California Hospice Services, Inc.

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (condition that healthcare organizations must meet in order to begin and continue participating in Medicare [a Federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint Federal and State program that helps cover medical costs for some people with limited income and resources] programs) for Initial and Comprehensive Assessment of the Patient was met as follows: The HA failed to ensure medications at the bedside were current and maintain an accurate medication profile for two of 14 sampled patients (Patient 15 and Patient 17). This deficient practice had the potential to place patients at risk for medication errors and adverse drug reactions. (Refer to L530) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulation for Initial and Comprehensive Assessment of the Patient to provide the identified hospice care and services to all certified patients receiving the benefits.”

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), Care Planning, and Coordination of Services was met as follows: The HA’s IDG failed to review and revise the plan of care related to discontinued medications and a newly prescribed medication and the necessary monitoring for one of fourteen sampled patients (Patient 17). This failure had the potential to result in an increased risk of medication error and inadequate monitoring of the patient’s current anticoagulant therapy. (Refer to L552). The HA failed to ensure that IDG members maintain responsibility for directing, coordinating, and supervising the care and services provided for three of fourteen sampled patients (Patient 1, Patient 5, and Patient 16). This failure had the potential to result in Patient 1, Patient 5, and Patient 16 not having their spiritual needs met. (Refer to L554). The HA failed to ensure that one of fourteen sampled patients (Patient 17) received the Hospice Aide services in accordance with the plan of care. This failure had the potential to result in the patient’s needs not being met, which can lead to psychosocial consequences like diminished dignity. (Refer to L555). The HA failed to ensure there was documentation indicating the physician was made aware of the missed hospice aide (a certified caregiver who provides personal care to a terminally ill patient) visit for one of fourteen sampled patients (Patient 17). This failure had the potential to result in a lack of coordination of care for the patient. (Refer to L557). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with the Federal Regulations for IDG, Care Planning, and Coordination of Services to ensure provision of quality care and services to patients.”

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Organization and Administration of Services was met as follows: The HA failed to ensure that a qualified administrator designee assumed the responsibility of the day-to-day operation including complying with all legal and regulatory requirements for three of fourteen sampled patients (Patient 10, Patient 15, and Patient 17) when the administrator is not available. This failure has the potential risk for the hospice agency being manage by an unqualified administrator designee that could impact the well-being of these certified hospice patients. (Refer to L651). The HA failed to provide documented evidence the skilled nurses completed the Wound Care Competency Verification before providing wound care treatment for one of 14 patients (Patient 10). This failure had the potential to result in the staff’s lack of knowledge to accurately assess the wound leading to the delay of treatment, further skin injury causing pain and discomfort to the terminally ill patient. (Refer to L663). The cumulative effect of these systemic practices resulted in the failure of the Hospice Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Organization and Administration of Services.”

“Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure medications at the bedside were current and maintained an accurate medication profile for two of 14 sampled patients (Patient 15 and Patient 17). This deficient practice had the potential to place patients at risk for medication errors and adverse drug reactions. a. During a review of Patient 15’s “Hospice Plan of Care,” (POC, an individualized, legally mandated document that outlines the comprehensive medical, physical, emotional, and spiritual services to address for a terminally ill patient and their family), for the certification period from 5/10/2026 to 7/8/2026, indicated Patient 15’s start of care date was 7/14/2025, with a terminal diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities). The POC indicated the frequency of visits for the skilled nurse (SN) included one visit every week and 3 visits as needed for 12 weeks. During a joint home visit, on 6/24/2026, at 1:32 p.m., at Patient 15’s residence, with Registered Nurse (RN) 2, Patient 15 was observed lying in bed and was accompanied by a caregiver (CG 3). During a review of Patient 15’s current medications on 6/24/2026 at 1:57 p.m., with RN 2, there was a bottle of acetaminophen /codeine phosphate (a prescription combination medication used to manage mild-to-moderate pain) 300 milligrams (mg, a unit of measurement) with an expiration date of 3/23/2026 available in Patient 15’s residence. CG 3 stated Patient 15 currently takes one acetaminophen/codeine tablet to treat chronic pain every morning. During an interview on 6/24/2026 at 2:07 p.m., with RN 2, stated the acetaminophen/codeine tablets were expired. RN 2 stated he would contact the agency office to request a new refill. During an interview on 6/25/2026 at 10:44 a.m., with the Administrator Designee (ADMD), stated medication reconciliation should be completed every visit. The ADMD stated completing medication reconciliation at each visit is important to ensure medications are not expired and potential medication interactions are identified. The ADMD stated patients should not take expired medications because the medications could be less effective. During an interview on 6/25/2026 at 11:29 a.m., with the Intake Coordinator (IC), stated the HA did not have a policy or procedure for expired medication. b. During a review of Patient 17’s medical record titled, Patient Information, it indicated the patient had a start of care of 6/9/2026 with a diagnosis of chronic systolic congestive heart failure (CHF, a condition when the heart muscle is too weak and does not pump blood to the body efficiently) and a history of pulmonary embolism (a blood blockage in a blood vessel of the lungs restricting blood flow). During a review of Patient 17’s medical record titled, Current Treatment/Medication/DME (durable medical equipment) List, provided by the agency, it did not indicate the patient was taking the medication Jardiance (medication used to help the heart pump blood more efficiently in CHF). During a review of Patient 17’s medical record titled, Current Treatment/Medication/DME List, provided by the assisted living, it indicated the patient was taking the medication Jardiance 10 milligrams (mg, a unit of measure) tablet daily for diabetes (elevated blood sugar level). During a concurrent interview and record review on 6/25/2026 at 9: 45 a.m., with the Administrator Designee (ADMD), Patient 17’s Current Treatment/Medication/DME List was reviewed. The ADMD stated the patient was no longer taking Jardiance and was discontinued on 6/16/2026. ADMD stated Patient 17’s medication list did not indicate a stop date for Jardiance. The ADMD stated a nurse visit was done on 6/18/2026 and the nurses conduct a medication reconciliation every visit as part of the nurse’s procedure. ADMD stated the facility should have an updated medication list and that it was important for the facility to have it to avoid medication errors. ADMD stated it was important to have communication between the hospice and the facility. During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile”, revised 4/2017, the P&P indicated “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.””

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the plan of care (POC, a personalized, written document that outlines a patient’s health needs, specific treatment goals, and medical and supportive services required to achieve them) was updated to accurately reflect the current medication regimen after Eliquis (a medication used to thin the blood and to help prevent blood blockages) and Jardiance (medication used to help the heart pump blood more efficiently in CHF) were discontinued and Coumadin (medication used to thin the blood) was initiated for one of fourteen sampled patients (Patient 17). This failure had the potential to result in an increased risk of medication error and inadequate monitoring of the patient’s current anticoagulant therapy. During a review of Patient 17’s medical record titled, Patient Information, it indicated the patient had a start of care of 6/9/2026 with a diagnosis of chronic systolic congestive heart failure (CHF, a condition when the heart muscle is too weak and does not pump blood to the body efficiently) and a history of pulmonary embolism (a blood blockage in a blood vessel of the lungs restricting blood flow). During a review of Patient 17’s medical record titled, Medication and DME orders, dated 6/9/2026 to 6/30/2026, it indicated Eliquis was discontinued on 6/10/2026 and Jardiance was discontinued on 6/16/2026. During a review of Patient 17’s medical record titled, Medication and DME orders, dated 6/9/2026 to 6/30/2026, it indicated Coumadin had an order date and start date of 6/10/2026. During a review of Patient 17’s medical record titled, Plan of Care, dated 6/23/2026, it indicated “Reinforce administration and compliance with prescribed cardiac medications including…Apixaban (Eliquis)…and Jardiance as ordered for symptom management and comfort”. During a review of Patient 17’s medical record titled, Plan of Care, dated 6/23/2026, it did not indicate an issue, goal or intervention for Coumadin. During an interview on 6/24/2026 at 3:50 p.m. with Registered Nurse 2 (RN 2), RN 2 stated the POC should be updated with the medications that are discontinued and with the Coumadin medication so that it reflects what the patient is taking. During a concurrent interview and record review on 6/25/2026 at 10:12 a.m. with the Administrator Designee (ADMD), Patient 17’s POC was reviewed. ADMD stated the POC was used for all the disciplines to refer to, address the patient’s problems and needs, and so they know how to take care of the patient. The ADMD stated the POC is used so that all disciplines are on the same page. The ADMD stated the POC included mobility, diagnosis for the patient’s cardiac output, safety issues, and bleeding risks. The ADMD stated Patient 17 was taking Eliquis when the patient was admitted to hospice and was no longer taking Eliquis because it was discontinued on 6/10/2026. ADMD stated the medication Jardiance was discontinued on 6/16/2026 and the POC should have been updated on the day the medication was discontinued. ADMD stated the POC is reviewed during their interdisciplinary group (a core team of professionals who work together to manage the physical, emotional and spiritual needs of a patient) meetings every 2 weeks or as needed and the case manager was responsible for updating the POC. ADMD stated it was important for the POC to be updated so the agency knows the patient is no longer taking Eliquis and Jardiance. During a concurrent interview and record review on 6/25/2026 at 10:20 a.m., with the ADMD, Patient 17’s POC was reviewed. The ADMD stated the patient was started on Coumadin on 6/10/2026 and the POC should have been updated to reflect the patient was taking Coumadin. The ADMD stated that with Coumadin, lab work such as prothrombin time (PT, a lab test that measures in seconds the time it takes for the blood to form a clot) and international normalized ratio (INR, a calculation that ensures clotting results are accurate) is being monitored and it helps check the risk for bleeding and it is not indicated on the POC. The ADMD stated not updating the POC can affect the patient because the POC is a tool that is used for communication between the agency staff and the facility staff and symptoms observed such as abnormal bleeding needs to be reported. During a review of the facility’s policy and procedure (P&P) titled, “ The Plan of Care”, revised 4/2017, the P&P indicated “The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process…This plan will focus on identified problems, goals and interventions…The written plan of care will contain, but not limited to, the following: Drugs and treatments (including allergies).””

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure that IDG members (team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) maintain responsibility for directing, coordinating, and supervising the care and services provided for three of fourteen sampled patients (Patient 1, Patient 5, and Patient 16). This failure had the potential to result in Patient 1, Patient 5, and Patient 16 not having their spiritual needs met. a. During a review of Patient 1’s Personal Information, the Personal Information indicated that Patient 1 was admitted to the HA on 2/15/2026 with a primary diagnosis of senile degeneration of the brain (age-related cognitive decline that leads to dementia [a decline in mental abilities severe enough to interfere with daily life]). Patient 1 was discharged from the HA on 6/10/2026 due to extended prognosis (the disease has stabilized, allowing the patient to outlive the initial 6-month life expectancy). During a review of Patient 1’s POC/IDG Review, dated 6/9/2026, the POC/IDG Review indicated that there was no spiritual intervention needed at this time. The Chaplain’s signature column at the end of the POC/IDG Review was blank. During a concurrent interview and record review with the Director of Patient Care Services/Administrator Designee (ADMD) on 6/25/2026 at 1:16 p.m., the DPCS/AD reviewed the POC/IDG Review, dated 6/9/2026, for Patient 1 and the HA’s IDG binder. The ADMD stated that the Chaplain did not sign Patient 1’s POC/IDG Review, dated 6/9/2026. The DPCS/AD stated the IDG meetings took place every 2 weeks. The ADMD stated, “For June 2026, there were 2 IDG meetings: 6/9/2026 and 6/23/2026. The IDG members who attended the meeting needed to sign the POC/IDG Review, which meant that they reviewed their portion in the updated POC. They also needed to sign the sign-in sheet as a proof of their attendance.” The ADMD stated the Chaplain always attended the IDG meetings, but he did not sign. When the ADMD was asked for evidence of attendance, The DPCS/AD stated that there was no sign-in sheet filed for June 2026. The DPCS/AD stated, “We’re not consistent with the patient report.” The ADMD stated that she had no idea how to print the sign-in sheet. The ADMD stated that she did not know who was responsible for filing the sign-in sheet in the IDG binder. b. During a review of Patient 5’s “Personal Information,” the Personal Information indicated Patient 5 was admitted to the HA on 5/1/2026 with a primary diagnosis of malignant neoplasm of the brain (a cancerous brain tumor). Patient 5 was discharged from the HA on 5/21/2026 due to death. During a review of Patient 5’s “Plan of Care (POC)/IDG Review,” dated 5/26/2026, the POC/IDG Review indicated there was no spiritual intervention needed at this time. The Chaplain’s signature column at the end of the POC/IDG Review was blank. During a concurrent interview and record review on 6/25/2026 at 1:16 p.m. with the Administrator Designee (ADMD), Patient 5’s “POC/IDG Review,” dated 5/26/2026 and the HA’s IDG Binder were reviewed. The ADMD stated the Chaplain did not sign Patient 5’s POC/IDG Review, dated 6/25/2026. The ADMD stated if a member did not sign the POC/IDG Review, it indicates they did not review the POC. The ADMD also stated members that attend IDG Meetings are expected to sign the sign in sheet in the IDG Binder as proof of their attendance. The ADMD stated the IDG Binder did not have a completed sign-in sheet for 5/26/2026. The ADMD stated she (ADMD) did not know who was responsible for filing the sign-in sheet in the IDG Binder. c. During a review of Patient 16’s “Personal Information,” the Personal Information indicated Patient 16 was admitted to the HA on 5/26/2026 with a primary diagnosis of intrahepatic bile duct carcinoma (caner that originates in the small bile duct branches inside the liver). Patient 16 was discharged from the HA on 5/30/2026 due to death. During a review of Patient 16’s “POC/IDG Review,” dated 5/26/2026, the POC/IDG Review indicated the Chaplain would schedule his (Chaplain) initial visit for spiritual assessment and support. The Chaplain’s signature column at the end of the POC/IDG Review was blank. During a review of Patient 16’s “POC/IDG Review,” dated 6/9/2026, the POC/IDG Review indicated bereavement follow-up services would be provided to the family for a minimum of 13 months following Patient 16’s death. The Chaplain’s signature column at the end of the POC/IDG Review was blank. During a concurrent interview and record review on 6/25/2026 at 1:16 p.m. with the ADMD, Patient 16’s “POC/IDG Review,” dated 5/26/2026 and 6/9/2026 were reviewed. The ADMD stated the Chaplain did not sign Patient 16’s POC/IDG Review dated 5/26/2026 or the POC/IDG Review dated 6/9/2026. ADMD stated if a member did not sign the POC/IDG Review, it indicates they did not review the POC. The ADMD stated POCs should be reviewed by IDG members to ensure all patients’ needs are being met. During a concurrent interview and record review on 6/25/2026 at 1:20 p.m. with the ADMD, the IDG Binder Sign-In Sheets dated 5/26/2026 and 6/9/2026 were reviewed. The ADMD stated the IDG Binder did not have a completed sign-in sheet for 5/26/2026 or 6/9/2026. The ADMD stated members that attend IDG Meetings are expected to sign the sign in sheet in the IDG Binder as proof of their attendance. The ADMD stated she (ADMD) did not know who was responsible for filing the sign-in sheet in the IDG Binder. During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Group Meeting” revised 4/2017, the P & P indicated that: Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor.””

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the hospice aide (a certified caregiver who provides personal care to a terminally ill patient) visited the patient twice a week as ordered for one of fourteen sampled patients (Patient 17). This failure had the potential to result in the patient’s needs not being met, which can lead to psychosocial consequences including diminished dignity. During a review of Patient 17’s medical record titled, Patient Information, it indicated the patient had a start of care of 6/9/2026 with a diagnosis of chronic systolic congestive heart failure (CHF, a condition when the heart muscle is too weak and does not pump blood to the body efficiently) and a history of pulmonary embolism (a blood blockage in a blood vessel of the lungs restricting blood flow). During a review of Patient 17’s medical record titled, “Physician Order”, it indicated a Hospice Aide would visit the patient twice weekly for activities of daily living (ADL’s, basic, routine self-care tasks performed every day). During a review of Patient 17’s medical record titled, Plan of Care (POC, a personalized, written document that outlines a patient’s health needs, specific treatment goals, and medical and supportive services required to achieve them) dated, 6/23/2026, it indicated a frequency of visit for the hospice aide was 2 per week. During a concurrent interview and record review on 6/25/2026 at 9:45 a.m., with Administrator Designee (ADMD), Patient 17’s medical chart was reviewed. The ADMD stated the patient received hospice aide services twice a week as indicated in the orders. The ADMD stated the hospice aide’s duties included bathing, bed linen change, and report to the agency if any skin problems are noted or if the patient has complaints. The ADMD stated the last visit was done on 6/17/2026 and the hospice aide had only seen the patient once that week. The ADMD stated a missed visit from the hospice aide can affect the patient regarding hygiene and it would affect the patients psychosocial needs. The ADMD stated it was important for the hospice aide to keep up with the visits, so the patient remains clean and can associate with her friends at the facility, keep Patient 17’s self-dignity, and any skin problems that arise could be addressed. During an interview on 6/25/2026 at 11:45 a.m., with the ADMD, the ADMD stated the aide was supposed to notify the front desk at the office if the visit to the patient cannot be done and the front desk would then notify administrator, the director of patient care services, the case manager, the licensed vocational nurse, social worker, pastor and the physician. The ADMD stated there was no documentation addressing the missed visit. During a review of the facility’s policy and procedure (P&P) titled, “Missed Visits”, revised 4/2017, the P&P indicated “If a visit is 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.””

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure there was a documented evidence the physician was made aware of the missed hospice aide (a certified caregiver who provides personal care to a terminally ill patient) visit for one of fourteen sampled patients (Patient 17). This failure had the potential to result in a lack of coordination of care for the patient. During a review of Patient 17’s medical record titled, Patient Information, it indicated the patient had a start of care of 6/9/2026 with a diagnosis of chronic systolic congestive heart failure (CHF, a condition when the heart muscle is too weak and does not pump blood to the body efficiently) and a history of pulmonary embolism (a blood blockage in a blood vessel of the lungs restricting blood flow). During a review of Patient 17’s medical record titled, Plan of Care (POC, a personalized, written document that outlines a patient’s health needs, specific treatment goals, and medical and supportive services required to achieve them) dated, 6/23/2026, it indicated a frequency of visit for the hospice aide was 2 times per week. During a concurrent interview and record review on 6/25/2026 at 9:45 a.m., with the Administrator Designee (ADMD), Patient 17’s medical record was reviewed. Patient 17’s, “Physician Order”, indicated a hospice aide would visit the patient twice weekly for activities of daily living (ADL’s, basic, routine self-care tasks performed every day). The ADMD stated the patient received hospice aide services twice a week as indicated in the orders. The ADMD stated the last visit was made on 6/17/2026 and the hospice aide had only seen the patient once during the week of 6/14/2026 to 6/20/2026. The ADMD stated the physician would be notified of a missed visit but there was no documentation that indicated the physician was made aware. The ADMD stated it was important for the physician to be made aware to continue the coordination of care. During a review of the facility’s policy and procedure (P&P) titled, “Monitoring Patient’s Response/Reporting to Physician”, revised 4/2017, the P&P indicated the following: “The patient’s physician and/or the hospice Medical Director will be contacted on the same day when any of the following occurs: H. There is any problem implementing the plan of care.” The P&P indicated “All conferences or attempts to communicate with the attending physician and/or hospice Medical Director will be documented in the clinical record. Documentation of physician notification will include: Date and time contacted Patient name Name of physician notified or his/her representative Reason for notification Physician’s response Action taken or orders obtained.””

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure that a Registered Nurse (RN) conducted annual evaluation to assess the competency of the Hospice Aides for one of fourteen sampled patients (Patient 17). This failure had the potential to result in patient receiving services from incompetent (lacks abilities and skills) Hospice Aides, which may lead to patient injuries and substandard care. During a review of Patient 17’s Patient Information, indicated that Patient 17 had a start of care of 6/9/2026 with a diagnoses that included chronic systolic congestive heart failure (CHF, a condition when the heart muscle is too weak and does not pump blood to the body efficiently) and a history of pulmonary embolism (a blood blockage in a blood vessel of the lungs restricting blood flow).During a review of Patient 17’s medical record titled, Plan of Care (POC, a personalized, written document that outlines a patient’s health needs, specific treatment goals, and medical and supportive services required to achieve them) dated, 6/23/2026, it indicated a frequency of visit for the hospice aide was 2 per week.During a review of Hospice Aide 1’s (AIDE 1) employee file, the employee file indicated that AIDE 1 was hired on 5/19/2021.During a review of a form, titled CHHA (Certified Home Health Aide) Annual Competency, dated 5/10/2024, the form listed AIDE 1’s name along with AIDE 1’s date of hire. The form displayed the following information: Competency for the Medical Social Worker/Social Work Associate. The form displayed number “4” under the “Yes” column for the skills listed. There was no information on the form on what number “4” meant. The form had a signature on the employee signature line and a signature on the preceptor signature line. There was no information on who the preceptor was.During a review of a form, titled CHHA Annual Competency, dated 5/01/2025, the form listed AIDE 1’s name along with AIDE 1’s date of hire. The form displayed the following information: Competency for the Medical Social Worker/Social Work Associate. The form displayed number “4” under the “Yes” column for the skills listed. There was no information on the form on what number “4” meant. The form had a signature on the employee signature line and a signature on the preceptor signature line. There was no information on who the preceptor was.During a review of Hospice Aide 2’s (AIDE 2), employee file, the employee file indicated that AIDE 2 was hired on 11/17/2023.During a review of a form, titled CHHA Annual Competency, dated 11/18/2024, the form listed AIDE 2’s name along with AIDE 2’s date of hire. The form displayed the following information: Competency for the Medical Social Worker/Social Work Associate. The form marked “Yes” for the skills listed. The form had a signature on the employee signature line and a signature on the preceptor signature line. There was no information on who the preceptor was.During a review of a form, titled CHHA Annual Competency, dated 11/17/2025, the form listed AIDE 2’s name along with AIDE 2’s date of hire. The form displayed the following information: Competency for the Medical Social Worker/Social Work Associate. The form marked “Yes” for the skills listed. The form had a signature on the employee signature line and a signature on the preceptor signature line. There was no information on who the preceptor was.During a concurrent interview and record review with the Director of Patient Care Services (DPCSD) on 6/26/2026 at 1:03 p.m., the DPCS reviewed AIDE 1’s and AIDE 2’s employee files. The DPCSD confirmed that CHHA Annual Competency was an evaluation form the HA used to evaluate the Hospice Aides’ skills. The DPCSD stated that annual competency was done every year to make sure the Hospice Aides were competent to care for the patients. The DPCSD stated that the evaluation must be done by an RN. The DPCSD stated that the CHHA Annual Competency 2024 and 2025 for AIDE 1 and AIDE 2 did not indicate who conducted the evaluation, as there were no name and title of the preceptor. The DPCSD stated, “If there’s no name you cannot verify if the person who signed it is qualified.” The DPCSD stated there could be negative outcome from not having the annual competency completed appropriately, such as the Hospice Aides not being able to perform the skills assigned to them safely, which could possibly harm the patient. During a review of the facility’s policy and procedure (P&P) titled, “Competency Assessment” revised 4/2017, the P & P indicated the following: Competency assessments will be completed at least one time per year. Additional competencies may be required for performance problems, new technology, or other appropriate indications.”

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure that a qualified administrator designee would assume the responsibility of the day-to-day operation including complying with all legal and regulatory requirements for three of fourteen sampled patients (Patient 10, Patient 15, and Patient 17) when the administrator is not available. This failure has the potential risk for the hospice agency being manage by an unqualified administrator designee that could impact the well-being of these certified hospice patients. During an interview on 6/25/2026 at 1:16 p.m. with the Administrator Designee (ADMD), stated her role was both Director of Patient Care Services (DPCS) and ADMD. The ADMD stated she did not know how long she had the role of ADMD. The ADMD stated she was not sure of her responsibilities as ADMD. The ADMD stated she has never had to fulfill the requirements of ADMD because the DPCSD and the ADM manage the day-to-day operations of the HA. During an interview with the Intake Coordinator (IC) on 6/26/2026 at 1:27 p.m., the IC stated that the Administrator (ADM) had been out of the country since 6/5/2026.a. During a review of Patient 10’s Personal Information, the Personal Information indicated Patient 10’s start of care (SOC) date of 3/21/2025, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities) with late onset.b. During a review of Patient 15’s “Hospice Plan of Care,” (POC, an individualized, legally mandated document that outlines the comprehensive medical, physical, emotional, and spiritual services to address for a terminally ill patient and their family), for the certification period from 5/10/2026 to 7/8/2026, the POC indicated Patient 15’s start of care date was 7/14/2025, with a terminal diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities).c. During a review of Patient 17’s Patient Information, the Patient Information indicated that Patient 17 had a start of care of 6/9/2026 with a diagnoses that included chronic systolic congestive heart failure (CHF, a condition when the heart muscle is too weak and does not pump blood to the body efficiently) and a history of pulmonary embolism (a blood blockage in a blood vessel of the lungs restricting blood flow).d. During a review of Hospice Aide 1’s (AIDE 1) employee file, the employee file indicated that AIDE 1 was hired on 5/19/2021.During a review of a form, titled CHHA (Certified Home Health Aide) Annual Competency, dated 5/10/2024, the form listed AIDE 1’s name along with AIDE 1’s date of hire. The form displayed the following information: Competency for the Medical Social Worker/Social Work Associate. The form displayed number “4” under the “Yes” column for the skills listed. There was no information on the form on what number “4” meant. The form had a signature on the employee signature line and a signature on the preceptor signature line. There was no information on who the preceptor was.During a review of a form, titled CHHA Annual Competency, dated 5/01/2025, the form listed AIDE 1’s name along with AIDE 1’s date of hire. The form displayed the following information: Competency for the Medical Social Worker/Social Work Associate. The form displayed number “4” under the “Yes” column for the skills listed. There was no information on the form on what number “4” meant. The form had a signature on the employee signature line and a signature on the preceptor signature line. There was no information on who the preceptor was.e. During a review of Hospice Aide 2’s (AIDE 2), employee file, the employee file indicated that AIDE 2 was hired on 11/17/2023.During a review of a form, titled CHHA Annual Competency, dated 11/18/2024, the form listed AIDE 2’s name along with AIDE 2’s date of hire. The form displayed the following information: Competency for the Medical Social Worker/Social Work Associate. The form marked “Yes” for the skills listed. The form had a signature on the employee signature line and a signature on the preceptor signature line. There was no information on who the preceptor was.During a review of a form, titled CHHA Annual Competency, dated 11/17/2025, the form listed AIDE 2’s name along with AIDE 2’s date of hire. The form displayed the following information: Competency for the Medical Social Worker/Social Work Associate. The form marked “Yes” for the skills listed. The form had a signature on the employee signature line and a signature on the preceptor signature line. There was no information on who the preceptor was.During a concurrent interview and record review with the Director of Patient Care Services (DPCSD) on 6/26/2026 at 1:03 p.m., the DPCS reviewed AIDE 1’s and AIDE 2’s employee files. The DPCSD confirmed that CHHA Annual Competency was an evaluation form the HA used to evaluate the Hospice Aides’ skills. The DPCSD stated that annual competency was done every year to make sure the Hospice Aides were competent to care for the patients. The DPCSD stated that the evaluation must be done by an RN. The DPCSD stated that the CHHA Annual Competency 2024 and 2025 for AIDE 1 and AIDE 2 did not indicate who conducted the evaluation, as there were no name and title of the preceptor. The DPCSD stated, “If there’s no name you cannot verify if the person who signed it is qualified.” The DPCSD stated there could be negative outcome from not having the annual competency completed appropriately, such as the Hospice Aides not being able to perform the skills assigned to them safely, which could possibly harm the patient. During a review of the Clinical Director/Director of Patient Care Services Job Description, revised 4/2017, the Director of Patient Care Services Job Description indicated, “In the absence of the Executive Director/Administrator, the Clinical Director/Director of Patient Care Services will become the acting Executive Director/Administrator and will be vested with authority to act in behalf of the Executive Director/Administrator.” During a review of the Executive Director/Administrator Job Description, revised 4/2017, the Executive Director/Administrator Job Description indicated that the Administrator’s responsibilities included staff development, including orientation, in-service, continuing education, and competency testing, and quality assessment performance improvement.”

“Based on interview and record review, the Hospice Agency (specialized, compassionate care for terminally ill individuals nearing the end of life) failed to provide documented evidence the skilled nurses completed the Wound Care Competency Verification before providing wound care treatment for one of 14 patients (Patient 10).This failure had the potential to result in the staff’s lack of knowledge to accurately assess the wound leading to the delay of treatment, further skin injury causing pain and discomfort to the terminally ill patient. During a review of Patient 10’s “POC/IDG Review” (the mandatory, periodic evaluation of a patient’s Plan of Care (POC) by the patient’s Interdisciplinary Group (IDG)) dated 6/24/26, “POC/IDG Review” indicated “The patient continues to experience an intermittent Stage 2 pressure injury (a shallow, partial-thickness skin wound that comes and goes) over the sacrococcygeal area (region at the base of the spine where the sacrum (the large triangular bone at the lower back) connects to the coccyx (the tailbone)”. During a concurrent interview and record review on 6/26/2026 at 11:52 am., with Director of Patient Care Services Designee (DPCSD), the last page of the “Wound Care In-Service Comprehensive Training Guide for RN & LVN dated 5/22/2026, titled “Post-Test – Wound Care Competency Verification,” was reviewed. The DPCSD stated the hospice nurses who completed the mandatory wound care training held on 5/22/2026, were required to complete the “Post-Test – Wound Care Competency Verification”. The post-test was to measure their competency in performing wound care.The DPCSD was unable to provide documented evidence of the completed post-tests. DPCSD stated the nurses did not complete the post tests, and there was no way of knowing if the nurses were competent to perform wound care and educate patients.”

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the patient’s medical record included completed hospice aide (a certified caregiver who provides personal care to a terminally ill patient) visit notes for the week of 6/14/2026 to 6/20/2026 for one of fourteen sampled patients (Patient 17). This failure had the potential to result in a lack of continuity of care for the patient. During a review of Patient 17’s medical record titled, Patient Information, it indicated the patient had a start of care of 6/9/2026 with diagnoses of chronic systolic congestive heart failure (CHF, a condition when the heart muscle is too weak and does not pump blood to the body efficiently), and a history of pulmonary embolism (a blood blockage in a blood vessel of the lungs restricting blood flow). During a concurrent interview and record review on 6/25/2026 at 9:45 a.m., with the Administrator Designee (ADMD), Patient 17’s medical record was reviewed. Patient 17’s, “Physician Order”, indicated a hospice aide would visit the patient twice weekly for activities of daily living (ADLs, basic, routine self-care tasks performed every day). The ADMD stated the patient received hospice aide services twice a week as indicated in the orders. The ADMD stated the hospice aide’s duties included bathing the patient, bed linen change, and report to the agency if any skin problems are noted or if the patient has complaints. The ADMD stated the last visit was made on 6/17/2026 and the hospice aide had only seen the patient once that week. The ADMD stated proof that the visits were being made was the notes and the patient’s chart contained hospice aide notes on 6/17/2026 and no other notes after that. The ADMD stated visit notes are meant to be submitted to the agency withing 48 to 72 hours. During an interview on 6/25/2026 at 9:55 a.m., with the ADMD, the ADMD stated it was important for the hospice aide to keep up with the visits, so the Patient 17 remains clean and can socialize with her friends at the facility, keeps her self-dignity, and any skin problems that arise could be addressed. The ADMD stated it was important to have visit notes in the patient’s chart because the hospice staff needs to know what is going on with the patient, creates good communication, continuity of care, and follow up of patient if needed. During a review of the facility’s policy and procedure (P&P) titled, “Submission of Clinical Notes Policy”, undated, the P&P indicated “All clinical staff are required to submit completed clinical notes for all patient visits on a timely basis…All clinical notes for services rendered during the week shall be submitted no later than 72 hours after the visits occurred…Late documentation may delay patient care coordination, physician review, quality assurance activities, and billing processes.””

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (condition that healthcare organizations must meet in order to begin and continue participating in Medicare [a Federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint Federal and State program that helps cover medical costs for some people with limited income and resources] programs) for Initial and Comprehensive Assessment of the Patient was met as follows: The HA failed to ensure a completed pressure wound (also known as bedsores or pressure ulcers, are injuries to the skin and underlying tissues) assessment was conducted for two of 14 sampled patients (Patient 7 and Patient 10). This deficient practice had the potential to result in the delayed provision of wound treatment that could lead to infection and deterioration of the wound causing patient’s discomfort and/or pain. (Refer to L524)The HA failed to ensure the comprehensive assessments accurately identified the patients’ need for hospice care (a specialized care that provides comfort and emotional, social, and spiritual support for people nearing the end of life) and services for one of 14 sampled patients (Patient 1). This failure placed Patient 1 at increased risk to experience a decline in health that could lead to serious harm, hospitalization, and death due to not having proper medical oversight and access to needed specialist, medications, and medically necessary treatments; and have the potential to lose their hospice eligibility/hospice benefits and not receive hospice care when needed and eligible in the future. (Refer to L525)The HA failed to review and reconcile (the process of comparing a patient’s medication orders to all of the medications that the patient has been taking) all medications the patients were taking and update their medication profile with the currently used medications for three of 14 sampled patients (Patient 1, Patient 5, and Patient 10). This failure had the potential to place patients at risk for medication errors and adverse drug reactions. (Refer to L530)The HA failed to conduct an updated comprehensive assessment that includes psychosocial and spiritual care assessment during two recertifications for one of 14 sampled patients (Patient 10). This deficient practice may result in failure to identify changes in patient’s psychosocial and spiritual needs, and the inability to provide the care and services necessitated by the change. (Refer to L533)The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulation for Initial and Comprehensive Assessment of the Patient to provide the necessary care and services to the patients. Findings:1. The HA failed to ensure a completed pressure wound (also known as bedsores or pressure ulcers, are injuries to the skin and underlying tissues) assessment was conducted for two of 14 sampled patients (Patient 7 and Patient 10). This deficient practice had the potential to result in the delayed provision of wound treatment that could lead to infection and deterioration of the wound causing patient’s discomfort and/or pain. (Refer to L524)2. The HA failed to ensure the comprehensive assessments accurately identified the patients’ need for hospice care (a specialized care that provides comfort and emotional, social, and spiritual support for people nearing the end of life) and services for one of 14 sampled patients (Patient 1). This failure placed Patient 1 at increased risk to experience a decline in health that could lead to serious harm, hospitalization, and death due to not having proper medical oversight and access to needed specialist, medications, and medically necessary treatments; and have the potential to lose their hospice eligibility/hospice benefits and not receive hospice care when needed and eligible in the future. (Refer to L525)3. The HA failed to review and reconcile (the process of comparing a patient’s medication orders to all of the medications that the patient has been taking) all medications the patients were taking and update their medication profile with the currently used medications for three of 14 sampled patients (Patient 1, Patient 5, and Patient 10). This failure had the potential to place patients at risk for medication errors and adverse drug reactions. (Refer to L530)4. The HA failed to conduct an updated comprehensive assessment that includes psychosocial and spiritual care assessment during two recertifications for one of 14 sampled patients (Patient 10). This deficient practice may result in failure to identify changes in patient’s psychosocial and spiritual needs, and the inability to provide the care and services necessitated by the change. (Refer to L533) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulation for Initial and Comprehensive Assessment of the Patient to provide the necessary care and services to the patients.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (condition that healthcare organizations must meet in order to begin and continue participating in Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Interdisciplinary Group, Care Planning, and Coordination of Services was met as follows: The HA failed to provide education about the “Hospice Plan of Care” (POC, an individualized, legally mandated document that outlines the comprehensive medical, physical, emotional, and spiritual services to address for a terminally ill patient and their family), to the caregiver of one of 14 sampled patients (Patient 1). This failure resulted in a lack of communication and collaboration with Patient 1’s caregiver (CG 2) regarding the POC. (Refer to L543)The HA failed to provide education to the caregiver for one of 14 sampled patients (Patient 1). This failure resulted in Patient 1’s caregiver (CG 2) not receiving education and training to effectively care for Patient 1. (Refer to L544)The HA’s Interdisciplinary Group (IDG, team members from different disciplines working collaboratively with a common purpose to set goals, make decisions, and share resources and responsibilities) failed to communicate and coordinate a wound consult order for one of 14 sampled patients (Patient 7). This failure resulted in Patient 7 not receiving necessary interventions to manage the wounds. (Refer to L554)The HA failed to provide medical supplies necessary for one of 14 sampled patients (Patient 1).This failure had the potential to result in unmanaged discomfort and poor symptom management for Patient 1. (Refer to L550)The HA failed to ensure that one of 14 sampled patients (Patient 10) received visits from the Skilled Nurse and MSW per plan of care. This failure… (Refer to L555)The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulation for Interdisciplinary Group, Care Planning, and Coordination of Services to provide the necessary care and services to the patients. Findings:1. The HA failed to provide education about the “Hospice Plan of Care” (POC, an individualized, legally mandated document that outlines the comprehensive medical, physical, emotional, and spiritual services to address for a terminally ill patient and their family), to the caregiver of one of 14 sampled patients (Patient 1). This failure resulted in a lack of communication and collaboration with Patient 1’s caregiver (CG 2) regarding the POC. (Refer to L543)2. The HA failed to provide education to the caregiver for one of 14 sampled patients (Patient 1). This failure resulted in Patient 1’s caregiver (CG 2) not receiving education and training to effectively care for Patient 1. (Refer to L544)3. The HA failed to provide medical supplies necessary for one of 14 sampled patients (Patient 1). This failure had the potential to result in unmanaged discomfort and poor symptom management for Patient 1. (Refer to L550)4. The HA failed to ensure that the Interdisciplinary Group (IDG, team members from different disciplines working collaboratively with a common purpose to set goals, make decisions, and share resources and responsibilities) coordinated and supervised the care and services provided, in regard to a wound consult order for one of fourteen sampled patients (Patient 7). This failure resulted in Patient 7 not receiving necessary interventions to manage the wounds. (Refer to L554)5. The HA failed to ensure home visits were conducted in accordance with the plan of care for one of 14 sampled patients (Patient 11). This deficient practice had the potential to negatively affect the patients’ physical comfort, psychosocial well-being, and not receiving the needed and necessary services timely. (Refer to L555)The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily (written law) mandated compliance with federal regulation for Interdisciplinary Group, Care Planning, and Coordination of Services to provide the necessary care and services to the patients.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (condition that healthcare organizations must meet in order to begin and continue participating in Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Clinical Records was met as follows: 1. The HA failed to ensure the agency staff submitted complete clinical notes and pertinent clinical records were included to reflect the care and assessment provided to one of fourteen sampled patients (Patient 10). This failure resulted in patient’s incomplete clinical record that could lead to misinformation and lack of care and services provided to the patient. (Refer to L672)2. The HA failed to include a discharge order from the Medical Director for one of fourteen sampled patients (Patient 8). This failure had the potential to result in unsafe care transition and improperly coordinated necessary follow-up care. (Refer to L678).3. The HA failed to complete a discharge summary for one of fourteen sampled patients (Patient 8). This failure might disrupt the patient’s continuity of care and affect patient safety post discharge. (Refer to L684). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the federal regulation for Clinical Records in maintaining accurate and updated clinical records for all patients.”

“Based on observation, interview, and record review, the hospice agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure two of 14 sampled patients (Patient 5 and Patient 10) have the right to be involved in the development of their plans of care (POC, a personalized, comprehensive document that outlines the medical, emotional, psychosocial, and spiritual needs of a patient and their family during hospice care). This deficient practice had the potential to result in the patient/patient’s family and/or caregiver being unable to be an active participant in his or her care. Findings: a. During a review of Patient 5’s Personal Information, the Personal Information indicated that Patient 5 was admitted to the HA on 5/1/2026 with a primary diagnosis of malignant neoplasm of brain (tumor of the brain). During a review of Patient 5’s Plan of Care Summary (POC Summary, a summary of a plan of care: a document outlining the services needed by the patient, health care professionals who provide these services, how often the patient needed the services, the medical equipment needed by patient, and what results the doctor expected), as of 5/12/2026, indicated Patient 5 had Skilled Nurse (SN, a licensed nurse in general) visit per week plus three as needed visits for pain and symptom management, Hospice Aide visit per week to assist with activities of daily living (ADLs, the fundamental self-care tasks people perform every day to live independently), Social Worker visit to assess for psychosocial needs, and one Chaplain visit to assess for spiritual needs. During a joint home visit with the Director of Patient Care Services (DPCS) on 5/13/2026 at 12 p.m., Patient 5 was observed lying in a hospital bed, eyes open. Patient 5 did not respond verbally when greeted or spoken to. Patient 5’s spouse, who acted as the patient’s caregiver (CG 3) was present during the home visit. During the joint home visit, a review of the home folder was done with the DPCS. There was no copy of the Plan of Care/POC inside the patient’s home folder. CG 3 stated that all the documents from the HA were kept inside the home folder. CG 3 stated that she had never seen Patient 5’s Plan of Care. During an interview with the DPCS on 5/13/2026 at 1:15 p.m., the DPCS stated that the HA had not provided Patient 5 and/or the family/caregiver with a copy of the POC but was supposed to. The DPCS stated that the POC would allow the family to be informed of the interventions and goals for the patient, and if the patient or the family wanted to add an intervention they could. The DPCS stated that having a copy of the POC would encourage the patient or family to participate in the care. b. During a review of Patient 10’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated Patient 10’s start of care (SOC) date of 3/21/2025, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities) with late onset. During a review of Patient 10’s clinical record titled, POC/IDG Review (Plan of Care/Interdisciplinary Group Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness), dated 4/28/2026, the POC/IDG Review indicated the frequency of visits of the skilled nurse (SN) to one visit per week plus 3 PRN (pro re nata, which means “as needed”) visits, the social worker (MSW) and the spiritual counselor (SC) to one visit a month plus 1 prn visit, and the hospice aide to two visits per week for assistance with ADLs ( or Activities of Daily Living - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). Volunteer service was declined. During a joint home visit at Patient 10’s residence, on 5/13/2026 at 10:30 a.m., with the licensed vocational nurse (LVN 1), Patient 10 was observed lying in a hospital bed, awake, alert but aphasic (someone experiencing a loss or impairment of the ability to use or understand language), accompanied by a caregiver (CG 1). During a review of Patient 10’s hospice folder located at the patient’s home, on 5/13/2026 at 11:02 a.m., a copy of the patient’s current POC could not be found. During a concurrent interview with CG 1, stated there was no copy of Patient 10’s POC at home. During an interview with the Director of Patient Care Services Designee (DPCS Designee), on 5/15/2026 at 11:10 a.m., DPCS Designee stated that the plan of care needed to be updated at least every 2 weeks because patients’ condition might have changed, and patients should have a copy of their current POC at home and be placed in their hospice folder. The DPCS Designee stated and acknowledged the findings. During a review of the HA’s policy and procedure (P&P) titled, The Plan of Care, revised April 2017, the P&P indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care.”

“Based on interview and record review, the hospice agency (HA, an agency providing care to terminally ill patients who has six months or less to live) nursing staff failed to ensure a completed pressure wound (also known as bedsores or pressure ulcers, are injuries to the skin and underlying tissues) assessment was conducted for two of 14 sampled patients (Patient 7 and Patient 10). This deficient practice had the potential to result in the delayed provision of wound treatment that could lead to infection and deterioration of the wound causing patient’s discomfort and/or pain. Findings: a. During a review of Patient 7’s Personal Information, the Personal Information indicated that Patient 7 was admitted to the HA on 11/15/2025 with a primary diagnosis of malignant neoplasm of unspecified site of right female breast (a medical term for breast cancer found in the right breast). The end of care date on the Personal Information was 3/18/2026. Patient 7 passed away on that date. During a review of Patient 7’s Plan of Care Summary (POC Summary, a summary of a plan of care, a document outlining the services needed by the patient, health care professionals who provide these services, how often the patient needed the services, the medical equipment needed by patient, and what results the doctor expected), as of 5/14/2026, indicated that Patient 7 had two Licensed Vocational Nurse (LVN) visits per week plus three as needed visits for pain and symptom management. During a review of Patient 7’s Visit Note Short Form, dated 2/28/2026, the Visit Note Short Form indicated that LVN 2 conducted a visit on that date and observed a new, open wound on Patient 7’s right heel. The Visit Note Short Form indicated that MD 1 was notified and a wound consult order was obtained. The Visit Note Short Form indicated that LVN 2 took a picture of the wound and sent it to MD 1 and the hospice team. The Visit Note Short Form indicated that LVN 2 cleansed the wound with wound cleanser, applied triple antibiotic, and covered with a rolled gauze. There was no wound assessment documented that included the wound’s appearance, complete measurement, drainage, surrounding skin, or if there was any pain. There was no Skin Assessment completed for the visit on 2/28/2026. During a phone interview with LVN 2 on 5/14/2026 at 1:14 p.m., LVN 2 stated that she was assigned to Patient 7 and was familiar with Patient 7. LVN 2 stated that on 2/28/2026, Patient 7’s caregiver called her (LVN 2) and informed her (LVN 2) that Patient 7 had an open wound. LVN 2 stated that she made a visit immediately, notified MD 1 and the hospice agency about the wound, measured the wound, and took a picture of the wound. LVN 2 stated that MD 1 ordered a wound consult for Patient 7. When LVN 2 was asked if she remembered completing a Skin Assessment for the visit on 2/28/2026, LVN 2 stated, “The assessment should all be in my note.” During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCS Designee) on 5/14/2026 at 1:48 p.m., the DPCS Designee reviewed Patient 7’s POC Summary as of 5/14/2026 and Visit Note Short Form dated 2/28/2026. The DPCS Designee stated that LVN 2 did not complete the Skin Assessment during her visit on 2/28/2026. The DPCS Designee stated, “When the patient had skin impairment, especially if it’s a new wound, a separate Skin Assessment needs to be done.” The DPCS Designee stated the Skin Assessment covered the full assessment of the patient’s wound, such as measurement, if there was any drainage, the type of drainage, and the color of the wound bed and surrounding skin. The DPCS Designee stated that a full wound assessment was important in monitoring the patient’s wound progression, which might determine the treatment the patient needed. b. During a review of Patient 10’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated Patient 10’s start of care (SOC) date of 3/21/2025, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities) with late onset. During a review of Patient 10’s Re-Cert Assessment (or Recertification Comprehensive Assessment, a thorough evaluation of a patient’s overall health status, encompassing physical, psychological, social, and spiritual aspects) dated 3/2/2026, the Re-Cert assessment indicated Patient 10 was still noted with Stage 2 pressure ulcer (partial-thickness loss of skin, presenting as a shallow open sore or wound) to coccyx area (commonly known as the tailbone, it is the small, triangular bone at the very base of the human spinal column) with no infection seen during the assessment. During a review of Patient 10’s clinical record titled, POC/IDG Review (Plan of Care/Interdisciplinary Group Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness), dated 3/31/2026, the POC/IDG Review indicated the frequency of visit of the skilled nurse (SN) to one visit per week plus 3 prn (pro re nata, which means “as needed”) visits to assess safety concerns/issues, assess and monitor effectiveness of medications, to assess alteration in skin integrity every visit, and to assess and document wound appearance, size, drainage, surrounding skin condition, and perform wound care as ordered using clean/aseptic technique on coccyx Stage 2 pressure wound. During a concurrent interview and record review, on 5/15/2026 at 11:10 a.m., with the Director of Patient Care Services Designee (DPCS Designee), the DPCS Designee reviewed Patient 10’s Skin Assessment record dated 3/2/2026, 4/23/2026, 4/27/2026, and 5/4/2026. The DPCS Designee stated a completed wound assessment on stage 2 pressure ulcer would include measuring the wound’s length, width, and depth to track healing. The DPCS Designee stated and acknowledged that on the nurses’ visits dated 3/2/2026, 4/23/2026, 4/27/2026, and 5/4/2026, the width and depth of the wound was not measured or assessed. On 5/15/2026, the DPCS Designee stated the HA did not have a policy and procedure on wound assessment or pressure injury management. The DPCS Designee stated that any wound assessment is covered under the Ongoing Assessment policy and procedure. During a review of the agency’s policy and procedure (P&P) titled Ongoing Comprehensive Assessments, revised April 2017, the P&P indicated the scope and intensity of ongoing hospice patient assessments will be determined by the patient’s prognosis, diagnoses, condition, desire for care, response to previous care, and the care setting. During each home visit, the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. The nurse will assess the patient on each visit, for: skin integrity and current treatment related to the identified symptoms and the patient’s response.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live), failed to ensure the comprehensive assessments accurately identify patient’s need for continuous hospice care (a specialized care that provides comfort and emotional, social, and spiritual support for people nearing the end of life) and services for one of 14 sampled patients (Patient 1). Patient 1’s LCD Hospice Eligibility indicated “the patient did not qualify based on LCD Guidelines.” The interdisciplinary group (IDG, a collaborative group of healthcare professionals who work together to manage the medical, physical, emotional, social, and spiritual needs of a hospice patient and their family) members failed to review Patient 1’s comprehensive assessments to determine Patient 1’s continuous need to receive the hospice benefits. This failure resulted in Patient 1 being recertified and re-admitted for hospice care and services. During a review of Patient 1’s “Hospice Plan of Care” for the certification period from 4/12/2026 to 6/14/2026, the POC indicated Patient 1’s start of care date was 2/15/2026, with a terminal diagnosis of senile degeneration of the brain (the progressive, age-related decline of brain tissue and cognitive function). The POC indicated the frequency of visits for the skilled nurse (SN) included one visit every week for 12 weeks and 3 visits as needed. During a joint home visit, on 5/13/2026, at 12:02 p.m., at Patient 1’s residence, with Licensed Vocational Nurse (LVN) 1, Patient 1 was observed sitting in a wheelchair at the dining table eating lunch and was accompanied by a caregiver (CG 2). Patient 1 was observed to be alert and oriented. During an interview on 5/13/2026 at 1:03 p.m., with CG 2 stated Patient 1 had no worsening symptom management in the 12 months period, including aspiration pneumonia (a lung infection caused by inhaling food, liquid, saliva, or vomit into the airways rather than swallowing them), pyelonephritis (a specific type of urinary tract infection that occurs when bacteria travel from the bladder up into one or both kidneys), septicemia (a life-threatening bloodstream infection), stage 3 or stage 4 pressure ulcer (severe, full-thickness wound where skin tissue is lost and underlying muscles, tendons, or bones are exposed), recurrent fever after antibiotics, or weight loss due to insufficient fluid and calorie intake. During a concurrent interview and record review on 5/15/2026 at 12:40 p.m., with the Director of Patient Care Services Designee (DPCS Designee), Patient 1’s “Local Coverage Determination (LCD, a tool that describes the qualifying criteria for hospice care) Hospice Eligibility Determination,” dated 4/12/2026, was reviewed. The LCD Hospice Eligibility Determination indicated a diagnosis of dementia due to Alzheimer’s was used to determine hospice eligibility. The LCD Hospice Eligibility from indicated a “No,” for the following sections; aspiration pneumonia in past 12 months, pyelonephritis in past 12 months, septicemia in past 12 months, decubitus ulcer – stage 3 or 4 in past 12 months, recurrent fever after antibiotics in past 12 months, inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 grams (g, a unit of measurement)/deciliter (dl, a unit of measurement). The LCD Hospice Eligibility indicated Patient 1 “does not qualify per LCD Guidelines.” The DPCS Designee stated that based on the LCD Guidelines, Patient 1 should not have been recertified for hospice care. The DPCS Designee stated the interdisciplinary group (IDG, a collaborative group of healthcare professionals who work together to manage the medical, physical, emotional, social, and spiritual needs of a hospice patient and their family) members are responsible for reviewing Patient 1’s comprehensive assessments to determine if Patient 1 was an appropriate hospice patient. During a record review of the agency’s policy and procedure (P&P) titled, “Admission Criteria and Process,” revised 4/2017, the P&P indicated, “The patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria in the organization’s intermediary Local Coverage Determinations.””

“Based on observation, interview, and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) staff failed to review and reconcile (the process of comparing a patient’s medication orders to all of the medications that the patient has been taking) all medications the patients were taking and update their medication profile with the currently used medications for three of 14 sampled patients (Patient 1, Patient 5, and Patient 10). This failure had the potential to place patients at risk for medication errors and adverse drug reactions. Findings: a. During a review of Patient 1’s “Hospice Plan of Care” (POC, an individualized, legally mandated document that outlines the comprehensive medical, physical, emotional, and spiritual services to address for a terminally ill patient and their family), for the certification period from 4/12/2026 to 6/14/2026, the POC indicated Patient 1’s start of care date was 2/15/2026, with a terminal diagnosis of senile degeneration of the brain (the progressive, age-related decline of brain tissue and cognitive function). The POC indicated the frequency of visits for the skilled nurse (SN) included one visit every week for 12 weeks and 3 visits as needed. During a joint home visit, on 5/13/2026, at 12:02 p.m., at Patient 1’s residence, with Licensed Vocational Nurse (LVN) 1, Patient 1 was observed sitting in a wheelchair at the dining table eating lunch and was accompanied by a caregiver (CG 2). During a review of Patient 1’s current medications on 5/13/2026 at 12:06 p.m., with LVN 1, the following medications were available in Patient 1’s residence but not listed in Patient 1’s medication profile or plan of care provided by the HA:-Loperamide (a medication used to treat diarrhea) 2 milligrams (mg, a unit of measurement) oral tablet.-Mupirocin (a topical antibiotic used to treat skin infections) 2% ointment.-Acetaminophen (used to treat mild-to-moderate pain and reduce fever) 325 mg oral tablet.-Acetaminophen 650 mg suppository.-Lorazepam (a medication used to treat anxiety) 2 mg oral tablet.-Bisacodyl (a medication used to treat constipation) 10 mg suppository.-Ondansetron (a medication used to prevent nausea and vomiting) 4 mg oral tablet.-Albuterol (a medication used to treat breathing difficulties) 0.083% inhalation solution. During an interview on 5/14/2026 at 1:15 p.m., with the Director of Patient Care Services Designee (DPCS Designee), the DPCS Designee stated medication reconciliation should be completed every visit. The DPCS Designee stated that completing medication reconciliation at each visit is important to ensure medications are being taken as prescribed, the medication profile remains current and accurate, and potential medication interactions are identified. b. During a review of Patient 5’s Personal Information, the Personal Information indicated that Patient 5 was admitted to the HA on 5/1/2026 with a primary diagnosis of malignant neoplasm of brain (tumor of the brain). During a joint home visit with the Director of Patient Care Services (DPCS) on 5/13/2026 at 12 p.m., Patient 5 was observed lying in a hospital bed, eyes open. Patient 5 did not respond verbally when greeted or spoken to. Patient 5’s spouse, who acted as the patient’s caregiver (CG 3) was present during the home visit. During the joint visit, a medication review was performed with the DPCS through concurrent observation and record review. The following medication was observed in Patient 5’s home but not included in the Current Treatment/Medication/DME (Durable Medical Equipment, medically necessary devices designed for long-term use to assist individuals with medical conditions, disabilities, or injuries) List:Clonidine transdermal patch (a prescription medication used to treat hypertension [high blood pressure] by continuously delivering medication through the skin over a 7-day period) 0.1 milligram (mg, a measurement unit)/24 hour. Apply one patch topically to arm once a week. During an interview with CG 3 on 5/13/2026 at 12:50 p.m., stated Clonidine transdermal patch was not a new medication. CG 3 stated Patient 5 had been using the Clonidine patch for a while. CG 3 also stated Patient 5 was allergic to Lorazepam (a prescription medication to treat anxiety). CG 3 had informed the nurse about Patient 5’s allergy to Lorazepam but the nurse told her to keep the Lorazepam in case Patient 5 needed it. Lorazepam 2 mg/ml in a 15 ml bottle was observed at the home, with the instructions to give the patient 0.5 mg/0.25 ml under the tongue every 4 hours as needed for anxiety. During an interview with the DPCS on 5/13/2026 at 1:10 p.m., the DPCS stated that Clonidine transdermal patch needed to be added to Patient 5’s Current Treatment/Medication/DME List. The DPCS stated that the visiting nurse should have notified the physician upon receiving report from CG 3 that Patient 5 was allergic to Lorazepam, so that Lorazepam could be discontinued. The DPCS stated, “If the patient is allergic, of course he shouldn’t take it.” The DPCS stated that an accurate and updated Current Treatment/Medication/DME List was very important so that the patient or family/caregiver or family knew what medications the patient was on. The DPCS stated that medication reconciliation needed to be done every visit. The DPCS stated that an updated medication list could help prevent medication errors. c. During a review of Patient 10’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated Patient 10’s start of care (SOC) date of 3/21/2025, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities) with late onset. During a review of Patient 10’s clinical record titled, POC/IDG Review (Plan of Care/Interdisciplinary Group Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness), dated 4/28/2026, the POC/IDG Review indicated the frequency of visit of the skilled nurse (SN) to one visit per week plus 3 PRN (pro re nata, which means “as needed”) visits to monitor and assess effectiveness of current and new medication/treatment, and to instruct patient/patient caregiver (PCG) regarding new medication/treatment order and side effects (unwanted, usually unpleasant, effects caused by medicines). During a joint home visit at Patient 10’s residence, on 5/13/2026 at 10:30 a.m., with the licensed vocational nurse (LVN 1), Patient 10 was observed lying in a hospital bed, awake, alert but aphasic (someone experiencing a loss or impairment of the ability to use or understand language), accompanied by a caregiver (CG 1). During a review of Patient 10’s current medication, on 5/13/2026 at 11:06 a.m. with LVN 1 and CG 1, there was a bottle of melatonin (a supplement that helps regulate your sleep cycle) 10 milligrams (mg, a unit of measurement) 1 tablet by mouth at bedtime found at the patient’s residence with a filled date of 4/1/2026. However, Patient 10’s current medication profile list provided by the HA did not indicate Patient 10 was on melatonin. During an interview with CG 1, CG 1 stated Patient 10 was taking melatonin 10 mg before bedtime since early April 2026. During an interview with the DPCS Designee, on 5/15/2026 at 11:10 a.m., stated that the hospice nursing staff should check and reconcile patient’s medications on every visit. The DPCS Designee stated there would be an increased risk of medication errors if medication reconciliation was not conducted frequently or on every nurse’s visit. The DPCS Designee acknowledged the findings. During a review of the hospice agency’s policy and procedure (P&P) titled, Medication Profile, revised April 2017, the P&P indicated 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.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to conduct an updated comprehensive assessment that includes psychosocial and spiritual care assessment during recertification for one of 14 sampled patients (Patient 10). This deficient practice may result in failure to identify changes in patient’s psychosocial and spiritual needs, and the inability to provide the care and services necessitated by the change. Findings: During a review of Patient 10’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated Patient 10’s start of care (SOC) date of 3/21/2025, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities) with late onset. During a review of Patient 10’s clinical record titled, POC (or Plan of Care, a written document that outlines the specific needs and services provided to a patient facing a terminal illness) Summary, the POC Summary included an order dated 3/21/2025, for the medical social worker ( or MSW, a licensed professional who provides emotional, psychosocial, and practical support to patients with life-limiting illnesses and their families) and the spiritual counselor (or SC, a professional who plans, assesses, and cares for a patient’s spiritual needs) to visit during initial, recertification, and plus 1 visit as needed for psychosocial and spiritual support to patient and/or patient caregiver/family. During a concurrent interview and record review, on 5/15/2026 at 11:10 a.m., with the Director of Patient Care Services Designee (DPCS Designee), the DPCS Designee reviewed Patient 10’s comprehensive recertification assessment for the benefit period starting from 6/19/2025 to 9/16/2025, and from 9/17/2025 to 11/15/2025. The DPCS Designee stated and acknowledged that there was no psychosocial and spiritual assessment conducted for Patient 10 for two recertification periods starting from 6/19/2025 to 9/16/2025, and from 9/17/2025 to 11/15/2025. The DPCS Designee stated the hospice agency was required to conduct a comprehensive assessment upon admission and on every recertification that included psychosocial and spiritual care assessment to meet the patient emotional, social and spiritual needs and not just physical symptoms. During a review of the hospice agency’s policy and procedure (P&P) titled, Psychosocial Assessment, revised April 2017, the P&P indicated an in-depth psychosocial assessment will be completed by a qualified hospice social worker or hospice registered nurse. The assessment includes but is not limited to coping with and adjusting to the patient’s illness, making final arrangements, reaction to the terminal illness and subsequent bereavement needs, and social and financial needs. If the patient and/or family/caregiver refuses psychosocial visits, patient and family/caregiver needs will continue to be assessed on an ongoing basis. During a review of the hospice agency’s P&P titled, Spiritual Assessment, revised April 2017, the P&P indicated an in-depth spiritual assessment will be completed for each patient/family by the hospice Chaplain. The assessment will include, but not be limited to, evaluation of the following:Coping with and adjusting to the patient’s terminal illnessAssessing bereavement needsReligious and/or spiritual reactions to terminal illness.If the patient and family/caregiver refused these services, the refusal will be documented. The interdisciplinary group members will continue to assess for spiritual needs and offer appropriate services to the patient and family/caregiver.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live failed to provide education about the “Hospice Plan of Care” (POC, an individualized, legally mandated document that outlines the comprehensive medical, physical, emotional, and spiritual services to address for a terminally ill patient and their family), to the caregiver of one of 14 sampled patients (Patient 1). This failure resulted in a lack of communication and collaboration with Patient 1’s caregiver (CG 2) regarding the POC. During a review of Patient 1’s “Hospice Plan of Care” for the certification period from 4/12/2026 to 6/14/2026, the POC indicated Patient 1’s start of care date was 2/15/2026, with a terminal diagnosis of senile degeneration of the brain (the progressive, age-related decline of brain tissue and cognitive function). The POC indicated the frequency of visits for the skilled nurse (SN) included one visit every week for 12 weeks and 3 visits as needed. During a joint home visit, on 5/13/2026, at 12:02 p.m., at Patient 1’s residence, with Licensed Vocational Nurse (LVN) 1, Patient 1 was observed sitting in a wheelchair at the dining table eating lunch and was accompanied by Caregiver 2 (CG 2). During an interview on 5/13/2026 at 1:03 p.m., with CG 2 stated Patient 1’s visiting nurses have never discussed the plan of care with him (CG 2) since the start of care. CG 2 stated it would be beneficial for the visiting nurses to communicate the POC with him (CG 2) to facilitate collaboration for Patient 1’s care. During an interview on 5/14/2026 at 1:22 p.m., with the Director of Patient Care Services Designee (DPCS Designee), the DPCS Designee stated the importance of ensuring communication with all patient care providers, including caregivers. The DPCS Designee stated visiting nurses should collaborate with patient caregivers about the plan of care during every visit. The DPCS Designee stated not communicating the plan of care to caregivers could result in the plan of care not being followed, which could negatively impact patient safety. During a record review of the agency’s policy and procedure (P&P) titled, “The Plan of Care,” revised 4/2017, the P&P indicated, “The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care.””

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to provide education to the caregiver for one of 14 sampled patients (Patient 1). This failure resulted in Patient 1’s caregiver (CG 2) not receiving education and training to effectively care for Patient 1. During a review of Patient 1’s “Hospice Plan of Care” for the certification period from 4/12/2026 to 6/14/2026, the plan of care (POC) indicated Patient 1’s start of care date was 2/15/2026, with a terminal diagnosis of senile degeneration of the brain (the progressive, age-related decline of brain tissue and cognitive function). The POC indicated the frequency of visits for the skilled nurse (SN) included one visit every week for 12 weeks and 3 visits as needed. During a joint home visit, on 5/13/2026, at 12:02 p.m., at Patient 1’s residence, with Licensed Vocational Nurse (LVN) 1, Patient 1 was observed sitting in a wheelchair at the dining table eating lunch and was accompanied by CG 2. During an interview on 5/13/2026 at 1:03 p.m., with CG 2 stated Patient 1’s visiting nurses have never provided education or training about how to care for Patient 1 since the start of care. CG 2 stated visiting nurses only assess Patient 1 and ask him if he needs any refills for supplies or medications during visits. CG 2 stated it would be beneficial for visiting nurses to teach him about Patient 1’s diagnoses to understand the best way to care for Patient 1. During an interview on 5/14/2026 at 1:22 p.m., with the Director of Patient Care Services Designee (DPCS Designee) stated the importance of ensuring communication with all patient care providers, including caregivers. The DPCS Designee stated visiting nurses should educate patient caregivers about safe patient care during every visit. The DPCS Designee stated that a lack of education and training to caregivers could result in caregivers not following the plan of care, which could negatively impact patient safety. During a record review of the agency’s policy and procedure (P&P) titled, “The Plan of Care,” revised 4/2017, the P&P indicated, “As needed, the patient and family/caregiver will receive written instructions regarding treatments or aspects of care that will be the responsibility of the patient and family/caregiver to provide or follow through with.””

“Based on interview and record review, the facility failed to provide medical supplies necessary for one of 14 sampled patients (Patient 1). This failure had the potential to result in unmanaged discomfort and poor symptom management for Patient 1. During a review of Patient 1’s “Hospice Plan of Care” (POC, an individualized, legally mandated document that outlines the comprehensive medical, physical, emotional, and spiritual services to address for a terminally ill patient and their family), for the certification period from 4/12/2026 to 6/14/2026, the POC indicated Patient 1’s start of care date was 2/15/2026, with a terminal diagnosis of senile degeneration of the brain (the progressive, age-related decline of brain tissue and cognitive function). The POC indicated the frequency of visits for the skilled nurse (SN) included one visit every week for 12 weeks and 3 visits as needed. During a joint home visit, on 5/13/2026 at 12:02 p.m., at Patient 1’s residence, with Licensed Vocational Nurse (LVN) 1, Patient 1 was observed sitting in a wheelchair at the dining table eating lunch and was accompanied by caregiver (CG 2). During a concurrent interview and record review on 5/13/2026 at 12:47 p.m. with CG 2, Patient 1’s POC, dated 5/12/2026, was reviewed. The POC indicated there were orders for face masks, Ensure (a brand of nutritional supplements and meal replacement shakes), wipes, body lotion, body wash and shampoo, chux (an absorbent, waterproof pad used to protect furniture, mattresses, and wheelchairs from bodily fluids), diapers, gloves, and perineal cleanser. CG 2 stated they have not received any of the ordered supplies for this month. CG 2 stated the supplies are needed to properly care for Patient 1. During an interview on 5/14/2026 at 1:22 p.m., with the Director of Patient Care Services Designee (DPCS Designee), the DPCS Designee stated the supplies should have been sent at the beginning of the month. The DPCS Designee stated the importance of ensuring supplies are sent in a timely manner so caregivers can provide safe and effective care. During a record review of the agency’s policy and procedure (P&P) titled, “Interdisciplinary Group Coordination of Care,” revised 4/2017, the P&P indicated, “Core hospice services will be available 24 hours a day, seven days a week, as will be drugs, biologicals, and medical supplies.””

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure that the Interdisciplinary Group (IDG, team members from different disciplines working collaboratively with a common purpose to set goals, make decisions, and share resources and responsibilities) coordinated and supervised the care and services provided, in regards to a wound consult order for one of fourteen sampled patients (Patient 7). This failure resulted in Patient 7 not receiving necessary intervention and treatment to manage the patient’s wounds. During a review of Patient 7’s Personal Information, the Personal Information indicated that Patient 7 was admitted to the HA on 11/15/2025, with a primary diagnosis of malignant neoplasm of unspecified site of right female breast (a medical term for breast cancer found in the right breast). The end of care date on the Personal Information was 3/18/2026. Patient 7 passed away on 3/18/2026. During a review of Patient 7’s Plan of Care Summary (POC Summary, a summary of a plan of care, a document outlining the services needed by the patient, health care professionals who provide these services, how often the patient needed the services, the medical equipment needed by patient, and what results the doctor expected), as of 5/14/2026, indicated that Patient 7 had two Licensed Vocational Nurse (LVN) visits per week plus three as needed visits for pain and symptom management. During a review of Patient 7’s Visit Note LVN, dated 12/10/2025, the Visit Note LVN indicated that during the visit of Patient 7 on 12/10/2025, LVN 2 observed a deep tissue injury (DTI, a type of pressure injury that affects the deeper layers of tissue beneath the skin, such as muscles, subcutaneous fat, and sometimes bone, while the overlying skin remains intact or appears discolored [deep red, maroon, or purple]) on the left heel and the right heel. A pressure injury is an injury to the skin and underlying tissues caused by prolonged pressure on the skin, often occurring in individuals who are immobile for extended periods. The narrative section of the Visit Note LVN indicated that LVN 2 notified Medical Director 1 (MD 1) and obtained a wound treatment order. During a review of Patient 7’s Skin Assessment, dated 12/10/2025, the Skin Assessment indicated that LVN 2 performed the wound treatment on the DTI on Patient 7’s bilateral heels as ordered by MD 1. During a review of Physicians Order, dated 12/10/2025, the Physicians Order indicated that MD 1 prescribed the following wound treatment: Cleanse with wound cleanser, paint with Betadine, and leave open to air daily for 30 days, then reassess. During a review of Patient 7’s Visit Note RN, dated 2/21/2026, the Visit Note RN indicated that “bilateral heels were previously noted with redness/pressure risk; ongoing pressure prevention in place.” RN 1, who did the visit on 2/21/2026, did not document Patient 7’s DTI on the Visit Note RN. There was also no documentation about whether the wound treatment was done or not. During a review of Patient 7’s Skin Assessment, dated 2/21/2026, RN 1 documented in the Skin Assessment that Patient 7 now had an unstageable wound on the left heel and the right heel. An unstageable wound is a medical term for a pressure injury when full-thickness skin and tissue loss occurs, but the extent of tissue damage within the injury cannot be determined because it is obscured by slough (a type of dead tissue that commonly forms in open or chronic wounds; it appears as a moist, stringy, or sticky substance that is typically pale yellow, cream, tan, or white) or eschar (a thick, dry, leathery layer of dead, necrotic tissue that forms over a wound). There was no documented evidence that the physician was notified about the unstageable wound on Patient 7’s bilateral heels. A phone call to interview RN 1 was made on 5/14/2026 at 1:11 p.m. The call was not answered or returned. During a review of Patient 7’s Visit Note Short Form, dated 2/28/2026, the Visit Note Short Form indicated that LVN 2 conducted a visit on that date and observed a new, open wound on Patient 7’s right heel. The Visit Note Short Form indicated that MD 1 was notified and a wound consult order was obtained. The Visit Note Short Form indicated that LVN 2 took a picture of the wound and sent it to MD 1 and the hospice team. The Visit Note Short Form indicated that LVN 2 cleaned the wound with wound cleanser, applied triple antibiotic, and covered with a rolled gauze. During a phone interview with LVN 2 on 5/14/2026 at 1:14 p.m., LVN 2 stated that she was assigned to Patient 7 and was familiar with Patient 7. LVN 2 stated that on 2/28/2026, Patient 7’s caregiver called her (LVN 2) and informed her (LVN 2) that Patient 7 had an open wound. LVN 2 stated that she made the visit immediately, notified MD 1 and the hospice agency about the wound, measured the wound, and took a picture of the wound. LVN 2 stated that MD 1 ordered a wound consult for Patient 7. LVN 2 stated, “MD 1 thought it looked pretty bad, so he wanted a wound consult.” LVN 2 stated that she made the hospice agency aware regarding the wound consult order. LVN 2 was asked if she uploaded the wound picture she took on 2/28/2026 to Patient 7’s clinical record, LVN 2 stated that she sent the picture to a communication system that the hospice agency used for their staff communication. LVN 2 stated that the hospice agency should be the one uploading the picture. During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD) on 5/14/2026 at 1:48 p.m., the DPCSD reviewed Patient 7’s POC Summary as of 5/14/2026, Visit Note LVN dated 12/10/2025, Skin Assessment dated 12/10/2025, Physician Order dated 12/10/2025, Visit Note RN dated 2/21/2026, Skin Assessment dated 2/21/2026, and Visit Note Short Form dated 2/28/2026. The DPCSD stated that there was no evidence that RN 1 notified the physician on 2/21/2026 that Patient 7’s DTI was observed open and became an unstageable pressure injury. The DPCSD stated that if RN 1 had observed a new unstageable wound on Patient 7’s left heel and right heel then RN 1 would need to notify the physician so the physician could give an order on what to do next. The DPCSD stated that there was no new treatment order for the unstageable wound because the physician was not notified. The DPCSD stated that the wound consult order received by LVN 2 from MD 1 was not transcribed to Patient 7’s orders until 3/3/2026. The DPCSD stated there was no follow-up on the wound consult order. The DPCSD stated that Patient 7 was never seen by a wound specialist until she passed away on 3/18/2026. On 5/14/2026 at 2:28 p.m., the HA’s Chief Financial Officer (CFO) stated that he remembered Patient 7’s wound consult order. The CFO stated that the wound specialist that MD 1 referred Patient 7 to did not accept the patient’s insurance. The CFO stated, “I still have the e-mail from them.” The CFO stated, “I looked for another wound specialist that would accept the patient’s insurance. I found one but Patient 7 already passed away before the wound specialist was able to see her.” On 5/14/2026 at 2:35 p.m., the DPCSD stated that Patient 7 had an IDG conference on 3/3/2026. There was no documentation on the follow-up for the wound consult order. The DPCSD stated that Patient 7’s wound consult, including if there were problems with the insurance, was supposed to be discussed during the IDG meeting. The DPCSD stated, “There’s no care coordination.” During a review of the HA’s policy and procedure (P&P) titled “Interdisciplinary Group Coordination of Care”, revised April 2017, the P&P indicated the following: The HA’s personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication. The P&P also indicated the following: 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.During a review of the HA’s P&P, titled “Monitoring Patient’s Response/Reporting to Physician,” revised April 2017, the P&P indicated that the patient’s physician and/or the hospice Medical Director would be contacted on the same day when any of the following occur:Changes in the patient’s condition”

“Based on interview and record review, the hospice agency failed to ensure home visits were conducted in accordance with the plan of care (POC, a personalized, comprehensive document that outlines the medical, emotional, psychosocial, and spiritual needs of a patient and their family during hospice care) for one of 14 sampled patients (Patient 11). This deficient practice had the potential to negatively affect the patients’ physical comfort, psychosocial well-being, and not receiving the needed and necessary services timely. Findings:During a review of Patient 11’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated Patient 11’s start of care (SOC) date of 7/14/2025, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities). During a review of Patient 11’s clinical record titled, POC/IDG Review (Plan of Care/Interdisciplinary Group Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness), dated 4/14/2026, the POC/IDG Review indicated the frequency of visits of the skilled nurse (SN) to one visit per week plus 3 PRN (pro re nata, which means “as needed”) visits and the social worker (MSW) to one visit per month plus 1 PRN visit. The spiritual counselor (SC), hospice aide and volunteer services were declined. During a review of Patient 11’s clinical record titled, History of Visit Notes, the History of Visit Notes indicated there was no SN visit conducted for the week starting on 4/26/2026 (Sunday) and ending on 5/2/2026 (Saturday). The History of Visit Notes further indicated Patient 11 was not seen by the social worker for the month of February 2026. During a concurrent interview and record review, on 5/15/2026 at 11:10 a.m., with the Director of Patient Care Services Designee (DPCS Designee), the DPCS Designee reviewed Patient 11’s History of Visit Notes and History of Psychosocial Assessment for 2026. The DPCS Designee stated and acknowledged Patient 11 was not visited by SN for the week from 4/26/2026 to 5/2/2026, and by the social worker for the month of February 2026. The DPCS Designee stated if patients are not seen as scheduled, it may lead to unmanaged pain and increased patient anxiety. During a review of the HA’s policy and procedure (P&P) titled, The Plan of Care, revised April 2017, the P&P indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live), failed to ensure infection control practices were implemented for one of 14 sampled patients (Patient 1), by the skilled nurse while assessing Patient 1. This failure has the potential to result in cross contamination and jeopardize the health and safety of the patients. During a review of Patient 1’s “Hospice Plan of Care” for the certification period from 4/12/2026 to 6/14/2026, the POC indicated Patient 1’s start of care date was 2/15/2026, with a terminal diagnosis of senile degeneration of the brain (the progressive, age-related decline of brain tissue and cognitive function). The POC indicated the frequency of visits for the skilled nurse (SN) included one visit every week for 12 weeks and 3 visits as needed. During a joint home visit, on 5/13/2026, at 12:28 p.m., at Patient 1’s residence, with Licensed Vocational Nurse (LVN) 1, Patient 1 was observed lying down in the bedroom with a caregiver (CG 2) present at bedside. LVN 1 was observed performing a head to toe assessment on Patient 1and did not change gloves after touching the patient’s perineal area (the diamond-shaped region at the base of the pelvis) to get supplies from her (LVN 1) clean bag. During an interview on 5/13/2026 at 1:20 p.m. with LVN 1 stated she did not follow standard infection control practices when she did not change gloves or clean hands before reaching into the bag. LVN 1 stated the importance of following infection control procedures to prevent the spread of disease. During an interview on 5/14/2026 at 1:29 p.m. with the Director of Patient Care Services Designee (DPCS Designee), the DPCS Designee stated LVN 1 should have removed her (LVN 1) gloves and performed handwashing before reaching into the clean supplies. The DPCS Designee stated implementing infection control practices are important to ensure diseases are not spread between different patients. During a record review of the agency’s policy and procedure (P&P) titled, “Standard Precautions,” undated, the P&P indicated that gloves are to be changed:1. Between tasks and procedures on the same patient2. During changing or cleaning an incontinent patient3. After removing an old dressing4. When the integrity of the glove is in doubt”

“Based on interview and record review, the hospice agency (HA, an agency providing care to terminally ill patients who have six months or less to live)) failed to ensure the hospice staff submitted completed clinical notes and pertinent clinical record information to reflect the care and assessment provided to one of 14 sampled patients (Patient 10). This failure resulted in patient’s incomplete clinical record that could lead to misinformation and lack of care and services provided to the patient. Findings:During a review of Patient 10’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated Patient 10’s start of care (SOC) date of 3/21/2025, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities) with late onset. During a review of Patient 10’s clinical record titled, POC (or Plan of Care, a written document that outlines the specific needs and services provided to a patient facing a terminal illness) Summary, the POC Summary included an order dated 3/21/2025, for the medical social worker ( or MSW, a licensed professional who provides emotional, psychosocial, and practical support to patients with life-limiting illnesses and their families) and the spiritual counselor (or SC, a professional who plans, assesses, and cares for a patient’s spiritual needs) to visit during initial, recertification, and plus 1 visit as needed for psychosocial and spiritual support to patient and/or patient caregiver/family. During a concurrent interview and record review, on 5/15/2026 at 11:10 a.m., with the Director of Patient Care Services Designee (DPCS Designee), the DPCS Designee reviewed Patient 10’s comprehensive recertification assessment for the benefit period starting from 6/19/2025 to 9/16/2025, and from 9/17/2025 to 11/15/2025. The DPCS Designee stated and acknowledged that there was no psychosocial and spiritual assessment conducted for Patient 10 for two recertification periods starting from 6/19/2025 to 9/16/2025, and from 9/17/2025 to 11/15/2025. The DPCS Designee stated Patient 10’s clinical records were incomplete because of the missing assessment from the MSW and SC for the recertification period starting from 6/19/2025 to 9/16/2025, and from 9/17/2025 to 11/15/2025. During a review of the hospice agency’s policy and procedure (P&P) titled, Entries into the Clinical Record, revised April 2017, the P&P indicated hospice personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. A clinical record will be initiated and maintained for each patient receiving care or services, according to organization policies found in this manual, and will include at a minimum: initial plan of care, updated plans of care, initial comprehensive and updated comprehensive assessments and clinical notes.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to include a discharge order from the Medical Director for one of fourteen sampled patients (Patient 8). This failure had the potential to result in an unsafe care transition and improperly coordinated follow-up hospice care. During a review of Patient 8’s Personal Information, the Personal Information indicated that Patient 8 was admitted to the HA on 7/10/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (a form of heart disease where plaque has built up in the heart’s blood vessels, narrowing them, but the person does not experience chest pain or tightness known as angina). The end of care date on the Personal Information was 5/5/2026. The Personal Information indicated the discharge was due to extended prognosis. During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD) on 5/15/2026 at 12:02 p.m., the DPCSD was asked about the discharge process. According to the DPCSD, if a patient remained stable, no further decline, discharge plan would be discussed during IDG meeting (Interdisciplinary Group meeting, a meeting where the Registered Nurse, Medical Social Worker, Chaplain, and Physician come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families), then a physician or Nurse Practitioner would do a face-to-face assessment, and the findings would be discussed in the IDG meeting. If the patient was stable, then IDG would plan to discharge and notify the patient and/or family, order necessary supplies and medications, and refer the patient back to the Primary Care Physician (PCP, main healthcare professional who serves as the first point of contact for non-emergency medical needs, routine physicals, and ongoing wellness). A discharge order would then be obtained from the Medical Director (MD). The DPCSD stated, “The discharge order is very important to ensure that the physician is aware that patient was going to be discharged, that patient is stable upon discharge. It’s part of a safe discharge due to extended prognosis.” During a review of Patient 8’s clinical records, indicated there was no discharge order from the Hospice Medical Director. The end of care date was on 5/5/2026. The Personal Information indicated the discharge was due to extended prognosis. During a review of the HA’s policy and procedure (P&P) titled “Contents of the Clinical Record,” revised April 2017, the P&P indicated the following information would be available in the clinical record, as applicable to care and services provided:Relevant communication to the patient’s physician.Any referrals made to internal or external care clinicians and to community agencies.Discharge summary and other summary reports sent to the physician as required by law, regulation, and organization policy.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to complete a discharge summary for one of fourteen sampled patients (Patient 8). This failure might disrupt the patient’s continuity of care and affect patient’s health and safety post discharge. During a review of Patient 8’s Personal Information, the Personal Information indicated that Patient 8 was admitted to the HA on 7/10/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (a form of heart disease where plaque has built up in the heart’s blood vessels, narrowing them, but the person does not experience chest pain or tightness known as angina). The end of care date on the Personal Information was 5/5/2026. The Personal Information indicated the discharge was due to extended prognosis. During a review of the Discharge Summary for Patient 8, the Discharge Summary was not done. The Discharge Summary had Patient 8’s name on it, the date 5/5/2026, and extended prognosis as the discharge reason; there was no other information. During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD) on 5/15/2026 at 12:02 p.m., the DPCSD reviewed Patient 8’s Discharge Summary, dated 5/5/2026. The DPCSD stated there was no discharge summary completed for Patient 8. The DPCSD stated, “This is not done.” The DPCSD stated that completing a discharge summary was very important because it would have the patient’s diagnosis, reason for hospice admission, services provided by the HA, and medications. The DPCSD stated that the lack of a discharge summary could cause a break in the patient’s care. During a review of the HA’s policy and procedure (P&P) titled “Discharge Summary,” revised April 2017, the P&P indicated that each patient discharged from a service and from hospice would have a discharge summary filed in the clinical record. The discharge summary and other relevant clinical record documents would be completed and submitted within 72 hours of discharge from service.”