Absolute Hospice Inc.

“Based on record review and interview, the Hospice agency failed to (1) ensure all core services participated in the interdisciplinary group (IDG) meeting, (2) update the plan of care (POC) for three of 14 patients (Patient (P)6, P9, and P10), and (3) provide services as identified in the POC for five of 14 patients (Patient (P)4, P5, P8, P9, and P10). These failures had the potential to result in unmet patient and family needs. Findings include:Failed to ensure the Medical Social Work (MSW) attended 11 of 12 interdisciplinary group (IDG) meetings. Refer to L541.Failed to update the POC based on the interdisciplinary group (IDG) review at least every 15 calendar days for three of 14 patients (Patient (P)6, P9, and P10). Refer to L552.Failed to provide services as identified in the plan of care (POC) and updated POC for five of 14 patients (Patient (P)4, P5, P8, P9, and P10). Refer to L555.”

“Based on record review and interviews, the Hospice agency failed to develop and maintain an ongoing quality assessment and performance improvement (QAPI) program. The Hospice agency was unable to produce any documentation to show a functioning QAPI program. This had the potential to impact the quality of care of all patients receiving services from the agency including the current 15 patients. Findings include:The Hospice agency failed to track, measure, and analyze quality indicators that could adversely affect the wellbeing and safety of patients receiving services. Refer to L562.The Governing Body failed to approve the data collected as a part of the agency’s QAPI program and failed to ensure that the agency had a functioning QAPI program. Refer to L565.The Hospice failed to develop or implement a performance improvement project (PIP). Refer to L571.”

“Based on document review, interview, and policy review, the Hospice agency failed to develop and maintain a volunteer program that included volunteer orientation and training, ongoing efforts to recruit volunteers, or meet the minimum requirement that volunteer services equal five percent of total patient care hours. The failure to meet the requirements for the use of volunteers as a part of the hospice program had the potential to affect services available to assist with administrative tasks or help patients and caregivers with tasks not routinely provided by paid hospice employees such as shopping or companionship. Findings include:Failed to develop a hospice volunteer orientation and training program. Refer to L643.Failed to engage in ongoing volunteer recruitment efforts. Refer to L645.Failed to achieve volunteer hours equal to five percent of total patient care hours. Refer to L647.”

“Based on record review and interview, the Hospice agency failed to manage the administration of hospice services to patients and caregivers. The Hospice’s Governing Body failed to ensure a functioning quality assessment performance improvement program (QAPI) was implemented. In addition, the hospice failed to provide services consistent with accepted standards of practice when it did not ensure that the physician was signing orders or the medical social worker (MSW) was completed visit as required. Findings include: The Hospice agency’s Governing Body failed to ensure the agency developed and maintained a functional quality assessment and performance improvement (QAPI) program. Refer to L651. The Hospice agency failed to provide services in a manner consistent with accepted standards of practice as evidenced by there were no signed physician orders and the MSW did not complete visits as ordered in the plan of care (POC). Refer to L652.”

“Based on record review and interview, the Hospice agency failed to ensure the medical record for 14 of 14 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) included appropriately authenticated, signed, and dated physician orders. The Hospice agency also failed to ensure a discharge summary was sent to the attending physician for four of four patients (Patient (P)2, P5, P12, and P13) who signed a revocation of the hospice benefit. This had the potential to affect the care and services for all of the hospice agency patients. Findings include:1. Review of 14 medical records revealed none of the patient plans of care, admission order, written certification, or new medication orders were signed or dated by the Medical Director. (L678)2. Review of the medical record revealed a discharge summary had not been completed or sent to the patients attending physician for the four patients who revoked the hospice benefit (L683)”

“Based on record review and interview, the Hospice agency failed to ensure all members of the interdisciplinary group (IDG) completed the comprehensive assessment within five calendar days after the election of the hospice benefit for five of 14 patients (Patient (P)2, P6, P9, P12, and P14). Failure to complete the comprehensive assessment within five days had the potential for patients not to have physical, psychosocial, spiritual, or financial needs addressed in a timely manner. Findings include:1. Review of P2’s “Misc,” [miscellaneous] tab in the electronic medical record (EMR) revealed P2’s representative signed the “Consent for Election of Medicare/Medicaid Hospice Benefit” (EOB) on 04/12/25. Review of the “MSW” [Master of Social Work] tab revealed an assessment was not completed by the hospice MSW. The EMR did not include documentation that the patient or the patient’s representative refused a visit by the MSW or that the MSW attempted to arrange a visit to complete the social work portion of the interdisciplinary assessment.2. Review of P6’s “Misc,” tab in the EMR failed to show a signed EOB had been uploaded. Review of the “(HOPE [Hospice Outcomes and Patient Evaluation]) RN Initial Assessment,” located in the “Nursing” tab revealed a start of care (SOC) date of 01/19/26. Review of the “MSW” tab revealed a MSW visit had a “Target Date” assigned of 01/23/26 and a “Status” identified as “Not Started.” The EMR did not include documentation that the patient refused a visit by the MSW or that the MSW attempted to arrange a visit to complete the social work portion of the interdisciplinary assessment.3. Review of P9’s “Misc,” tab in the EMR revealed the patient’s representative signed the EOB on 07/20/25 with authorization for the hospice benefit to begin on 07/31/25. Review of the “MSW” tab revealed an assessment was not completed by the hospice MSW. The EMR did not include documentation that the patient or the patient’s representative refused a visit by the MSW or that the MSW attempted to arrange a visit to complete the social work portion of the interdisciplinary assessment.4. Review of P12’s “Misc,” tab in the EMR failed to show a signed EOB had been uploaded. Review of an “Eligibility Check” located in the “Misc” tab showed P12 had Medicare Part A. Review of the “RN Initial Assessment” located in the “Nursing” tab of the EMR showed a SOC date of 03/27/25. Review of the “MSW” tab revealed the MSW visit was not completed until 04/03/25 which is more than five days after the SOC. The EMR did not include documentation of the reason for the delay in the MSW visit or completion of the interdisciplinary assessment.5. Review of P14’s “Misc,” tab in the EMR revealed the patient’s representative signed the EOB with care to begin on 01/07/26. Review of the “Orders” tab in the EMR revealed a physician order “Ok for MSW to see patient and family on 1/14/2026 per patient request.” Review of the “MSW” tab revealed no visit was completed by the MSW and there was no MSW interdisciplinary assessment.During an interview on 01/30/26 at 11:00 AM, the Director of Patient Care Services (DPCS) confirmed that the five patient records did not include an assessment by the MSW and stated, “the patient or family might have refused.” The DPCS confirmed there was no documentation of an attempt by the MSW to schedule the visits. The DPCS also confirmed that the agency was unable to provide a policy regarding the completion of the comprehensive assessment by the IDG. The DPCS stated, “I found some policies from “The Corridor Group dated 2018 but many are missing and I only have the table of contents. I will need to order from them again.””

“Based on document review and interview the Hospice failed to ensure the Medical Social Work (MSW) attended 11 of 12 interdisciplinary group (IDG) meetings. This failure had the potential to affect the care and services provided to six of six patients (Patient (P)6, P8, P9, P10, P13, and P14) who were receiving hospice services between 07/03/25 to 01/16/26 out of a total 14 patients reviewed. Findings include:Based on review of the IDG sign-in sheets, the Hospice MSW did not attend the IDG meeting on 11 of 12 occasions documented between 07/03/25 and 01/16/26. The IDG sign in sheets revealed the following:07/03/25 – MSW signed.07/18/25 – There is a line drawn through the space for MSW signature.08/01/25 – There is a line drawn through the space for MSW signature.08/15/25 – The space for MSW signature is blank.08/27/25 – There is a line drawn through the space for MSW signature.09/26/25 – There is a line drawn through the space for MSW signature.10/08/25 – The space for MSW signature is blank.10/24/25 – The space for MSW signature is blank.11/07/25 – The space for MSW signature shows “Not available.”11/21/25 – The space for MSW signature shows “Not available.”12/05/25 – The space for MSW signature shows “Not available.”01/16/26 – The space for MSW signature shows “Not available.”During an interview on 01/30/26 at 11:00 AM, the Director of Patient Care Services (DPCS) confirmed the above documentation found in the IDG sign-in sheets. The DPCS stated, “Maybe [he/she] called in to the meeting and we didn’t document that.” The DPCS also confirmed that the agency was unable to provide a policy regarding the IDG attendance by the core group to include the nurse, physician, chaplain, and social worker. The DPCS stated, “I found some policies from “The Corridor Group dated 2018 but many are missing and I only have the table of contents. I will need to order from them again.”The MSW was not available for interview.”

“Based on record review and interview, the Hospice agency failed to update the plan of care (POC) based on the interdisciplinary group (IDG) review at least every 15 calendar days for three of 14 patients (Patient (P)6, P9, and P10). Failure to document changes in services and physician orders had the potential to affect the care provided to all patients receiving care from the agency. Findings include: 1. Review of P6’s initial “POC,” dated 04/12/25 located in the “IDG/POC” tab in the electronic medical record (EMR), revealed diagnosis included Alzheimer’s disease, cerebral infarction (stroke), hemiplegia (paralysis that affects one side of the body) and hemiparesis (weakness or reduced motor function on one side of the body), and dysphagia (difficulty swallowing).Review of P6’s “IDG updated POC’s,” located in the “IDG/POC” tab in the EMR revealed the IDG met 04/15/25 and did not meet again or update the POC until 06/06/25. It further revealed that the IDG met on 06/20/25 but did not meet again until 08/01/25.Review P6’s initial “POC,” dated 04/12/25, located in the “IDG/POC” tab, revealed the frequency of services as: skilled nursing (SN) one to two times a week, Medical Social Worker (MSW) one time a month, Hospice Aide one time a week, and Chaplain one time a month.Review of the “MSW” tab in the EMR revealed no visits were completed by the MSW during the time P6 was receiving hospice care. Review of the “Chaplain” tab in the EMR revealed the Chaplain completed visits on 04/15/25, 05/06/25, and 10/20/25. Review of the “Aide” tab in the EMR revealed aide visits were completed two to three times per week. Review of all the P6’s POC updates revealed the POC had not been updated with a change in frequency.Review of P6’s “IDG,” notes located in the “Interdisciplinary Communication History” tab in the EMR revealed the following: a. The “IDG,” note dated 06/06/25 revealed, “Patient with increased difficulty swallowing. New order for thickener. No change in frequency.” Review of the “IDG/POC” dated 06/06/25 failed to show the POC was updated to include thickener.b. The “IDG,” note dated 09/26/25 revealed, “Per [Medical Director] increase Seroquel [an atypical antipsychotic medication] to 4x’s [times] per day instead of 3x’s day.” Review of the “IDG/POC,” dated 09/26/25, failed to show that Seroquel was increased from three times a day to four times a day. 2. Review of P9’s “POC,” dated 07/31/25 located in the “IDG/POC” tab in the EMR revealed diagnosis of heart disease, metabolic encephalopathy (brain dysfunction resulting in symptoms like confusion, seizures, or coma often caused by liver disease, kidney failure, infections, or diabetes), and type two diabetes.Review of P9’s “IDG,” note, dated 08/01/25 located in the “Interdisciplinary Communication History” tab in the EMR, revealed “increase fentanyl to two 25 mcg [micrograms] patches every 72 hours.” Review of the “IDG/POC” dated 08/01/25 revealed the order for fentanyl 25 mcg one patch every 72 hours had not been updated. 3. Review of P10’s “POC,” dated 08/26/25 located in the “IDG/POC” tab in the EMR, revealed diagnosis of squamous cell carcinoma of skin of scalp and neck, heart disease, and end stage renal disease.Review of P10’s “IDG” note, dated 09/26/25 located in the “Interdisciplinary Communication History” tab, in the EMR revealed “increase SN to 7 days a week.”Review of P10’s initial “POC,” dated 08/26/25 located in the “IDG/POC” tab, revealed SN frequency as 21 visits per quarter.Review of P10’s “POC,” dated 09/26/25, revealed the frequency for SN remained 21 visits per quarter.Review of the “Nursing” tab in the EMR revealed the SN was completing visits five days per week, Monday thru Friday, until P10’s death on 10/15/25.During an interview on 01/29/26 at 2:30 PM, the Director of Patient Care Services (DPCS) confirmed that the POCs located in the “IDG/POC” tab are the reviewed and updated POC based on the discussions during the IDG meeting. The DPCS also pointed out and confirmed the IDG notes located in the “Interdisciplinary Communication History” tab are notes dictated during the IDG.During an interview on 01/30/26 at 11:00 AM, the DPCS stated he/she was able to locate some policies in the computer from “The Corridor Group,” dated 2018, but that many policies were missing. The DPCS stated the agency did not have policies addressing IDG or revision of the POC.”

“Based on record review and interview, the Hospice agency failed to provide services as identified in the plan of care (POC) and updated POC for five of 14 patients (Patient (P)4, P5, P8, P9, and P10). Failure to provide services as ordered in the POC had the potential to result in unmet patient needs. Findings include:1. Review of P4’s initial “POC,” located in the “IDG/POC” tab in the electronic medical record (EMR) showed a start of care (SOC) date of 09/16/24. Diagnoses included Unspecified dementia, dysphagia (difficulty swallowing), aphasia (difficulty speaking), and adult failure to thriveThe frequency of visits for the Medical Social Worker (MSW) and Chaplain was identified as one time a month.Review of the “MSW,” visits located in the “MSW” tab and Chaplain visits located in the “Chaplain” tab showed one visit during the first five days of care but no further visits after that.Review of P4’s updated “POC,” located in the “IDG/POC” tab, completed every two weeks during the interdisciplinary group (IDG) meetings, failed to show a change in the frequency for the MSW or Chaplain.Review of the “Discharge – Death,” documentation in the “Nursing” tab in the EMR showed the patient died on 03/25/25. 2. Review of P5’s initial “POC,” located in the “IDG/POC” tab in the EMR showed a SOC date of 10/07/25. Diagnoses included heart failure, atrial fibrillation (common type of heart arrhythmia, characterized by a rapid, chaotic, and irregular heartbeat originating in the heart’s upper chambers), atherosclerotic heart disease (buildup of plaque in the arterial wall), and myocardial infarction (heart attack). The visit frequency on the POC includes: MSW one time a month, Chaplain one time a month, and Hospice Aide one time a week.Review of completed “Aide Visits,” located in the “Aide” tab in the EMR revealed no aide visit during week two of services and two to three visits each week thereafter.Review of MSW visits in the “MSW” tab failed to show that any MSW visits were completed.Review of the “Chaplain,” visits in the “Chaplain” tab showed a completed visit on 04/12/25, 05/06/25, and 10/20/25.Review of P5’s updated POCs located in the “IDG/POC” tab completed during IDG meetings failed to show any change in orders from the original frequency documented or a discussion about change in frequency. 3. Review of P8’s “POC,” located in the “IDG/POC” tab in the EMR showed a SOC date of 07/05/25. Diagnoses included cerebral infarction (stroke), adult failure to thrive, and dysphagia. The visit frequency on the POC revealed hospice aide one time a week.Review of the completed “Aide Visits,” located in the “Aide” tab in the EMR revealed no aide visit during week one and week two of services. The aide completed two visits during the third week of services.Review of the “Discharge – Death,” document located in the “Nursing” tab showed P8 died on 07/19/25. 4. Review of P9’s “POC,” located in the “IDG/POC” tab in the EMR showed a SOC date of 07/31/25. Diagnoses included heart failure, metabolic encephalopathy (broad term for brain dysfunction caused by chemical imbalances such as infections, organ failure, or diabetes), and type two diabetes. The hospice aide frequency on the POC revealed hospice aide services twice a week.Review of the completed “Aide Visits,” located in the “Aide” tab in the EMR revealed no aide visits during week one of services.Review of the “Discharge – Death,” document located in the “Nursing” tab showed P9 died on 08/10/25. 5. Review of P10’s “POC,” located in the “IDG/POC” tab in the EMR showed a SOC date of 08/26/25. Diagnoses included squamous cell carcinoma of skin of scalp and neck, heart failure, and end stage renal disease.Review of the initial POC, dated 08/26/25, revealed MSW frequency for visits was identified as one time per month. Subsequent POC updates completed during the interdisciplinary group (IDG) meetings continued to show MSW frequency as one time a month. Review of the completed MSW visits located in the “MSW” tab in the EMR revealed the MSW completed a visit one time for the assessment on 08/29/25 and no further visits were completed by the MSW.Review of the initial POC revealed no hospice aide frequency was identified. Review of the POC update completed during the IDG meeting, dated 09/26/25, revealed a hospice aide was added once per week. Review of completed hospice aide visits in the “Aide” tab revealed beginning the week of 09/14/25 the hospice aide was completing visits twice a week.”

“Based on document review and interview, the Hospice agency failed to track, measure, and analyze quality indicators that might adversely impact patient care as a part of a quality assessment and performance improvement (QAPI) program. This failure had the potential to affect the care and safety provided to all patients receiving services from the agency. Findings include:During the hospice survey the agency provided a binder identified as the Home Health care QAPI Program. Review of the information and data collection in the binder revealed it only contained information relevant to the Home Health agency and that it did not include quality indicators associated with the Hospice program.During an interview on 01/30/25 at 11:00 AM, the Director of Patient Care Services (DPCS) confirmed that the Hospice agency did not have documentation to show tracking of quality indicators or adverse patient events.”

“Based on document review and interview, the Hospice agency’s governing body did not approve of the data to be collected as a part of the agency’s quality assessment and performance improvement (QAPI) program. The failure of the governing body to ensure a functioning QAPI program had the potential to miss opportunities to improve patient care and safety. Findings include:Review of a binder entitled “Leadership Meetings” which was identified as the agency’s governing body showed it was composed of various members of the hospice agency including the Chief Operating Officer (COO), Director of Patient Care Services (DPCS), Medical Social Worker (MSW), and Medical Director. The documentation did not include any reference to the Hospice agency’s QAPI program or the frequency or detail of data collection to be utilized by a QAPI program.During an interview on 01/30/26 at 10:15 AM, the COO confirmed he/she is the owner of the agency and the information identified as “Leadership Meetings” was the agency’s governing body.During an interview on 01/30/26 at 11:00 AM, the DPCS confirmed that there was no additional information available to show that the Leadership discussed the Hospice agency’s QAPI program.”

“Based on an interview, the Hospice agency failed to develop or implement a performance improvement project (PIP). The failure to identify opportunities to improve performance and implement actions to promote improved outcomes had the potential to compound adverse patient events for all patients receiving care from the agency. Findings include:During an interview on 01/30/26 at 11:00 AM, the Director of Patient Care Services (DPCS) confirmed the hospice agency did not have documentation of a quality assessment performance improvement (QAPI) program and had not identified any PIP specific to the Hospice agency. The DPCS stated he/she was able to locate some policies in the computer from “The Corridor Group” dated 2018 but many policies were missing. The DPCS was unable to locate any policies regarding QAPI or the development of a PIP.”

“Based on an interview, the Hospice agency failed to ensure that Hospice Aides completed 12 hours of in-service training during a 12-month period. This had the potential to affect the safety and quality of care provided to all patients receiving Aide services from the Hospice agency. Findings include:During an interview on 01/30/26 at 11:00 am, the Director of Patient Care Services (DPCS) stated the agency did not provide in-service training to ensure all Hospice Aides completed 12 hours during a 12-month period. The DPCS stated, “They are supposed to do that on their own.” The DPCS confirmed the agency did not have any documentation regarding the Hospice Aide completion of training towards the 12-hour requirement.During this same interview, the DPCS stated the agency was unable to produce a policy regarding the 12-hour training requirement for Hospice Aides.”

“Based on interview and policy review, the Hospice agency failed to develop a volunteer training program. This failure had the potential to affect the ability of volunteers to provide services based on their knowledge of hospice policies and practices. Findings include: During an interview on 01/30/26 at 11:30 AM, the Registered Nurse (RN) 2 confirmed he/she was responsible for the agency’s volunteer program. He/she stated the agency has had one volunteer during the past year and that the agency does not have an orientation or training program. Review of the agency’s policy titled, “Volunteer Coordinator,” job description dated 2018 provided by the agency revealed, “Essential job functions/responsibilities … Develop and maintain volunteer training and orientation program.” Review of the agency’s policy titled, “Volunteer Staff,” job description dated 2018 revealed, “Volunteers attend an orientation program specific to hospice services and the jobs/tasks to be performed.””

“Based on interview and policy review, the Hospice agency failed to show evidence of ongoing efforts to recruit volunteers. Failure to recruit volunteers had the potential to affect services available to assist with hospice administrative tasks or help patients/family with shopping, companionship, or household chores. Findings include: During an interview on 01/30/26 at 11:30 AM, the Registered Nurse (RN) 2 stated he/she had not engaged in any recruitment activities and had only been in the position for a few months. Review of the agency’s policy titled, “Volunteer Coordination,” job description dated 2018 provided by the agency revealed, “Recruits, educates, and selects volunteer from at least three (3) recruitment sessions a year.””

“Based on document review, interview, and policy review, the Hospice agency failed to achieve volunteer services equal to a minimum of five percent of the total patient care hours of all paid hospice staff. Failure to engage volunteers to an extent that meets the minimum requirement had the potential to affect the services available to assist with administrative tasks or help patient/family with supportive activities such as shopping, companionship, or household chores. Findings include:During an interview on 01/30/26 at 11:30 AM, the Registered Nurse (RN) 2 who is responsible for the agency’s volunteer program confirmed that the agency did not meet the requirement during 2025.Review of an agency document titled, “Absolute Hospice Volunteer Hours,” revealed in August 2025 volunteer hours equaled one hour and thirty minutes total which was 3.3% of total patient care hours for that month. The remaining 11 months of 2025 showed zero volunteer hours.Review of the agency’s policy titled, “Documentation of Volunteer Utilization,” dated 2018, revealed, “Monthly and annual statistical reports will determine the percentage of services given by volunteers in relationship to the other discipline … The Volunteer Coordinator will estimate the dollar costs that hospice would have incurred if paid hospice personnel occupied the identified positions.””

“Based on record review and interview, the Hospice agency’s Governing Body failed to ensure the agency developed and maintained a functional quality assessment and performance improvement (QAPI) program. This failure had the potential to affect the quality and safety of patient care services for all patients receiving hospice care. Findings include:Review of a binder labelled, “Leadership Meeting” provided by the agency revealed monthly meetings were held and included attendance by the Chief Operating Officer (COO), Director of Patient Care Services (DPCS), Clinical Supervisor, and Office Manager. Review of documentation present in the “Leadership Meeting” failed to show documentation addressing the Hospice agency requirement to engage in a functional QAPI program.During an interview on 01/28/26 at 9:15 AM, the COO stated that he/she would be considered the “Administrator” per the Center for Medicare and Medicaid Services (CMS) hospice requirements and that he/she was also the owner of the agency.During an interview on 01/30/26 at 11:00 AM, the DPCS confirmed the hospice agency did not have any QAPI documentation for the hospice program.During an interview on 01/28/30 at 12:30 AM, the COO confirmed that the monthly “Leadership Meeting” functions as the hospice agency’s Governing Body.”

“Based on record review and interview, the Hospice agency failed to provide services in a manner consistent with accepted standards of practice. The hospice failed to ensure the Medical Director signed orders for 14 of 14 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) and the Medical Social Worker (MSW) failed to complete services ordered in the plan of care (POC) for three of 14 patient (Patient (P)6, P10, and P14). The agency failed to have policies or procedures to address these issues. These failures had the potential to affect the care and safety of all hospice patients receiving services Findings include:1. Review of the electronic medical record (EMR) for P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14 revealed that there were no orders signed by the Hospice agency’s Medical Director who was overseeing the care and services. Specifically, the EMR did not include signed patient plans of care (POC), medication orders, written certification, or admission orders.2. Review of MSW frequency ordered in the POC and visits completed by the licensed MSW showed the following:a. Review of P6’s initial “Plan of Care Order” (POC) dated 04/15/25, located in the “ Interdisciplinary Group [IDG]/POC” tab in the EMR revealed MSW visit frequency was ordered once a month. Review of P6’s POC for the certification period, dated 07/11/25 to 10/08/25, revealed MSW frequency was ordered for once a month. P6’s POC for the certification period, dated 10/09/25 to 12/07/25, revealed MSW frequency ordered for one time a month.Review of P6’s “(HOPE) Discharge – Death” located in the “Nursing” tab revealed P6 died on 10/21/25Review of P6’s “MSW” tab in the EMR revealed the MSW did not complete any visits for the entirety of P6’s hospice care. Review of the EMR failed to show any documentation of why MSW visits weren’t done or an order to change the frequency or discontinue MSW services.b. Review of P10’s initial POC, dated 08/26/25, located in the “IDG/POC” tab in the EMR revealed MSW visit frequency was ordered once a month.Review of P10’s “(HOPE) Discharge – Death” located in the “Nursing” tab revealed P10 died on 10/15/25.Review of P10’s “MSW” tab in the EMR revealed the MSW completed an initial assessment on 08/29/25. There is no documentation that a MSW visit was completed in September 2025 or in October 2025 prior to P10’s death on 10/15/25. Review of the EMR failed to show any documentation of why MSW visits weren’t done or an order to change the frequency or discontinue MSW services.c. Review of P14’s initial POC revealed a start of care (SOC) of 01/07/26.Review of a verbal “Physician Order,” dated 01/07/26, signed by the DPCS revealed “Ok for MSW to see patient and family on 01/14/26 per patient request.”Review of the “MSW” tab in the EMR revealed an MSW visit was not done during the patients hospice stay.Review of P14’s “(HOPE) Discharge – Death” located in the “Nursing” tab revealed P10 died on 01/17/26.During an interview on 01/30/26 at 11:00 AM, the DPCS confirmed the lack of any physician signatures in the EMR and confirmed the missed MSW visits. The DPCS stated the Hospice agency did not have any policies or procedures related to the requirement for the physician to sign orders or for the completion of visits per the orders identified in the patient’s POC. The DPCS acknowledged that it would be considered a Standard of Practice for physicians to be expected to authenticate orders and for staff to follow physician orders.”

“Based on record review and interview, the Hospice agency failed to ensure the Medical Director who provided the medical oversight failed to sign the “Written Certification” for 14 of 14 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14). This failure had the potential to admit patients for hospice care who may not have met criteria. Findings include:Review of the “Written Certification” for P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14 located in the “Orders” tab of the electronic medical record (EMR) revealed the Medical Director did not sign any of the documents. Further review on 01/30/26 revealed the Medical Director had signed all the documents on 01/29/26 and identified that it was for the specific date each patient was admitted. The signed document was then attached to the unsigned “Written Certification.”During an interview on 01/28/26 at 3:45 PM, the Director of Patient Care Services (DPCS) confirmed he/she was aware the “Written Certification” for each patient was not signed by the Medical Director. He/she stated “Yes, I know but I didn’t have any way to send them to him.” The DPCS stated the Medical Director does come to the interdisciplinary group (IDG) meetings and that he/she “didn’t know how to print them to get a signature.”During an interview on 01/29/26 at 10:40 AM, the Medical Director stated, “I’m not good with computers” when asked why there were no signed and dated “Written Certification(s)” in the EMR.During an interview on 01/30/26 at 11:00 AM, the DPCS stated the agency did not have a policy and procedure regarding the completion of the “Written Certification” or authentication of documentation.”

“Based on record review and interview, the Hospice agency failed to ensure the medical record included signed physician orders for 14 or 14 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14). The failure to have a medical record that included signed physician orders had the potential to affect patient care and services for all hospice patients. The lack of signed physician orders also had the potential to affect the hospice licensed staff who were carrying out orders without the signature of the physician. Findings include:1. Review of P1’s initial “Plan of Care Order”(POC), dated 07/07/25, located in the “Interdisciplinary Group IDG/POC” tab of the electronic medical record (EMR) and subsequent biweekly POCs completed during the (IDG) meetings revealed that none of the POCs included a physician signature.Review of the documents located in the “Orders” tab of the EMR for P1 revealed the following orders did not include a physician signature:a. “Admission Orders,” dated 07/07/25.b. “Written Certification,” dated 07/07/25,c. Physician order for Macrobid (antibiotic) 100 mg twice a day for 10 days, dated 10/04/25.d. Physician order to start Doxycycline 100 mg twice a day for ten days and discontinue Paxlovid related to COVID diagnosis, dated 10/20/252.Review of the documents located in the “Orders” tab of the EMR for P2 revealed the following orders did not include a physician signature:a. “Admission Orders,” dated 01/19/26.b. “Written Certification,” dated 01/19/26.3. Review of P3’s initial POC, dated 09/08/25, located in the “IDG/POC” tab of the EMR revealed it did not include a physician signature. Review of the documents located in the “Orders” tab of the EMR for P3 revealed the following orders did not include a physician signature:a. “Admission Orders,” dated 09/08/25.b. “Written Certification,” dated 09/08/25. 4. Review of P4’s initial POC, dated 09/16/24, located in the “IDG/POC” tab of the EMR and subsequent bi-weekly POCs completed during IDG revealed that none of the POCs included a physician signature.Review of the documents located in the “Orders” tab of the EMR for P4 revealed the following orders did not include a physician signature:a. “Admission Orders,” dated 09/16/25.b. “Written Certification,” dated 09/16/25. 5. Review of P5’s initial POC, dated 10/07/25, located in the “IDG/POC” tab of the EMR revealed it did not include a physician signature.Review of the documents located in the “Orders” tab of the EMR for P4 revealed the following orders did not include a physician signature:a. “Admission Orders,” dated 10/07/25,b. “Written Certification,” dated 10/07/25, 6. Review of P6’s initial POC, dated 04/15/25, located in the “IDG/POC” tab of the EMR and subsequent biweekly POCs completed during IDG revealed that none of the POCs included a physician signature.Review of the documents located in the “Orders” tab of the EMR for P6 revealed the following orders did not include a physician signature:a. “Admission Orders,” dated 04/12/25.b. “Written Certification,” dated 04/12/25.c. Physician Order for PT (Physical Therapy) evaluation for ROM (range of motion), dated 06/13/25.Review of a note, dated 09/26/25, located in the “Interdisciplinary Communication History” in the “IDG Communication” tab for P6 revealed, “Per [Medical Director] increase Seroquel to 4 [four] times a day …” Review of the “Order” tab and the corresponding IDG POC, dated 09/26/25, revealed there was no signed physician order in the EMR. 7. Review of P7’s initial POC, dated 07/28/25, located in the “IDG/POC” tab of the EMR revealed it did not include a physician signature.Review of the documents located in the “Orders” tab of the EMR for P7 revealed the following orders did not include a physician signature:a. “Admission Orders,” dated 07/25/25.b. “Written Certification,” dated 07/25/25. 8. Review of P8’s initial POC, dated 07/05/25, located in the “IDG/POC” tab of the EMR revealed it did not include a physician signature.Review of the documents located in the “Orders” tab of the EMR for P8 revealed the following orders did not include a physician signature:a. “Admission Orders,” dated 07/05/25.b. “Written Certification,” dated 07/05/25. 9. Review of P9’s initial POC, dated 07/31/25, located in the “IDG/POC” tab of the EMR and subsequent biweekly POCs completed during IDG revealed that none of the POCs included a physician signature.Review of the documents located in the “Orders” tab of the EMR for P9 revealed the following orders did not include a physician signature:a. “Admission Orders,” dated 07/31/25.b. “Written Certification,” dated 07/31/25. Review of a note, dated 08/01/25, located in the “Interdisciplinary Communication History” in the “IDG Communication” tab for P9 revealed, “increase Fentanyl to two 25 mcg patches every 72 hours Review of the “Order” tab and the corresponding IDG POC, dated 08/01/25, revealed there was no signed physician order in the EMR. 10. Review of P10’s initial POC, dated 08/26/25, located in the “IDG/POC” tab of the EMR and subsequent bi-weekly POCs completed during IDG revealed that none of the POCs included a physician signature.Review of the documents located in the “Orders” tab of the EMR for P10 revealed the following orders did not include a physician signature:a. “Admission Orders,” dated 08/26/25.b. “Written Certification,” dated 08/26/25.c. “Physician Order,” dated 09/05/25, for Fentanyl Patch 25 mcg every 72 hoursd. “Physician Order,” dated 09/24/25, for flagyl gel 1 tube. Apply to neck wound daily. 11. Review of P11’s initial POC dated 12/22/25 located in the “IDG/POC” tab of the EMR revealed it did not include a physician signature.Review of the documents located in the “Orders” tab of the EMR for P9 revealed the following orders did not include a physician signature:a. “Admission Orders,” dated 12/22/25.b. “Written Certification,” dated 12/22/25. 12. Review of P12’s initial POC, dated 03/27/25, and located in the “IDG/POC” tab of the EMR revealed it did not include a physician signature.Review of the documents located in the “Orders” tab of the EMR for P9 revealed the following orders did not include a physician signature:a. “Admission Orders,” dated 03/27/25.b. “Written Certification,” dated 03/27/25. 13. Review of P13’s initial POC, dated 01/02/26, and located in the “IDG/POC” tab of the EMR revealed it did not include a physician signature.Review of the documents located in the “Orders” tab of the EMR for P9 revealed the following orders did not include a physician signature:a. “Admission Orders,” dated 01/02/26.b. “Written Certification,” dated 01/02/26,14. Review of P14’s “Nursing” tab in the EMR revealed an “RN Initial Assessment” with a start of care (SOC), date of 01/07/26, and a “Discharge – Death” document, dated 01/17/25.Review of the “IDG/POC” tab in the EMR revealed there was no POC completed which would have included physician orders for hospice care and frequency of services in the EMR.Review of the documents located in the “Orders” tab of the EMR for P14 revealed the following orders did not include a physician signature:a. “Admission Orders,” dated 01/07/26.b. “Written Certification,” dated 01/07/26,During an interview on 01/29/26 at 10:40 AM, the Medical Director stated, “I’m not good with computers” when asked why there were no signed physician order in anywhere in the EMR.During an interview on 01/30/26 at 11:00 AM, the Director of Patient Care Services (DPCS) confirmed that none of the POCs or physician orders were signed by the Medical Director. The DPCS also stated that he/she was able to locate some policies in the computer from “The Corridor Group,” dated 2018, but that many policies were missing. The agency was unable to produce a policy addressing physician signing orders.”

“Based on record review and interview, the Hospice agency failed to send a discharge summary to the attending Physician for four of four patients (Patient (P)2, P5, P12, and P13) who revoked Hospice out of 14 total records reviewed. Failure to send a discharge summary had the potential to affect the continuity of care for the patient. Findings include:1. Review of P2’s “(HOPE [Hospice Outcome and Patient Education]) Discharge – Live” dated 01/26/26, located in the “Nursing” tab in the electronic medical record (EMR) revealed, “Reason for Discharge: Discharged – Revoked … Patient full code. Family elected to revoke and call 911.”Review of P2’s EMR failed to show a completed discharge summary sent to P2’s attending physician. 2. Review of P5’s “Hospice Revocation” dated 10/10/25, located in the “Nursing” tab in the EMR as an attachment revealed a box checked showing “Desire to seek treatment not included in my palliative plan of care.”Review of P5’s EMR failed to show a completed discharge summary sent to P5’s attending physician. 3. Review of P12’s “Discharge – Live” dated 04/10/25, located in the “Nursing” tab in the EMR revealed, “Patient Status: Discharge to Home or Self Care … Reason for Discharge: Discharged – Patient moved out of hospice service area … Comments: Patient revocation in order to seek hospital services.”Review of P12’s EMR failed to show a completed discharge summary sent to P12’s attending physician. 4. Review of P13’s “(HOPE) Revocation Statement” dated 01/14/26, located in the “Nursing” tab in the EMR revealed, “Comments: Patient verbalized desire to resume cancer treatment infusions to prolong life and will revoke hospice services at this time. Patient will be transferred back to Home Health services effective immediately.”Review of P13’s EMR failed to show a completed discharge summary sent to P13’s attending physician. During an interview on 01/30/26 at 11:00 AM, the Director of Patient Care Services (DPCS) stated, “I didn’t know we had to send a discharge summary when a patient revoked.” The DPCS also confirmed the agency did not have a hospice policy that addresses patient revocation or the requirement for a discharge summary to be sent to the attending physician.”