a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician). During an interview with the ADM on 2/6/2025, at 1:51 p.m., the ADM stated that HMD made the agency aware two months ago that NP was seeing the agencys patients (Patient 5, 6, and 7) for recertification assessments. During an interview with the ADM on 2/6/2025, at 1:54 p.m., the ADM stated that HMD has never provided the agency with the list of the agencys patients being seen by NP. ADM stated that he (ADM) believes it was the HMD responsibility to conduct a criminal background check on NP. During an interview with the ADM on 2/6/2025, at 1:59 p.m., the ADM stated that a criminal background check should have been completed for NP by the HA. ADM stated that the HA agency needs to ensure that subcontractors such as NP are in “;good standing” (one’s license is up-to-date, active, not under investigation or suspension and not subjected to any form of sanction, suspension, or disciplinary action). ADM stated that it is important to conduct a criminal background check to ensure that no emotional, financial, and or physical abuse has occurred. During an interview with the DON on 2/6/2025, at 2:02 p.m., the DON stated that by exposing patients to an individual without the HA verifying the individuals credentials and checking for a criminal background, patients can be financially exploited (illegal misuse of someone’s money, property, or resources). DON stated that patients are vulnerable, and the HA wants to keep patients safe. During a record review of the HAs undated document titled “;Sub-Contractor Policy”, indicated subcontractors must adhere to the organizations policies, procedures, and regulatory requirements. A formal contract must be executed between contractor and the subcontractor outlining the scope of work, responsibilities, and compliance expectations. Subcontractors must provide valid credentials and licensure, as applicable. Subcontractors must undergo background checks and verification of qualifications before engagement. Subcontractors must maintain complete and accurate records for all services provided. During a record review of the HAs Job Description for the Hospice Medical Director, dated October 2015, indicated the medical directors duties and responsibilities included the need to adhere to requirements, terms, and conditions required by Medicare (a federal health insurance program that helps people pay for healthcare) Conditions of Participation (CoP-a set of minimum professional standards all hospice agencies must meet to participate in Medicare and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs), accrediting body, and federal and state statutes governing the provision of services.” During a record review of the HAs document titled, “;Professional Services Agreement Medical Director”, dated 5/2/2019, indicated that the Medical Director will abide by the Bylaws (rules made by the agency) and Rules and Regulations of the agency.”

“Based on observation, interviews and record review, the Hospice Agency (HA) failed to ensure the patient’s clinical record contained the initial and updated plans of care (POC), initial comprehensive, ongoing assessments, visit notes by licensed nurses identifying the Stage 3 pressure sore (full-thickness skin loss due to prolonged pressure on bony prominence) on the sacrococcyx (area at base of the spine) of one of 17 sampled patients (Patient 5). This failure could lead to the lack of hospice staff’s coordination of patient’s clinical information and continuity of care services provided to the patients certified to receive the benefits. During a review of Patient 5s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC date of 10/26/2023 with a primary diagnosis of Alzheimers disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a review of Patient 5s medical form, titled “;Comprehensive Nursing Assessment,” dated 10/26/2023, the “;Comprehensive Nursing Assessment” indicated Patient 5 had an “;open wound on her sacrococcyx (fused tailbone and sacrum bones) area.” During a review of Patient 5s medical form, titled “;Physician Verbal Orders,” dated 10/26/2023,” the “;Physician Verbal Orders” indicated the treatment order “;Stage 2 coccyx sore: Cleanse with normal saline, pat dry, apply barrier cream until resolves (sore looks pink).” During a review of Patient 5s medical form from Wound Care Specialist 1 (WCS 1), titled “;Progress Report,” dated 10/31/2023, the “;Progress Report” indicated Patient 5 had a Stage 3 pressure sore to the sacrococcyx with the following measurements: length – 1.68 centimeter (cm, unit of measurement), width – 2.3 cm, and depth – 0.3 cm. During a review of Patient 5s medical form from WCS 1, titled “;Progress Report,” dated 1/23/2025, the “;Progress Note” indicated Patient 5 had a Stage 3 pressure sore to the sacrococcyx with the following measurements: length – 2.66 cm, width – 3.8 cm, and depth – 1.2 cm. During a concurrent observation and interview on a joint home visit on 1/29/2025 at 12:10 p.m., with Licensed Vocational Nurse 1 (LVN 1), Patient 5 was observed with a foam dressing to the sacrococcyx area. LVN 1 stated Patient 5s caregiver changed the wound dressing in the morning prior to the skilled nursing visit, so LVN 1 did not change the wound dressing at the time. Patient 5s wound care supplies, not labeled with Patient 5s name, were observed inside the bedside nightstand. The wound care ointments included: wound cleanser, Tetracyte (antibiotic) topical spray, Therahoney gel (medical grade honey to assist with wound healing), alginate and foam dressing. However, upon concurrent observation of the Patient 5s home hospice binder, LVN 1 stated there was no evidence of specific wound care orders and plan of care for Patient 5s wound. During a concurrent interview and record review on 1/31/2025 at 11:30 a.m., with the Director of Patient Care Services (DPCS), Patient 5s electronic health records were reviewed. The DPCS stated there was no documented evidence of hospice wound care orders entered in Patient 5s eHR. The DPCS stated there was no documented evidence of an individualized plan of care developed and implemented for Patient 5s wound in the eHR. The DPCS stated there was no documented evidence of comprehensive wound care assessments by the licensed nursing during skilled nursing visits. The DPCS stated the Wound Care Specialist was responsible for writing the wound care orders and ordering wound care supplies. The DPCS stated the hospice nurses were in-charge of performing wound care to Patient 5 during skilled nursing visits. The DPCS stated the caregivers and family were responsible for performing wound care on the other days. The DPCS was unable to state Patient 5s current wound care treatments, other interventions to address the long-term wound, and Patient 5s progress towards desired outcomes. The DPCS stated it was important to have hospice wound care orders in Patient 5s eHR to ensure there was “;a specific plan of care to follow” and ensure all hospice licensed nurses consistently implemented the plan. The DPCS stated it was important for the hospice licensed nurses to assess and measure Patient 5s wound and perform wound care every visit to determine if Patient 5s wound care interventions were effective, and Patient 5 was progressing towards the goal of improving the wound condition. During a review of HAs undated P&P 1, titled “;Contents of Clinical Record,” P&P 1 indicated the clinical record must contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. During a review of HAs undated P&P 2, titled “;Wound Assessment and Documentation,” P&P 2 indicated the following: 1. The treatment and condition of the wound must be documented as each visit and must include the following: 1) wound bed appearance, 2) depth and location of undermining in centimeters, 3) color, odor, and estimated amount of drainage, 4) weekly staging of the wound and progress with the goals of therapy, 5) patient/caregiver instructions on wound care, and 6) wound measurements every 2 weeks, including the length, depth, and width of the wound in centimeters. 2. Patients care plan must be updated. 3. The physician must be consulted, and the care plan revised as needed, if the wound is not healing. During a review of the HAs P&P 3, titled “;Ongoing Assessments,” dated 4/2020, P&P 3 indicated the following: 1. The Case Manager or other discipline must evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. 2. The nurse must assess each patient on each visit for the following, but not limited to: a. Current treatment related to the identified symptoms and the patient response b. Skin integrity c. Progress towards hospice goals and patient needs and problems d. Compliance with treatments and medication regimen 3. Based on the assessments, the plan of care, including problems, needs, goals, and outcomes, must be reviewed and updated by the IDG members responsible for the case. During a review of the HAs P&P 3, titled “;The Plan of Care,” dated 4/2020, P&P 3 indicated the following: 1. Each patient must be monitored for his/her response to care or services provided against established patient goals and outcomes to evaluate progress toward goals. 2. Care decisions and services to be provided must be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes.”

“Based on observation, interviews and record review, the Hospice Agency (HA) failed to ensure the hospice licensed nurses documented the patients responses to the care services and treatment orders provided for the Stage 3 pressure sore (full-thickness skin loss due to prolonged pressure on bony prominence) on the sacrococcyx (area at base of the spine) for one of 17 sampled patients (Patient 5). This failure had the potential to lead to worsening of the patients wound related to the lack of continuity of care and inconsistent wound treatments. During a review of Patient 5s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC date of 10/26/2023 with a primary diagnosis of Alzheimers disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a review of Patient 5s medical form, titled “;Comprehensive Nursing Assessment,” dated 10/26/2023, the “;Comprehensive Nursing Assessment” indicated Patient 5 had an “;open wound on her sacrococcyx (fused tailbone and sacrum bones) area.” During a review of Patient 5s medical form, titled “;Physician Verbal Orders,” dated 10/26/2023,” the “;Physician Verbal Orders” indicated the treatment order “;Stage 2 coccyx sore: Cleanse with normal saline, pat dry, apply barrier cream until resolves (sore looks pink).” During a review of Patient 5s medical form from WCS 1, titled “;Progress Report,” dated 10/24/2024, the “;Progress Report,” indicated Patient 5 had a Stage 3 pressure sore to the sacrococcyx with the following measurements: length – 4.49 cm, width – 3.01 cm, and depth – 1 cm. During a review of Patient 5s medical form from WCS 1, titled “;Progress Report,” dated 1/23/2025, the “;Progress Note” indicated Patient 5 had a Stage 3 pressure sore to the sacrococcyx with the following measurements: length – 2.66 cm, width – 3.8 cm, and depth – 1.2 cm. During a concurrent observation and interview while on a joint home visit on 1/29/2025 at 12:10 p.m. with Licensed Vocational Nurse 1 (LVN 1), Patient 5 was observed with a foam dressing to the sacrococcyx area. LVN 1 stated Patient 5s caregiver changed the wound dressing in the morning prior to the skilled nursing visit, so LVN 1 did not change the wound dressing at the time. Patient 5s wound care supplies, not labeled with Patient 5s name, were observed inside the bedside nightstand. The wound care ointments included: wound cleanser, Tetracyte (antibiotic) topical spray, Therahoney gel (medical grade honey to assist with wound healing), alginate and foam dressing. However, upon concurrent observation of the Patient 5s home hospice binder, LVN 1 stated there was no evidence of specific wound care orders and plan of care for Patient 5s wound. During a concurrent interview and record review on 1/31/2025 at 11:30 a.m. with the Director of Patient Care Services (DPCS), Patient 5s electronic health records were reviewed. The DPCS stated there was no documented evidence of hospice wound care orders entered in Patient 5s eHR. The DPCS stated there was no documented evidence of an individualized plan of care developed and implemented for Patient 5s wound in the eHR. The DPCS stated there was no documented evidence of comprehensive wound care assessments by the licensed nursing during skilled nursing visits. The DPCS stated the Wound Care Specialist was responsible for writing the wound care orders and ordering wound care supplies. The DPCS stated the hospice nurses were in-charge of performing wound care to Patient 5 during skilled nursing visits. The DPCS stated the caregivers and family were responsible for performing wound care on the other days. The DPCS was unable to state Patient 5s current wound care treatments, other interventions to address the long-term wound, and Patient 5s progress towards desired outcomes. The DPCS stated it was important to have hospice wound care orders in Patient 5s eHRs to ensure there was “;a specific plan of care to follow” and ensure all hospice licensed nurses consistently implemented the plan. The DPCS stated it was important for the hospice licensed nurses to assess and measure Patient 5s wound and perform wound care every visit to determine if Patient 5s wound care interventions were effective and Patient 5 was progressing towards the goal of improving the wound condition. During a review of HAs undated P&P 1, titled “;Contents of Clinical Record,” P&P 1 indicated the clinical record must contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. During a review of the HAs P&P 2, titled “;The Plan of Care,” dated 4/2020, P&P 2 indicated the following: 1. Each patient must be monitored for his/her response to care or services provided against established patient goals and outcomes to evaluate progress toward goals. 2. Care decisions and services to be provided must be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes.”

“Based on observation, interviews and record review, the Hospice Agency (HA) failed to ensure the clinical record contained physician orders to treat the Stage 3 pressure sore (full-thickness skin loss due to prolonged pressure on bony prominence) on the sacrococcyx (area at base of the spine) of one of 17 sampled patients (Patient 5). This failure had the potential to lead to worsening of the patients wound related to the lack of continuity of care and properly documented wound treatment orders. During a review of Patient 5s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC date of 10/26/2023 with a primary diagnosis of Alzheimers disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a review of Patient 5s medical form, titled “;Comprehensive Nursing Assessment,” dated 10/26/2023, the “;Comprehensive Nursing Assessment” indicated Patient 5 had an “;open wound on her sacrococcyx (fused tailbone and sacrum bones) area.” During a review of Patient 5s medical form, titled “;Physician Verbal Orders,” dated 10/26/2023,” the “;Physician Verbal Orders” indicated the treatment order “;Stage 2 coccyx sore: Cleanse with normal saline, pat dry, apply barrier cream until resolves (sore looks pink).” During a review of Patient 5s medical form from Wound Care Specialist 1 (WCS 1), titled “;Progress Report,” dated 10/31/2023, the “;Progress Report” indicated Patient 5 had a Stage 3 pressure sore to the sacrococcyx with the following measurements: length – 1.68 centimeter (cm, unit of measurement), width – 2.3 cm, and depth – 0.3 cm. During a review of Patient 5s medical form from WCS 1, titled “;Progress Report,” dated 1/23/2025, the “;Progress Note” indicated Patient 5 had a Stage 3 pressure sore to the sacrococcyx with the following measurements: length – 2.66 cm, width – 3.8 cm, and depth – 1.2 cm. During a concurrent observation and interview while on a joint home visit on 1/29/2025 at 12:10 p.m. with Licensed Vocational Nurse 1 (LVN 1), Patient 5 was observed with a foam dressing to the sacrococcyx area. LVN 1 stated Patient 5s caregiver changed the wound dressing in the morning prior to the skilled nursing visit, so LVN 1 did not change the wound dressing at the time. Patient 5s wound care supplies, not labeled with Patient 5s name, were observed inside the bedside nightstand. The wound care ointments included: wound cleanser, Tetracyte topical spray, Therahoney gel (medical grade honey to assist with wound healing), alginate and foam dressing. However, upon concurrent observation of the Patient 5s home hospice binder, LVN 1 stated there was no evidence of specific wound care orders and plan of care for Patient 5s wound. During a concurrent interview and record review on 1/31/2025 at 11:30 a.m., with the Director of Patient Care Services (DPCS), Patient 5s electronic health record was reviewed. The DPCS stated there was no documented evidence of hospice wound care orders entered in Patient 5s eHR. The DPCS stated there was no documented evidence of an individualized plan of care developed and implemented for Patient 5s wound in the eHR. The DPCS stated there was no documented evidence of comprehensive wound care assessments by the licensed nursing during skilled nursing visits. The DPCS stated the Wound Care Specialist was responsible for writing the wound care orders and ordering wound care supplies. The DPCS stated the hospice nurses were in-charge of performing wound care to Patient 5 during skilled nursing visits. The DPCS stated the caregivers and family were responsible for performing wound care on the other days. The DPCS was unable to state Patient 5s current wound care treatments, other interventions to address the long-term wound, and Patient 5s progress towards desired outcomes. The DPCS stated it was important to have hospice wound care orders in Patient 5s eHRs to ensure there was “;a specific plan of care to follow” and ensure all hospice licensed nurses consistently implemented the plan. The DPCS stated it was important for the hospice licensed nurses to assess and measure Patient 5s wound and perform wound care every visit to determine if Patient 5s wound care interventions were effective, and Patient 5 was progressing towards the goal of improving the wound condition. During a review of HAs undated P&P 1, titled “;Contents of Clinical Record,” P&P 1 indicated the clinical record must contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. During a review of HAs P&P 2, titled “;Verification of Physician Orders,” dated 4/2020, P&P 2 indicated the following: 1. Orders must be documented on a form provided by Olympia Hospice Care, Inc. dated and signed by the professional receiving the order. 2. The original order form must be delivered to the physician for signature. During a review of the HAs P&P 3, titled “;The Plan of Care,” dated 4/2020, P&P 3 indicated the following: 1. Each patient must be monitored for his/her response to care or services provided against established patient goals and outcomes to evaluate progress toward goals. 2. Care decisions and services to be provided must be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes.”

“Based on interviews and record review, the Hospice Agency (HA- a healthcare agency that provides care for terminally ill patients with life expectancy of 6 months or less) failed to ensure the clinical records were authenticated by the author for 11 of 17 sample selected patients (Patient 1, 2, 3, 4, 5, 6, 7, 10, 12, 16 and 17). Registered Nurse 3 (RN 3), who did not attend regular interdisciplinary group (IDG, group of healthcare professionals from different disciplines that collaborate to develop and implement a comprehensive, individualized care plans to achieve optimal patient outcomes) meetings, documented out-of-the ordinary hour entries of the IDG meeting notes on the patients’ electronic health records (eHRs), including in-person IDG meeting notes. This failure resulted in clinical information being entered in the patients electronic health records (eHRs) without validation of the accuracy of information and assurance that the note reflected the care being provided by the appropriate staff. a. During a review of Patient 1s medical record form, titled “;Personal Information,” it indicated start of care (SOC, admission date) on 9/16/2024 with the diagnosis of malignant neoplasm of the right bronchus of lung (cancer of the lung). During a review of Patient 1s eHR, Patient 1s medical record forms, titled “;IDT/POC Review” were reviewed. The “;IDT/POC Review” indicated Registered Nurse 3 (RN 3) documented on the IDG meeting notes on the following dates: 1/8/2025 at 5:45 p.m., 12/25/2024 at 12 midnight, 12/11/2024 at 12 midnight, 11/27/2024 at 4:30 p.m., and 11/13/2024 at 4:30 p.m. b. During a review of Patient 2s medical record form, titled “;Personal Information,” it indicated SOC on 11/6/2024 with the primary diagnosis of malignant neoplasm of connective and soft tissue (cancerous tumor of the muscles, tendons, ligaments, fats and cartilage). During a review of Patient 2s eHR, Patient 2s medical record forms, titled “;IDT/POC Review” were reviewed. The “;IDT/POC Review” indicated RN 3 documented on the IDG meeting notes on the following dates: 1/8/2025 at 6:45 p.m. 12/15/2024 at 4:45 p.m., 12/11/2024 at 8:15 p.m., 11/27/2024 at 12:00 midnight, 11/13/24 at 3:30 p.m. c. During a review of Patient 3s medical record form, titled “;Personal Information,” it indicated SOC on 4/4/2024 with the primary diagnosis of squamous cell carcinoma of the skin (skin cancer). During a review of Patient 3s eHR, Patient 3s medical record forms, titled “;IDT/POC Review” were reviewed. The “;IDT/POC Review” indicated RN 3 documented on the IDG meeting notes on the following dates: 11/13/2024 at 5:15 p.m., 10/30/2024 at 12:00 midnight, 10/16/2024 at 4:15 p.m., 10/2/2024 at 12:00 midnight, and 9/19/2024 at 12:00 midnight. d. During a review of Patient 4s medical record form, titled “;Personal Information,” it indicated SOC on 4/4/2024 with the primary diagnosis of squamous cell carcinoma of the skin. During a review of Patient 4s eHR, Patient 4s medical record forms, titled “;IDT/POC Review” were reviewed. The “;IDT/POC Review” indicated RN 3 documented on the IDG meeting notes on the following dates: 1/22/2025 at 12:00 midnight, 1/8/2025 at 7:15 p.m., 12/25/2024 at 7:15 p.m., 12/11/2024 at 10:45 p.m., and 11/27/2024 at 4:45 p.m. e. During a review of Patient 5s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC date of 10/26/2023 with a primary diagnosis of Alzheimers disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a review of Patient 5s eHR, Patient 5s medical record form, titled “;IDT/POC Review” dated 1/22/2025 was reviewed. The “;IDT/POC Review” indicated RN 3 documented on the IDG meeting note 1/22/2025 at 12 a.m. f. During a review of Patient 6s medical record form, titled “;Personal Information,” it indicated that SOC on 1/25/2023 with the primary diagnosis of Stage 4 chronic kidney disease (deterioration of the kidneys and inability to function adequately). During a review of Patient 6s eHR, Patient 6s medical record forms, titled “;IDT/POC Review” were reviewed. The “;IDT/POC Review” indicated RN 3 documented on the IDG meeting notes on the following dates: 1/22/2025 at 3:30 p.m., 1/8/2025 at 7:30 p.m., 12/25/2024 at 12:00 midnight, 12/11/2024 at 11:15 p.m., and 11/27/2024 at 5:45 p.m. g. During a review of Patient 7s medical record form, titled “;Personal Information,” it indicated SOC on 1/25/2023 with the primary diagnosis of heart disease (group of conditions that affect the heart and its blood vessels, causing damage to the heart muscle, block blood flow to the heart, or disrupt the heart’s rhythm). During a review of Patient 7s eHR, Patient 7s medical record forms, titled “;IDT/POC Review” were reviewed. The “;IDT/POC Review” indicated RN 3 documented on the IDG meeting notes on the following dates: 1/22/2025 at 3:30 p.m., 1/8/2025 in person on 7:30 p.m., 12/25/2024 in person at 12:00 midnight, 12/11/2024 in person at 11:35 p.m., 11/27/2024 in person at 5:45 p.m. h. During a review of Patient 10s medical record form, titled “;Personal Information,” it indicated SOC on 1/25/2023 with the primary diagnosis of chronic obstructive pulmonary disease (COPD, group of disease of the lungs that makes it difficult for the patient to breathe). During a review of Patient 10s eHR, Patient 10s medical record forms, titled “;IDT/POC Review” were reviewed. The “;IDT/POC Review” indicated RN 3 documented on the IDG meeting notes on the following dates: 1/22/2025 at 3;30 p.m., 1/8/2025 at 7:45 p.m., 12/25/2024 at 12:00 midnight, 12/11/2024 at 11:15 p.m., 11/27/2025 at 5:45 p.m. i. During a review of Patient 12s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC date of 2/20/2023 with a primary diagnosis of atherosclerosis of aorta (buildup of fatty deposits on the inner walls of the main artery of the body). During a review of Patient 12s eHR, Patient 12s medical record form, titled “;IDT/POC Review” dated 1/22/2025 was reviewed. The “;IDT/POC Review” indicated RN 3 documented on the IDG meeting note 1/22/2025 at 3:30 p.m. j. During a review of Patient 16s medical record form, titled “;Personal Information,” it indicated SOC on 5/13/2022 with the primary diagnosis of Parkinsons disease. During a review of Patient 16s eHR, Patient 16s medical record forms, titled “;IDT/POC Review” were reviewed. The “;IDT/POC Review” indicated RN 3 documented on the IDG meeting notes on the following dates: 7/10/2024 at 12:00 midnight, 6/26/2024 at 12:00 midnight., 6/12/2024 at 12:00 midnight, 5/15/2024 at 12:00 midnight. k. During a review of Patient 17s medical record form, titled “;Personal Information,” it indicated SOC on 5/13/2022 with the primary diagnosis of Parkinsons disease. During a review of Patient 17s eHR, Patient 17s medical record forms, titled “;IDT/POC Review” were reviewed. The “;IDT/POC Review” indicated RN 3 documented on the IDG meeting notes on the following dates: 12/11/2024 at 10:15 p.m., 10/16/2024 at 12:00 midnight, 10/2/2024 at 12:00 midnight and 9/4/2024 at 5:15 p.m. During a concurrent interview and record review on 1/30/2025 at 2:44 p.m. with the Administrator and the Director of Patient Care Services (DPCS), the IDG meeting notes for the sampled patients were reviewed. The Administrator stated the HA conduct their IDG meetings every 15 days every Wednesday between 9 a.m. to 12 noon. The Administrator stated IDG meetings were conduct in-person every other week and alternately over the telephone alternately. The Administrator and DPCS stated the HA kept separate attendance sheets for IDG meetings, but these attendance sheets were not part of the patients eHRs and did not include the patient names and notes as discussed in the IDG meeting. The Administrator stated the DPCS would create the agenda for every IDG meeting. The Administrator stated the IDG would usually discuss the patients who expired first, then the new admissions to create the care plans, then the patients who had a change in condition, and finally, the rest of the patients who need to be discussed or had concerns after their home visits. The Administrator stated the contracted RN served as a “;QA,” had access to eHRs, and documented on the patients IDG meeting notes. The DPCS and Administrator stated RN 3 was not present during the IDG meetings. During a review of the HAs P&P 1, titled “;Clinical/Service Data Collection” dated 4/2020, P&P 1 indicated the following: 1. Home Care Personnel providing patient care and supervisory functions have authority to make entries into the clinical/service record. 2. Documentation in the clinical/service record must be timely, detailed, accurate, and reflect the care or services provided. 3. The record format must be reviewed and updated as necessary. 4. Entries to the clinical/service record must be made only by organization personnel and/or by contract personnel who have a written agreement with the organization. During a review of the HAs P&P 2, titled “;Provision of Care and Record Management,” dated 4/2020, P&P 2 indicated a clinical record must be maintained for each patient receiving care. P&P 2 indicated the clinical record must contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice IDG members and contract personnel. P&P 2 indicated the documentation must include a plan of care developed/revised by the IDG based on comprehensive assessments and desired outcomes with time frames. P&P 2 indicated each entry must be dated and signed, including title and credentials, by the person providing the care/service.”

“Based on interviews and record review, the Hospice Agency (HA- a healthcare agency that provides care for terminally ill patients with life expectancy of 6 months or less) failed to ensure all Protected Health Information (PHI, any health information that can identify a patient, including names, addresses, birthdates, medical records) was safeguarded against unauthorized access to the electronic health records (eHRs, digital version of the patients medical chart). The hospice contracted Medical Director shared his Hospice Login information (username and password entered to enter a secured computer system or program) with another hospice staff for 17 out of 17 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, and 17). This failure has the potential risk resulting in an unauthorized access and breach of the confidentiality of the patients’ health information (PHI) leading to an inaccurate assessment information will be entered by an unauthorized clinician. a. During a review of Patient 1s medical record form, titled “;Personal Information,” it indicated start of care (SOC, admission date) on 9/16/2024 with the diagnosis of malignant neoplasm of the right bronchus of lung (cancer of the lung). b. During a review of Patient 2s medical record form, titled “;Personal Information,” it indicated SOC on 11/6/2024 with the primary diagnosis of malignant neoplasm of connective and soft tissue (cancerous tumor of the muscles, tendons, ligaments, fats and cartilage). c. During a review of Patient 3s medical record form, titled “;Personal Information,” it indicated SOC on 4/4/2024 with the primary diagnosis of squamous cell carcinoma of the skin (skin cancer). d. During a review of Patient 4s medical record form, titled “;Personal Information,” it indicated SOC on 4/4/2024 with the primary diagnosis of squamous cell carcinoma of the skin. e. During a review of Patient 5s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC date of 10/26/2023 with a primary diagnosis of Alzheimers disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). f. During a review of Patient 6s medical record form, titled “;Personal Information,” it indicated that SOC on 1/25/2023 with the primary diagnosis of Stage 4 chronic kidney disease (deterioration of the kidneys and inability to function adequately). g. During a review of Patient 7s medical record form, titled “;Personal Information,” it indicated SOC on 1/25/2023 with the primary diagnosis of heart disease (group of conditions that affect the heart and its blood vessels, causing damage to the heart muscle, block blood flow to the heart, or disrupt the heart’s rhythm). h. During a review of Patient 10s medical record form, titled “;Personal Information,” it indicated SOC on 1/25/2023 with the primary diagnosis of chronic obstructive pulmonary disease (COPD, group of disease of the lungs that makes it difficult for the patient to breathe). i. During a review of Patient 11s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC date of 2/1/2023 with a primary diagnosis of Parkinsons disease (progressive neurodegenerative disorder that affects movement, balance, and coordination). j. During a review of Patient 12s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC date of 2/20/2023 with a primary diagnosis of atherosclerosis of aorta (buildup of fatty deposits on the inner walls of the main artery of the body). k. During a review of Patient 13s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC date of 1/22/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (narrowing of the blood vessels supplying blood to the heart due to plaque buildup). l. During a review of Patient 14s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC of 1/13/2025 with a primary diagnosis of malignant neoplasm of colon (cancer of the large intestine). m. During a record review of Patient 15s medical record form, titled “;Personal Information,” the “;Personal Information” indicated SOC of 1/22/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery. n. During a review of Patient 16s medical record form, titled “;Personal Information,” it indicated SOC on 5/13/2022 with the primary diagnosis of Parkinsons disease. o. During a review of Patient 17s medical record form, titled “;Personal Information,” it indicated SOC on 5/13/2022 with the primary diagnosis of Parkinsons disease. During an observation on 1/28/2025 at 3:00 p.m., upon entry to the agency office, there was a reception area, a conference room, and three office tables with three computers. Three office staff members were logged into and observed documented on the electronic health records (eHRs). During an interview on 1/31/2025 at 2:53 p.m., the HA medical director (MD) stated that he does not log in to eHRs for the “decades-long experience” he had as a hospice doctor to sign the interdisciplinary team (IDT) meetings and sign physicians orders in the eHRs. MD stated he shared his login and password to the hospice staff for them to electronically sign his orders and IDT documentation. During a review of the HA’s policy and procedures, titled “;Clinical/Service Data Collection,” dated 4/2020, the P&P indicated the purpose of the P&P was to define who has authority to make entries into the clinical/service record and to provide guidelines for valid data collection. Home care personnel providing patient care and supervisory functions have authority to make entries into the clinical/service record. Documentation in the clinical/service record must be timely, detailed, accurate, and reflect the care or services provided. Entries to the clinical/service record must be made only by organization personnel and/or by contract personnel who have a written agreement with the organization. Personnel authorized to use a computer to authenticate documentation must sign a computer confidentiality statement, verifying that no one else will be allowed to use their computer password. Each staff member will be responsible for the security of his/her computer password.”