AR Hospice Care, Inc.

“Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) for Initial, Comprehensive Assessment (a thorough evaluation process that gathers data from multiple sources) of the patient was met as follows: 1. The HA failed to document in the comprehensive assessments that Patients 1 had stage 3 pressure ulcer (bedsore, tissue damage where the skin is completely broken through exposing the fatty tissue layer) on the sacrum (bone area located at the base of spine) upon admission on 11/19/2025 and Patient 12 had stage 4 pressure ulcer (bedsore where the skin is lost, exposing underlying muscle, tendon or bone) on the left heel upon admission on 7/1/2024 that included location, size, stage, depth, presence or absence of drainage, description of any drainage, description of surrounding tissue and any discomfort to the patient and identify patients’ need related to wound management. These failures had a potential to result in Patient 1 and Patient 12 not receiving the necessary care and wound treatment that could result in Patient 1 and Patient 12 experiencing pain, discomfort, and worsening of the wound that could lead to poor quality of life. (Refer to L524). 2. The HA failed to ensure that a comprehensive assessment, was completed within five (5) days of the start of care to identify the physical, psychosocial , emotional, and spiritual needs for seven of 14 sampled patients (Patient 8, Patient 9, Patient 12, Patient 13 and Patient 14). This failure place Patient 8, Patient 9, Patient 12, Patient 13 and Patient 14 at increased risk of unmet needs unmanaged symptoms, and delays in addressing physical, psychosocial, emotional, and spiritual concerns. (Refer to L523). 3. The HA failed to ensure an initial bereavement (is the physical and mental impact of losing a loved one) assessment was completed for one of 14 sampled patients (Patient 9).This failure had the potential to result in placing Patient 9 and family/caregiver at risk of spiritual, emotional distress and to impact a family members’ abilities to cope with the patients’ death. (Refer to L531). These systemic practices resulted in the failure of the Hospice Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Initial, Comprehensive Assessment of the patient are provided to patients certified to receive home health benefits.”

“Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) for IDG, care planning and coordination of services of the patient was met as follows: 1. The HA failed to develop an individualized plan of care for sacral (bone area located at the base of spine) stage 3 pressure injury (bedsore, tissue damage where the skin is completely broken through exposing the fatty tissue layer) and right knee wound for one of eight sampled patients (Patient 1). This failure had the potential to result in Patient 1 sacral pressure injury worsening and to experience pain and discomfort that could lead to poor quality of life. (Refer to L545). 2. The HA failed to ensure to obtain a physician order for pressure ulcer (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) treatments for two of eight sampled patients (Patient 1 and Patient 12). a. For Patient 1 who was admitted with stage 3 pressure injury (bedsore, tissue damage where the skin is completely broken through exposing the fatty tissue layer) of sacral area (bone area located at the base of spine) and right knee wound. b. For Patient 12 who was admitted with left heel stage 4 pressure ulcer (bedsore where the skin is lost, exposing underlying muscle, tendon or bone). This failure placed Patient 1 and Patient 12 at increased risk for worsening wounds, infection, pain, discomfort, and reduced quality of life. (Refer to L549) 3. The HA failed to ensure the patient’s primary caregiver was involved in developing and implementing the plan of care for one of eight sampled patients (Patient 1). This failure had the potential for Patient 1’s needs and the primary caregiver’s (PCG 1) goals to be unmet, which could result in dissatisfaction with hospice services and possible termination of hospice care. (Refer to L551). 4. The HA failed to ensure the Administrator/Director of Patient Care Services (ADM/DPCS) coordinated the care and treatment needed for the presence of pressure ulcers (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) identified during the initial comprehensive assessment (a thorough evaluation process that gathers data from multiple sources) for two of eight sampled patients (Patient 1 and Patient 12). This failure placed Patient 1 and Patient 12 at increased risk of worsening wounds, infection, pain and discomfort. (Refer to L554). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for IDG, care planning and coordination of services are provided to patients certified to receive home health 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 (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) for Medical Director of the patient was met as follows: a. The HA failed to complete an initial certification of terminal illness (CTI – the first diagnosis or medical condition that a doctor confirms is likely to cause a person’s death within six months) for one of 14 sampled patients (Patient 1). This failure had the potential for Patient 1 to receive services that were insufficient or inappropriate for the patient’s condition. (Refer to L667). b. The HA failed to complete the required recertification CTI at beginning of the certification period (timeframe during physician certifies a patient is terminally ill) for two of 14 sampled patients (Patient 1 and Patient 4). This failure had the potential for Patient 1 and Patient 4 to receive services that were insufficient or inappropriate for their current condition. (Refer to L668). The cumulative effect of these systemic failures resulted in the HA’s inability to ensure medical director oversight necessary to meet statutory (a legal obligation established by a statute or law) and regulatory requirements for patients certified to receive hospice services.”

“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 (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) for Clinical Records of the patient was met as follows: The HA failed to ensure the clinical record included updated comprehensive assessment and clinical notes for eight of eight sampled patients (Patient 1, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L672) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Clinical Records are provided to patients certified to receive home health 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 that a comprehensive assessment (a thorough, mandatory evaluation conducted by a hospice nurse [usually done within five days of admission] to identify the physical, psychosocial [relating to the interrelation of social factors and individual thought and behavior], emotional, and spiritual needs of a patient), was completed within five (5) days of the start of care to identify the physical, psychosocial , emotional, and spiritual needs for seven of 14 sampled patients (Patient 8, Patient 9, Patient 12, Patient 13 and Patient 14) This failure place Patient 8, Patient 9, Patient 12, Patient 13 and Patient 14 at increased risk of unmet needs unmanaged symptoms, and delays in addressing physical, psychosocial, emotional, and spiritual concerns Findings: a. During a review of Patient 8’s record, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 8’s start of care (SOC) date of 12/2/2024 with diagnosis that included Alzheimer’s disease (a progressive, incurable neurological disorder characterized by memory loss, cognitive decline, and behavioral changes due to brain cell damage). During a concurrent interview and record review on 3/20/2026, at 2 PM, Patient 8’s clinical record titled, “Assessment” was reviewed with the Administrator/ Director of Patient Care Services (ADM/DPCS). The clinical record indicated the last comprehensive assessment/reassessment was done on 11/21/2025. The ADM/DPCS confirmed Patient 8 did not have updated assessment since 11/21/2025 and had missing updated assessment for 2026. The ADM/DPCS stated she was unaware that there were no documented updated assessments since last year (2025) and that the assessments should have been done by the registered nurse. b. During a review of Patient 9’s information sheet, the information sheet indicated Patient 9 had a start of care date of 2/17/2026 with diagnosis including heart failure unspecified (a chronic progressive condition in which the heart is unable to pump sufficient blood to meet the body’s needs, resulting in decreased perfusion and flood overload). During a concurrent interview and record review on 3/20/2026 at 2:30 PM, with the Administrator /Director of Patient Care Services (ADM/DPCS) of Patient 9’s clinical record form titled Comprehensive Assessment (a formal evaluation conducted by hospice professionals to identify the emotional, social, spiritual, and cultural needs of a patient’s family and caregivers) “, dated 2/17/2026 to 3/20/2026, indicated pages 3 to 8 of the assessment form had no entries documented. The ADM/DPCS confirmed that the comprehensive Assessment form was incomplete and stated the form should have been completed within five (5) days of start of Care (SOC). c. During a review of Patient 10’s information sheet, the patient information sheet indicated Patient 10 had a start of care date of 3/5/2024 with a diagnosis of Alzheimer’s disease (a progressive neuro-degenerative disorder affecting cognition and functional ability). During a concurrent interview and record review on 3/20/2026 at 2:30 PM, with the ADM/DPCS, Patient 10’s clinical record contained no documented evidence that a comprehensive assessment was completed within five days of the SOC.The ADM/DPCS confirmed the assessment was not completed for Patient 10 as required. d. During a review of Patient 11’s information sheet, the patient information sheet indicated Patient 11 had a start of care date of 9/14/2025, with a diagnosis of Senile degeneration of brain (a progressive condition characterized cognitive decline in neurological impairment). During a concurrent interview and record review on 3/20/2026 at 2:30 PM, Patient 11’clinical records titled “Assessment” was reviewed with the ADM/DPCS. The record indicated there was no documented evidence that a comprehensive assessment or reassessment was completed since start of care (9/14/2025). The ADM/DPCS stated she did not know the reason the assessment was not completed e. During a review of Patient 12’s patient information sheet, the patient information sheet indicated Patient 12 had a start of care date of 7/1/2024 with diagnosis of Alzheimer’s disease (a progressive neuro-degenerative disorder affecting cognition and functional ability). During a concurrent interview and record review on 3/20/26 at 2:30 PM., Patient 12’s clinical record, titled, “Assessment” was reviewed with the ADM/DPCS. There was no record that indicated reassessments were documented for Patient 12. The ADM/DPCS stated there should have been documentation of ongoing reassessments of the left heel wound which should have included documentation of the size, measurements, staging and reassessment of the wound condition. The ADM/DPCS stated,” If it was not documented, it was not done.” f. During a review of Patient 13’s patient information sheet, the patient information sheet indicated Patient 13 had a start of care date of 11/18/2025, with a diagnosis of Alzheimer’s disease (a progressive neuro-degenerative disorder affecting cognition and functional ability). During a concurrent record review with the ADM/DPCS on 3/20 at 2:30 PM the clinical record lacked an initial comprehensive assessment and contained no updated assessments. g. During a review of Patient 14 information sheets, the patient information sheet indicated Patient 14 had a start of care date of 1/13/2025, with a diagnosis of cerebral infarction (interruption of blood flow to the brain causing neurological deficits). During a concurrent interview and record review on 3/20/2026 at 2:30 PM, Patient 14’s clinical record titled “Comprehensive Assessment was reviewed with the ADM/DPCS. The clinical record did not have comprehensive assessment completed for the duration of patient care. The ADM/DPCS stated the assessments should have been completed at the start of care and should be ongoing to identify the patients’ current care needs. During an interview with the ADM/DPCS on 3/20/2026 at 2:30 PM, she stated that the registered nurse was responsible for completing assessments but could not provide evidence that assessments were completed. During a telephone interview with the medical director on 3/20/2026 at 5 p.m., he stated he relied on the Registered Nurse for the assessments and that he assumed the assessments were completed.”

“Based on observation, interview and record review, the Hospice (HA, agency providing care to terminally ill patients who have six months or less to live) failed to conduct an accurate wound assessment and update the comprehensive assessment (a thorough evaluation process that gathers data from multiple sources) that reflected the patients’ current health status and need for hospice care and services related to wound management for two of eight sampled patients (Patient 1 and Patient 12) by failing to: 1. Document in the comprehensive assessments Patients 1 had stage 3 pressure ulcer (bedsore, tissue damage where the skin is completely broken through exposing the fatty tissue layer) on the sacrum (bone area located at the base of spine) upon admission on 11/19/2025 and Patient 12 had Stage 4 pressure ulcer (bedsore where the skin is lost, exposing underlying muscle, tendon or bone) on the left heel upon admission on 7/1/2024 that included location, size, stage, depth, presence or absence of drainage, description of any drainage, description of surrounding tissue and any discomfort to the patient. 2. Obtain physician order and treatment for Patient 1’s stage 3 pressure ulcer on the sacrum and Patient 12’s left heel stage 4 pressure ulcer identified upon admission. 3. Develop and implement a plan of care for Patient 1’s sacral (sacrum, bone area located at the base of spine) pressure ulcer and Patient 12 left heel pressure ulcer. These failures had a potential to result in Patient 1 and Patient 12 not receiving the necessary care and wound treatment that could result in Patient 1 and Patient 12 experiencing pain, discomfort, and worsening of the wound that could lead to poor quality of life. On 3/20/2026 at 12:57p.m., the California Department of Public Health (CDPH) called an Immediate Jeopardy (IJ, a situation in which the provider’s non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) while onsite, in the presence of the Administrator/ Director of Patient Care Services (ADM/DPCS)and Office Manager (OM) related to the hospice agency’s (HA, agency providing care to terminally ill patients who have six months or less to live) failure to conduct and document an accurate comprehensive wound assessment (initial and ongoing) that reflected the patient’s current health status and identify patients’ need for hospice care and services related to wound management for two of 14 sampled patients (Patients 1 and Patient12). On 3/20/2026 3:50 p.m., the HA was unable to submit an acceptable IJ removal plan (IJRP, includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 3/20/2026 at 4 pm, the survey team completed the survey tasks and conducted an exit conference while onsite in the presence of the ADM/DPCS and OM with the IJ situation not being removed. On 3/25/2026 at 10:22 am, the HA submitted an IJ removal plan (IJRP, a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation). The IJ removal plan was reviewed and accepted at 12:05 p.m. On 3/25/2026 p.m. at 3 pm, the IJ was removed while onsite, in the presence of the DPCS and Office Manager after the survey team verified and confirmed the implementation of the IJ removal plan. Findings: a. During a review of Patient 1 “Personal Information” (admission record, summary of patient’s basic information), indicated Patient 1 had a start of care (SOC) date on 11/19/2025, with diagnoses that included congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), type II diabetes mellitus (DM II - a disorder characterized by difficulty in blood sugar control and poor wound healing), and acute pulmonary edema (rapid accumulation of fluid in the lungs). During a concurrent observation and interview on 3/18/2026 at 11:12 am, at Patient 1’s residence at a Board and Care (B&C, a licensed residential home providing continuous non-medical care) while on a joint home visit with Registered Nurse (RN) 1, Patient 1 was alert and oriented to self, and able to verbalize some needs. RN 1 was observed to remove previous dressing on sacral area and measure sacral wound at 3 centimeters (cm, unit of length) by (x) 4 cm x 0.1 cm with 80 % (percent, represents a portion out of 100) slough (dead cells or tissue, acts as a barrier to healing), 20 % granulation tissue (new tissue that forms during wound healing), with minimal serous drainage (clear, thin and watery fluid that drains from the wound). RN 1 stated the sacral wound appears to be stage 3 pressure ulcer. RN 1 measured a wound on left sacral 1.8 cm x 2.0 cm, with 100% granulation, with minimal to no drainage. RN 1 stated Patient 1 was a high risk for skin breakdown due to her co-morbidities (multiple health issues) such as diabetes mellitus and poor nutritional intake. During an interview on 3/18/2026 at 2:06 pm with Licensed Vocational Nurse (LVN) 1. LVN 1 stated every home visit should include a head-to-toe skin assessment to ensure all new and current skin issues were being addressed. LVN 1 stated Patient 1 had multiple wounds on bilateral lower extremities (both legs from hips to toes). LVN 1 stated he only follows what was indicated in Patient 1’s plan of care, that indicated to provide wound treatment on bilateral lower extremities. LVN 1 stated he does not provide wound treatment on Patient 1’s sacral pressure ulcer. During an interview on 3/18/2026 at 2:58 pm with the Director of Patient Care Services (DPCS). The DPCS stated she recalled upon Patient 1’s SOC on 11/19/2025, Patient 1 already had a stage 3 pressure injury, estimated measurement of 4 cm x 5.5 cm with 50% granulation tissue and 50% slough. During a concurrent interview and record review on 3/19/2026 at 11:10 am with the DPCS, Patient 1’s “Comprehensive Assessment”, dated 11/19/2025 was reviewed. The DPCS stated Patient 1 was at high risk for skin impairment. The DPCS stated the skin assessment section did not indicate the presence of sacral pressure injury upon admission. The DPCS stated the assessment was incomplete and did not reflect the actual wound Patient 1 had upon admission. The DPCS stated having an accurate and completed assessment of patients’ wound was important to evaluate patients’ progress or decline. The DPCS stated that without a skin assessment, licensed nurses may not provide treatment and interventions appropriately that may lead to worsening wounds and patient to experience undue pain and discomfort. During a concurrent interview and record review on 3/19/2026 at 11:10 am with the DPCS, Patient 1’s “Skin Impairment Assessment” on 11/21/2025, 12/1/2025, 12/19/2025, 12/29/2025, 1/12/2026, 1/26/2026 were reviewed. The DPCS stated the “Skin Impairment Assessment” were blank. The DPCS stated there was no documented evidence that indicated that the skin assessment for Patient 1 was completed. The DPCS stated skin assessment should include the location of the wound, measurement of the wound, depth, drainage, odor, appearance of the wound and peri-wound area (surrounding area of the wound). The DPCS stated the skin assessment should also indicate what treatment was provided for the wound. During a concurrent interview and record review on 3/19/2026 at 11:40 am with the DPCS, Patient 1’s “Plan of Care/Interdisciplinary Group (IDG, a group of professionals responsible in patients’ holistic care) Review”, dated 12/26/2025, 1/9/2026, 1/23/2026, 2/6/2026, 2/20/2026 and 3/6/2026 was reviewed. The DPCS stated the IDG Review record did not indicate IDG discussion related to Patient 1’s wound progress or treatment. During a concurrent interview and record review on 3/19/2026 at 11:48 am with the DPCS. Patient 1’s “Current Treatment/Medication/DME (durable medical equipment, refers to reusable, doctor prescribed medical devices) List”, for period 2/17/2026 to 5/17/2026 was reviewed. The DPCS stated there was no treatment order for Patient 1’s sacral pressure ulcer and there was no documentation treatment was being provided to Patient 1’s sacral pressure ulcer. During a review of HA’s policies and procedures (P&P), titled “Initial Assessment” dated April 2020. The P&P indicated the following: - “Admitting registered nurse uses an assessment scale/rating tool to assess for problems and to establish a baseline status of each symptom rated. - Admitting registered nurse uses will determine the patients’ and caregivers’ primary concern, goals and immediate care needs. - Admitting registered nurse will gather... orders for specific hospice services and disciplines, treatments and procedures (amount/frequency/duration). - Based on the initial assessment, the plan of care will be initiated on the day of admission” During a review of HA’s P&P, titled “Comprehensive Assessment”, dated April 2020. The P&P indicated the following: - “During the comprehensive assessment, all baseline date and other pertinent information will be documented...a physical assessment including skin and other relevant date related to physical findings and the patient’s terminal illness.” b. During a review of Patient 12’s Patient Information form, indicated Patient 12 was admitted to the hospice agency on 7/1/2024 with diagnoses including Alzheimer’s Disease (a progressive, incurable neurological disorder characterized by memory loss, cognitive decline, and behavioral changes due to brain cell damage). During a review of Patient 12’s POC dated 7/1/2024, the POC indicated for the Skilled Nurse (SN) to assess alteration in skin integrity every visit and to assess change in wound status –check size, integrity, location, type/stage, signs and symptoms of infection, drainage, effectiveness of current treatment for Patient 12. During a review of Patient 12’s current treatment/ medication/ DME list dated 7/1/2024, the record did not indicate an order for treatment for left heel stage 4 pressure ulcer. During a concurrent interview and record review on 3/20/2026, at 10 a.m., Patient 12’s Comprehensive Nursing Assessment, dated 7/1/2024 was reviewed with the Administrator/ Director of Patient Care Services (ADM/DPCS). The ADM/DPCS stated the Comprehensive Nursing Assessment indicated Patient 12 was admitted with healing stage 4 pressure ulcer on left heel but did not indicate wound measurement, presence or absence of drainage, description of surrounding tissue. During an interview on 3/20/2026, at 1:20 p.m., the ADM/DPCS stated she (ADM/DPCS) and the nurses providing care to Patient 12 should have followed the physician’s order and measured Patient 12’s left heel pressure ulcer from the start of care date of 7/1/2024 and all skilled nurses visit afterwards until it healed. The ADM/DPCS stated there was no physician’s order for treatment or POC for the left heel pressure ulcers and that she (ADM) did not know when or if the pressure sore healed due to no documentation of the wounds and stated there should be notes to reflect the visits, care and treatments being provided to patients. The ADM/DPCS stated there was no Skilled Nursing notes in Patient 12’s EMR from the SOC of 7/1/2024 to discharge on 1/6/2026, that indicated the patient was being visited and that Patient 12’s left heel pressure ulcer was being measured/treated per the physician’s order. The ADM/DPCS stated she did not document in the Electronic Medical record due to her not knowing how to document in the EMR and that she documented her visits on paper but unable to provide paper documentation that indicated Patient 12 was being visited and that Patient 12’s left heel pressure ulcer was being measured/treated per the physician’s order. The ADM/DPCS confirmed there were no skilled nurses’ notes in Patient 12’s EMR since the start of Care on 7/1/2024 until 1/6/2026. During a review of HA’s P&P, titled “Initial Assessment” dated April 2020. The P&P indicated the following: -The Hospice Agency must have a system in place to ensure that wound assessment and comprehensive assessment of the skin are being done and documented. - Notify the physician and IDG of any wound deterioration and revise the plan of care accordingly. - “Admitting registered nurse uses an assessment scale/rating tool to assess for problems and to establish a baseline status of each symptom rated. - Admitting registered nurse uses will determine the patients’ and caregivers’ primary concern, goals and immediate care needs. - Admitting registered nurse will gather... orders for specific hospice services and disciplines, treatments and procedures (amount/frequency/duration). - Based on the initial assessment, the plan of care will be initiated on the day of admission” During a review of HA’s P&P, titled “Comprehensive Assessment”, dated April 2020. The P&P indicated the following: - “During the comprehensive assessment, all baseline date and other pertinent information will be documented...a physical assessment including skin and other relevant date related to physical findings and the patient’s terminal illness.””

“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 an initial bereavement (the physical and mental impact of losing a loved one) assessment was completed for one of 14 sampled patients (Patient 9). This failure had the potential to result in placing Patient 9 and family/caregiver at risk of spiritual, emotional distress and to impact a family members’ abilities to cope with the patients’ death. Findings: a. During a review of Patient 9’s information sheet, the patient information sheet indicated Patient 9 had a start of care date of 2/17/2026 with diagnosis of heart failure unspecified (a chronic progressive condition in which the heart is unable to pump sufficient blood to meet the body’s needs, resulting in decreased perfusion and flood overload). During a concurrent interview and record review on 3/20/2026 at 2:30 PM, Patient 9’s clinical record titled “Bereavement Assessment” (a systematic evaluation of the needs of surviving family members conducted both before and at least one year following the death of a hospice enrollee) was reviewed with the Administrator/Director of Patient Care Services (ADM/DPCS). The review revealed no evidence of an initial bereavement assessment for Patient 9. The ADM/DPCS stated that Patient 9 did not have records indicating that an assessment or reassessment of psychosocial or bereavement needs had been completed within five (5) days of the start of care, as required.”

“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 develop an individualized plan of care for sacral (bone area located at the base of spine) stage 3 pressure injury (bedsore, tissue damage where the skin is completely broken through exposing the fatty tissue layer) and right knee wound for one of eight sampled patients (Patient 1). This failure had the potential to result in Patient 1 sacral pressure injury worsening and to experience pain and discomfort that could lead to poor quality of life. Findings: During a review of Patient 1 “Personal Information” (admission record, summary of patient’s basic information), had a start of care (SOC) date of 11/19/2025, with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), type II diabetes mellitus (DM II - a disorder characterized by difficulty in blood sugar control and poor wound healing), and acute pulmonary edema (rapid accumulation of fluid in the lungs). During a concurrent observation and interview on 3/18/2026 at 11:12 AM, at Patient 1’s residence at a Board and Care (a licensed residential home providing continuous non-medical care) while on a joint home visit with Registered Nurse (RN) 1, RN 1 was observed removing dressing on Patient 1’s sacral area and measured sacral wound at 3 centimeters (cm, unit of length) by (x) 4 cm x 0.1 cm with 80 % (percent, represents a portion out of 100) slough (dead cells or tissue, acts as a barrier to healing), 20 % granulation tissue (new tissue that forms during wound healing), with minimal serous drainage (clear, thin and watery fluid that drains from the wound). RN 1 stated the sacral wound appears to be stage 3 pressure ulcer. RN 1 measured a wound on left sacral 1.8 cm x 2.0 cm, with 100% granulation, with minimal to no drainage. RN 1 measured the wound on right knee as 6.0 cm x 3.5 cm, 60% granulation and 40 % slough and eschar (dry, black or brown layer of dead tissue that forms over the wound and impairs healing) with small amount of serosanguinous drainage (mixture of blood and thin clear liquid fluid). RN 1 stated Patient 1 was a high risk for skin breakdown due to her co-morbidities (multiple health issues) such as diabetes mellitus and poor nutritional intake. During a concurrent interview and record review on 3/18/2026 at 10:54 AM with RN 1, Patient 1’s “Plan of Care” (POC), dated 3/17/2026 was reviewed. The POC did not indicate a plan of care to address Patient 1’s sacral pressure injury and right knee wound. RN 1 stated there were no POC developed for Patient 1’s sacral pressure injury and right knee wound. RN 1 stated POC should have been created to ensure interventions were being provided, education to caregivers was given and determined if the wounds were worsening or improving. RN 1 stated Patient 1’s wound may get worse or infected that would lead to Patient 1 to experience pain and discomfort. During a concurrent interview and record review on 3/19/2026 at 11:40 AM, Patient 1’s “Plan of Care/Interdisciplinary Group (IDG, a group of professionals responsible in patients ‘care) Review”, dated 12/26/2025, 1/9/2026, 1/23/2026, 2/6/2026, 2/20/2026 and 3/6/2026 were reviewed with the Administrator/Director of Patient Care Services (ADM/DPCS). The POC/IDG Review under “Updated Nursing Assessment” section did not contain any information. The ADM/DPCS stated the IDG Review record did not indicate IDG discussion related to Patient 1’s wound progress or treatment. The ADM/DPCS stated the “Updated Comprehensive Assessment” should include the discussion of what licensed nurses did during visits, assessments that evaluates Patient 1’s condition and new or ongoing concerns. During a review of HA’s policy and procedure (P&P), titled “The Plan of Care”, dated April 2020. The P&P indicated the following: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care after the consents are signed. The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the cope and frequency of services needed to meet the patient’s and family/caregivers needs, goals and outcome achievement.”

“Based on observation, interview and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients who have six months or less to live) failed to ensure to obtain a physician order for pressure ulcer (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) treatments for two of eight sampled patients (Patient 1 and Patient 12. ) 1. For Patient 1 who was admitted with stage 3 pressure injury (bedsore, tissue damage where the skin is completely broken through exposing the fatty tissue layer) of sacral area (bone area located at the base of spine) and right knee wound. 2. For Patient 12 who was admitted with left heel stage 4 pressure ulcer (bedsore where the skin is lost, exposing underlying muscle, tendon or bone). This failure placed Patient 1 and Patient 12 at increased risk for worsening wounds, infection, pain, discomfort, and reduced quality of life. Findings: a. During a review of Patient 1 “Personal Information” (admission record, summary of patient’s basic information), indicated Patient 1 had a start of care (SOC) date of 11/19/2025, with diagnoses that included congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), type II diabetes mellitus (DM II - a disorder characterized by difficulty in blood sugar control and poor wound healing), and acute pulmonary edema (rapid accumulation of fluid in the lungs). During a concurrent observation and interview on 3/18/2026 at 11:12 am, at Patient 1’s residence, a Board and Care (B&C, a licensed residential home providing continuous non-medical care) while on a joint home visit with Registered Nurse (RN) 1. RN 1 was observed removing the dressing from Patient 1’s sacral wound and measuring the sacral wound as 3 centimeters (cm, unit of length) by (x) 4 cm x 0.1 cm, with approximately 80% slough (dead cells or tissue, acts as a barrier to healing), 20 % granulation tissue (new tissue that forms during wound healing), and minimal serous drainage (clear, thin and watery fluid that drains from the wound). RN 1 stated the sacral wound appeared to be stage 3 pressure ulcer. RN 1 measured an additional left sacral wound as 1.8 cm x 2 cm, with 100% granulation, with minimal to no drainage. RN 1 measured the wound on the right knee as 6 cm x 3.5 cm, with approximately 60% granulation tissue and 40 % slough and eschar (dry, black or brown layer of dead tissue that forms over the wound and impairs healing) with small amount of serosanguinous drainage (mixture of blood and thin clear liquid fluid). RN 1 was observed cleaning the wounds with wound cleanser, applying Silvercel dressing (antimicrobial agent used to treat wounds) and cover with dry dressing. During a concurrent interview and record review on 3/18/2026 at 10:54 AM with RN 1, Patient 1’s “Plan of Care” (POC), dated 3/17/2026, was reviewed. The POC did not include a plan of care to address Patient 1’s sacral pressure injury and right knee wound. RN 1 stated there were no POC developed for Patient 1’s sacral pressure injury and right knee wound. RN 1 stated that a POC should have been created to ensure appropriate interventions were provided, to guide caregiver education, and to evaluate whether the wounds were improving or worsening. RN 1 stated that the absence of a wound specific POC could result in Patient 1’s wounds worsening or becoming infected, leading to pain and discomfort. During a concurrent interview and record review on 3/20/2026 at 10:10 AM with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 1’s “Current Treatment/Medication List”, for period 2/17/2026 to 5/17/2026 was reviewed. The list did not include a wound treatment orders for Patient 1’s sacral pressure injury and right knee wound. The ADM/DPCS stated a supply order for Silvercel dressing was obtained on 1/8/2026; however, the order did not specify which wound it was intended for or how the dressing was to be applied.The ADM/DPCS stated there was no documented evidence of physician-ordered wound treatment for Patient 1’s sacral pressure injury and right knee wound. The ADM/DPCS stated the wound orders must include the wound type, location, the name of medication or treatment to apply and the frequency on how to provide the treatment. The ADM/DPCS stated licensed nurses will not be able to provide the treatment and educate patients and their caregivers on how to care for wound without wound treatment order. The ADM/DPCS stated Patient 1’s wound may worsen and wound may be left untreated causing undue pain and poor quality of life. b. During a review of Patient 12’s “Personal Information” (admission record, summary of patient’s basic information),, indicated a start of care (SOC) date of 7/1/2024, with a primary diagnosis of Alzheimer’s Disease (a progressive, incurable neurological disorder characterized by memory loss, cognitive decline, and behavioral changes due to brain cell damage). During a concurrent interview and record review on 3/20/2026 at 2 p.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 12’s chart was reviewed. The document titled “Assessment” showed no documented evidence of wound assessments or wound treatment for the left heel pressure ulcer. The ADM/DPCS stated that wound measurements, size, staging, and treatment should have been documented at every visit. During a concurrent interview and record review on 3/20/2026 at 2 p.m. with the ADM/DPCS, Patient 12’s clinical record titled, “Nurse Visit Notes,” “Updated Assessments,” and “Physician’s Orders”—were reviewed for the period from the start of care (SOC) on 7/1/2024 through 3/20/2026. The review showed no documented entries of wound assessments, wound measurements, wound treatment, or physician orders for left heel wound care. During a review of HA’s policies and procedures (P&P), titled “The Plan of Care”, dated April 2020. The P&P indicated the following: -The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the cope and frequency of services needed to meet the patient’s and family/caregivers needs, goals and outcome achievement. -The written POC will contain statement of treatment goals, pain and symptom management interventions, drugs and treatments, frequency/amount/duration and type of services provided.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the patient’s primary caregiver was involved in developing and implementing the plan of care for one of eight sampled patients (Patient 1). This failure had the potential for Patient 1’s needs and the primary caregiver’s (PCG 1) goals to be unmet, which could result in dissatisfaction with hospice services and possible termination of hospice care. Findings: During a review of Patient 1 “Personal Information” (admission record, summary of patient’s basic information), the personal information indicated Patient 1 had a start of care (SOC) date of 11/19/2025, with diagnoses that included congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), type II diabetes mellitus (DM II - a disorder characterized by difficulty in blood sugar control and poor wound healing), and acute pulmonary edema (rapid accumulation of fluid in the lungs). During an interview on 3/18/2026 at 12:20 PM with Patient 1’s Primary Caregiver (PCG), PCG 1 stated the HA did not communicate the plans for Patient 1’s care. PCG 1 stated she had requested updates regarding Patient 1’s prognosis (medical professionals educated prediction about the outcome of the disease), requested for joint home visit with Medical Director (MD) and licensed nurse, and an opportunity to speak directly to the MD. PCG 1 stated the lack of communication had been occurring since November 2025. PCG 1 stated she had spoken to Licensed Vocational Nurse 1 (LVN 1), social worker and the Office Manager (OM) regarding her concern to speak to MD to get updates for Patient 1 prognosis. PCG 1 stated she felt like Patient 1 did not receive the services and treatment Patient 1 needed to maintain a quality of life. During an interview on 3/18/2026 at 2:06 PM with LVN 1. LVN 1 stated PCG 1 requested to speak to the MD from his last visit on 2/25/2026. LVN 1 stated he notified the OM and the interdisciplinary group (IDG, a group of professionals responsible in patients’ care) regarding PCG 1 wanted to speak with MD about Patient 1’s prognosis and a joint visit. During an interview on 3/18/2026, at 2:28 PM with the Administrator/Director of Patient Care Services (ADM/DPCS). The ADM/DPCS stated she recalled PCG 1 requested to speak with MD in the beginning of March 2026. The ADM/DPCS stated the MD was notified regarding PCG 1’s request to speak to the MD but did not follow up. During an interview on 3/18/2026 at 2:42 PM with Director of Patient Care Services Designee (DPCS Designee). The DPCS Designee stated she had spoken with PCG 1 regarding the request to speak with the MD back in February 2026. The DPCS Designee stated the MD was notified regarding PCG 1’s request to speak with MD about Patient 1’s prognosis. During a concurrent interview and record review on 3/19/2026 at 11:40 AM, Patient 1’s “Plan of Care/Interdisciplinary Group (IDG, a group of professionals responsible in patients ‘care) Review”, dated 3/6/2026 was reviewed with the Administrator/Director of Patient Care Services (ADM/DPCS). The POC/IDG Review under “Updated Nursing Assessment” section did not contain any information. The ADM/DPCS stated the IDG Review record did not indicate IDG discussion regarding PCG 1’s request to speak with MD regarding Patient 1’s prognosis and request for joint home visit. During a concurrent interview and record review on 3/19/2026 at 1:20 p.m. with the ADM/DPCS, Patient 1’s “Communication Log”, for the service date 2/17/2026 to 5/17/2026 was reviewed. The ADM/DPCS stated there was no documented evidence that PCG 1’s request to speak with MD about Patient 1’s prognosis and a joint visit was in Patient 1’s electronic medical record. The ADM/DPCS stated that communicating with patient caregivers ensures they are involved with patients’ plans of care and aware of patients’ progress and decline of patients. The ADM/DPCS stated any form of communication such as PCG 1’s request to speak with MD about Patient 1’s prognosis and a joint visit should be documented in the “Communication Log” to ensure the concerns were addressed and followed up on. During an interview on 3/19/2026 at 2:15 PM with the Office Manager (OM). The OM stated she received an email from PCG 1 requesting revocation of all hospice services for Patient 1 effective 3/18/2026 due to lack of communication. The OM stated she recalled that PCG 1 had requested to speak to MD at the beginning of March 2026 and stated she was not aware if the MD has contacted PCG 1. During an interview on 3/20/2026 at 4:13 PM with the MD. The MD stated he had not seen Patient 1 since SOC on 11/19/2026. The MD stated he was notified on 3/10/2026 regarding PCG 1’s request to speak to him but has not spoken to PCG 1. The MD stated not being aware of PCG 1’s request, to speak with him regarding Patient 1’s prognosis and request for joint visit that has been ongoing for several months. During a review of HA’s P&P titled “The Plan of Care”, dated April 2020. The P&P indicated the following: The patient and family/caregiver will be encouraged to participate in the development and continued updating of the plan of care. The plan of care will be reviewed and revised as frequently as deemed necessary by the IDG with input from the attending physician, patient and the family/caregiver, based on ongoing comprehensive assessments (a thorough evaluation process that gathers data from multiple sources) of the patient and family/caregiver. The written plan of care will contain patient or representative’s level of understanding, involvement and agreement with the plan of care.”

“Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Administrator/Director of Patient Care Services (ADM/DPCS) coordinated the care and treatment needed for the presence of pressure ulcers (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) identified during the initial comprehensive assessment (a thorough evaluation process that gathers data from multiple sources) for two of eight sampled patients (Patient 1 and Patient 12). This failure placed Patient 1 and Patient 12 at increased risk of worsening wounds, infection, pain and discomfort. Findings: a. During a review of Patient 1 “Personal Information” (admission record, summary of patient’s basic information), indicated Patient 1 had a start of care (SOC) date of 11/19/2025, with diagnoses that included congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), type II diabetes mellitus (DM II - a disorder characterized by difficulty in blood sugar control and poor wound healing), and acute pulmonary edema (rapid accumulation of fluid in the lungs). During a concurrent observation and interview on 3/18/2026 at 11:12 AM, at Patient 1’s residence at a Board and Care (B&C, a licensed residential home providing continuous non-medical care) while on a joint home visit with Registered Nurse (RN) 1, RN 1 was observed to remove dressing on Patient 1’s sacral wound and measured sacral wound at 3 centimeters (cm, unit of length) by (x) 4 cm x 0.1 cm. RN 1 stated the sacral wound had 80% slough (dead cells or tissue, acts as a barrier to healing), 20 % granulation tissue (new tissue that forms during wound healing), with minimal serous drainage (clear, thin and watery fluid that drains from the wound). RN 1 stated the sacral wound appears to be stage 3 pressure ulcer. RN 1 measured a wound on left sacral 1.8 cm x 2 cm, with 100% granulation, with minimal to no drainage. During an interview on 3/18/2026 at 2:06 PM with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Patient 1 had multiple wounds on bilateral lower extremities (both legs from hips to toes). LVN 1 stated he only follows what was indicated in Patient 1’s plan of care, that indicated to provide wound treatment on bilateral lower extremities. LVN 1 stated he did not provide wound treatment on Patient 1’s sacral pressure ulcer. During an interview on 3/18/2026 at 2:42 PM with the Director of Patient Care Services Designee (DPCS Designee). The DPCS Designee stated she was assigned to Patient 1’s care in February 2026 and had seen Patient 1 for home visit twice on 3/10/2026 and 2/1/2026. The DPCS Designee stated Patient 1 did not have sacral pressure ulcer or any wound, and the multiple wounds on Patient 1’s lower extremities were the ones being treated. The DPCS Designee stated wounds should be checked and provided treatment as wounds may worsen overnight and may lead to infection and sepsis (life-threating emergency where the body responds to an infection) that requires hospitalization and patients may experience undue pain and discomfort. During an interview on 3/18/2026 at 2:58 PM with the Administrator/Director of Patient Care Services (ADM/DPCS). The ADM/ADM/ DPCS stated she recalled upon Patient 1’s SOC on 11/19/2025, Patient 1 already had a stage 3 pressure injury, estimated measurement of 4 cm x 5.5 cm with 50% granulation tissue and 50% slough. During a concurrent interview and record review on 3/19/2026 at 11:40 AM with the ADM/DPCS, Patient 1’s “Plan of Care/Interdisciplinary Group (IDG, a group of professionals responsible in patients’ care) Review”, dated 12/26/2025, 1/9/2026, 1/23/2026, 2/6/2026, 2/20/2026 and 3/6/2026 was reviewed. The “Plan of Care/IDG Review” under updated comprehensive assessment nursing section did not contain any information. The ADM/DPCS stated the IDG Review record did not indicate IDG discussion related to Patient 1’s wound progress or treatment. During a concurrent interview and record review on 3/19/2026 at 11:48 AM with the ADM/DPCS, Patient 1’s electronic medical record from 11/19/2025 to 5/17/2026 was reviewed. The ADM/DPCS was unable to provide documented evidence that Patient 1’s sacral stage 3 pressure injury was communicated to other health staff. b. During a review of Patient 12’s Patient Information form, indicated Patient 12 was admitted to the hospice agency on 7/1/2024 with diagnoses including Alzheimer’s Disease (a progressive, incurable neurological disorder characterized by memory loss, cognitive decline, and behavioral changes due to brain cell damage). During a review of Patient 12’s POC dated 7/1/2024, the POC indicated an order for the Skilled Nurse (SN) to assess alteration in skin integrity every visit and to assess change in wound status –check size, integrity, location, type/stage, signs and symptoms of infection, drainage, effectiveness of current treatment for Patient 12. During a review of Patient 12’s current treatment/ medication/ Durable Medical Equipment list dated 7/1/2024, the record did not indicate an order for treatment for left heel stage 4 pressure ulcer. During a concurrent interview and record review on 3/20/2026, at 10 a.m., Patient 12’s Comprehensive Nursing Assessment, dated 7/1/2024 was reviewed with the Administrator/ Director of Patient Care Services (ADM/DPCS). The ADM/DPCS stated the Comprehensive Nursing Assessment indicated Patient 12 was admitted with healing stage 4 pressure ulcer on left heel but did not indicate wound measurement, presence or absence of drainage, description of surrounding tissue. During an interview on 3/20/2026, at 1:20 p.m., the ADM/DPCS stated she (ADM/DPCS) and the nurses providing care to Patient 12 should have followed the physician’s order and measured Patient 12’s left heel pressure ulcer from the start of care date of 7/1/2024 and all skilled nurses visit afterwards until it healed. The ADM/DPCS stated there was no physician’s order for treatment or POC for the left heel pressure ulcers and that she (ADM) did not know when or if the pressure sore healed due to no documentation of the wounds and stated there should be notes to reflect the visits, care and treatments being provided to patients. The ADM/DPCS stated there was no Skilled Nursing notes in Patient 12’s EMR from the SOC of 7/1/2024 to discharge on 1/6/2026, that indicated the patient was being visited and that Patient 12’s left heel pressure ulcer was being measured/treated. The ADM/DPCS stated she did not document in the Electronic Medical record due to her not knowing how to document in the EMR and that she documented her visits on paper but unable to provide paper documentation that indicated Patient 12 was being visited and that Patient 12’s left heel pressure ulcer was being measured/treated. The ADM/DPCS confirmed there were no skilled nurses’ notes in Patient 12’s EMR since the start of Care on 7/1/2024 until 1/6/2026. The ADM/DPCS stated there was no documented evidence of communication between disciplines and no coordination of services was done to ensure continuity of care for Patient 12’s left heel pressure ulcer. During a review of HA’s policies and procedures (P&P), titled “IDG Plan of Care”, dated April 2020. The P&P indicated the following: -It will be the responsibility of the Case Manager to facilitate communication about changes in the patient’s status between IDG members and the patient’s attending physician. -The HA’s personnel will communicate changes in a timely manner via telephone, one-to-one meetings, IDG meetings, and home visits. Documentation of all communications will be included in the clinical record on a communication note, IDG form and/or clinical note. During a review of the DPCS’ “Job Description”, signed 1/29/2021. The “Job Description” indicated essential job function includes coordinates and oversees all direct and indirect patient services provided by clinical organization personnel.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to complete an initial certification of terminal illness (CTI – the first diagnosis or medical condition that a doctor confirms is likely to cause a person’s death within six months) for one of 14 sampled patients (Patient 1). This failure had the potential for Patient 1 to receive services that were insufficient or inappropriate for their current condition. Findings: During a review of Patient 1 “Personal Information” (admission record, summary of patient’s basic information), indicated Patient 1 had a start of care (SOC) date of 11/19/2025, with diagnoses that included congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), type II diabetes mellitus (DM II - a disorder characterized by difficulty in blood sugar control and poor wound healing), and acute pulmonary edema (rapid accumulation of fluid in the lungs). During a concurrent interview and record review on 3/20/2026 at 4:13 PM with Medical Director (MD), Patient 1’s ‘Physician’s Certification for Hospice Benefits” (CTI), dated 11/19/2026 was reviewed. The MD stated Patient 1’s CTI was assigned to him, however, the physician narrative contained no information, and the document was unsigned. The MD stated the CTI certifies that a patient has a life expectancy of six months or less if the terminal illness runs its natural course. The MD stated he was unaware Patient 1 had been assigned to him and confirmed he had not verified Patient 1’s eligibility for hospice services by completing a face‑to‑face assessment or reviewing Patient 1’s past medical history since the SOC (11/19/2025). During a review of HA’s policies and procedures (P&P), titled ‘Certification of Terminal Illness’, dated April 2020. The P&P indicated the following: - At the time of admission to hospice, the hospice MD or the patient’s attending physician will complete a certification narrative that reflects the patient’s individual circumstances based on his/her review of the patient’s medical record or examination of the patient. - The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to complete the required recertification CTI (certification of terminal illness, the first diagnosis or medical condition that a doctor confirms is likely to cause a person’s death within six months) at beginning of the certification period (timeframe during physician certifies a patient is terminally ill) for two of 14 sampled patients (Patient 1 and Patient 4). This failure had the potential for Patient 1 and Patient 4 to receive services that were insufficient or inappropriate for their current condition. Findings: a. During a review of Patient 1 “Personal Information” (admission record, summary of patient’s basic information), had a start of care (SOC) date of 11/19/2025, with diagnoses that included congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), type II diabetes mellitus (DM II - a disorder characterized by difficulty in blood sugar control and poor wound healing), and acute pulmonary edema (rapid accumulation of fluid in the lungs). During a concurrent interview and record review on 3/20/2026 at 4:13 p.m. with the Medical Director (MD), Patient 1’s “Physician’s Certification for Hospice Benefits” (CTI) for the certification period 2/17/2026 to 5/17/2026 was reviewed. The MD stated the CTI was assigned to him; however, the physician narrative contained no information, and the document was unsigned. The MD stated the CTI certifies that a patient has a life expectancy of six months or less if the terminal illness runs its normal course. The MD stated he was unaware that Patient 1 had been assigned to him and confirmed he had not verified Patient 1’s hospice eligibility through a face‑to‑face assessment or by reviewing Patient 1’s medical history since the SOC date (11/19/2025). b. During a review of Patient 4 “Personal Information”, indicated patient 4 had a SOC date of 3/14/2024, with diagnosis of Alzheimer’s disease (a progressive, incurable neurological disorder characterized by memory loss, cognitive decline, and behavioral due to brain cell damage). During a concurrent interview and record review on 3/20/2026 at 4:18 PM with MD, Patient 4’s ‘Physician’s Certification for Hospice Benefits” (CTI), for the certification period number twelve (12) from 3/4/2026 to 5/2/2026 was reviewed. The MD stated he was assigned to review Patient 4’s hospice eligibility. The MD stated he had not scheduled a face‑to‑face visit to evaluate whether Patient 4 remained eligible for hospice benefits. The MD stated that having a diagnosis of Alzheimer’s disease alone does not necessarily qualify a patient for hospice and that the patient must be evaluated for appropriateness. During a review of HA’s policies and procedures (P&P), titled “Certification of Terminal Illness”, dated April 2020. The P&P indicated thsa subsequent recertification, at the beginning of each new benefit period, the HA’s MD must compose and sign the narrative based on a review of patient’s medical record, or review examination of the patient.” During a review of the Hospice Agency’s policies and procedures (P&P), titled “Certification of Terminal Illness,” dated April 2020, the P&P indicated that a subsequent recertification at the beginning of each new benefit period must be composed and signed by the hospice medical director based on review of the patient’s medical record or examination of the patient. During a review of the P&P titled “Face-to-Face Encounter,” revised April 2020, the P&P indicated: • A face‑to‑face encounter must be performed for patients entering the third and all subsequent benefit periods. • The hospice physician or hospice‑employed nurse practitioner (NP) must perform the face‑to‑face encounter within 30 days prior to recertification for the third and subsequent benefit periods. • During the face‑to‑face encounter, the hospice MD or NP must gather and document clinical findings to determine continued hospice eligibility.”

“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 clinical record included updated comprehensive assessment and clinical notes for eight of eight sampled patients (Patient 1, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) This failure had the potential to leave staff unaware of Patient 1, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14’s clinical status and changes, risking avoidable pain, ineffective interventions, and diminished quality of life. Findings: a. During a review of Patient 1 “Personal Information” (admission record, summary of patient’s basic information), had a start of care (SOC) date on 11/19/2025, with diagnoses that included congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), type II diabetes mellitus (DM II - a disorder characterized by difficulty in blood sugar control and poor wound healing), and acute pulmonary edema (rapid accumulation of fluid in the lungs). During an interview on 3/18/2026 at 2:42 PM with the Director of Patient Care Services Designee (DPCS Designee), the DPCS Designee stated she was responsible for updating the Plan of Care/Interdisciplinary Group (POC/ IDG, team-based approach structured for individualized roadmap for managing the care of patients with terminal illnesses) review record for Patient 1 but had not attended the Interdisciplinary Group (IDG, team of healthcare professionals who work together to develop an individualized plan for the patients and support the families) meeting since January 2026 and does not update Patient 1’s IDG review if absent. The DPCS Designee stated the “Plan of Care/ IDG Review” should document patient changes/decline, effectiveness of interventions, and risks. The DPCS stated that failure to update the comprehensive assessment could result in Patient 1 experiencing avoidable pain that may lead to poor quality of life. During an interview on 3/19/2026 at 11 AM, the Administrator/Director of Patient Care Services (ADM/DPCS). The ADM/DPCS stated the IDG consists of the medical director, registered nurse, the chaplain and social worker meet every other week to review Patient 1’s electronic medical records including visit notes, assessments, plan of care, medication and treatment. The ADM/DPCS stated that the IDG meeting is held to assist in coordinating Patient 1’s progress or decline and if the treatments and services being provided to patients are effective. During a concurrent interview and record review on 3/19/2026 at 11:40 AM with the ADM/DPCS, Patient 1’s “Plan of Care/ IDG Review”, dated 12/26/2025, 1/9/2026, 1/23/2026, 2/6/2026, 2/20/2026 and 3/6/2026 were reviewed. The ADM/DPCS stated the IDG Review under “Updated Comprehensive Assessment” nursing section was blank and did not contain any information. The ADM/DPCS stated the “Updated Comprehensive Assessment” should include the discussion of what licensed nurses did during visits, assessments that evaluates Patient 1’s condition and new or ongoing concerns. The ADM/DPCS stated the Medical Director and herself did not sign the IDG meeting. The ADM/DPCS stated the IDG should sign the “Plan of Care/ IDG Review” form to attest review and awareness of what was discussed during the meeting. During a review of HA’s policies and procedures (P&P), titled “Contents of Clinical Record”, dated April 2020. The P&P indicated a clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to accurately document care provided and results in detail and facilitate continuity of care among hospice IDG members and contact personnel.” During a review of HA’s P&P, titled “IDG Meeting”, dated April 2020. The P&P indicated the following: - The IDG group will meet on regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, changes in patients’ circumstances. - Members at the IDG meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor. - An IDG meeting plan of care update form will be used for update of the patient and family/caregiver and the attending physician. It will note changes, response to treatment and progress towards targeted outcomes. b. During a review of Patient 8’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 8’s start of care (SOC) on 12/2/2024 with diagnoses that included Alzheimer’s disease (a progressive, incurable neurological disorder characterized by memory loss, cognitive decline, and behavioral changes due to brain cell damage). During a concurrent interview and record review with the Administrator/Director of Patient Care Services (ADM/DPCS) on 3/20/2026 at 2:30 p.m., Patient 8’s clinical record titled “Nurse Visit Notes” from 12/24/2024 to 3/20/2026 was reviewed. The record indicated that skilled nursing visits had been conducted since the patient’s start of care (12/2/2024); however, there was no documentation of Patient 8’s condition, interventions provided, or monitoring performed in the visit notes. The ADM/DPCS reviewed the record and confirmed that no skilled nursing visit notes were present in Patient 8’s clinical record and stated that the documentation “should be there.c. During a review of Patient 9’s “Patient Information Report,” the “Patient Information Report” indicated Patient 9’s start of care (SOC) date of 2/17/2026, with diagnoses including heart disease, unspecified (a general medical term used for heart conditions, but diagnostic documentation lacks sufficient detail to classify it into a specific type). During a concurrent interview and record review with the ADM/DPCS on 3/20/2026 at 2 p.m., Patient 9’s clinical record titled “Bereavement” was reviewed. The review indicated no bereavement assessment (a required evaluation of the needs of the surviving family before and for at least one year after the death of a hospice enrollee) was reviewed. The ADM/DPCS confirmed the missing documentation and stated that the bereavement assessment should have been completed within five days of the SOC. During a concurrent interview and record review with the ADM/DPCS on 3/20/2026 at 2:10 p.m., Patient 9’s clinical record titled “Skilled Nurse Visit” was reviewed. The review indicated no documented skilled nursing visit notes since the SOC of 2/17/2026. The ADM/DPCS confirmed the absence of skilled nursing documentation and stated that nurses should document at every visit. During concurrent interview and record review with the ADM/DPCS at 2:15 p.m., Patient 9’s clinical record titled “Comprehensive Assessment,” dated 2/17/2026, was reviewed. The initial comprehensive assessment was incomplete and lacked required documentation including, but not limited to:• Vital signs and measurements – not documented• Patient/Caregiver section – not documented• Mobility section – not documented• Nature and Condition of Terminal Illness/LCD Eligibility – not documented• Head to toe assessment – not documented• Cardiovascular section – not documented• Gastrointestinal and nutrition section – not documented• Visiting Registered Nurse Narrative – not documented• Additional required assessment components – not documented There was no documented evidence of any skilled nursing visit notes in the clinical record since the SOC. The ADM/DPCS confirmed the missing entries in the comprehensive assessment and confirmed that no skilled nursing visit notes had been documented since the SOC.c. During a review of Patient 10’s “Patient Information Report”, the report indicated Patient 10’s SOC date of 3/5/2024 with diagnoses that included Alzheimer’s disease (a progressive, incurable neurological disorder characterized by memory loss, cognitive decline, and behavioral changes due to brain cell damage). During a concurrent interview and record review with the ADM/DPCS on 3/20/2026, at 2:39 pm., Patient 10’s clinical record titled,” Nurse Visit Notes” was reviewed. The record indicated that skilled nursing visits had occurred since the SOC (3/5/2024; however, there were no skilled nursing visit notes documenting Patient 10’s condition, interventions provided, or monitoring performed. The ADM/DPCS confirmed the absence of skilled nursing visit notes in Patient 10’s record. During a concurrent interview and record review with the ADM/DPCS on 3/20/2026, at 2:45 pm., Patient 10’s clinical record titled, “Assessment” for 8/14/2024 and 8/21/2024 was reviewed. The updated assessments dated 8/14/2024 and 8/21/2024 contained no entries. The ADM/DPCS confirmed that no documentation had been entered in these assessments and stated that staff “should document.” d. During a review of Patient 11’s “Patient Information Report,” the “Patient Information Report” indicated Patient 11’s start of care (SOC) on 9/14/2025 with diagnosis including Alzheimer’s disease (a progressive, incurable neurological disorder characterized by memory loss, cognitive decline, and behavioral changes due to brain cell damage). During a concurrent interview and record review with the ADM/DPCS on 3/20/2026, at 2pm., of Patient 11’s clinical record titled, “Assessment and Nurse Visit” was reviewed. The record indicated no documented comprehensive assessment, no updated assessments, and no skilled nursing visit notes in the patient’s chart since the SOC 9/14/2025. The ADM/DPCS confirmed the missing and incomplete documentation and stated that the skilled nurse “should document at every visit.” e. During a review of Patient 12’s “Personal Information”, indicated a start of care (SOC) date of 7/1/2024, with a primary diagnosis of Alzheimer’s Disease. During a concurrent interview and record review with the ADM/DPCS of Patient 12’s chart on 3/20/2026, at 2 pm., Patient 12’s clinical record titled “Assessment” was reviewed from SOC 7/1/2024 to 1/6/2026. The review indicated no documented wound assessments and no documented treatment of the patient’s left heel wound. The ADM/DPCS stated that wound measurements, size, staging, and treatment should have been documented at every visit. During a concurrent interview and record review with the ADM/DPCS on 3/20/2026, at 2 pm, Patient 12’s Physician’s order from 7/1/2024 to 1/6/2026 were reviewed. The records indicated no physician orders for left heel wound care. The ADM/DPCS confirmed that the facility failed to obtain physician order for the left heel wound. During a concurrent interview and record review with the ADM/DPCS on 3/20/2026 of Patient 12’s clinical record titled,” Nurse Visit” from 7/1/2024 to 1/6/2026. The review indicated no skilled nursing visit documentation and no documented evidence of nursing services addressing the left heel wound since the SOC. The ADM/DPCS stated she was not aware of the missing entries and that staff should document every visit. f. During a review of Patient 13’s “Patient Information Report,” the “Patient Information Report” indicated Patient 13’s start of care (SOC) date of 11/18/2025 with diagnoses that included End Stage Senile Dementia (the final, irreversible phase of neurodegenerative diseases where cognitive and physical functions decline severely. Patients become entirely dependent for daily care, often losing the ability to walk, speak, eat, or recognize loved ones). During a concurrent interview and record review with the ADM/DPCS on 3/20/2026, at 2pm., Patient 13’s clinical record titled, “nurse Visits” from 7/1/2024 to 1/6/2026 were reviewed. The review indicated no documented skilled nursing visit notes since the SOC of 7/1/2024 to 1/6/2026. There was no documentation of Patient 13’s condition, interventions, or ongoing evaluations. The ADM/DPCS reviewed the record and confirmed the absence of documentation. g. During a review of Patient 14’s “Patient Information Report,” the “Patient Information Report” indicated Patient 14’s start of care (SOC) date of 1/13/2025 with diagnoses including cerebral infarction (medical emergency caused by blocked blood flow to the brain). During a concurrent interview and record review with the ADM/DPCS on 3/20/2026, at 2pm., Patient 14’s clinical record titled, Nurse Visit was reviewed from 1/13/2025 to 3/202/2026. The review indicated no documented skilled nursing visit notes in the record since the SOC date of 1/13/2025. There was no documentation of Patient 14’s condition, interventions provided, or ongoing evaluations. The ADM/DPCS stated the nurses were responsible for documentation at every visit. The ADM/DPCS stated that some visit may not have been documented and acknowledge that records had not been routinely audited.”

“Upon patient record review, 3 of 5 (Patients #1,2,5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: The MSW visit on 6/18/25 and the SC visit on 6/20/25 did not have evidence of signature(s) by either discipline. Patient #2: The SC visit on 7/2/25 did not have evidence of a signature for this discipline. Patient #5: The RN visit on 7/11/25 did not have evidence of a signature for this discipline.”

“Upon patient record review and home visit, 1 of 14 (Patient #3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #3 did not have evidence that the medications the caregiver was administering were consistent with the medications on the current medication profile. The following medications were presented by the caregiver in the patient’s home and were not on the hospice medication profile: Salonpas Pain Patch, Bisoprolol-fumarate 5mg at bedtime. Caregiver states patient was diagnosed with a “medication reaction to Amlodipine 5mg which was discontinued that same visit”. Amlodipine remained on hospice medication profile. The following medications were on the hospice medication profile and were not able to be found during the home visit: Percocet 5mg-325mg tablet. and Promethazine Dm 6.25mg (15mg/5ml) syrup.”

“Upon patient record review, 2 of 14 (Patient #1, 3) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #1 Order frequencies: RN 1 every 2 weeks, SN 1 every week. Documentation of April 2025 visits as follows: RN visit 4/05 only with next RN visit was 5/03. Patient #3 Order frequencies: SN 1 every week. Documentation of visits for current certification period #3 (4/14-6/12) as follows: 3/28 “missed” 4/18 RN, 5/02 RN, no further nursing visits documented as of day of survey.”

“Upon observation, there was no evidence the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. Patient #9 The initial IDG meeting 9/13/24 and 9/20/24 had only RN contribution and signature. No evidence the IDG was composed of all individuals to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient.”

“Upon patient record review, 2 of 14 (Patient #11,13) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient#11 On 2/20/25-a communication note reporting, ”call from Board & Care staff reporting multiple episodes of diarrhea. Physician notified, new order for Imodium” There was no evidence of a follow-up visit. In addition, a PRN visit for change in condition on 3/14 the RN narrative had well-described decline that certainly denoted a transition phase for patient. There was no increase in visit frequency. No further visits or Communication notes found in record. Discharge summary stated, “Patient expired at 11:15pm on 03/17/25 per report given by board and care staff. MD and IDT informed.” Patient #13 Communication note 1/03/25 stated, “Board and care manager reports no food intake since 12/31/24. Nurse will visit this afternoon. Comfort Kit ordered.” The next visit documented by nurse was on 1/07/25. Patient passed 1/09/25.”

“Upon patient record review, 2 of 14 (Patient #3,7) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #3 The following medications were presented by the caregiver in the patient’s home and were not on the POC. Salonpas Pain Patch, Bisoprolol-fumarate 5mg at bedtime. Caregiver states patient was diagnosed with a “medication reaction to Amlodipine 5mg which was discontinued that same visit”. Amlodipine remained on the hospice POC. Patient #7 Plan of care shows order for “Albuterol solution 0.083% , inhalation as needed for wheezing”. No frequency listed.”

“Upon patient record review, 7 of 14 (Patient #1,2,3,4,5,11,12) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient’s condition requires but no less frequently then every 15 calendar days. Patient #1 No MD signature for IDG meeting 5/02/25, 5/16/25. The disciplines were actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation. Patient #2 No MD signature for IDG meetings, 2/07/25, 02/21/25, 3/07/25, 3/21/25,4/18/25, 5/02/25, 5/16/25. No Nurse contribution or signature 3/21/25. No SC signature or contribution 2/07/25. The disciplines were actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation. Patient #3 No MD signature for IDG meeting 5/16/25, No RN contribution or signature 5/02/25. The disciplines were actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation. Patient #4 No RN contribution or signature 5/02/25. The disciplines were actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation. Patient #5 IDG 5/16/25 had only RN contribution and signature. The disciplines were actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation. Patient #11 Documentation showed IDG meetings on 2/07/25 and 02/21/25 no further IDG documented. Patient expired 03/17/25 and no discussion of death/bereavement at any further IDG meetings. The disciplines were actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation. Patient #12 No MSW signature for IDG meetings 01/1/25 or 1/10/25. The disciplines were actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation.”

“Upon patient record review, 2 of 14 (Patient #11,13) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient#11 On 2/20 Board & Care reported multiple episodes of diarrhea which agency obtained order for Imodium, on 3/6/25 noted Board & Care request medication for patient N/V and agency obtained order for Zofran, and on 3/14 RN narrative noted well-described decline in patient however, there was no evidence of updates of problems/goals/interventions to the POC for all patient needs. Patient #13 Communication note 1/03/25 stated, “Board and care manager reports no food intake since 12/31/24. Nurse will visit this afternoon. Comfort Kit ordered.” The next visit documented by nurse was on 1/07/25. Patient passed 1/09/25. No evidence of updates of problems/goals/interventions to the POC”

“Upon patient record review, 5 of 14 (Patient #1,3,5,10,11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 Order frequencies not followed: RN 1 every 2 weeks, SN 1 every week. Visits documented for April 2025 visits as follows. RN visit 4/05/25 with next RN visit 5/03. LVN visit 4/11 and 4/25. Patient #3 Order frequencies not followed: SN 1 every week. Visits documented 3/28 “missed” LVN, 4/10 LVN, 4/18 RN, 5/02 RN, no further nursing visits documented as of day of survey. Patient #5 Order frequencies not followed: LVN 1 every week. Documentation of LVN visits: 2/26, 3/24, 4/07, 4/21, 5/09, and 5/19. Patient #10 Order frequencies not followed: SN 1 every week. Visits documented 1/31/25, 2/12, there were no SN visits documented the week of 2/3. Patient #11 Order frequencies not followed: There were no SN visits documented the week of 02/09-02/15, the LVN was ordered 1 per week and 3 prn change of condition. In addition, there were no LVN visits documented the week of 3/2 and 3/15.”

“Upon patient record review, 5 of 14 (Patient #10,11,12,13,14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #10,11,12,13,14 Did not have evidence of a Bereavement Plan of Care that was updated after death, there was only a spreadsheet in the office showing mailings.”

“Upon personnel record review, 1 of 14 (Personnel #4) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #4 Competency observed “shower/tub bath” (not specified whether both methods observed, unclear) aide competency did not include “sponge bath”. Competency only states, “shampoo” and did not observe this care in a “Sink, Tub, and bed”.”

“Upon patient record review, 6 of 14 (Patient #1,3,4,6,9,10) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: RN 3/8/25, 3/27, 3/29, 4/05, 5/03, 5/17 and LVN 4/11, 4/25, visit notes without evidence of a signature. Patient #3: RN 5/02/25, visit notes without evidence of a signature. Patient #4: RN 4/16/25, 4/30, 5/14, visit notes without evidence of a signature. Patient #6: RN 5/01/25, 5/15, visit notes without evidence of a signature. Patient #9: Initial SW assessment and Bereavement Risk Assessment 9/14/24 not signed. Patient #10: Initial Bereavement Risk Assessment 1/16/25 not signed.”

“Upon patient record review, 2 of 14 (Patient #8, 9) did not have evidence that the discharge summary includes all required information. Patient #8 Documentation states reason for discharge as “Revocation”. The discharge summary, dated 01/31/25 states, “Family decided to bring patient to the hospital. Seeking aggressive treatment. MD and IDT aware.” No other information documented in discharge summary. Patient #9 Documents reason for discharge as “Revocation”. The discharge summary, dated 10/02/24 states, “Patient caregiver called AR Hospice that patient was brought to hospital. MD and IDT informed.” No other information documented in discharge summary.”