Aster Palliative and Hospice Care

“Based on observation, record review, and interview, the hospice failed to ensure the initial and comprehensive assessments were completed, reviewed, and revised to address and meet the patients’ care needs as evidenced by: 1.The hospice failed to ensure the comprehensive assessments were completed no later than five calendar days after the election of hospice care. Cross reference to L523.2.The hospice failed to ensure the comprehensive assessment included assessment for volunteer need. Cross reference to L524.3.The hospice failed to ensure the comprehensive assessments included the assessment for the imminence of death. Cross reference to L528.4.The hospice failed to ensure the medication profiles were reviewed to include the patient’s current medications. Cross reference to L530.5. The hospice failed to ensure the comprehensive assessments included the initial bereavement assessments to address the needs of the patient’s family and other individuals/PCG focusing on the social, religious, and cultural factors which may impact their ability to cope with patient’s death. Cross reference to L531.6.The hospice failed to ensure the updated comprehensive assessments included the changes that had occurred since the initial assessment, information on the patient’s progress, and reassessment of the patient’s responses. Cross reference to L533. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the initial and comprehensive assessments to meet the patients’ care needs.”

“Based on interview and record review, the hospice failed to ensure the IDT, care planning, and coordination of services were provided to meet the patient’s care needs as evidenced by: 1. The hospice failed to ensure the care and services were provided in accordance with the POC. Cross reference to L543.2. The hospice failed to ensure the individualized care plans were developed. Cross reference to L545.3. The hospice failed to ensure the initial and revised POCs included the indication for the PRN discipline visits. Cross reference to L547.4. The hospice failed to ensure the POCs included measurable outcomes. Cross reference to L548.5. The hospice failed to ensure the ID had reviewed/revised the patient’s POCs no less frequently than every 15 calendar days. Cross reference to L552.6. The hospice failed to ensure the revised POCs included the patient’s progress toward goals specified in the POCs. Cross reference to L553.7. The hospice failed to ensure the IDT maintained the responsibility for directing and supervising the care and services. Cross reference to L554.The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the interdisciplinary team, care planning and coordination of services to meet the patients’ care needs.”

“Based on interview and record review, the hospice failed to ensure the volunteer services were provided to meet the patient’s care needs as evidenced by:Findings: 1. The hospice failed to ensure the ongoing efforts for recruiting and retaining volunteers was documented. This failure had the potential of not providing the adequate volunteer services. Cross reference to L645.2. The hospice failed to ensure the cost saving for the volunteers provided for the total patient care hours of all paid hospice employees and contracted staff. Cross reference to L646.3. The hospice failed to ensure the volunteers provided at a minimum, equals to 5% of the total patient care hours of all paid hospice employees and contracted staff. Cross reference to L647. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the volunteer services to meet the patients’ care needs.”

“Based on interview and record review, the hospice failed to ensure the clinical records for each hospice patient were completed and contained correct clinical information as evidenced by: 1. The hospice failed to ensure the patients’ clinical records were complete and accurate. Cross reference to L672.2. The hospice failed to ensure the election of hospice statement was completed. Cross reference to L673.3. The hospice failed to authenticate the entries made into the clinical record. Cross reference to L679.The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the clinical records to be complete and accurate.”

“Based on interview and record review, the hospice failed to ensure the comprehensive assessment was completed no later than five calendar days after the election of hospice care for one of 10 sampled patients (Patient 4). 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 4/2020 showed a comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with the attending physician. Review of Patient 4’s closed clinical record was initiated on 1/15/26. The clinical record showed the SOC was 6/25/25. The patient was certified for hospice services during the certification period from 6/25/25 to 9/22/25.The Election of Hospice Benefit Informed Consent dated 6/25/25, showed the family member authorized for hospice services.The initial comprehensive nursing assessment was conducted on 6/25/25.Further review of the closed clinical record showed the Physicians Order dated 6/25/25, for SC and MSW visit within 5 days from admission to assess and evaluate spiritual and psycho-social needs of patient, family and primary caregiver. However, review of the closed clinical record showed no documented evidence the hospice had completed the initial comprehensive spiritual and psychosocial assessments for the patient.On 1/23/26 at 0938 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator /CEO was asked as to the timeline of the completion of spiritual and psychosocial comprehensive assessments. The Administrator replied, it should be completed within 5 days from admission. The Administrator/CEO was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the comprehensive assessment included the assessment for volunteer needs for four of 10 sampled patients (Patients 2, 5, 7, and 9). This failure had the potential risk of not identifying and addressing the care needs for these patients.Findings: xx.Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26 and 1/16/26 to 3/16/26.However, further review of the clinical record failed to show documented evidence the initial comprehensive assessment included the assessment of he patient’s need for volunteer services.On 1/23/26 at 1040 hours, an interview and concurrent clinical review was conducted with RN 2. RN 2 verified and acknowledged the finding. ##. Review of Patient 7’s clinical record was initiated on 1/16/26. The clinical record showed the SOC was 7/7/25. The patient was certified for hospice services during the certification periods from 7/15/25 to 9/12/25, 9/13/25 to 11/11/25 and 11/12/25 to 1/10/26.Review of the Comprehensive Nursing Assessment dated 7/8/25, showed the RN 1 had performed the initial comprehensive assessment. However, there was no documented evidence of the need for volunteer services was included on the initial comprehensive assessment.On 1/23/26 at 1030 hours, an interview and concurrent clinical review with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. ##. Review of Patient 2’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 9/15/25. The patient was certified for hospice services during the certification periods from 9/15/25 to 11/13/25, 11/14/25 to 1/12/26 and 1/13/256 to 3/13/26.Review of the Comprehensive Nursing Assessment dated 9/15/25, showed the Quality Assurance Director had performed the initial comprehensive assessment. However, there was no documented evidence of the need for volunteer services was included on the initial comprehensive assessment.On 1/23/26 at 1151 hours, an interview and concurrent clinical review with the Administrator/CEO. The Administrator /CEO was informed and acknowledged the findings. ###. Review of Patient 9’s clinical record was initiated on 1/21/26. The clinical record showed the SOC was 5/16/25. The patient was certified for hospice services during the certification periods from 5/16/25 to 8/13/25, 8/14/25 to 10/12/25, 10/13/25 to 12/11/25 and 12/12/25 to 2/9/2026. Review of the Comprehensive Nursing Assessment dated 5/1625, showed the Quality Assurance Director had performed the initial comprehensive assessment. The comprehensive assessment included bereavement screening. However, there was no documented evidence the bereavement assessment was completed as the section was left blank. In addition, there was no documented evidence of the need for volunteer services was included on the initial comprehensive assessment.On 1/23/26 at 1028 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.”

“Based on record review and interview, the hospice failed to ensure the comprehensive assessments included the imminence of death for 10 of 10 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10). This failure had the potential risk of not appropriately addressing the patients’ needs. Review of the hospice’s P&P titled Comprehensive Assessment revised 4/2020, showed during comprehensive assessment, all baseline data and other relevant information will be documented in the patient’s clinical record including imminence of death.Review of 10 sampled patients’ clinical records (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) showed no documented evidence the initial and comprehensive assessments identified the imminence of death for these patients. For example:xx. Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26 and 1/16/26 to 3/16/26.Review of the initial Comprehensive Nursing Assessment dated 5/21/25 showed RN 1 had assessed patient’s communication and other factors and body system (head-to-toe).However, further review of the clinical records showed the initial Comprehensive Assessment did not identify the imminence of death for Patient 5.On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings.xx.Review of Patient 3’s clinical record was initiated on 1/14/26. The clinical record showed SOC was 3/18/25. The patient was certified for hospice services during the certification periods from 3/18/25 to 6/15/25, 6/16/25 to 9/13/25, 9/14/25 to 11/12/25, 11/13/25 to 1/11/26, 1/12/26 to 3/13/26.Review of the initial Comprehensive Nursing Assessment dated 3/18/25 showed RN 5 had assessed patient’s communication and other factors and body system (head-to-toe).However, further review of the clinical records showed the initial Comprehensive Assessment did not identify the imminence of death for Patient 3.On 1/23/26 at 0955 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings.xx.Review of Patient 10’s closed clinical record was initiated on 1/22/26. The clinical record showed SOC was 6/19/25. The patient was certified for hospice services during the certification periods from 6/19/25 to 9/16/25 and 9/17/25 to 12/15/25. Patient was discharged on 11/12/25.Review of the initial Comprehensive Nursing Assessment dated 6/19/25 showed RN 6 had assessed patient’s communication and other factors and body system (head-to-toe).However, further review of the clinical records showed the initial Comprehensive Assessment did not identify the imminence of death for Patient 10.On 1/23/26 at 1134 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings. XX. Review of Patient 1’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 2/12/25. The patient was certified for hospice service during the certification period from 2/12/25 -5/12/25, 5/13/25 - 8/10/25, 8/11/25 - 10/9/25, 10/10/25 -12/8/25, 12/9/25 - 2/6/26 and 2/7/25 - 4/726. Review of Patient 1’s initial Comprehensive Nursing Assessment dated 2/12/25 showed RN 3’s assessment on patient’s communication and other factors and body system (head-to-toe).However, further review of the clinical records showed no documentation on the initial assessment for Imminently Dying. XX. Review of Patient 6’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 3/26/25. The patient was certified for hospice service during the certification period from 3/26/25 - 6/23/25, 6/24/25 - 9/21/25, 9/22/25 - 11/20/25, 11/21/25 - 1/19/26 and 1/20/26 to 3/20/26. Review of the initial Comprehensive Nursing Assessment dated 3/26/25 showed RN 6’s s assessment on patient’s communication and other factors and body system (head-to-toe).However, further review of Patient 6’s clinical records showed no documentation on the initial assessment for Imminently Dying. XX. Review of Patient 8’s clinical record was initiated on 1/14/26. The clinical record showed the POC was 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 - 6/3/25, 6/4/25 - 9/1/25, 9/2/25 - 10/31/25, 11/1/25 - 12/30/25 and 12/31/25 - 2/28/26. Review of the initial Comprehensive Nursing Assessment dated 3/6/25 showed RN 3’s assessment on patient’s communication and other factors and body system (head-to-toe).However, further review of Patient 8’s clinical records showed no documentation on the initial assessment for Imminently Dying. On 1/23/26 at 0958 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed of the above findings and acknowledged assessment on imminently dying were all were blank. ##. Review of Patient 7’s clinical record was initiated on 1/16/26. The clinical record showed the SOC was 7/7/25. The patient was certified for hospice services during the certification periods from 7/15/25 to 9/12/25, 9/13/25 to 11/11/25 and 11/12/25 to 1/10/26.Review of the Comprehensive Nursing Assessment dated 7/8/25, showed the RN 1 had performed initial comprehensive assessment. The assessment included a section for imminently dying. However, the initial comprehensive assessment was not completed as the section for imminently dying was left blank. On 1/23/26 at 1030 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/CEO The Administrator/CEO was informed and acknowledged the findings. Review of the hospice’s P&P titled Comprehensive Assessment revised 4/2020 showed during comprehensive assessment, all baseline data and other relevant information will be documented in the patient’s clinical record including imminence of death.Review of 10 sampled patients’ clinical records (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) showed no documented evidence the initial and comprehensive assessments included the imminence of death for these patients. For example:1. Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26, and 1/16/26 to 3/16/26.Review of the initial Comprehensive Nursing Assessment dated 5/21/25, showed RN 1 had assessed the patient’s communication and other factors and body system (head-to-toe).However, further review of the clinical record showed the initial Comprehensive Assessment did not include the imminence of death for Patient 5.On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings. 2. Review of Patient 3’s clinical record was initiated on 1/14/26. The clinical record showed SOC was 3/18/25. The patient was certified for hospice services during the certification periods from 3/18/25 to 6/15/25, 6/16/25 to 9/13/25, 9/14/25 to 11/12/25, 11/13/25 to 1/11/26, and 1/12/26 to 3/13/26.Review of the initial Comprehensive Nursing Assessment dated 3/18/25, showed RN 5 had assessed the patient’s communication and other factors and body system (head-to-toe).However, further review of the clinical record showed the initial Comprehensive Assessment did not include the imminence of death for Patient 3.On 1/23/26 at 0955 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings. 3. Review of Patient 10’s closed clinical record was initiated on 1/22/26. The clinical record showed SOC was 6/19/25. The patient was certified for hospice services during the certification periods from 6/19/25 to 9/16/25 and 9/17/25 to 12/15/25. Patient10 was discharged on 11/12/25.Review of the initial Comprehensive Nursing Assessment dated 6/19/25, showed RN 6 had assessed the patient’s communication and other factors and body system (head-to-toe).However, further review of the clinical record showed the initial Comprehensive Assessment did not include the imminence of death for Patient 10.On 1/23/26 at 1134 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings. 4. Review of Patient 7’s clinical record was initiated on 1/16/26. The clinical record showed the SOC was 7/7/25. The patient was certified for hospice services during the certification periods from 7/15/25 to 9/12/25, 9/13/25 to 11/11/25, and 11/12/25 to 1/10/26.Review of the Comprehensive Nursing Assessment dated 7/8/25, showed RN 1 had performed the initial comprehensive assessment. The assessment included a section for imminently dying. However, the section for imminently dying was left blank. On 1/23/26 at 1030 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. 5. Review of Patient 1’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 2/12/25. The patient was certified for hospice service during the certification periods from 2/12/25 to 5/12/25, 5/13/25 to 8/10/25, 8/11/25 to 10/9/25, 10/10/25 to 12/8/25, 12/9/25 to 2/6/26 and 2/7/25 to 4/726. Review of Patient 1’s initial Comprehensive Nursing Assessment dated 2/12/25 showed RN 3’s assessment on the patient’s communication and other factors and body system (head-to-toe).However, further review of the clinical record showed no documentation of the initial assessment for imminently dying. 6. Review of Patient 6’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 3/26/25. The patient was certified for hospice service during the certification periods from 3/26/25 to 6/23/25, 6/24/25 to 9/21/25, 9/22/25 to 11/20/25, 11/21/25 to 1/19/26, and 1/20/26 to 3/20/26. Review of the initial Comprehensive Nursing Assessment dated 3/26/25, showed RN 6’s s assessment on the patient’s communication and other factors and body system (head-to-toe).However, further review of Patient 6’s clinical records showed no documentation of the initial assessment for imminence of death. 7. Review of Patient 8’s clinical record was initiated on 1/14/26. The clinical record showed the POC was 3/6/25. The patient was certified for hospice services during the certification periods from 3/6/25 to 6/3/25, 6/4/25 to 9/1/25, 9/2/25 - 10/31/25, 11/1/25 - 12/30/25 and 12/31/25 - 2/28/26. Review of the initial Comprehensive Nursing Assessment dated 3/6/25 showed RN 3’s assessment on patient’s communication and other factors and body system (head-to-toe).However, further review of Patient 8’s clinical records showed no documentation on the initial assessment for Imminently Dying.On 1/23/26 at 0958 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed of the above findings and acknowledged assessment on imminently dying were all were blank.”

“Based on observation, interview, and record review, the hospice failed to ensure the medication profiles were reviewed to include all current medications for four of 10 sampled patients (Patients 1, 2, 5, and 6). This failure had the potential for patients not receiving the appropriate care and necessary services that could negatively affect the patient’s well-being.Findings: XX. Review of Patient 1’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 2/12/25. The patient was certified for hospice service during the certification period from 2/12/25 -5/12/25, 5/13/25 - 8/10/25, 8/11/25 - 10/9/25, 10/10/25 -12/8/25, 12/9/25 - 2/6/26 and 2/7/25 - 4/726. Review of Patient 1’s Current Treatment/ Medication List Profile showed a physician’s order dated 12/3/25, magnesium glycinate (dietary supplement) 250 mg one capsule daily.On 1/15/26 at 1126 hours, a home visit was conducted with LVN 3 to Patient 1’s residence. A concurrent medication profile review, and an interview was conducted with LVN 3. A bottle of magnesium glycinate with an expiration dated of 8/2025 was observed to be included in the Patient 1’s medication tray. LVN 3 was informed of the expiration date and acknowledged it should have been disposed.XX. Review of Patient 6’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 3/26/25. The patient was certified for hospice service during the certification period from 3/26/25 - 6/23/25, 6/24/25 - 9/21/25, 9/22/25 - 11/20/25, 11/21/25 - 1/19/26 and 1/20/26 to 3/20/26. Review of Patient 6’s Current Treatment/ Medication List available at Patient 1’s residence showed the patient’s medication included a physician’s order dated 12/28/25, to administer prednisone 10 mg (indicated for upper respiratory infection/ wheezing/ shortness of breath) 10 mg one tablet once a day for 5 days. However, the medication profile failed to show a stop date or discontinued date. On 1/20/26 at 1136 hours, a home visit was conducted with CHHA 1 to Patient 6’s residence. A concurrent medication profile review, and an interview was conducted with CHHA 1 and the Patient 1’s Authorized Representative/ emergency Contact. CHHA 1 was asked to check if there was a physician’s discontinued order from Patient 1’s Medication Profile for prednisone. CHHA 1 acknowledged, she could not find the discontinued / stop date of prednisone medication. On 1/23/26 at 1415 hours, a concurrent medication profile review, and an interview was conducted with RN 1. RN 1 was informed and acknowledged the above findings. ###. Review of Patient 2’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 9/15/25. The patient was certified for hospice services during the certification periods from 9/15/25 to 11/13/25, 11/14/25 to 1/12/26 and 1/13/256 to 3/13/26.The Medication Profile showed the patient’s medications included the following:-Bactroban (topical antibiotic ) 2% topical ointment 1 gram topical daily,-hydrocortisone (topical steroid) 1% cream 1 gram topical apply a thin layer to affected area twice a day as needed, -Tylenol arthritis pain (analgesic) 650 mg extended release gel tab 650 mg one tablet oral Q8H PRN.A joint home visit with RN 2 was conducted on 1/20/26 at 1033 hours at the patient’s home.Review of the patient’s medications included the following:-Bactroban (topical antibiotic) 2% topical ointment. The medication was not available, per PCG the medication will be delivered on the day of the visit.-hydrocortisone (topical steroid)1% cream was expired. The medication was expired. The expiration date was 1/1/26. Per PCG the medication was used 2 days ago.-Tylenol arthritis pain (analgesic) 650 mg extended release gel tab. The instruction on the bottle was to take once a day for pain instead of Q8H PRN. On 1/20/26 at 1113 hours an interview and concurrent clinical record review was conducted with RN 2 and the PCG. RN 2 verified the above findings.On 1/23/26 at 1205 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. The hospice’s P&P titled Medication Profile revised 4/2020 showed, patient’s 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.xx. Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26 and 1/16/26 to 3/16/26.The Medication Profile showed the patient’s medications included the following:-acetaminophen (treats mild to moderate pain) 325 mg two tablets as needed every four hours as needed.-melatonin (used to fall asleep faster) 5 mg once a day at bedtime.-Promethazine DM (used for the temporary relief of cough) 6.25 mg-15 mg/5 ml syrup 5 ml every eight hours as needed-Diclofenac (used to treat mild to moderate pain and inflammation) 25 mg capsule every eight hours as needed.A joint home visit with LVN 1 was conducted on 1/20/26 at 1020 hours at the patient’s home.Review of the patient’s medications included the following:-acetaminophen 500 mg taken as needed, per PCG.-melatonin was discontinued.-Promethazine DM was discontinued.The Diclofenac was ordered on 1/18/26, however, the medication has not been delivered to the patient’s home yet.On 1/20/26 at 1100 hours, an interview and concurrent clinical record review were conducted with LVN 1 and the PCG. LVN 1 verified and acknowledged the findings.On 1/23/26 at 1630 hours, the Administrator was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the comprehensive assessments included the initial bereavement assessments to address the needs of the patient’s family and other individuals/PCG focusing on the social, religious, and cultural factors which may impact their ability to cope with patient’s death for five of 10 sampled patients (Patients 1, 4, 5, 7,and 10). This failure had the potential of not addressing the bereavement needs for these patients’ family/PCG.Findings: xx.Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26 and 1/16/26 to 3/16/26.Review of the clinical record showed no documented evidence the initial bereavement assessment was completed.On 1/23/26 at 1040 hours, an interview and concurrent clinical review was conducted with RN 2. RN 2 verified and acknowledged the finding.xx.Review of Patient 10’s closed clinical record was initiated on 1/22/26. The clinical record showed SOC was 6/19/25. The patient was certified for hospice services during the certification periods from 6/19/25 to 9/16/25 and 9/17/25 to 12/15/25. Patient was discharged on 11/12/25.Review of the clinical record showed no documented evidence the initial bereavement assessment was completed.On 1/23/26 at 1134 hours, an interview and concurrent clinical review was conducted with RN 2. RN 2 verified and acknowledged the finding. ##. Review of Patient 4’s closed clinical record was initiated on 1/15/26. The clinical record showed the SOC was 6/25/25. The patient was certified for hospice services during the certification period from 6/25/25 to 9/22/25. The Election of Hospice Benefit Informed Consent dated 6/25/25, showed the family member authorized for hospice services.Review of the Physicians Order dated 6/25/25 showed an order for Bereavement Coordination to assess and evaluate bereavement and grieving risk factors within 5 days from admission. However, review of the closed clinical record failed to show documented evidence of the initial bereavement assessment was completed.On 1/23/26 at 0938 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator replied, it should be completed within 5 days from admission. The Administrator/CEO was informed and acknowledged the findings. ##. Review of Patient 7’s closed clinical record was initiated on 1/16/26. The clinical record showed the SOC was 7/7/25. The patient was certified for hospice services during the certification periods from 7/15/25 to 9/12/25, 9/13/25 to11/11/25 and 11/12/25 to 1/10/26.Review of the clinical record showed failed to show documented evidence of the initial bereavement assessment was completed.On 1/23/26 at 1030 hours, an interview and concurrent clinical review with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. Review of the hospice’s P&P titled Bereavement Services revised 4/2020 showed a bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care. XX. Review of Patient 1’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 2/12/25. The patient was certified for hospice service during the certification period from 2/12/25 -5/12/25, 5/13/25 - 8/10/25, 8/11/25 - 10/9/25, 10/10/25 -12/8/25, 12/9/25 - 2/6/26 and 2/7/25 - 4/726. Review of Patient 1’s POC Summary dated 1/14/26 showed a physician’s order dated 2/12/25, for Bereavement Coordination to assess and evaluate bereavement and grieving risk factors within 5 days of admission.Review of the clinical record showed the initial bereavement assessment section was blank.On 1/23/26 at 0958 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the above findings.”

“Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments included the changes that had occurred since the initial assessment, information on the patient’s progress, and reassessment of the patient’s responses for six of 10 sampled patients (Patients 4, 5, 6, 7, 8 and 9). This failure had the potential of not addressing the care needs for these patients.Findings: Review of the P&P titled Plan of Care Process revised 4/2020, 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.xx.Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26 and 1/16/26 to 3/16/26.Review of LVN 1’s Visit Note dated 9/1/25, showed in the narrative Patient 5 had some bruising and skin discoloration on the outer side of the right knee, left arm and forearm.However, the Hospice POC/IDG Review dated 9/12/25, showed no documented evidence the IDG had discussed the patient’s bruising and skin discoloration.Review of LVN 1’s Visit Note dated 9/29/25, showed in the narrative patient noted with minor scratches under the knee. The PCG reported patient had a fall on 9/23/25.However, the Hospice POC/IDG Review dated 10/10/25, showed no documented evidence the IDG had discussed the patient’s incident of fall and minor scratches under the knee.On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings. XX. Review of Patient 6’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 3/26/25. The patient was certified for hospice service during the certification period from 3/26/25 - 6/23/25, 6/24/25 - 9/21/25, 9/22/25 - 11/20/25, 11/21/25 - 1/19/26 and 1/20/26 to 3/20/26. Record of Patient 6’s LVN 1 Visit Notes dated 11/26/25 showed on the narrative, a pressure ulcer was noted in the buttock area. specific However, review of the POC/IDG Review Notes dated 12/5/25 failed to show updated IDG comprehensive assessment review for Patient 6’s pressure ulcer. Record of Patient 6’s LVN 1’s Visit Notes dated 12/3/25 showed on the narrative, a coccyx pressure ulcer with redness was noted. However , review of the POC/IDG Review Notes dated 12/5/25 failed to show updated IDG comprehensive assessment review for Patient 6’s coccyx pressure ulcer. Record of Patient 6’s LVN 1 Visit Notes dated 12/29/25 showed on the narrative, the patient experienced diarrhea during the visit, which the caregiver reported was likely related to the administration of a suppository and milk magnesia. However, review of the POC/IDG Review Notes dated 1/2/26 failed to show updated IDG comprehensive assessment review Patient 6’s episode of diarrhea. XX. Review of Patient 8’s clinical record was initiated on 1/14/26. The clinical record showed the POC was 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 - 6/3/25, 6/4/25 - 9/1/25, 9/2/25 - 10/31/25, 11/1/25 - 12/30/25 and 12/31/25 - 2/28/26. Review of Patient 8’s LVN 1 Visit Notes dated 12/8/25 showed on Integumentary skin assessment right calf wound. Wound care provided. Cleanse wound with wound cleanser, pat dry, cover with gauze sponge, apply gauze and secure with tape. However, review of Patient 8’s POC/IDG Review Notes dated 12/19/25 failed to show specific assessment to reflect Patient 8’s right calf wound. The POC/IDG Integumentary/ Skin Assessment target date was also blank. On 1/23/26 at 0958 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was asked if there was any documentation for Patient 6 and 8 on any revised plan of care. RN 1 acknowledged above findings and verified it should have been done. ##. Review of Patient 4’s closed clinical record was initiated on 1/15/26. The clinical record showed the SOC was 6/25/25. The patient was certified for hospice services during the certification period from 6/25/25 to 9/22/25. The patient passed away on 8/5/25.Review of the Update Assessment dated 7/9, 7/23/25 showed the RN had performed the comprehensive assessment.Further review of the Update Assessment dated 8/4/25 showed the DPCS had performed the comprehensive assessment.However, the section to assessed for Imminently Dying was left blank. On 1/23/26 at 0938 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.##. Review of Patient 7’s clinical record was initiated on 1/16/26. The clinical record showed the SOC was 7/7/25. The patient was certified for hospice services during the certification periods from 7/15/25 to 9/12/25, 9/13/25 to 11/11/25 and 11/12/25 to 1/10/26.Review of the Update Assessment dated 11/25, 12/9 and 12/23/25, showed the RN 2 had performed the comprehensive assessment.However, the section to assessed for Imminently Dying was left blank. On 1/23/26 at 1030 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. ###. Review of Patient 9’s clinical record was initiated on 1/21/26. The clinical record showed the SOC was 5/16/25. The patient was certified for hospice services during the certification periods from 5/16/25 to 8/13/25, 8/14/25 to 10/12/25, 10/13/25 to 12/11/25 and 12/12/25 to 2/9/2026. Review of the Update Assessment dated 10/24, 11/9 7, 11/21 and 12/5, 12/19, and 1/2/26, showed the RN 2 had performed the comprehensive assessment.However, the section to assessed for Imminently Dying was left blank. On 1/23/26 at 1106 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. Review of the P&P titled Plan of Care Process revised 4/2020, 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 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26 and 1/16/26 to 3/16/26.Review of LVN 1’s Visit Note dated 9/1/25, showed Patient 5 had some bruising and skin discoloration on the outer side of the right knee, left arm, and forearm.However, the Hospice POC/IDG Review dated 9/12/25, showed no documented evidence the IDG had discussed the patient’s bruising and skin discoloration.Review of LVN 1’s Visit Note dated 9/29/25, showed the patient noted with minor scratches under the knee. Documetation showed the PCG reported the patient had a fall on 9/23/25.However, the Hospice POC/IDG Review dated 10/10/25, showed no documented evidence the IDG had discussed the patient’s incident of fall and minor scratches under the knee.On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings.2. Review of Patient 4’s closed clinical record was initiated on 1/15/26. The clinical record showed the SOC was 6/25/25. The patient was certified for hospice services during the certification period from 6/25/25 to 9/22/25. The patient passed away on 8/5/25.Review of the Update Assessment dated 7/9 and 7/23/25, showed the RN had performed the comprehensive assessment.Further review of the Update Assessment dated 8/4/25, showed the DPCS had performed the comprehensive assessment.However, the section to assess for imminently dying was left blank. On 1/23/26 at 0938 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.3. Review of Patient 7’s clinical record was initiated on 1/16/26. The clinical record showed the SOC was 7/7/25. The patient was certified for hospice services during the certification periods from 7/15/25 to 9/12/25, 9/13/25 to 11/11/25 and 11/12/25 to 1/10/26.Review of the Update Assessment dated 11/25, 12/9, and 12/23/25, showed RN 2 had performed the comprehensive assessment.However, the section to assess for imminently dying was left blank. On 1/23/26 at 1030 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.4. Review of Patient 9’s clinical record was initiated on 1/21/26. The clinical record showed the SOC was 5/16/25. The patient was certified for hospice services during the certification periods from 5/16/25 to 8/13/25, 8/14/25 to 10/12/25, 10/13/25 to 12/11/25, and 12/12/25 to 2/9/2026. Review of the Update Assessment dated 10/24, 11/9, 11/21, 12/5, and 12/19 and 1/2/26, showed RN 2 had performed the comprehensive assessment.However, the section to assess for imminently dying was left blank. On 1/23/26 at 1106 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.5. Review of Patient 6’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 3/26/25. The patient was certified for hospice service during the certification period from 3/26/25 to 6/23/25, 6/24/25 to 9/21/25, 9/22/25 to 11/20/25, 11/21/25 to 1/19/26, and 1/20/26 to 3/20/26. Record of Patient 6’s LVN 1 Visit Notes dated 11/26/25 showed a pressure injury was noted on the buttock area. However, review of the POC/IDG Review Notes dated 12/5/25, failed to show updated IDG comprehensive assessment review for Patient 6’s pressure injury.Record of Patient 6’s LVN 1’s Visit Notes dated 12/3/25, showed a coccyx pressure injury with redness was noted. However, review of the POC/IDG Review Notes dated 12/5/25, failed to show updated IDG comprehensive assessment review for Patient 6’s coccyx pressure injury. Record of Patient 6’s LVN 1 Visit Notes dated 12/29/25, showed the patient experienced diarrhea during the visit which the caregiver reported was likely related to the administration of a suppository and milk magnesia. However, review of the POC/IDG Review Notes dated 1/2/26, failed to show updated IDG comprehensive assessment review of Patient 6’s episode of diarrhea. On 1/23/26 at 0958 hou6. Review of Patient 8’s clinical record was initiated on 1/14/26. The clinical record showed the POC was 3/6/25. The patient was certified for hospice services during the certification periods from 3/6/25 to 6/3/25, 6/4/25 to 9/1/25, 9/2/25 to 10/31/25, 11/1/25 to 12/30/25, and 12/31/25 to 2/28/26. Review of Patient 8’s LVN 1 Visit Notes dated 12/8/25 showed on Integumentary skin assessment right calf wound. Wound care provided. Cleanse wound with wound cleanser, pat dry, cover with gauze sponge, apply gauze and secure with tape. However, review of Patient 8’s POC/IDG Review Notes dated 12/19/25 failed to show specific assessment to reflect Patient 8’s right calf wound. The POC/IDG Integumentary/ Skin Assessment target date was also blank. On 1/23/26 at 0958 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was asked if there was any documentation for Patient 6 and 8 on any revised plan of care. RN 1 acknowledged above findings and verified it should have been done.”

“Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for six of 10 sampled patients (Patients 2, 5, 6, 8, 9, and 10). 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 4/2020 showed the written plan of care will contain, but will not be limited to, the following:A. Start of care date, B. Certification period, C. Patient demographics, D. Diagnosis, E. Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, bereavement and counseling F. Reduction in risk factors, G. Functional limitations, H. Mental Status I. Safety Measures to protect against abuse, injury, infection, or communicable disease as appropriate J. Nutritional requirements K. Prognosis L. DME and medical supplies necessary to meet patient needs M. Frequency/ Amount/ Duration and type of services N. Placement at the appropriate level of care and referrals as needed for counseling, additional disciplines, volunteers and and adjunctive services O. Individualized interventions to assist with end-of-lie care P. Patient and family/caregiver educational needs and assessment of their ability to learn and understand teaching and their ability to safely self administer drugs and biologicals Q. Statement of treatment of goals R. Interdisciplinary group assessment of needs S. Pain and symptoms management interventions T. Drugs and Treatments (including allergies) U. Physician-directed instruction to patient and family/ caregiver V. Physician (or other authorized licensed independent practitioner) orders W. Measurable outcomes anticipated from implementing and coordinating the plan of care X. Patient or representatives level of understanding, involvement and agreement with the plan of care Y. End of life preferences Z. Anticipated discharge and bereavement care needs of the family.XX. Review of Patient 6’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 3/26/25. The patient was certified for hospice service during the certification period from 3/26/25 - 6/23/25, 6/24/25 - 9/21/25, 9/22/25 - 11/20/25, 11/21/25 - 1/19/26 and 1/20/26 to 3/20/26. Review of Patient 6’s POC/ IDG review 1/2/26 showed frequency of visit of LVN: 1 per week and PRN visits, MSW: 1 as needed and Recertification and SC: 1 as needed and Recertification.Record of Patient 6’s History of Nursing Assessments showed RN 2 provided Recertification visits dated 1/7/26.However, record of Patient 6’s History of Spiritual Counsellor Assessment Notes and History of Psychosocial Assessment Notes failed to show any documentation of visits during the RN Recertification dated 1/7/26.XX. Review of Patient 8’s clinical record was initiated on 1/14/26. The clinical record showed the POC was 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 - 6/3/25, 6/4/25 - 9/1/25, 9/2/25 - 10/31/25, 11/1/25 - 12/30/25 and 12/31/25 - 2/28/26. Review of Patient 8’s POC/ IDG review 10/24/25 showed frequency of visit of LVN: 1 per week and PRN visits, MSW: 1 as needed and Recertification and SC: 1 as needed and Recertification.Record of Patient 8’s History of Nursing Assessments showed RN provided Recertification visits dated 10/21/25 and 12/30/25.However, record of Patient 8’s History of Spiritual Counsellor Assessment Notes failed to show any documentation of visits during the RN Recertification visits dated 10/21/25 and 12/30/25.Record of Patient 8’s LVN 4 visit notes dated 11/24/25 and 12/4/25 showed missed visits. However, there was no documentation the hospice physician was informed and no documentation of a rescheduled visit. On 1/23/26 at 0958 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed of the above findings and acknowledged whatever was on the hospice patients’ plan of care, all should be followed. RN 1 also verified the missed visits should have been informed to the physician and should have been rescheduled. xx. Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26 and 1/16/26 to 3/16/26.The POC/IDG Review dated 1/2/26 showed a wound care treatment for right hand tear. Cleanse wound with appropriate wound cleanser and gently pat dry. Apply Xeroform dressing (a dressing used for wound care to maintain a moist environment, reduce odor and prevent sticking to wound) daily. On alternate days apply triple antibiotic ointment as clinically indicated. Cover with 4x4 non-adhesive gauze, wrap with Kerlix (a six ply fluff dried bandage) and secure with paper tape. Monitor wound for signs of infection, including increased redness, drainage, or odor.Furthermore, review of the POC for integumentary/skin opened on 12/22/25, intervention includes assess changes in wound status – check size, integrity, location, type/stage, signs and symptoms of infection, drainage and effectiveness of current treatment.However, LVN 1’s Visit Notes dated 12/29/25, 1/5/26 and 1/12/26, and RN 2’s Recert Assessment dated 1/2/26 showed no documented evidence LVN 1 and RN 2 have performed wound care on the right hand’s tear. Furthermore, there was no documented evidence the wound status was assessed.On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings.xx.Review of Patient 10’s closed clinical record was initiated on 1/22/26. The clinical record showed SOC was 6/19/25. The patient was certified for hospice services during the certification periods from 6/19/25 to 9/16/25 and 9/17/25 to 12/15/25. Patient was discharged on 11/12/25.The POC/IDG Review dated 9/12, 9/26, 10/10, 10/24 and 11/7/25 showed LVN one visit per week plus one PRN visit. The LVN Visit Notes showed no documented evidence the LVN conducted a visit on Week 1 (9/14/25 to 9/20/25), Week 3 (9/28/25 to 10/4/25) and Week 5 (10/12/25 to 10/18/25) instead of one visit per week as per the POC.On 1/23/26 at 1134 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 confirmed and acknowledged the findings. ##. Review of Patient 2’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 9/15/25. The patient was certified for hospice services during the certification periods from 9/15/25 to 11/13/25, 11/14/25 to 1/12/26 and 1/13/256 to 3/13/26.The POC/IDG Review dated 11/21, 12/5, 12/19, and 1/2/26 showed a care plan for gastrointestinal. The intervention included to assess bowel status every visit.Review of the Visit Note LVN dated 11/18, 11/25, 12/2, 12/10, 12/16, 12/23, 12/30 and 1/6/26 showed the LVN 1 had performed an assessment. However, the LVN 1 failed to assessed the patient last bowel movement as part of the bowel status as ordered in the POC. On 1/23/26 at 1218 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. ###. Review of Patient 9’s clinical record was initiated on 1/21/26. The clinical record showed the SOC was 5/16/25. The patient was certified for hospice services during the certification periods from 5/16/25 to 8/13/25, 8/14/25 to 10/12/25, 10/13/25 to 12/11/25 and 12/12/25 to 2/9/2026. The POC/IDG Review dated 12/19, 1/2 and 1/16/26 showed the RN visit frequency cited as one per two week and one PRN visits-recertification. Review of the clinical record showed the RN 2 had visited the patient on Week 2 (12/14 to 12/20) and Week 4 (12/28 to 1/3/26) as ordered in the POC. However, there was no documented evidence of the RN 2 had visited the patient on Week 6 (1/11 to 1/17/26) as ordered in the POC. On 1/23/26 at 1028 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was asked if the RN visit was missed. The Administrator/CEO replied, if there was no documentation it was missed. The Administrator/CEO was informed and acknowledged the findings. Review of the hospice’s P&P titled The Plan of Care revised 4/2020 showed the written plan of care will contain, but will not be limited to, the following:A. Start of care dateB. Certification periodC. Patient demographicsD. DiagnosisE. Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, bereavement and counselingF. Reduction in risk factorsG. Functional limitationsH. Mental StatusI. Safety Measures to protect against abuse, injury, infection, or communicable disease as appropriateJ. Nutritional requirementsK. PrognosisL. DME and medical supplies necessary to meet patient needsM. Frequency/ Amount/ Duration and type of servicesN. Placement at the appropriate level of care and referrals as needed for counseling, additional disciplines, volunteers and and adjunctive servicesO. Individualized interventions to assist with end-of-lie careP. Patient and family/caregiver educational needs and assessment of their ability to learn and understand teaching and their ability to safely self administer drugs and biologicalsQ. Statement of treatment of goalsR. Interdisciplinary group assessment of needsS. Pain and symptoms management interventionsT. Drugs and Treatments (including allergies)U. Physician-directed instruction to patient and family/ caregiverV. Physician (or other authorized licensed independent practitioner) ordersW. Measurable outcomes anticipated from implementing and coordinating the plan of careX. Patient or representatives level of understanding, involvement and agreement with the plan of careY. End of life preferencesZ. Anticipated discharge and bereavement care needs of the family.1. Review of Patient 6’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 3/26/25. The patient was certified for hospice service during the certification period from 3/26/25 to 6/23/25, 6/24/25 to 9/21/25, 9/22/25 to 11/20/25, 11/21/25 to 1/19/26 and 1/20/26 to 3/20/26. Review of Patient 6’s POC/ IDG review 1/2/26, showed the frequency of visit of LVN was 1 per week and PRN visits, the MSW visit was 1 as needed and recertification and the SC was 1 as needed and recertification.Record of Patient 6’s History of Nursing Assessments showed RN 2 provided Recertification visit dated 1/7/26.However, record of Patient 6’s History of Spiritual Counsellor Assessment Notes and History of Psychosocial Assessment Notes failed to show any documentation of MSW and SC visits during the RN Recertification dated 1/7/26.2. Review of Patient 8’s clinical record was initiated on 1/14/26. The clinical record showed the POC was 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25, 6/4/25 to 9/1/25, 9/2/25 to 10/31/25, 11/1/25 to 12/30/25, and 12/31/25 to 2/28/26. Review of Patient 8’s POC/ IDG Review dated 10/24/25, showed the frequency of the LVN visit was 1 per week and PRN visits, the MSW visit was 1 as needed and recertification, and the SC visit was 1 as needed and recertification.Record of Patient 8’s History of Nursing Assessments showed RN provided Recertification visits dated 10/21/25 and 12/30/25.However, record of Patient 8’s History of Spiritual Counsellor Assessment Notes failed to show any documentation of SC visits during the RN Recertification visits dated 10/21/25 and 12/30/25.Record of Patient 8’s LVN 4 visit notes dated 11/24 and 12/4/25 showed missed visits. However, there was no documentation the hospice physician was informed and no documentation of a rescheduled visit. On 1/23/26 at 0958 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed of the above findings and acknowledged whatever was on the hospice patients’ plan of care, all should be followed. RN 1 also verified the missed visits should have been informed to the physician and should have been rescheduled.3. Review of Patient 2’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 9/15/25. The patient was certified for hospice services during the certification periods from 9/15/25 to 11/13/25, 11/14/25 to 1/12/26, and 1/13/256 to 3/13/26.The POC/IDG Review dated 11/21, 12/5, 12/19, and 1/2/26 showed a care plan addressing patient’s gastrointestinal sytem. Documentation showed the intervention included to assess bowel status every visit.Review of the Visit Note LVN dated 11/18, 11/25, 12/2, 12/10, 12/16, 12/23, 12/30 and 1/6/26 showed the LVN 1 had performed an assessment. However, LVN 1 failed to assess the patient’s last bowel movement as part of the bowel status as ordered in the POC. On 1/23/26 at 1218 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.4. Review of Patient 9’s clinical record was initiated on 1/21/26. The clinical record showed the SOC was 5/16/25. The patient was certified for hospice services during the certification periods from 5/16/25 to 8/13/25, 8/14/25 to 10/12/25, 10/13/25 to 12/11/25, and 12/12/25 to 2/9/2026. The POC/IDG Review dated 12/19/25 and 1/2 and 1/16/26 showed the RN visit frequency cited as one per two week and one PRN visits-recertification. Review of the clinical record showed RN 2 had visited the patient on Week 2 (12/14/25 to 12/20/25) and Week 4 (12/28/25 to 1/3/26) as ordered in the POC. However, there was no documented evidence RN 2 had visited the patient on Week 6 (1/11 to 1/17/26) as ordered in the POC. On 1/23/26 at 1028 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was asked if the RN visit was missed. The Administrator/CEO replied, if there was no documentation it was missed. The Administrator/CEO was informed and acknowledged the findings.5. Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26 and 1/16/26 to 3/16/26.The POC/IDG Review dated 1/2/26 showed a wound care treatment for right hand tear. Cleanse wound with appropriate wound cleanser and gently pat dry. Apply Xeroform dressing (a dressing used for wound care to maintain a moist environment, reduce odor and prevent sticking to wound) daily. On alternate days apply triple antibiotic ointment as clinically indicated. Cover with 4x4 non-adhesive gauze, wrap with Kerlix (a six ply fluff dried bandage) and secure with paper tape. Monitor wound for signs of infection, including increased redness, drainage, or odor.Furthermore, review of the POC for integumentary/skin opened on 12/22/25, intervention includes assess changes in wound status – check size, integrity, location, type/stage, signs and symptoms of infection, drainage and effectiveness of current treatment.However, LVN 1’s Visit Notes dated 12/29/25, 1/5/26 and 1/12/26, and RN 2’s Recert Assessment dated 1/2/26 showed no documented evidence LVN 1 and RN 2 have performed wound care on the right hand’s tear. Furthermore, there was no documented evidence the wound status was assessed.On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings.6. Review of Patient 10’s closed clinical record was initiated on 1/22/26. The clinical record showed SOC was 6/19/25. The patient was certified for hospice services during the certification periods from 6/19/25 to 9/16/25 and 9/17/25 to 12/15/25. Patient was discharged on 11/12/25.The POC/IDG Review dated 9/12, 9/26, 10/10, 10/24 and 11/7/25 showed LVN one visit per week plus one PRN visit. The LVN Visit Notes showed no documented evidence the LVN conducted a visit on Week 1 (9/14/25 to 9/20/25), Week 3 (9/28/25 to 10/4/25) and Week 5 (10/12/25 to 10/18/25) instead of one visit per week as per the POC.On 1/23/26 at 1134 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 confirmed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for eight of 10 sampled patients (Patients 1, 2, 3, 4, 5, 6, 8, and 10). This failure had the potential to cause inconsistent delivery of care which can result in the decline or lack of improvement of the patients’ health conditions.Findings: xx. Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26 and 1/16/26 to 3/16/26.The POC/IDG Review dated 8/22/25, showed it was discussed in the IDG that the patient was on warfarin (a blood thinner medication that can cause easy bruising and bleeding).Furthermore, LVN 1’s Visit Note dated 1/12/26 showed in the narrative that patient’s warfarin level was slightly higher than the desired range. The patient’s medication included an order dated 1/12/26 for warfarin 2 mg one tablet once a day for Tuesday, Wednesday, Thursday, Saturday, Sunday and take ½ tablet on Monday and Friday.However, there was no documented evidence the IDG had developed an individualized POC to address Patient 5’s risk for easy bruising, bleeding and use of warfarin.On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings.xx.Review of Patient 3’s clinical record was initiated on 1/14/26. The clinical record showed SOC was 3/18/25. The patient was certified for hospice services during the certification periods from 3/18/25 to 6/15/25, 6/16/25 to 9/13/25, 9/14/25 to 11/12/25, 11/13/25 to 1/11/26, 1/12/26 to 3/13/26.a.The POC/IDG Review dated 12/13/25 showed it was discussed in the IDG under psychosocial that patient articulated a profound sense of being forgotten which exacerbated feelings of sadness and emotional detachment.Furthermore, MSW’s Visit Note dated 12/13/25 showed in the narrative patient articulated a profound sense of being forgotten which exacerbated feelings of sadness and emotional detachment.However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s feeling of sadness and emotional detachment.b.Review of RN 5’s assessment dated 9/12/25 showed, patient have increased episodes of moderate shortness of breath on mild exertion, poor appetite and lack of sleep.However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s increased episodes of moderate shortness of breath on mid exertion, poor appetite and lack of sleep.On 1/23/26 at 0955 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings.xx.Review of Patient 10’s closed clinical record was initiated on 1/22/26. The clinical record showed SOC was 6/19/25. The patient was certified for hospice services during the certification periods from 6/19/25 to 9/16/25 and 9/17/25 to 12/15/25. Patient was discharged on 11/12/25.Review of LVN 10’s Visit Note dated 10/30/25 showed, patient reported having sputum with cough.However, there was no documented evidence the IDG had developed an individualized POC to address Patient 10’s respiratory problem.On 1/23/26 at 1134 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings. Review of the hospice’s P&P titled The Plan of Care revised 4/2020 showed the written plan of care will contain, but will not be limited to, the following:A. Start of care date, B. Certification period, C. Patient demographics, D. Diagnosis, E. Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, bereavement and counseling F. Reduction in risk factors, G. Functional limitations, H. Mental Status I. Safety Measures to protect against abuse, injury, infection, or communicable disease as appropriate J. Nutritional requirements K. Prognosis L. DME and medical supplies necessary to meet patient needs M. Frequency/ Amount/ Duration and type of services N. Placement at the appropriate level of care and referrals as needed for counseling, additional disciplines, volunteers and and adjunctive services O. Individualized interventions to assist with end-of-lie care P. Patient and family/caregiver educational needs and assessment of their ability to learn and understand teaching and their ability to safely self administer drugs and biologicals Q. Statement of treatment of goals R. Interdisciplinary group assessment of needs S. Pain and symptoms management interventions T. Drugs and Treatments (including allergies) U. Physician-directed instruction to patient and family/ caregiver V. Physician (or other authorized licensed independent practitioner) orders W. Measurable outcomes anticipated from implementing and coordinating the plan of care X. Patient or representatives level of understanding, involvement and agreement with the plan of care Y. End of life preferences Z. Anticipated discharge and bereavement care needs of the family. XX. Review of Patient 1’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 2/12/25. The patient was certified for hospice service during the certification period from 2/12/25 -5/12/25, 5/13/25 - 8/10/25, 8/11/25 - 10/9/25, 10/10/25 -12/8/25, 12/9/25 - 2/6/26 and 2/7/25 - 4/726. Review of Patient 1’s POC Summary dated 1/15/26 showed a physician’s orders dated 7/8/25, to administer metoprolol tartrate ( anti-hypertensive medication) 25 mg, 1/2 tablet twice a day and losartan potassium (anti-hypertensive medication) 100 mg, 1 tablet once a day. However, there was no documentation evidence the IDG had developed an individualized specific POC to address Patient 1’s risk for hypotension. XX. Review of Patient 6’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 3/26/25. The patient was certified for hospice service during the certification period from 3/26/25 - 6/23/25, 6/24/25 - 9/21/25, 9/22/25 - 11/20/25, 11/21/25 - 1/19/26 and 1/20/26 to 3/20/26. Record of Patient 6’s LVN 1 Visit Notes dated 12/29/25 showed on the narrative, the patient experienced diarrhea during the visit, which the caregiver reported was likely related to the administration of a suppository and milk magnesia. However, there was no documentation the IDG had developed an individualized specific POC to address diarrhea. XX. Review of Patient 8’s clinical record was initiated on 1/14/26. The clinical record showed the POC was 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 - 6/3/25, 6/4/25 - 9/1/25, 9/2/25 - 10/31/25, 11/1/25 - 12/30/25 and 12/31/25 - 2/28/26. Review of Patient 8’s Medication List showed a physician’s order dated 12/6/25, to administer Eliquis (blood thinner) 5 mg 1 tablet twice a day. Additionally, another physician’s orders dated 3/6/25 showed the following: losartan potassium (anti-hypertensive) 50 mg 1 tablet once a day, metoprolol tartrate (anti-hypertensive) 50 mg two tablets twice a day and hydralazine hydrochloride (anti-hypertensive) 50 mg 1 tablet every 8 hours as needed for BP more than160. However, there was no documentation the IDG had developed an individualized specific POC to address Patient 8’s risk for bleeding and hypotension. On 1/23/26 at 0958 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed of the above findings and verified the findings. XXX. Review of Patient 4’s closed clinical record was initiated on 1/15/26. The clinical record showed the SOC was 6/25/25. The patient was certified for hospice services during the certification period from 6/25/25 to 9/22/25.Review of the Comprehensive Nursing Assessment dated 6/25/25 on the section of narrative showed the patient was assessed with the following:-had experienced weight loss of eleven pounds in the past 6 months,-incontinent of bowel and bladder requires assistance with hygiene management,- requires assistance with transfers and ADLs due to generalized weakness and immobility,The POC/IDG Review dated 6/26, 7/4/25 showed the IDG had discussed the patient weight loss, incontinence of bowel and bladder, requires assistance with transfers and ADLs due to generalized weakness and immobility. However, there was no documented evidenced of a care plan was developed to address the patients identified care issues. Further review of the POC/IDG dated 7/18/25 showed the IDG had discussed the patients continued to exhibit functional decline with increased dependence for mobility. However, there was no documented evidenced of a care plan was developed to address the patients functional decline with increased dependence for mobility.Moreover, the POC/IDG dated 8/1/25 showed the IDG had discussed the patients decrease nutritional intake. However, there was no documented evidenced of a care plan was developed to address the patients decrease nutritional intake.On 1/23/26 at 0938 hours an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. ##. Review of Patient 2’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 9/15/25. The patient was certified for hospice services during the certification periods from 9/15/25 to 11/13/25, 11/14/25 to 1/12/26 and 1/13/256 to 3/13/26.Review of the POC Summary - As of 1/14/26 showed an order for fall and bleeding precautions. The POC Summary included the medication list. The medications included Eliquis (blood thinners) 2.5 mg one tablet oral BID and Tylenol Arthritis Pain 650 mg extended release gel tab one tablet oral Q8H for mild to moderate pain. However, review of the POC/IDG Review dated 11/7, 11/21, 12/5, 12/19 and 1/2/26 failed to show documented evidenced of a care plan was developed to address the precautions for fall, bleeding and pain.Further review of the Updated Assessment dated 11/18, 12/2, 12/6, 12/30 and 1/23/26 on the section of narrative showed the patient was assessed to have generalized hip and leg pain. However, there was no care plan developed to address the patients identified pain to the hip and leg. On 1/23/26 at 1151 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator /CEO was informed and acknowledged the findings. Review of the hospice’s P&P titled The Plan of Care revised 4/2020 showed the written plan of care will contain, but will not be limited to, the following:A. Start of care date,B. Certification period,C. Patient demographics,D. Diagnosis,E. Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, bereavement and counselingF. Reduction in risk factors,G. Functional limitations,H. Mental StatusI. Safety Measures to protect against abuse, injury, infection, or communicable disease as appropriateJ. Nutritional requirementsK. PrognosisL. DME and medical supplies necessary to meet patient needsM. Frequency/ Amount/ Duration and type of servicesN. Placement at the appropriate level of care and referrals as needed for counseling, additional disciplines, volunteers and and adjunctive servicesO. Individualized interventions to assist with end-of-lie care P. Patient and family/caregiver educational needs and assessment of their ability to learn and understand teaching and their ability to safely self administer drugs and biologicals Q. Statement of treatment of goals R. Interdisciplinary group assessment of needs S. Pain and symptoms management interventions T. Drugs and Treatments (including allergies) U. Physician-directed instruction to patient and family/ caregiver V. Physician (or other authorized licensed independent practitioner) orders W. Measurable outcomes anticipated from implementing and coordinating the plan of care. Patient or representatives level of understanding, involvement and agreement with the plan of care Y. End of life preferences Z. Anticipated discharge and bereavement care needs of the family.1.Review of Patient 1’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 2/12/25. The patient was certified for hospice service during the certification period from 2/12/25 -5/12/25, 5/13/25 - 8/10/25, 8/11/25 - 10/9/25, 10/10/25 -12/8/25, 12/9/25 - 2/6/26 and 2/7/25 - 4/726. Review of Patient 1’s POC Summary dated 1/15/26 showed a physician’s orders dated 7/8/25, to administer metoprolol tartrate ( anti-hypertensive medication) 25 mg, 1/2 tablet twice a day and losartan potassium (anti-hypertensive medication) 100 mg, 1 tablet once a day.However, there was no documentation evidence the IDG had developed an individualized specific POC to address Patient 1’s risk for hypotension. 2. Review of Patient 6’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 3/26/25. The patient was certified for hospice service during the certification period from 3/26/25 - 6/23/25, 6/24/25 - 9/21/25, 9/22/25 - 11/20/25, 11/21/25 - 1/19/26 and 1/20/26 to 3/20/26. Record of Patient 6’s LVN 1 Visit Notes dated 12/29/25 showed on the narrative, the patient experienced diarrhea during the visit, which the caregiver reported was likely related to the administration of a suppository and milk magnesia. However, there was no documentation the IDG had developed an individualized specific POC to address diarrhea.3.. Review of Patient 8’s clinical record was initiated on 1/14/26. The clinical record showed the POC was 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 - 6/3/25, 6/4/25 - 9/1/25, 9/2/25 - 10/31/25, 11/1/25 - 12/30/25 and 12/31/25 - 2/28/26. Review of Patient 8’s Medication List showed a physician’s order dated 12/6/25, to administer Eliquis (blood thinner) 5 mg 1 tablet twice a day. Additionally, another physician’s orders dated 3/6/25 showed the following: losartan potassium (anti-hypertensive) 50 mg 1 tablet once a day, metoprolol tartrate (anti-hypertensive) 50 mg two tablets twice a day and hydralazine hydrochloride (anti-hypertensive) 50 mg 1 tablet every 8 hours as needed for BP more than160.However, there was no documentation the IDG had developed an individualized specific POC to address Patient 8’s risk for bleeding and hypotension.On 1/23/26 at 0958 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed of the above findings and verified the findings.4. Review of Patient 4’s closed clinical record was initiated on 1/15/26. The clinical record showed the SOC was 6/25/25. The patient was certified for hospice services during the certification period from 6/25/25 to 9/22/25.Review of the Comprehensive Nursing Assessment dated 6/25/25 on the section of narrative showed the patient was assessed with the following:-had experienced weight loss of eleven pounds in the past 6 months,-incontinent of bowel and bladder requires assistance with hygiene management,- requires assistance with transfers and ADLs due to generalized weakness and immobility,The POC/IDG Review dated 6/26, 7/4/25 showed the IDG had discussed the patient weight loss, incontinence of bowel and bladder, requires assistance with transfers and ADLs due to generalized weakness and immobility. However, there was no documented evidenced of a care plan was developed to address the patients identified care issues. Further review of the POC/IDG dated 7/18/25 showed the IDG had discussed the patients continued to exhibit functional decline with increased dependence for mobility. However, there was no documented evidenced of a care plan was developed to address the patients functional decline with increased dependence for mobility.Moreover, the POC/IDG dated 8/1/25 showed the IDG had discussed the patients decrease nutritional intake. However, there was no documented evidenced of a care plan was developed to address the patients decrease nutritional intake.On 1/23/26 at 0938 hours an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. 5. Review of Patient 2’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 9/15/25. The patient was certified for hospice services during the certification periods from 9/15/25 to 11/13/25, 11/14/25 to 1/12/26 and 1/13/256 to 3/13/26.Review of the POC Summary - As of 1/14/26 showed an order for fall and bleeding precautions. The POC Summary included the medication list. The medications included Eliquis (blood thinners) 2.5 mg one tablet oral BID and Tylenol Arthritis Pain 650 mg extended release gel tab one tablet oral Q8H for mild to moderate pain. However, review of the POC/IDG Review dated 11/7, 11/21, 12/5, 12/19 and 1/2/26 failed to show documented evidenced of a care plan was developed to address the precautions for fall, bleeding and pain.Further review of the Updated Assessment dated 11/18, 12/2, 12/6, 12/30 and 1/23/26 on the section of narrative showed the patient was assessed to have generalized hip and leg pain. However, there was no care plan developed to address the patients identified pain to the hip and leg. On 1/23/26 at 1151 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator /CEO was informed and acknowledged the findings.6. Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26, and 1/16/26 to 3/16/26.The POC/IDG Review dated 8/22/25, showed it was discussed in the IDG that the patient was on warfarin (a blood thinner medication that can cause easy bruising and bleeding).Furthermore, LVN 1’s Visit Note dated 1/12/26 showed in the narrative that patient’s warfarin level was slightly higher than the desired range. The patient’s medication included an order dated 1/12/26 for warfarin 2 mg one tablet once a day for Tuesday, Wednesday, Thursday, Saturday, Sunday and take ½ tablet on Monday and Friday.However, there was no documented evidence the IDG had developed an individualized POC to address Patient 5’s risk for easy bruising, bleeding and use of warfarin.On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings.7..Review of Patient 3’s clinical record was initiated on 1/14/26. The clinical record showed SOC was 3/18/25. The patient was certified for hospice services during the certification periods from 3/18/25 to 6/15/25, 6/16/25 to 9/13/25, 9/14/25 to 11/12/25, 11/13/25 to 1/11/26, 1/12/26 to 3/13/26.a.The POC/IDG Review dated 12/13/25 showed it was discussed in the IDG under psychosocial that patient articulated a profound sense of being forgotten which exacerbated feelings of sadness and emotional detachment.Furthermore, MSW’s Visit Note dated 12/13/25 showed in the narrative patient articulated a profound sense of being forgotten which exacerbated feelings of sadness and emotional detachment.However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s feeling of sadness and emotional detachment.b.Review of RN 5’s assessment dated 9/12/25 showed, patient have increased episodes of moderate shortness of breath on mild exertion, poor appetite and lack of sleep.However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s increased episodes of moderate shortness of breath on mid exertion, poor appetite and lack of sleep.On 1/23/26 at 0955 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings.8..Review of Patient 10’s closed clinical record was initiated on 1/22/26. The clinical record showed SOC was 6/19/25. The patient was certified for hospice services during the certification periods from 6/19/25 to 9/16/25 and 9/17/25 to 12/15/25. Patient was discharged on 11/12/25.Review of LVN 10’s Visit Note dated 10/30/25 showed, patient reported having sputum with cough.However, there was no documented evidence the IDG had developed an individualized POC to address Patient 10’s respiratory problem.On 1/23/26 at 1134 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged 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 eight of 10 sampled patients (Patient 1, 2, 3, 4, 6, 8, 9, and 10). This failure had the potential of not providing necessary services for these patients. Findings: XX. Review of Patient 1’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 2/12/25. The patient was certified for hospice service during the certification period from 2/12/25 -5/12/25, 5/13/25 - 8/10/25, 8/11/25 - 10/9/25, 10/10/25 -12/8/25, 12/9/25 - 2/6/26 and 2/7/25 - 4/726. Review of Patient 1’s POC Summary dated 1/14/26 showed frequency of visits for LVN 1 per week + PRN visits, MSW: 1 visit as needed and Recert, SC: 1 visit as needed and Recert.However, there was no documented evidence showing the indication for the PRN discipline visits. XX. Review of Patient 6’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 3/26/25. The patient was certified for hospice service during the certification period from 3/26/25 - 6/23/25, 6/24/25 - 9/21/25, 9/22/25 - 11/20/25, 11/21/25 - 1/19/26 and 1/20/26 to 3/20/26. Review of Patient 6’s POC/ IDG Review dated 11/7/25 showed frequency of visits for LVN 1 per week + 1 PRN visits, MSW: 1 visit as needed and Recertification and SC: 1 visit as needed and Recertification. However, there was no documented evidence showing the indication for the PRN discipline visits. XX. Review of Patient 8’s clinical record was initiated on 1/14/26. The clinical record showed the POC was 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 - 6/3/25, 6/4/25 - 9/1/25, 9/2/25 - 10/31/25, 11/1/25 - 12/30/25 and 12/31/25 - 2/28/26. Review of Patient 8’s POC/ IDG Review dated 11/7/25 showed frequency of visits for LVN: 1 visit per week + PRN visits, MSW: 1 visit as needed and Recertification and SC: 1 visit as needed and Recertification. On 1/23/26 at 0958 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged PRN visits have no indications. xx.Review of Patient 3’s clinical record was initiated on 1/14/26. The clinical record showed SOC was 3/18/25. The patient was certified for hospice services during the certification periods from 3/18/25 to 6/15/25, 6/16/25 to 9/13/25, 9/14/25 to 11/12/25, 11/13/25 to 1/11/26, 1/12/26 to 3/13/26.The POC/IDG Review dated 9/12, 9/26, 10/10, 10/24, 11/7, 11/21, 12/5, 12/19/25 and , 1/2/26 showed LVN one visit per week plus one PRN visit, MSW one as needed and Recert and SC one as needed and Recert.However, there was no documented evidence showing the indication for the PRN visits.On 1/23/26 at 0955 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 confirmed and acknowledged the findings.xx.Review of Patient 10’s closed clinical record was initiated on 1/22/26. The clinical record showed SOC was 6/19/25. The patient was certified for hospice services during the certification periods from 6/19/25 to 9/16/25 and 9/17/25 to 12/15/25. Patient was discharged on 11/12/25.The POC/IDG Review dated 9/12, 9/26, 10/10, 10/24 and 11/7/25 showed LVN one per week plus one PRN visit, MSW as needed and Recert and SC one time then PRN.However, there was no documented evidence showing the indication for the PRN visits.On 1/23/26 at 1134 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 confirmed and acknowledged the findings. Review of the clinical records for Patients 1, 2, 4, 6, 8, 9 and 10 failed to show documented evidence of the indication for the PRN discipline visits on the POCs. For example:1. Review of Patient 4’s closed clinical record was initiated on 1/15/26. The clinical record showed the SOC was 6/25/25. The patient was certified for hospice services during the certification period from 6/25/25 to 9/22/25.The POC/IDG Review dated 6/26, 7/4, 7/18, 8/1 and 8/15/25 showed LVN one visit per week and PRN and MSW one time PRN and recert within 5 days of admissionHowever, there was no documented evidence showing the indication for the PRN discipline visits. On 1/23/26 at 0938 hours an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. 2. Review of Patient 2’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 9/15/25. The patient was certified for hospice services during the certification periods from 9/15/25 to 11/13/25, 1/14/25 to 1/12/26 and 1/13/256 to 3/13/26.The POC/IDG Review dated 11/21, 12/5, 12/19, and 1/2/26 showed SN one visit per week and one PRN, SC one PRN - within 5 days of admission, MSW one PRN and recertification.However, there was no documented evidence showing the indication for the PRN discipline visits. On 1/23/26 at 1218 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. Review of the clinical records for Patients 1, 2, 3, 4, 6, 8, 9, and 10 failed to show documented evidence of the indication for the PRN discipline visits on the POCs. For example:1. Review of Patient 4’s closed clinical record was initiated on 1/15/26. The clinical record showed the SOC was 6/25/25. The patient was certified for hospice services during the certification period from 6/25/25 to 9/22/25.The POC/IDG Review dated 6/26, 7/4, 7/18, 8/1, and 8/15/25 showed the LVN visit was one visit per week and PRN and the MSW visit was one time PRN and recert within 5 days of admission.However, there was no documented evidence showing the indication for the PRN visits. On 1/23/26 at 0938 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. 2. Review of Patient 2’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 9/15/25. The patient was certified for hospice services during the certification periods from 9/15/25 to 11/13/25, 1/14/25 to 1/12/26, and 1/13/256 to 3/13/26.The POC/IDG Review dated 11/21, 12/5, 12/19, and 1/2/26, showed the SN visit was one visit per week and one PRN, the SC visit was one PRN- within 5 days of admission; and the MSW visit was one PRN and recertification.However, there was no documented evidence showing the indication for the PRN visits. On 1/23/26 at 1218 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.3.Review of Patient 3’s clinical record was initiated on 1/14/26. The clinical record showed SOC was 3/18/25. The patient was certified for hospice services during the certification periods from 3/18/25 to 6/15/25, 6/16/25 to 9/13/25, 9/14/25 to 11/12/25, 11/13/25 to 1/11/26, and 1/12/26 to 3/13/26.The POC/IDG Review dated 9/12, 9/26, 10/10, 10/24, 11/7, 11/21, 12/5, 12/19/25 and 1/2/26, showed the LVN visit was one visit per week plus one PRN visit, the MSW visit was one as needed and recertification and the SC visit was one as needed and recertification.However, there was no documented evidence showing the indication for the PRN visits.On 1/23/26 at 0955 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 confirmed and acknowledged the findings.4.Review of Patient 10’s closed clinical record was initiated on 1/22/26. The clinical record showed SOC was 6/19/25. The patient was certified for hospice services during the certification periods from 6/19/25 to 9/16/25 and 9/17/25 to 12/15/25. The patient was discharged on 11/12/25.The POC/IDG Review dated 9/12, 9/26, 10/10, 10/24, and 11/7/25, showed the LVN visit was one per week plus one PRN visit; the MSW visit was as needed and recertifiication, and the SC visit was one time then PRN.However, there was no documented evidence showing the indication for the PRN visits.On 1/23/26 at 1134 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 confirmed and acknowledged the findings.5. Review of Patient 1’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 2/12/25. The patient was certified for hospice service during the certification period from 2/12/25 to 5/12/25, 5/13/25 to 8/10/25, 8/11/25 to 10/9/25, 10/10/25 to 12/8/25, and 12/9/25 to 2/6/26.Review of Patient 1’s POC Summary dated 1/14/26, showed the frequency of visits for LVN was 1 per week plus PRN visits, the MSW visit was 1 visit as needed and recertification, and the SC visit was 1 visit as needed and recertification.However, there was no documented evidence showing the indication for the PRN discipline visits. 6. Review of Patient 6’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 3/26/25. The patient was certified for hospice service during the certification period from 3/26/25 to 6/23/25, 6/24/25 to 9/21/25, 9/22/25 to 11/20/25, 11/21/25 to 1/19/26, and 1/20/26 to 3/20/26. Review of Patient 6’s POC/ IDG Review dated 11/7/25, showed the frequency of visit for LVN was 1 per week plus 1 PRN visit, the MSW visit was 1 visit as needed and recertification and the SC visit was 1 visit as needed and recertification. However, there was no documented evidence showing the indication for the PRN discipline visits. 7. Review of Patient 8’s clinical record was initiated on 1/14/26. The clinical record showed the POC was 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25, 6/4/25 to 9/1/25, 9/2/25 to 10/31/25, 11/1/25 to 12/30/25, and 12/31/25 - 2/28/26. Review of Patient 8’s POC/ IDG Review dated 11/7/25, showed frequency of visits for LVN was 1 visit per week plus PRN visits, the MSW visit was 1 visit as needed and recertification and the SC visit was 1 visit as needed and recertification.On 1/23/26 at 0958 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged PRN visits have no indications.”

“Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for 10 of 10 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10). This failure had the potential risk of not evaluating the POC and providing appropriate care and services to these patients.Findings: xx. Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26 and 1/16/26 to 3/16/26.The POC/IDG Review dated 8/22, 9/12, 9/26, 10/10, 10/24/25, showed the patient’s identified problem included altered cardiac status related to multiple cardiac medications. The goal was established for the identified problem.However, the goal listed was not measurable and specific to the patient’s needs. For example, the goal for altered cardiac status related to multiple cardiac medications was to maintain therapeutic blood pressure and heart rate throughout care. There was no documented evidence of the measurable outcome as to what blood pressure and heart rate would be therapeutic to the patient.On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings.xx.Review of Patient 3’s clinical record was initiated on 1/14/26. The clinical record showed SOC was 3/18/25. The patient was certified for hospice services during the certification periods from 3/18/25 to 6/15/25, 6/16/25 to 9/13/25, 9/14/25 to 11/12/25, 11/13/25 to 1/11/26, 1/12/26 to 3/13/26.The POC/IDG Review dated 9/12/, 9/26, 10/10, and 10/24/25 showed the patient’s identified problem included altered cardiac status related to edema and uncontrolled BP. The goal was established for the identified problems.However, the goal listed was not measurable and specific to the patient’s needs. For example, the goal for altered cardiac status was to achieve and maintain peripheral circulation for patient comfort. There was no documented evidence of the measurable outcome as to what peripheral circulation would comfort patient.On 1/23/26 at 0955 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings.xx.Review of Patient 10’s closed clinical record was initiated on 1/22/26. The clinical record showed SOC was 6/19/25. The patient was certified for hospice services during the certification periods from 6/19/25 to 9/16/25 and 9/17/25 to 12/15/25. Patient was discharged on 11/12/25.Review of the POC/IDG Review dated 8/1, 8/15, 8/29, 9/12, 9/26, 10/10, 10/24 and 11/7/25 showed the following identified problems:-Diabetes, the goal was established for the identified problem. However, the goal listed was not measurable and specific to the patient’s needs. For example, the goal for Diabetes was for blood sugar management for patient comfort. There was no documented evidence as to what blood sugar management or blood sugar range would be related to patient’s comfort.-Unsteady gait, the goal was established for the identified problem. However, the goal listed was not measurable and specific to the patient’s needs. For example, the goal for unsteady gait was for the patient/PCG will verbalize understanding of safety intervention. There was no documented evidence as to what kind of safety interventions that the patient/PCG will verbalize understanding.-Potential for altered bladder elimination related to disease process, the goal was established for the identified problem. However, the goal listed was not measurable and specific to the patient’s needs. For example, the goal for potential for altered bladder elimination related to disease process was patient/PCG will verbalize having urinary elimination needs met at an acceptable level. There was no documented evidence as to what urinary elimination would be acceptable level for patient/PCG.On 1/23/26 at 1134 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 showed no documented evidence the POCs included measurable outcomes. For example:##. Review of Patient 7’s clinical record was initiated on 1/16/26. The clinical record showed the SOC was 7/7/25. The patient was certified for hospice services during the certification periods from 7/15/25 to 9/12/25, 9/13/25 to 11/11/25 and 11/12/25 to 1/10/26.The POC/IDG Review dated 11/21,12/5, 12/19 and 1/2/25 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: nutrition, one of the goals for reduced food portion consumption was to have an adequate food and fluids as tolerated or desired in 2 weeks. There was no documented evidence as to what an adequate food and fluids as tolerated was.On 1/23/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. ##. Review of Patient 2’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 9/15/25. The patient was certified for hospice services during the certification periods from 9/15/25 to 11/13/25, 11/14/25 to 1/12/26 and 1/13/256 to 3/13/26.The POC/IDG Review dated 11/21, 12/5, 12/19 and 1/2/25 showed the patient’s identified problems with the established goal and interventions. For example the goal for the following showed:-cardiovascular: to achieve and maintain peripheral circulation for patient comfort,-gastrointestinal: elimination needs met at an acceptable level,-ADL: needs are met, -endocrine: blood sugar management for patient comfort.However, there was no documented evidence of what an acceptable level, needs are met, maintain peripheral circulation and blood sugar management was. On 1/23/26 at 1248 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. ##. Review of Patient 9’s clinical record was initiated on 1/21/26. The clinical record showed the SOC was 5/16/25. The patient was certified for hospice services during the certification periods from 5/16/25 o 8/13/25, 8/14/25 to 10/12/25, 10/13/25 to 12/11/25 and 12/12/25 to 2/9/2026. The POC/IDG Review dated 12/19, 1/2 and 1/16/26 showed the patient’s identified problems with the established goal and interventions. For example the goal for the following showed:-cardiovascular: to achieve and maintain peripheral circulation for patient comfort,-genitourinary: urinary elimination needs met at an acceptable level and-respiratory: Oxygen treatment to achieve and maintain peripheral circulation for patient comfort.However, there was no documented evidence of what an acceptable level and maintain peripheral circulation for patient comfort was.On 1/23/26 at 1028 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 showed no documented evidence the POCs included measurable outcomes. For example:1. Review of Patient 7’s clinical record was initiated on 1/16/26. The clinical record showed the SOC was 7/7/25. The patient was certified for hospice services during the certification periods from 7/15/25 to 9/12/25, 9/13/25 to 11/11/25, and 11/12/25 to 1/10/26.The POC/IDG Review dated 11/21,12/5, 12/19, and 1/2/25 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 7 had a care plan problem addressing nutrition and reduced food portion consumption. Documentation showed one of the goals for reduced food portion consumption was to have an adequate food and fluids as tolerated or desired in two weeks. There was no documented evidence as to what an adequate food and fluids as tolerated was.On 1/23/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.2. Review of Patient 2’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 9/15/25. The patient was certified for hospice services during the certification periods from 9/15/25 to 11/13/25, 11/14/25 to 1/12/26 and 1/13/256 to 3/13/26.The POC/IDG Review dated 11/21, 12/5, 12/19 and 1/2/25 showed the patient’s identified problems with the established goal and interventions. For example the goal for the following showed:-cardiovascular: to achieve and maintain peripheral circulation for patient comfort,-gastrointestinal: elimination needs met at an acceptable level,-ADL: needs are met, -endocrine: blood sugar management for patient comfort.However, there was no documented evidence of what an acceptable level, needs are met, maintain peripheral circulation and blood sugar management was. On 1/23/26 at 1248 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. 3. Review of Patient 9’s clinical record was initiated on 1/21/26. The clinical record showed the SOC was 5/16/25. The patient was certified for hospice services during the certification periods from 5/16/25 o 8/13/25, 8/14/25 to 10/12/25, 10/13/25 to 12/11/25 and 12/12/25 to 2/9/2026. The POC/IDG Review dated 12/19, 1/2 and 1/16/26 showed the patient’s identified problems with the established goal and interventions. For example the goal for the following showed:-cardiovascular: to achieve and maintain peripheral circulation for patient comfort,-genitourinary: urinary elimination needs met at an acceptable level and-respiratory: Oxygen treatment to achieve and maintain peripheral circulation for patient comfort.However, there was no documented evidence of what an acceptable level and maintain peripheral circulation for patient comfort was.On 1/23/26 at 1028 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.4. Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26 and 1/16/26 to 3/16/26.The POC/IDG Review dated 8/22, 9/12, 9/26, 10/10, 10/24/25, showed the patient’s identified problem included altered cardiac status related to multiple cardiac medications. The goal was established for the identified problem.However, the goal listed was not measurable and specific to the patient’s needs. For example, the goal for altered cardiac status related to multiple cardiac medications was to maintain therapeutic blood pressure and heart rate throughout care. There was no documented evidence of the measurable outcome as to what blood pressure and heart rate would be therapeutic to the patient.On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings.5. Review of Patient 3’s clinical record was initiated on 1/14/26. The clinical record showed SOC was 3/18/25. The patient was certified for hospice services during the certification periods from 3/18/25 to 6/15/25, 6/16/25 to 9/13/25, 9/14/25 to 11/12/25, 11/13/25 to 1/11/26, 1/12/26 to 3/13/26.The POC/IDG Review dated 9/12/, 9/26, 10/10, and 10/24/25 showed the patient’s identified problem included altered cardiac status related to edema and uncontrolled BP. The goal was established for the identified problems.However, the goal listed was not measurable and specific to the patient’s needs. For example, the goal for altered cardiac status was to achieve and maintain peripheral circulation for patient comfort. There was no documented evidence of the measurable outcome as to what peripheral circulation would comfort patient.On 1/23/26 at 0955 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings.6. Review of Patient 10’s closed clinical record was initiated on 1/22/26. The clinical record showed SOC was 6/19/25. The patient was certified for hospice services during the certification periods from 6/19/25 to 9/16/25 and 9/17/25 to 12/15/25. Patient was discharged on 11/12/25.Review of the POC/IDG Review dated 8/1, 8/15, 8/29, 9/12, 9/26, 10/10, 10/24 and 11/7/25 showed the following identified problems:-Diabetes, the goal was established for the identified problem. However, the goal listed was not measurable and specific to the patient’s needs. For example, the goal for Diabetes was for blood sugar management for patient comfort. There was no documented evidence as to what blood sugar management or blood sugar range would be related to patient’s comfort.-Unsteady gait, the goal was established for the identified problem. However, the goal listed was not measurable and specific to the patient’s needs. For example, the goal for unsteady gait was for the patient/PCG will verbalize understanding of safety intervention. There was no documented evidence as to what kind of safety interventions that the patient/PCG will verbalize understanding.-Potential for altered bladder elimination related to disease process, the goal was established for the identified problem. However, the goal listed was not measurable and specific to the patient’s needs. For example, the goal for potential for altered bladder elimination related to disease process was patient/PCG will verbalize having urinary elimination needs met at an acceptable level. There was no documented evidence as to what urinary elimination would be acceptable level for patient/PCG.On 1/23/26 at 1134 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patient’s POCs no less frequently than every 15 calendar days for three of 10 sampled patients (Patient 3, 5, and 10). This failure had the potential for not providing appropriate, consistent, and quality care to these patients.Findings: ##. Review of Patient 7’s clinical record was initiated on 1/16/26. The clinical record showed the SOC was 7/7/25. The patient was certified for hospice services during the certification periods from 7/15/25 to 9/12/25, 9/13/25 to 11/11/25 and 11/12/25 to 1/10/26.The POC/IDG Review dated 11/7, 11/21, 12/5, 12/19 and 1/2/26, on the section of frequency of visit showed Volunteer declined. However, there was no documented evidenced of the IDG had reviewed/ discussed the reason why the volunteer services was declined.On 1/23/26 at 1030 hours, an interview and concurrent clinical review with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. The hospice’s P&P titled Interdisciplinary Group Membership and Responsibilities revised April 2020 showed the hospice interdisciplinary group membership includes at a minimum:a. Physicianb. Registered Nursec. Social Workerd. Pastoral or other counselorThe hospice’s P&P titled Interdisciplinary Group Meeting revised April 2020 showed the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths, and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program, Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently than every 15 days or more frequently if the patient condition requires. Members at the interdisciplinary group meeting will sign an attendance from that will be kept by the hospice Clinical Supervisor.xx. Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26 and 1/16/26 to 3/16/26.Review of LVN 1’s Visit Note dated 9/29/25, showed in the narrative that PCG reported patient had a fall on 9/23/25.Furthermore, review of the Incident Occurrence dated 10/22/25 showed that PCG reported patient had a fall on 10/13/25.The POC/IDG Review dated 9/26/25 and 10/24/25, showed the IDT conducted the meetings. However, the care plan for Environment/Safety was not updated. The care plan still showed an open date of 5/21/25.On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 stated the POC should be updated. RN 2 verified and acknowledged the findings.xx.Review of Patient 3’s clinical record was initiated on 1/14/26. The clinical record showed SOC was 3/18/25. The patient was certified for hospice services during the certification periods from 3/18/25 to 6/15/25, 6/16/25 to 9/13/25, 9/14/25 to 11/12/25, 11/13/25 to 1/11/26, 1/12/26 to 3/13/26.The POC/IDG Review dated 9/12/, 9/26, 10/10, and 10/24/25 showed the patient’s identified problem included altered cardiac status related to edema, diabetes, and generalized pain. The identified problems were opened on 3/18/25 and target date were dated on 6/15/25.There was no documented evidence the identified problems were updated to provide appropriate care for the patient.On 1/23/26 at 0955 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings.xx.Review of Patient 10’s closed clinical record was initiated on 1/22/26. The clinical record showed SOC was 6/19/25. The patient was certified for hospice services during the certification periods from 6/19/25 to 9/16/25 and 9/17/25 to 12/15/25. Patient was discharged on 11/12/25.Review of the POC/IDG Review dated 8/1, 8/15, 8/29, 9/12, 9/26, 10/10, 10/24 and 11/7/25 showed the patient’s identified problem included Diabetes, unsteady gait, potential for altered bladder elimination related to disease process, and generalized body pain. The identified problems were opened on 6/19/25.There was no documented evidence the identified problems were updated to provide appropriate care for the patient.On 1/23/26 at 1134 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the revised POCs included the patient’s progress toward goals specified in the POCs for five of 10 sampled patients (Patients 4, 5, 6, 8, and 9). This failure had the potential of not identifying the care needs and providing necessary care and services to meet the care needs for these patients.Findings: xx. Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26 and 1/16/26 to 3/16/26.Review of the POC/IDG Review on the following dates showed patient’s identified problems as resolved and controlled:-11/7/25 – all problems identified which includes altered cardiac status, potential for harm and increased risk and generalized pain showed resolved date of 11/7/25 and controlled status.-11/21/25 - all problems identified which includes altered cardiac status, potential for harm and increased risk, generalized pain, and altered sleep patterns, showed resolved date of 11/21/25 and controlled status.-12/19/25 - all problems identified which includes altered cardiac status, potential for harm and increased risk, generalized pain, and altered sleep patterns, showed resolved date of 12/19/25 and controlled status.There was no documented evidence that patient had an updated POC on the abovementioned dates which note the patient’s progress toward outcomes and goals.On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 stated resolved in the POC means the problem was discontinued. RN 2 was asked if the POC was resolved and controlled, was there a plan to discharge patient. RN 2 was unable to comment.On 1/23/26 at 1630 hours, the Administrator acknowledged the findings. ###. Review of Patient 4’s closed clinical record was initiated on 1/15/26. The clinical record showed the SOC was 6/25/25. The patient was certified for hospice services during the certification period from 6/25/25 to 9/22/25. The patient passed away on 8/5/25.Review of the POC/IDG dated 8/15/25 showed the patients identified care plan problems and goals. The care plan problems and goals included cardiovascular, pain, respiratory and sleep. The status of the identified care plans showed a resolved date of 8/525. However, the status should have been closed instead of resolved as the patient passed away on 8/5/25.On 1/23/26 at 0938 hours an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. ###. Review of Patient 9’s clinical record was initiated on 1/21/26. The clinical record showed the SOC was 5/16/25. The patient was certified for hospice services during the certification periods from 5/16/25 o 8/13/25, 8/14/25 to 10/12/25, 10/13/25 to 12/11/25 and 12/12/25 to 2/9/2026. The POC/IDG Review dated 12/19, 1/2 and 1/16/25 showed the patients identified problems as resolved and controlled. The identified problems included cardiovascular: edema and hypertension; environment/ safety: fall risk, oxygen use: genitourinary: benign prostatic hyperplasia: respiratory: altered respiratory status related to disease process, SOB, and oxygen therapy. The identified problems showed the resolved date of 12/19/25 and controlled status.However, there was no documented evidence that patient had an updated POC on the abovementioned dates which note the patient’s progress toward outcomes and goals. On 1/23/26 at 1028 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was asked if the patient was still eligible for hospice service since all the care plan problems that were identified were resolved and the status was controlled. The Administrator/CEO replied, no that’s why we have a plan to discharge the patient on the IDG meeting due to extended prognosis. The Administrator/CEO was also asked if the discharge planning was discussed in the POC/IDG dated 12/19, 1/2 and 1/16/25. The Administrator/CEO replied yes, we should. The Administrator/CEO was informed and acknowledged the findings. Review of the hospice’s P&P titled Interdisciplinary Group Membership and Responsibilities showed the interdisciplinary group will collaborate with the patient’s attending physician to develop an individualized written plan of care. The interdisciplinary group responsibilities include but are not limited to participation in the establishment of the plan of care for each patient admitted to the hospice service.XX. Review of Patient 6’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 3/26/25. The patient was certified for hospice service during the certification period from 3/26/25 - 6/23/25, 6/24/25 - 9/21/25, 9/22/25 - 11/20/25, 11/21/25 - 1/19/26 and 1/20/26 to 3/20/26. Review of the POC/IDG Review on the following dates showed patient’s identified problems as controlled: -11/7/25, 11/21/25, 12/5/25, 12/19/25, 1/2/26, 1/16/26 and 1/22/26 – all problems identified which includes deficit in self care related to late dementia, potential for altered cardiac conditions with increased risk for chest pain, risk of constipation due to impaired locomotion and decreased peristalsis, potential for altered neurological status related to dementia diagnosis with behaviors of agitation, altered behavior, anxiety, generalized body pain related to disease process and altered sleep patterns related to cognitive decline showed resolved dated 1/16/26 and a controlled status.However, there was no documentation noting the patient’s progress toward outcomes and goals specified in the plan of care. XX. Review of Patient 8’s clinical record was initiated on 1/14/26. The clinical record showed the POC was 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 - 6/3/25, 6/4/25 - 9/1/25, 9/2/25 - 10/31/25, 11/1/25 - 12/30/25 and 12/31/25 - 2/28/26. Review of the POC/IDG Review on the following dates showed patient’s identified problems as controlled: -12/19/25, 1/2/26, 1/16/26, 1/20/26 -all problems identified which includes selfcare deficit related to decreased strength and endurance as evidenced by impaired ability to perform daily selfcare activities, potential for altered cardiac status related to cardiac diagnosis including hypertension, atrial fibrillation, treatment of murmur and fluid retention. diabetes, dependent on insulin, oral meds, impaired thyroid with use of oral medication, potential for altered neurological status related to seizure disorder and generalized body pain/ discomfort showed resolved dated 1/16/26 and a controlled status.However, there was no documentation noting the patient’s progress toward outcomes and goals specified in the plan of care. On 1/23/26 at 0958 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and verified the findings.”

“Based on interview and record review, the hospice failed to ensure the IDT maintained the responsibility for directing and supervising the care and services provided for two of 10 sampled patients (Patients 6 and 10) and one nonsampled patient (Patient U). This failure created the risk of not addressing the care needs for these patients. Review of the hospice’s P&P titled Coordination of Care with Contracts and (undated) showed coordination of care with all providers involved includes, but is limited to: A. making relevant information available to all providers B. Clearly outlining each provider’s responsibilities in providing care C. Communicating changes in patient status and care in a timely manner. Review of the Durable Medical Equipment and Supplies (undated) showed those supplies required for optimal comfort, care and management of the hospice patient will be obtained from hospice stock supplies or approved company if the patient is receiving Medicare, Medicaid or private insurance hospice benefit. XX. Review of Patient 6’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 3/26/25. The patient was certified for hospice service during the certification period from 3/26/25 - 6/23/25, 6/24/25 - 9/21/25, 9/22/25 - 11/20/25, 11/21/25 - 1/19/26 and 1/20/26 to 3/20/26. On 1/20/26 at 1040 hours, a home visit was conducted with CHHA 1 to Patient 6’s residence. Patient 6’s caregiver and authorized representative stated they only have one pair of gloves supply left and small size diapers instead of medium sized were provided for Patient 6. Patient 6’s authorized representative stated she already have followed up with the hospice office staff and made visiting staff aware about the stock of supplies needed for Patient 6 since two weeks ago, however no information was relayed when she followed up again from last week hospice staff visit regarding the mentioned supplies. CHHA 1 asked again Patient 6’s authorized representative if she called the agency office staff and made them aware. Patient 6’s authorized representative stated she kept following up with no relayed information on cause of delay. The size of the diaper was observed to be not fitted for Patient 6 after CHHA 1 provided Patient 6 a bed bath and a pair of medium sized gloves were observed to be the only stock left for Patient 6.On 1/20/26 at 1332 hours, an interview was conducted with LVN 3. LVN 3 was asked how soon should delivery of supplies of diapers, wipes and gloves be provided for hospice patients. LVN 3 was informed of the above findings and acknowledged the delivery of supplies as diapers, wipes and gloves should not take more than two weeks.XX. Review of Non sampled Patient 31 personal information was initiated on 1/20/26. The patient information showed patient’s primary diagnosis was Alzheimer’s disease, unspecified. Patient’s authorized representative/ emergency contact was patient’s son. On 1/20/26 at 1501 hours, a first attempted random phone call for interview was conducted to Non sampled Patient 31. Left voicemail message. The following day at 0918 hours conducted a second phone call with no answer again and left voicemail message. At 1/21/26 at 0945 hours, received a callback from Nonsampled Patient 31’s son. Patient’s son was asked permission for interview regarding hospice services by the agency. Patient’s son permitted for the phone call interview. Patient’s son was asked how was the hospice care services, how were the staff if they are polite and respectful, if they have missed visits and were rescheduled, who referred patient to hospice and if patient needs volunteer services. Patient’s son stated he has no problems with the hospice agency, staff were respectful and polite, no issues with staff visits, was referred when patient was in the hospital. However, patient’ son stated he never knew about hospice agency have volunteer services and he was interested about learning how was the hospice agency’s volunteer services. On 1/23/26 at 1415 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed about the above findings and acknowledged staff should be provided in-services about hospice services. Review of the hospice agency’s P&P titled Interdisciplinary Group Membership and Responsibilities revised 4/2020, showed the IDG responsibilities include but are not limited to: participation in the establishment of the plan of care for each patient admitted to the hospice service, participation in the periodic review and updating of the plan of care for each patient receiving hospice services, taking a proactive approach in developing/revising the POC by planning ahead for anticipated patient changes and needs, and provision and/or supervision and coordination of hospice care and services.xx.Review of Patient 10’s closed clinical record was initiated on 1/22/26. The clinical record showed SOC was 6/19/25. The patient was certified for hospice services during the certification periods from 6/19/25 to 9/16/25 and 9/17/25 to 12/15/25. Patient was discharged on 11/12/25.a.Review of the Visit Note Declined Note dated 8/6/25 showed LVN 9 called the patient. Patient 10 refused the visit, does not need LVN visit and fine with the RN visits once a month only.However, there was no documented evidence Patient 10’s refusal of LVN visits was coordinated with the IDG. Review of the POC/IDG Review dated 8/15/25 showed to continue with current POC with weekly visits and observations.b. Review of LVN 10’s Visit Note dated 10/30/25 showed, patient reported having sputum with cough.However, there was no documented evidence Patient 10’s respiratory problem was coordinated with the IDG. Review of the POC/IDG dated 11/7/25 showed no evidence the respiratory problem was discussed.On 1/23/26 at 1134 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 confirmed and acknowledged the findings. Review of the hospice agency’s P&P titled Interdisciplinary Group Membership and Responsibilities revised 4/2020 showed the IDG responsibilities include but are not limited to: participation in the establishment of the plan of care for each patient admitted to the hospice service, participation in the periodic review and updating of the plan of care for each patient receiving hospice services, taking a proactive approach in developing/revising the POC by planning ahead for anticipated patient changes and needs, and provision and/or supervision and coordination of hospice care and services.Review of the hospice’s P&P titled Coordination of Care with Contracts (undated) showed coordination of care with all providers involved includes, but is limited to:A. Making relevant information available to all providers B. Clearly outlining each provider’s responsibilities in providing care C. Communicating changes in patient status and care in a timely manner. Review of the hospice’s P&P titled Durable Medical Equipment and Supplies (undated) showed those supplies required for optimal comfort, care, and management of the hospice patient will be obtained from hospice stock supplies or approved company if the patient is receiving Medicare, Medicaid or private insurance hospice benefit.1.Review of Patient 10’s closed clinical record was initiated on 1/22/26. The clinical record showed SOC was 6/19/25. The patient was certified for hospice services during the certification periods from 6/19/25 to 9/16/25 and 9/17/25 to 12/15/25. Patient was discharged on 11/12/25.a. The POC/IDG Review dated 8/1/25, showed LVN visit 1 per week and 1 PRN and RN visit 1 per two weeks and 1 PRN visits -recertification.Review of the Visit Note Declined Note dated 8/6/25, showed LVN 9 called the patient. Documentation showed Patient 10 refused the visit and did not need the LVN visit. Documentation showed the patient was fine with the RN visit once a month only.The POC/IDG Review dated 8/15/25, showed LVN visit 1 per week and 1 PRN and RN visit 1 per two weeks and 1 PRN visits -recertification. Documentation showed to continue with current POC with weekly visits and observations.However, there was no documented evidence Patient 10’s refusal of LVN visit was coordinated with the IDG. b. Review of LVN 10’s Visit Note dated 10/30/25, showed the patient reported having sputum with cough.Review of the POC/IDG dated 11/7/25, showed no evidence the patient’s respiratory problem was discussed. However, there was no documented evidence Patient 10’s respiratory problem was coordinated with the IDG. On 1/23/26 at 1134 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 confirmed and acknowledged the findings.2. Review of Patient 6’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 3/26/25. The patient was certified for hospice service during the certification period from 3/26/25 to 6/23/25, 6/24/25 to 9/21/25, 9/22/25 to 11/20/25, 11/21/25 to 1/19/26, and 1/20/26 to 3/20/26. On 1/20/26 at 1040 hours, a home visit was conducted with CHHA 1 to Patient 6’s residence. Patient 6’s caregiver and authorized representative stated they only have one pair of gloves left, and small-sized diapers were provided instead of medium sized. Patient 6’s authorized representative stated she had followed up with the hospice office staff and made the visiting staff aware about the stock of supplies needed for Patient 6 since two weeks ago; however, no information was relayed when she followed up again from last week’s hospice staff visit on the mentioned supplies. CHHA 1 asked again Patient 6’s authorized representative if she called the agency office staff and made them aware. Patient 6’s authorized representative stated she kept following up with no relayed information on the cause of the delay. The size of the diaper was observed to not fit for Patient 6 after CHHA 1 provided Patient 6 a bed bath and a pair of medium-sized gloves was observed to be the only stock left for Patient 6.On 1/20/26 at 1332 hours, an interview was conducted with LVN 3. LVN 3 was asked how soon should the delivery of supplies of diapers, wipes, and gloves be provided for the hospice patients. LVN 3 was informed of the above findings and acknowledged the delivery of supplies such as diapers, wipes, and gloves should not take more than two weeks.3. Review of Patient U’s clinical record was initiated on 1/20/26. The patient information showed patient’s primary diagnosis was Alzheimer’s disease, unspecified. The clinical record showed the patient’s authorized representative/ emergency contact was 5the patient’s family member.On 1/20/26 at 1501 hours, a telephone call was conducted to Patient U and a voicemail was left. On 1/21/26 at 0918 hours, a telephone call was conducted to Patient U and a left voicemail .At 1/21/26 at 0945 hours, a telephone call was conducted with the Patient U’s family member. The family member was asked permission for interview regarding hospice services by the agency. The family member permitted for the telephone interview. The family member was asked how was the hospice care services, if the staff were polite and respectful, if there were any missed visits and were rescheduled, who referred patient to hospice, and if patient needed volunteer services. Patient’s son stated he had no problem with the hospice agency, staff were respectful and polite, no issues with staff visits, and the patient was referred when patient was in the hospital. However, the patient’s family member stated he never knew about the hospice agency had volunteer services and he was interested about learning about the the hospice’s volunteer services. On 1/23/26 at 1415 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed about the above findings and acknowledged staff should be provided in-services about the hospice services.”

“Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for six of 10 sampled patients (Patients 2, 5, 6, 8, 9, and 10). 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 4/2020 showed the written plan of care will contain, but will not be limited to, the following:A. Start of care dateB. Certification periodC. Patient demographicsD. DiagnosisE. Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, bereavement and counselingF. Reduction in risk factorsG. Functional limitationsH. Mental StatusI. Safety Measures to protect against abuse, injury, infection, or communicable disease as appropriateJ. Nutritional requirementsK. PrognosisL. DME and medical supplies necessary to meet patient needsM. Frequency/ Amount/ Duration and type of servicesN. Placement at the appropriate level of care and referrals as needed for counseling, additional disciplines, volunteers and and adjunctive servicesO. Individualized interventions to assist with end-of-lie careP. Patient and family/caregiver educational needs and assessment of their ability to learn and understand teaching and their ability to safely self administer drugs and biologicalsQ. Statement of treatment of goalsR. Interdisciplinary group assessment of needsS. Pain and symptoms management interventionsT. Drugs and Treatments (including allergies)U. Physician-directed instruction to patient and family/ caregiverV. Physician (or other authorized licensed independent practitioner) ordersW. Measurable outcomes anticipated from implementing and coordinating the plan of careX. Patient or representatives level of understanding, involvement and agreement with the plan of careY. End of life preferencesZ. Anticipated discharge and bereavement care needs of the family.1. Review of Patient 6’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 3/26/25. The patient was certified for hospice service during the certification periods from 3/26/25 to 6/23/25, 6/24/25 to 9/21/25, 9/22/25 to 11/20/25, 11/21/25 to 1/19/26, and 1/20/26 to 3/20/26. Review of Patient 6’s POC/ IDG review 1/2/26, showed the frequency of visit of LVN was 1 per week and PRN visits, the MSW visit was 1 visit as needed and recertification, and the SC visit was 1 visit as needed and recertification.Record of Patient 6’s History of Nursing Assessments showed RN 2 provided the recertification visit dated 1/7/26.However, record of Patient 6’s History of Spiritual Counsellor Assessment Notes and History of Psychosocial Assessment Notes failed to show any documentation of the MSW and SC visits during the RN recertification dated 1/7/26.2. Review of Patient 8’s clinical record was initiated on 1/14/26. The clinical record showed the POC was 3/6/25. The patient was certified for hospice services during the certification periods from 3/6/25 to 6/3/25, 6/4/25 to 9/1/25, 9/2/25 to 10/31/25, 11/1/25 to 12/30/25, and 12/31/25 to 2/28/26. Review of Patient 8’s POC/IDG Review dated 10/24/25, showed the frequency of the LVN visit was 1 visit per week and PRN visits, the MSW visit was 1 visit as needed and recertification, and the SC visit was 1 visit as needed and recertification.Record of Patient 8’s History of Nursing Assessments showed the RN provided the recertification visits dated 10/21 and 12/30/25.However, record of Patient 8’s History of Spiritual Counsellor Assessment Notes failed to show any documentation of SC visits during the RN recertification visits dated 10/21 and 12/30/25.Record of Patient 8’s LVN 4 visit notes dated 11/24 and 12/4/25, showed missed visits. However, there was no documentation the hospice physician was informed of the missed visits. There was no documentation of a rescheduled visit. On 1/23/26 at 0958 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed of the above findings and acknowledged whatever was on the hospice patients’ plan of care, all should be followed. RN 1 also verified the missed visits should have been informed to the physician and should have been rescheduled.3. Review of Patient 2’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 9/15/25. The patient was certified for hospice services during the certification periods from 9/15/25 to 11/13/25, 11/14/25 to 1/12/26, and 1/13/26 to 3/13/26.The POC/IDG Review dated 11/21, 12/5, 12/19, and 1/2/26, showed a care plan addressing the patient’s gastrointestinal system. Documentation showed the intervention included to assess bowel status every visit.Review of the Visit Note LVN dated 11/18, 11/25, 12/2, 12/10, 12/16, 12/23, 12/30 and 1/6/26, showed LVN 1 had performed an assessment. However, LVN 1 failed to assess the patient’s last bowel movement as part of the bowel status as cited in the POC. On 1/23/26 at 1218 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.4. Review of Patient 9’s clinical record was initiated on 1/21/26. The clinical record showed the SOC was 5/16/25. The patient was certified for hospice services during the certification periods from 5/16/25 to 8/13/25, 8/14/25 to 10/12/25, 10/13/25 to 12/11/25, and 12/12/25 to 2/9/2026. The POC/IDG Review dated 12/19/25, 1/2, and 1/16/26, showed the RN visit frequency cited as one visit per two weeks and one PRN visit-recertification. Review of the clinical record showed RN 2 had visited the patient on Week 2 (12/14/25 to 12/20/25) and Week 4 (12/28/25 to 1/3/26) as ordered in the POC. However, there was no documented evidence RN 2 had visited the patient on Week 6 (1/11/26 to 1/17/26) as ordered in the POC. On 1/23/26 at 1028 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was asked if the RN visit was missed. The Administrator/CEO stated if there was no documentation, it was missed. The Administrator/CEO was informed and acknowledged the findings.5. Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26, and 1/16/26 to 3/16/26.The POC/IDG Review dated 1/2/26, showed a wound care order for the patient’s right hand tear. Documentation showed the following: cleanse wound with appropriate wound cleanser and gently pat dry. Apply Xeroform dressing (a dressing used for wound care to maintain a moist environment, reduce odor and prevent sticking to wound) daily. On alternate days apply triple antibiotic ointment (antibiotic) as clinically indicated, then cover with 4x4 non-adhesive gauze, wrap with Kerlix (a six ply fluff dried bandage), and secure with paper tape. Documentation showed to monitor wound for signs of infection, including increased redness, drainage, or odor.Furthermore, review of the POC showed a care plan problem for integumentary/skin “Open dated 12/22/25.” Documentation showed the intervention included to assess changes in wound status, check the size, integrity, location, type/stage, signs and symptoms of infection, drainage, and effectiveness of the current treatment.However, LVN 1’s Visit Notes dated 12/29/25; and 1/5 and 1/12/26, and RN 2’s Recert Assessment dated 1/2/26, showed no documented evidence LVN 1 and RN 2 had performed wound care on the patient’s right hand’s tear. Furthermore, there was no documented evidence the wound status was assessed.On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 verified and acknowledged the findings.6. Review of Patient 10’s closed clinical record was initiated on 1/22/26. The clinical record showed SOC was 6/19/25. The patient was certified for hospice services during the certification periods from 6/19/25 to 9/16/25 and 9/17/25 to 12/15/25. Patient 10 was discharged on 11/12/25.The POC/IDG Review dated 9/12, 9/26, 10/10, 10/24, and 11/7/25, showed LVN visit frequency was one visit per week, plus one PRN visit. The LVN Visit Notes showed no documented evidence the LVN conducted a visit during Week 1 (9/14/25 to 9/20/25), Week 3 (9/28/25 to10/4/25), and Week 5 (10/12/25 to 10/18/25), instead of one visit per week as per the POC.On 1/23/26 at 1134 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 confirmed and acknowledged the findings.”

“Based on interview and document review, the hospice failed to ensure the ongoing efforts for recruiting and retaining volunteers was documented. This failure had the potential of not providing the adequate volunteer services.Findings: Review of the hospice’s P&P titled Volunteer Services revised 4/2020 showed the Volunteer Coordinator will document ongoing efforts to recruit, train, and retain volunteers of all ages and ethnic backgrounds. Retention activities may include support groups, partnering with other volunteers, recognition events, regular communication and changing assignments as necessary. Review of the hospice’s volunteer program was initiated on 1/16/26. The Volunteer Management Program Binder included the Volunteer Recruitment Record for the years of 2020 to 2024. However, there was no documented evidence of the Volunteer Recruitment Record for the year 2025.In addition, review of the Volunteer Management Program Binder showed the agency’s plan for Volunteer Recruitment for the years of 2023 to 2024. However, there was no documented evidence of the plan for volunteer recruitment for the year 2025.Further review of the Volunteer Management Program Binder showed the agency’s Volunteer Retention Plan for the year 2024. However, there was no documented evidence of the plan for volunteer retention plan for the year of 2025.On 1/23/26 at 1000 hours, an interview and concurrent hospice document review was conducted with the Administrator. The Administrator was asked if they were recruiting for volunteers. The Administrator stated no. The Administrator stated the hospice have two volunteers and when the patient was asked if they needed volunteers, they decline. The Administrator also reported most of the volunteers just walked in to the office. The Administrator was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the cost saving achieved through the use of volunteers was documented. This failure had the potential of not providing the adequate volunteer services.Findings: Review of the hospice’s P&P titled Volunteer Services revised 4/2020 showed the Volunteer Coordinator will track the use of volunteers, the cost saving achieved. The Volunteer Coordinator will provide an annual report to the Governing Body to demonstrate the cost savings of volunteer activities. Review of the hospice’s volunteer program was initiated on 1/16/26. The Volunteer Management Program Binder showed the Volunteer hours: Ratio to Direct Patient Care Employee Hours for the years of 2022 and 2023. The documentation also included the monthly cost saving and the YTD (year to date) cost saving. However, there was there was no documented evidence of the cost saving for the years of 2024 and 2025. On 1/23/26 at 1000 hours, an interview and concurrent hospice document review was conducted with the Administrator The Administrator was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the volunteers provided at a minimum, equals to 5% of the total patient care hours of all paid hospice employees and contracted staff. This failure had the potential of not providing the adequate volunteer services.Findings: Review of the hospice’s P&P titled Volunteer Services revised 4/2020 showed the Volunteer Coordinator will track the use of volunteers, the cost saving achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel. Review of the hospice’s volunteer program was initiated on 1/16/26. The Volunteer program showed the Volunteer hours: Ratio to Direct Patient Care Employee Hours for the years 2022 of and 2023. However, there was no documented evidence of the Volunteer hours: Ratio to Direct Patient Care Employee Hours for the years of 2024 and 2025.The hospice’s documents showed no documented evidence the volunteers provided day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff for the years of 2024 and 2025In addition, a telephone interview was conducted with Volunteer. The Volunteer was asked if he provided direct patient care and administrative duties. The Volunteer stated he was not given an assignment since he was hired.On 1/23/26 at 1000 hours, an interview and concurrent hospice document review was conducted with the Administrator The Administrator was informed and acknowledged the findings.”

“Based on interview and record review, the hospice’s GB and Administrator failed to be responsible for the day-to-day operations of the organization and maintain the administrative responsibility as evidenced by:-Failure to ensure the Administrator directed the hospice services, resulting in non-compliance with the COPs under 418.54 (Initial & Comprehensive Assessment); 418.56 (Interdisciplinary Group, Care Planning, and Coordination of Services); 418:78 (Volunteers); 418.100 (Organization and Administration of Services); and 418.104 (Clinical Records).-Failure to ensure the completion of tuberculosis screening, background check, skilled competency, performance evaluation and physical examination for nine of 12 employee files reviewed (the Spiritual Counsellor, RN 2, SC/BC, RN 5, DPCS, LVN 1, MSW, HA 2, and Volunteer Coordinator).-Failure to ensure the Medical Director’s written agreement included the specific rights, roles and responsibilities as per the standards.-Failure to ensure the Medical Director Designee’s roles and responsibilities included the bereavement follow up in he written agreement.-Failure of the Governing Body to address the volunteer program plan as identified on the meeting minutes. -Failure to ensure patient’s competency to sign a consent to participate in a hospice program prior to receiving care.-Failure to ensure the infection control practices were implemented during home visit.These failures had the potential for poof health outcomes for the patients received hospice services.Findings: Review of the employees’ files was initiated on 1/15/26 with the Administrator.a.Review of the following RNs personnel file showed the following:-RN 2 showed the hiring date was 10/20/25. The file included the Physical Examination Form. The Physical Examination Form showed the date of exam was 11/14/24. The physical examination was performed more than six months prior to employment.Furthermore, a TB skin test was performed on 11/19/24 and result came back on 11/21/24. The TB testing was completed more than six months prior to employment.-RN 5 showed the hiring date was 2/3/25. The file included the Physical Examination Form. The Physical Examination Form showed the date of the exam was 8/9/23. The physical examination was performed more than six months prior to employment.Furthermore, a background check was completed for RN 5 on 9/17/25. The background check was completed more than six months from date of employment.b.The DPCS showed the hiring date was 2/1/25. The file included the Physical Examination Form. The Physical Examination Form showed the date of exam was 8/7/25. The physical examination performed was more than 14 days from date of employment.Also, a TB skin test was completed on 8/29/25. The TB testing was completed more than 14 days of employment.Furthermore, a background check was completed for the DPCS on 9/17/25. The background check was completed more than six months from date of employment.c.The SC/BC showed the hiring date was 2/1/25. The file included the Physical Examination Form. The Physical Examination Form showed the date of the exam was 7/26/25. The physical examination performed was more than 14 days from date of employment.Furthermore, a background check was completed for the SC/BC on 9/17/25. The background check was completed more than six months from date of employment.d.The MD showed the hiring date was 2/1/25. The file included the Physical Examination Form. The Physical Examination Form showed the date of the exam was 10/5/25. The physical examination performed was more than 14 days from date of employment.Also, there was no evidence of a TB skin test on file.Furthermore, a background check was completed for the MD on 9/17/25. The background check was completed more than six months from date of employment.d.LVN 1 showed the hiring date was 1/1/25. The file included the Skills/Competency Check. The Skills/Competency check showed it was completed on 9/1/24. The Skills/Competency Check was completed prior to date of employment.Also, there were no documented evidence that a Performance Evaluation conducted and TB test was completed six months prior or 14 days from date of employment.Furthermore, a background check was completed for LVN 1 on 9/17/25. The background check was completed more than six months from date of employment.e.The MSW showed the hiring date was 10/20/25. The file included a TB test which was completed on 3/1/23. TB testing was completed more than six months prior to employment.Furthermore, the file included the Physical Examination Form. The Physical Examination Form showed the date of the exam was 12/8/23. The physical examination performed was more than six months prior to employment.f.The Volunteer showed the hiring date was 11/6/24. The file included the Orientation which was completed on 6/4/25. The Orientation was completed prior to date of hiring.Also, a TB skin test was completed on 1/24/25. The TB testing was completed more than 14 days of employment.Furthermore, a background check was completed for the Volunteer on 9/17/25. The background check was completed more than six months from date of employment.g.HA 2 showed the hiring date was 2/21/25. The Physical Examination Form showed the date of the exam was 1/10/24. The physical examination performed was more than six months prior to employment.Also, there was no documented evidence that a TB test was completed.Furthermore, only one hour of in-service was completed for the 12 hour in-service requirement.h.The Volunteer Coordinator showed the hiring date was 2/13/25. The Physical Examination Form showed the date of the exam was 11/28/22. The physical examination performed was more than six months prior to employment.Also, a TB skin test was completed on 12/13/25. The TB testing was completed more than 14 days of employment.Furthermore, a background check was completed for the Volunteer Coordinator on 9/17/25. The background check was completed more than six months from date of employment.On 1/23/26 at 0908 hours, an interview and concurrent document review was conducted with the Administrator. The Administrator verified and acknowledged all findings.Review of the P&P titled Clean vs. Aseptic Technique revised 4/2020 showed, all hospice personnel will use the appropriate technique for the procedure being performed. Clean technique refers to infection control strategies utilized to reduce the number of microorganisms or to reduce or prevent the transmission of microorganisms from one person to another. Clean technique includes the following strategies including decontaminate hands using an alcohol-based hand rub before and after the procedure.Review of the P&P titled Bag Technique revised April 2020 showed, as part of the infection/exposure control plan, the hospice personnel will consistently implement principles to maximize efficient use of the patient’s care supply bag when used in caring for patients. The bag technique includes among others, when the visit is completed, reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solution, hands will be washed, and equipment and supplies will be returned to the bag.xx. Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26 and 1/16/26 to 3/16/26.A joint home visit with LVN 1 was conducted on 1/20/26 at 1020 hours at the patient’s home. The following were observed:LVN 1 performed a wound care to the left hand and to the left anterior leg. However, after performing wound care to the left hand, LVN 1 did not wash hands and changed gloves but continued to perform wound care on the left anterior leg.Furthermore, LVN 1 was observed to place the used stethoscope in the bag without cleaning with alcohol or other appropriate solution.On 1/20/26 at 1020 hours, an interview was conducted with LVN 1. LVN 1 confirmed and acknowledged the findings. Review of the P&P titled Informed Consent for Patient and Family/Caregiver revised 4/2020 showed the patient or his/her legal representative (when the patient is not competent) must sign a consent to participate in a hospice program prior to receiving care. The admitting hospice registered nurse will review the form with the patient and family/caregiver so that there is an understanding of the philosophy, goals, and services provided by the program.Review of the Hospice Election Statement, Release of Information & Consent for Treatment, Patient Rights and Responsibilities, Decline of Specific Services, Notice of Care Privacy Practices, Advance Directives, Home Oxygen and Risk Assessment, Patient Acknowledgement in Receipt of Information and Phone Side Information dated 5/21/25 showed Patient 5 as signatory for all abovementioned forms.Furthermore, review of the Individual Patient Emergency Preparedness Plan signed by RN 1 showed Alzheimer’s (a progressive and irreversible brain disorder that destroys memory, thinking, and language skills) as primary diagnosis.Also, a review of the Comprehensive Nursing Assessment dated 5/21/25 showed a FAST score of 7a, indicating the first substage of severe Alzheimer’s Disease where patients may become eligible for hospice.During a joint home visit with LVN 1 conducted on 1/20/25 at 1020 hours, Patient 5 was observed to be alert to self only. Patient 5 can talk, however, during conversations, patient observed to go from one topic to another.An interview was conducted with the PCG, the PCG stated the patient had signed the forms for hospice. The PCG was with the patient during the signing of the consents, however, explanation of hospice benefits was not explained. RN 1 just had the patient signed the consents. On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 confirmed and acknowledged the findings. Review of the agency’s P&P titled Governing Body revised 4/2020 showed the Governing Body will assume the full legal authority, responsibility, decision making and accountability for overall management and operations, the provision of services, fiscal operations, human resource management and operational plans. Review of the Job Description signed 11/26/24 showed the Executive Director/Administrator is responsible for the overall direction of the hospice services. She is responsible for the provision of hospice services, directly, and the delegation to and coordination of hospice personnel evaluations, is responsible for establishing standards of care to comply with federal and state regulations and guidelines. Review of the hospice’s P&P tilted Competency Assessments revised 4/2020 showed the purpose was to outline the process of assessing professional and paraprofessional competence. The policy includes the competence of all organization clinical personnel (employed, contract, or volunteer) will be assessed during orientation, during probationary period, periodically throughout the course of the year and during the annual performance evaluation. The hospice’s P&P tilted Performance Evaluation revised 4/2020 showed the purpose was to provide consistent and regular performance evaluations to promote improvement. The procedure includes performance evaluations will be completed (and dated) on all personnel during the probationary period, at the end of the first three (3) months of employment and annually.The hospice’s P&P tilted Selection/Hiring of Personnel undated showed the procedure for hiring includes a criminal background check and national sex offender check, if not part of the criminal background check will be obtained for positions required by law and regulations. A current physical and TB test/chest X-ray must be received prior to the first day of employment. All new personnel must attend an orientation program prior to assuming job responsibilities. A specific orientation program will be conducted which address job responsibilities and a further review of organization policies. According to Standards of Quality Hospice Care 2005 Section 6.3 (a) (1) (2):-All persons providing physician, nursing or home health aide services shall have a health examination by a physician, nurse practitioner or physician’s assistant six months prior to employment or within 14 days of the date of employment. The initial health examination shall include a tuberculosis screening. Review of the employees’ files was initiated on 1/22/256 with the Administrator. a. Review of Spiritual Counsellor’s personnel file showed the hiring date of 1/3/25. The file included the Physical Examination Form. The Physical Examination Form showed the date of exam was 2/5/25. However the physical examination was performed more than 14 days from the date of employment.In addition, the physical examination showed a TB skin test was performed on 1/25/25 and was resulted on 1/27/25. However, the TB testing was completed more than 14 days from the date of employment.Further review of the personnel file showed the criminal background check was performed on 9/17/25. However, the criminal background check was performed more than eight months after employment date. Moreover, there was no documented evidence of the skills competency was performed as per P&P.Furthermore, there was no documented evidence of the performance evaluation was conducted as per P&P. On 1/22/26 at 1512 hours an interview and concurrent document review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. b. Review of the Professional Services Agreement Medical Director Designee effective 1/3/25 on the section for compliance and standards showed the Medical Director will perform all services and duties under this agreement in strict accordance with all laws, rules, regulations, ordinances, and judicial and administrative interpretations thereof of the United States, State of California as well as the bylaws, rules and regulations, guidelines, policies and procedure of Altair Hospice Care Inc., as all of the foregoing may from time be in effect. Review of the written agreement showed the roles and responsibilities of the program and the contracted individual. However, there was no documented evidenced of roles and responsibilities for bereavement follow-up. In addition, on the section for the parties who executed the written agreement showed the agency’s Administrators /CEO name, signature and date. However, there was no documented evidence of the signature and date of the Medical Director Designee as part of the written contract agreement. On 1/22/26 at 1525 hours an interview and concurrent document review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. c. Review of the Governing Body Meeting Minutes dated 6/2/2025 included the Quarter 1 2025 QAPI Meeting Findings. The period covered from January 1, 2025 to March 31,2025. The Governing Body reviewed the key areas including volunteer services activity. Further review of the GB meetings included the approval of Quarter 2 2025 QAPI work plan. The plan included volunteer program development. However, there was no documented evidence the GB develop an action plan to address the volunteer services activity and specific volunteer program plan as identified during the GB meeting. Moreover, review of the GB Meeting Minutes dated 1/2/2026 showed the Governing Body reviewed a comprehensive summary of QAPI activities spanning Quarter 1 2025 to Quarter 1 2026. The Governing Body identified the quality indicators included ongoing lack of volunteer utilization, administrative tracking and documentation improvements underway and administrative/ volunteer program PIP remains active. The oversight determination showed the Governing Body directed continued development and documentation of the volunteer program and administrative oversight. However, there was no documented evidence the GB developed an action plan to address the ongoing lack of volunteer utilization, administrative tracking and documentation as identified.On 1/22/26 at 1400 hours an interview and concurrent document review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. Cross ref. G-647”

“Based on record review and interview, the hospice failed to ensure the medical director or physician designee reviewed the patient’s clinical information to certify the patient for hospice services as per the hospice’s P&P for three of 10 sampled patients (Patient 2, 3, and 7). This failure had the potential for not identifying patient’s care needs for these patients.Findings: ##. Review of Patient 7’s clinical record was initiated on 1/16/26. The clinical record showed the SOC was 7/7/25. The patient was certified for hospice services during the certification periods from 7/15/25 to 9/12/25, 9/13/25 to11/11/25 and 11/12/25 to 1/10/26.Review of the clinical record showed the Physician’s Certification for Hospice Benefit for the certification period from 11/12/25 to 1/10/26 was conducted. The certification included the face - to - face narrative by the physician or NP.However, there was no documented evidence of the face to face encounter performed by the physician or nurse practitioner within the 30 days prior to the third benefit period certification.On 1/23/26 at 1030 hours, an interview and concurrent clinical review with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. ##. Review of Patient 2’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 9/15/25. The patient was certified for hospice services during the certification periods from 9/15/25 to 11/13/25, 11/14/25 to 1/12/26 and 1/13/256 to 3/13/26.Review of the clinical record showed the Physician’s Certification for Hospice Benefit for the certification period from 1/13/256 to 3/13/26 was conducted. The certification included the face to face narrative by the physician or NP.However, there was no documented evidence of the face to face encounter performed by the physician or nurse practitioner within the 30 days prior to the third benefit period certification.On 1/23/26 at 1151 hours, an interview and concurrent clinical review with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. Review of the hospice’s P&P titled Face-To-Face Encounter revised 4/2020 showed, a face-to-face encounter will be performed for patients entering the third and all subsequent benefit periods. The hospice director, or a hospice employed nurse practitioner will perform face-to-face encounter within 30 days prior to the hospice recertification for the third and all subsequent benefit periods.xx. Review of Patient 3’s clinical record was initiated on 1/14/26. The clinical record showed SOC was 3/18/25. The patient was certified for hospice services during the certification periods from 3/18/25 to 6/15/25, 6/16/25 to 9/13/25, 9/14/25 to 11/12/25, 11/13/25 to 1/11/26, 1/12/26 to 3/13/26.Review of the Physician’s Certification for Hospice Benefit for the certification period from 11/13/25 to 1/11/26, showed documentation the certification was based on face to face encounter.However, there was no documented evidence of the face to face encounter performed by the physician or nurse practitioner within the 30 days prior to the fourth benefit period certification.On 1/23/26 at 0955 hours, a concurrent clinical record review and interview with RN 2 was conducted. RN 2 verified and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the patients’ clinical records were complete and accurate for nine of 10 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, and 9). This failure had the potential for the patients to receive a substandard care and disrupt the continuity of care due to the clinical records were incomplete and inaccurate.Findings: Review of the hospice’s P&P titled Clinical/Service Data Collection revised 4/2020 showed documentation in the clinical/service record will be timely, detailed, accurate and reflect the care or services provided. The record format will be reviewed and updated as necessary. A clinical/service 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: A. Patient Consent B. Pertinent Medical History C. Physician (or other authorized licensed independent practitioner) orders and evidence of physician oversight activities D. Changes to the plan of care/service E, Dates , times and types of interventions, assessments, and coordination of care /service F. Patient response to care and services in analyzed and documented as measurable goals G. Patient and family education H. Reasons for interruptions in the provision of care and services I. Current patient status and progress towards goals J. Outcomes of care/services. Entries into the clinical/service record will be clear, concise and specific statements of fact. Entries into the clinical/service record will be legible. Entries into the clinical/service record will be made on the day care/services is provided to the patient. All documentation will be turned into the office at the end of the workday. XX. Review of Patient 1’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 2/12/25. The patient was certified for hospice service during the certification period from 2/12/25 -5/12/25, 5/13/25 - 8/10/25, 8/11/25 - 10/9/25, 10/10/25 -12/8/25, 12/9/25 - 2/6/26 and 2/7/25 - 4/726. Review of Patient 1’s Physician’s Certification for Hospice Benefit dated effective 10/10/25 - 12/8/25 and 12/9/25 - 2/6/26 showed Patient 1’s primary diagnosis was Malignant Neoplasm of Prostate.Review of RN 3 Nursing Assessment notes dated 2/12/25 showed Patient 1’s primary diagnosis was Malignant neoplasm of Prostate and with Genitourinary Reproductive assessment that included: urinary incontinence, also included with answered “yes” on a question, has the cancer metastasized and is untreatable at presentation and has the cancer metastasized regardless of therapy.Review of LVN 2 visit notes dated 2/17/25, 2/26/25, 3/6/25, and 3/13/25, LVN 6 visit notes dated 4/4/25, 5/16/25, 5/30/25, 6/1325, and 6/27/25 showed assessed/ no issues on Patient1’s Genitourinary/Reproductive Assessment. Furthermore, LVN 5 visit notes dated 10/15/25, 10/29/25, 11/5/25, 11/26/25, 12/3/25, 12/17/25, 12/24/25, and 12/31/25 showed Genitourinary Reproductive Assessment documentation that included urinary problem: never, Incontinent: yes and other symptom: none. Review of Patient 1’s LVN 5 visit notes dated 10/15/25, 10/29/25, 11/5/25, 11/26/25, 12/3/25, 12/17/25, 12/24/25 and12/31/25 were with missed assessments on sections of Imminently Dying, Fall Incidence/ Occurrence and Safety Issues. XX. Review of Patient 6’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 3/26/25. The patient was certified for hospice service during the certification period from 3/26/25 - 6/23/25, 6/24/25 - 9/21/25, 9/22/25 - 11/20/25, 11/21/25 - 1/19/26 and 1/20/26 to 3/20/26. Review of Patient 6’s LVN 1 visit notes dated 12/3/25, 12/11/25, 12/17/25, 12/26/25, 12/29/25, 1/5/25 and 1/12/25 were with missed assessments on sections of Imminently Dying, Fall Incidence/ Occurrence and Safety Issues. XX. Review of Patient 8’s clinical record was initiated on 1/14/26. The clinical record showed the POC was 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 - 6/3/25, 6/4/25 - 9/1/25, 9/2/25 - 10/31/25, 11/1/25 - 12/30/25 and 12/31/25 - 2/28/26. Review of Patient 8’s LVN 1 visit notes dated 11/3/25, 11/10/25, 11/17/25, 12/8/25, 12/16/25, and 12/23/25 were with missed assessments on sections of Imminently Dying, Fall Incidence/ Occurrence and Safety Issues. Additionally, LVN 4 visit notes dated 12/23/25, 12/30/25, 1/6/26, and 1/13/26 were also with missed assessments on sections of Imminently Dying, Fall Incidence/ Occurrence and Safety Issues. On 1/23/26 at 0958 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the above findings. Review of the hospice’s P&P titled Contents of Clinical Record revised 4/2020 showed, a clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail. xx. Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26 and 1/16/26 to 3/16/26.a.Review of the initial Comprehensive Nursing Assessment dated 5/21/25 showed the following:-patient was able to understand and participate in own care and can safely administer medications. However, Patient 5 has primary diagnosis of Alzheimer’s disease and a FAST score of 7a which was inconsistent.-patient/PCG needs teaching for oxygen. However, per Home Oxygen Safety and Risk Assessment dated 5/21/25, there was no specific MD orders written for Oxygen Administration which was inconsistent.b.Review of the Visit Note LVN dated 9/29/25 and 11/24/25 showed there was no change in safety issues, however, per narrative the caregiver reported that patient had a fall on 9/23/25 and 11/22/25 (a Saturday), respectively, which was inconsistent.c. Review of the Visit Note LVN dated 12/22/25 showed in the narrative that patient had a skin tear on the right lower arm. However, during joint home visit conducted with LVN 2 on 1/20/26 at the patient’s home, a wound care treatment was observed to be provided on the left hand which was inaccurate.On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 stated Patient 5 has the wound on the left hand. RN 2 confirmed and acknowledged the findings.xx.Review of Patient 3’s clinical record was initiated on 1/14/26. The clinical record showed SOC was 3/18/25. The patient was certified for hospice services during the certification periods from 3/18/25 to 6/15/25, 6/16/25 to 9/13/25, 9/14/25 to 11/12/25, 11/13/25 to 1/11/26, 1/12/26 to 3/13/26.a.Review of the POC/IDG Review dated 3/18/25 showed a treatment order for SN/PCG to administer oxygen at 2-5 LPM via NC as needed for shortness of breath/dyspnea (labored breathing).However, review of the initial Comprehensive Nursing Assessment dated 3/18/25 showed patient was not on oxygen therapy, no oxygen concentrator was placed on DME device and no teaching was needed for oxygen which was inconsistent.b.Review of the POC/IDG Review dated 11/7, 11/21, and 12/5/25 showed the IDG Discussion/Updated Comprehensive Assessment Review for Psychosocial were the same for the aforementioned POC/IDG Review.On 1/23/26 at 0955 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 stated the documentation was copy and pasted. RN 2 confirmed and acknowledged the findings. ##. Review of Patient 4’s closed clinical record was initiated on 1/15/26. The clinical record showed the SOC was 6/25/25. The patient was certified for hospice services during the certification period from 6/25/25 to 9/22/25. The patient passed away on 8/5/25.Review of the Visit Note LVN dated 8/5/25 showed the LVN 8 had performed an assessment.Further review of the LVN notes dated 8/5/25, showed the patient was started on a continuous care. However, the section to assessed for Imminently Dying was left blank which was inconsistent. On 1/23/26 at 0938 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator /CEO was informed and acknowledged the findings. ##. Review of Patient 7’s clinical record was initiated on 1/16/26. The clinical record showed the SOC was 7/7/25. The patient was certified for hospice services during the certification periods from 7/15/25 to 9/12/25, 9/13/25 to 11/11/25 and 11/12/25 to 1/10/26.Review of the Visit Note LVN dated 11/2, 11/14, 11/21, 11/29, 12/5, 12/12, 12/19 and 1/2/26 showed the LVN 7 had performed an assessment.However, the section to assessed for Imminently Dying was left blank. On 1/23/26 at 1030 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. ##. Review of Patient 2’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 9/15/25. The patient was certified for hospice services during the certification periods from 9/15/25 to 11/13/25, 11/14/25 to 1/12/26 and 1/13/256 to 3/13/26.Review of the Visit Note LVN dated 11/18, 11/25, 12/2, 12/10, 12/16, 12/23, 12/30 and 1/2/26 showed LVN 1 had performed an assessment. The assessment included the section for Imminently Dying, Fall incidence/occurrence and Safety issues. However, LVN 1 failed to complete the assessment as those sections were left blank. On 1/23/26 at 1218 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. ##. Review of Patient 9’s clinical record was initiated on 1/21/26. The clinical record showed the SOC was 5/16/25. The patient was certified for hospice services during the certification periods from 5/16/25 o 8/13/25, 8/14/25 to 10/12/25, 10/13/25 to 12/11/25 and 12/12/25 to 2/9/2026. a. Review of the Visit Note LVN dated 12/15/25 showed on the section of narrative showed the patient was assessed to have mild shortness of breath, lung sounds were diminished, no cough, nasal flaring shortness of breath was noted at rest. The assessment also showed skin discoloration and edema was noted on the lower extremities.However, the section for signs and symptoms screening for respiratory, cardiovascular and integumentary showed a check mark on the section of “Assessed/No Issues Reported” which was inconsistent. In addition, review of the Visit Note LVN dated 1/5/26 on the section of narrative note showed the patient was assessed to have a dry wound to the right hand with edema.However, the section for signs and symptoms screening for integumentary showed a wound assessment was documented as “None” which was inaccurate. On 1/23/26 at 1028 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was asked if the assessment was consistent. The Administrator/CEO reviewed the clinical records and replied no, it was inconsistent. The Administrator/CEO was informed and acknowledged the findings.b. Review of the Visit Note LVN dated 10/13, 10/27, 11/10, 11/24, 12/1 and 12/8, 12/15, 12/22, 12/29/25, 1/5, 1/12, and 1/19/26 showed the LVN 1 had performed an assessment. However, the section to assessed for Imminently Dying was left blank. On 1/23/26 at 1106 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. Review of the hospice’s P&P titled Clinical/Service Data Collection revised 4/2020 showed documentation in the clinical/service record will be timely, detailed, accurate and reflect the care or services provided. The record format will be reviewed and updated as necessary. A clinical/service 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:A. Patient ConsentB. Pertinent Medical HistoryC. Physician (or other authorized licensed independent practitioner) orders and evidence of physician oversight activities D. Changes to the plan of care/serviceE. Dates , times and types of interventions, assessments, and coordination of care /serviceF. Patient response to care and services in analyzed and documented as measurable goalsG. Patient and family educationH. Reasons for interruptions in the provision of care and servicesI. Current patient status and progress towards goalsJ. Outcomes of care/services. Entries into the clinical/service record will be clear, concise and specific statements of fact. Entries into the clinical/service record will be legible. Entries into the clinical/service record will be made on the day care/services is provided to the patient. All documentation will be turned into the office at the end of the workday. 1. Review of Patient 1’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 2/12/25. The patient was certified for hospice services during the certification periods from 2/12/25 to 5/12/25, 5/13/25 to 8/10/25, 8/11/25 to 10/9/25, 10/10/25 to 12/8/25, and 12/9/25 to 2/6/26Review of Patient 1’s Physician’s Certification for Hospice Benefit effective date 10/10/25 to 12/8/25 and 12/9/25 to 2/6/26 showed Patient 1’s primary diagnosis was malignant neoplasm of prostate.Review of RN 3’s Nursing Assessment note dated 2/12/25, showed Patient 1’s primary diagnosis was malignant neoplasm of prostate. Documentation showed on the section of Genitourinary Reproductive assessment the patient had urinary incontinence. Documentation showed the cancer had metastasized, was untreatable at presentation, and the cancer had metastasized regardless of therapy.Review of LVN 2’s visit notes dated 2/17, 2/26, 3/6, and 3/13/25; and LVN 6’s visit notes dated 4/4, 5/16, 5/30, 6/13, and 6/27/25, showed Patient 1’s Genitourinary/Reproductive was assessed/no issues reported.Furthermore, LVN 5’s visit notes dated 10/15, 10/29, 11/5, 11/26, 12/3, 12/17, 12/24, and 12/31/25, showed in the section of Genitourinary Reproductive assessment the patient was incontinent, there was never a urinary problem, and there was no other symptom.However, the genitourinary assessments were not consistent as there was information the patient had urinary incontinence, information there was no issues reported, and there was never a urinary problem.Review of Patient 1’s LVN 5 visit notes dated 10/15, 10/29, 11/5, 11/26, 12/3, 12/17, 12/24, and12/31/25 were with missed assessments on sections of Imminently Dying, Fall Incidence/ Occurrence and Safety Issues.On 1/23/26 at 1153 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the above findings. 2. Review of Patient 6’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 3/26/25. The patient was certified for hospice services during the certification period from 3/26/25 to 6/23/25, 6/24/25 to 9/21/25, 9/22/25 to 11/20/25, 11/21/25 to 1/19/26, and 1/20/26 to 3/20/26. Review of Patient 6’s LVN 1 visit notes dated 12/3, 12/11, 12/17, 12/26, and 12/29/25, and 1/5/26 and 1/12/25, showed missed assessments on the sections of Imminently Dying, Fall Incidence/ Occurrence, and Safety Issues.On 1/23/26 at 1415 hours, a concurrent interview and clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the above findings. 3. Review of Patient 8’s clinical record was initiated on 1/14/26. The clinical record showed the POC was 3/6/25. The patient was certified for hospice services during the certification periods from 3/6/25 to 6/3/25, 6/4/25 to 9/1/25, 9/2/25 to 10/31/25, 11/1/25 to 12/30/25, and 12/31/25 to 2/28/26. Review of Patient 8’s LVN 1 visit notes dated 11/3, 11/10, 11/17, 12/8, 12/16, and 12/23/25, showed missed assessments on sections of Imminently Dying, Fall Incidence/ Occurrence, and Safety Issues. Additionally, LVN 4’s visit notes dated 12/23 and 12/30/25; 1/6 and 1/13/26 showed missed assessments on sections of Imminently Dying, Fall Incidence/ Occurrence, and Safety Issues.On 1/23/26 at 0958 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the above findings.4. Review of Patient 4’s closed clinical record was initiated on 1/15/26. The clinical record showed the SOC was 6/25/25. The patient was certified for hospice services during the certification period from 6/25/25 to 9/22/25. The patient passed away on 8/5/25.Review of the Visit Note LVN dated 8/5/25, showed LVN 8 had performed an assessment.Further review of the LVN notes dated 8/5/25, showed the patient was started on a continuous care. However, the section to assess for Imminently Dying was left blank which was inconsistent. On 1/23/26 at 0938 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator /CEO was informed and acknowledged the findings.5. Review of Patient 7’s clinical record was initiated on 1/16/26. The clinical record showed the SOC was 7/7/25. The patient was certified for hospice services during the certification periods from 7/15/25 to 9/12/25, 9/13/25 to 11/11/25, and 11/12/25 to 1/10/26.Review of the Visit Note LVN dated 11/2, 11/14, 11/21, 11/29, 12/5, 12/12, 12/19/25; and 1/2/26 showed LVN 7 had performed an assessment.However, the section to assess for Imminently Dying was left blank. On 1/23/26 at 1030 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.6.Review of Patient 2’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 9/15/25. The patient was certified for hospice services during the certification periods from 9/15/25 to 11/13/25, 11/14/25 to 1/12/26, and 1/13/26 to 3/13/26.Review of the Visit Note LVN dated 11/18, 11/25, 12/2, 12/10, 12/16, 12/23, 12/30/25; and 1/2/26, showed LVN 1 had performed an assessment. The assessment included the section for Imminently Dying, Fall Incidence/Occurrence, and Safety issues. However, LVN 1 failed to complete the assessment as those sections were left blank. On 1/23/26 at 1218 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.7.Review of Patient 9’s clinical record was initiated on 1/21/26. The clinical record showed the SOC was 5/16/25. The patient was certified for hospice services during the certification periods from 5/16/25 to 8/13/25, 8/14/25 to 10/12/25, 10/13/25 to 12/11/25, and 12/12/25 to 2/9/2026. a. Review of the Visit Note LVN dated 12/15/25, showed on the narrative section of the note the patient was assessed to have mild shortness of breath, lung sounds were diminished, no cough, nasal flaring, “or” shortness of breath was noted at rest. The assessment also showed skin discoloration and edema was noted on the lower extremities.However, the section for Signs and Symptoms screening for Respiratory, Cardiovascular and Integumentary showed a check mark on the section of “Assessed/No Issues Reported,” which was inconsistent. In addition, review of the Visit Note LVN dated 1/5/26, on the narrative section of the note the patient was assessed to have a dry wound on the right hand with edema.However, the section for Signs and Symptoms Screening for Integumentary showed a wound assessment was documented as “None,” which was inaccurate. On 1/23/26 at 1028 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was asked if the assessment was consistent. The Administrator/CEO reviewed the clinical records and stated no, it was inconsistent. The Administrator/CEO was informed and acknowledged the findings.b. Review of the Visit Note LVN dated 10/13, 10/27, 11/10, 11/24, 12/1, 12/8, 12/15, 12/22, and 12/29/25; 1/5, 1/12, and 1/19/26, showed LVN 1 had performed an assessment. However, the section to assess for Imminently Dying was left blank. On 1/23/26 at 1106 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.8. Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26, and 1/16/26 to 3/16/26.a. Review of the initial Comprehensive Nursing Assessment dated 5/21/25, showed the following:-Patient was able to understand and participate in own care and can safely administer medications. However, Patient 5 had primary diagnosis of Alzheimer’s disease and a FAST score of 7a (tool to assess the declining abilities of individuals with Alzheimer’s, higher numbers indicate advanced stage of cognitive decline), which was inconsistent.Patient/PCG needs teaching for oxygen. However, the Home Oxygen Safety and Risk Assessment dated 5/21/25, showed there was no specific physician’s orders written for Oxygen Administration which was inconsistent.b.Review of the Visit Note LVN dated 9/29 and 11/24/25, showed there was no change in safety issues; however, documentation showed the caregiver reported the patient had a fall on 9/23 and 11/22/25 (Saturday), respectively, which was inconsistent.c. Review of the Visit Note LVN dated 12/22/25, showed the patient had a skin tear on the right lower arm. However, during joint home visit conducted with LVN 2 on 1/20/26, at the patient’s home, a wound care treatment was observed to be provided on the left hand which was inaccurate.On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 stated Patient 5 had the wound on the left hand. RN 2 confirmed and acknowledged the findings.9.Review of Patient 3’s clinical record was initiated on 1/14/26. The clinical record showed SOC was 3/18/25. The patient was certified for hospice services during the certification periods from 3/18/25 to 6/15/25, 6/16/25 to 9/13/25, 9/14/25 to 11/12/25, 11/13/25 to 1/11/26, 1/12/26 to 3/13/26.a. Review of the POC/IDG Review dated 3/18/25, showed a treatment order for SN/PCG to administer oxygen at 2-5 LPM via NC as needed for shortness of breath/dyspnea.However, review of the initial Comprehensive Nursing Assessment dated 3/18/25, showed patient was not on oxygen therapy, no oxygen concentrator was placed on the DME device, and there was no teaching needed for oxygen which was inconsistent.b. Review of the POC/IDG Review dated 11/7, 11/21, and 12/5/25, showed the IDG Discussion/Updated Comprehensive Assessment Review for the section on Psychosocial had the same information for the aforementioned POC/IDG Review.On 1/23/26 at 0955 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 stated the documentation was copied and pasted. RN 2 confirmed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the election of hospice statement was completed for eight of 10 sampled patients (Patients 1, 3, 4, 5, 7, 8, 9 and 10). This failure had the potential for not providing the necessary services for these patients. Findings: xx. Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26 and 1/16/26 to 3/16/26.Review of Hospice Election Statement dated 5/21/25 documented the patient’s name, however, the following section were left blank or no checked mark:-elect or declined to receive the Patient Notification of Hospice Non-Covered Items, Service and Drugs.-if the Volunteer Services, Social Worker and Spiritual Counselor was declined.On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 confirmed and acknowledged the findings.xx.Review of Patient 3’s clinical record was initiated on 1/14/26. The clinical record showed SOC was 3/18/25. The patient was certified for hospice services during the certification periods from 3/18/25 to 6/15/25, 6/16/25 to 9/13/25, 9/14/25 to 11/12/25, 11/13/25 to 1/11/26, 1/12/26 to 3/13/26.Hospice Election Statement dated 3/18/25 was reviewed, however, the following section were left blank or no checked marked:-Hospice Election has no name and Start of Care Date.-Right to choose an attending physician was blank.-Home Oxygen Safety Risk Assessment was not signed and dated by the patient or responsible party.-Phone Side Information was blank and was not signed and dated by the patient or responsible party.-elect or declined to receive the Patient Notification of Hospice Non-Covered Items, Service and Drugs.On 1/23/26 at 0955 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 confirmed and acknowledged the findings.xx.Review of Patient 10’s closed clinical record was initiated on 1/22/26. The clinical record showed SOC was 6/19/25. The patient was certified for hospice services during the certification periods from 6/19/25 to 9/16/25 and 9/17/25 to 12/15/25. Patient was discharged on 11/12/25.Review of Hospice Election Statement dated 5/21/25 documented the patient’s name, however, the following section were left blank or no checked mark:-Start of Care Date was blank.-elect or declined to receive the Patient Notification of Hospice Non-Covered Items, Service and Drugs.-if the Volunteer Services, Social Worker and Spiritual Counselor was declined.-Medi-Cal Hospice Program Election Notice’s Section three and four were blank.-Phone Side Information was blank.On 1/23/26 at 1134 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 confirmed and acknowledged the findings. XX. Review of Patient 1’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 2/12/25. The patient was certified for hospice service during the certification period from 2/12/25 -5/12/25, 5/13/25 - 8/10/25, 8/11/25 - 10/9/25, 10/10/25 -12/8/25, 12/9/25 - 2/6/26 and 2/7/25 - 4/726. Review of Patient 1’s Hospice Election Statement dated 2/12/25 showed the document was dated and signed, however there was a blank documentation on the right to choose an attending physician, the boxes to place a mark if a patient wish to choose attending physician or if patient acknowledges choice for attending physician, the physician full name, boxes to place a mark, if patient choose to elect to receive the Patient Notification of Hospice Non Covered Items, Services and Drugs or patient chooses to decline to receive the Patient Notification of Hospice Non Covered Items, Services and Drugs. Review of Patient 1’s Individual Patient Emergency Preparedness Plan showed it was signed and dated, however all the information to be completed as patient identifying information, relevant healthcare information and emergency plan were all blank. Review of Patient 1’s Phone side Information was signed and dated by patient’s representative, however all information needed to complete were all blank.Review of Patient 1’s Home Oxygen Safety and Risk Assessment showed no marks on any of the boxes needed for completion or with blank documentation. XX. Review of Patient 8’s clinical record was initiated on 1/14/26. The clinical record showed the POC was 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 - 6/3/25, 6/4/25 - 9/1/25, 9/2/25 - 10/31/25, 11/1/25 - 12/30/25 and 12/31/25 - 2/28/26. Review of Patient 8’s Hospice Election Statement dated 3/6/25 showed the document was dated and signed, however there was a blank documentation on the right to choose an attending physician, the boxes to place a mark if a patient wish to choose attending physician or if patient acknowledges choice for attending physician, the physician full name, boxes to place a mark, if patient choose to elect to receive the Patient Notification of Hospice Non Covered Items, Services and Drugs or patient chooses to decline to receive the Patient Notification of Hospice Non Covered Items, Services and Drugs. Review of Patient’s Home Oxygen Safety and Risk Assessment dated 3/6/25 was signed and dated, however boxes were left unmarked for assessment. On 1/23/26 at 0958 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed of the above findings of blank documentation and acknowledged it was not filled up or completed. The agency’s P&P titled Admission Criteria and Process revised 2/2020, showed the process included the initial home visit will be made within 24 hours or within the time frame requested by the referral source and according to organization policy, or as ordered by the physician (or other authorized independent practitioner). The purpose of the initial visit will be to review appropriate forms and subsequently sign forms by patient and family/caregiver once agreement for the hospice program has been decided.###. Review of Patient 4’s closed clinical record was initiated on 1/15/26. The clinical record showed the SOC was 6/25/25. The patient was certified for hospice services during the certification period from 6/25/25 to 9/22/25.Review of the Hospice Election Statement dated 6/25/25 showed the patients name was documented. However, on the section of the start of care date was left blank.On 1/23/26 at 0938 hours an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrato/CEO was informed and acknowledged the findings. ###. Review of Patient 7’s clinical record was initiated on 1/16/26. The clinical record showed the SOC was 7/7/25. The patient was certified for hospice services during the certification periods from 7/15/25 to 9/12/25, 9/13/25 to 11/11/25 and 11/12/25 to 1/10/25. Review of the Hospice Election Statement showed the patients’ name. However, the section of the start of care date was left blank.Further review of the Hospice Election Statement showed the patients’ name and signature of the patient legal representative dated “7/25”. However, the date was incomplete. Moreover, the section for the agency’s representative showed RN 1 name and signature. However, the section for the date was left blank. Furthermore, review of the following document showed the name of the patients’ legal representative and RN 1:-Consent for Treatment,-Patient Rights and Responsibilities. -Decline of Specific Services,-Notice of Agency’s Privacy Practices and-Advance directive. However, review of the above document failed to show documented evidence of when the consent was completed as the section for the date was left blank. On 1/23/26 at 1030 hours an interview and concurrent closed clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. ###. Review of Patient 9’s clinical record was initiated on 1/21/26. The clinical record showed the SOC was 5/16/25. The patient was certified for hospice services during the certification periods from 5/16/25 o 8/13/25, 8/14/25 to 10/12/25, 10/13/25 to 12/11/25 and 12/12/25 to 2/9/2026. Review of the Hospice Election Statement dated 5/15/25 included the sections for the patients’ name and start of care. However, these sections were left blank. On 1/23/26 at 1028 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. The agency’s P&P titled Admission Criteria and Process revised 2/2020, showed the process included the initial home visit will be made within 24 hours or within the time frame requested by the referral source and according to organization policy, or as ordered by the physician (or other authorized independent practitioner). The purpose of the initial visit will be to review appropriate forms and subsequently sign forms by patient and family/caregiver once agreement for the hospice program has been decided. 1.Review of Patient 4’s closed clinical record was initiated on 1/15/26. The clinical record showed the SOC was 6/25/25. The patient was certified for hospice services during the certification period from 6/25/25 to 9/22/25. Review of the Hospice Election Statement dated 6/25/25, showed the section of the start of care date was left blank. On 1/23/26 at 0938 hours an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the finding. 2.Review of Patient 7’s clinical record was initiated on 1/16/26. The clinical record showed the SOC was 7/7/25. The patient was certified for hospice services during the certification periods from 7/15/25 to 9/12/25, 9/13/25 to 11/11/25, and 11/12/25 to 1/10/25. Review of the Hospice Election Statement dated “7/25,” showed the section of the start of care date was left blank and the date was incomplete. In addition, the hospice’s representative showed RN 1’s name and signature; however, the date was left blank. Review of the Consent for Treatment, Patient Rights and Responsibilities, Decline of Specific Services, Notice of Agency’s Privacy Practices and Advance directive. showed the name of the patient’s legal representative and RN 1. However, the section for the date was left blank. On 1/23/26 at 1030 hours an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. 3. Review of Patient 9’s clinical record was initiated on 1/21/26. The clinical record showed the SOC was 5/16/25. The patient was certified for hospice services during the certification periods from 5/16/25 o 8/13/25, 8/14/25 to 10/12/25, 10/13/25 to 12/11/25, and 12/12/25 to 2/9/2026. Review of the Hospice Election Statement dated 5/15/25, showed the sections for the patient’s name and start of care were left blank. On 1/23/26 at 1028 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the finding. 4. Review of Patient 1’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 2/12/25. The patient was certified for hospice service during the certification period from 2/12/25 to 5/12/25, 5/13/25 to 8/10/25, 8/11/25 to 10/9/25, 10/10/25 to 12/8/25, and 12/9/25 to 2/6/26. Review of Patient 1’s Hospice Election Statement dated 2/12/25, showed it was signed and dated; however, the sections to choose an attending physician and to receive/decline the Patient Notification of Hospice Non Covered Items, Services and Drugs were not completed. Review of Patient 1’s Individual Patient Emergency Preparedness Plan and Phone Side Information showed the forms were only signed and dated; and the rest of the sections were left blank. Review of Patient 1’s Home Oxygen Safety and Risk Assessment was not completed. 5. Review of Patient 8’s clinical record was initiated on 1/14/26. The clinical record showed the POC was 3/6/25. The patient was certified for hospice services during the certification periods from 3/6/25 to 6/3/25, 6/4/25 to 9/1/25, 9/2/25 to 10/31/25, 11/1/25 to 12/30/25 and 12/31/25 to 2/28/26. Review of Patient 8’s Hospice Election Statement dated 3/6/25, showed it was signed and dated; however, the sections to choose an attending physician and to receive/decline the Patient Notification of Hospice Non Covered Items, Services and Drugs were not completed. Review of Patient’s Home Oxygen Safety and Risk Assessment dated 3/6/25, was only signed and dated, and the rest of the sections were left blank. On 1/23/26 at 0958 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed of the above findings and acknowledged it was not filled up or completed. 6. Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26 and 1/16/26 to 3/16/26. Review of Hospice Election Statement dated 5/21/25, showed the sections to elect or decline to receive the Patient Notification of Hospice Non-Covered Items, Service and Drugs and if the Volunteer Services, Social Worker and Spiritual Counselor were declined were left blank. On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 was informed and acknowledged the findings. 7. Review of Patient 3’s clinical record was initiated on 1/14/26. The clinical record showed SOC was 3/18/25. The patient was certified for hospice services during the certification periods from 3/18/25 to 6/15/25, 6/16/25 to 9/13/25, 9/14/25 to 11/12/25, 11/13/25 to 1/11/26, 1/12/26 to 3/13/26. Hospice Election Statement dated 3/18/25, showed the name on the hospice election section and start of care date, and right to choose an attending physician were left blank or not completed: The Home Oxygen Safety Risk Assessment form was not signed and dated by the patient or responsible party. The Phone Side Information form was not completed; and signed and dated by the patient or responsible party. On 1/23/26 at 0955 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 was informed and acknowledged the findings. 8. Review of Patient 10’s closed clinical record was initiated on 1/22/26. The clinical record showed SOC was 6/19/25. The patient was certified for hospice services during the certification periods from 6/19/25 to 9/16/25 and 9/17/25 to 12/15/25. Patient was discharged on 11/12/25. Review of Hospice Election Statement dated 6/19/25, showed the start of care date was left blank; and the section to elect or decline to receive the Patient Notification of Hospice Non-Covered Items, Service and Drugs was not completed. The Phone Side Information form was signed and dated by the patient and hospice personnel; however, the rest of sections were left blank. The Medi-Cal Hospice Program Election Notice showed the section for admitting terminal diagnosis and services currently being provided to recipient by other agencies were left blank. On 1/23/26 at 1134 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to authenticate the entries made into the clinical records for eight out of 10 sampled patients (Patients 1, 2, 3, 5, 6, 7, 9 and 10). This failure had the potential for not having the updated medical information for these patients.Findings: Review of the hospice’s P&P titled Contents of Clinical Record revised 4/2020 showed the following will be available in the clinical record as applicable to care and services provided: legible, complete and individualized diagnostic and therapeutic orders authenticated within the timeframe defined by the organization or according to law and regulation. Documentation should include signed and dated clinical notes. Each entry will be dated and signed, including title and credentials, by the person providing the care/services.1. Review of Patient 1’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 2/12/25. The patient was certified for hospice service during the certification period from 2/12/25 -5/12/25, 5/13/25 - 8/10/25, 8/11/25 - 10/9/25, 10/10/25 -12/8/25, 12/9/25 - 2/6/26 and 2/7/25 - 4/726. Review of Patient 1’s IDG Notes showed IDG team members conducted a meeting and had their team discussion dated 1/2/26. There was documentation on Spiritual Council review for Patient 1. However, there was no documentation the Spiritual Councilor electronically signed the IDT meeting on the IDT team notes.Review of Patient 1’s Spiritual Assessment showed Spiritual Counsellor visited Patient 1 dated 2/17/25, however there was no documentation the Spiritual Counsellor electronically signed.Review of Patient 1’s Psychosocial Assessment showed MSW visited Patient 1 dated 2/15/25, however there was no documentation the MSW electronically signed. Review of Patient 1’s LVN Nursing Clinical Notes showed LVN 2 visited Patient 1 on the following dates: 2/17/25, 2/26/25, 3/6/25, and 3/13/25. However, there was no documentation LVN 2 electronically signed the visit notes. 2. Review of Patient 6’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 3/26/25. The patient was certified for hospice service during the certification period from 3/26/25 - 6/23/25, 6/24/25 - 9/21/25, 9/22/25 - 11/20/25, 11/21/25 - 1/19/26 and 1/20/26 to 3/20/26. Review of Patient 6’s IDG Notes showed IDT team members conducted a meeting and had their team discussion for Patient 6 dated 12/19/25. There was documentation on Spiritual Council review for Patient 6. However there was no documentation the Spiritual counsellor electronically signed. On 1/23/26 at 1153 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was informed on the above findings and was asked what is the agency process on electronic signatures. RN 1 stated she did not know why the above documents were not electronically signed, and acknowledged it should be addressed to the hospice staff regarding issues in their electronic medical records. Review of the hospice’s P&P titled Contents of the Clinical Records revised 4/2020 showed the clinical record will contain sufficient information to identify the patients, describe the patients’ problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. Documentation will include signed and dated clinical notes. Each entry will be dated and signed, including title and credentials, by the person providing the care and service.xx. Review of Patient 5’s clinical record was initiated on 1/16/26. The clinical record showed SOC was 5/21/25. The patient was certified for hospice services during the certification periods from 5/21/25 to 8/18/25, 8/19/25 to 11/16/25, 11/17/25 to 1/15/26 and 1/16/26 to 3/16/26.a.The initial Spiritual Assessment dated 5/23/25, showed no documented evidence of the SC’s electronic signature.b.The POC/IDG Review dated 8/22, 9/12, 9/26/25, showed no documented evidence of the MSW and SC’s electronic signature.c.The POC/IDG Review dated 10/10, 10/24, 11/7, 11/21 and 12/5/25, showed no documented evidence of the SC’s electronic signature.On 1/23/26 at 1040 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 confirmed and acknowledged the findings.xx.Review of Patient 3’s clinical record was initiated on 1/14/26. The clinical record showed SOC was 3/18/25. The patient was certified for hospice services during the certification periods from 3/18/25 to 6/15/25, 6/16/25 to 9/13/25, 9/14/25 to 11/12/25, 11/13/25 to 1/11/26, 1/12/26 to 3/13/26.a.The initial Comprehensive Nursing Assessment dated 3/18/25, showed no documented evidence of RN 5’s signature.b.The POC/IDG Review dated 3/18, 9/12, 9/26/25, showed no documented evidence of the MSW’s signature.c.The POC/IDG Review dated 12/5 and 12/19/25, showed no documented evidence of the MD and SC’s signature.On 1/23/26 at 0955 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 confirmed and acknowledged the findings. xx.Review of Patient 10’s closed clinical record was initiated on 1/22/26. The clinical record showed SOC was 6/19/25. The patient was certified for hospice services during the certification periods from 6/19/25 to 9/16/25 and 9/17/25 to 12/15/25. Patient was discharged on 11/12/25.a.The POC/IDG Review dated 8/1, 8/15, 8/29, 9/12, 9/26, 10/10, and 10/24/25, showed no documented evidence of the MSW’s signature.b.The POC/IDG Review dated 11/12/25 showed no documented evidence of the SC’s signature.On 1/23/26 at 1134 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 confirmed and acknowledged the findings. ##. The hospice’s P&P titled Interdisciplinary Group Membership and Responsibilities revised 4/2020 showed the hospice interdisciplinary group membership includes at a minimum: a Physician (a doctor of medicine or osteopathy), Registered Nurse, Social Worker and Pastoral or other Counselor. Review of the hospice’s P&P titled Interdisciplinary Group Meeting revised 4/2020 showed members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor.Review of Patient 7’s clinical record was initiated on 1/16/26. The clinical record showed the SOC was 7/7/25. The patient was certified for hospice services during the certification periods from 7/15/25 to 9/12/25, 9/13/25 to 11/11/25 and 11/12/25 to 1/10/26.-The POC/IDG Review dated 11/7 and 11/21/25 showed an IDG meeting was conducted and documentation showed the POC was discussed. The Medical Director, DPCS and the MSW electronically signed the meeting. However, there was no documented evidence of the Chaplain attended the IDG meeting minutes as the section for the electronic signature was left blank. -The POC/IDG Review dated 12/5 and 12/19/25 showed an IDG meeting was conducted, and documentation showed the POC was discussed. The Medical Director and the MSW electronically signed the meeting. However, there was no documented evidence of the DPCS and the Chaplain attended the IDG meeting minutes as the section for the electronic signature was left blank. -The POC/IDG Review dated 1/2/25 showed an IDG meeting was conducted and documentation showed the POC was discussed. The Medical Director, MSW and the Chaplain electronically signed the meeting. However, there was no documented evidence of the DPCS attended the IDG meeting minutes as the section for the electronic signature was left blank. On 1/23/26 at 1030 hours, an interview and concurrent clinical review with the Administrator/CEO. The Administrator/CEO was asked as to the members of the IDG. The Administrator/CEO replied, Physician, DPCS, Chaplain, MSW, Administrator/CEO and the CFO. The Administrator/CEO was also asked if the members needed to electronically sign the meeting. The Administrator /CEO replied, they did not electronically sign the meeting but they attended. The Administrato/CEO was informed and acknowledged the findings. ##. Review of Patient 2’s clinical record was initiated on 1/14/26. The clinical record showed the SOC was 9/15/25. The patient was certified for hospice services during the certification periods from 9/15/25 to 11/13/25, 11/14/25 to 1/12/26 and 1/13/256 to 3/13/26.-The POC/IDG Review dated 12/19 and 1/2/26 showed an IDG meeting was conducted and documentation showed the POC was discussed. The Medical Director, DPCS, RN 2 and the MSW electronically signed the meeting. However, there was no documented evidence of the Chaplain attended the IDG meeting minutes as the section for the electronic signature was left blank. On 1/23/26 at 1218 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator /CEO was informed and acknowledged the findings. ###. Review of Patient 9’s clinical record was initiated on 1/21/26. The clinical record showed the SOC was 5/16/25. The patient was certified for hospice services during the certification periods from 5/16/25 to 8/13/25, 8/14/25 to 10/12/25, 10/13/25 to 12/11/25 and 12/12/25 to 2/9/2026. Review of the clinical record showed the SC had performed an assessment dated 5/19/25. However, the SC failed to electronically sign the visit.On 1/23/26 at 1028 hours, an interview and concurrent clinical review was conducted with the Administrator/CEO. The Administrator/CEO was asked if the SC needed to electronically sign the visit note. The Administrator/CEO replied, yes on the day of the visit. The Administrator/CEO was informed and acknowledged the findings.”