Dignity Hospice Provider

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients) failed to include information on the patient’s weight change as part of the recertification assessment for one of six sampled patients (Patient 1).This deficient practice had a potential to result in Patient 1 not appropriately assessed and therefore not receiving appropriate interventions. During a review of Patient 1’s Personal Information, the Personal Information indicated Patient 1 was admitted to the HA on 6/26/2024 with a primary diagnosis of Alzheimer’s disease (a progressive and irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to carry out everyday tasks). During a review of Patient 1’s Local Coverage Determination (LCD) Hospice Eligibility Determination, dated 4/21/2025, the LCD Hospice Eligibility Determination indicated that Patient 1 did not qualify to receive hospice services per LCD guidelines. LCD used by hospice providers to determine eligibility for beneficiaries for hospice benefits. The LCD indicated that to qualify for hospice, all sections in part 1, which was related to ADL (activities of daily living; basic tasks individuals perform to care for themselves, such as eating, bathing, dressing, and moving around) must be met, and at least one of the conditions in part 2 must be met. The LCD indicated that Patient 1 did not meet all the criteria in part 1 and did meet any of the criteria in part 2. During a review of Patient 1’s Re-Cert Assessment (recertification assessment, a periodic evaluation used to determine if a patient continues to meet the criteria for hospice services), dated 4/21/2025, the Re-Cert Assessment indicated that Patient 1 did not have any of the following, which are the components of part 2 in the LCD Hospice Eligibility Determination:- Aspiration pneumonia (a type of pneumonia caused by breathing in foreign substances, like food, liquid, or vomit, into the lungs, instead of swallowing them) in the past 12 months.- Pyelonephritis (a type of urinary tract infection where bacteria or viruses infect one or both kidneys) in the past 12 months. - Septicemia (a bloodstream infection where bacteria or other germs enter the bloodstream and cause a life-threatening response) in the past 12 months. - Decubitis ulcer (a wound that develops due to prolonged pressure on the skin, often over bony areas like the hips, back, and ankles) stage 3 or 4 in the past 12 months. - Recurrent fever even after antibiotics in the past 12 month.- Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous 6 months or serum albumin (the most abundant protein in blood plasma, produced by the liver; it plays a crucial role in maintaining fluid balance and transporting various substances throughout the body) less than 2.5 gram/deciliter (a measurement unit). During a concurrent interview and record review with Registered Nurse 1 (RN 1) on 6/4/2025 at 12:43 p.m., RN 1 reviewed Patient 1’s LCD Hospice Eligibility Determination and Re-Cert Assessment, both dated 4/21/2025. RN 1 confirmed and stated she (RN1) completed the Re-Cert Assessment and LCD Hospice Eligibility Determination for Patient 1. RN 1 stated that based on her assessment, Patient 1 qualified for hospice due to her cognitive or mental decline. RN 1 stated that Patient 1 had become more forgetful and confused. When RN 1 was asked if Patient 1 met any of the components in part 2 of the LCD Hospice Eligibility Determination, RN 1 stated that Patient 1 had fluctuating calorie intake from day to day, so Patient 1 would meet the inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous 6 months requirement. RN 1 was not able to provide a documentation indicating Patient 1’s weight loss within the past 6 months. RN 1 stated she did not know if Patient 1 had lost 10% of her weight within the past 6 months because there was no weights documented. RN 1 stated that Patient 1’s Re-Cert assessment was incomplete, which resulted in the LCD Hospice Eligibility Determination indicating Patient 1 not qualified for hospice. During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD) on 6/4/2025 at 1:20 p.m., the DPCSD reviewed Patient 1’s LCD Hospice Eligibility Determination and Re-Cert Assessment, both dated 4/21/2025. The DPCSD stated it was very important that patient assessment was updated appropriately to reflect the patient’s most current condition, so that the HA could make determination if the patient would still be eligible for hospice. During a review of the HA’s policy and procedure, titled “Eligibility for Hospice Care,” dated 2018, the policy and procedure indicated that complete and timely documentation of the specific clinical factors that qualify a patient for the Medicare hospice benefit is provided in the patient’s clinical record. During a review of the HA’s policy and procedure, titled “Ongoing Assessments,” revised November 2021, the policy and procedure indicated that ongoing comprehensive assessments should focus on: B. Changes in patient condition, level of deterioration.”

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the interdisciplinary group written plan of care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient’s family/caregiver) was individualized in accordance with the patient’s needs for one of 6 sampled patients (Patient 20). This deficient practice had the potential to cause serious complications that could cause delayed care, and undetected signs of physical, emotional, and spiritual needs when transitioning to the final stages of the dying process. Findings:During a review of Patient 20’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 20’s start of care (SOC) date of 1/16/2025, with a terminal diagnosis of compression of brain (occurs when something within the skull increases pressure on the brain and surrounding tissues). During an interview with Patient 20’s caregiver (Pcg 1), on 6/3/2025 at 11:16 a.m., Pcg 1 stated Patient 20 had a colostomy (a surgical procedure that creates an opening in the abdomen where the colon [large intestine] is brought out to the surface of the skin, allowing stool to be collected in an external pouch) on her left lower abdomen for several years, and the HA were sending all the supplies needed for colostomy care. During a review of Patient 20’s most current POC/Interdisciplinary Group Review form, dated 5/27/2025, the POC/IDG Review form indicated the frequency of visits of skilled nurse (SN) to one visit per week plus 1-3 prn (pro re nata, which means “as needed”) visits for pain and symptom management. The POC/IDG Group Review form did not contain a written plan of care that includes goals and specific interventions for care of Patient 20’s colostomy. During a concurrent interview and record review, on 6/4/2025 at 12:55 p.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD reviewed Patient 20’s POC. The DPCSD stated and confirmed there was no care plan developed with specific goals and interventions for colostomy care. The DPCSD stated it was important to have a care plan developed for a patient with colostomy so that the agency’s nursing staff knew what to do in case there are complications like leakage and skin infection at the colostomy site. During a review of the agency’s policy and procedure (P&P) titled The Plan of Care, revised November 2021, 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.”

“Based on observation, interview, and record review the Hospice Agency (HA, agency providing care to terminally ill patients) failed to provide medical supplies necessary for the use of supplemental oxygen for one of six sampled patients (Patient 21). This deficient practice had the potential to result in uncontrolled symptoms, which could affect the patient’s quality of life. Findings:During a review of Patient 21’s Personal Information, the Personal Information indicated Patient 21 was admitted to the HA on 4/19/2025 with a primary diagnosis of cerebellar stroke syndrome (a stroke affecting the cerebellum, a part of the brain responsible for coordination and balance). During a review of Patient 21’s Plan of Care/Interdisciplinary Group Review (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 5/27/2025, indicated the respiratory goal for Patient 21 was a reduction of shortness of breath episodes to no more than two occurrences per day, lasting no longer than 10 minutes, over the next 14 days. The interventions in the POC/IDG Review did not mention the use of oxygen concentrator. The POC/IDG Review only indicated elevating the head of bed by 30 degrees and repositioning the patient every 2 hours to maximize respiratory status. During a review of Patient 21’s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List indicated that an oxygen concentrator (a device that separates and concentrates oxygen from the air, providing a higher concentration of oxygen for patients who need it) was ordered for Patient 21 upon admission. During a joint home visit to Patient 21’s residence with Registered Nurse 1 (RN 1) on 6/3/2025 at 11 a.m., Patient 21 was observed awake, alert, and oriented. Patient 21 was observed sitting on a chair, a cane was observed next to the chair. An oxygen concentrator was observed in the living room, where Patient 21 was sitting.During the home visit, the surveyor observed that the oxygen concentrator was connected to parts that would normally used with a nebulizer (a medical device that transforms liquid medication into a fine mist, allowing it to be inhaled directly into the lungs) for breathing treatment purposes. Instead of a nasal cannula (a medical device used to deliver supplemental oxygen to patients; it consists of a flexible tube with two prongs that fit into the nostrils, delivering oxygen directly into the nasal passages) or a simple face mask (a plastic, rubber, or silicone mask that covers the nose and mouth, allowing the delivery of oxygen through the nose and mouth), the oxygen concentrator was connected to a reservoir tube that was connected to a medication cup on one part and a mouthpiece on the other part. During an interview on 6/4/2025 at 11:55 a.m., with Patient 21, Patient 21 stated she used the oxygen concentrator as needed, when she had shortness of breath episodes. According to Patient 21, she usually used it 2-3 times a week. When Patient 21 was asked how she would use the oxygen concentrator to relieve her shortness of breath, Patient 21 stated she would insert the mouthpiece, which was connected to the oxygen concentrator through the tubing, in her mouth and inhale. Patient 21 stated she had never received a nasal cannula to use with the oxygen concentrator. Patient 21 told the surveyor that she used nasal cannula when she was hospitalized. During an interview on 6/3/2025 at 12:05 p.m., with RN 1, RN 1 stated that Patient 21 did not have the correct supplies to be used with her oxygen concentrator. RN 1 stated that oxygen delivery through the nebulizer mouthpiece was not effective, and the patient might not get adequate relief from her shortness of breath. During an interview on 6/4/2025 at 12:20 p.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated that RN 1 had reported to him about Patient 21 not having the nasal cannula. The DPCSD stated that the HA needed to order the appropriate supplies for Patient 21. During a review of the HA’s policy and procedure, titled “The Plan of Care,” revised November 2021, the policy and procedure indicated that the written plan of care will contain DME and medical supplies necessary to meet patient needs.”

“Upon personnel record review, 3 of 5 (Personnel #2,3,5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed Personnel #2,3,5 did not have evidence of the competency being updated to include Sponge bath, tub AND shower bath. Shampoo competency only assessed, “Shampoo”. The competency has not been updated to include Shampoo in sink, tub and bed. This was to be compliant by 03/27/25 per the most recent Plan of Correction.”

“Upon patient record review, 1 of 3 (Patient #1) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Notification of the individual’s (or representative’s) right to receive an election statement addendum if there are conditions, items, services, and drugs the hospice has determined to be unrelated to the individual’s terminal illness and related conditions and would not be covered by the hospice. • Information on the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), including the right to immediate advocacy and BFCC-QIO contact information Patient #1 Had an incomplete Election Statement: Items left blank were hospice diagnosis, name of the hospice to provide service, choice to decline or elect the Addendum for Non-covered items left blank...no Addendum in record. The information about the BFCC-QIO was included, however; the blanks for the name an phone number were left blank. Page 2 of the Election statement did not have a printed patient name, left blank. There was no evidence of signed copies of the notice of patient rights, only a box checked on page 2 of Election Statement that states, “I have received verbal and written information and explanation regarding the following”: where “patient rights and responsibilities” is an item listed.”

“Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes: • The Medical Director must be a doctor of medicine or osteopathy who is an employee or is under contract. • When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director. Upon reviewing the Designated Alternate Medical Directors contract, the contract was developed and named for a Medical Director to include all duties and responsibilities, not a Alternate Medical Director. The physician acting as medical director has a contract in place to be the Medical Director. There was not an Alternate Medical Director’s job description in the intended alternate medical director’s file.”

“Upon patient record review, 2 of 14 (Patients # 13, 14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient # 13: Upon review of the patients bereavement POC, the frequency of activities where not included. Patient # 14: Upon review of the patient’s bereavement POC the frequency of activities where not included.”

“Upon personnel record review, 1 of 12 (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. ·Appropriate and safe techniques in personal hygiene and grooming that include-- (A) Bed bath (B) Tub, and shower bath (C) Shampoo, sink, tub, and bed”

“Upon patient record review, 1 of 14 (Patients # 5) 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 # 5: Upon review of hospice aide POC, a frequency for changing of bed linens was not contained in the POC.”

“Upon patient record review 1 of 14 (Patient # 5) 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 # 5: Upon review of visit notes, the patient’s aide POC ordered a bed bath. The aide documented a shower with chair was given to patient on 2/3, 2/6, 2/10, 2/14, 2/17, 2/21, 2/24, 2/28, 3/3, 3/7.”

“Upon patient record review 2 of 14 (Patients # 2, 3) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient # 2: Upon review of patient chart, hospice aide seeing patient weekly. There was not evidence of aide supervisory visits by an RN from 12/24/24 to 1/11/25. Patient #3: Upon review of patient chart, hospice aide supervisory visits were not made every 14 days. Dates of supervisory visits were on 10/31, 12/6, 1/6, 2/13/25.”

“Upon patient client record review, 14 of 14 (Patients # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Upon review of patients’ medical records election statements, there was no evidence of information on the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), including the right to immediate advocacy and BFCC-QIO contact information, and information about the BFCC-QIO to request immediate advocacy being provided at the time of admission.”

“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 ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal health insurance program that helps people pay for health care] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), Care Planning, and Coordination of Services for one of 14 sampled patients (Patient 4) were met as follows: 1. The HA failed to ensure a blood sugar log (a record of your blood sugar levels measured over time used to help identify patterns in blood sugar levels which can help manage diabetes [the bodies inability to control the amount of sugar in the blood]) was maintained for Patient 4 as per physician orders. (Refer to L543) 2. The HA failed to ensure that Registered Nurse 1 (RN 1) provided teaching to Patient 4s caregiver (Caregiver 1 [PCG 1]) regarding the importance of documenting Patient 4s blood sugar levels, the amount of insulin (medication that lowers the amount of sugar in the blood) administered to Patient 4 as per physician orders. (Refer to L543). These deficient practices resulted in Patient 4s blood sugar levels being left unmonitored which placed Patient 4 at risk for complications associated with diabetes, such as hypoglycemia (low blood sugar level) or hyperglycemia (high blood sugar level). 3. The HA failed to provide education and training as to the patient/caregiver appropriate to their responsibilities for the care and services related to the patients condition for Patient 1 and Patient 4. (Refer to L544) 4. The HA failed to include all services necessary for the palliation and management of the terminal illness and related conditions for Patient 1, Patient 8, and Patient 9. (Refer to L545) These deficient practices resulted in Patient 1s, Patient 8s, and Patient 9s blood pressure unmonitored, that could place the patients at risk for complications associated with high blood pressure. 5. The HA failed to provide three of fourteen sampled patients (Patient 1, Patient 8, and Patient 9) with necessary medical supplies (supplemental oxygen, suction machine [medical device that is primarily used for removing obstructions, such as mucus, saliva, blood, or secretions from a person’s airway], and Yankauer [a medical device used to remove fluid and debris from the body during medical procedures]). (Refer to L550) This deficient practice had the potential to result in uncontrolled symptoms, which could affect the patients quality of life. 6. Thee HA failed to ensure the IDG (Interdisciplinary Group, IDG – meeting where the Registered Nurse [RN], Medical Social Worker [MSW], Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) members met to review the IDG/POC for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 9, Patient 10, Patient 11, and Patient 12.) (Refer to L552) This deficient practice had the potential to result in patients’ progress or decline will not be coordinated to the members of the IDG to update information on the POC for further intervention and palliation (medical care that relieves symptoms). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure provision of quality care and services to patients.”

“Based on 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 (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding the Patients Rights are met as follows: 1. The hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the hospice made all reasonable efforts on patients behalf as a hospice patient to fully understand his/her rights when the patient was unable to act for him or herself due to being legally blind (partial or complete loss of sight that can’t be corrected with lenses) vision impairment for one of 14 patients. This deficient practice resulted in the patient to blindly signed the Election of Hospice Medicare Benefit and Patient Authorization and the Admission Agreement and not fully informed and understood the scope of the hospice care, rights, and responsibilities as a patient certified to receive the hospice benefits. (Refer to L502). 2. The hospice agency failed to ensure a completed copy of written information regarding advance directive (a legal document that outlines person’s wishes in the event an individual is unable to express wishes for healthcare and treatments) policies and descriptions was provided for one of fourteen sampled patients (Patient 9). (Refer to L503). The cumulative effects of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with Federal regulation for Patients Rights to ensure their rights as certified hospice patients are not violated and provided the highest quality of hospice care and services.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding the Initial and Comprehensive Assessment of Patient (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process) was met as follows: 1. The Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the comprehensive assessment included a psychosocial (includes mental, emotional, social, and spiritual effects of a disease to patient) assessment for one of fourteen sampled patients (Patient 11).This deficient practice had the potential to result in the patient not being provided the identified psychosocial needs to promote patient’s wellbeing throughout the dying process. (Refer to L524). 2. The hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) staff failed to review all the medications and update the medication profile with the currently used medications for three of fourteen sampled patients (Patient 1, Patient 8, and Patient 9). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. Refer to L530. The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily (written law) mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation on Clinical Records was met as follows: 1. The HA failed to ensure a completed copy of written information regarding advance directive (a legal document that outlines person’s wishes in the event an individual is unable to express wishes for healthcare and treatments) policies and descriptions for one of fourteen sampled patients (Patient 9). (Refer to 677). 2. The HA failed to ensure the IDG (Interdisciplinary Group, IDG – meeting where the Registered Nurse [RN], Medical Social Worker [MSW], Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) members authenticated their entries for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 9, Patient 10, Patient 11, and Patient 12). (Refer to L679). The cumulative effects of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients clinical records are completed, updated and accurately documented. .”

“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 hospice made all reasonable efforts on patients behalf as a hospice patient to fully understand his/her rights when the patient was unable to act for him or herself due to being legally blind (partial or complete loss of sight that can’t be corrected with lenses) vision impairment for one of 14 patients. This deficient practice resulted in the patient to blindly signed the Election of Hospice Medicare Benefit and Patient Authorization and the Admission Agreement and not fully informed and understood the scope of the hospice care, rights, and responsibilities as a patient certified to receive the hospice benefits. During a review of Patient 4s Personal Information, the Personal Information indicated that Patient 4 was admitted to the HA on 12/24/2024 with a primary diagnosis of heart disease (a group of conditions that affect the heart’s structure and function). During a review of Patient 4s Comprehensive Nursing Assessment, dated 12/14/2024, the Comprehensive Nursing Assessment indicated that Patient 4 was blind. During a review of Patient 4s Election of Hospice Medicare Benefit and Patient Authorization, dated 12/14/2024, and Admission Agreement, dated 12/14/2024, a signature was observed on the “;Signature of Patient or Legal Representative” line. During a telephone interview with Registered Nurse 1 (RN 1) on 1/30/2025 at 10:31 a.m., RN 1 stated she admitted Patient 4 for hospice care and conducted the comprehensive assessment on 12/14/2024. RN 1 stated Patient 4 was legally blind. RN 1 stated, Patient 4 was only able to see light and dark. RN 1 stated that Patient 4 was not able to read letters printed on a document. During the interview, RN 1 stated Patient 4 signed the Election of Hospice Medicare Benefit and Patient Authorization and the Admission Agreement. RN 1 was asked how Patient 4 was able to read and sign the consents if she was blind. RN 1 stated that she read the consents to Patient 4, then she guided Patient 4s hand and placed it on the signature line. RN 1 stated that Patient 4 formed the letters on the signature line herself. RN 1 stated that it was wrong to make a blind patient sign a document. RN 1 stated she had Patient 4 sign the consents because there was nobody else that could serve as a witness. RN 1 stated that Patient 4 told her she had no family members or relatives. RN 1 stated she should have called the HAs office and informed them about the situation. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 1/30/2025 at 11:50 a.m., the DPCS reviewed the Election of Hospice Medicare Benefit and Patient Authorization, dated 12/14/2024, and the Admission Agreement, dated 12/14/2024, which were signed by Patient 4. The DPCS stated that Patient 4 should not have been made to sign the consents since she was blind. The DPCS stated that RN 1 should have notified the HAs office the patient was blind and therefore was unable to sign. According to the DPCS, even though RN 1 had read the consents to Patient 4, Patient 4 would not be able to see if the documents she was signing were the ones RN 1 read to her. During a review of the HAs policy and procedure, titled “;Patient Bill of Rights/Responsibilities,” revised November 2021, the policy and procedure indicated that Patient Bill of Rights/Responsibilities would be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services. This explanation will be in a language and manner he/she can reasonably be expected to understand. The policy and procedure did not specify the procedure for visually impaired patient.”

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure a completed copy of written information regarding advance directive (a legal document that outlines person’s wishes in the event an individual is unable to express wishes for healthcare and treatments) policies and descriptions for one of fourteen sampled patients (Patient 9). This failure had the potential to result in the patients family and/or caregivers not knowing what the patients medical decisions are, which can result in psychological distress to the patient/patients family/caregiver. During a review of Patient 9s “;Personal Information”, indicated a start of care (SOC) date of 12/30/2024, with a primary diagnosis of heart disease (a type of disease that affects the heart or the blood vessels), unspecified. During a home visit observation on 1/29/2025, at 11:30 a.m., to Patient 9s residence, with Licensed Vocational Nurse (LVN 2), Patient 9 was observed resting comfortably on her bed. Patient 9 is alert, awake and oriented to her name, time, place and events. During a concurrent review of Patient 9s hospice folder with LVN 2, The folder had the name of the agency, inside of the folder was a copy of Patient 9s plan of care, active medication list signed notice of patients rights and a POLST (Physician Orders for Life-Sustaining Treatment), dated 4/1/2024, indicated no selection mark on section: A. Cardiopulmonary Resuscitation (CPR, a method that can help save a life during cardiac arrest, when the heart stops beating or beats too ineffectively to circulate blood to the brain and other vital organs) , no selection mark on section C. Artificially Administered Nutrition, section D. Information and Signatures, indicated no selection mark on discussed with and no signature of Physician/Nurse Practitioner/Physician Assistant. During interview with LVN 2, stated he was unaware that Patient 9s Legal Representative, stated that POLST is not valid unless it was completed and signed by the patient or legal representative. LVN 2 stated it should have been check and processed by the social worker. LVN 2 stated that if Patient 9s heartbeat stops, then a CPR must perform since the POLST was not completed yet and the code status of the patient is full code and not DNR (Do Not Resuscitate). During a concurrent record review and interview on 1/31/2025, at 10:30 a.m., with the Director of Patient Care Services (DPCS), indicated Patient 9s POLST copy in her folder was incomplete and unsigned by the physician. DPCS confirmed that Patient 9s POLST, dated 4/1/2024, is incomplete and the physician did not sign it. DPCS stated that the agencys office has the completed POLST of Patient 9, however, the updated copy was forgotten to provide to Patient 9. DPCS stated that a completed copy should have been provided to Patient 9s hospice agencys home folder for future reference to define the code status of the patient. During a telephone interview on 1/31/2025, at 10:34 a.m., with the Master of Social Work (MSW), MSW stated that she assists hospice patients on preparing their respective POLST. MSW stated that an incomplete POLST should have not been placed to Patient 9s hospice folder as it could create a confusion of Patient 9s code status. MSW stated that a completed POLST is very important for the healthcare providers future reference when Patient 3s medical condition decline or if his heartbeat stops. MSW stated that the healthcare team should check the hospice folder and POLST to ensure that everything is updated and completed. During a review of the HAs policy and procedure entitled, “;Do Not Resuscitate/Do Not Intubate Orders”, revised November 2023, the policy and procedure indicated that a written Do Not Resuscitate (DNR) order signed by the patients physician (or authorized independent practitioner) must be on file in the patients clinical record and admission folder in the patients home.”

“The Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the comprehensive assessment included a psychosocial (includes mental, emotional, social, and spiritual effects of a disease to patient) assessment for one of fourteen sampled patients (Patient 11). This deficient practice had the potential to result in the patient not being provided the identified needs to promote wellbeing throughout the dying process. During a review of Patient 11s untitled admission sheet, it indicated a start of care date on 9/8/2024 with a primary diagnosis of chronic kidney disease, stage 5 (also known as end stage kidney disease, is the most severe stage where kidneys can no longer effectively filter waste from blood). During a concurrent interview and record review on 1/31/2025 at 10:45 a.m., with the Director of Patient Care Services (DPCS), Patient 11s “;Comprehensive Nursing Assessment (a thorough evaluation of a patient’s overall health status, taking into account their physical condition, mental state, lifestyle factors, and social circumstances, to gather all necessary information to develop a personalized care plan)” dated 12/30/2024 was reviewed. The comprehensive nursing assessment indicated an incomplete assessment under psychosocial screening section. DPCS confirmed and stated that the psychosocial screening section was left blank and was not completed. DPCS stated that a completed psychosocial assessment should be included in the comprehensive assessment to determine patients individualized needs to include in formulating a plan of care. During a concurrent interview and record review on 1/31/2025 at 10:55 a.m., with DPCS, Patient 11s “;History of Psychosocial Assessment” was reviewed. The history of psychosocial assessment indicated no documented evidence. DPCS confirmed and stated that the history of psychosocial assessment was left blank and no documentation. DPCS stated that a completed psychosocial assessment should be included in history of psychosocial assessment if completed. During a review of the agencys policy and procedure (P&P) titled “;Comprehensive Assessment”, dated November 2021, the procedure indicated that the patient’s psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source and adequacy of environmental and other resources, coping mechanisms, and the patient’s and family/caregiver’s reaction to illness.”

“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) staff failed to review all the medications and update the medication profile with the currently used medications for three of fourteen sampled patients (Patient 1, Patient 8, and Patient 9). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. a. During a review of Patient 1s Personal Information, the Personal Information indicated that Patient 1 was admitted to the HA on 6/26/2024 with a primary diagnosis of Alzheimers disease (a progressive and irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to carry out everyday tasks). During a review of Patient 1s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List indicated that on 7/5/2024, the HAs physician ordered the following medications as part of the comfort pack for Patient 1: - Bisacodyl (a medication to treat constipation) 10 mg (milligram, a measurement unit) suppository (medications inserted into the rectum, vagina, or urethra) - Levsin (medication used to treat excessive oropharyngeal [part of the throat] secretions) 0.125 mg tablet - Lorazepam (medication used to treat anxiety and/or agitation) 0.5 mg tablet - Ondansetron Hydrochloride (medication used to treat nausea and vomiting) 4 mg tablet - Morphine Sulfate (medication used to treat pain and dyspnea [shortness of breath or difficulty breathing]) 20 mg/ml solution During a joint home visit to Patient 1s residence with Licensed Vocational Nurse 1 (LVN 1) on 1/29/2025 at 10:30 a.m., observed Patient 1 awake, alert, and oriented. Patient 1 lives in a private residence with Family Member 1 (FM 1) and Family Member 2 (FM 2), who acted as the patient’s caregivers. During the home visit, at 11:20 a.m., a medication review was performed with LVN 1. According to FM 1, all the medications that we reviewed were all the medications that Patient 1 was taking. LVN 1 asked FM 1 if he could look inside the refrigerator, to check the medications in the comfort pack were kept refrigerated. LVN 1 and FM 1 then looked for the comfort pack inside the refrigerator. LVN 1 stated that there was no comfort pack in the refrigerator. During an interview with Patient 1 on 1/29/2025 at 11:40 a.m., Patient 1 stated that she did not have pain. During an interview with LVN 1 on 1/29/2025 at 11:45 a.m., LVN 1 stated usually the comfort pack was kept in the refrigerator. LVN 1 stated he was not sure why the comfort pack was not available at Patient 1s home. LVN 1 stated he would notify the HAs office. LVN 1 stated it was important to have comfort pack available as ordered by the physician because the HA needed to ensure the medications would be available when needed. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 1/31/2025 at 10:18 a.m., the DPCS reviewed Patient 1s Current Treatment/Medication/DME List. The DPCS stated the medications in the comfort pack were provided by the HA, however the DPCS was not sure why they were not available at the patients home. The DPCS stated the visiting nurse should have conducted medication reconciliation on every visit, to ensure that patient had all the ordered medications. b. During a review of Patient 8s “;Personal Information”, indicated a start of care (SOC) date of 10/17/2024, with a primary diagnosis of atherosclerosis heart disease of native coronary artery with angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood with chest pain and involuntary contraction). During a review of Patient 8s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List indicated that the HAs physician ordered the following medications as part of the comfort pack for Patient 8: - Bisacodyl (a medication to treat constipation) 10 mg (milligram, a measurement unit) suppository (medications inserted into the rectum, vagina, or urethra) - Levsin (medication used to treat excessive oropharyngeal [part of the throat] secretions) 0.125 mg tablet - Lorazepam (medication used to treat anxiety and/or agitation) 0.5 mg tablet - Ondansetron Hydrochloride (medication used to treat nausea and vomiting) 4 mg tablet - Morphine Sulfate (medication used to treat pain and dyspnea [shortness of breath or difficulty breathing]) 20 mg/ml solution During a joint home visit to Patient 8s residence with Licensed Vocational Nurse 2 (LVN 2) on 1/29/2025 at 10:30 a.m., Patient 8 was observed sitting comfortably on her chair, awake, alert, and oriented to her name, place, time and events. Patient 8 is with Family Member 3 (FM 3/Patient 8s niece) and acted as her authorized representative/emergency contact. During the home visit, at 10:50 a.m., a medication review was performed with LVN 2. Per FM 3, the medications that reviewed were all the medications that Patient 8 were taking. LVN 2 asked FM 3 if she could look inside the refrigerator, as the medications in the comfort pack needed to be kept refrigerated. LVN 2 and FM 3 then looked for the comfort pack inside the refrigerator. LVN 2 stated that there were no comfort kit medications in the refrigerator. During an interview with LVN 2 on 1/29/2025 at 10:55 a.m., LVN 2 stated that the comfort pack should be kept in the refrigerator. LVN 2 stated he was not sure why the comfort pack was not available at Patient 8s home. LVN 2 stated he would notify the HAs office and the Director of Patient Care Services (DPCS). LVN 2 stated it was important to have comfort pack readily available as ordered by the physician because the HA needed to ensure the medications would be available when needed if patients condition suddenly changed. c. During a review of Patient 9s “;Personal Information”, indicated a start of care (SOC) date of 12/30/2024, with a primary diagnosis of heart disease (a type of disease that affects the heart or the blood vessels), unspecified. During a review of Patient 9s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List indicated that the HAs physician ordered the following medications as part of the comfort pack for Patient 9: - Bisacodyl (a medication to treat constipation) 10 mg (milligram, a measurement unit) suppository (medications inserted into the rectum, vagina, or urethra) - Levsin (medication used to treat excessive oropharyngeal [part of the throat] secretions) 0.125 mg tablet - Lorazepam (medication used to treat anxiety and/or agitation) 0.5 mg tablet - Ondansetron Hydrochloride (medication used to treat nausea and vomiting) 4 mg tablet - Morphine Sulfate (medication used to treat pain and dyspnea [shortness of breath or difficulty breathing]) 20 mg/ml solution During a joint home visit to Patient 9s residence with Licensed Vocational Nurse 2 (LVN 2) on 1/29/2025 at 11:30 a.m., Patient 9 was observed sitting comfortably on her bed, awake, alert, and oriented to her name, place, time and events. Patient 9 is with Family Member 4 (FM 4/Patient 9s granddaughter) and acted as her authorized representative/emergency contact. During the home visit, at 11:50 a.m., a medication review was performed with LVN 2. Per FM 4, the medications that reviewed were all the medications that Patient 9 were taking. LVN 2 asked FM 4 if she could look inside the refrigerator, as the medications in the comfort pack needed to be kept refrigerated. LVN 2 and FM 4 then looked for the comfort pack inside the refrigerator. LVN 2 stated that there were no comfort kit medications in the refrigerator. During an interview with LVN 2 on 1/29/2025 at 11:58 a.m., LVN 2 stated that the comfort pack should be kept in the refrigerator. LVN 2 stated he was not sure why the comfort pack was not available at Patient 9s home. LVN 2 stated he would notify the HAs office and the Director of Patient Care Services (DPCS). LVN 2 stated it was important to have comfort pack readily available as ordered by the physician because the HA needed to ensure the medications would be available when needed if patients condition suddenly changed. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 1/31/2025 at 10:18 a.m., the DPCS reviewed Patient 8 and Patient 9s Current Treatment/Medication/DME List. The DPCS stated the medications in the comfort pack were provided by the HA, however the DPCS was not sure why they were not available at the patients home. The DPCS stated the visiting nurse should have conducted medication reconciliation on every visit, to ensure that patient had all the ordered medications. The HA did not provide a policy and procedure on medication reconciliation as requested by the survey team on 1/31/2025.”

“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 follow physicians order for one of fourteen sampled patients (Patient 4) by failing to: 1. Ensure a blood sugar log was maintained for Patient 4 as per physician orders to help identify patterns, understand how medications such as insulin affect blood sugar levels, and help prevent complications associated with diabetes. 2. Ensure that Registered Nurse 1 (RN 1) provided teaching to Patient 4s caregiver (Caregiver 1 [PCG 1]) regarding the importance of documenting Patient 4s blood sugar levels, along with the amount of insulin administered to Patient 4 as per physician orders, potentially leading to poor quality of care, and placed Patient 4 at increased risk for complications of diabetes. These deficient practices resulted in Patient 4s blood sugar unmonitored, that could place Patient 4 at risk for complications associated with diabetes, such as hypoglycemia (low blood sugar level) or hyperglycemia (high blood sugar level).On 1/30/2025, at 2:58 p.m., an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was called in the presence of the agencys Administrator and Director of Patient Care Services related to the agencys failure to follow the physicians order for Patient 4’s blood sugar management. Registered Nurse 1 (RN 1) failed to monitor Patient 4s blood sugar levels during home visits and to provide teaching to Patient 4s caregiver on blood sugar monitoring, which resulted in Patient 4s blood sugar levels unmonitored, and placed Patient 4 at increased risk for complications of diabetes. On 1/31/2025, at 3 p.m., the agency was unable to submit an IJ removal plan. The survey team completed the survey tasks and exited with the IJ not removed. Findings: During a review of Patient 4s Personal Information, the Personal Information indicated that Patient 4 was admitted to the HA on 12/24/2024 with a primary diagnosis of heart disease (a group of conditions that affect the heart’s structure and function). During a review of Patient 4s Comprehensive Nursing Assessment, dated 12/14/2024, the Comprehensive Nursing Assessment indicated that Patient 4 had diabetes mellitus (a chronic [persisting for a long time] condition that happens when a persons blood sugar level is too high) comorbidity (a disease or medical condition that is simultaneously present with another or others in a patient). The Comprehensive Nursing Assessment also indicated that Patient 4 was blind. During a review of Patient 4s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List, dated 12/14/2024 indicated that Insulin Lispro (medication used to lower blood sugar levels rapidly) 100 unit per milliliter (u/ml- unit of measure) and Lantus SoloStar (medication used to lower blood sugar levels slowly over a period of time) 100 u/ml were ordered for Patient 4 by the HA physician. 1. 1. Insulin Lispro 100 units/ml was to be administered subcutaneously (by injection just under the skin) daily before meals, four to-18 units based on a sliding scale (the increasing administration of the pre‐meal insulin dose based on the blood sugar level before the meal). The sliding scale is as follows: a. for blood sugar levels of 180 to200 milligrams per deciliter (mg/dL- unit of measure), give four units b. for blood sugar 201 to230 mg/dL, give five units c. for blood sugar 231-260 mg/dL, give six units d. for blood sugar 261-290 mg/dL give nine units e. for blood sugar 291-320 mg/dL, give 12 units f. for blood sugar 321-350 mg/dL, give 15 units g. for blood sugar higher than 351 mg/dL, give 18 units and notify the physician. 2. 2. Lantus SoloStar 100 units/ml, administered 10 units subcutaneously daily in the morning and 25 units subcutaneously at bedtime. During a review of Patient 4s POC/IDG Review (Plan of Care/Interdisciplinary Group Review, a document detailing a patients health needs, created by a healthcare team based on a comprehensive assessment of the patients condition and goals, outlining interventions and expected outcomes to be achieved), dated 1/21/2025, the POC/IDG Review indicated the interventions for Patient 4 included blood sugar management and instruction for patient and/or caregiver regarding medication/treatment/side effects. During a telephone interview with RN 1 on 1/30/2025 at 10:31 a.m., RN 1 stated she (RN 1) admitted Patient 4 to the HA and conducted the comprehensive assessment on 12/14/2024. RN 1 stated that Patient 4 was legally blind, unable to check her (Patient 4) own blood sugar using a glucometer (a medical device for determining the approximate concentration of sugar in the blood), and Patient 4 was unable to administer the insulin independently. RN 1 stated that Patient 4 required maximum assistance (a level of assistance where a patient requires a caregiver to perform most of a task) with all activities of daily living (ADL, the tasks of everyday life, such as eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). When asked how the HA was monitoring Patient 4s blood sugar levels,. RN 1 stated that during her (RN 1) weekly visit for Patient 4, RN 1 would check Patient 4s blood sugar levels and would also ask PCG 1 about Patient 4s blood sugar levels. RN 1 stated that PCG 1 had always said that Patient 4s blood sugar was “;good.” RN 1 stated she (RN 1) was not sure the approximate blood sugar level value when PCG 1 said that Patient 4s blood sugar levels were “;good”. RN 1 further stated that according to PCG 1, the Patient 4 would often refuse to have her (Patient 4) blood sugar check. RN 1 stated she (RN 1) did not know how often Patient 4 received insulin. RN 1 stated that RN 1 checked Patient 4s blood sugar during every visit but did not document the blood sugar levels of Patient 4. RN 1 stated she (RN 1) should have recorded Patient 4s blood sugar each time RN 1 checked Patient 4s blood sugar level as part of the blood sugar monitoring intervention. RN1 further stated that she (RN 1) had never provided teachings or instructions to PCG 1 regarding recording Patient 4s blood sugar levels. RN 1 stated that she (RN 1) had never provided teachings or instructions to PCG 1 regarding recording Patient 4s administered insulin doses. RN 1 stated that since there was no blood sugar log for Patient 4, it would be hard for the HA to monitor Patient 4s blood sugar levels and to determine if Patient 4s blood sugar levels were well-managed or not. During a review of Patient 4s Visit Note RN, dated 12/19/2024, 12/26/2024, 1/2/2025, 1/9/2025, and 1/16/2025, the blood sugar section was marked “;none” by RN 1. The narrative section did not mention Patient 4s blood sugar levels. During a review of Patient 4s Visit Note RN, dated 1/23/2025, the blood sugar level was documented as 140 to 200. There was no other documentation of Patient 4s blood sugar. During a telephone interview with PCG 1 on 1/30/2025 at 12:54 p.m., PCG 1 stated she (PCG 1) was one of the two caregivers assigned to Patient 4. PCG 1 stated she (PCG 1) would administer all of Patient 4s medication, check Patient 4s blood sugar levels, and administer the ordered insulin to Patient 4. PCG 1 stated the Patient 4s blood sugar was last checked on 1/29/2025 at 8 a.m. Per PCG 1, Patient 4s blood sugar was 103 mg/dL on 1/29/2025, at 8am. PCG 1 stated that Patient 4s glucometer stopped working after that. PCG 1 stated she (PCG 1) never recorded Patient 4s blood sugar levels. PCG 1 stated she (PCG 1) was never provided instructions that Patient 4s blood sugar levels should be documented onto a log. PCG 1 stated that PGC 1 had never received training from Patient 4s HA regarding checking of blood sugar levels, administration of insulin, and blood sugar monitoring. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 1/30/2025 at 1:20 p.m., the DPCS reviewed Patient 4s Current Treatment/Medication/DME List, POC/IDG Review dated 1/21/2025, and Visit Note RN dated 12/19/2024, 12/26/2024, 1/2/2025, 1/9/2025, and 1/16/2025. The DPCS stated the HA did not maintain a blood sugar log for Patient 4. The DPCS stated he (DPCS) was not aware that there was no blood sugar log maintained for Patient 4. The DPCS stated that verbal report from PGC 1 informing RN 1 that Patient 4s blood sugar levels were “;good” was not adequate blood sugar monitoring. When DPCS was asked if Patient 4 had a hemoglobin A1C test (HbA1c-a test that measures the average blood sugar levels of a patient over a period of two to three months) laboratory test done since admission to the HA, DPCS stated that no HbA1c laboratory test was done for Patient 4 since admission to the HA. The DPCS stated that by not monitoring Patient 4s blood sugar levels, Patient 4 was placed at increased risk of a negative outcome which included having too high or too low of a blood sugar level. DPCS further stated that because Patient 4s blood sugar levers were not monitored, the HA staff and the physician would not be aware if Patient 4s blood sugar level was out of range. The DPCS stated that RN 1 should have documented the blood sugar levels of Patient 4 each time that RN 1 checked Patient 4s blood sugar level. The DPCS stated that RN 1 should have instructed PCG 1 regarding the importance of maintain a blood sugar log as part of Patient 4s blood sugar management. During a review of the HAs policy and procedure, titled “;The Plan of Care,” revised November 2021, the policy and procedure indicated that a written, individualized, patient and family/caregiver plan of care would 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. During a review of the HAs policy and procedure, titled “;Provision of Care to Residents of Skilled Nursing Facility/ Nursing Facility (SNF/NF) or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID),”revised November 2021, the policy and procedure indicated that a delineation of the hospices responsibilities, which include, but are not limited to the following: providing medical direction and management.”

“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 primary caregivers for two of fourteen sampled patients (Patient 1 and Patient 4) received education and training as appropriate to their responsibilities related to the patients condition. This deficient practice resulted in Patient 1s blood pressure unmonitored and Patient 4s blood sugar unmonitored, which could place Patient 1 at risk for complications associated with high blood pressure and Patient 4 at risk for complications associated with diabetes, such as hypoglycemia (low blood sugar level) or hyperglycemia (high blood sugar level). a. During a review of Patient 1s Personal Information, the Personal Information indicated that Patient 1 was admitted to the HA on 6/26/2024 with a primary diagnosis of Alzheimers disease (a progressive and irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to carry out everyday tasks). During a review of Patient 1s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List indicated that Patient 1 was on the following blood pressure medications: - Amlodipine Besylate (a medication that is used to treat high blood pressure and chest pain) 5 mg (a measurement unit) tablet, one tablet, once daily - Furosemide (a medication that works by increasing the amount of urine the body makes, which helps reduce swelling and symptoms of fluid retention and helps lower high blood pressure) 20 mg tablet, one tablet, once daily - Losartan Potassium (a medication that is used to treat high blood pressure) 50 mg tablet, one tablet, once daily There are no parameters (a specific measurable factor or characteristic that indicates a patient’s physiological state, like blood pressure, heart rate, respiratory rate, or blood glucose level, which doctors use to assess overall health and guide treatment decisions) for the three medications. During a joint home visit to Patient 1s residence with Licensed Vocational Nurse 1 (LVN 1) on 1/29/2025 at 10:30 a.m., observed Patient 1 awake, alert, and oriented. Patient 1 lives in a private residence with Family Member 1 (FM 1) and Family Member 2 (FM 2), who acted as her caregivers. During the home visit, LVN 1 took Patient 1s blood pressure, which was 106/57 mmHg (millimeters of mercury, a unit of pressure that measures how high a column of mercury would rise; it is commonly used in medicine to measure blood pressure and intracranial pressure). During a medication review with LVN 1, Amlodipine Besylate 5 mg, Furosemide 20 mg, and Losartan Potassium 50 mg were available at Patient 1s residence. Per FM 1, Patient 1 would take her medications in the morning. During an interview with Patient 1 and FM 1 on 1/29/2025 at 11:30 a.m., FM 1 stated he never checked Patient 1s blood pressure at home. Patient 1 stated that she would have her blood pressure checked by the hospice nurse once a week, and when she saw her physician. FM 1 stated to check with FM 2 since FM 2 was the one managing Patient 1s medications. During a telephone interview with FM 2 on 1/30/2025 at 12:13 p.m., FM 2 stated he would prepare all of Patient 1s medications and put them in her pill box. FM 2 stated he never checked Patient 1s blood pressure at home. Per FM 2, Patient 1 had her blood pressure checked at the doctors office. FM 2 stated he was never instructed by the HA nurse regarding checking Patient 1s blood pressure or recording it. FM 2 stated the HA did not provide him with a log where he could record Patient 1s blood pressure. During a review of Patient 1s POC/IDG Review (Plan of Care/Interdisciplinary Group Review, a document detailing a patients health needs, created by a healthcare team based on a comprehensive assessment of the patients condition and goals, outlining interventions and expected outcomes to be achieved), dated 1/21/2025, the POC/IDG Review did not include cardiopulmonary (relating to the heart and the lungs) system in Patient 1s plan of care. The plan of care did not include problems, goals, and interventions for Patient 1 related to her high blood pressure. During an interview with LVN 1 on 1/29/2025 at 12 p.m., LVN 1 stated he had never seen Patient 1 before. LVN 1 stated Patient 1s caregivers needed to be educated on how to monitor her blood pressure. LVN 1 stated he would communicate with the office regarding the lack of parameters for Amlodipine Besylate 5 mg, Furosemide 20 mg, and Losartan Potassium 50 mg. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 1/30/2025 at 11:30 a.m., the DPCS reviewed Patient 1s Current Treatment/Medication/DME List and POC/IDG Review, dated 1/21/2025. The DPCS confirmed there were no parameters for Amlodipine Besylate 5 mg, Furosemide 20 mg, and Losartan Potassium 50 mg. The DPCS stated the HA did not include cardiopulmonary system in Patient 1s plan of care because he had instructed the nurses to report it to the physician if the patients blood pressure is lower than 90 mmHg or higher than 160 mmHg. The DPCS stated it was important to educate the caregiver regarding checking the blood pressure, so the HA can better monitor Patient 1s blood pressure. b. During a review of Patient 4s Personal Information, the Personal Information indicated that Patient 4 was admitted to the HA on 12/24/2024 with a primary diagnosis of heart disease (a group of conditions that affect the heart’s structure and function). During a review of Patient 4s Comprehensive Nursing Assessment, dated 12/14/2024, the Comprehensive Nursing Assessment indicated that Patient 4 had diabetes mellitus (a chronic [persisting for a long time] condition that happens when a persons blood sugar level is too high) comorbidity (a disease or medical condition that is simultaneously present with another or others in a patient). The Comprehensive Nursing Assessment also indicated that Patient 4 was blind. During a review of Patient 4s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List indicated that Insulin Lispro 100 unit/ml (milliliter, a measurement unit) and Lantus SoloStar 100 units/ml were ordered for Patient 4 by the HAs physician. Insulin Lispro 100 units/ml was to be administered subcutaneously (by injection just under the skin) daily before meals, 4-18 units based on the sliding scale. The sliding scale was as follows: for blood sugar 180-200, give 4 units; for blood sugar 201-230, give 5 units; for blood sugar 231-260, give 6 units; for blood sugar 261-290, give 9 units; for blood sugar 291-320, give 12 units; for blood sugar 321-350, give 15 units; for blood sugar higher than 351, give 18 units and notify the physician. Lantus SoloStar 100 units/ml was to be administered 10 units subcutaneously daily in the morning and 25 units subcutaneously at bedtime. During a review of Patient 4s POC/IDG Review (Plan of Care/Interdisciplinary Group Review, a document detailing a patients health needs, created by a healthcare team based on a comprehensive assessment of the patients condition and goals, outlining interventions and expected outcomes to be achieved), dated 1/21/2025, the POC/IDG Review indicated the interventions for Patient 4 under endocrine (a term that refers to the glands and tissues that produce and release hormones into the bloodstream) included blood sugar management and instruction for patient and/or caregiver regarding medication/treatment/side effects. During a telephone interview with RN 1 on 1/30/2025 at 10:31 a.m., RN 1 stated she admitted Patient 4 to the HA and conducted the comprehensive assessment on 12/14/2024. RN 1 stated Patient 4 was legally blind, unable to check her own blood sugar using the glucometer (a medical device for determining the approximate concentration of glucose in the blood), and unable to administer the insulin independently. Per RN 1, Patient 4 resides in a board and care facility (a type of assisted living facility that provides 24-hour non-medical care and supervision for residents). During a telephone interview with Caregiver 1 (PCG 1) on 1/30/2025 at 12:54 p.m., PCG 1 stated she was one of the two caregivers assigned to Patient 4. PCG 1 stated she would administer all of Patient 4s medication, check her blood sugar, and administer the insulin. PCG 1 stated the Patient 4s blood sugar was last checked on 1/29/2025 at 8 a.m. Per PCG 1, the blood sugar was 103 on 1/29/2025. PCG 1 stated she had never recorded Patient 4s blood sugar. PCG 1 stated she had never been instructed to record it. During the interview, PCG 1 was asked if she had received training from the HA on blood sugar check, insulin administration, and blood sugar monitoring. PCG 1 stated she had never received training from the HA. PCG 1 stated she knew how to use a glucometer and administer insulin because she herself had been on insulin for fourteen years. During an interview with the Director of Patient Care Services (DPCS) on 1/30/2025 at 1:40 p.m., the DPCS stated caregiver training should have been provided, since the patient lived in a facility and relied on the caregivers assistance to have her blood sugar checked and insulin administered. The DPCS stated the caregiver needed to be educated so she would know when to report to the HA. Per DPCS, the HA staff should have instructed the caregiver to maintain a blood sugar log as part of the blood sugar management for Patient 4. During a review of the HAs policy and procedure, titled “;Patient/Caregiver Education,” copyrighted 2018, the policy and procedure indicated that patients/caregivers are provided with written and verbal education and information as appropriate and needed. The policy and procedure also indicated that verbal or written information may be provided related to, but not limited to the following: h. Treatment and disease management education.”

“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 include all services necessary for the palliation and management of the terminal illness and related conditions for three of fourteen sampled patients (Patient 1, Patient 8, and Patient 9). This deficient practice resulted in Patient 1s, Patient 8s, and Patient 9s blood pressures left unmonitored, placing the patients at risk for complications associated with high blood pressure or low blood pressure. b. During a review of Patient 8s “;Personal Information”, indicated a start of care (SOC) date of 10/17/2024, with a primary diagnosis of atherosclerosis heart disease of native coronary artery with angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood with chest pain and involuntary contraction). During a review of Patient 8s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List indicated that Patient 8 was on the following blood pressure medications: - Amlodipine Besylate (a medication that is used to treat high blood pressure and chest pain) 5 mg (a measurement unit) tablet, one tablet, once daily - Losartan Potassium (a medication that is used to treat high blood pressure) 50 mg tablet, one tablet, once daily There are no indicated parameters (a specific measurable factor or characteristic that indicates a patient’s physiological state, like blood pressure, heart rate, respiratory rate, or blood glucose level, which doctors use to assess overall health and guide treatment decisions) for the two medications. During a joint home visit to Patient 8s residence with Licensed Vocational Nurse 2 (LVN 2) on 1/29/2025 at 10:30 a.m., Patient 8 was observed sitting comfortably on her chair, awake, alert, and oriented to her name, place, time and events. Patient 8 is with Family Member 3 (FM 3/Patient 8s niece) and acted as her authorized representative/emergency contact During the home visit, LVN 2 took Patient 8s blood pressure, which was 128/90 mmHg (millimeters of mercury, a unit of pressure that measures how high a column of mercury would rise; it is commonly used in medicine to measure blood pressure and intracranial pressure). During the home visit, at 10:50 a.m., a medication review was performed with LVN 2. During the medication review, Amlodipine Besylate 5 mg and Losartan Potassium 50 mg were available at Patient 8s residence. Per FM 3, Patient 8 would take her medications in the morning. During an interview with Patient 8 and FM 3 on 1/29/2025 at 11:00 a.m., FM 3 stated she never checked Patient 8s blood pressure at home. Patient 8 stated that she would have her blood pressure checked by the hospice nurse once a week, and when she saw her physician. FM 3 and Patient 8 both stated that they were not instructed by the hospice nurse to check the blood pressure before taking the medications and to keep a record of the blood pressure readings. FM 3 stated the HA did not provide them with a log where they could record Patient 8s blood pressure. During a review of Patient 8s POC/IDG Review (Plan of Care/Interdisciplinary Group Review, a document detailing a patients health needs, created by a healthcare team based on a comprehensive assessment of the patients condition and goals, outlining interventions and expected outcomes to be achieved), dated 12/10/2024, the POC/IDG Review did not include cardiopulmonary (relating to the heart and the lungs) system in Patient 8s plan of care. The plan of care did not include problems, goals, and interventions for Patient 8 related to her high blood pressure. c. During a review of Patient 9s “;Personal Information”, indicated a start of care (SOC) date of 12/30/2024, with a primary diagnosis of heart disease (a type of disease that affects the heart or the blood vessels), unspecified. During a review of Patient 9s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List indicated that Patient 8 was on the following blood pressure medications: - Losartan Potassium (a medication that is used to treat high blood pressure) 25 mg tablet, one tablet, once daily There are no indicated parameters (a specific measurable factor or characteristic that indicates a patient’s physiological state, like blood pressure, heart rate, respiratory rate, or blood glucose level, which doctors use to assess overall health and guide treatment decisions) for the medication. During a joint home visit to Patient 9s residence with Licensed Vocational Nurse 2 (LVN 2) on 1/29/2025 at 11:30 a.m., Patient 9 was observed sitting comfortably on her bed, awake, alert, and oriented to her name, place, time and events. Patient 9 is with Family Member 4 (FM 4/Patient 9s granddaughter) and acted as her authorized representative/emergency contact. During the home visit, at 11:50 a.m., a medication review was performed with LVN 2. During the medication review, Losartan Potassium 25 mg was available at Patient 9s residence. Per FM 4, Patient 9 would take her medications in the morning. During an interview with Patient 9 and FM 4 on 1/29/2025 at 11:55 a.m., FM 4 stated she never checked Patient 9s blood pressure at home. Patient 9 stated that she would have her blood pressure checked by the hospice nurse once a week, and when she saw her physician. FM 4 and Patient 9 both stated that they were not instructed by the hospice nurse to check the blood pressure before taking the medications and to keep a record of the blood pressure readings. FM 4 stated the HA did not provide them with a log where they could record Patient 9s blood pressure. During a review of Patient 8s POC/IDG Review (Plan of Care/Interdisciplinary Group Review, a document detailing a patients health needs, created by a healthcare team based on a comprehensive assessment of the patients condition and goals, outlining interventions and expected outcomes to be achieved), dated 1/21/2025, the POC/IDG Review did not include cardiopulmonary (relating to the heart and the lungs) system in Patient 9s plan of care. The plan of care did not include problems, goals, and interventions for Patient 9 related to her high blood pressure. During an interview with LVN 2 on 1/29/2025 at 12:10 p.m., LVN 2 stated Patient 8 and Patient 9s caregivers needed to be educated on how to monitor patients blood pressure. LVN 2 stated he would communicate with the office regarding the lack of parameters for Amlodipine Besylate 5 mg, and Losartan Potassium blood pressure medications. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 1/31/2025 at 11:35 a.m., the DPCS reviewed Patient 8 and Patient 9s Current Treatment/Medication/DME List and POC/IDG Review. The DPCS confirmed there were no parameters for the blood pressure medications: Amlodipine Besylate and Losartan Potassium. The DPCS stated the HA did not include cardiopulmonary system in Patient 8 and Patient 9s plan of care because he had instructed the nurses to report it to the physician if the patients blood pressure is lower than 90 mmHg or higher than 160 mmHg. The DPCS stated that Patient 8 and Patient 9s blood pressure monitoring needed to be included in the plan of care because it would provide guidance to the HAs staff and the patients caregivers, so the patients blood pressure can be appropriately monitored. During a review of the HAs policy and procedure, titled “;The Plan of Care,” revised November 2021, the policy and procedure indicated that the written plan of care will contain, but will not be limited to, the following: U. Physician-directed instruction to patient and family/caregiver. a. During a review of Patient 1s Personal Information, the Personal Information indicated that Patient 1 was admitted to the HA on 6/26/2024 with a primary diagnosis of Alzheimers disease (a progressive and irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to carry out everyday tasks). During a review of Patient 1s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List indicated that Patient 1 was on the following blood pressure medications: - Amlodipine Besylate (a medication that is used to treat high blood pressure and chest pain) 5 mg (a measurement unit) tablet, one tablet, once daily - Furosemide (a medication that works by increasing the amount of urine the body makes, which helps reduce swelling and symptoms of fluid retention and helps lower high blood pressure) 20 mg tablet, one tablet, once daily - Losartan Potassium (a medication that is used to treat high blood pressure) 50 mg tablet, one tablet, once daily There are no parameters (a specific measurable factor or characteristic that indicates a patient’s physiological state, like blood pressure, heart rate, respiratory rate, or blood glucose level, which doctors use to assess overall health and guide treatment decisions) for the three medications. During a joint home visit to Patient 1s residence with Licensed Vocational Nurse 1 (LVN 1) on 1/29/2025 at 10:30 a.m., observed Patient 1 awake, alert, and oriented. Patient 1 lives in a private residence with Family Member 1 (FM 1) and Family Member 2 (FM 2), who acted as her caregivers. During the home visit, LVN 1 took Patient 1s blood pressure, which was 106/57 mmHg (millimeters of mercury, a unit of pressure that measures how high a column of mercury would rise; it is commonly used in medicine to measure blood pressure and intracranial pressure). During the home visit, at 11:20 a.m., a medication review was performed with LVN 1. During the medication review, Amlodipine Besylate 5 mg, Furosemide 20 mg, and Losartan Potassium 50 mg were available at Patient 1s residence. Per FM 1, Patient 1 would take her medications in the morning. During an interview with Patient 1 and FM 1 on 1/29/2025 at 11:30 a.m., FM 1 stated he never checked Patient 1s blood pressure at home. Patient 1 stated that she would have her blood pressure checked by the hospice nurse once a week, and when she saw her physician. FM 1 stated to check with FM 2 since FM 2 was the one managing Patient 1s medications. During a telephone interview with FM 2 on 1/30/2025 at 12:13 p.m., FM 2 stated he would prepare all of Patient 1s medications and put them in her pill box. FM 2 stated he never checked Patient 1s blood pressure at home. Per FM 2, Patient 1 had her blood pressure checked at the doctors office. FM 2 stated he was never instructed by the HA nurse regarding checking Patient 1s blood pressure or recording it. FM 2 stated the HA did not provide him with a log where he could record Patient 1s blood pressure. During a review of Patient 1s POC/IDG Review (Plan of Care/Interdisciplinary Group Review, a document detailing a patients health needs, created by a healthcare team based on a comprehensive assessment of the patients condition and goals, outlining interventions and expected outcomes to be achieved), dated 1/21/2025, the POC/IDG Review did not include cardiopulmonary (relating to the heart and the lungs) system in Patient 1s plan of care. The plan of care did not include problems, goals, and interventions for Patient 1 related to her high blood pressure. During an interview with LVN 1 on 1/29/2025 at 12 p.m., LVN 1 stated he had never seen Patient 1 before. LVN 1 stated Patient 1s caregivers needed to be educated on how to monitor her blood pressure. LVN 1 stated he would communicate with the office regarding the lack of parameters for Amlodipine Besylate 5 mg, Furosemide 20 mg, and Losartan Potassium 50 mg. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 1/30/2025 at 11:30 a.m., the DPCS reviewed Patient 1s Current Treatment/Medication/DME List and POC/IDG Review, dated 1/21/2025. The DPCS confirmed there were no parameters for Amlodipine Besylate 5 mg, Furosemide 20 mg, and Losartan Potassium 50 mg. The DPCS stated the HA did not include cardiopulmonary system in Patient 1s plan of care because he had instructed the nurses to report it to the physician if the patients blood pressure is lower than 90 mmHg or higher than 160 mmHg. The DPCS stated that Patient 1s blood pressure monitoring needed to be included in the plan of care because it would provide guidance to the HAs staff and the patients caregivers, so the patients blood pressure can be appropriately monitored. During a review of the HAs policy and procedure, titled “;The Plan of Care,” revised November 2021, the policy and procedure indicated that the written plan of care will contain, but will not be limited to, the following: U. Physician-directed instruction to patient and family/caregiver.”

“Based on observation and interview, the Hospice Agency (HA) failed to provide three of fourteen sampled patients (Patient 1, Patient 8, and Patient 9) with necessary medical supplies (supplemental oxygen, suction machine [medical device that is primarily used for removing obstructions, such as mucus, saliva, blood, or secretions from a person’s airway], and Yankauer suction tip [a medical device used to remove fluid and debris from the body during medical procedures]). This deficient practice had the potential to result in not meeting the needs of the patients that could affect the patients quality of care and wellbeing. b. During a review of Patient 8s “;Personal Information”, indicated a start of care (SOC) date of 10/17/2024, with a primary diagnosis of atherosclerosis heart disease of native coronary artery with angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood with chest pain and involuntary contraction). During a review of Patient 8s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List indicated that on 10/17/24, the HAs physician ordered the following: - Administer oxygen via nasal cannula (a device used to deliver supplemental oxygen) at 2 liters (a measurement unit)/minute as needed for shortness of breath. May titrate (the process of gradually adjusting the amount of oxygen administered to a patient to maintain a specific level of oxygen saturation in the blood) up to 5 liters/minute as needed with increments of 0.5 liter/minute every fifteen minutes to keep oxygen saturation above 90% or per patient comfort. - May suction using Yankauer tip as needed due to excessive oral secretions. During a joint home visit to Patient 8s residence with Licensed Vocational Nurse 2 (LVN 2) on 1/29/2025 at 10:30 a.m., Patient 1 was observed sitting comfortably on her chair, awake, alert, and oriented to her name, place, time and events. Patient 8 is with Family Member 3 (FM 3/Patient 8s niece) and acted as her authorized representative/emergency contact. During an interview with Patient 8 and FM3 on 1/29/2025 at 10:50 a.m., Patient 8 stated the HA never provided her with supplemental oxygen, nasal cannula, suction machine (a medical device that removes fluids, gases, or secretions; suction machines are used to clear airways and prevent blockages that can interfere with breathing), or a Yankauer suction tip. c. During a review of Patient 9s “;Personal Information”, indicated a start of care (SOC) date of 12/30/2024, with a primary diagnosis of heart disease (a type of disease that affects the heart or the blood vessels), unspecified. During a review of Patient 9s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List indicated that on 4/1/24, the HAs physician ordered the following: - Administer oxygen via nasal cannula (a device used to deliver supplemental oxygen) at 2 liters (a measurement unit)/minute as needed for shortness of breath. May titrate (the process of gradually adjusting the amount of oxygen administered to a patient to maintain a specific level of oxygen saturation in the blood) up to 5 liters/minute as needed with increments of 0.5 liter/minute every fifteen minutes to keep oxygen saturation above 90% or per patient comfort. - May suction using Yankauer tip as needed due to excessive oral secretions. During a joint home visit to Patient 9s residence with Licensed Vocational Nurse 2 (LVN 2) on 1/29/2025 at 11:30 a.m., Patient 9 was observed sitting comfortably on her bed, awake, alert, and oriented to her name, place, time and events. Patient 9 is with Family Member 4 (FM 4/Patient 9s granddaughter) and acted as her authorized representative/emergency contact. During an interview with Patient 9 and FM4 on 1/29/2025 at 11:50 a.m., Patient 9 stated the HA never provided her with supplemental oxygen, nasal cannula, suction machine (a medical device that removes fluids, gases, or secretions; suction machines are used to clear airways and prevent blockages that can interfere with breathing), or a Yankauer suction tip. During an interview with LVN 2 on 1/29/2025 at 12:10 p.m., LVN 2 confirmed that oxygen tanks, nasal cannula and suction machines were not in Patient 8 and Patient 9s residence and stated he was not sure why Patient 8 and Patient 9 had no supplemental oxygen, nasal cannula, and suction machine at their residence. During an interview with the Director of Patient Care Services (DPCS) on 1/31/2025 at 11 a.m., the DPCS stated that supplemental oxygen, nasal cannula, and suction machine are standard orders for the HAs patients. According to the DPCS, standard order means they were ordered for all of the HAs patients. The DPCS stated if the supplemental oxygen, nasal cannula, and suction machine were ordered by the physician, then the HA needed to provide them for the patients, even though the patient might not need them immediately. The DPCS stated he did not know why the patients never received the supplies. The HA did not provide a policy and procedure on medical supplies and appliances necessary for the patient as requested by the survey team on 1/31/2025. a. During a review of Patient 1s Personal Information, the Personal Information indicated that Patient 1 was admitted to the HA on 6/26/2024 with a primary diagnosis of Alzheimers disease (a progressive and irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to carry out everyday tasks). During a review of Patient 1s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List indicated that on 7/5/2024, the HAs physician ordered the following: - Administer oxygen via nasal cannula (a device used to deliver supplemental oxygen) at 2 liters (a measurement unit)/minute as needed for shortness of breath. May titrate (the process of gradually adjusting the amount of oxygen administered to a patient to maintain a specific level of oxygen saturation in the blood) up to 5 liters/minute as needed with increments of 0.5 liter/minute every fifteen minutes to keep oxygen saturation above 90% or per patient comfort. - May suction using Yankauer tip as needed due to excessive oral secretions. During a joint home visit to Patient 1s residence with Licensed Vocational Nurse 1 (LVN 1) on 1/29/2025 at 10:30 a.m., observed Patient 1 awake, alert, and oriented. Patient 1 lives in a private residence with Family Member 1 (FM 1) and Family Member 2 (FM 2), who acted as the patient’s caregivers. During an interview with Patient 1 on 1/29/2025 at 11:50 a.m., Patient 1 stated the HA never provided her with supplemental oxygen, nasal cannula, suction machine (a medical device that removes fluids, gases, or secretions; suction machines are used to clear airways and prevent blockages that can interfere with breathing), or a Yankauer suction tip. During an interview with LVN 1 on 1/29/2025 at 12:10 p.m., LVN 1 was not sure why Patient 1 did not have supplemental oxygen, nasal cannula, and suction machine at her residence. During an interview with the Director of Patient Care Services (DPCS) on 1/31/2025 at 11 a.m., the DPCS stated that supplemental oxygen, nasal cannula, and suction machine are standard orders for the HAs patients. According to the DPCS, standard order means they were ordered for all of the HAs patients. The DPCS stated if the supplemental oxygen, nasal cannula, and suction machine were ordered by the physician, then the HA needed to provide them for the patients, even though the patient might not need them immediately. The DPCS stated he did not know why the patients never received the supplies. The HA did not provide a policy and procedure on medical supplies and appliances necessary for the patient as requested by the survey team on 1/31/2025.”

“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 IDG (Interdisciplinary Group, IDG – meeting where the Registered Nurse [RN], Medical Social Worker [MSW], Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) members met to review the IDG/POC for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 10, Patient 11, and Patient 12). This deficient practice had the potential to result in patients’ progress or decline will not be coordinated to the members of the IDG to update information on the POC for further intervention and palliation (medical care that relieves symptoms). f. During a review of Patient 8s “;Personal Information”, indicated a start of care (SOC) date of 10/17/2024, with a primary diagnosis of atherosclerosis heart disease of native coronary artery with angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood with chest pain and involuntary contraction). During a concurrent record review and interview on 1/31/2025 at 12:15 p.m., with the Director of Patient Care Services (DPCS) of Patient 1 s clinical record titled “;Plan of Care/Interdisciplinary Group Review” (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), indicated the following: - 12/10/2024, no documented signature of Master of Social Work (MSW) - 12/24/2024, no documented signature of MSW. - 1/7/2025, no documented signature of MSW. - 1/21/2025, no documented signature of MSW. g. During a review of Patient 10s “;Personal Information”, indicated a start of care (SOC) date of 8/14/2024, with a primary diagnosis of heart failure (occurs when the heart is unable to pump enough blood to meet the body’s needs), unspecified. During a concurrent record review and interview on 1/31/2025 at 12:20 p.m., with the DPCS of Patient 10 s clinical record titled “;POC/IDG Review”, indicated the following: - 12/10/2024, no documented signature of MSW. - 12/24/2024, no documented signature of MSW. - 1/7/2025, no documented signature of MSW. - 1/21/2025, no documented signature of MSW. h. During a review of Patient 11s “;Personal Information”, it indicated a start of care date on 9/8/2024 with a primary diagnosis of chronic kidney disease, stage 5 (also known as end stage kidney disease, is the most severe stage where kidneys can no longer effectively filter waste from blood). During a concurrent record review and interview on 1/31/2025 at 12:25 p.m., with the DPCS of Patient 11 s clinical record titled “;POC/IDG Review”, indicated the following: - 12/30/2024, no documented signatures of MSW, Medical Director (MD) and Spiritual Chaplain (SC). - 1/7/2025, no documented signatures of MSW, MD and SC. - 1/21/2025, no documented signatures of MSW, MD and SC. I. During a review of Patient 12s “;Personal Information”, it indicated a start of care date on 5/17/2024 with a primary diagnosis of chronic obstructive pulmonary disease with acute exacerbation (a lung disease that damages the airways and makes it hard to breathe). During a concurrent record review and interview on 1/31/2025 at 12:30 p.m., with the DPCS of Patient 12 s clinical record titled “;POC/IDG Review”, indicated the following: - 12/10/2024, no documented signature of MSW. - 12/24/2024, no documented signature of MSW. - 1/7/2025, no documented signatures of MSW and MD. The DPCS confirmed the reviewed POC/IDG Review of Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 10, Patient 11 and Patient 12 were missing the IDG members signatures particularly the MD and MSW. The DPCS stated that there is no separate sign-in sheet for IDG members during meeting. The DPCS stated the IDG members would only sign electronically when they attended the IDG meetings, there was no separate sign-in sheet. The DPCS stated if the POC/IDG Review was not signed by a particular IDG member, it would mean that IDG member was not present during the meeting to review the patients individualized plan of care. During a telephone interview on 1/31/2025, at 12:34 p.m., with the MSW, MSW stated she attended the IDG meeting which is every 14 days with the other IDG members consist of the MD, RN, and SC. MSW stated they do not have any sign in sheet, they sign electronically to validate their attendance. MSW stated she does not remember what happened when her signatures were missing on Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 10, Patient 11and Patient 12s IDG/POC reviews. MSW stated she was busy and was behind with her documentations but stated she will review and ensure it will not happen again. During a review of the agencys policy and procedure (P&P) titled “;Interdisciplinary Group Membership and Responsibilities”, revised November 2021, the procedure indicated that the hospice interdisciplinary group responsibilities include but not limited to: B. Participation in the periodic review and updating of the plan of care for each patient receiving hospice services. a. During a review of Patient 1s Personal Information, the Personal Information indicated that Patient 1 was admitted to the HA on 6/26/2024 with a primary diagnosis of Alzheimers disease (a progressive and irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to carry out everyday tasks). During a review of Patient 1s Plan of Care/Interdisciplinary Group Review (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 12/10/2024, 12/24/2024, 1/7/2025, and 1/21/2025, it was noted the MSWs (Master of Social Work, social worker, responsible for the psychosocial aspect of patient care) signatures were missing. b. During a review of Patient 2s Personal Information, the Personal Information indicated that Patient 2 was admitted to the HA on 11/14/2024 with a primary diagnosis of hypertensive heart disease (a condition that develops when prolonged high blood pressure damages the heart muscle) without heart failure (a condition in which the heart cannot pump enough blood to meet the body’s needs). During a review of Patient 2s POC/IDG Review, dated 12/24/2024, 1/7/2025, and 1/21/2025, indicated the Medical Directors (MD, physician), MSWs, and Chaplains signatures were missing. c. During a review of Patient 3s Personal Information, the Personal Information indicated that Patient 3 was admitted to the HA on 5/6/2024 with a primary diagnosis of Alzheimers disease (a progressive and irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to carry out everyday tasks). During a review of Patient 3s POC/IDG Review, dated 12/24/2024, 1/7/2025, and 1/21/2025, indicated the MSWs and Chaplains signatures were missing. d. During a review of Patient 4s Personal Information, the Personal Information indicated that Patient 4 was admitted to the HA on 12/24/2024 with a primary diagnosis of heart disease (a group of conditions that affect the heart’s structure and function). During a review of Patient 4s POC/IDG Review, dated 12/14/2024, indicated the MDs, MSWs, and Chaplains signatures were missing. During a review of Patient 4s POC/IDG Review, dated 1/8/2025, it was noted the POC/IDG Review was not signed by and of the IDG members. During a review of Patient 4s POC/IDG Review, dated 1/21/2025, indicated the MDs and MSWs signatures were missing. e. During a review of Patient 5s Personal Information indicated that Patient 5 was admitted to the HA on 9/24/2024 with a primary diagnosis of malignant neoplasm of bone and articular cartilage (an aggressive cancer that forms in the bones and cartilage [a tough, flexible tissue that lines joint and gives structure to the nose, ears, larynx, and other parts of the body]). During a review of Patient 5s POC/IDG Review, dated 12/24/2024, 1/7/2025, and 1/21/2025, it indicated the MSWs signatures were missing. During a review of the agencys policy and procedure (P&P) titled “;Care/Service Coordination”, revised November 2021, the policy and procedure indicated that written evidence of care coordination may be found in the plan of care/service, case conference summary forms, clinical notes in the patient’s clinical record or interdisciplinary group meeting notes.”

“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 medical social services was provided for one of fourteen sampled patients reviewed (Patients 11). This failure had the potential for Patient 11 to not receive information regarding supportive services for terminal illness, the dying process, and community resources. During a review of Patient 11s untitled admission sheet indicated a start of care date on 9/8/2024 with a primary diagnosis of chronic kidney disease, stage 5 (also known as end stage kidney disease, is the most severe stage where kidneys can no longer effectively filter waste from blood). During a review of Patient 11s clinical record indicated there was no documented evidence that the Master of Social Works (MSW) conducted an initial encounter or visit with the patient and/or the patients family/caregiver. During a concurrent interview and record review on 1/31/2025 at 12:15 p.m., with the Director of Patient Care Services (DPCS), DPCS stated that during the initial Skilled Nurse assessment of patient, the patient may have refused MSW visit but MSW still needs to have an initial assessment in the patients clinical record of the services that was offered and the reason for refusal. DPCS acknowledged there was no MSW assessment in the patients clinical record. During a telephone interview on 1/31/2025, at 12:34 p.m., with the MSW stated, she attended the IDG meeting which is every 14 days with the other IDG members consist of the MD, RN, and SC. MSW stated they do not have any sign in sheet, they sign electronically to validate their attendance. MSW stated she does not remember what happened when her signatures were missing on Patient 8, Patient 10, Patient 11 and Patient 12s IDG/POC reviews. MSW stated she was busy and was behind with her documentations but stated she will review and ensure it will not happen again. MSW stated that she still needs to complete an initial assessment even if patients declined to have social services visits. A review of the hospice agencys medical social worker job description, undated, indicated that the medical social worker, contracted or employed through the organization is responsible for the implementation of standards of care for medical social work services and for adherence to all conditions in the service agreement. The essential job functions/responsibilities which include to maintain clinical records on all patients referred to social work. A review of the hospice agencys policy and procedure titled “;Contents of Clinical Records”, undated, indicated that a clinical record will be maintained for each patient receiving care, the clinical record will 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 the continuity of care among hospice interdisciplinary group members and contract personnel.”

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to conduct a post bereavement assessment for two of fourteen sampled patients (Patient 6 and Patient 7). This deficient practice had the potential to impact a family members’ abilities to cope with the patients’ death. a. During a review of Patient 6s “;Personal Information”, indicated a start of care (SOC) date of 7/15/2024 and an end of care (EOC) date of 1/12/2025, with a primary diagnosis of acute kidney failure (is a condition where the kidneys are unable to filter waste from the blood). During a review of Patient 6s POC/IDG Review (Plan of Care/Interdisciplinary Group Review, a document detailing a patients health needs, created by a healthcare team based on a comprehensive assessment of the patients condition and goals, outlining interventions and expected outcomes to be achieved), dated 12/10/2024, the POC/IDG Review indicated a goal of tips and resources to get through grief. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 1/31/2025 at 12:35 p.m., the DPCS reviewed Patient 6s electronic health records and “;History of Post-Death Bereavement Assessment” indicated no documented evidence that a post-bereavement assessment was conducted. b. During a review of Patient 7s “;Personal Information”, indicated a start of care (SOC) date of 7/8/2024 and an end of care (EOC) date of 10/3/2024, with a primary diagnosis of atherosclerosis heart disease of native coronary artery with angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood with chest pain and involuntary contraction). During a review of Patient 7s POC/IDG Review (Plan of Care/Interdisciplinary Group Review, a document detailing a patients health needs, created by a healthcare team based on a comprehensive assessment of the patients condition and goals, outlining interventions and expected outcomes to be achieved), dated 8/20/2024, the POC/IDG Review indicated a goal of tips and resources to get through grief. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 1/31/2025 at 12:45 p.m., the DPCS reviewed Patient 7s electronic health records and “;History of Post-Death Bereavement Assessment” indicated no documented evidence that a post-bereavement assessment was conducted. The DPCS stated that a post bereavement assessment should be conducted after patients death. The DPCS stated that Patient 6 and Patient 7s did not have a post bereavement assessment that should be conducted after death, DPCS stated that it is important to ensure that deceased patients family are coping well with the grieving process and to ensure what assistance and resources the HA can provide to them. During a review of the HA’s policy and procedure titled “Bereavement Assessment”, dated 11/2021, indicated that the hospice bereavement plan of care will be developed based on an initial assessment of the patient and family/caregiver needs, during the course of care, and at the time of patients death as part of the comprehensive assessment.”

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure a completed copy of written information regarding advance directive (a legal document that outlines person’s wishes in the event an individual is unable to express wishes for healthcare and treatments) policies and descriptions for one of fourteen sampled patients (Patient 9). This failure had the potential to result in the patients family and/or caregivers not knowing what the patients medical decisions are, which can result in psychological distress to the patient/patients family/caregiver. During a review of Patient 9s “;Personal Information”, indicated a start of care (SOC) date of 12/30/2024, with a primary diagnosis of heart disease (a type of disease that affects the heart or the blood vessels) unspecified. During a home visit observation on 1/29/2025, at 11:30 a.m., to Patient 9s residence, with Licensed Vocational Nurse (LVN 2), Patient 9 was observed resting comfortably on her bed. Patient 9 was alert, awake and oriented to her name, time, place and events. During a concurrent review of Patient 9s hospice folder with LVN 2, the folder had the name of the HA. Inside the folder was a copy of Patient 9s plan of care, active medication list, signed notice of patients rights, and a POLST (Physician Orders for Life-Sustaining Treatment), dated 4/1/2024, indicated no selection mark on section: A. Cardiopulmonary Resuscitation (CPR, a method that can help save a life during cardiac arrest, when the heart stops beating or beats too ineffectively to circulate blood to the brain and other vital organs), no selection mark on section C. Artificially Administered Nutrition, section D. Information and Signatures, indicated no selection mark on discussed with and no signature of Physician/Nurse Practitioner/Physician Assistant. During interview with LVN 2, stated he was unaware that Patient 9 has Legal Representative, stated that POLST was not valid unless it was completed and signed by the patient or legal representative. LVN 2 stated it should have been check and processed by the social worker. LVN 2 stated that if Patient 9s heartbeat stops, then a CPR will be performed since the POLST was not completed yet and the code status of the patient was full code and not DNR (Do Not Resuscitate). During a concurrent record review and interview on 1/31/2025, at 10:30 a.m., with the Director of Patient Care Services (DPCS), indicated Patient 9s POLST copy in her folder was incomplete and unsigned by the physician. DPCS confirmed that Patient 9s POLST, dated 4/1/2024, was incomplete and the physician did not sign it. DPCS stated that the agencys office has the completed POLST of Patient 9, however, the updated copy was not provided to Patient 9. DPCS stated that a completed copy should have been provided to Patient 9s hospice agencys home folder for future reference to define the code status of the patient. During a telephone interview on 1/31/2025, at 10:34 a.m., with the Master of Social Work (MSW) stated, that she assists hospice patients on preparing their respective POLST. MSW stated that an incomplete POLST should have not been placed to Patient 9s hospice folder as it could create a confusion of Patient 9s code status. MSW stated that a completed POLST was very important for the healthcare providers future reference when Patient 3s medical condition decline or if his heartbeat stops. MSW stated that the healthcare team should check the hospice folder and POLST to ensure that everything was updated and completed. During a review of the HAs policy and procedure entitled, “;Do Not Resuscitate/Do Not Intubate Orders”, revised November 2023, the policy and procedure indicated that a written Do Not Resuscitate (DNR) order signed by the patients physician (or authorized independent practitioner) must be on file in the patients clinical record and admission folder in the patients home. A review of the HA agencys policy and procedure titled “;Contents of Clinical Records”, undated, indicated that a clinical record will be maintained for each patient receiving care, the clinical record will 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 the continuity of care among hospice interdisciplinary group members and contract personnel.”

“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 IDG (Interdisciplinary Group, IDG – meeting where the Registered Nurse [RN], Medical Social Worker [MSW], Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) members authenticated their entries for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 10, Patient 11, and Patient 12.). This deficient practice had the potential for the clinical records to contain inaccurate information which can affect the formulation of patients’ Plan of Care (POC - an individualized guide for the needs and services supplied to patient and their care givers/family facing a terminal illness), interventions, and quality of care and services provided to all the patients receiving hospice care benefits. f. During a review of Patient 8s “;Personal Information”, indicated a start of care (SOC) date of 10/17/2024, with a primary diagnosis of atherosclerosis heart disease of native coronary artery with angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood with chest pain and involuntary contraction). During a concurrent record review and interview on 1/31/2025 at 12:15 p.m., with the Director of Patient Care Services (DPCS) of Patient 1 s clinical record titled “;Plan of Care/Interdisciplinary Group Review” (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), indicated the following: - 12/10/2024, no documented signature of Master of Social Work (MSW). - 12/24/2024, no documented signature of MSW. - 1/7/2025, no documented signature of MSW. - 1/21/2025, no documented signature of MSW. g. During a review of Patient 10s “;Personal Information”, indicated a start of care (SOC) date of 8/14/2024, with a primary diagnosis of heart failure (occurs when the heart is unable to pump enough blood to meet the body’s needs), unspecified. During a concurrent record review and interview on 1/31/2025 at 12:20 p.m., with the DPCS of Patient 10 s clinical record titled “;POC/IDG Review”, indicated the following: - 12/10/2024, no documented signature of MSW. - 12/24/2024, no documented signature of MSW. - 1/7/2025, no documented signature of MSW. - 1/21/2025, no documented signature of MSW. h. During a review of Patient 11s “;Personal Information”, it indicated a start of care date on 9/8/2024 with a primary diagnosis of chronic kidney disease, stage 5 (also known as end stage kidney disease, is the most severe stage where kidneys can no longer effectively filter waste from blood). During a concurrent record review and interview on 1/31/2025 at 12:25 p.m., with the DPCS of Patient 11 s clinical record titled “;POC/IDG Review”, indicated the following: - 12/30/2024, no documented signatures of MSW, Medical Director (MD) and Spiritual Chaplain (SC). - 1/7/2025, no documented signatures of MSW, MD and SC. - 1/21/2025, no documented signatures of MSW, MD and SC. I. During a review of Patient 12s “;Personal Information”, it indicated a start of care date on 5/17/2024 with a primary diagnosis of chronic obstructive pulmonary disease with acute exacerbation (a lung disease that damages the airways and makes it hard to breathe). During a concurrent record review and interview on 1/31/2025 at 12:30 p.m., with the DPCS of Patient 12 s clinical record titled “;POC/IDG Review”, indicated the following: - 12/10/2024, no documented signature of MSW. - 12/24/2024, no documented signature of MSW. - 1/7/2025, no documented signatures of MSW and MD. The DPCS confirmed the reviewed POC/IDG Review of Patient 8, Patient 10, Patient 11 and Patient 12 were missing the IDG members signatures particularly the MD and MSW. The DPCS stated that there is no separate sign-in sheet for IDG members during meeting. The DPCS stated the IDG members would only sign electronically when they attended the IDG meetings, there was no separate sign-in sheet. The DPCS stated if the POC/IDG Review was not signed by a particular IDG member, it would mean that IDG member was not present during the meeting to review the patients individualized plan of care. During a telephone interview on 1/31/2025, at 12:34 p.m., with the MSW, MSW stated she attended the IDG meeting which is every 14 days with the other IDG members consist of the MD, RN, and SC. MSW stated they do not have any sign in sheet, they sign electronically to validate their attendance. MSW stated she does not remember what happened when her signatures were missing on Patient 8, Patient 10, Patient 11and Patient 12s IDG/POC reviews. MSW stated she was busy and was behind with her documentations but stated she will review and ensure it will not happen again. During a review of the agencys policy and procedure (P&P) titled “;Interdisciplinary Group Membership and Responsibilities”, revised November 2021, the procedure indicated that the hospice interdisciplinary group responsibilities include but not limited to: B. Participation in the periodic review and updating of the plan of care for each patient receiving hospice services. a. During a review of Patient 1s Personal Information, the Personal Information indicated that Patient 1 was admitted to the HA on 6/26/2024 with a primary diagnosis of Alzheimers disease (a progressive and irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to carry out everyday tasks). During a review of Patient 1s Plan of Care/Interdisciplinary Group Review (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 12/10/2024, 12/24/2024, 1/7/2025, and 1/21/2025, it was observed that the MSWs (Master of Social Work, social worker, responsible for the psychosocial aspect of patient care) signature was missing. b. During a review of Patient 2s Personal Information, the Personal Information indicated that Patient 2 was admitted to the HA on 11/14/2024 with a primary diagnosis of hypertensive heart disease (a condition that develops when prolonged high blood pressure damages the heart muscle) without heart failure (a condition in which the heart cannot pump enough blood to meet the body’s needs). During a review of Patient 2s POC/IDG Review, dated 12/24/2024, 1/7/2025, and 1/21/2025, it was observed that the Medical Directors (MD, physician), MSWs, and Chaplains signatures were missing. c. During a review of Patient 3s Personal Information, the Personal Information indicated that Patient 3 was admitted to the HA on 5/6/2024 with a primary diagnosis of Alzheimers disease (a progressive and irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to carry out everyday tasks). During a review of Patient 3s POC/IDG Review, dated 12/24/2024, 1/7/2025, and 1/21/2025, it was observed that the MSWs and Chaplains signatures were missing. d. During a review of Patient 4s Personal Information, the Personal Information indicated that Patient 4 was admitted to the HA on 12/24/2024 with a primary diagnosis of heart disease (a group of conditions that affect the heart’s structure and function). During a review of Patient 4s POC/IDG Review, dated 12/14/2024, it was observed that the MDs, MSWs, and Chaplains signatures were missing. During a review of Patient 4s POC/IDG Review, dated 1/8/2025, it was observed that the POC/IDG Review was not signed by and of the IDG members. During a review of Patient 4s POC/IDG Review, dated 1/21/2025, it was observed that the MDs and MSWs signatures were missing. e. During a review of Patient 5s Personal Information, the Personal Information indicated that Patient 5 was admitted to the HA on 9/24/2024 with a primary diagnosis of malignant neoplasm of bone and articular cartilage (an aggressive cancer that forms in the bones and cartilage [a tough, flexible tissue that lines joints and gives structure to the nose, ears, larynx, and other parts of the body]). During a review of Patient 5s POC/IDG Review, dated 12/24/2024, 1/7/2025, and 1/21/2025, it was observed that the MSWs signature was missing.”