Geiss Med Hospice LLC

“Based on interview and record review, the hospice failed to ensure the care and services was provided in accordance with the POC for one of three patients (Patient 2). This failure had the potential for not providing appropriate, consistent, and quality care to this patient.Findings: Review of the hospice’s P&P titled The Plan of Care revised 11/2023 showed the written plan of care will contain, but not limited to, the following:- Diagnosis- Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, and counseling.- Individualized interventions to assist with end-of-life care- Drugs and treatments (including allergies)- Physician (or other authorized licensed independent practitioner) ordersReview of Patient 2’s clinical record was initiated on 5/26/26. The clinical record showed the SOC was 10/29/24. The patient was certified for hospice services during the certification periods from 10/29/24 to 1/26/25, 1/27/25 to 4/26/25, 4/27/25 to 6/25/25, 6/26/25 to 8/24/25, 8/25/25 to 10/23/25, 10/24/25 to 12/22/25, 12/23/25 to 2/20/26, 2/21/26 to 4/21/26, and 4/22/26 to 6/20/26.Review of LVN 1’s Visit Note dated 2/26/26, showed an abrasion/excoriation to bilateral inner buttocks with peri-wound maceration was noted. Documentation showed wound care was provided and DuoDERM (wound dressing) dressings were placed.The POC/IDG Review dated 2/11/26, showed a new wound care order dated 2/10/26, for the abrasion/excoriation in the buttocks. Documentation included to cleanse area with normal saline or wound cleanser with gauze pad, pat dry with gauze pad, and apply barrier cream.The POC/IDG Review dated 2/25/26, showed the wound care order was discontinued on 2/24/26, for the buttock abrasion/excoriation. The wound care included to cleanse area with normal saline or wound cleanser with gauze pad, pat dry with gauze pad, and apply barrier cream. A new wound care order dated 2/24/26, showed MASD in buttocks, to cleanse the area with normal saline using gauze pad, pat dry with gauze pad, and apply barrier cream.However, there was no documented evidence the physician had ordered DuoDERM dressing to be placed on the patient’s bilateral inner buttocks with peri-wound maceration.On 5/28/26 at 1128 hours, an interview and concurrent clinical record were conducted with the ED and DPCS. The DPCS acknowledged and confirmed the findings.”

“Based on interview and record review, the hospice failed to ensure individualized care plans were developed for three of three sampled patients (Patients 1, 2, and 3). This failure had the potential to cause inconsistent delivery of care which could result in the decline or lack of improvement in the patients’ health conditions.Findings: Review of the hospice’s P&P titled The Plan of Care revised 11/2023 showed the written plan of care will contain, but not limited to, the following:- Diagnosis- Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, and counseling.- Reduction in risk factors- Prognosis- Individualized interventions to assist with end-of-life care- Statement of treatment goals- Interdisciplinary group assessment of needs- Pain and symptom management interventions- Drugs and treatments (including allergies)- Physician (or other authorized licensed independent practitioner) orders- Measurable outcomes anticipated from implementing and coordinating the plan of care.1. Review of Patient 1’s clinical record was initiated on 5/26/26. The clinical record showed the SOC was 12/23/25. The patient was certified for hospice services during the certification periods from 12/23/25 to 3/22/25 and 3/23/25 to 6/20/25.a. Review of the Nursing Updated Assessment dated 3/10/26, showed in the Narrative and Disease Trajectory, per facility, the patient had increased confusion with staff and the urine had odor. Documentation showed the patient was currently treated for UTI with Macrobid (antibiotic).The POC/IDG Review dated 3/11/26, showed a new order for Macrobid 100 mg capsule BID for seven days for UTI symptoms.However, there was no documentation the IDG had developed an individualized POC to address Patient 1’s increased confusion, odor in the urine, and UTI.b. Review of LVN 2’s Visit Note dated 4/20/26, showed Patient 1 had complaint of right shoulder pain. The POA requested to try lidocaine patches (topical medication used to temporarily relieve localized muscle and joint pain). Documentation showed the physician agreed to start lidocaine 4% topical patch to affected area once a day for pain, on for 12 hours and off for 12 hours.Review of the POC/IDG dated 4/22/26, showed a new order for lidocaine 4% maximum strength pain relief patch, to apply one patch to affected right shoulder and neck area once a day as needed for pain relief on for 12 hours and off for 12 hours.However, there was no documentation the IDG had developed an individualized POC to address Patient 1’s right shoulder pain and the application of the lidocaine patch.On 5/28/26 at 1115 hours, an interview and concurrent clinical record review were conducted with the ED and DPCS. The DPCS acknowledged and verified the findings.2. Review of Patient 2’s clinical record was initiated on 5/26/26. The clinical record showed the SOC was 10/29/24. The patient was certified for hospice services during the certification periods from 10/29/24 to 1/26/25, 1/27/25 to 4/26/25, 4/27/25 to 6/25/25, 6/26/25 to 8/24/25, 8/25/25 to 10/23/25, 10/24/25 to 12/22/25, 12/23/25 to 2/20/26, 2/21/26 to 4/21/26, and 4/22/26 to 6/20/26.a. The POC/IDG Review dated 2/11/26, showed a new wound care order dated 2/10/26, for the abrasion/excoriation in buttocks. The wound care included to cleanse area with normal saline or wound cleanser with gauze pad, pat dry with a gauze pad, and apply barrier cream.However, there was no documentation the IDG had developed an individualized POC to address Patient 2’s abrasion/excoriation in the buttocks.b. The POC/IDG Review dated 3/25/26, showed a new wound care order dated 3/13/25, for nystatin (antifungal medication) 100,000 units/g topical powder two times a day for 14 days for the fungal rash in the groin area.However, there was no documentation the IDG had developed an individualized POC to address Patient 2’s fungal rash in the groin area.On 5/28/26 at 1128 hours, an interview and concurrent clinical review were conducted with the ED and DPCS. The DPCS acknowledged and verified the findings.3. Review of Patient 3’s clinical record was initiated on 5/27/26. The clinical record showed the SOC was 3/24/26. The patient was certified for hospice services during 3/24/26 to 5/22/26 and 5/23/26 and 7/21/26.Review of the Comprehensive Nursing Assessment dated 3/24/26, showed in the Narrative and Disease Trajectory section, the patient had Stage 1 sacrococcyx pressure injury. Documentation showed per the facility, maintaining a dressing in the area was unsustainable because it gets soiled easily. Documentation showed the regimen that will be used was mix small amount of calamine zinc (relieves minor skin irritation) with vitamin A and D ointment (skin protectant) and apply to pressure site with each diaper change.The POC/IDG Review dated 3/25/26, showed an order for the patient’s Stage 1 saccrococcyx pressure injury. Documentation showed per the facility, maintaining a dressing in area was unsustainable because it gets soiled easily. Documentation showed the regimen that will be used was mix small amount of calamine zinc with vitamin A and D ointment and apply to pressure site with each diaper change.However, there was no documentation the IDG had developed an individualized POC to address Patient 3’s Stage 1 sacrococcyx pressure injury.On 5/28/26 at 1145 hours, an interview and concurrent clinical review were conducted with the ED and DPCS. The DPCS acknowledged and verified the findings.”

“Based on interview and record review, the hospice failed to ensure the revised POCs included the indication for the PRN discipline visits for one of three sampled patients (Patient 2). This failure had the potential of not providing necessary services for this patient.Findings: Review of Patient 2’s clinical record was initiated on 5/26/26. The clinical record showed the SOC was 10/29/24. The patient was certified for hospice services during the certification periods from 10/29/24 to 1/26/25, 1/27/25 to 4/26/25, 4/27/25 to 6/25/25, 6/26/25 to 8/24/25, 8/25/25 to 10/23/25, 10/24/25 to 12/22/25, 12/23/25 to 2/20/26, 2/21/26 to 4/21/26, and 4/22/26 to 6/20/26.The POC/IDG Review dated 2/11, 2/25, 3/11, 3/25, 4/8, 4/22, 5/6, and 5/13/26, showed a frequency of visit for the SN two per week plus three PRN visits.However, there was no documented evidence showing the indication of the PRN visits.On 5/28/26 at 1128 hours, an interview and concurrent clinical review were conducted with the ED and DPCS. The DPCS acknowledged and verified the finding.”

“Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patients’ POCs no less frequently than every 15 calendar days for two of three sampled patients (Patients 1 and 2). This failure had the potential for not providing appropriate, consistent, and quality care to these patients.Findings: The hospice’s P&P titled Interdisciplinary Group Meeting revised 11/2021 showed the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires.1. Review of Patient 1’s clinical record was initiated on 5/26/26. The clinical record showed the SOC was 12/23/25. The patient was certified for hospice services during the certification periods from 12/23/25 to 3/22/25 and 3/23/25 to 6/20/25.The POC/IDG Review dated 12/31/25, 1/14, 3/11, 3/25, 4/8, 4/22, 5/6, and 5/20/26, showed the patient’s identified care plan problem included hypertension, history of constipation, incontinence, at risk for skin breakdown, bedbound status, depression, poor oral intake, altered comfort related to lower legs pain, and the need for ongoing education related to hospice philosophy, need for continuous oxygen and benefit for patient/caregiver/family. The identified problems were opened on 12/23/25.There was no documented evidence the identified care plan problems were updated to provide appropriate care for the patient.On 5/28/26 at 1115 hours, an interview and concurrent clinical record review was conducted with the ED and DPCS. The DPCS acknowledged and verified the findings.2. Review of Patient 2’s clinical record was initiated on 5/26/26. The clinical record showed the SOC was 10/29/24. The patient was certified for hospice services during the certification periods from 10/29/24 to 1/26/25, 1/27/25 to 4/26/25, 4/27/25 to 6/25/25, 6/26/25 to 8/24/25, 8/25/25 to 10/23/25, 10/24/25 to 12/22/25, 12/23/25 to 2/20/26, 2/21/26 to 4/21/26, and 4/22/26 to 6/20/26.The POC/IDG Review dated 2/11, 2/25, 3/11, 3/25, 4/8, 4/22, 5/6, and 5/13/26, showed the patient’s identified care plan problem included risk of deficit of self-care, risk for falls/injury related to cognitive deficits/confusion, risk for constipation related to poor mobility, risk for skin breakdown related to incontinence, at risk for skin breakdown, at risk for falls due to lower extremity weakness, an unsteady gait, and episodes of confusion, at risk for impaired mobility, increased contracture to bilateral hands, at risk for episodes of agitation, risk to aspirate related to dysphagia, need for ongoing education related to the hospice philosophy and benefit for patient/caregiver/family, at risk for episodes of shortness of breath,and at risk for somnolence. The identified problems were opened on 10/29/24.There was no documented evidence the identified care plan problems were updated to provide appropriate care for the patient.On 5/28/26 at 1128 hours, an interview and concurrent clinical review were conducted with the ED and DPCS. The DPCS acknowledged and verified the findings.”

“Based on interview and record review, the hospice failed to ensure the revised POCs included the patient’s progress toward goals specified in the POCs for one of three sampled patients (Patient 1). This failure had the potential of not identifying the care needs and providing necessary care and services to meet the care needs for this patient.Findings: Review of the hospice’s P&P titled Interdisciplinary Group Meeting revised 11/2021 showed an interdisciplinary group meeting plan of care update form will be used for update of the patient and family/caregiver and the attending physician. It will note changes, response to treatment and progress toward targeted outcomes.Review of the hospice’s P&P titled Interdisciplinary Group Coordination of Care revised 11/2021 showed the interdisciplinary group (in collaboration with the attending physician) will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of every two weeks.Review of Patient 1’s clinical record was initiated on 5/26/26. The clinical record showed the SOC was 12/23/25. The patient was certified for hospice services during the certification periods from 12/23/25 to 3/22/25 and 3/23/25 to 6/20/25.The POC/IDG Reviews dated 12/31/25, 1/14, 3/11, 3/25, 4/8, 4/22, 5/6, and 5/20/26, showed the patient’s identified care problems included a target date. The identified care problems were hypertension, history of constipation, incontinence, at risk for skin breakdown, bedbound status, depression, poor oral intake, altered comfort related to lower legs pain, the need for ongoing education related to hospice philosophy, and the need for continuous oxygen and benefit for patient/caregiver/family. The identified problems showed a target date of 3/22/26.However, there was no documented evidence of the patient’s progress towards the outcome and goals specified in the plan of care.On 5/28/26 at 1115 hours, an interview and concurrent clinical record review were conducted with the ED and DPCS. The DPCS acknowledged and verified the findings.”

“Based on observation, interview, and record review, the hospice IDG failed to maintain the responsibility for directing, coordinating, and supervising the care and services provided for two of three sampled patients (Patient 2 and 3) related to: -coordination of the change in condition and missed visits (Patients 2 and 3).-assessment of imminence of death was included (Patient 2).-medication profile to include all current medications (Patient 2).These failures had the potential of not addressing the care needs for these patients.Findings: Review of the hospice’s P&P titled Interdisciplinary Group Meeting revised 11/2021 showed the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. The interdisciplinary group shall direct, coordinate, and supervise the hospice services.1. Review of the hospice’s P&P titled Interdisciplinary Group Coordination of Care revised 11/2021, showed the type and scope of services provided by the interdisciplinary group will be based upon the comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions.Review of the hospice’s P&P titled Missed Visits revised 11/2021, showed the missed visits will be communicated to the Interdisciplinary Group at the IDG meeting. The procedure includes among others if a patient is routinely refusing visits, the clinician and the IDG should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with input from the patient and Medical Director.a. Review of Patient 2’s clinical record was initiated on 5/26/26. The clinical record showed the SOC was 10/29/24. The patient was certified for hospice services during the certification periods from 10/29/24 to 1/26/25, 1/27/25 to 4/26/25, 4/27/25 to 6/25/25, 6/26/25 to 8/24/25, 8/25/25 to 10/23/25, 10/24/25 to 12/22/25, 12/23/25 to 2/20/26, 2/21/26 to 4/21/26, and 4/22/26 to 6/20/26.Review of LVN 1’s Visit Note dated 4/3/26, showed the patient’s right middle toe (third toe on right foot) appeared broken. Documentation showed upon palpating the toe, the patient verbalized discomfort. Documentation showed the toe was bent in an unusual way and flopped when attempting to put sock over it.However, there was no documented evidence the middle toe that appeared to be broken was coordinated with the IDG.Review of the Communication Log dated 4/8/26, showed the facility reported a small amount of blood when wiping the patient after a bowel movement. However, there was no documented evidence the small amount of blood following a bowel movement was coordinated with the IDG.The IDG failed to supervise the care and services related to the coordination of the patient’s middle toe that appeared to be broken and the blood after the patient’s bowel movement.On 5/28/26 at 1128 hours, an interview and concurrent clinical review was conducted with the ED and DPCS. The DPCS acknowledged and verified the findings.b. Review of Patient 3’s clinical record was initiated on 5/27/26. The clinical record showed the SOC was 3/24/26. The patient was certified for hospice services during the certification periods from 3/24/26 to 5/22/26 and from 5/23/26 and 7/21/26.The POC/IDG Review for 4/8, 4/22, 5/6, and 5/13/26, showed a frequency of visit for SN as two visits per week plus two PRN visits for pain and symptom management.Review of RN 1’s Visit Note Declined Visit for 4/17, 4/24, 5/1, 5/8, 5/15, and 5/22/26, showed the caregiver declined the visit and reported the patient’s current symptoms were well managed.However, there was no documented evidence the missed visits were coordinated with the IDG.On 5/28/26 at 1145 hours, an interview and concurrent clinical review was conducted with the ED and DPCS. The ED stated the missed visits should have been addressed and the physician should be notified. Furthermore, the DPCS stated the missed visits were not coordinated with the IDG. The IDG failed to supervise the care and services related to the coordination of the missed visits.2. Review of the hospice’s P&P titled Comprehensive Assessment revised 11/2021, showed the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s clinical record which include among others the imminence of death. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patient’s condition requires but at a minimum of every 15 days. The interdisciplinary group is required to only update those sections that require updating. If no changes are needed, then that must be documented, and if there has been a change in the patient’s condition/status then the comprehensive assessment must be updated.Review of Patient 2’s clinical record was initiated on 5/26/26. The clinical record showed the SOC was 10/29/24. The patient was certified for hospice services during the certification periods from 10/29/24 to 1/26/25, 1/27/25 to 4/26/25, 4/27/25 to 6/25/25, 6/26/25 to 8/24/25, 8/25/25 to 10/23/25, 10/24/25 to 12/22/25, 12/23/25 to 2/20/26, 2/21/26 to 4/21/26, and 4/22/26 to 6/20/26.Review of the Re-Cert Assessment dated 2/10 and 4/7/26, showed an RN performed comprehensive assessment.Review of the Visit Notes dated 4/3, 4/9, 4/16, 4/21, 4/24, 4/28, 4/30, 5/5, 5/7, 5/12, 5/14 and 5/21/26, showed an SN performed “Signs & Symptoms Screening.”However, the comprehensive assessments and the “Signs & Symptoms Screening” were incomplete as the section for imminently dying was left blank.Furthermore, there was no documented evidence the update assessment for the imminence of death for the patient was coordinated with the IDG.The IDG failed to supervise the care and services related to the assessment of the imminence of dealth.On 5/28/26 at 1138 hours, an interview and concurrent clinical record review were conducted with the ED and DPCS. The DPCS acknowledged and verified the findings.3. Review of the hospice’s P&P titled Medication Profile revised 11/2021, showed patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.Review of Patient 2’s clinical record was initiated on 5/26/26. The clinical record showed the SOC was 10/29/24. The patient was certified for hospice services during the certification periods from 10/29/24 to 1/26/25, 1/27/25 to 4/26/25, 4/27/25 to 6/25/25, 6/26/25 to 8/24/25, 8/25/25 to 10/23/25, 10/24/25 to 12/22/25, 12/23/25 to 2/20/26, 2/21/26 to 4/21/26, and 4/22/26 to 6/20/26.On 5/27/26 at 0900 hours, a home visit was conducted with the CS and HA 1 to the assisted living facility where Patient 2 resided. Bisacodyl (laxative) 10 mg rectal suppository for no BM times three days was included in the patient’s current medication.However, review of the current medication for Patient 2 at the assisted living did not include the abovementioned medication. The CS confirmed the findings.The IDG failed to supervise the care and services related to the medication profile to include all current medications. On 5/28/26 at 1138 hours, an interview and concurrent clinical record review were conducted with the ED and DPCS. The DPCS acknowledged and verified the findings.”

“Based on observation, interview, and record review, the hospice failed to ensure the HA provided HA services in accordance with the POC for one of three sampled patients (Patient 2). This failure had the potential for not providing the appropriate, consistent, and quality care to Patient 2.Findings: Review of Patient 2’s clinical record was initiated on 5/26/26. The clinical record showed the SOC was 10/29/24. The patient was certified for hospice services during the certification periods from 10/29/24 to 1/26/25, 1/27/25 to 4/26/25, 4/27/25 to 6/25/25, 6/26/25 to 8/24/25, 8/25/25 to 10/23/25, 10/24/25 to 12/22/25, 12/23/25 to 2/20/26, 2/21/26 to 4/21/26, and 4/22/26 to 6/20/26.Review of the HA visits for the weeks 4/5/26 to 4/11/26, 4/12/26 to 4/18/26, 4/19/26 to 4/25/26, 4/26/26 to 5/2/26, 5/3/26 to 5/9/26, 5/10/26 to 5/16/26, and 5/17/26 to 5/23/26, showed the HA conducted a visit three times per week to the patient.However, there was no documented evidence the physician had ordered for an HA frequency of visit for three times per week. Furthermore, review of the HA Assignment dated 6/17/25, showed the HA to provide ADL services that includes the following every visit:-blow dry-brush teeth; and-application of deodorantOn 5/27/26 at 0900 hours, a home visit was conducted with the CS and HA 1 to the assisted living facility where Patient 2 resided. HA 1 was observed to provide ADL care to the patient. However, HA 1 did not blow dry, brush the client’s teeth and apply deodorant on the patient.On 5/27/26 at 0940 hours, an interview was conducted with HA 1. HA 1 stated Patient 2 did not have a blow dryer, oral swabs were used to clean teeth, and the patient ran out of deodorant.On 5/28/26 at 1138 hours, an interview and concurrent clinical record review were conducted with the ED and DPCS. The DPCS acknowledged the findings.”

“Based on interview and record review, the hospice’s Administrator failed to be responsible for the day-to-day operations of the organization and maintain administrative and supervisory responsibility for all the care provided as follows:-The Administrator failed to ensure the patient/POA was notified with the change in attending physician to one of three sampled patients (Patient 3).-The Administrator failed to ensure the performance evaluations were completed for three of seven employee files reviewed (RNs 1, 2, and MSW 1).-The Administrator failed to ensure the license/certification was checked for one of seven employees (HA 2).-The Administrator failed to ensure the 12-hour training for HA was completed for one of two HAs reviewed (HA 1).These failures had the potential to have a negative impact on the hospice’s operational performance.Findings: Review of the hospice’s P&P titled Governing Body undated showed a governing body assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement. A qualified administrator appointed by and reporting to the governing body is responsible for the day-to-day operation of the hospice. Review of the Job Title/Position for Executive Director/Administrator the Executive Director/Administrator is responsible for the overall direction of the hospice services. He/she is responsible for the employment of qualified hospice personnel; is responsible for the provision of hospice services, directly, and the delegation to a coordination of hospice personnel evaluation; is responsible for establishing standards of care to comply with federal and state regulations and guidelines.1. Review of the hospice’s P&P titled Rights/Responsibilities revised 11/2024 showed each patient will be an active, informed participant in his/her plan of care. To ensure this process, the patient will be empowered with certain rights and responsibilities which includes among others, the right to choose their attending physician.Review of Patient 3’s clinical record was initiated on 5/27/26. The clinical record showed the SOC was 3/24/26. The patient was certified for hospice services during 3/24/26 to 5/22/26 and 5/23/26 and 7/21/26.Review of the Hospice Election Statement signed on 3/24/26, showed the patient chose MD 2 as the attending physician.Review of Patient 3’s Personal Information showed MD 1 would follow as attending physician.* However, there was no documented evidence the patient/POA was notified of the change in attending physician.On 5/28/26 at 0945 hours, an interview and concurrent personnel record review was conducted with the HR. The HR stated MD 1 resigned on 4/10/26.On 5/28/26 at 1145 hours, an interview and concurrent clinical record review were conducted with the ED and DPCS. The ED and DPCS verified there were no documentation family was notified of the change of the attending physician.2. Review of the hospice’s P&P titled Performance Evaluations revised 11/2021, showed all hospice staff will be evaluated at periodic intervals based on their job description:-during the probationary period-at the end of the first three months of employment-annually, based on personnel’s annual evaluation date-after a promotion and/or transfer; and-other occasions, as performance warrants.a. Review of the employee file for RN 1 was initiated on 5/28/26. RN 1 was hired on 3/7/22.However, RN 1’s employee file showed no documented evidence the annual performance evaluations were completed for the years of 2023, 2024, and 2025.b. Review of the employee file for RN 2 was initiated on 5/28/26. RN 2 was hired on 7/25/26.However, RN 2’s employee file showed no documented evidence the performance evaluations were completed during the probationary period and at the end of the first three months of employment.c. Review of the employee file for MSW 1 was initiated on 5/28/26. MSW 1 was hired on 3/25/24, and terminated on 12/19/25.However, MSW 1’s employee file showed no documented evidence the annual performance evaluations were completed for 2025.On 5/28/26 at 1152 hours, an interview and concurrent personnel record was conducted with the ED, DPCS and HR. The ED and HR acknowledged and verified the findings.3. Review of the hospice’s P&P titled Selection/Hiring of Personnel revised 11/2021, showed the organization defines the qualifications and competencies for staff positions based on its mission, population and care, treatment and service goals. Hospice will use a consistent process for the selection of all hospice staff. The procedure includes among others for Selection and Screening that when a current license, certification or registration are required by law to practice a profession, the organization verifies these credentials with the primary source on hire and expiration.Review of the employee file for HA 2 was initiated on 5/28/26. HA 2 was hired on 4/22/25, and resigned on 6/2/25.HA 2’s employee file showed a certification number with expiration date of 6/2025. However, when the HR checked for the certification number, there was no documented evidence of the existence of the certification number. On 5/28/26 at 1152 hours, an interview and concurrent personnel record was conducted with the ED, DPCS and HR. The ED and HR acknowledged and verified the findings.4. Review of the hospice’s Job Title for Hospice Aide under Certification. Licenses, and other special requirements showed the Hospice Aide to meet the training requirements of the State and must be up to date with all requirements for HA license.Review of the employee file for HA 1 was initiated on 5/28/26. HA 1 was hired on 5/17/22.However, HA 1’s employee file showed no documented evidence of the 12-hour training for HA 1 was completed for 2023 and 2024.On 5/28/26 at 1152 hours, an interview and concurrent personnel record was conducted with the ED, DPCS and HR. The ED and HR acknowledged and verified the findings.”

“Based on interview and record review, the hospice failed to ensure the hospice’s staff directly providing care to the patients had their criminal background checked for three of seven personnel files reviewed (RN 1, MSWs 1, and 2). This failure had the potential for not providing the health and safety needs of the hospice patients.Findings: Review of the hospice’s P&P titled Selection/Hiring of Personnel revised 11/2021 showed a criminal background check will be obtained for positions required by law, regulation or organizational policy. If the decision not to hire a candidate is made due to unsatisfactory background check results, the results of the background check will be provided to the candidate to ensure compliance with the Fair Credit Reporting Act.Review of RN 1 and MSW 1’s personnel files were initiated on 5/28/26. However, the personnel files failed to show documented evidence that background checks were obtained for RN 1 and MSW 1.In addition, review of MSW 2’s personnel file was initiated on 5/28/26. The file contained the background check obtained on 6/28/24. However, the background check was for another person with the same last name.On 5/28/26 at 1152 hours, an interview and concurrent personnel record review were conducted with the ED, DPCS, and HR. The HR acknowledged and verified the findings.”

“Based on interview and record review, the hospice failed to ensure the hospice’s staff directly providing care to the patients had their background checked within three months from date of employment for two of seven employees (LVN 3 and HA 1). This failure had the potential for not providing the health and safety needs of the hospice patients.Findings: 1. Review of the employee file for LVN 3 was initiated on 5/28/26. LVN 3 was hired on 4/21/22.The employee file of LVN 3 showed the background checks were obtained on 2/3/23 and 3/25/26, which was more than three months from the date of employment.2. Review of the employee file for HA 1 was initiated on 5/28/26. HA 1 was hired on 5/17/22.The employee file of HA 1 showed the background checks were obtained on 2/3/23 and 7/6/24, which was more than three months from the date of employment.On 5/28/26 at 1152 hours, an interview and concurrent personnel record review was conducted with the ED, DPCS, and HR. The HR acknowledged and verified the findings.”

“Observed in Record Review. In 3 of 3 new admissions completed in the last 30 days, the hospice nurse surveyor observed that care plans were not individualized with goals that were measurable and specific to the care needs of the patient. On RRNHV #1, it was noted that goals were not measurable and specific to the patients care needs. Patient’s episodes of stool incontinence will be effectively managed by caregiver staff according to the policies and procedures of their agency or hospice and Patient will have adequate oral intake and appear well nourished and well hydrated during benefit period. MSW had a goal for DNR/POLST will be completed but the patient was assessed by the nurse to already have a POLST in place. On RRNHV #2, the MSW identified on assessment that the patient had not made funeral arrangements but there was no goals for the MSW developed. On RRNHV #3, MSW goals were not measurable and specific with the goal of Complement added resources and support, MSW provided resources during visit and followed up with additional resources via email.This was reviewed and validated with the Administrator and DCPS.”

“Based on interview and record review, the hospice failed to ensure the comprehensive assessment identified the imminence of death for one of three sampled patients (Patient 2). This failure created the risk of not appropriately addressing the care needs for this patient. Findings: 1. The hospice’s P&P tilted Comprehensive Assessment revised 11/2021 showed a comprehensive patient assessment will be performed by the hospice IDG no later than 5 calendar days after the election of hospice care in consultation with attending physician. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients’ clinical record, including imminence of death.Review of Patient 2’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 5/28/25. The patient was certified for hospice services during the certification periods from 5/28/25 to 8/25/25, 8/26/25 to 11/23/25, 11/24/25 to 1/22/26, and 1/23/26 to 3/23/26. The patient had expired on 2/19/26. The Informed Consent and Treatment Authorization showed the effective date of hospice election was 5/28/25. The Comprehensive Nursing Assessment dated 5/28/25, showed the RN had performed the initial comprehensive assessment. The assessment included a section for imminently dying. However, the initial comprehensive assessments did not identify the imminence of death as the section was left blank. On 3/2726 at 1359 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 2. The hospice’s P &P Titled Ongoing Comprehensive Assessment revised 5/2023 showed during each home visit, the case manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. Ongoing assessment will focus on changes in patient condition and level of deterioration. Review of the SN visit notes dated 11/24, 11/26/12/1, 12/4, 12/8, 12/11, 12/15, 12/18, 12/22, 12/24, and 12/31/25, showed the SN had performed the body system assessment. The assessment included the section for Imminently dying. However, there was no documented evidence the imminently dying was assessed during the home visit as the section was left blank. On 3/2726 at 1359 hours an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for one of three sampled patients (Patients 2). This failure created the risk of not providing appropriate, consistent, and quality care to this patient. Findings: The hospices’ P&P titled Missed Visits revised 11/2021 showed missed visit will be communicated to the interdisciplinary group at the IDG Meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. If a visit was missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. Review of Patient 2’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 5/28/25. Patient 2 was certified for hospice services during the certification periods from 5/28/25 to 8/25/25, 8/26/25 to 11/23/25, 11/24/25 to 1/22/26, and 1/23/26 to 3/23/26. The patient had expired on 2/19/26. The POC/IDG Review dated 12/2/, 12/16, 12/30/25, and 1/13/26, cited SN visit 2W (two times a week) and 3 PRN visits.Review of the closed clinical record showed the SN visit was conducted one time on 1/14/26, instead of two times as week as cited in the POC. On 3/27/26 at 1345 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was asked if this was a missed visit and if the visit was rescheduled. The Administrator Designee replied it should have been rescheduled and documented. The Administrator Designee was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for two of three sampled patients (Patients 2 and 3). This failure had the potential to cause inconsistent delivery of care which could result in the decline or lack of improvement of the patients’ health conditions. Findings: The hospices’ P&P titled The Plan of Care revised 11/2023 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals and interventions.1. Review of Patient 2’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 5/28/25. Patient 2 was certified for hospice services during the certification periods from 5/28/25 to 8/25/25, 8/26/25 to 11/23/25, 11/24/25 to 1/22/26, and 1/23/26 to 3/23/26. The patient had expired on 2/19/26. Review of the Visit Notes RN dated 12/29/25 and 1/5/26, showed RN 2 had performed the body system assessment including skin assessment. RN 2 documented the patient had a Stage 1 pressure injury to the coccyx and wound treatment was provided. In addition, review of the Visit Note LVN dated 12/31/25 and 1/7/26, showed the LVN1 had performed the body system assessment including skin assessment. LVN 1 documented the patient had a Stage 1 pressure injury to the coccyx and wound treatment was provided. However, the POC/IDG Review dated 12/30/25 and 1/13/26, failed to show documented evidence of an individualized care plan developed to address the patient’s Stage 1 pressure injury to the buttocks. On 3/27/26 at 1345 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 2. Review of Patient 3’s clinical record was initiated on 3/26/26. The clinical record showed the SOC was on 1/23/26. Patient 3 was certified for hospice services during the certification period from 1/23/26 to 4/22/26. a. Review of the Visit Note LVN dated 3/21/26 showed the LVN 3 performed the body system assessment. LVN 3 documented in the section of narrative a visit was requested due to UTI symptoms and “The patient reported having burning upon urination the last two days and increased frequency of urination. Patient completed Levaquin 500 mg QD for five days for suspected urinary tract infection. The physician was notified and ordered Macrobid 100mg BID for seven days and Pyridium 100mg TID for seven days.”However, the POC/IDG Review dated 3/25/26, failed to show documented evidencethe IDG had developed an individualized care plan to address the patient’s symptoms of UTI. In addition, there was no documented evidence an individualized care plan was developed to address the patient’s medications for UTI. b. Review of the ALF H&P examination dated 1/21/26, showed the patient’s health summary included a diagnosis of Type 2 diabetes mellitus.Further review of the ALF H&P examination dated 1/21/26, showed the patients medication list including metformin 500 mg tablet one tablet by mouth daily.In addition, review of the Comprehensive Nursing Assessment (HOPE Admission) date 1/23/26, showed the patient was assessed to have diabetes - NIDDM.However, review of the clinical record failed to show documented evidenced of an individualized care plan developed to address the patient’s type 2 diabetes mellitus. On 3/27/26 at 1131 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patient’s POCs no less frequently than every 15 calendar days for three of three sampled patients (Patients 1, 2, and 3). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. Findings: The hospices’ P&P titled Interdisciplinary Group Coordination of Care revised 11/2023 showed the interdisciplinary group (in collaboration with the attending physician, if any) will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of every two (2) weeks.1.Review of Patient 3’s clinical record was initiated on 3/26/26. The clinical record showed the SOC was on 1/23/26. The patient was certified for hospice services during the certification periods from 1/23/26 to 4/22/26. Review of the Visit Note LVN dated 3/21/26, showed LVN 3 performed the body system assessment. LVN 3 documented in the section of narrative that a visit was requested due to UTI symptoms. “The patient reported having burning upon urination the last two days and increased frequency of urination. Patient completed Levaquin 500 mg QD for five days for suspected urinary tract infection. The physician was notified and ordered Macrobid 100mg BID for seven days and Pyridium 100mg TID for seven days.”However, the POC/IDG Review dated 3/25/26, failed to show documented evidence the IDG had discussed/revised the POC to reflect the patient’s symptoms of UTI.In addition, there was no documented evidenced of the IDG had discussed/revised the POC to address the medications ordered for the treatment of UTI. On 3/27/26 at 1131 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was asked if UTI was discussed in the IDG meeting. The Administrator Designee reviewed the clinical record and replied no, it should have been discussed on the 3/25/26 IDG meeting and the medications were not discussed as well. The Administrator Designee was informed and acknowledged the findings. 2. Review of Patient 1’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 1/30/26. The patient was certified for hospice services during the certification period from 1/30/26 to 4/29/26. The patient expired on 2/21/26. The POC/IDG Review dated 2/24/26, showed the patient’s identified care plan problems and goals, including bereavement and spiritual.However, the care plan goals and intervention for bereavement and spiritual were not revised to reflect the patient’s passing on 2/21/26.On 3/27/26 at 1324 hours an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator was asked if the care plan for bereavement and spiritual was revised. The Administrator Designee replied it was not revised. The Administrator Designee was informed and acknowledged the findings. 3. Review of Patient 2’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 5/28/25. The patient was certified for hospice services during the certification periods from 5/28/25 to 8/25/25, 8/26/25 to 11/23/25, 11/24/25 to 1/22/26, and 1/23/26 to 3/23/26. The patient had expired on 2/19/26. The POC/IDG Review dated 2/24/26, showed the patient’s identified care plan problems and goals, including bereavement and spiritual. Howver, the care plan goals and intervention for bereavement and spiritual were not revised to reflect the patient’s passing on 2/19/26.On 3/27/26 at 1359 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the revised POCs included the patient’s progress toward goals specified in the POCs for two of three sampled patients (Patients 1 and 2). This failure had the potential of not identifying the care needs and providing necessary care and services to meet the care needs for these patients.Findings: The hospice’s P&P titled the Plan of Care revised 11/2023 showed each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to evaluate progress towards goal. The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group based on ongoing comprehensive assessments of the patient and family/caregiver. Revision dates will be noted on the plan of care. 1. Review of Patient 1’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 1/30/26. The patient was certified for hospice services during the certification period from 1/30/26 to 4/29/26. The patient expired on 2/21/26. The POC/IDG Review dated 2/24/26, showed the patient’s identified care plan problems and goals. The care plan problems and goals included cardiovascular, environment/safety, gastro-intestinal, genitourinary, imminently dying, infections/immunological, integumentary/skin, mobility, musculoskeletal, neurological/mental, nutrition, pain, psychosocial, respiratory, sleep and spiritual. The status of the identified care plans showed pending.However, the status should have been closed instead of pending as the patient had passed away on 2/21/26.On 3/27/26 at 1324 hours an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was asked to the status of the identified care plan problem and goals. The Administrator Designee reviewed the closed clinical record. The Administrator Designee replied, it should have been closed instead of pending. 2. Review of Patient 2’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 5/28/25. The patient was certified for hospice services during the certification periods from 5/28/25 to 8/25/25, 8/26/25 to 11/23/25, 11/24/25 to 1/22/26, and 1/23/26 to 3/23/26. The patient had expired on 2/19/26. The POC/IDG Review dated 2/24/26, showed the patient’s identified care plan problems and goals for ADL, cardiovascular, endocrine, environment/safety, genitourinary, mobility, musculoskeletal, neurological/mental, nutrition, and pain. The status of the identified care plan problems showed controlled. However, the status should have been closed as the patient passed away on 2/19/26.In addition, the care plan problems and goals for imminently dying, integumentary/skin, psychosocial and sleep. The status of the identified care plans showed pending. However, the status should have been closed as the patient passed away on 2/19/26.On 3/27/26 at 1359 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to maintain a system of communication and integration in accordance with their P&P to ensure the IDG had maintained responsibility for directing, coordinating, and supervising the care and services provided for three of three sampled patients (Patients 1, 2, and 3). This failure had the potential of not addressing the care needs for these patients. Findings: The hospice’s P&P titled Interdisciplinary Group Coordination of Care dated 11/23 showed the hospice will utilize a case management system to guide an interdisciplinary group to provide comprehensive coordinated hospice care to patients and family/caregivers. It will be the responsibility of the Clinical Supervisor/Nursing Supervisor to assign a Case Manager who is a RN. The IDG will maintain the responsibility for the provision of care regardless of the setting where care is provided to its patients. The hospice’s P&P tilted Comprehensive Assessment revised 11/2021 showed a comprehensive patient assessment will be performed by the hospice IDG no later than 5 calendar days after the election of hospice care in consultation with attending physician. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients’ clinical record. Review of current and related past medication including prescription and other medication information whether the medication is unrelated to the terminal illness or related conditions (ensure that there is clinical documentation to support unrelatedness).1. Review of Patient 1’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 1/30/26. The patient was certified for hospice services during the certification period from 1/30/26 to 4/29/26. The patient had expired on 2/21/26. Review of the Current/Treatment/Medication/DME List showed the list of the patients’ medications. The order dated 1/30/26, showed the list of the discontinued medications. The discontinued medications included rivaroxaban, diltiazem, levothyroxine, and digoxin. Review of the Comprehensive Nursing Assessment (HOPE Admission) dated 1/30/26, showed RN 2 had discussed the patients’ status with the physician. The initial order included the medications/DME/Treatment.However, there was no documented evidence RN 2 had discussed with the physician and patient/PCG regarding the reason for the discontinuation of rivaroxaban, diltiazem, levothyroxine, and digoxin as per the hospice’s P&P.On 3/26/26 at 1354 hours, a telephone interview and concurrent closed clinical record review was conducted with RN 2. RN 2 was asked if the medications were discussed with the physicians during admission. RN 2 replied yes, all routine medications were discontinued because the patient was starting to refuse the routine medications prior to hospice. The patient was just placed on the comfort medications. RN 2 was also asked if the discontinued medications were discussed with the patient/PCG. RN 2 could not recall. On 3/27/26 at 0926 hours, a telephone interview was conducted with the VP of Operations/DPCS. The VP of Operations/DPCS was asked if there should be documentation of the discussion related to the discontinued medications. The VP of Operations/DPCS replied it should be in the narrative notes of the initial comprehensive and/or the IDG notes showing the reason why it was discontinued. On 3/27/26 at 1324 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was asked if they needed to discuss the reason for the discontinuation of the routine medications to include rivaroxaban, diltiazem, levothyroxine, and digoxin. The Administrator replied no discussion of the discontinuation of the medications; and in the initial comprehensive assessment, there should be documentation about the medications discontinuation between the patient, family and the physician. The Administrator Designee was informed and acknowledged the findings. 2. Review of Patient 2’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 5/28/25. Patient 2 was certified for hospice services during the certification periods from 5/28/25 to 8/25/25, 8/26/25 to 11/23/25, 11/24/25 to 1/22/26, and 1/23/26 to 3/23/26. The patient had expired on 2/19/26. *Review of the H&P examination showed the patient’s list of medication, including atorvastatin calcium oral tablet 40 mg and aspirin 81 oral tablet chewable. However, review of the closed clinical record failed to show documented evidence the atorvastatin calcium oral tablet 40 mg and aspirin 81 oral tablet chewable were included on the hospice’s Current Treatment/Medication/DME list as per the hospice’s P&P. *Moreover, review of the Comprehensive Nursing Assessment dated 5/28/26, showed RN 3 had discussed the patient’s status with the physician. The initial order included the medications/DME/Treatment.However, there was no documented evidence RN 3 had discussed with the physician and patients/PCG regarding the reason for the medications atorvastatin calcium and aspirin not included in the hospice’s current medication list.On 3/2726 at 1359 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was asked if the above medications were discontinued. The Administrator Designee reviewed the closed clinical record and replied yes, will provide the document. The Administrator Designee was also asked if there was any documentation of the discussion as to the reason for the discontinuation of the above medications. The Administrator Designee replied no. The Administrator Designee was informed and acknowledged the findings. 3. Review of Patient 3’s clinical record was initiated on 3/26/26. The clinical record showed the SOC was on 1/23/26. The patient was certified for hospice services during the certification period from 1/23/26 to 4/22/26. *Review of the ALF H&P examination dated 1/21/26, showed the patient’s health summary included a diagnosis of Type 2 diabetes mellitus.Further review of the ALF H&P examination dated 1/21/26, showed the patient’s medication list included metformin 500 mg one tablet by mouth daily.However, review of the clinical record failed to show documented evidence of the metformin 500 mg included on the hospices’ Current Treatment/Medication/DME list as per the hospice’s P&P. *Moreover, review of the Comprehensive Nursing Assessment (HOPE Admission) dated 1/23/26, showed RN 1 had discussed the patient’s status with the physician. The initial order included the medications/DME/Treatment.However, there was no documented evidence RN 1 had discussed with the physician and patients/PCG regarding the reason for the metformin was not included in the hospice current medication list.On 3/27/26 at 1131 hours an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was asked if metformin was discontinued. The Administrator Designee replied metformin was not included in the order. The Administrator Designee was also asked if there was a discussion for the reason why the metformin was not ordered. The Administrator Designee replied there should be a discussion between the family and physician. The Administrator Designee was informed and acknowledged the findings.”

“Based on interview and record review, the hospice’s Administrator failed to be responsible for the day-to-day operations of the organization and maintain the administrative and supervisory responsibility for all care provided as follows:-The Administrator failed to ensure the DPOA legal document was available in the patient’s closed clinical record (Patient 1).-The Administrator failed to ensure the clinical records were accurate as per the hospice’s P&P (Patients 1, 2, and 3).These failures had the potential to negatively impact on the hospice’s operational performance. Findings: The hospice’s P&P titled Executive Director/Administrator revised 11/2021 showed the Executive Director/Administrator is responsible for the overall direction of the day-to-day operations of the hospice services. He/she is responsible for establishing standards of care to comply with federal and state regulations and guidelines. Ensuring that appropriate service policies and procedures are developed and implemented to accomplished identified outcomes. The hospice’s P&P titled Contents of the Clinical Record revised 11/2021 showed a clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe patient problems/needs, justify care, accurately document care provided and results in detail and facilitate continuity of care among hospice interdisciplinary group members. 1.a. Review of Patient 1’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 1/30/26. Patient 1 was certified for hospice services during the certification period from 1/30/26 to 4/29/26. The patient had expired on 2/21/26. Review of the Hospice Election Statement dated 1/28/26, showed the electronic signature of the patient’s representative. The patient’s representative was documented as son/trustee- POA.However, review of the closed clinical record failed to show documented evidenced of a copy of the Durable Power of Attorney filed in the patient’s clinical record. On 3/27/26 at 0926 hours, a telephone interview was conducted with the VP of Operations/DPCS. The VP of Operations/DPCS was asked if the patient had a DPOA and if the hospice requested for the document. The VP of Operations/DPCS replied, “we have to ask for the paperwork and if the family did not provide the paperwork, they are not the DPOA. We have to document on the system, we cannot just take their words for it.” The VP of Operations/DPCS was also asked as who was responsible to make sure the DPOA documents were available on the clinical record. The VP of Operations/DPCS replied, the admission nurse and the whole team. The VP of Operations/DPCS was further asked if they needed to document the follow-up. The VP of Operations/DPCS replied yes, their attempts should be documented.On 3/27/26 at 1324 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was asked if the DPOA document was available on the clinical record. The Administrator Designee replied there should be a document and the coordination notes for follow up. The Administrator Designee was informed and acknowledged the finding. On 3/27/26 at 1449 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee and Admission Supervisor. The Admission Supervisor was asked if they needed to check the patient’s DPOA document. The Admission Supervisor replied yes, they requested for the POA paperwork, if the document was not available during the intake visit, they would pass along/coordinate with the team member to follow up for the legal document. If the patient’s family member said they were the POA, the hospice would request for the document, could not rely on the verbal statement. They were informed and acknowledged the finding. b. Review of the Visit Note RN dated 2/3/26, showed pain assessment was conducted. The pain assessment included the level of pain reported during this visit, which was documented as “0.” However, the section for narrative note showed the patient was assessed to have a pain level of 4 (on a 0-10 pain scale, 0=no pain and 10=worst pain) to the bilateral knee. Further review of the Visit Note LVN dated 2/12/26, showed the pain assessment was conducted. The pain assessment included the level of pain reported during this visit, which was documented as “0.” However, the section for narrative note showed the patient had a pain level of 7 to the bilateral knee. On 3/27/26 at 1324 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 2. Review of Patient 2’s clinical record was initiated on 3/25/26. The clinical record showed the SOC was 5/28/25. Patient 2 was certified for hospice services during the certification periods from 5/28/25 to 8/25/25, 8/26/25 to 11/23/25, 11/24/25 to 1/22/26, and 1/23/26 to 3/23/26. The patient had expired on 2/19/26. Review of the Visit Notes RN dated 12/29/25 and 1/5/26, showed RN 2 had performed the body system assessment including integumentary/skin. RN 2 documented on the section for wound as none and ulcer/bed sores as mild.However, the section for skin assessment showed the patient had a Stage 1 pressure injury to the coccyx. In addition, review of the Visit Note LVN dated 12/31/25 and 1/7/26, showed LVN1 had performed the body system assessment including integumentary/skin. LVN 1 documented on the sections for wound as none and ulcer/bed sores as mild.However, the section for skin assessment showed the patient had a Stage 1 pressure injury to the coccyx. On 3/27/26 at 1345 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 3. Review of Patient 3’s clinical record was initiated on 3/26/26. The clinical record showed the SOC was on 1/23/26. Patient 3 was certified for hospice services during the certification period from 1/23/26 to 4/22/26. Review of the Visit Note LVN dated 3/21/26, showed LVN 3 had performed the body system assessment including genitourinary/reproductive system. LVN 3 documented in the section for other symptom as “none.”However, the section for narrative note showed a visit was requested due to UTI symptoms and “The patient reported having burning upon urination the last two days and increased frequency of urination.” On 3/27/26 at 1131 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.”

“Observed in Tracer Activities. the hospice surveyor observed that the organization has not developed a continuity of operations plan. This was reviewed with the Administrator. Observed in Tracer Activities. The organization did not have a defined delegation plan in the event of an emergency or disaster. The organization did not have a written delegation of authority plan that provided the individual(s) with the legal authorization to act on behalf of the organization for specified purposes and to carry out specific duties. This was reviewed and validated with the Administrator. Observed in Tracer Activities. The organization did not have a continuity of operations plan and thus there was no written order of succession plan that identifies who is authorized to assume a particular leadership or management role when that person(s) is unable to fulfill their function or perform their duties. This was reviewed and validated with the Administrator. Observed in Tracer Activities. the hospice surveyor observed that the organization did not have a continuity of operations plan. The organization could not state an alternate location for business operations. This was reviewed and validated with the Administrator.”

“Observed in Tracer Visit. The organization did not conduct table top exercises for the last 2 years, and they did not have after action reports. Therefore the organization had not reviewed or updated the plan every 2 years as required and presented it to the Governing Body. This was reviewed and validated with the Administrator. Observed in Tracer Activities. The organization failed to evaluate its emergency management program, emergency operations plan, and continuity of operations plan. The hospice surveyor observed that there were no documented after action reports for the last 2 years. This was reviewed and validated with the Administrator.”

“Observed in Record Review. In 13 of 19 patient records reviewed, the hospice surveyor observed that the initial bereavement assessment not completed. In HOSRRBRV#1 the second POA did not have a completed bereavement assessment. In HOSRRBRV #2 the son did not have a completed assessment, In HOSRRBRV #3 the niece did not have a bereavement assessment completed. In HOSRRDC #1 the son in law did not have a bereavement assessment completed, of note the patient lives with the daughter and son in law. IN HOSRRHV #1 the two daughters did not have a completed bereavement assessment. In HOSRRHV #2 the patient’s daughter who she lives with did not have a bereavement assessment completed. In HOSRRHV #3 one of the sons did not have a bereavement assessment completed. In HOSRRHV #4 both the son and daughter in law who care for the patient had not had a bereavement assessment completed. In HOSRRNHV #6 the niece did not have a bereavement assessment completed. In HOSRRNHV #7 neither the nephew or niece had a bereavement assessment completed. In HOSRRNHV #8 and HOSRRNHV #9 the son and daughter did not have a bereavement assessment completed. In HOSRRNHV #10 the daughter did not have a bereavement assessment completed. Per the organization’s Bereavement Policy 2-010.1 it stated that bereavement services will be proided to the family and caregivers of hospice paitent’s at the time of admission. This was reviewed and validated with the Administrator.”

“Observed in Record Review. In 11 of 19 patient records reviewed, the hospice surveyor observed that the RN, MSW, and Chaplain care plans were not individualized across records. In HOSRRBRV #1 the RN documented a care plan for pain which stated, patient/CG will verbalize understanding of pain medication, dose, frequency, side effects and disposal. The organization’s Pain Assessment Policy 2-032.1 states that the patients’ pain goal will be assessed and addressed in the plan of care. In HOSRRBRV #2 The chaplain care plan stated, Continue to monitor changes in the patient’s condition. It is not clear what changes are being monitored. HOSRRRBRV #3 the patient’s pain goal in the plan of care stated an acceptable level of pain using a verbal score of 0/10 but the assessment stated the goal was 3/10. The MSW care plan stated, MSW to work with patient and caregiver on functional coping skills It is not clear what the functional coping skills that will be addressed. The chaplain care plan stated, Patent expresses hope in and value of her own belief system. It is not clear what specifically in the patient’s belief system is being addressed. In HOSRRDC #2 the MSW goal stated, Patient and family to express feelings and emotions. No clear indication of what the feelings are that they are coping with. This same MSW goal was used in HOSRRHV #4. The chaplain goal stated, Patient expresses hope in and value of her own belief system (Christianity). It is not clear what values or beliefs he is working on. This same chaplain goal was used in HOSRRNHV #6, HOSRRNHV #8 and HOSRRNHV #10.HOSRRHV #1, HOSRRNHV #6 HOSRRDC #2 the nurse used an observational tool to assess pain but, in the care, plan the nurse used a verbal descriptor of 3/10 as a pain goal. Per the Pain Assessment PolicyIn HOSRRHV #3 and HOSRRBRV #2 the MSW care plan goal stated family to exhibit functional coping skills, it is not clear what functional coping skills would be. The chaplain goals stated, RN/Chaplain will work to monitor for changes in the patient needs. It is not clear what needs the patient may have. This was reviewed and validated with the Administrator.”

“Observed in Record Review. In 4 of 19 patient records reviewed, the hospice surveyor observed that the POC was not individualized. In HOSRRBRV #3 the patient was on Eliquis daily and the RN did not include bleeding precautions in the plan of care. This patient was also on oxygen and there was no care plan entered on oxygen safety. This patient also had an order of Oxygen 2-3 liters as needed for comfort, there were no clear instructions on when to use 2 or 3 liters of oxygen. In HOSRRBRV #2 the patient had duplicate orders entered on the same day for oxygen, one order was for Oxygen at 3 liters via nasal canula as needed for comfort and the other order was for Oxygen 5 liters as needed for comfort. IN HOSRRDC #1 the patient was on both ASA 81 mg daily and Plavix 75 mg daily and there was no care plan on bleeding precautions in the plan of care. In HOSRRDC #2 the patient had Seroquel ordered for agitation and this was not added to the plan of care and the patient also had a rash to her right breast and the wound care was not entered in the plan of care. This patient had also been diagnosed with an Extended Spectrum Beta Lactamases (ESBL) and this was not included in the plan of care. This was reviewed and validated with the Administrator.”

“Observed in Record Review. In 9 of 19 patient records reviewed, the hospice surveyor observed that duplicate medications were ordered and the instructions for use were not clear. In HOSRRHV #1 the medications in the home did not reconcile with the medication list for example the Lorazepam 0.5 mg one tablet at bedtime was on the medication list for the organization but it was not in the home, Polyethylene Glycol 3530 17 gm powder states to take with water, there was no specific amount of fluid for it to be mixed with, there were Artificial tears 1% ophthalmic 2 drops twice a day with no documentation on which eye or eyes that they should go into. Nystatin100,000 units topical powder a thin layer on rashes, no specific location of where the rashes are located, MS 20mg/5 ml solution 1.25 ml every 4 hours as needed for severe pain 7/10 or SOB, not in the home. In HOSRRHV #3 the patient had orders for Fentanyl 50 mcg/hr transdermal patch every 72 hours as needed for pain and Lidocaine 4% topical patch once a day for 12 hours for pain, but the orders did not indicate when to take which medication. Also the patient had an order for MS 15 mg immediate release tablet every 2 hours as needed for severe pain and he also had an order for MS 20 mg solution 0.25ml every 4 hours and as needed for severe pain with no indication of when to take which medication.. In HOSRRHV #4 the patient had orders for Lantus 100 units 12 units at bedtime and Lantus 100 units 24 units at bedtime, and another order for Lantus 100 units 12 units at bedtime. It is not clear if the patient is to take one or all of these medications. Additionally, this patient had an order for Humalog 100 Units per sliding scale. There was no sliding scale added to the medication list. In HOSRRNHV #3, HOSRRNHV #7, and HOSRRNHV #9 the patient had orders for Morphine Sulfate 15 mg immediate release tablet every 2 hours as needed for severe pain and Morphine Sulfate 0.25mg every 4 hours as needed for severe pain with no indication of when to take which medication. In HOSRRNHV #8 the patient had orders for Clotrimazole cream to affected area and Lidocaine patch 4% to affected area every 72 hours, no instructed where to apply the cream or patch. Patient was also on Robitussin 100 mg/5ml syrup every 8 hours as needed for cough and Tussin DM 5ml every 4 hours as needed for cough, it is not clear when the patient should take one over the other. In HOSRRBRV #3 the nurse placed a foley catheter with no orders. The surveyor looked at the note when the catheter was changed but there is no documentation of the size of the catheter or the balloon used. In HOSRRHV #4 the RN provided wound care to the left lateral ankle with no wound care orders. The nurse cleansed the wound and applied an antibiotic cream and covered with a dressing. IN HOSRRNHV #1 the patient had a wound to left third toe and R large toe and the RN did not document the wound care provided for three visits in March. The RN documented, see the MAR for wound care orders.This was reviewed and validated with the Administrator.”

“Observed in Tracer Activities. In 4 of 10 HR files reviewed, the hospice surveyor observed that there was no documentation of annual competence assessment per the organization’s Competency Assessment Policy 1-008.1. In HR #2 the medical director’s last competency was done 3 years ago. In HR #3 the alternate medical director last had a competency done 4 years ago. In HR #4 the RN did not have an annual competency done in 2024. In HR #5 the CHHA had two missing competencies from 2023 and 2024. This was reviewed and validated with the Director of HR.”

“Observed in Record Review. In 8 of 19 patient records reviewed, the hospice surveyor observed that the aide care plan did not include all the instruction needed for patient care. In HOSRRBRV #1 and HOSRRNHV #8 the patient was on 2 liters of oxygen via nasal cannula at admission and this was never added as a precaution in the HHA care plan and no instructions on what to do with the oxygen when bathing the patient. In HOSRRBRV #3 the patient was on oxygen and there were no instructions as to what the aide should do with the oxygen when bathing the patient. This patient also had multiple wounds and there were no instructions what she should do with the dressings if they became dislodged during bathing. In HOSRRDC #2 the patient was on oxygen with no instructions as to what the aide could do with the oxygen while bathing the patient. Additionally, this patient had been diagnosed with an ESBL and there were no precautions in the aide assignment as to any protection the aide should take. In HOSRRHV #1 the patient was bedbound and needed to be moved with a hoyer lift, neither the bedbound status nor the need for the Hoyer lift were added to the aide assignment. In HOSRRNHV #5 the patient was on 81 mg ASA daily with no bleeding precautions entered. This patient was also on 5 liters of oxygen continuous and there were no instructions as what the aide should do with the oxygen when bathing the patient. In HOSRRNHV #10 the patient was on Warfarin daily and there was no bleeding precautions and there were no fall precautions entered for the aide. This patient also had a wound to her left foot with a dressing and there were no instructions as to what to do with the dressing when bathing the patient. In HOSRRHV #2 the hospice surveyor observed that the patient had been on service for 7 months and the aide assignment had not been updated. The patient was no longer using diapers, she was on 2 liters of oxygen at bedtime instead of the 3 Liters of continuous oxygen, she was bed to chair at admission and now the patient was up walking with a walker. This was reviewed and validated with the Administrator.”

“Observed in Patient Home. In 3 of 3 home visits conducted, where medication reconciliation was performed the hospice surveyor observed that the medication list was discovered to be inaccurate. In HOSRRHV #1 the medication list in the home indicated Acetaminophen 650 mg suppository 1 every 6 hours as needed for elevated temperature above 100.4. Then prescription label stated for mild pain or fever. In HOSRRHV #2 the medication list in the organization showed Glucose 4 gm chewable tablets and the facility medication technician stated they did not have this for the patient’s low blood sugars. The patient had atorvastatin 40 mg 1 tablet at night daily this was not on the organizations medication list. Lantus Solostar prefilled pen 24 units at bedtime and Humulin N 100 units before each meal was written incorrectly and this was also discontinued over two months ago due to low blood sugars. In HOSRRHV #4 the patient was on Metoprolol Extended Release 25 mg tablet at bedtime, the medication list at the organization had an alert to hold if systolic blood pressure was less than 110, this was not included on the patient’s prescription label. This patient also had an order for MiraLAX 17 gm powder daily there were no instructions on the patient’s home medication list to mix this with 4-8 ounces of fluid. Per the grandson this patient also takes Acetaminophen 325 mg one tablet every 4 hours for pain. This was reviewed and validated with the Administrator.”

“Observed in Patient Home. In 2 of 4 home visits conducted, the hospice surveyor observed that the staff failed to secure and or properly store the portable oxygen tanks. In HOSRRHV #1 the patient had a portable tank in an enclosed closet with items surrounding and covering it. In HOSRRHV #2 the patient’s daughter had 6 portable tanks standing upright in the corner of the dining room china cabinet and 5 of them were not secured in a holder. Neither the RN nor the HHA provided education during the visit to reinforce the safety of securing the tanks. This was reviewed and validated with the Administrator.”

“Based on interview and record review, the hospice failed to ensure hospice interdisciplinary group updated the comprehensive assessments for five of five sampled patients (Patients 1, 2, 3, 4, and 5 ). This failure had the potential of not addressing the care needs of these patients. Review of the hospice’s P&P titled Interdisciplinary Group Coordination of Care revised 11/2021 showed the type and scope of services provided by the interdisciplinary group will be based upon the comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals and interventions. The exact combination of services and the level of care will be unique to each patient and family/caregiver unit and it will change as the needs of the patient and family/caregiver evolve over the course of their involvement with hospice. The interdisciplinary group will maintain responsibility for the provision and coordination of care, regardless of the setting where care is provided to its patients. Geiss Med Hospice LLC personnel will communicate changes in a timely manner via telephone, one to one meetings, interdisciplinary group meetings and hoe visits. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication. Written evidence of care coordination will be found in the plan of care and/or interdisciplinary group meeting forms in the patient’s clinical record, and will involve the hospice patient’s attending physician. 1.Review of Patient 1’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 12/2/25. The patient was certified for hospice services during the certification periods from 12/2/25 to 3/1/26.Review of Patient 1’s Communication Log Notes showed the following:-dated 1/17/26 at 2340 hours showed, Assisted Living Medication Technician Staff called hospice agency to report patient was agitated, requested for a nurse follow up to administer Ativan and hospice LVN staff assigned.-dated 1/18/26 at 1541 hours showed, Assisted Living Staff 2 and Assisted Living Staff 3 called and reported patient just fell and was agitated.-dated 1/18/26 at 2335 hours showed Assisted Living Facility Staff 4 called to report patient had another fall, sustained a skin tear to the right hand, nonemergency lift assist was called to help the patient up and hospice staff assigned.Review of Patient 1’s POC/IDG review dated 1/28/26 failed to show any documentation IDG team members discussed or reviewed Patient 1’s episode of agitation dated 1/17/26, episodes of fall and skin breakdown dated 1/18/26 at 1541 hours and 2335 hours. 2.Review of Patient 2’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 6/16/25. The patient was certified for hospice services during the certification periods from 6/16/26 - 9/13/25, 9/14/25 - 12/12/25 and 12/13/25 - 2/10/25.Review of Patient 2’s Incident/Occurrence Note dated 1/23/26 showed SN PRN after hours tuck in and comfort check visit done to patient tonight for post status fall, sent out to ER via 911 per facility protocols. Review of Patient 2’s POC/IDG Review Notes dated 1/28/26 failed to show IDG members discussed /reviewed Patient2’s episode of fall dated 1/23/26.3. Review of Patient 5’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 8/3/26. The patient was certified for hospice services during the certification periods from 8/23/26 -11/20/25 and 11/21/25 to 2/18/26.Review of Patient 5’s Incident/Occurrence Notes dated 10/17/26 showed PRN post fall visit for 85 year old female with primary diagnosis: unspecified diastolic heart failure. Per family the patient got up from her chair and became weak and fell attempting to take a step to walk by herself.Review of Patient 5’s POC/IDG Review Notes dated 10/21/25 failed to show IDG members discussed/ reviewed Patient 5’s episode of fall dated 10/17/26.On 2/11/26 at 1009 hours, an interview and concurrent document review was conducted with the Clinical Manager. The Clinical Manager was informed of the above findings and verified for any incidents of fall or any change of condition as episodes of agitation, all should have been reviewed or discussed among the IDG members. 4. Review of Patient 3’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 12/17/25. The patient was certified for hospice services during the certification periods from 12/17/25 to 3/16/26.a. Review of Patient 3’s Communication Log Notes showed the following:-dated 1/4/26 at 2100 hours, showed Patient 3 had an unwitnessed fall. He was found lying on his right side next to his hospital bed and did not recall how it happened. Hospice LVN staff was assigned.-dated 1/11/26 at 1140 hours, showed Assisted Living Medication Technician staff called the hospice agency to report that the patient was agitated and requested a nurse. Hospice LVN staff was assigned.b. Review of the Visit Note RN dated 12/18/25, showed the RN had performed a skin assessment. Patient 3 had a left heel pressure ulcer.Review of Physician order dated 12/31/25 showed the following wound care instructions:-Left arm skin tear: Cleanse the wound with wound cleanser or normal saline, then gently pat dry with clean gauze. Apply a Xeroform dressing cut to fit the wound and cover with an island dressing. Change the dressing twice weekly or as needed if soiled. Care to be provided by a skilled nurse.-Stage 2 pressure ulcer on coccyx: Cleanse the coccyx with wound cleanser or normal saline and pat dry with clean gauze. Apply skin barrier cream and cover the wound with a silicone foam dressing. Change the dressing twice weekly by a skilled nurse, or as needed if soiled or dislodged.Review of Patient 3’s POC/IDG review dated 1/13/26 failed to show any documentation that IDG team members discussed or reviewed Patient 3’s episode of agitation dated 1/4/26, the fall episode dated 1/11/26 at 1140 hours, and the new skin impairment dated 12/31/25.5. Review of Patient 4’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 12/26/25. The patient was certified for hospice services during the certification periods from 12/26/2025 To 3/25/2026.-dated 1/18/26 at 1135 hours, showed Assisted living staff called to report the patient was complaining of left abdominal pain, normally constant. The patient had been taking Tylenol as needed and routinely, but was now requesting a visit due to worsening pain. Hospice LVN staff was assigned.Review of Patient 4’s POC/IDG review dated 1/26/26 failed to show any documentation IDG team members discussed or reviewed Patient 4’s episode of left abdominal pain dated 1/18/26. On 2/9/26 at 1600 hours, an interview and concurrent document review was conducted with the Clinical Manager. The Clinical Manager was informed of the above findings and verified for any incidents of fall, agitation, new wound, abdominal pain or any change of condition, all should have been reviewed or discussed among the IDG members. The POC/IDG should be updated the next day, or on the next business day if it falls on a weekend.”

“Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for three of five sampled patients (Patients 1, 3, and 4). This failure had the potential for not providing appropriate, consistent, and quality care to the patients. Review of the hospice’s P&P titled Continuous Care Services revised 11/2021 showed continuous care level of care must be provided a minimum of eight hours to 24 hours a day during short periods in which an individual patient and family caregiver require continuous nursing care to achieve palliation, to manage acute medical symptoms and to maintain the patient in his/her residence. Review of hospice’s P &P titled Monitoring Patient’s Response revised 11/2021 showed Clinicians will monitor document, and report the patient’s response to care and treatment provided in each hospice visit.Review of hospice’s P&P titled Administration and Documentation of Medication revised 11/2021 showed Licensed nursing personnel will administer and document only those medications that have been ordered as a part of the plan of care and have been approved for safe administration and monitoring during hospice visit. As part of the assessment process, a drug history will be taken and a comparison made between the physician’s orders and the current medication the patient is taking. The nurse will document diagnosis, condition, or indication for use of each medication. Non licensed personnel will not administer medications. Review of Patient 1’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 12/2/25. The patient was certified for hospice services during the certification periods from 12/2/25 to 3/1/26.Review of Patient 1’s Physician’s order dated 1/19/26 at 1345 hours, showed to start continuous care for terminal agitation. Another physician’s order dated 1/25/25 at 1516 hours, showed to discontinue continuous care for terminal agitation. Review of Patient 1’s SN visits showed the following:-dated 1/21/26 showed SN visited from 1200 hours - 0100 hours,-dated 1/21/26 showed SN visited from 0230 hours - 0330 hours and -dated 1/21/26 showed SN visit from 1600 hours - 1600 hours, and with comments see uploaded CC (continuous care) paper notes for complete detailed CC narratives. However, there was no evidence of CC paper documentation uploaded and there was no completion on minimum of 8 hours to 24 hours as per hospice’s policy of continuous care level of care. Review of Patient 1’s Physician order showed the following:-dated 1/24/26 at 2215 hours, to start on Morphine Sulfate (for shortness of breath/pain) 0.25 ml prefilled syringe concentrated solution, every 4 hours by mouth and lorazepam (for restlessness/agitation) 1 ml prefilled syringe concentrated solution every 4 hours by mouth and-dated 1/26/26 at 0750 hours, to discontinue Morphine Sulfate (for shortness of breath/pain) 0.25 ml prefilled syringe concentrated solution, every 4 hours by mouth and lorazepam (for restlessness/agitation) 1 ml prefilled syringe concentrated solution every 4 hours by mouth and to start on Morphine Sulfate (for shortness of breath) 0.25 ml prefilled syringe concentrated solution every 8 hours by mouth and lorazepam (for agitation) 1 ml prefilled syringe concentrated every 8 hours by mouth. Review of Patient 1’s SN visit notes dated 1/25/26 at 1500 hours, showed Morphine Sulfate 0.25 ml every 4 hours and lorazepam 1ml every 4 hours was the last dose administered to Patient 1 that followed physician’s routine order for Morphine Sulfate 0.25 ml and lorazepam 1ml every 4 hours. SN visit notes showed a missing medication administration documentation in following physician’s order to administer Morphine Sulfate and lorazepam medication every 4 hours from 1/25/26 1900 hours to 1/26/26 at 0700 hours. On 2/10/26 at 1333 hours, an interview and concurrent clinical review was conducted with the Clinical Manager. The Clinical Manager was asked to review SN visit dated 1/21/26 at 1600 hours and was asked if she could provide the uploaded CC paper notes for complete detailed CC narratives. The Clinical Manager verified that she could not find any uploaded detailed CC narratives and acknowledged if it was not documented, it was considered to be not done. The Clinical Manager also acknowledged the continuous care level of care was not met since there was no documentation. Furthermore, the Clinical Manager was also informed on the missing medication administration on Morphine Sulfate and lorazepam routinely every 4 hours as prescribed by the physician and verified there was no evidence of documentation completing the medication administration of Morphine Sulfate and lorazepam for the above dates. Review of Patient 1’s POC/IDG Review dated 1/14/26 showed the following:-for Neurological/Mental Interventions included SN to assess neurological/cognitive status at each visit. SN to evaluate effectiveness of interventions/ medications and need to modify as needed. SN to provide companionship to patient during visits. SN to teach caregivers regarding medications to address symptoms of agitation.-for Integumentary Skin Interventions included SN to assess for skin breakdown. SN to assess wound. -for Mobility Interventions included SN to assess alteration in mobility and its effect on ADLs need for assistance, potential fall risk and safety needs, SN to assess for safety measures in place. -for Patient Caregiver Interventions included ongoing assessment of patient/family/ patient caregiver needs and concerns for assistance, support and/ or counselling. Triage support, nursing advice to resolve issue. Review of Patient 1’s Communication Log Notes showed the following:-dated 1/16/26 at 2000 hours showed Assisted Living Facility Staff 1 called back to request for an additional visit to give another dose of Ativan and hospice staff assigned for follow up.-dated 1/16/26 at 2336 hours, Assisted Living Facility RNCN requested for afternoon comfort checks Sat/Sun and was assigned to hospice staff. -dated 1/17/26 at 2340 hours showed Assisted Living Facility Medication Technician Staff called to report patient was agitated, requested for a nurse follow up to administer Ativan and hospice staff assigned.-dated 1/18/26 at 1541 hours showed Assisted Living Facility Staff 2 and Assisted Living Facility Staff 3 reported patient just fell and was agitated, requested for SN visit and hospice staff assigned.-dated 1/18/26 at 2335 hours, an Assisted Facility Staff 4 called to report patient had another fall, sustained skin tear to the right hand, nonemergency lift assist was called to help the patient up and hospice staff was assigned. Review of Patient 1’s SN Visit Notes failed to show any SN assessments and SN visits indicated for requests for medication administration, follow up visit, weekend comfort checks, incidents of fall, episodes of agitation and incident of skin breakdown. There were no evidence of SN visits documentation for the above communicated requests from the Assisted Living Facility Staff. On 2/9/26 at 1600 hours, an interview and concurrent clinical record review was conducted with the clinical manager. The Clinical Manager was informed of the above findings, acknowledged the submission of documentation was over past due and verified if there was no documentation, it never happened. On 2/11/26 at 0941 hours, an interview was conducted with LVN3 who was scheduled and assigned for Patient 1 on the requested visits. LVN3 was asked if she was really scheduled to see Patient 1 on 1/16, 1/17 and 1/18/26 . LVN 3 stated she saw Patient 1 on 1/16, 1/17 and 1/18/26. LVN 3 further added she saw Patient 1 dated 1/24 and 1/25/26. LVN 3 was informed of no evidence of documentation regarding her SN visits scheduled for Patient 1 and her documentation submission was overdue. LVN 3 verified all the SN visits documentation were overdue. Review of the hospice’s P&P titled The Plan of Care revised 11/2021 showed care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes. Care provided to the patient will be in accordance with the plan of care.2.Review of Patient 3’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 12/17/25. The patient was certified for hospice services during the certification periods from 12/17/2025 To 03/16/2026.Review of the Visit Note RN dated 12/18/25, showed RN 4 performed a skin assessment. However, RN 4 failed to assess the wound depth on the patient’s left heel. Review of the Comprehensive Nursing Assessment dated 12/23/25 showed RN 4 performed a skin assessment. However, RN 4 failed to measure the wound depth on the patient’s left heel.The POC/IDG Review dated 12/30/25, showed a care plan addressing the patient’s altered skin integrity related wound left heel pressure ulcer. Documentation showed the intervention included SN to assess wound and assigning the Registered Nurse (RN) to measure the wound every seven days.Review of Physician order dated 12/31/25 showed the following wound care instructions:-Left arm skin tear – Cleanse the wound with wound cleanser or normal saline, then gently pat dry with clean gauze. Apply a Xeroform dressing cut to fit the wound and cover with an island dressing. Change the dressing twice weekly or as needed if soiled. Care to be provided by a skilled nurse.-Stage 2 pressure ulcer on coccyx – Cleanse the coccyx with wound cleanser or normal saline and pat dry with clean gauze. Apply skin barrier cream and cover the wound with a silicone foam dressing. Change the dressing twice weekly by a skilled nurse, or as needed if soiled or dislodged.Review of the Visit Note LVN dated 12/30, and 1/7/26, showed LVN 4 performed a skin assessment. However, LVN 4 failed to assess the patient’s wound on the left heel, as well as the new wounds on the left arm (skin tear) and coccyx.Review of the Nursing Updated Assessment dated 1/5/26 showed RN 4 performed a skin assessment. However, RN 4 failed to measure the patient’s wound depth on the left heel as well as the new wound on left arm skin tear and coccyx.On 2/9/26 at 1600 hours, an interview and concurrent closed clinical review was conducted with the Clinical manager. The Clinical Manager stated that wound measurements should have been completed every seven days and should have included documentation of the depth of the left heel wound, as well as any new wounds. The clinical manager verified and acknowledged the findings.3. Review of Patient 4’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 12/26/25. The patient was certified for hospice services during the certification periods from 12/26/2025 To 03/25/2026.The POC/IDG Review dated 1/12/26, showed a care plan addressing stage 1 pressure ulcer. Documentation showed the intervention included SN to assess wound and assigning the Registered Nurse (RN) to measure the wound every seven days.Review of Nursing Updated Assessment dated 1/13/26 showed RN performed a skin assessment. However, RN failed to measure the patient’s wound for coccyx stage 1 pressure ulcer.On 2/9/26 at 1600 hours, an interview and concurrent clinical review was conducted with the Clinical manager. The Clinical Manager stated that wound measurements should have been completed every seven days. The RN should have measured the wound and documented any changes in wound size. The Clinical Manager verified and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for three of five sampled patients (Patients 1, 2, and 5). This failure had the potential to cause inconsistent delivery of care which could result in the decline or lack of improvement of the patients’ health conditions. Findings: Review of the hospice’s P&P titled The Plan of Care revised 11/2021, showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs. 1. Review of Patient 1’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 12/2/25. The patient was certified for hospice services during the certification period from 12/2/25 to 3/1/26. a. Review of Patient 1’s Communication Notes showed the following:- dated 1/17/26 at 2340 hours, the Assisted Living Medication Technician Staff called to report the patient was agitated, requested for a nurse follow up to administer Ativan (antianxiety medication). A hospice staff member was assigned- dated 1/18/26 at 1541 hours, the Assisted Living Facility Staff 2 and Assisted Living Facility Staff 3 informed the patient just fell and was agitated, request for an SN visit. A hospice staff member was assigned- dated 1/18/26 at 2335 hours, the Assisted Living Facility Staff 4 called to report the patient had another fall, sustained a skin tear to the right hand and nonemergency lift assist was called to help the patient up. However, Patient 1’s POC/ IDG Review Notes dated 1/28/26 failed to show documented evidence a plan of care was developed to address episodes of agitation, incidents of fall and the skin breakdown. b. Review of Patient 1’s Physician’s Order dated 12/3/25, showed patient’s medication included alprazolam (antianxiety) 0.5 mg one tablet every eight hours as needed. However, Patient 1’s POC/ IDG Review Notes dated 12/17/26, failed to show documented evidence a plan of care was developed to address the episodes of agitation. 2. Review of Patient 2’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 6/16/25. The patient was certified for hospice services during the certification periods from 6/16/25 to 9/13/25, 9/14/25 to 12/12/25 and 12/13/25 to 2/10/26. Review of Patient 2’s Incident/Occurrence Note dated 1/23/26, showed an SN PRN after hours tuck-in and comfort check visit was completed after the fall and the patient was sent out to acute care hospital ED via 911 as per the facility’s protocols. Review of Patient 2’s POC/IDG Review Notes dated 1/28/26, failed to show documented evidence a plan of care was developed to address Patient 2’s incident of fall. 3. Review of Patient 5’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 8/3/25. The patient was certified for hospice services during the certification periods from 8/23/25 to 11/20/25 and 11/21/25 to 2/18/26. Review of Patient 5’s Incident/Occurrence Notes dated 10/17/26, showed a PRN post fall visit was completed for Patient 5. Documentation showed according to the family, the patient got up from her chair, became weak, and fell when attempting to take a step to walk by herself. Review of Patient 5’s POC/IDG Review Notes dated 10/21/25, failed to show documented evidence a plan of care was developed to address Patient 5’s incident of fall. On 2/11/26 at 1009 hours, an interview and concurrent clinical review was conducted with the Clinical Manager. The Clinical Manager was informed and verified the above findings.”

“Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patient’s POCs no less frequently than every 15 calendar days for one of five sampled patients (Patient 3). This failure had the potential for not providing the appropriate, consistent, and quality care to the patient. Findings: Review of the hospice’s P&P titled Plan of Care dated 11/2021 showed the plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver. Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care. Any change in the patient’s condition must result in a change in the plan of care, prior to implementation of the new service. Review of Patient 3’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 12/17/25. The patient was certified for hospice services during the certification period from 12/17/2025 To 03/16/2026. a. Review of the Physician order dated 12/31/25 showed the following wound care instructions:- left arm skin tear, to cleanse the wound with wound cleanser or normal saline, gently pat dry with clean gauze, apply a Xeroform dressing (a sterile, non- adherent, petrolatum-impregnated gauze) cut to fit the wound, and cover with an island dressing. Change the dressing twice weekly or as needed if soiled and care to be provided by a skilled nurse- Stage 2 pressure ulcer on coccyx, to cleanse the coccyx with wound cleanser or normal saline and pat dry with clean gauze, apply skin barrier cream and cover the wound with a silicone foam dressing. Change the dressing twice weekly by a skilled nurse, or as needed if soiled or dislodged. The POC/IDG Review dated 12/30/25, showed the patient’s identified care plan problem included altered skin integrity related to the wound left heel pressure ulcer. The identified problems were opened on 12/17/25, and the target date was 3/16/26. However, there was no documented evidence the identified care plan problems were updated to provide the appropriate care for the patient’s new skin tear on the left arm and stage 2 coccyx pressure ulcer. b. Review of Incident dated 1/4/26, showed Patient 3 reported he fell out of bed and was seen for post fall follow up. The POC/IDG Review dated 12/30/25 and 1/13/26, showed the patient’s identified care plan problem included increased risk for falls/injury related to cognitive deficits/confusion, unsteady gait, and history of falls. The identified problem was opened on 12/17/25 and the target date was 3/16/26. However, there was no documented evidence the identified care plan problem for the increased risk for falls/injury was updated to provide the appropriate care for the patient status post fall. c. Review of Communication log dated 1/11/26, showed Patient 3 was agitated in the morning and LVN 3 conducted a visit. The POC/IDG Review dated 12/30/26 and 1/13/26, showed the patient’s identified care plan problem included confusion. The identified problem was opened on 12/17/25 and target date was 3/16/26. However, there was no documented evidence that the identified care plan problems was updated to address the patient’s status, specifically the episode of agitation on 1/11/26. On 2/9/26 at 1600 hours, an interview and concurrent clinical record review was conducted with the Clinical Manager. The Clinical Manager verified and acknowledged the above findings.”

“Based on interview and record review, the hospice’s GB and Administrator failed to assume responsibility for the day-to-day operations of the organization and maintain administrative oversight, as evidenced by: * Failure to develop a P&P addressing wound care. * Failure to ensure the maintenance of the QAPI program. These failures had the potential for poor health outcomes for the patients who received hospice services. Findings: Review of the hospice’s P&P titled Improving Organizational Performance dated 11/2021 showed the organization shall develop, implement and evaluate performance improvement projects. All personnel will be active participants in hospice’s QAPI activities. The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, maintained and evaluated annually. The Governing Body will review the QAPI plan and update it to reflect any changes in strategic priorities and in response to any changes in the internal or external environment. 1. On 2/9/26 at 1600 hours, an interview was conducted with the Clinical Manager. The Clinical Manager stated the hospice did not have a P&P addressing wound care. The Clinical Manager verified and acknowledged the above finding. 2. On 2/10/26 at 1500 hours, an interview was conducted with the Vice President for Clinical Regional Consulting. The Vice President was asked about the last QAPI meeting. The Vice President stated the three staff members who were in charge of QAPI had left the hospice last month. The QAPI meeting should have been conducted in January but it never occurred and acknowledged the above finding.”