Acute Hospice Care, Inc.

“Based on interview, and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for patient rights was not met as follows: 1. The HA failed to ensure one of fourteen sampled patients (Patient 2), and their representatives, were provided notice of patients’ rights and responsibilities in their preferred language and language they understand. This failure resulted in violation of Patient 2 and Patient Care Giver 3 (PCG)’ rights and not knowing their rights and responsibilities. (Refer to L502). 2. The HA failed to include the patient’s caregivers in the development of plan of care for one of fourteen sampled patients (Patient 1) in development of the plan of care. This failure excluded Patient 1’s Care giver (Patient Care Giver [PCG] 1 and PCG 2) from providing pertinent and timely patient health information to the hospice team, which place Patient 3 at risk for untreated health issues, medication errors, and slower response times in emergencies negatively affecting the patient’s safety and quality of care. (Refer to L513). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulation for Patient rights to ensure the highest quality of care was being provided to patients certified to receive the hospice benefits.”

“Based on interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (CoP, requirements that healthcare organizations must meet to participate in federal healthcare programs) for Initial & Comprehensive Assessment (thorough evaluation of the patient’s needs that must be addressed to promote comfort and dignity throughout the dying process) of patients was met as follows: 1.The HA failed to ensure the comprehensive assessments were complete, accurate, reflected the patients’ current health condition, and validated the patients’ need for hospice care and services for four of 14 sampled patients (Patients 5, Patient 6, Patient 8, and Patient 11). This failure had the potential to result in a decline in the patients’ health condition due to not having proper medical oversight and access to needed medications and medical treatments. (Refer to L524). 2. The HA failed to ensure the medication profile review (comprehensive assessment of the patient’s medications to evaluate a patient’s medication regimen, assess patient teaching needs, and guides care planning for the patient) was conducted in accordance with the agency’s policy and procedures for one of 14 sampled patients (Patient 2). This failure placed Patient 2 at increased for ineffective drug therapy and adverse outcomes (undesirable experience associated with use of medical product in a patient) due to medications not being taken or managed as prescribed by the physician. (Refer to L530). 3. The HA failed to complete a bereavement assessment (a structured, often ongoing, evaluation of an individual’s response to loss, aiming to identify risks for complicated grief) in accordance with the agency’s policy and procedures for one of 14 sampled patients (Patient 2). This failure had the potential to result in lack of emotional support for Patient 2’s caregivers and family members following the patient’s death. (Refer to L531). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulation for Initial and Comprehensive Assessment of Patients to ensure the highest quality of care was being provided to patients certified to receive the hospice benefits.”

“Based on observation, interviews, and record review, the hospice agency (HA, agency that provides specialized care and support for people with a terminal illness and nearing the end of life) failed to ensure the Condition of Participation (CoP, refer to the requirements that healthcare organizations must meet to participate in federal healthcare /programs) for Interdisciplinary Group (IDG, team of healthcare professionals who work together to develop an individualized plan for the patients and support the families) Care Planning, and Coordination of Services was met as follows: 1. The HA failed to ensure that all members of the interdisciplinary group (IDG, team of healthcare professionals who work together to develop an individualized plan for the patients and support the families) meet to discuss and plan the physical, psychosocial, emotional, and spiritual needs for one of 14 sampled patients (Patient 3). This failure had the potential to result in Patient 3 not receiving the comprehensive and coordinated care and services necessary to meet Patient 3’s individualized needs during his end-of-life process that could result in ineffective treatment, pain and discomfort and decrease in quality of life. (Refer to L541). 2. The HA failed to ensure the patient’s plan of care (POC, structured, patient-specific document detailing a patient’s health problem/s, goals, and specific interventions) was individualized and included all the interventions ordered for the primary diagnosis of one of 14 sampled patients (Patient 6). This failure had the potential to result in decline in Patient 6’s health and quality of life related to not receiving the necessary services to provide comfort during the end-of-life stage. (Refer to L545). 3. The HA failed to ensure there was a physician order for the routine (scheduled, regular, intermittent) visits of skilled nurses (SNs, licensed as either a registered nurse [RN] or licensed vocational nurse [LVN]) for five of 14 sampled patients (Patients 6, Patient 8, Patient 9, Patient 10, and Patient 11). This failure had the potential to cause a decline in the patients’ condition that can lead to hospitalization related to the potential missed SN visits and changes in patients’ condition not being assessed timely. (Refer to L547). 4. The HA failed to ensure the Plan of Care (POC [documents the process of identifying a patient’s needs and facilitating complete care and ensures collaboration among nurses, patients, and other healthcare providers]) was implemented for one of 14 sampled patients (Patient 11). This failure had the potential to result in Patient 11’s decline in health and quality of life related to not receiving the necessary treatment and services as ordered by the physician. (Refer to L555). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure provision of quality care and services to patients certified to receive the hospice benefits.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (CoP, refers to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Medical Director was met as follows: 1. The HA Based on interviews and record review, the Hospice Agency (HA, healthcare agency that provides specialized care and support for people with a terminal illness and nearing the end of life) failed to ensure the Medical Director reviewed past medical history and physicals (H&P), hospital records, diagnostic, and/or laboratory findings to confirm the patients met the hospice eligibility criteria to be admitted into the hospice patient care program for six of 14 sampled patients (Patient 5, Patient 6, Patient 8, Patient 9, Patient 10 and Patient 11). This failure had the potential to result in a decline in the patients’ health and quality of life due to the unmet needs of the patients and/or the family related to patients being enrolled to the HA without proper medical oversight of the implementation of the hospice services. (L667) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory (written law) mandated compliance with Federal regulation for Medical Director services to ensure quality of patient care was provided to the patients certified to receive hospice services.”

“Based on interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (CoP, requirements that healthcare organizations must meet to participate in federal healthcare programs) for Clinical Records was met as follows: 1. The HA failed to have a complete clinical record for two of 14 sampled patients (Patient 6 and Patient 14) by failing to: a. Ensure complete and accurate documentation of Patients 6’s oxygenation status (measures how well oxygen is being delivered to tissues and cells). b. Develop an individualized care plan for Patient 6’s Chronic Obstructive Pulmonary Disease (COPD, long-term lung disease characterized by difficulty breathing due to chronic inflammation that restricts airflow) that included the COPD medications. c. Ensure Patient 11’s blood sugar levels were monitored and documented during home visits. This failure resulted in the incomplete medical record for Patient 6 and Patient 14, which could have caused a break in continuity of care and not providing the patients with the necessary care and services needed to maintain comfort. (Refer to L672). 2. The HA failed to maintain an authenticated clinical record based on accepted standards of practice and regulations followed for two of 14 sampled patient (Patient 3 and Patient 8) by failing to: a. Ensure Patient 3’s Interdisciplinary Group (IDG, team of healthcare professionals who work together to develop an individualized plan for the patients and support the families) review notes were signed by the Medical Director (MD). b. Ensure Patient 3’s spiritual comprehensive assessment was signed and dated within five (5) days of the start of care by the Spiritual Counselor. c. Ensure that Patient 8’s initial comprehensive nursing assessment was signed and dated by the Registered Nurse (RN). These failures could result in delayed of delivery of care, treatment and services to the patients and affect patients’ quality of life. (Refer to L679). The cumulative effects of these systemic practices resulted in the failure of the hospice to deliver statutorily (written law) mandated compliance with Federal regulations for Clinical Records to ensure patients’ medical records are completed, updated and accurately documented.”

“Based on observation, interviews, and record review, the facility failed to ensure one of fourteen sampled patients (Patient 2), and their representatives, were provided notice of patients’ rights and responsibilities in their preferred language and language they understand. This failure resulted in violation of Patient 2 and Patient Care Giver 3 (PCG)’ rights and not knowing their rights and responsibilities. Findings: During a review of Patient’s 2’s medical record, titled “Personal information”, undated, indicated Patient 2 was admitted on 3/12/2026 with diagnosis of Alzheimer’s (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). The personal information indicated, Patient 2’s primary language was Spanish. During a review of Patient 2’s record titled “Informed Consent and Treatment Authorization” dated 3/12/2026, the consent was written in English. During a concurrent observation and interview on 3/26/2026 at 10:35 a.m. in Patient 2’s room, the Director of Patient Care Services Designee (DPCSD) was observed speaking to Patient 2 in English, without using an interpreter service. The DPCSD stated she attempted to communicate with Patient 2 based on the patient’s facial expressions and grimacing but acknowledged that it would have been better to use an interpreter service or requested assistance from a hospice staff member fluent in the patient’s language. The DPCSD stated that the HA has an interpreter service available, but she was unable to use it at that time because the service was “out of service” when she called. The DPCSD stated it was important to know and understand what the patient was saying to provide better care. During an interview on 3/26/2026 at 1:04 p.m. with Patient Care Giver (PCG) 3, PG3 stated she was never given explanation what hospice care was in a language she understood. PCG 3 stated she speaks “a little bit of English” but preferred to speak and read in Spanish, and the information provided to her at admission was not communicated in Spanish. During an interview on 4/1/2026 at 10:47 a.m. with the Administrator (ADM), the ADM stated that information and consent should be provided in the patient’s preferred language to ensure comfort and understanding of care. The ADM stated that if documents were not provided in the preferred language, the patient may not understand what they were signing. During a review of the facility’s Policy and Procedure (P&P) titled, “Facilitating Communication”, dated 2009, the P&P indicated, to ensure that patient’s, visitors, and personnel who have a limited command of the English language have access to appropriate interpretive assistance and other aids at no cost to patients being served... Written materials will be made available in the recognize major languages in the service area and state where the organization does business... Hospice will consistently and clearly communicate with patients in a language or form they can reasonably understand.”

“Based on interview and record review, the Hospice agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) failed to include the patient’s caregivers in the development of plan of care for one of fourteen sampled patients (Patient 1) in development of the plan of care. This failure excluded Patient 1’s Care giver (Patient Care Giver [PCG]1 and PCG 2) from providing pertinent and timely patient health information to the hospice team, which place Patient 3 at risk for untreated health issues, medication errors, and slower response times in emergencies negatively affecting the patient’s safety and quality of care. Findings: During an interview on 3/26/2026 at 1:59 p.m. with Patient Care Giver 1 (PCG 1), PCG 1 stated that Patient 1 was admitted to the board‑and‑care facility due to insurance reasons. PCG 1 stated that no one explained the hospice services that would be provided at the board‑and‑care and that she was not included in the development of Patient 1’s plan of care. During an interview on 3/27/2026 at 11:45 with the Administrator (ADM), the ADM stated Patient 1 was referred to the board‑and‑care facility by General Acute Hospital (GACH). The ADM stated Patient 1 was confused but understood what hospice was. During an interview on 3/27/2026 at 12:31 p.m. with PCG 2, PCG2 stated she was the responsible party for Pt 1 and the one to sign all Patient 1’s paperwork. PCG 2 stated she was not notified of Patient 1 being discharged from the GACH, being sent to the board‑and‑care facility or receiving hospice care. PCG 2 stated she signed consent for hospice care under duress and was not included in the plan of care. During an interview on 4/1/2026 at 12:27 p.m. with Registered Nurse 1 (RN 1), RN 1 stated she did not speak with any family member during the initial comprehensive assessment for Patient 1. RN 1 stated that family members needed to be involved in the plan‑of‑care. RN 1 stated that after completing the initial comprehensive assessment, the Interdisciplinary Group (IDG, team of healthcare professionals who work together to develop an individualized plan for the patients and support the families) reviews the findings, and then the Administrator (ADM) discusses the plan of care with the patient and family. RN 1 stated it was important for a clinician to discuss the plan of care with the patient because a clinician has a better understanding of the disease trajectory (the pattern of clinical events and health changes a patient experiences over time, helping predict outcomes and guide care planning). During a review of the facility’s policy and procedure (P&P) titled, “Rights and Responsibilities”, dated 2009, P&P indicated, Purpose: To encourage awareness of patient rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning... Each patient will be an active, informed participant in his/her plan of care. A patient may designate someone to act as his/her representative in accordance with state law... The patient will be informed during the initial assessment visit, in advance of furnishing care: The right to elect hospice; the organization’s mission and care and services provided directly or through contractual arrangements; Assured that the personnel who provide care are qualified through education and experience to carry out thee services for which they are responsible. During a review of the facility’s policy and procedure (P&P) titled, “The Plan of Care”, dated 2009, P&P indicated, a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The Patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care.”

“Based on interviews and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a terminal illness and nearing the end of life) failed to ensure the comprehensive assessments were complete and accurate, reflected the patients’ current health condition, and validated the patients’ need for hospice care and services for four of 14 sampled patients (Patients 5, Patient 6, Patient 8, and Patient 11). This failure had the potential to result in a decline in Patients 5, Patient 6, Patient 8, and Patient 11’s health condition due to not having proper medical oversight and access to needed medications and medical treatments. During a review of Patient’s 5’s medical record, titled Personal information, the personal information indicated, Patient 1 was admitted on 10/8/2025 with diagnosis of CVA , and Parkinson’s (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements)During a record review of Patient’s 5 “Electronic Medical Record (EMR), dated 11/27/2024, the EMR indicated Patient 5’s History and Physical document consisted of a face sheet. During a concurrent interview and record review on 4/1/2026 at 8:07 a.m. with Director of Patient Services Designee (DPCSD), patient 5’s face sheet/history physical was reviewed. DPCSD stated a face sheet dated 2024 is not appropriate to use as a history and physical document since its outdated and it would be more ideal for the Hospice agency to get more updated History and Physical documents.During an interview on 4/1/2026 at 11:44 a.m. with Medical Director (MD), MD stated a face sheet is not acceptable as a history and physical for a patient. MD stated the HA should request for hospitalization records. During a review of the HA’s policy and procedures (P&P 1), titled “Comprehensive Assessment,” dated 2009, P&P 1 indicated the following:All baseline data and other relevant information must be documented, through interview and observation, in the patient’s clinical record, including at least the following information, as relevant: -nature and condition causing admission (including the presence or lack of objective data and subjective complaints) -patient’s past and present medical and psychosocial history including pertinent diagnosis and any comorbid (medical conditions that coexist alongside a primary diagnosis) conditions -name and address of the patient’s attending physician -name of the hospital and other agencies or persons involved in the past and present care of the patient -laboratory results -medical, alcohol, and other drug history -past medical and surgical care, including dates of onset (when symptoms first experienced or signs first observed)/exacerbation (when symptoms worsened) -the need for referrals and further evaluation by appropriate health professionals -physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patient’s terminal illness d. During a review of Patient 11’s clinical record titled Personal Information, the personal information record indicated a Start of Care (SOC) date of 1/5/2026 with a primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a condition where plaque [fat, cholesterol, calcium] builds up in the heart’s original arteries, narrowing them and restricting blood flow causing chest pain).During a review of Patient 11’s Electronic Medical Record (EMR), the EMR indicated, under section Documents/images, a record titled Order summary Report dated 9/18/2025 from a skilled nursing facility, and a clinical record titled admission record (a summary document of the patient’s key information like demographic data, insurance details, emergency contacts, allergies and diagnosis) dated 9/18/2025 from a skilled nursing facility.During a review of Patient 11’s clinical record titled LCD hospice eligibility determination dated 1/5/2026, the LCD indicated that Patient 11 had heart disease and was eligible per guidelines with selected existing conditions marked yes for; patient optimally treated for heart disease with diuretics (medication that prompts the kidneys to remove excess salt and water from the body through increased urine production) and vasodilators (medications used to treat high blood pressure, chest pain, or heart failure by relaxing the smooth muscle blood vessel walls causing them to widen), and does meet criteria for New York heart association (NYHA) class IV level (the most severe level of heart failure characterized by inability to carry out any physical activity without discomfort and presence of symptoms at rest).During a review of Patient 11’s clinical record titled current treatment/ medication/ durable medical equipment (DME) list, undated, the list indicated a medication order for;nifedipine (vasodilator medication used to treat high blood pressure and chest pain by relaxing blood vessels to improve blood flow and reduce heart workload) 90 milligrams (mg, unit of measurement) extended release tablet (tablet that release its ingredients slowly over 12 to 24 hours rather that all at once, to allow for less frequent dosing) , take 1 tablet oral once a day for hypertension (high blood pressure).Patient 11’s list did not have documented evidence of an order for the use of diuretic medication.During a concurrent interview and record review on 4/1/2026 at 8:38 a.m. with the Director of Patient Care Services Designee (DPCSD) Patient 11’s current treatment/ medication/DME list was reviewed. The DPCSD stated that the list were orders given by the Medical Director (MD), that were to be followed by the patient’s care team. The DPCSD reviewed the medications on the list and stated and confirmed that Patient 11 was on a vasodilator called nifedipine but was not on any diuretic medication.During a concurrent interview and record review on 4/1/2026 at 8:42 a.m. with the DPCSD, Patient 11’s EMR was reviewed. The DPCSD stated and confirmed that Patient 11’s EMR indicated uploaded record titled Order summary Report dated 9/18/2025 from his previous skilled nursing facility, and an admission record dated 9/18/2025 from the same skilled nursing facility. The DPCSD stated that based on the dates of the patient’s medical records they were quite old to rely on for an accurate health background of the patient. The DPCSD stated that it would have been ideal for the HA to have contacted the skilled nursing facility to obtain more current records. The DPCSD stated that for all attempts done by the HA to get more current patient records from a skilled nursing facility, a hospital or doctors office, those attempts should be documented in a communication note in the patient’s EMR. During a concurrent interview and record review on 4/1/2026 at 8:45 a.m. with the Director DPCSD), Patient 11’s clinical record titled LCD hospice eligibility determination dated 1/5/2026 was reviewed. The DPCSD stated and confirmed that Patient 11’s LCD was documented for the diagnosis heart failure and the conditions that were selected as yes were that the patient was treated for heart disease with diuretics and vasodilators, and the patient did meet criteria for NYHA class IV level. The DPCSD stated the LCD is completed by the admitting nurse and the selection of conditions are verified through review of medical records or from the head-to-toe assessment. The DPCSD stated and confirmed that Patient 11’s LCD was inaccurately documented because Patient 11 was only on vasodilator medication and not on any diuretic medication. The DPCSD stated that also with no current medical records for Patient 11 it would not be as strong to qualify that the patient met the criteria for NYHA class 4 level.During a concurrent interview and record review on 4/1/2026 at 8:58 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 11’s clinical record titled current treatment/ medication/DME list was reviewed. The DPCSD stated and confirmed that Patient 11’s order list did not have documented evidence of frequency of visits for the nurses, the CHHA’s, the SC, and for the MSW. The DPCSD stated that the order list should have included the order of frequency of visits, again because it is an order and for it to be followed by the disciplines. Findings:During a review of Patient 5’s medical record, titled “Personal Information,” the “Personal Information” indicated the Start of Care (SOC) date of … b. During a review of Patient 6’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 11/2/2025 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, long-term lung disease characterized by difficulty breathing due to chronic inflammation that restricts airflow).During a review of Patient 6’s medical form, titled “Comprehensive Nursing Assessment,” dated 11/2/2025, the “Comprehensive Nursing Assessment” indicated Registered Nurse (RN) 5 documented the following:-Patient 6 had a respiratory rate (RR, number of breaths per minute with the normal adult range of 12-20 breaths per minute) of 18.-Patient 6 had an oxygen saturation (SpO2, amount of oxygen circulating in the blood with the safe and typical SpO2 for COPD patients at 88%-92%) of 96% on room air (RA, breathing normal air without needing supplemental oxygen [prescription oxygen ordered for people with low blood oxygen levels]). However, RN 5 also documented Patient 6 was on 2 liters per minute (LPM, unit of measurement of flow rate) of supplemental oxygen via nasal cannula (flexible tube with two prongs used to deliver supplemental oxygen directly into the nostrils).-Patient 6 was “poorly responsive or unresponsive to bronchodilators (medications that relax airway muscles to improve breathing).”-Patient 6 had “respiratory failure (progression of COPD leading to critically low level of oxygen or critically high levels of carbon dioxide in the body) and SpO2 less than or equal to 88% determined either by arterial blood gases (ABG, laboratory test that measures oxygen, carbon dioxide, and acid-base levels in arterial blood to evaluate respiratory failure) or SpO2 monitors.-Patient 6 had an unintentional weight loss greater than or equal to 10% of body weight over the last 6 months.During a review of Patient 6’s recertification assessment note, titled “Nursing Update Assessment,” dated 1/26/2026, the “Nursing Update Assessment” indicated RN 5 documented Patient 6 had a RR of 20 and SpO2 of 95% on room air with mild shortness of breath (SOB, feeling of not being able to catch one’s breath), was “poorly responsive or unresponsive to bronchodilators,” had “respiratory failure” with SpO2 less than or equal to 88%, and an unintentional weight loss greater than or equal to 10% of body weight over the last 6 months.During a concurrent interview and record review on 3/31/2026 at 10:56 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 6’s assessments, physician orders, and plan of care were reviewed. The DPCSD stated COPD patients must maintain an oxygen saturation between 88% - 92% to ensure the SpO2 was not too low and the carbon dioxide level was not too high. The DPCSD stated if Patient 6’s SpO2 was below 88% while on RA, more respiratory interventions, such as supplemental oxygen and/or bronchodilators, might be needed. The DPCSD stated if Patient 6’s SpO2 was above 92% while on supplemental oxygen, Patient 6 could be getting excessive oxygen, which could potentially worsen Patient 6’s breathing condition. The DPCSD stated if Patient 6’s SpO2 was above 92% on RA, Patient 6’s COPD was not advanced enough to qualify for hospice care and services. The DPCSD also stated the RN must ensure accurate documentation whether Patient 6’s oxygen saturation was measured on RA or with supplemental oxygen administered to ensure proper treatment and services are provided.During a concurrent interview and record review on 3/31/2026 at 11:05 a.m., Patient 6’s medical records were reviewed. The DPCSD stated there was no documented evidence that HA obtained Patient 6’s prior medical history to support that Patient 6 was “poorly responsive or unresponsive to bronchodilators,” had “respiratory failure” and had an “unintentional weight loss greater than or equal to 10% of body weight over the last 6 months.” The DPCSD stated there was no documented evidence that the HA contacted Patient 6’s primary care provider (PCP) to obtain Patient 6’s previous medical records. The DPCSD stated there was no documented evidence that HA staff discussed with Patient 6’s PCP whether Patient 6 was eligible to receive hospice care and services and if the PCP would like the HA to assume responsibility for Patient 6’s treatment and services. The DPCSD stated the RN must review Patient 6’s previous medical records to verify the patient’s current health condition and accurately determine Patient 6’s eligibility to receive hospice care. The DPCSD stated if incomplete and/or inaccurate assessment of Patient 6’s health condition could lead to incorrect hospice eligibility that could limit the treatment and services Patient 6 was qualified to receive. c. During a review of Patient 8’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 12/22/2025 with diagnoses including Alzheimer’s disease (brain disorder that negatively affects memory, thinking, and behavior severe enough to interfere with daily tasks) and essential hypertension (abnormally high blood pressure [BP, force of the blood pushing against the artery walls]).During a review of Patient 8’s medical form, titled “Comprehensive Nursing Assessment,” dated 12/22/2025, the “Comprehensive Nursing Assessment” indicated Patient 8 had “inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin (key indicator of overall nutritional status derived from a laboratory blood test) less than 2.5 grams (gm, unit of measurement of mass) per deciliter (dl, unit of measurement of volume).During a concurrent interview and record review on 3/31/2026 at 10:56 a.m. with the DPCSD, Patient 8’s medical records were reviewed. The DPCSD stated Patient 8’s “Physician Progress Note,” dated 5/2/2024, from Patient 8’s previous PCP could not be used to validate Patient 8’s weight loss or serum albumin level because the physician assessment was conducted about a year and half prior to Patient 8’s admission to the HA. The DPCSD stated there was no documented evidence that HA staff attempted to obtain more recent medical records from Patient 8’s PCP. The DPCSD stated there was no documented evidence that HA staff discussed with Patient 8’s PCP if Patient 8 was eligible to receive hospice care and services and if the PCP approved the HA to assume responsibility for Patient 8’s treatment and services. The DPCSD stated incomplete and/or inaccurate assessment of Patient 8’s health condition could lead to incorrect hospice eligibility that could limit the treatment and services Patient 8 was qualified to receive. d. During a review of Patient 11’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of… During a review of the HA’s policy and procedures (P&P 1), titled “Comprehensive Assessment,” dated 2009, P&P 1 indicated the following:All baseline data and other relevant information must be documented, through interview and observation, in the patient’s clinical record, including at least the following information, as relevant: -nature and condition causing admission (including the presence or lack of objective data and subjective complaints) -patient’s past and present medical and psychosocial history including pertinent diagnosis and any comorbid (medical conditions that coexist alongside a primary diagnosis) conditions -name and address of the patient’s attending physician -name of the hospital and other agencies or persons involved in the past and present care of the patient -laboratory results -medical, alcohol, and other drug history -past medical and surgical care, including dates of onset (when symptoms first experienced or signs first observed)/exacerbation (when symptoms worsened) -the need for referrals and further evaluation by appropriate health professionals -physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patient’s terminal illness 2. The comprehensive assessment must be updated by the Interdisciplinary Group (IDG, team of healthcare professionals who work together to develop an individualized plan for the patients and support the families) as frequently as the patient’s condition requires but at a minimum every 15 days. If no changes are needed, then that must be documented. If there has been a change in the patient’s condition/status, then the comprehensive assessment must be updated. During a review of the HA’s policy and procedures (P&P 2), titled “Ongoing Comprehensive Assessments,” dated 2009, P&P 2 indicated the nurse must assess each patient on each visit for compliance with treatments and medication regimen and progress toward hospice goals and patient needs and problems. P&P 2 indicated that ongoing comprehensive assessments must focus on patient’s response to care, changes in patient condition, changes in patient diagnoses/prognosis, and changes in the patient’s care environment or support systems. P&P 2 indicated the plan of care—including problems, needs, goals, and outcomes—must be reviewed and updated by the IDG members responsible for the case.”

“Based on observation, interviews, and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the medication profile review (comprehensive assessment of the patient’s medications to evaluate a patient’s medication regimen, assess patient teaching needs, and guides care planning for the patient) was conducted in accordance with the agency’s policy and procedures for one of 14 sampled patients (Patient 2). This failure placed Patient 2 at increased for ineffective drug therapy and adverse outcomes (undesirable experience associated with use of medical product in a patient) due to medications not being taken or managed as prescribed by the physician. Findings: During a review of Patient’s 2’s medical record titled “Personal information”, the personal information indicated, Patient 2 was admitted on 3/12/2026 with diagnosis of Alzheimer’s (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). During a concurrent observation and interview on 3/26/2026 at 10:35 a.m., with the Director of Patient Care Services Designee (DPCSD) in Patient 2’s room, the DPCSD was observed conducting a patient assessment without performing a medication reconciliation. When asked whether she should complete one, the DPCSD responded, “Should I?” The DPCSD stated that asking Patient 2 whether she needed medication refills constituted a medication reconciliation. The DPCSD further stated that medication reconciliation should be conducted at every visit to verify medications. During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile/Reconciliation”, undated, P&P indicated, During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen.”

“Based on observation, interviews, and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) failed to complete a bereavement assessment (a structured, often ongoing, evaluation of an individual’s response to loss, aiming to identify risks for complicated grief) in accordance with the agency’s policy and procedures for one of 14 sampled patients (Patient 2). This failure had the potential to result in lack of emotional support for Patient 2’s caregivers and family members following the patient’s death. Findings: During a review of Patient’s 2’s medical record, titled Personal information, the personal information indicated Patient 2 was admitted on 3/12/2026 with diagnosis of Alzheimer’s (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). During a concurrent interview and record review on 3/31/2026 at 12:57 p.m. with The Spiritual Care (SC), Patient 2’s “History of Bereavement Assessment” dated 4/1/2026 was reviewed. The SC stated there was no initial bereavement assessment done for Patient 2. The SC stated bereavement assessments are done in person or over the phone and completed within five (5) days of admission. The SC stated bereavement assessments and follow up assessments are done to support the family in a time of need. During a review of the facility’s policy and procedure titled, “Bereavement Assessment”, dated 2009, P&P indicated, on admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that will be given to the bereavement coordinator. The bereavement coordinator will develop a plan for intervention, based on the findings of the bereavement follow-up assessment and input from the interdisciplinary group members. The bereavement coordinator will document the interventions on the bereavement services checklist. All bereavement documentation will be submitted for filling in the patient’s permanent clinical record.”

“Based on interview and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure that all members of the interdisciplinary group (IDG, team of healthcare professionals who work together to develop an individualized plan for the patients and support the families) meet to discuss and plan the physical, psychosocial, emotional, and spiritual needs for one of 14 sampled patients (Patient 3). This failure had the potential to result in Patient 3 not receiving the comprehensive and coordinated care and services necessary to meet Patient 3’s individualized needs during his end-of-life process that could result in ineffective treatment, pain and discomfort and decrease in quality of life. Findings: During a review of Patient 3’s clinical record titled “Personal information,” Patient 3’s personal information record indicated a Start of Care (SOC) date of 7/18/2025 and a primary diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities). During a review of Patient 3’s clinical record titled “Plan of Care/ Interdisciplinary Group (POC/IDG) Review” dated 3/18/2026 for certification period #4, the POC/IDG review indicated an order for Skilled Nurse (SN) frequency visit of one time per week and as needed (PRN). During a review of Patient 3’s clinical record titled “POC/IDG Review “dated 12/16/2025, 12/30/2025, 1/7/2026 and 1/21/2026, the POC/IDG reviews indicated documented evidence of electronic signatures from the Master of Social Worker (MSW), Spiritual Counselor (SC), and the Registered Nurse (RN). However, there was no documented electronic signature from the Medical Director (MD). During a concurrent interview and record review on 4/1/2026 at 8:16 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 3’s POC/IDG Reviews dated 12/16/2025, 12/30/2025, 1/7/2026 and 1/21/2026 were reviewed. The DPCSD stated and confirmed that Patient 3’s POC/IDG Reviews dated 12/16/2025, 12/30/2025, 1/7/2026 and 1/21/2026 did not have documented evidence of an electronic signature from the MD. The DPCSD stated that the MD was a core member of the IDG and was required to attend every meeting. The DPCSD stated that the purpose of all core IDG members attending meetings and signing the POC/IDG Review was to validate that the IDG collectively reviewed and discussed the patient’s plan of care, agreed upon it, and signed off on it. During an interview on 4/1/2026 at 11:46 a.m. with the Medical Director (MD), the MD stated that he was part of the IDG and attends the meetings biweekly. The MD stated his presence at the IDG meetings was important because he works with the group to review new referrals and verify if accepted or not, review current active patient cases with the nurses for teaching /guidance with medication side effects, wound care, symptom management control, pain management, and also reassess if patients were still appropriate for hospice care. During a review of the HA’s Policy and Procedure (P&P) titled “Interdisciplinary Group Meeting”, undated, the P&P indicated that the hospice medical director and all hospice interdisciplinary group members will be present at the IDG meetings, and the patient’s plan of care will be updated no less frequently than every 15 days. The P&P indicated that the IDG will discuss patient and family/caregiver changes, progress updates to the plan of care, deaths, changes in patient, family circumstances, referrals, admission, and recertification of patient on hospice program. The P&P also indicated that the members of the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice clinical supervisors/nursing supervisor.”

“Based on interviews and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the patient’s plan of care (POC, structured, patient-specific document detailing a patient’s health problem/s, goals, and specific interventions) was individualized and included all the interventions ordered for the primary diagnosis of one of 14 sampled patients (Patient 6). This failure had the potential to result in decline in Patient 6’s health and quality of life related to not receiving the necessary services to provide comfort during the end-of-life stage. Findings: a. During a review of Patient 6’s medical record, titled “Personal Information,” the “Personal Information” indicated the start of care (SOC) date of 11/2/2025 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, long-term lung disease characterized by difficulty breathing due to chronic inflammation that restricts airflow). During a review of Patient 6’s medical form, titled “Comprehensive Nursing Assessment,” dated 11/2/2025, the “Comprehensive Nursing Assessment” indicated Registered Nurse (RN) 5 documented the following: -Patient 6 had an oxygen saturation (SpO2, amount of oxygen circulating in the blood [target range for COPD patients is 88 to 92% [percent]) of 96% while on room air (RA, breathing normal air without needing supplemental oxygen [prescription oxygen ordered for people with low blood oxygen levels]). However, RN 5 also documented Patient 6 was on 2 liters per minute (LPM, unit of measurement of flow rate) of supplemental oxygen via nasal cannula (flexible tube with two prongs used to deliver supplemental oxygen directly into the nostrils). -Patient 6 was “poorly responsive or unresponsive to bronchodilators (medications that relax airway muscles to improve breathing).” -Patient 6 had “respiratory failure (progression of COPD leading to critically low level of oxygen or critically high levels of carbon dioxide in the body) and SpO2 less than or equal to 88% determined either by arterial blood gases (ABG, laboratory test that measures oxygen, carbon dioxide, and acid-base levels in arterial blood to evaluate respiratory failure) or SpO2 monitors. During a review of Patient 6’s recertification assessment note, titled “Nursing Update Assessment,” dated 1/26/2026, the “Nursing Update Assessment” indicated RN 5 documented Patient 6 had SpO2 of 95% on RA with mild shortness of breath (SOB, feeling of not being able to catch one’s breath), was “poorly responsive or unresponsive to bronchodilators,” and had “respiratory failure” with SpO2 less than or equal to 88%. During a review of Patient 6’s medical record, titled “POC Summary,” as of 3/31/2026, Patient 6’s physician medication orders included: -albuterol (bronchodilator to treat COPD) 90 micrograms (mcg, unit of measurement of weight) per actuation (each puff inhaled) one (1) puff by mouth every four to six hours as needed for COPD/SOB/wheezing (high-pitched sound produced by air flowing through narrowed/obstructed airways). -albuterol 0.083% one (1) vial by mouth for oral inhalation via nebulizer (medical device used to convert liquid medication into a fine mist for inhalation) every six (6) hours as needed for wheezing /SOB. During a concurrent interview and record review on 3/31/2026 at 10:56 a.m. with the Director of Patient Care Services Designee (DPCSD), the clinical record for Patient 6 was reviewed, including assessments, physician orders, and plan of care. The DPCSD stated there was no documented evidence that Patient 6’s most updated POC was individualized and did not include the physician-ordered albuterol inhaler as one of the interventions to address Patient 6’s COPD. The DPCSD stated it was important to include all interventions ordered to address COPD were included in Patient 6’s POC to ensure all HA staff providing care and services to Patient 6 were aware of all the interventions that the HA must provide to Patient 6 and to monitor albuterol’s effectiveness. The DPCSD stated that not individualizing Patient 6’s POC could lead to Patient 6’s decline in health and quality of life related to not receiving the albuterol as ordered by the physician. During a review of the HA’s policy and procedure (P&P), titled “The Plan of Care,” dated 2009, the P&P indicated the following: 1.A written individualized patient and family/caregiver POC must be established and maintained for each individual admitted to the hospice program. 2. Each patient must be monitored for his/her response to care or services provided against established patient goals and patient outcomes to evaluate progress toward goals. 3. The written POC must contain, but will not be limited to: physician orders, drugs and treatments, and durable medical equipment (DME, medically necessary equipment ordered by the physician to treat illnesses or injuries) and medical supplies necessary to meet patient needs.”

“Based on interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure there was a physician order for the routine (scheduled, regular, intermittent) visits of skilled nurses (SNs, licensed as either a registered nurse [RN] or licensed vocational nurse [LVN]) for five of 14 sampled patients (Patients 6, Patient 8, Patient 9, Patient 10, and Patient 11). This failure had the potential to cause a decline in the patients’ condition that can lead to hospitalization related to the potential missed SN visits and changes in patients’ condition not being assessed timely. Findings: a. During a review of Patient 6’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 11/2/2025 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, long-term lung disease characterized by difficulty breathing due to chronic inflammation that restricts airflow). During a review of Patient 6’s medical form, titled “Plan of Care (POC)/Interdisciplinary Group (IDG) Review,” dated 3/18/2026, the “POC/IDG Review” indicated the frequency of RN visit of “1 per week for changes in condition.” During a concurrent interview and record review on 3/31/2026 at 10:56 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 6’s visit notes, physician orders, and plan of care were reviewed. The DPCSD stated there was no documented evidence that there was a physician’s order for the routine SN visits for Patient 6. The DPCSD stated there must be a physician’s order for the routine SN visits to ensure there are no missed SN visits that can lead to Patient 6’s decline in health and quality of life due to possible changes in Patient 6’s condition not being assessed timely. b. During a review of Patient 8’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 12/22/2025 with diagnoses including Alzheimer’s disease (brain disorder that negatively affects memory, thinking, and behavior severe enough to interfere with daily tasks) and essential hypertension (abnormally high blood pressure [BP, force of the blood pushing against the artery walls]). During a review of Patient 8’s medical form, titled “POC/IDG Review,” dated 3/18/2026, the “POC/IDG Review” indicated the frequency of RN visit of “1 Symptom Follow-Up Visit (SFV, in-person required hospice visit within 2 days of a previous assessment visit to address a particular symptom) 1 symptom visit.” During a concurrent interview and record review on 3/31/2026 at 10:56 a.m. with the DPCSD, Patient 8’s visit notes, physician orders, and plan of care were reviewed. The DPCSD stated there was no documented evidence that there was a physician’s order for the routine SN visits for Patient 8. The DPCSD stated there must be a physician’s order for the routine SN visits to ensure there are no missed SN visits that can lead to Patient 8’s decline in health and quality of life due to possible changes in Patient 8’s condition not being assessed timely. c. During a review of Patient 9’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 3/13/2026 and a primary diagnosis of unspecified sequelae of cerebral infarction (residual neurological deficits [conditions that affect how your nervous system functions like weakness to arms and legs, numbness, speech difficulties, vision changes or memory loss] and functional limitations that persist following a stroke). During a review of patient 9’s medical record, titled “Current Treatment/Medication/ Durable Medical Equipment (DME, medical equipment and supplies ordered by the health care provider for daily or extended use) List,” undated, the list did not indicate order for frequency of visits for skilled nurses, certified health home aides (CHHA), spiritual counselor (SC), and Master of Social work (MSW) for Patient 9. During a concurrent interview and record review on 4/1/2026 at 8:28 a.m. with the DPCSD, Patient 9’s medical record, titled “Current Treatment/Medication/DME List” was reviewed. The DPCSD stated that the “Current Treatment/Medication/DME List” is a list of orders received from the Medical Director (MD). The DPCSD stated and confirmed that Patient 9’s order list did not have documented evidence of frequency of visits for the nurses, the CHHA’s, the SC, and for the MSW. The DPCSD stated that the order list should have included the order of frequency of visits so that each discipline is aware of it and follows the order. d. During a review of Patient 10’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 1/8/2026 with a primary diagnosis of COPD. During a review of patient 10’s medical record, titled “Current Treatment/Medication/DME List,” undated, the list did not indicate order for frequency of visits for skilled nurses, certified health home aides (CHHA), spiritual counselor (SC), and Master of Social work (MSW) for Patient 10. During a concurrent interview and record review on 4/1/2026 at 8:32 a.m. with the DPCSD, Patient 10’s medical record, titled “Current Treatment/Medication/DME List” was reviewed. The DPCSD stated and confirmed that Patient 10’s order list did not have documented evidence of frequency of visits for the nurses, the CHHA’s, the SC, and for the MSW. The DPCSD stated that the order list should have included the order of frequency of visits so that they are followed. e. During a review of Patient 11’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 1/5/2026 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a condition where plaque [fat, cholesterol, calcium] builds up in the heart’s original arteries, narrowing them and restricting blood flow causing chest pain). During a review of Patient 11’s medical record, titled “Current Treatment/Medication/DME List,” undated, the list did not indicate order for frequency of visits for skilled nurses, certified health home aides (CHHA), spiritual counselor (SC), and Master of Social work (MSW) for Patient 11. During a concurrent interview and record review on 4/1/2026 at 8:58 a.m. with the DPCSD, Patient 11’s medical record, titled “Current Treatment/Medication/DME List” was reviewed. The DPCSD stated and confirmed that Patient 11’s order list did not have documented evidence of frequency of visits for the nurses, the CHHA’s, the SC, and for the MSW. The DPCSD stated that the order list should have included the order of frequency of visits, because it is an order and for it to be followed by the disciplines. During a review of the HA’s policy and procedures (P&P), titled “The Plan of Care,” dated 2009, the P&P indicated the following: The Case Manager (or admitting registered nurse) must notify the attending physician and a core member of the interdisciplinary group of the initial assessment findings, the identification of patient needs and the recommended services to meet those needs. The plan of care must identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs. Orders for the start of care must be verbally received by the Case Manager (or hospice registered nurse) from the attending physician and documented on the plan of care/physician order form. The individualized plan of care must be reviewed by the rest of the IDG within two (2) days of SOC.”

“Based on interview and record review the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the Plan of Care (POC [documents the process of identifying a patient’s needs and facilitating complete care and ensures collaboration among nurses, patients, and other healthcare providers]) was implemented for one of 14 sampled patients (Patient 11). This failure had the potential to result in Patient 11’s decline in health and quality of life related to not receiving the necessary treatment and services as ordered by the physician. Findings: During a review of Patient 11’s clinical record titled “Personal Information”, the personal information record indicated a Start of Care (SOC) date of 1/5/2026 with a primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a condition where plaque [fat, cholesterol, calcium] builds up in the heart’s original arteries, narrowing them and restricting blood flow causing chest pain). During a review of Patient 11’s clinical record titled “Plan of Care/ Interdisciplinary Group (POC/IDG) Review”, dated 3/18/2026 for certification period #1, the POC/IDG Review indicated a care plan for Diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing). The care plan included a goal for optimal blood sugar management for patient comfort and prevent complications, and that the patient’s caregiver would assume diabetes-related responsibilities and be competent in checking blood sugar daily, and doing glucometer (portable, handheld device used to measure the concentration of sugar in a small sample of blood) calibration (the process of comparing the performance of a measurement device against a recognized standard). The care plan also indicated interventions that included but not limited to; patient caregiver assumed diabetes responsibility and is confident, capable and competent in checking blood sugar daily, and glucometer calibration, and skilled nurse to monitor/assess effectiveness of current and new medication or treatments. During a concurrent interview and record review on 4/1/2026 at 8:50 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 11’s POC/IDG Review dated 3/18/2026 for certification period #1 was reviewed. The DPCSD stated that the POC/IDG Review indicated that the patient and/or family are to check the patient’s blood sugar daily and administer the insulin. The DPCSD stated that the skilled nurse’s responsibility was to educate and train the patient and/or family on checking blood sugar levels and administering the insulin and monitor if the insulins were effective for the patient by asking for the blood sugar levels at every home visit and documenting it on the visit note. The DPCSD stated that adhering to the POC/IDG Review was essential to ensure the patient received the individualized care required and because the plan reflects physician orders. The DPCSD stated that if the patient’s blood sugar levels are not documented on the visit note, it indicates that the skilled nurse did not follow the orders outlined in the POC/IDG Review. During a review of the HA’s Policy and Procedure (P&P) titled, “The Plan of Care”, undated, the P&P indicated that the plan of care will be individualized to the patient and family. The P&P indicated that the plan of care would identify the patient’s needs and services to meet those needs. The P&P also indicated that the care provided to the patient must be in accordance with the plan of care and each patient would be monitored for his/her response to care or services provided against established patient goals and outcomes to evaluate progress toward goals.”

“Based on interviews and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to provide bereavement services (specialized support to help individuals cope with the death of a loved one) to the family of one of 14 sampled patients (Patient 12) in accordance with the HA policy and procedures (P&P) after Patient 12 passed away on 1/21/2026. This failure had the potential to place the Patient 12’s family/caregiver at risk of spiritual, emotional, and mental distress related to not reassessing the factors that could impact the abilities of the family/caregiver to cope with the patient’s death and implementing the interventions. Findings: a. During a review of Patient 12’s medical record, titled “Personal Information,” the “Personal Information” indicated the start of care (SOC) date of 12/18/2025 and end of care (EOC) date of 1/21/2026 with diagnoses including pulmonary embolism without acute cor pulmonale (blood clot in the lung blood vessel without any immediate right-sided heart failure), cerebral vascular disease (conditions affecting blood flow to the brain), and adult failure to thrive (syndrome characterized by unintentional weight loss, malnutrition [deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients], mental decline, and reduced physical function). The “Personal Information” indicated Patient 12 had Family Member 12 (FM 12) listed as an authorized representative/emergency contact. During a review of Patient 12’s medical form, titled “Visit Note Death Visit,” dated 1/21/2026, the “Visit Note Death Visit” indicated Patient 12 was “pronounced deceased by the attending physician in conjunction with the registered nurse at 7:15 AM” and that Patient 12’s family members, including FM 12, were notified of Patient 12’s death. During a concurrent interview and record review on 3/31/2026 at 10:56 a.m., with the Director of Patient Care Services Designee (DPCSD), Patient 12’s medical records were reviewed. The DPCSD stated there was no documented evidence that post-death bereavement support was provided to Patient 12’s family members. The DPCSD stated there was no documented interventions or recommendations on the Post-Death Bereavement note, dated 1/22/2026. The DPCSD stated there was no documented evidence that a bereavement letter was sent to Patient 12’s family members after Patient 12’s death on 1/21/2026. The DPCSD stated it was important to provide bereavement care to Patient 12’s family after Patient 12’s death, such as, making phone calls and sending bereavement letters, to show the HA’s support to the family during this difficult time and let the family know they have someone to talk to. The DPCSD stated it was important for the Bereavement Coordinator (BC) to assess the condition of family member (in general) status during the grieving process and take action, if necessary, such as, if the family member was feeling lonely and “suicidal (at risk for ending one’s life due to extreme pain or hopelessness)” after the patient’s (in general) death. During a telephone interview on 10/31/2026 at 12:58 p.m., the BC was unable to recall if BC sent a bereavement letter to Patient 12’s family. BC stated it was important to check in with the family once the patient passed away to understand where the family was in the grieving process. BC stated bereavement letters are sent 1 month, 3 months, and 6 months after the patient’s death to make sure the family is well-supported during the difficult time, address any needs of the family, and/or bring any possible resources to the family. During a review of the HA’s policy and procedures (P&P), titled “Bereavement Services,” dated 2009, the P&P indicated the following: The HA must provide an organized bereavement program supervised by a qualified BC for up to one year following the death of the patient. The purpose of the bereavement services is to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing pathological grief reactions that may interfere with the eventual resolution and integration of their losses. The purpose is also to prepare the individual to function independently of hospice and to identify a support system with the individual. Within two (2) weeks after the death of a patient, a sympathy card must be sent to the bereaved. After three (3) weeks, a bereavement letter must be sent to the bereaved, offering support and outlining the hospice bereavement services. Within three to five weeks after the patient’s death, a bereavement assessment must be completed by the bereavement counselor following the family/caregiver. The assessment must identify any grief issues. If a person is noted as experiencing normal grief, the bereavement counselor must contact the bereaved person for ongoing assessment and support at three (3), six (6), and nine (9) months after the patient’s death and at the anniversary of the patient’s death. The bereavement counselor must make information available to the bereaved person regarding bereavement support groups, other support groups available in the community, and the availability of individual counseling by the hospice personnel. In addition to the abovementioned services, individuals deemed to be experiencing moderate or severe grief must be followed by the bereavement program with increased services and contact offered at intervals defined in the plan of care. Referrals to outside professionals may also be required.”

“Based on interviews and record review, the Hospice Agency (HA, healthcare agency that provides specialized care and support for people with a terminal illness and nearing the end of life) failed to ensure the Medical Director reviewed past medical history and physicals (H&P), hospital records, diagnostic, and/or laboratory findings to confirm the patients met the hospice eligibility criteria to be admitted into the hospice patient care program for six of 14 sampled patients (Patient 5, Patient 6, Patient 8, Patient 9, Patient 10 and Patient 11). This failure had the potential to result in a decline in the patients’ health and quality of life due to the unmet needs of the patients and/or the family related to patients being enrolled to the HA without proper medical oversight of the implementation of the hospice services. Findings:ATDuring a review of Patient 6’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 11/2/2025 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, long-term lung disease characterized by difficulty breathing due to chronic inflammation that restricts airflow).During a review of Patient 6’s medical form, titled “Comprehensive Nursing Assessment,” dated 11/2/2025, the “Comprehensive Nursing Assessment” indicated Registered Nurse (RN) 5 documented the following:-Patient 6 had an oxygen saturation (SpO2, amount of oxygen circulating in the blood with the safe and typical SpO2 for COPD patients at 88%-92%) of 96% on room air (RA, breathing normal air without needing supplemental oxygen [prescription oxygen ordered for people with low blood oxygen levels]). However, RN 5 also documented Patient 6 was on 2 liters per minute (LPM, unit of measurement of flow rate) of supplemental oxygen via nasal cannula (flexible tube with two prongs used to deliver supplemental oxygen directly into the nostrils).-Patient 6 was “poorly responsive or unresponsive to bronchodilators (medications that relax airway muscles to improve breathing).”-Patient 6 had “respiratory failure (progression of COPD leading to critically low level of oxygen or critically high levels of carbon dioxide in the body) and SpO2 less than or equal to 88% determined either by arterial blood gases (ABG, laboratory test that measures oxygen, carbon dioxide, and acid-base levels in arterial blood to evaluate respiratory failure) or SpO2 monitors.-Patient 6 had an unintentional weight loss greater than or equal to 10% of body weight over the last 6 months.During a concurrent interview and record review on 3/31/2026 at 10:56 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 6’s medical records were reviewed. The DPCSD stated there was no documented evidence that HA obtained Patient 6’s prior medical history to support Patient 6’s terminal illness and validate Patient 6’s eligibility for hospice admission. The DPCSD stated the RN must review Patient 6’s previous medical records to verify the patient’s current health condition and accurately determine Patient 6’s eligibility to receive hospice care. The DPCSD stated there was no documented evidence that the HA contacted Patient 6’s primary care provider (PCP) to obtain Patient 6’s previous medical records. The DPCSD stated there was no documented evidence that HA staff discussed with Patient 6’s PCP whether Patient 6 was eligible to receive hospice care and services and if the PCP approved the HA to assume responsibility for Patient 6’s treatment and services. The DPCSD stated incomplete and/or inaccurate assessment of Patient 6’s health condition could lead to incorrect hospice eligibility that could limit the treatment and services Patient 6 was qualified to receive.During an interview on 4/1/2026 at 11:38 a.m., the Medical Director stated he was unable to recall if he reviewed Patient 6’s previous medical records from the hospital or PCP. The Medical Director stated he must review the previous hospital or physician notes even if Patient 6 came from a different HA. The Medical Director stated he was responsible for reviewing the patients’ (in general) medical records prior to hospice admission to verify the patients’ medical history and determine if the patient is appropriate to receive hospice care and services. The Medical Director stated he would first ask the HA to obtain the previous medical records if not available before signing the patient’s initial Certification of Terminal Illness (CTI, a formal document, signed by the physician, stating that a patient has a life-limiting illness with a prognosis of six months or less to live if the disease takes its normal course). c. During a review of Patient 8’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 12/22/2025 with diagnoses including Alzheimer’s disease (brain disorder that negatively affects memory, thinking, and behavior severe enough to interfere with daily tasks) and essential hypertension (abnormally high blood pressure [BP, force of the blood pushing against the artery walls]).During a review of Patient 8’s medical form, titled “Comprehensive Nursing Assessment,” dated 12/22/2025, the “Comprehensive Nursing Assessment” indicated Patient 8 had “inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin (key indicator of overall nutritional status derived from a laboratory blood test) less than 2.5 grams (gm, unit of measurement of mass) per deciliter (dl, unit of measurement of volume).During a concurrent interview and record review on 3/31/2026 at 10:56 a.m. with the DPCSD, Patient 8’s medical records were reviewed. The DPCSD stated Patient 8’s “Physician Progress Note,” dated 5/2/2024, from Patient 8’s previous PCP could not be used to validate Patient 8’s weight loss or serum albumin level because the physician assessment was conducted about a year and half prior to Patient 8’s admission to the HA. The DPCSD stated there was no documented evidence that HA staff attempted to obtain more recent medical records from Patient 8’s PCP. The DPCSD stated there was no documented evidence that HA staff discussed with Patient 8’s PCP if Patient 8 was eligible to receive hospice care and services and if the PCP approved the HA to assume responsibility for Patient 8’s treatment and services. The DPCSD stated incomplete and/or inaccurate assessment of Patient 8’s health condition could lead to incorrect hospice eligibility that could limit the treatment and services Patient 8 was qualified to receive.During an interview on 4/1/2026 at 11:38 a.m., the Medical Director stated he would not consider Patient 8’s PCP previous referral for hospice when signing the CTI because the referral was more than 1 year old. The Medical Director stated he could not recall requesting to obtain updated medical records for Patient 8. The Medical Director stated the patient (in general) must be reevaluated first prior to HA admission to ensure accurate assessment information because weight loss could have stopped but the patient condition could have either improved or declined in other aspects. d. During a review of Patient 9’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 3/13/2026 and a primary diagnosis of unspecified sequelae of cerebral infarction (residual neurological deficits [conditions that affect how your nervous system functions like weakness to arms and legs, numbness, speech difficulties, vision changes or memory loss] and functional limitations that persist following a stroke).During a review of Patient 9’s Electronic Medical Record (EMR), the EMR indicated, under section Documents/Images, a record, titled, “Admission Record from a Skilled Nursing Facility (SNF),” dated 2024, and records from a general acute care hospital (GACH), dated 10/9/2024.During a concurrent interview and record review on 4/1/2026 at 8:20 a.m. with the DPCSD, Patient 9’s EMR was reviewed. The DPCSD stated and confirmed that Patient 9’s EMR under the section Documents/Images did include an admission record from a SNF that was dated from 7/2024 and hospital records dated from 10/9/2024. The DPCSD stated that the admission record, dated 7/2024, did have the patient’s weight of 237 pounds (lbs.) but was not a good record to use to monitor patient’s weight because it was 2 years ago. The DPCSD stated, in this case, the admitting nurse should have asked the patient what her weight was in the last 6 months and her current weight to verify the weight loss and documented it.During a concurrent interview and record review on 4/1/2026 at 8:26 a.m. with the DPCSD, Patient 9’s “Comprehensive Nursing Assessment,” dated 7/2024, was reviewed. The DPCSD stated the “Comprehensive Nursing Assessment” did not have documented evidence that the RN obtained the patient’s previous weight and weight loss amount. The DPCSD stated that if an RN received verbal information about the patients’ medical history that related to the terminal diagnosis, it was important that the RN document all that information on the nursing assessment to validate it. The DPCSD stated that it was important that if there was no history and physical that indicated the patients’ previous weight loss issues, then the RN should have obtained that information during the home visit, and document weight and weight loss in numbers not percentage, for accurate monitoring of the patient. The DPCSD stated if a patient is bedbound, another way to monitor a patient’s weight would be to measure the mid-arm circumference (MAC, measures muscle and fat reserves to assess nutritional status and estimate body mass index).During an interview on 4/1/2026 at 11:59 a.m., the Medical Director stated that for patients with a terminal diagnosis that includes weight loss, it is important to get accurate information of the weight loss and have current medical documents, like history and physical, dated 3 to 6 months prior. The Medical Director stated that patient medical documents that were from one year or more ago do not provide an accurate description of the patient’s current medical history and are not good to rely on to determine hospice eligibility and the patient’s current health status. e. During a review of Patient 10’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 1/8/2026 with a primary diagnosis of COPD.During a review of Patient 10’s EMR, the EMR indicated, under section Documents/Images, medical records from a GACH, dated from 1/26/202 to 3/23/2020, and a record, titled “Order Summary ,” dated 12/31/2025, from a SNF.During a review of Patient 10’s medical record, titled “Local coverage determination (LCD) Hospice Eligibility Determination (Medicare policy used by contractors to define specific clinical criteria, functional limitations, and documentation requirements that prove a patient has a terminal prognosis of six months or less), dated 1/22/2026, it indicated Patient 10 was eligible per LCD guidelines for pulmonary disease with yes selected for:-Documentation of forced expiratory volume in one second after bronchodilator, less than 30 % of predicted-Documentation of serial decrease of forced expiratory volume in one second (maximum amount of air a person can exhale in the first second of forced breath, measured via spirometry (a type of pulmonary function test that determines how well your lungs work by measuring how much air goes into and out of your lungs when you breathe) greater than 40 milliliters (ml, unit of measurement) per year-Unintentional progressive weight loss greater than or equal to 10% of body weight over last six monthsDuring a concurrent interview and record review on 4/1/2026 at 8:36 a.m. with the DPCSD, Patient 10’s EMR was reviewed. The DPCSD stated and confirmed that Patient 10’s LCD indicated patient was eligible due to pulmonary disease. The DPCSD stated the symptoms that were selected would be found during review of patient’s hospital records or history and physical. The DPCSD stated and confirmed that Patient 10’s EMR indicated hospital records, dated from 1/26/202 to 3/23/2020, and an Order Summary, dated 12/31/2025, from the patient’s previous SNF stay. The DPCSD stated those past records were not good indicators to use to qualify the patient for hospice eligibility because they were quite old. The DPCSD stated it would have been better if the HA reached out to the patient’s previous provider for current records.During an interview on 4/1/2026 at 11:59 a.m., the Medical Director stated that any past medical records 12 months or older were too old to rely on to review the patient’s medical history. The Medical Director stated records to review for a patient’s hospice eligibility would need to be within 3 to 6 months prior. The Medical Director stated if the patient did not have current records, then he would do a telehealth appointment with the patient to get more medical history from the patient or family or have the HA request hospital records from the previous primary care physician office. f. During a review of Patient 11’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 1/5/2026 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a condition where plaque [fat, cholesterol, calcium] builds up in the heart’s original arteries, narrowing them and restricting blood flow causing chest pain).During a review of Patient 11’s EMR, the EMR indicated, under section Documents/Images, a record, titled “Order Summary Report,” dated 9/18/2025 from a SNF, and a medical record, titled “Admission Record (a summary document of the patient’s key information like demographic data, insurance details, emergency contacts, allergies and diagnosis),” dated 9/18/2025, from a SNF.During a review of Patient 11’s medical record, titled “LCD Hospice Eligibility Determination,” dated 1/5/2026, the LCD indicated that Patient 11 had heart disease and was eligible per guidelines with selected existing conditions marked yes for; patient optimally treated for heart disease with diuretics (medication that prompts the kidneys to remove excess salt and water from the body through increased urine production) and vasodilators (medications used to treat high blood pressure, chest pain, or heart failure by relaxing the smooth muscle blood vessel walls causing them to widen), and does meet criteria for New York Heart Association (NYHA) Class IV level (the most severe level of heart failure characterized by inability to carry out any physical activity without discomfort and presence of symptoms at rest).During a review of Patient 11’s medical record, titled “Current Treatment/Medication/ Durable Medical Equipment (DME, medical equipment and supplies ordered by the health care provider for daily or extended use) List,” undated, the list indicated a medication order for:-nifedipine (vasodilator medication used to treat high blood pressure and chest pain by relaxing blood vessels to improve blood flow and reduce heart workload) 90 milligrams (mg, unit of measurement) extended release tablet (tablet that release its ingredients slowly over 12 to 24 hours rather that all at once, to allow for less frequent dosing) , take 1 tablet oral once a day for hypertension (high blood pressure).-Patient 11’s list did not have documented evidence of an order for the use of diuretic medication.During a concurrent interview and record review on 4/1/2026 at 8:38 a.m. with the DPCSD, Patient 11’s “Current Treatment/Medication/ DME List,” undated, was reviewed. The DPCSD stated that the list had orders given by the Medical Director that were to be followed by the patient’s care team. The DPCSD reviewed the medications on the list and stated and confirmed that Patient 11 was on a vasodilator called nifedipine but was not on any diuretic medication.During a concurrent interview and record review on 4/1/2026 at 8:42 a.m. with the DPCSD, Patient 11’s EMR was reviewed. The DPCSD stated and confirmed that Patient 11’s EMR indicated uploaded record, titled “Order Summary Report,” dated 9/18/2025 from his previous SNF, and an admission record, dated 9/18/2025 from the same SNF. The DPCSD stated that based on the dates of the patient’s medical records they were quite old to rely on for an accurate health background of the patient. The DPCSD stated that it would have been ideal for the HA to have contacted the skilled nursing facility to obtain more current records. The DPCSD stated that for all attempts done by the HA to get more current patient records from a skilled nursing facility, a hospital or doctor’s office, those attempts should be documented on a communication note in the patient’s EMR. During a concurrent interview and record review on 4/1/2026 at 8:45 a.m. with the DPCSD, Patient 11’s medical record, titled “LCD Hospice Eligibility Determination,” dated 1/5/2026, was reviewed. The DPCSD stated and confirmed that Patient 11’s LCD was documented for the diagnosis heart failure and the conditions that were selected as yes were that the patient was treated for heart disease with diuretics and vasodilators, and the patient did meet criteria for NYHA Class IV level. The DPCSD stated the LCD is completed by the admitting nurse and the selection of conditions are verified through review of medical records or from the head-to-toe assessment. The DPCSD stated and confirmed that Patient 11’s LCD was inaccurately documented because Patient 11 was only on vasodilator medication and not on any diuretic medication. The DPCSD stated that also with no current medical records for Patient 11 it would not be as strong to qualify that the patient met the criteria for NYHA Class IV level. During an interview on 4/1/2026 at 11: 55 a.m., the Medical Director stated that a patient’s face sheet from a nursing facility is not enough as a medical record to justify patient’s diagnosis. The Medical Director stated that in that case, he would ask the HA to request hospitalization records, or records from the nursing facility that were from a physician visit. The Medical Director stated he would also do a telehealth visit with that patient to obtain more information from the patient or family but would prefer medical records to review. The Medical Director stated he prefers medical records than verbally receiving health information from the patient/family because there can be a misdiagnosis due to misunderstanding, from the patient/family, and he (the Medical Director) would prefer to have medical records to review the patient’s symptoms and diagnosis given from a medical professional, to verify hospice eligibility. The Medical Director stated current records that were from 3 to 6 months prior are better to review for accuracy of patient’s health status.During a review of the HA’s policy and procedures (P&P), titled “Certification of Terminal Illness,” dated 2009, the P&P indicated the following:At the time of admission to hospice, the hospice Medical Director or the patient’s attending physician must complete a certification narrative that reflects the patient’s individual circumstances based on his/her review of the patient’s medical record or, if applicable, examination of the patient.Clinical information and other documentation that supports the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. d. During a review of Patient 9’s clinical record titled personal Information, the personal information record indicated a Start of Care (SOC) date of 3/13/2026 and a primary diagnosis of unspecified sequelae of cerebral infarction (residual neurological deficits [conditions that affect how your nervous system functions like weakness to arms and legs, numbness, speech difficulties, vision changes or memory loss] and functional limitations that persist following a stroke).During a review of Patient 9’s Electronic Medical Record (EMR), the EMR indicated, under section Documents/images, a record titled admission record from a skilled nursing facility dated 2024, and records from a general acute care hospital dated 10/9/2024.During a concurrent interview and record review on 4/1/2026 at 8:20 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 9’s Electronic Medical Record (EMR) was reviewed. The DPCSD stated and confirmed that Patient 9’s EMR under the section Documents/Images did include an admission record form a skilled nursing facility that was dated from 7/2024 and hospital records dated from 10/9/2024. The DPCSD stated that the admission record dated 7/2024 did have the patient’s weight of 237 pounds (lbs.) but was not a good record to use to monitor patient’s weight because it was 2 years ago. The DPCSD stated in this case the admitting nurse should have asked the patient what her weight was in the last 6 months and her current weight to verify the weight loss, and document it.During a concurrent interview and record review on 4/1/2026 at 8:26 a.m. with DPCSD, Patient 9’s nursing comprehensive assessment dated 7/2024 was reviewed. The DPCSD stated that the nursing comprehensive did not have documented evidence that the Registered Nurse (RN) obtained the patient’s previous weight and weight loss amount. The DPCSD stated that if an RN received verbal information about the patients’ medical history that related to the terminal diagnosis, it was important that the RN document all that information on the nursing assessment to validate it. The DPCSD stated that it was important that if there was no history and physical that indicated the patients’ previous weight loss issues, then the RN should have obtained that information during the home visit, and document weight and weight loss in numbers not percentage, for accurate monitoring of the patient. The DPCSD stated if a patient is bedbound, another way to monitor a patient’s weight would be my measuring the Mid-arm circumference (MAC, measures muscle and fat reserves to assess nutritional status and estimate body mass index).During an interview on 4/1/2026 at 11:59 a.m. with the medical director (MD), the MD stated that for patients with a terminal diagnosis that includes weight loss, it is important to get accurate information of the weight loss and have current medical documents, like history and physical, dated 3 to 6 months prior. The MD stated that patient medical documents that were from one year or more ago do not provide an accurate description of the patient’s current medical history and are not good to rely on to determine hospice eligibility and the patient’s current health status. e. During a review of Patient 10’s clinical record titled Personal Information, the personal information record indicated a Start of Care (SOC) date of 1/8/2026 with a primary diagnosis of Chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing).During a review of Patient 10’s Electronic Medical Record (EMR), the EMR indicated, under section Documents/images, medical records from a general acute care hospital (GACH) dated from 1/26/202 to 3/23/2020, and a record titled Order summary dated 12/31/2025 from a skilled nursing facility.During a review of Patient 10’s clinical record titled LCD (Local coverage determination) Hospice eligibility determination (Medicare policy used by contractors to define specific clinical criteria, functional limitations, and documentation requirements that prove a patient has a terminal prognosis of six months or less) dated 1/22/2026, it indicated Patient 10 was eligible per LCD guidelines for pulmonary disease with yes selected for;Documentation of forced expiratory volume in one second after bronchodilator, less than 30 % of predictedDocumentation of serial decrease of forced expiratory volume in one second (maximum amount of air a person can exhale in the first second of forced breath, measured via spirometry (a type of pulmonary function test that determines how well your lungs work by measuring how much air goes into and out of your lungs when you breathe) greater than 40 milliliters (ml, unit of measurement) per yearUnintentional progressive weight loss greater than or equal to 10% of body weight over last six monthsDuring a concurrent interview and record review on 4/1/2026 at 8:36 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 10’s EMR was reviewed. The DPCSD stated and confirmed that Patient 10’s LCD indicated patient was eligible due to pulmonary disease. The DPCSD stated the symptoms that were selected would be found during review of patient’s hospital records or history and physical. The DPCSD stated and confirmed that Patient 10’s EMR indicated hospital records dated from 1/26/202 to 3/23/2020, and an Order summary dated 12/31/2025 from the patient’s previous skilled nursing facility stay. The DPCSD stated those past records were not good indicators to use to qualify the patient for hospice eligibility because they were quite old. The DPCSD stated it would have been better if the HA reached out to the patient’s previous provider for current records.During an interview on 4/1/2026 at 11:59 a.m. with the MD, the MD stated that any past medical records 12 months or older were too old to rely on to review the patient’s medical history. The MD stated records to review for a patient’s hospice eligibility would need to be within 3 to 6 months prior. The MD stated if the patient did not have current records, then he would do a telehealth appointment with the patient to get more medical history from the patient or family or have the HA request hospital records from the previous primary care physician office. f. During a review of Patient 11’s clinical record titled Personal Information, the personal information record indicated a Start of Care (SOC) date of 1/5/2026 with a primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a condition where plaque [fat, cholesterol, calcium] builds up in the heart’s original arteries, narrowing them and restricting blood flow causing chest pain).During a review of Patient 11’s Electronic Medical Record (EMR), the EMR indicated, under section Documents/images, a record titled Order summary Report dated 9/18/2025 from a skilled nursing facility, and a clinical record titled admission record (a summary document of the patient’s key information like demographic data, insurance details, emergency contacts, allergies and diagnosis) dated 9/18/2025 from a skilled nursing facility.During a review of Patient 11’s clinical record titled LCD hospice eligibility determination dated 1/5/2026, the LCD indicated that Patient 11 had heart disease and was eligible per guidelines with selected existing conditions marked yes for; patient optimally treated for heart disease with diuretics (medication that prompts the kidneys to remove excess salt and water from the body through increased urine production) and vasodilators (medications used to treat high blood pressure, chest pain, or heart failure by relaxing the smooth muscle blood vessel walls causing them to widen), and does meet criteria for New York heart association (NYHA) class IV level (the most severe level of heart failure characterized by inability to carry out any physical activity without discomfort and presence of symptoms at rest).During a review of Patient 11’s clinical record titled current treatment/ medication/ durable medical equipment (DME) list, undated, the list indicated a medication order for;nifedipine (vasodilator medication used to treat high blood pressure and chest pain by relaxing blood vessels to improve blood flow and reduce heart workload) 90 milligrams (mg, unit of measurement) extended release tablet (tablet that release its ingredients slowly over 12 to 24 hours rather that all at once, to allow for less frequent dosing) , take 1 tablet oral once a day for hypertension (high blood pressure).Patient 11’s list did not have documented evidence of an order for the use of diuretic medication.During a concurrent interview and record review on 4/1/2026 at 8:38 a.m. with the Director of Patient Care Services Designee (DPCSD) Patient 11’s current treatment/ medication/DME list was reviewed. The DPCSD stated that the list was orders given by the Medical Director (MD), that were to be followed by the patient’s care team. The DPCSD reviewed the medications on the list and stated and confirmed that Patient 11 was on a vasodilator called nifedipine but was not on any diuretic medication.During a concurrent interview and record review on 4/1/2026 at 8:42 a.m. with the DPCSD, Patient 11’s EMR was reviewed. The DPCSD stated and confirmed that Patient 11’s EMR indicated uploaded record titled Order summary Report dated 9/18/2025 from his previous skilled nursing facility, and an admission record dated 9/18/2025 from the same skilled nursing facility. The DPCSD stated that based on the dates of the patient’s medical records they were quite old to rely on for an accurate health background of the patient. The DPCSD stated that it would have been ideal for the HA to have contacted the skilled nursing facility to obtain more current records. The DPCSD stated that for all attempts done by the HA to get more current patient records from a skilled nursing facility, a hospital or doctors office, those attempts should be documented in a communication note in the patient’s EMR. During a concurrent interview and record review on 4/1/2026 at 8:45 a.m. with the Director DPCSD), Patient 11’s clinical record titled LCD hospice eligibility determination dated 1/5/2026 was reviewed. The DPCSD stated and confirmed that Patient 11’s LCD was documented for the diagnosis heart failure and the conditions that were selected as yes were that the patient was treated for heart disease with diuretics and vasodilators, and the patient did meet criteria for NYHA class IV level. The DPCSD stated the LCD is completed by the admitting nurse and the selection of conditions are verified through review of medical records or from the head-to-toe assessment. The DPCSD stated and confirmed that Patient 11’s LCD was inaccurately documented because Patient 11 was only on vasodilator medication and not on any diuretic medication. The DPCSD stated that also with no current medical records for Patient 11 it would not be as strong to qualify that the patient met the criteria for NYHA class 4 level. During an interview on 4/1/2026 at 11: 55 a.m. with the MD, the MD stated that a patient’s face sheet from a nursing facility is not enough as a medical record to justify patient’s diagnosis. The MD stated that in that case, he would ask the HA to request hospitalization records, or records from the nursing facility that were from a physician visit. The MD stated he would also do a telehealth visit with that patient to obtain more information from the patient or family but would prefer medical records to review. The MD stated he prefers medical records than verbally receiving health information from the patient/family because there can be a misdiagnosis due to misunderstanding, from the patient/family, and he (the MD) would prefer to have medical records to review the patient’s symptoms and diagnosis given from a medical professional, to verify hospice eligibility. The MD stated current records that were from 3 to 6 months prior are better to review for accuracy of patient’s health status. During a review of Patient’s 5’s medical record, titled Personal information, the personal information indicated, Patient 5 was admitted on 10/8/2025 with diagnosis of CVA , and Parkinson’s (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements)During a review of Patient 5’s medical record, titled “Local coverage determination (LCD) Hospice Eligibility Determination (Medicare policy used by contractors to define specific clinical criteria, functional limitations, and documentation requirements that prove a patient has a terminal prognosis of six months or less), dated 3/27/2026, it indicated Patient 5 was eligible per LCD guidelines for Stroke with yes selected for: - Impairment of functional status: a Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) score of less than 40% (indicates severe impairment of functional status, generally signaling a need for significant, high-level care and a high likelihood of advanced, terminal illness.)? Yes- Unintentional progressive weight loss greater than or equal to 10% of body weight over last six months.During a concurrent interview and record review on 4/1/2026 at 8:07 a.m. with Director of Patient Care Services Designee (DPCSD), Patient 5’s “Electronic Medical Records (EMR) were reviewed, the EMR assessments indicated:-Nursing Recert Assessment, dated 9/12/2025, indicated: Weight- 200 , Mid Arm Circumference (MAC- which is used to assess nutritional status and estimate body weight) 26, Body Mass Index (BMI- is an estimate of a person’s leanness or body fat based on their body weight and height ) 28.7-Nursing Recert Assessment, dated 12/5/2025, indicated: Weight-200, MAC 26, BMI 28.7-Nursing Recert Assessment, dated 2/13/2026, indicated: Weight-200, MAC 26, BMI 28.7DPCSD stated the patients weight, MAC and BMI have not changed since 9/12/2025 which would not qualify him for hospice under the LCD criteria. DPCSD stated the weight, MAC, and BMI are prepopulated on the EMR and the visiting RNs have not been taking a weight. During an interview on 4/1/2026 at 11:44 a.m. with Medical Director (MD), MD stated that a patient who has not been losing weight needs to be reevaluated to determine if they qualify for hospice.During a review of the facility’s policy and procedure titled, “Certification of Terminal Illness”, dated 2009, P&P indicated, When certifying the patient as terminally ill, hospice medical director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis... Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification.”

“Based on interview and record review the HA (HA, agency providing care to terminally ill patients who have six months or less to live) failed to have a complete clinical record for two of 14 sampled patients (Patient 6 and Patient 14) by failing to: a. Ensure complete and accurate documentation of Patients 6’s oxygenation status (measures how well oxygen is being delivered to tissues and cells). b. Develop an individualized care plan for Patient 6’s Chronic Obstructive Pulmonary Disease (COPD, long-term lung disease characterized by difficulty breathing due to chronic inflammation that restricts airflow) that included the COPD medications. c. Ensure Patient 11’s blood sugar levels were monitored and documented during home visits. This failure resulted in the incomplete medical record for Patient 6 and Patient 14, which could have caused a break in continuity of care and not providing the patients with the necessary care and services needed to maintain comfort. b. During a review of Patient 11’s clinical record titled Personal Information, the personal information record indicated a Start of Care (SOC) date of 1/5/2026 with a primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a condition where plaque [fat, cholesterol, calcium] builds up in the heart’s original arteries, narrowing them and restricting blood flow causing chest pain).During a review of Patient 11’s clinical record titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 3/18/2026 for certification period #1, the POC/IDG Review indicated a care plan for Diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) with a goal for optimal blood sugar management for patient comfort and prevent that the patient caregiver assumes diabetes responsibilities and is competent in checking blood sugar daily, and doing glucometer (portable, handheld device used to measure the concentration of sugar in a small sample of blood) calibration. The care plan also indicated interventions that included but not limited to; patient caregiver assumed diabetes responsibility and is confident, capable and competent in checking blood sugar daily, and glucometer calibration, and skilled nurse to monitor/assess effectiveness of current and new medication/treatment.During a concurrent interview and record review on 4/1/2026 at 8:55 a.m. with the DPCSD, Patient 11’s EMR was reviewed. Patient 11’s EMR indicated, under visit notes, skilled nurse visit notes dated 2/2/2026, 2/9/2026, 2/16/2026, 2/23/2026, 3/2/2026, 3/9/2026, and 3/16/2026. During review;The DPCSD stated and confirmed that the visit note dated 2/2/2026 did not have documented evidence of the patient’s blood sugar level.The DPCSD stated and confirmed that the visit note dated 2/9/2026, under the section Endocrine diabetes blood sugar, had documentation of a number range of 140 – 200. The DPCSD stated and confirmed that the visit note dated 2/16/2026 did not have documented evidence of the patient’s blood sugar level.The DPCSD stated and confirmed that the visit note dated 2/23/2026, under the section Endocrine diabetes blood sugar, had documentation of a number range of 140 – 200.The DPCSD stated and confirmed that the visit note dated 3/2/2026 did not have documented evidence of the patient’s blood sugar level.The DPCSD stated and confirmed that the visit note dated 3/9/2026, under the section Endocrine diabetes blood sugar, had documentation of a number range of 140 – 200.The DPCSD stated and confirmed that the visit note dated 3/16/2026 did not have documented evidence of the patient’s blood sugar level.The DPCSD stated and confirmed that with lack of documentation of the patient’s blood sugar in the visit notes, then it meant the skilled nurse was not monitoring the patient and medication and was not following the POC. The DPCSD stated that the importance of documenting the exact blood sugar levels and not ranges, was to accurately monitor if the medication was working or not to prevent the patient from experiencing hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar) symptoms. During a review of the HA’s Policy and Procedure (P&P) titled Contents of the clinical record, undated, the P&P indicated that the information available in the patient’s clinical record, applicable to care and services provided will include but not limited to documentation of communication regarding conclusions and findings of patient medication monitoring.During a review of the HA’s Policy and Procedure (P&P) titled The plan of care, undated, the P&P indicated that the plan of care will be individualized to the patient and family. The P&P indicated that the care provided to the patient must be in accordance with the plan of care and each patient would be monitored for his/her response to care or services provided against established patient goals and outcomes to evaluate progress toward goals.During a review of the HA’s Policy and Procedure (P&P) titled Entries into the clinical record, undated, the P&P indicated that a clinical record would be initiated and maintained for each patient receiving care or services, according to organization policies and at a minimum will include; patient responses to care and services analyzed and documented as measurable goals. The P&P indicated that the clinical note would include patient responses to treatment and/or procedures with date of service provided and signature of clinical and his/her credentials. Findings:a. During a review of Patient 6’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 11/2/2025 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, long-term lung disease characterized by difficulty breathing due to chronic inflammation that restricts airflow).During a review of Patient 6’s medical form, titled “Comprehensive Nursing Assessment,” dated 11/2/2025, the “Comprehensive Nursing Assessment” indicated Registered Nurse (RN) 5 documented the following:-Patient 6 had an oxygen saturation (SpO2, amount of oxygen circulating in the blood with the safe and typical SpO2 for COPD patients at 88%-92%) of 96% on room air (RA, breathing normal air without needing supplemental oxygen [prescription oxygen ordered for people with low blood oxygen levels]). However, RN 5 also documented Patient 6 was on 2 liters per minute (LPM, unit of measurement of flow rate) of supplemental oxygen via nasal cannula (flexible tube with two prongs used to deliver supplemental oxygen directly into the nostrils).-Patient 6 was “poorly responsive or unresponsive to bronchodilators (medications that relax airway muscles to improve breathing).”-Patient 6 had “respiratory failure (progression of COPD leading to critically low level of oxygen or critically high levels of carbon dioxide in the body) and SpO2 less than or equal to 88% determined either by arterial blood gases (ABG, laboratory test that measures oxygen, carbon dioxide, and acid-base levels in arterial blood to evaluate respiratory failure) or SpO2 monitors.During a review of Patient 6’s recertification assessment note, titled “Nursing Update Assessment,” dated 1/26/2026, the “Nursing Update Assessment” indicated RN 5 documented Patient 6 had SpO2 of 95% on RA with mild shortness of breath (SOB, feeling of not being able to catch one’s breath), was “poorly responsive or unresponsive to bronchodilators,” and had “respiratory failure” with SpO2 less than or equal to 88%.During a concurrent interview and record review on 3/31/2026 at 10:56 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 6’s comprehensive nursing assessments were reviewed. The DPCSD stated the “Comprehensive Nursing Assessment,” dated 11/2/2025 and “Nursing Update Assessment,” dated 1/26/2026 were inaccurate because they did not clearly indicate whether Patient 6’s SpO2 was measured on RA or while on Patient 6 was on supplemental oxygen as both must not be selected at the same time. The DPCSD stated COPD patients must maintain SpO2 between 88% - 92% to ensure the oxygen level in the body was not too low and the carbon dioxide was not too high. The DPCSD stated if Patient 6’s SpO2 was below 88% while on RA, more respiratory interventions, such as supplemental oxygen and/or bronchodilators, might be needed. The DPCSD stated if Patient 6’s SpO2 was above 92% while on supplemental oxygen, Patient 6 could be getting excessive oxygen, which could potentially worsen Patient 6’s breathing condition and cause a decline in Patient 6’s health. The DPCSD stated if Patient 6’s SpO2 was above 92% on RA, Patient 6’s COPD might not be advanced enough to qualify for hospice care and services. The DPCSD also stated the RN must ensure accurate documentation whether Patient 6’s SpO2 was measured on room air or with supplemental oxygen to ensure proper treatment and services are provided.During a review of the HA’s policy and procedures (P&P 1), titled “Contents of the Clinical Record,” dated 2009, P&P 1 indicated the following:A clinical record must be maintained for each patient receiving care.The clinical record must contain sufficient information to identify the patient, describe patient problems/needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice IDG members and contract personnel.The following information must be available in the clinical record, as applicable to care and services provided: documentation of the assessment data collected, actions, and interventions performed, and patient response to care providedDuring a review of the HA’s policy and procedures (P&P 2), titled “Ongoing Comprehensive Assessments,” dated 2009, P&P 2 indicated the following:The nurse must assess the patient on each visit for factors that alleviate or exacerbate physical symptoms, vital signs appropriate to the patient’s condition, breath sounds, progress toward hospice goals and patient needs and problems, and compliance with treatments and medication regimen. b. During a review of Patient 6’s medical record, titled “POC Summary,” as of 3/31/2026, Patient 6’s physician medication orders included:-albuterol (bronchodilator to treat COPD) 90 micrograms (mcg, unit of measurement of weight) per actuation (each puff inhaled) 1 puff by mouth every 4-6 hours as needed for COPD/shortness of breath shortness of breath (SOB, feeling of not being able to catch one’s breath)/wheezing (high-pitched sound produced by air flowing through narrowed/obstructed airways)-albuterol 0.083% 1 vial by mouth for oral inhalation via nebulizer (medical device used to convert liquid medication into a fine mist for inhalation) every 6 hours as needed for wheezing/SOBDuring a concurrent interview and record review on 3/31/2026 at 10:56 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 6’s visit notes, physician orders, and plan of care (POC, structured, patient-specific document detailing a patient’s health problem/s, goals, and specific interventions) were reviewed. The DPCSD stated there was no documented evidence that Patient 6’s most updated POC was individualized and included the physician-ordered albuterol as one of the interventions to address Patient 6’s COPD. The DPCSD stated it was important to include and document all the interventions utilized to keep all staff who provide care and services to Patient 6 aware of all the interventions that the HA must provide to Patient 6 and to monitor albuterol’s effectiveness. The DPCSD stated not documenting an individualized POC for Patient 6 could lead to Patient 6’s decline in health and quality of life related to not receiving the albuterol as ordered by the physician.During a review of the HA’s policy and procedures (P&P 3), titled “The Plan of Care,” dated 2009, P&P 3 indicated that a written individualized patient and family/caregiver plan of care must be established and maintained for each individual admitted to the hospice program. P&P 4 indicated the plan of care must meet the documentation requirements of the physician-directed medical orders and the care planning process.During a review of the HA’s policy and procedures (P&P 4), titled “Entries into the Clinical Record,” dated 2009, P&P 4 indicated the following:Documentation in the clinical record must be timely, detailed, accurate, and reflect the care or services provided.A clinical record must be initiated and maintained for each patient receiving care or services, according to organization policies and must include at a minimum:-initial plan of care, updated plans of care, initial, comprehensive and updated comprehensive assessments and clinical notes-dates, times, and types of interventions, assessments, and coordination of care-patient response to care and services analyzed and documented as measurable goals-current patient status and progress toward goals3. Entries into the clinical record must be clear, concise, and specific statements of fact. c.During a review of Patient 11’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 1/5/2026 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a condition where plaque [fat, cholesterol, calcium] builds up in the heart’s original arteries, narrowing them and restricting blood flow causing chest pain).During a review of Patient 11’s medical record, titled “Plan of Care/Interdisciplinary Group (POC/IDG) Review,” dated 3/18/2026 for certification period #1, the “POC/IDG Review” indicated a care plan for diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) with a goal for optimal blood sugar management for patient comfort and prevent that the patient caregiver assumes diabetes responsibilities and is competent in checking blood sugar daily, and doing glucometer (portable, handheld device used to measure the concentration of sugar in a small sample of blood) calibration. The care plan also indicated interventions that included but not limited to; patient caregiver assumed diabetes responsibility and is confident, capable and competent in checking blood sugar daily, and glucometer calibration, and skilled nurse to monitor/assess effectiveness of current and new medication/treatment.During a concurrent interview and record review on 4/1/2026 at 8:55 a.m. with the DPCSD, Patient 11’s electronic medical records (EMR) was reviewed. Patient 11’s EMR indicated, under visit notes, skilled nurse visit notes dated 2/2/2026, 2/9/2026, 2/16/2026, 2/23/2026, 3/2/2026, 3/9/2026, and 3/16/2026. During review:-The DPCSD stated and confirmed that the visit note dated 2/2/2026 did not have documented evidence of the patient’s blood sugar level.-The DPCSD stated and confirmed that the visit note dated 2/9/2026, under the section Endocrine diabetes blood sugar, had documentation of a number range of 140 – 200.- The DPCSD stated and confirmed that the visit note dated 2/16/2026 did not have documented evidence of the patient’s blood sugar level.-The DPCSD stated and confirmed that the visit note dated 2/23/2026, under the section Endocrine diabetes blood sugar, had documentation of a number range of 140 – 200.-The DPCSD stated and confirmed that the visit note dated 3/2/2026 did not have documented evidence of the patient’s blood sugar level.-The DPCSD stated and confirmed that the visit note dated 3/9/2026, under the section Endocrine diabetes blood sugar, had documentation of a number range of 140 – 200.-The DPCSD stated and confirmed that the visit note dated 3/16/2026 did not have documented evidence of the patient’s blood sugar level.-The DPCSD stated and confirmed that with lack of documentation of the patient’s blood sugar in the visit notes, then it meant the skilled nurse was not monitoring the patient and medication and was not following the POC. The DPCSD stated that the importance of documenting the exact blood sugar levels and not ranges, was to accurately monitor if the medication was working or not to prevent the patient from experiencing hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar) symptoms.During a review of the HA’s policy and procedures (P&P 1), titled “Contents of the Clinical Record,” dated 2009, P&P 1 indicated that the information available in the patient’s clinical record, applicable to care and services provided2, will include but not limited to the documentation of communication regarding conclusions and findings of patient medication monitoring.During a review of the HA’s policy and procedures (P&P 3), titled “The Plan of Care,” dated 2009, P&P 3 indicated that the plan of care will be individualized to the patient and family. P&P 3 indicated that the care provided to the patient must be in accordance with the plan of care and each patient would be monitored for his/her response to care or services provided against established patient goals and outcomes to evaluate progress toward goals.During a review of the HA’s policy and procedures (P&P 4), titled “Entries into the Clinical Record,” dated 2009, P&P 4 indicated that a clinical record would be initiated and maintained for each patient receiving care or services, according to organization policies and at a minimum will include; patient responses to care and services analyzed and documented as measurable goals. P&P 4 indicated that the clinical note would include patient responses to treatment and/or procedures with date of service provided and signature of clinical and his/her credentials.”

“Based on interviews and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to maintain an authenticated clinical record based on accepted standards of practice and regulations followed for two of 14 sampled patient (Patient 3 and Patient 8) by failing to: a. Ensure Patient 3’s Interdisciplinary Group (IDG, team of healthcare professionals who work together to develop an individualized plan for the patients and support the families) review notes were signed by the Medical Director (MD). b. Ensure Patient 3’s spiritual comprehensive assessment was signed and dated within five (5) days of the start of care by the Spiritual Counselor. c. Ensure that Patient 8’s initial comprehensive nursing assessment was signed and dated by the Registered Nurse (RN). These failures could result in delayed of delivery of care, treatment and services to the patients and affect patients’ quality of life. Findings:a. During a review of Patient 3’s clinical record titled Personal information, Patient 3’s personal information record indicated a Start of Care (SOC) date of 7/18/2025 and a primary diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities).During a review of Patient 3’s clinical record titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 3/18/2026 for certification period #4, the POC/IDG review indicated an order for Skilled Nurse (SN) frequency visit of one time per week and as needed (PRN).During a review of Patient 3’s clinical records titled POC/IDG Review dated 12/16/2025, 12/30/2025, 1/7/2026 and 1/21/2026, the POC/IDG reviews indicated documented evidence of electronic signatures from the Masters of Social Worker (MSW), Spiritual Counselor (SC), and the Registered Nurse (RN), and a missing electronic signature for the Medical Director (MD).During a review of Patient 3’s clinical record titled Spiritual Assessment dated 7/21/2025, the Spiritual Assessment indicated an electronic signature from the Director of Patient Care Services (DPCS) to close the note on behalf of the staff assigned and was dated 12/3/2025.During a concurrent interview and record review on 4/1/2026 at 8:11 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 3’s Spiritual assessment dated 7/21/2025 was reviewed. The DPCSD stated and confirmed that Patient 3’s Spiritual Assessment was signed and dated by the DPCS and not the Spiritual Counselor (SC). The DPCSD stated the spiritual assessment should be completed by the SC because the SC would know how to address the patient and/or family’s spiritual needs and make a plan to address them. The DPCSD also stated that the spiritual assessment should be completed within 5 days of SOC, and Patient 3’s spiritual assessment was dated 12/3/2025, which was 5 months after the patient’s SOC, which is a late submission.During a concurrent interview and record review on 4/1/2026 at 8:16 a.m. with the Director of Patient Care Services Designee (DPCSD), Patient 3’s POC/IDG Reviews dated 12/16/2025, 12/30/2025, 1/7/2026 and 1/21/2026 were reviewed. The DPCSD stated and confirmed that Patient 3’s POC/IDG Reviews dated 12/16/2025, 12/30/2025, 1/7/2026 and 1/21/2026 did not have documented evidence of an electronic signature from the MD. The DPCSD stated that the MD is a core member of the IDG and he should attend every meeting. The DPCSD stated that the importance of all IDG core members attending IDG meetings and sign the POC/IDG Review is to validate that the IDG together reviewed and discussed the patient’s POC, agreed on it and signed off on it. During a review of he HA’s Policy and Procedure (P&P) titled Comprehensive assessment, undated, the P&P indicated that a patient comprehensive assessment will be completed by the IDG no later than 5 calendar days after the election of hospice care. During a review of he HA’s Policy and Procedure (P&P) titled Spiritual assessment, undated, the P&P indicated that the spiritual assessment will be completed for each patient/family by the hospice Chaplain. Findings:a. During a review of Patient 8’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 12/22/2025 with diagnoses including Alzheimer’s disease (brain disorder that negatively affects memory, thinking, and behavior severe enough to interfere with daily tasks) and essential hypertension (abnormally high blood pressure [BP, force of the blood pushing against the artery walls]).During a concurrent interview and record review on 4/1/2026 at 8:05 a.m., with the Director of Patient Care Services Designee (DPCSD), Patient 8’s medical form, titled “Comprehensive Nursing Assessment,” dated 12/22/2025, was reviewed. The DPCSD stated there was no documented evidence that the Registered Nurse (RN) signed and dated Patient 8’s “Comprehensive Nursing Assessment,” dated 12/22/2025. The DPCSD stated it was important to ensure valid entries as Patient 8’s “Comprehensive Nursing Assessment” to ensure correct treatments and services are provided based on accurate assessments.During a review of the HA’s policy and procedures (P&P), titled “Entries into the Clinical Record,” dated 2009, the P&P indicated the following:Documentation in the clinical record must be timely, detailed, accurate, and reflect the care or services provided.Signature authorization of clinical documentation must include the staff member’s name and credentials.All entries into the clinical record must reflect the date care was provided, including the month, day, and year.”

“Upon patient record review, 2 of 14 (Patient #7, 9) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 7: The scope and frequency recorded on the plan of care indicated, “RN:1-SFV”. The initial plan of care created 10/16/25 nor any subsequent updates recorded any visit frequency for skilled nursing services despite SN visits completed once weekly since the time of admission. Patient 9: The scope and frequency recorded on the plan of care indicated, “RN:1-SFV”. The initial plan of care created 10/08/25 nor any subsequent updates recorded any visit frequency for skilled nursing services despite SN visits completed once weekly since the time of admission.”

“Upon patient record review 1 of 14 (Patient #9) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 9: The RN nursing visit dated 10/23/25 contained Hospice Aide supervision details. There was no further documented evidence found of the completion of an aide supervisory visit completed by the RN between the 10/23/25 visit and the date of review on 12/04/25.”