Heartford Hospice

“Based on interview and record review, the hospice failed to ensure the comprehensive assessments were completed no later than five calendar days after the election of hospice care for one of three sampled patients (Patient 2). This failure had the potential for not addressing the care needs for this patient.Findings: Review of the hospice’s P&P titled Comprehensive Assessment revised 11/2021 showed a comprehensive patient assessment will be performed by the interdisciplinary group no later than five calendar days after the election of hospice care in consultation with the attending physician.Review of Patient 2’s closed clinical record was initiated on 9/18/26. The clinical record showed SOC was 12/23/25. The patient was certified for hospice services during the certification periods from 12/23/25 to 3/22/26, 3/23/26 to 6/20/26, and 6/21/26 to 8/19/26. Patient 2 was discharged on 7/31/26.The Admission Consent dated 12/23/25, showed the family member had consented for hospice services.The RN Initial/Comprehensive Assessment was completed on 12/23/25.However, the Spiritual Counselor Comprehensive Assessment was completed on 12/29/25, which was more than five days after the election of hospice care.On 9/22/26 at 1400 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS was informed and confirmed the findings.”

“Based on observation, interview, and record review, the hospice failed to ensure the medication profile was reviewed to include all current medications for one of three sampled patients (Patient 1). This failure had the potential for the patient not receiving the appropriate care and necessary services that could negatively affect the patient’s well-being.Findings: The hospice’s P&P titled Medication Profile revised 11/2021 showed the patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.Review of Patient 1’s clinical record was initiated on 9/17/26. The clinical record showed the SOC was 7/16/26. The patient was certified for hospice services during the certification period from 7/16/26 to 10/13/26.On 9/18/26 at 1400 hours, a home visit was conducted with LVN 1 to the assisted living facility where Patient 1 resided. The signed Medication Profile for the benefit period 7/16/26 to 10/13/26, showed the patient’s medications included the following:-Ativan (antianxiety) 0.5 mg one tablet every six hours as needed by mouth for anxiety. -morphine sulfate (opioid pain medication) 100 mg/5 ml oral solution 0.25 ml every four hours as needed for moderate to severe pain or shortness of breath.However, the medication pack at the patient’s assisted living facility showed the following:-Ativan 0.5 mg oral tablet one tablet by mouth two times a day as needed for agitation and severe agitation.-morphine sulfate 15 mg one-half tablet every four hours as needed for pain and shortness of breath. An interview and concurrent medication profile review was conducted with LVN 1. LVN 1 was informed and confirmed the patient’s medication profile was not updated.On 9/22/26 at 1347 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments included the changes that occurred since the initial assessments, information on the patients’ progress, and reassessment of the patients’ responses for two of three sampled patients (Patients 1 and 3). This failure had the potential of not addressing the care needs for these patients.Findings: Review of the hospice’s P&P titled Plan of Care revised 11/2021, showed the plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every 15 days. The plan of care must be initiated at start of care.1. Review of Patient 1’s clinical record was initiated on 9/17/26. The clinical record showed the SOC was 7/16/26. The patient was certified for hospice services during the certification period from 7/16/26 to 10/13/26.Review of the Care Coordination Note dated 7/24/26, showed the facility staff called to report the patient had swollen left and right fingers. However, there was no documented evidence the IDG had discussed and updated the comprehensive assessment to include the changes that had occurred regarding the patient’s swollen left and right fingers.On 9/22/26 at 1329 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS acknowledged and confirmed the findings.2. Review of Patient 3’s clinical record was initiated on 9/22/26. The clinical record showed the SOC was 4/10/26. The patient was certified for hospice services during the certification periods from 4/10/26 to 7/8/26 and 7/9/26 to 10/6/26.Review of the IDG Summary/Comprehensive Assessment dated 9/2/26, showed the IDG discussion for nursing and SC updates.However, there was no documented evidence of the IDG discussion for the psychosocial updates.On 9/22/26 at 1420 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS acknowledged and confirmed the findings.”

“Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POCs for two of three sampled patients (Patients 1 and 3). This failure had the potential for not providing appropriate, consistent, and quality care to the patients.Findings: Review of the hospice’s P&P titled the Plan of Care, revised 11/2021, showed the written plan of care will contain, but not limited to, the following:-diagnosis-identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, bereavement and counseling-reduction in risk factors-mental status-nutritional requirements-prognosis-frequency/amount/duration and type of services-individualized interventions to assist with end-of-life care-statement of treatment goals-interdisciplinary group assessment of needs-pain and symptom management interventions-drugs and treatments-physician orders-measurable outcomes anticipated from implementing and coordinating the plan of care.1. Review of Patient 1’s clinical record was initiated on 9/17/26. The clinical record showed the SOC was 7/16/26. The patient was certified for hospice services during the certification period from 7/16/26 to 10/13/26.a. Review of the Skilled Nurse Visit dated 7/17, 7/23, 7/21, 7/31, 8/3, 8/6, 8/12, 8/17, 8/19, 8/21, 8/24, and 9/4/26, showed Patient 1 was on the intermittent oxygen use at two liters per minute via nasal cannula.However, there was no documented evidence of a physician’s order for the use of intermittent oxygen at two liters per minute.On 9/18/26 at 1039 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS confirmed the findings.b. Review of the Spiritual Counselor Visit dated 8/10/26, showed the SC conducted a spiritual care visit for the patient. However, there was no documented evidence a physician had ordered a visit for the patient.c. Review of the IDG Summary/Comprehensive Assessment dated 8/19/26, showed the SC’s active frequency was two visits per month for two months from 8/19/26 to 9/30/26.However, there was no documented evidence the SC had conducted visits from 8/19/26 to 8/31/26, as ordered in the POC.On 9/22/26 at 1329 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS acknowledged and confirmed the findings.2. Review of Patient 3’s clinical record was initiated on 9/22/26. The clinical record showed the SOC was 4/10/26. The patient was certified for hospice services during the certification periods from 4/10/26 to 7/8/26 and 7/9/26 to 10/6/26.a. Review of the IDG Summary/Comprehensive Assessment dated 7/8, 7/22, 8/5, 8/19, 9/2, and 9/16/26 showed an active frequency for the HA for two visits for nine weeks from 7/9/26 to 9/5/26.However, review of the HA Visit documentation showed the HA conducted three visits for the weeks of 7/12/26 to 7/18/26, 7/19/26 to 7/25/26, 7/26/26 to 8/1/26, 8/2/26 to 8/8/26, 8/9/26 to 8/15/26, 8/16/26 to 8/22/26, 8/23/26 to 8/29/26, and 8/30/26 to 9/5/26, which was not in accordance with the POC.Further review of the HA Visit documentation showed the HA conducted visits for the weeks of 9/6/26 to 9/12/26 and 9/13/26 to 9/19/26; however, there was no documented evidence the physician had ordered HA visits after 9/5/26.b. Review of the IDG Summary/Comprehensive Assessment dated 7/8/26, showed MSW visits one visit per month from 4/10/26 to 6/30/26.Review of the Psychosocial Visit dated 7/13/26, showed the MSW conducted a psychosocial routine visit, wherein the visit occurred was beyond the ordered time frame. There was no documented evidence the physician had ordered an MSW visit after 7/8/26.c. Review of the IDG Summary/Comprehensive Assessment dated 7/8/26, showed SC visits two times per month in three months from 4/10/26 to 6/30/26.Review of the Spiritual Counselor Visit dated 7/20/26, showed the SC conducted a spiritual care visit, wherein the visit conducted was beyond the ordered time frame. However, there was no documented evidence a physician had ordered an SC visit after 7/8/26.d. Review of the IDG Summary/Comprehensive Assessment dated 8/5/26, showed the Orders Updates Since Last IDG Meeting for impaired skin integrity related to two new wounds: 1) right lateral ankle popped blister measuring 1 cm x 1 cm, and 2) a right lower leg intact friction blister.Review of the SN Visit dated 8/14/26, showed the following wound documentation:-Feet-ankle, lateral right foot: skin tear/trauma measuring 1 cm x 1 cm, popped blister, cleansed with normal saline, patted dry, applied triple antibiotic ointment, and covered with island dressing for protection.-Front-lower leg, middle, right lower leg: Intact friction blister measuring 2 cm x 1.5 cm , applied 4 x 4 island dressing (absorbent pad surrounded by an adhesive border) for added protection.Review of the SN Visit dated 8/17/26, showed the following wound documentation:- Lateral right foot: Skin tear/trauma measuring 1 cm x 1 cm, popped blister, cleansed with normal saline, patted dry, applied triple antibiotic ointment, and covered with island dressing for protection.-Front lower leg, right lower leg: intact friction blister measuring 2 cm x 1.5 cm, cleansed with normal saline, patted dry, applied triple antibiotic ointment, and covered with island dressing.On 9/22/26 at 1420 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS acknowledged and confirmed the findings.”

“Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for one of three sampled patients (Patient 1). This failure had the potential to cause inconsistent delivery of care which could result in the decline or lack of improvement of the patient’s health conditions.Findings: Review of the hospice’s P&P titled the Plan of Care revised 11/2021 showed the written plan of care will contain, but not limited to, the following:-diagnosis-identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, bereavement and counseling-reduction in risk factors-mental status-nutritional requirements-prognosis-frequency/amount/duration and type of services-individualized interventions to assist with end-of-life care-statement of treatment goals-interdisciplinary group assessment of needs-pain and symptom management interventions-drugs and treatments-physician orders-measurable outcomes anticipated from implementing and coordinating the plan of care.Review of Patient 1’s clinical record was initiated on 9/17/26. The clinical record showed the SOC was 7/16/26. The patient was certified for hospice services during the certification period from 7/16/26 to 10/13/26.a. Review of the Initial IDG Summary/Comprehensive Assessment dated 7/22/26, showed the following updates:-Both legs were swollen with +2 pitting edema (moderate fluid buildup in body tissues) to both lower extremities; and-During attempts to reposition, the patient became verbally agitated, screaming, yelling, and cursing. Patient 1 intermittently grabbed and dug fingernails into the staff’s skin during care.However, there was no documentation the IDG had developed an individualized POC to address Patient 1’s +2 pitting edema and behavior.b. Review of the IDG Summary/Comprehensive Assessment dated 8/5/26 showed the diet order for the patient as follows: may have pureed diet with nectar thickened liquids as tolerated.However, there was no documentation the IDG had developed an individualized POC to address Patient 1’s pureed diet order.On 9/22/26 at 1329 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS acknowledged and confirmed the findings.”

“Based on interview and record review, the hospice failed to ensure the initial and revised POCs included the indication for the PRN discipline visits for two of three sampled patients (Patients 1 and 2). This failure had the potential of not providing necessary services for these patients.Findings: 1. Review of Patient 1’s clinical record was initiated on 9/17/26. The clinical record showed the SOC was 7/16/26. The patient was certified for hospice services during the certification period from 7/16/26 to 10/13/26.Review of the IDG Summary/Comprehensive Assessment dated 8/5, 8/19, 9/2, and 9/16/26, showed SN visits as eight PRN visits from 7/16/26 to 10/13/26.However, there was no documented evidence showing the indication for the PRN visits.On 9/22/26 at 1329 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS acknowledged and confirmed the findings.2. Review of Patient 2’s closed clinical record was initiated on 9/18/26. The clinical record showed SOC was 12/23/25. The patient was certified for hospice services during the certification periods from 12/23/25 to 3/22/26, 3/23/26 to 6/20/26, and 6/21/26 to 8/19/26. Patient 2 was discharged on 7/31/26.Review of the IDG Summary/Comprehensive Assessments dated 4/8, 4/22, 5/6, 5/20, 6/3, and 6/17/26 showed SN visits as eight PRN visits from 3/23/26 to 6/20/26.Review of the IDG Summary/Comprehensive Assessments dated 6/17, 7/1, and 7/15/26, showed SN visits as nine PRN visits from 6/21/26 to 8/19/26.Review of the IDG Summary/Comprehensive Assessment dated 7/29/26, showed SN visits as nine PRN visits from 6/21/26 to 7/31/26.Review of the IDG Summary/Comprehensive Assessments dated 5/6, 5/20, 6/3, and 6/17/26 showed MSW visits as two PRN visits from 4/25/26 to 6/20/26.However, there was no documented evidence showing the indication for the SN and MSW PRN visits.On 9/22/26 at 1400 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS acknowledged and confirmed the findings.”

“Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for three of three sampled patients (Patients 1, 2, and 3). This failure had the potential risk of not evaluating the POC and providing appropriate care and services to these patients.Findings: 1. Review of Patient 1’s clinical record was initiated on 9/17/26. The clinical record showed the SOC was 7/16/26. The patient was certified for hospice services during the certification period from 7/16/26 to 10/13/26.The Initial IDG Summary/Comprehensive Assessment dated 7/22/26, showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for patient’s identified problems. For example, Patient 1 had a care plan addressing impaired skin integrity related to immobility. Documentation showed one of the goals was skin will heal to maximum potential. There was no documented evidence as to what the maximum potential for the skin to heal.The IDG Summary/Comprehensive Assessment dated 8/5/26, showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for patient’s identified problems. For example, Patient 1 had a care plan addressing the bilateral lower extremity edema related to advance cardiac disease. Documentation showed the SN to educate the patient/caregiver on medications used to achieve optimal cardiac function. There was no documented evidence as to what optimal cardiac function to achieve.On 9/22/26 at 1329 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS acknowledged and confirmed the findings.2. Review of Patient 2’s closed clinical record was initiated on 9/18/26. The clinical record showed SOC was 12/23/25. The patient was certified for hospice services during the certification periods from 12/23/25 to 3/22/26, 3/23/26 to 6/20/26 and 6/21/26 to 8/19/26. Patient 2 was discharged on 7/31/26.Review of the IDG Summary/Comprehensive Assessment dated 3/25, 4/8, 4/22, 5/6, 6/3, 6/17, 7/1, and 7/15/26, showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example, Patient 2 had a care plan addressing pain. Documentation showed one of the goals was the patient will exhibit a decrease in pain-related behaviors. There was no documented evidence of what pain-related behavior exhibited would be decreased by the patient.On 9/22/26 at 1400 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS acknowledged and confirmed the findings.3. Review of Patient 3’s clinical record was initiated on 9/22/26. The clinical record showed the SOC was 4/10/26. The patient was certified for hospice services during the certification periods from 4/10/26 to 7/8/26 and 7/9/26 to 10/6/26.Review of the IDG Summary/Comprehensive Assessment dated 7/8, 7/22, 8/5, and 9/2/26, showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example, Patient 3 had a care plan addressing pain. Documentation showed one of the goals was that caregiver will verbalize understanding of non-verbal pain cues. There was no documented evidence of what non-verbal pain cues to be understood by the caregiver.On 9/22/26 at 1420 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS acknowledged and confirmed the findings.”

“Based on interview and record review, the hospice failed to ensure the Interdisciplinary Group reviewed and revised the patient’s Plans of Care at least every 15 calendar days for one of three sampled patients (Patient 3). This failure had the potential to result in this patient not receiving appropriate, consistent, and quality hospice care.Findings: Review of Patient 3’s clinical record was initiated on 9/22/26. The clinical record showed the SOC was 4/10/26. The patient was certified for hospice services during the certification periods from 4/10/26 to 7/8/26 and 7/9/26 to 10/6/26.Review of the Care Coordination dated 7/19/26, showed a telephone call reporting Patient 3 had a witnessed fall. Documentation showed the patient lost his balance and landed on his back.Review of the IDG Summary/Comprehensive Assessment dated 7/22, 8/5, 8/19, 9/2, and 9/16/26, showed the patient’s identified care plan problem included falls.However, there was no documented evidence the identified care plan problem for fall was updated to provide appropriate care for the patient.On 9/22/26 at 1420 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS acknowledged and confirmed the findings.”

“Based on observation, interview and record review, the hospice failed to ensure the IDG maintained responsibility for directing and supervising the care and services provided for one of three sampled patients (Patient 1). This failure had the potential of not addressing the care needs for this patient.Findings: Review of the hospice’s P&P titled Interdisciplinary Group Membership and Responsibilities revised 11/2023 showed the interdisciplinary group responsibilities include among others: participation in the establishment of the plan of care for each patient admitted to the hospice services, participation in the periodic review and updating of the plan of care for each patient receiving hospice services, and provision and/or supervision and coordination of hospice are and services.Review of the hospice’s P&P titled Interdisciplinary Group Plan of Care revised 11/2021 showed the type and scope of services provided by the interdisciplinary group will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions.Review of Patient 1’s clinical record was initiated on 9/17/26. The clinical record showed the SOC was 7/16/26. The patient was certified for hospice services during the certification period from 7/16/26 to 10/13/26.a. Review of the Care Coordination Note dated 7/24/26, showed the facility staff called to report Patient 1 having swollen left and right fingers.However, there was no documented evidence the patient’s swollen left and right fingers problem was coordinated with the IDG.b. Review of the IDG Summary/Comprehensive Assessment dated 7/16, 8/5, 8/19, 9/2, and 9/16/26, showed the plans of care were updated on the mentioned dates.On 9/18/26 at 1400 hours, a home visit was conducted with LVN 1 to the assisted living facility where Patient 1 resided. The hospice binder at the assisted living facility had an attached Initial IDG Summary/Comprehensive Assessment dated 7/22/26. However, the hospice binder did not include the updated IDG Summary/Comprehensive Assessments.An interview and concurrent clinical record review were conducted with LVN 1. LVN 1 confirmed the hospice binder at the assisted living facility did not include the updated plans of care.On 9/22/26 at 1329 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS acknowledged and confirmed the findings.”

“Based on interview and record review, the hospice’s GB and the Administrator failed to maintain the administrative responsibility and the day-to-day operations of the hospice as evidenced by:-Failure to ensure the RN provided timely supervision to the HAs for one of three sampled patients (Patient 1).-Failure to ensure the patient’s clinical records were complete and accurate for three of three sampled patients for three of three sampled patients (Patients 1, 2, and 3).-Failure to ensure the members of the IDG signed the IDG meeting attendance form for three of three sampled patients (Patients 1, 2, and 3).These failures had the potential for poor health outcomes for the patients receiving hospice services.Findings: Review of the hospice’s P&P titled Governing Body revised 11/2021 showed the Governing Body will assume full legal authority, responsibility, decision-making and accountability for the overall management and operations, the provision of services, fiscal operations, human resource management, review of the organization’s budget and operational plans, and its quality assessment and performance improvement (QAPI) program. The Governing Body of the hospice agency will serve as the governing authority for the home care program, which will function according to the hospice agency’s bylaws.Review of the hospice’s Job Description for the Executive Director/Administrator, undated, showed the Executive Director/Administrator is responsible for the overall direction of the day-to-day operations of the hospice services. He/she is responsible for establishing standards of care to comply with federal and state regulations and guidelines. The essential job functions/responsibilities included ensuring organizational compliance with legal, regulatory, and accreditation requirements; and ensuring the appropriate service policies and procedures are developed and implemented to accomplish identified outcomes.1. According to 42 CFR 418.76(h)(1)(i), a registered nurse (RN) must make an on‑site supervisory visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that the services ordered by the hospice interdisciplinary group meet the patient’s needs. The hospice aide does not have to be present during this visitReview of the hospice’s P&P titled Hospice Nursing Care revised 11/2021 showed nursing services will be provided in accordance with accepted standards of practice by or under the supervision of a registered nurse. The hospice registered nurse will supervise licensed practical/vocational nurses, hospice aides, homemakers and volunteers in the home.Review of Patient 1’s clinical record was initiated on 9/17/26. The clinical record showed the SOC was 7/16/26. The patient was certified for hospice services during the certification period from 7/16/26 to 10/13/26.Review of the Initial IDG Summary/Comprehensive Assessment dated 7/16/26, showed HA visits two times per week for 13 weeks from 7/19/26 to 10/13/26.Review of the clinical record during certification period from 7/16/26 to 10/13/26, showed the HA conducted visits for the weeks of 7/19/26 to 7/25/26, 7/26/26 to 8/1/26, 8/2/26 to 8/8/26, 8/9/26 to 8/15/26, 8/16/26 to 8/22/26, 8/23/26 to 8/29/26, and 8/30/26 to 9/5/26.* However, there was no documented evidence the RN conducted HA supervision every 14 days.On 9/22/26 at 1329 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS acknowledged and confirmed the findings.2. Review of the hospice’s P&P titled Clinical Record Review, revised 11/2021, showed clinical records will be reviewed at least quarterly by qualified organizational personnel to assure that documentation entered is reliable, timely, valid and accurate.a. Review of Patient 1’s clinical record was initiated on 9/17/26. The clinical record showed the SOC was 7/16/26. The patient was certified for hospice services during the certification period from 7/16/26 to 10/13/26.Review of the RN Initial/Comprehensive Assessment dated 7/16/26, showed the following:-Psychosocial Assessment was left blank; and-Hours of sleep per day indicated “14”; however, there was no documented evidence to identify if there was no problem identified or if it was an abnormal behavior.On 9/22/26 at 1329 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS acknowledged and confirmed the findings.b. Review of Patient 2’s closed clinical record was initiated on 9/18/26. The clinical record showed SOC was 12/23/25. The patient was certified for hospice services during the certification periods from 12/23/25 to 3/22/26, 3/23/26 to 6/20/26, and 6/21/26 to 8/19/26. Patient 2 was discharged on 7/31/26.Review of the IDG Summary/Comprehensive Assessment dated 1/14/26, showed an MSW’s psychosocial updates/progress toward goals. * However, the psychosocial updates/progress toward goals shown was for another patient.Review of the Skilled Nurse Visit dated 3/23/26, showed Patient 2 had a deep- tissue injury on the back/coccyx , mid/lower section.* Review of the IDG Summary/Comprehensive Assessment dated 3/25/26, showed Patient 2 had a Stage 1 pressure injury on the coccyx which was inconsistent with the above SN visit.Review of the IDG Summary/Comprehensive Assessment dated 7/1/26, showed RN 1’s nursing updates/progress toward goals.* However, the discussed nursing updates/progress towards goals were dated 4/13/26.On 9/22/26 at 1400 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS acknowledged and confirmed the findings.c. Review of Patient 3’s clinical record was initiated on 9/22/26. The clinical record showed the SOC was 4/10/26. The patient was certified for hospice services during the certification periods from 4/10/26 to 7/8/26 and 7/9/26 to 10/6/26.Review of the IDG Summary/Comprehensive Assessment dated 7/8/26, showed the physician’s order dated 7/4/26, for wound care to the right foot, 2 cm x 2 cm, open blister.* However, the plan of care update showed impaired skin integrity related to 2 cm x 2 cm popped blister on the left lower leg, which was inconsistent with the location of the blister in the physician’s order.Review of the LVN Visit dated 7/10/26, showed no problem identified in the integumentary system. Additionally, LVN 1 answered “No” to the question, “Does the patient have one or more skin condition?”* However, the interventions performed during the visit included wound care to the left lower leg which was inconsistent with the above problem identification.On 9/22/26 at 1420 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS acknowledged and confirmed the findings.3. Review of the hospice’s P&P titled Interdisciplinary Group Membership and Responsibilities, revised 11/2023, showed the hospice interdisciplinary group membership includes at a minimum: a Physician, Registered Nurse, Social Worker, and Pastoral or other counselor.Review of the hospice’s P&P titled Interdisciplinary Group Meeting revised 11/2021 showed members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor.a. Review of Patient 1’s clinical record was initiated on 9/17/26. The clinical record showed the SOC was 7/16/26. The patient was certified for hospice services during the certification period from 7/16/26 to 10/13/26.Review of the Initial IDG Summary/Comprehensive Assessment dated 7/22/26, and the IDG Summary/Comprehensive Assessments dated 8/5, 8/19, 9/2, and 9/16/26, showed the POC was discussed during the IDG Meeting. A check mark was shown for the Physician Orders, SN, MSW and SC.* However, the signatures for the physician, RN, MSW and SC were missing.On 9/22/26 at 1329 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS acknowledged and confirmed the findings.b. Review of Patient 2’s closed clinical record was initiated on 9/18/26. The clinical record showed SOC was 12/23/25. The patient was certified for hospice services during the certification periods from 12/23/25 to 3/22/26, 3/23/26 to 6/20/26, and 6/21/26 to 8/19/26. Patient 2 was discharged on 7/31/26.Review of the Initial IDG Summary/Comprehensive Assessment dated 12/31/25 and the IDG Summary/Comprehensive Assessments dated 1/14, 1/28, 2/11, 2/25, 3/11, 3/25, 4/8, 4/22, 5/6, 5/20, 6/3, 6/17, 7/1, 7/15, and 7/29/26, showed the POC was discussed during the IDG Meetings. A check mark was shown for the Physician Orders, SN, MSW, and SC.* However, the signatures for the physician, RN, MSW, and SC were missing.On 9/22/26 at 1400 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS acknowledged and confirmed the findings.c. Review of Patient 3’s clinical record was initiated on 9/22/26. The clinical record showed the SOC was 4/10/26. The patient was certified for hospice services during the certification periods from 4/10/26 to 7/8/26 and 7/9/26 to 10/6/26.Review of the Initial IDG Summary/Comprehensive Assessment dated 4/15/26, showed the POC was discussed during the IDG Meeting. A check mark was shown for the Physician Orders, SN, MSW, and SC. * However, the signatures for the physician, RN, MSW, and SC were missing.Review of the IDG Summary/Comprehensive Assessments dated 4/29, 5/13, 5/27, 6/10, 6/24, 7/8, 7/22, 8/5, 8/19, 9/2, and 9/16/26, showed the POC discussed during the IDG Meeting. A check mark was shown for the Physician Orders, SN, MSW and SC. However, the signatures for the physician, RN, MSW, and SC were missing.On 9/22/26 at 1420 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS acknowledged and confirmed the findings.”

“Based on observation, interview, and record review, the hospice failed to review and update frequency of the prescribed medication for one out of three sampled patients (Patient 2). This failure had the potential for the patients to not receive the appropriate care and necessary services and negatively affect the patient’s well-being.Findings: The hospice’s P&P titled Medication Profile revised 11/2021 showed to include the following:-Patients receiving medication administered by the organization will have current, accurate medication profile in the clinical record.-Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current medication regimen, including name, dosage, strength, route, frequency, date and time of administration. -A drug regimen review will be performed by a registered nurse at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with addition of a new medication. -Using the medication profile to evaluate the use of the drugs in the home setting. The medication profile includes, but is not limited to all current medications, date prescribed, name of medication, dose, frequency, drug classification and date discontinued. Review of Patient 2’s clinical record was initiated on 6/29/26. The clinical record showed the SOC was 11/17/25. The patient was certified for hospice services during the certification periods from 11/17/25 to 2/14/26, 2/15/26 to 5/15/26, and 5/16/26 to 7/14/26. A joint home visit with RN 1 was conducted on 7/1/26 at 0904 hours, to the assisted living facility where Patient 2 resided. Review of the Medication Profile for the certification period from 5/16/26 to 7/14/26, showed the patient’s medications included Aspirin (blood thinner) 81 mg one oral tablet daily as needed. On 7/1/26 at 1020 hours, an interview and concurrent clinical record review was conducted with RN 1 and Medication Technician 1 (the assisted living facility’s staff). Review of the Aspirin medication available showed Aspirin enteric coated 81 mg one tablet by mouth everyday for CVA. Medication Technician 1 was asked if Patient 2 ever had a medication stored and labeled as Aspirin 81 mg one tablet daily as needed. Medication Technician 1 stated Patient 2 never had Aspirin as needed. RN 1 was informed and verified that the Medication Profile should have been corrected. RN 1 further stated Patient 2 was always receiving Aspirin daily and not as needed. On 7/1/26 at 1527 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS was informed and verified the medication profile should have been checked every visit.”

“Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments included the changes that occurred since the initial assessments, information on the patients’ progress, and reassessment of the patients’ responses for three of three sampled patients (Patients 1, 2, and 3). This failure had the potential of not addressing the care needs for these patients.Findings: The hospice’s P&P titled Interdisciplinary Group Plan of Care dated 11/2021 showed agency will communicate changes in a timely manner via telephone, one to one meetings, interdisciplinary group meetings and home visits. The interdisciplinary group in collaboration with the attending physician, if any will conduct assessments, develop and update plan of care, and review the effectiveness of care a minimum of every 15 calendar days. 1. Review of Patient 2’s clinical record was initiated on 6/29/26. The clinical record showed the SOC was 11/17/25. The patient was certified for hospice services during the certification periods from 11/17/25 to 2/14/26, 2/15/26 to 5/15/26, and 5/16/26 to 7/14/26. Review of the Care Coordination Note dated 5/14/26, showed the following:- Medication Technician 2 called to report the patient had a change of condition.- The patient lost consciousness for three minutes. The patient also had an increase heart rate up to 130 beats per minute. Medication Technician 2 requested for a nurse to visit. Review of the IDG Summary/ Comprehensive Assessment Meeting dated 5/27/26, showed an updated plan of care for the use of new medications which were Cipro (antibiotic) 250 mg one oral tablet twice a day for seven days for urinary tract infection, with a start date 5/15/26 and end date 5/22/26, and another medication, nystatin (antifungal) 100,000 unit/gram one application three times a day for seven days on affected groin rashes, with a start date 5/14/26 and end date 5/21/26. *However, there was no documented evidence the IDG had discussed and updated the comprehensive assessment to include the changes that had occurred regarding the patient’s lost of consciousness and increased heart rate up to 130 beats per minute. On 7/2/26 at 1357 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS was informed and verified the finding. 2. Review of Patient 3’s clinical record was initiated on 6/29/26. The clinical record showed the SOC was 5/11/25. The patient was certified for hospice services during the certification periods from 5/11/25 to 8/8/25, 8/9/25 to 10/7/25, 10/8/25 to 12/6/25, 12/7/25 to 2/4/26, 2/5/26 to 4/5/26, 4/6/26 to 6/4/26, and 6/5/26 to 8/3/26. Review of the Care Coordination Note dated 3/13/26, showed the facility staff called and documentation included swelling of the left foot with pain upon palpation. Review of the IDG Summary/Comprehensive Assessment Meeting dated 3/18/26, showed Patient 2 had an updated plan of care on the use of new medications that included Lasix (diuretic) 20 mg one oral tablet daily for the left foot edema, with a start date of 03/15/26. However, there was no documented evidence the IDG had discussed and updated the comprehensive assessment to include the changes that had occurred regarding Patient 3’s left foot swelling with pain upon palpation. On 7/2/26 at 1423 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS was informed and verified the finding. 3. Review of Patient 1’s clinical record was initiated on 6/29/26. The clinical record showed the SOC was 12/27/24. The patient was certified for hospice services during the certification periods from 12/27/24 to 3/26/25, 3/27/25 to 6/24/25, 6/25/25 to 8/3/25, 8/24/25 to 10/22/25, 10/23/25 to 12/21/25, 12/22/25 to 2/19/26, 2/20/26 to 4/20/26, 4/21/26 to 6/19/26, and 6/20/26 to 8/18/26. Review of the Care Coordination Note dated 6/16/26, showed a call was received from the facility staff to report that the patient had increased secretions and there was no oxygen in the room. Documentation showed the caller thought the patient needed to have a nurse visit and the caller reported the patient had hyoscyamine sulfate (used to reduce oral secretions) every four hours as needed. Review of the IDG Summary/Comprehensive Assessment Meeting dated 6/17/26, showed Patient 1 had an updated plan of care on the use of new medications that included Ativan (antianxiety) 1 mg one oral tablet every two hours as needed for shortness of breath/restlessness, with a start date of 6/17/26. *However, there was no documented evidence the IDG had discussed and updated the comprehensive assessment to include the changes that had occurred regarding Patient 1’s increased secretions and there was no oxygen in the room. On 7/2/26 at 1023 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding.”

“Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for one out of three sampled patients (Patient 3). This failure created the risk of not providing appropriate, consistent, and quality care to this patient. The hospice’s P&P titled The Plan of Care revised 11/2021 showed care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes. The hospice’s P&P titled Missed Visit revised 11/2021 showed 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. If a visit is missed and not rescheduled the clinician will notify the IDG and clinical supervisor of the missed visit and reason for missed visit. Document in the patient’s clinical record the following information: patient name, date and type of visit that was missed, description of any unmet needs and how the patient’s needs were met, any other follow up needed, other person(s) that were notified of the missed visit, and signature of staff member reporting the information. The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits. Review of Patient 3’s clinical record was initiated on 6/29/26. The clinical record showed the SOC was 5/11/25. The patient was certified for hospice services during the certification periods from 5/11/25 to 8/8/25, 8/9/25 to 10/7/25, 10/8/25 to 12/6/25, 12/7/25 to 2/4/26, 2/5/26 to 4/5/26, 4/6/26 to 6/4/26, and 6/5/26 to 8/3/26. Review of the Physician’s Order dated 4/1/26, showed SN visits two times a week for nine weeks, start date on 4/6/26, end date on 6/4/26. Review of the SN Visit Notes for the week of 4/26 to 5/2/26, showed the SN Visit Note dated 4/30/26. *However, there was no documented evidence the SN visited two times a week for the week of 4/26 to 5/2/26. On 7/2/26 at 1423 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding.”

“Based on record review and interview, the hospice failed to ensure the written POC was developed to reflect the patient and family goals and interventions based on the problems identified for one of three sampled patients (Patient 2). This failure created the risk of not addressing the care needs for this patient.Findings: Review of Patient 2’s clinical record was initiated on 6/29/26. The clinical record showed the SOC was 11/17/25. The patient was certified for hospice services during the certification periods from 11/17/25 to 2/14/26, 2/15/26 to 5/15/26, and 5/16/26 to 7/14/26. Review of the Comprehensive Plan of Care dated 5/29/26, showed a physician’s order for Aspirin 81 mg one oral tablet daily as needed for blood thinner. *However, there was no documented evidence of an individualized POC developed to address the use of Aspirin as a blood thinning agent. On 7/2/26 at 1357 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS was informed and verified the finding.”

“Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for supervising and coordinating the care and services related to the bereavement assessment for one of three sampled patients (Patient 2). This failure created the risk of not addressing the care needs for this patient.Findings: The hospice’s P&P titled Interdisciplinary Group Membership and Responsibilities revised date 11/2023 showed the IDG responsibilities include but are not limited to:-Provision and/or supervision and coordination of hospice care and services. The hospice’s P&P titled Bereavement Services (undated) showed a bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. Review of Patient 2’s clinical record was initiated on 6/29/26. The clinical record showed the SOC was 11/17/25. The patient was certified for hospice services during the certification periods from 11/17/25 to 2/14/26, 2/15/26 to 5/15/26, and 5/16/26 to 7/14/26. Review of the Bereavement Assessment Narrative Note dated 11/18/25, showed the MSW left a message to the Patient 2’s legal representative regarding the patient. Documentation showed the MSW to continue to be available and provide support as needed. *However, there was no documented evidence for any communication or coordination to follow up with Patient 2’s legal representative on the rescheduling for the bereavement assessment. The IDG failed to supervise and coordinate the rescheduling of the bereavement assessment. On 7/2/26 at 1357 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS was informed and verified the finding.”