Hospice and Palliative Care of California, 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 Conditions of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]), regarding Initial and Comprehensive Assessment of the Patient was met as follows: 1. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after election of hospice care for four of 28 sampled patients (Patient 1, Patient 11, Patient 17, and Patient 22). This failure had the potential to result in patients not being properly evaluated, which could have resulted in them not providing individualized focused care (Refer to L523). 2. The HA failed to ensure the comprehensive assessments accurately reflected the patient’s current health condition related to hospice eligibility and management of terminal illness and identified the patients need for hospice care and services for seven of 11 active sample patients (Patient 1, Patient 10, Patient 16, Patient 17, Patient 22, Patient 23, and Patient 24). As a result, Patient 1, Patient 10, Patient 16, Patient 17, Patient 22, Patient 23, and Patient 24 have the potential to experience a decline in health that could lead to serious harm, hospitalization, and death due to not having proper medical oversight and access to needed specialist, medications, and medically necessary treatments, and have the potential to lose their hospice eligibility/hospice benefits and not receive hospice care when needed and eligible in the future. (Refer to L525). 3. The HA failed to ensure the HA staff review all the medications and update the medication profile with currently used medications for three of 28 sampled patients (Patient 1, Patient 16, and Patient 22). This failure had the potential to result in Patient 1, Patient 16, and Patient 22 were put at risk for medication errors and adverse drug reactions. (Refer to L530). 4. The HA failed to ensure five of 28 sample patients (Patient 1, Patient 8, Patient 9, Patient 11, and Patient 14) families/caregivers were provided with a bereavement assessment. This failure had the potential to result in patient family/caregivers having pain and suffering due to the grief and/or loss of their loved one. (Refer to L531). 5. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for four of 28 sampled patients (Patient 1, Patient 8, Patient 9, Patient 17). This failure resulted in patients not being properly evaluated which resulted in them not being provided individualized focused care. (Refer to L533). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulation for Initial and Comprehensive Assessment of the Patient to ensure highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.”

“Based on observation, interview, and record review, the Hospice Agency (HA, a program that provides care and support for patients who are terminally ill and have stopped treatment to cure their disease) failed to ensure the Conditions of Participations (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) regarding Medical Director was met as follows: 1. The HA failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications for three of twenty eight sampled patients (Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10) to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patient’s pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. The agency failed to: Ensure there was documentation of clinical information that included patient’s history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice care and services. This failure resulted in the hospice medical director and/or the designee certified patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses. (Refer to L667). 2. The Medical Director failed to document an accurate Certification of Terminal Illness (CTI) that reflected the patient’s current health status and identify patients’ need for hospice care and services related to hospice eligibility and management of terminal illness for seven of eleven sampled active patients (Patient 1, Patient 10, Patient 16, Patient 17, Patient 22, Patient 23, and Patient 24). As a result, Patient 1, Patient 10, Patient 16, Patient 17, Patient 22, Patient 23, and Patient 24 were at risk for losing their hospice eligibility/hospice benefits, not receiving hospice care when needed in the future and the necessary care and services that could lead to hospitalization and death. (Refer to L668). 3. The HA failed to ensure the medical director oversaw the implementation of the entire hospice program, to include nursing services, to ensure that these areas consistently met patient needs, for one of 28 sampled selected patients (Patient 1). This failure resulted in delay of care, and potential health decline by not meeting the needs of the patient. (Refer to L669). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulation for Medical Director to ensure to provide the necessary care and services to the patients.”

“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 on Patient Rights was met as follows: 1. The HA failed to ensure two of twenty-eight sampled patients (Patient 1 and Patient 13) pain and symptoms were managed timely. This failure resulted in delays of care, continued pain and discomfort. (Refer to L512). 2. The HA failed to ensure one of twenty-eight sample patients (Patient 1) was informed of his right to have a primary care doctor. This failure resulted in violation of patient rights. (Refer to L515). 3. The HA failed to inform two of 28 sampled patients (Patient 16 and Patient 22) about the services the HA provided and the limitations of these services. This failure had the potential for Patient 16 and Patient 22 to have confusion, anxiety and distrust for not being informed about the purpose of the hospice care and service. (Refer to L519). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulation for Patient Rights to ensure their rights are not violated and these certified patients receive the highest quality of hospice.”

“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 on Interdisciplinary group, Care planning, and Coordination of services was met as follows: 1. The HA failed to ensure three of twenty-eight sampled patients (Patient 1, Patient 8, and Patient 22) received services as indicated in the plan of care (POC, an individualized, written roadmap developed by a hospice team to meet the holistic needs of a terminally ill patient and their family, focusing on comfort and quality of life rather than a cure). This failure had the potential to result in unmanaged needs due to not following a plan of care. (Refer to L543). 2. The HA failed to ensure two of twenty-eight sample patients (Patient 8 and Patient 16) care plans included their identified problems with goals and interventions to provide continuous assessment to be able to manage their care. This failure had the potential to result in patients not being assessed, which can cause failed treatments to manage their care and needs. (Refer to L545). 3. The HA failed to provide one of twenty-eight sampled patients (Patient 16) with drugs and treatment necessary to meet the needs of the patient. This failure had the potential to result in uncontrolled symptoms, which could affect the patient’s quality of life. (Refer to L549). 4. The HA failed to provide one of twenty-eight sampled patients (Patient 16) with medical supplies and appliances necessary to meet the needs of the patient. This failure had the potential to result in patient’s comfort, safety, and quality of life being compromised. (Refer to L550). 5. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) review, revise, and document the individualized plan of care as the patient’s condition requires, at least every 15 days for five of twenty eight sampled patients (Patient 1, Patient 2, Patient 8, Patient 9, and Patient 17). This failure resulted in patients not being properly evaluated which resulted in them not being provided individualized focused care. (Refer to L 552). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulation for Interdisciplinary group, care planning, and coordination of services to provide the necessary care and services to the patients certified to receive the hospice benefits.”

“Based on interview and record review, the Hospice Agency (HA – agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation on Clinical Records was met as follows: 1.The HA failed to ensure four of twenty-eight sampled patients (Patient 1, Patient 9, Patient 11, and Patient 14) medical records included comprehensive assessments and completed clinical notes. This failure resulted in an incomplete medical record. (Refer to L672). 2. The HA failed to ensure the Physician’s Certification for Hospice Benefit (or CTI, a document signed by a physician certifying that a patient is terminally ill with a life expectancy of six months or less) was completed and signed by the Medical Director, for nine of twenty-eight sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 10, Patient 16, Patient 17, Patient 23 and Patient 24). This deficient practice had the potential for the patient’s facing denial of Medicare (federal health insurance program in the United States for people age 65 or older, and for younger individuals with certain disabilities) coverage, loss of hospice services and disruptions in care that could lead to unnecessary suffering and a diminished quality of life during the final months of a terminal illness. (Refer to L676). 3. The HA failed to ensure any amendments, corrections or late entries within an electronic health record must clearly identify the original content, the modified content, date, and authorship of each record modification for six of twenty-eight sampled patients (Patient 1, Patient 2, Patient 3, Patient 14, Patient 16, and Patient 17). (Refer to L679). 4. The HA failed to ensure three of twenty-eight sample patients (Patient 12, Patient 14, and Patient 21) discharge summaries were in their medical record. This failure resulted in lack of coordination of care. (Refer to L684). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily (written law) mandated compliance with Federal regulations for Clinical Records to ensure patients’ medical records are safeguarded from unauthorized access by any individuals or hospice staff.”

“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 two of twenty-eight sampled patients (Patient 1 and Patient 13) pain and symptoms were managed and controlled effectively. This failure resulted in delay of care, intervention, treatment, unmitigated pain, discomfort, and distressing symptoms manifested by the terminally ill patients. Findings: 1. During a record review of Patient 1’s Personal Information sheet indicated a start of care date of 8/13/2025, with a terminal diagnosis of prostate cancer (a cancer of a male organ). During a concurrent observation and interview at the home visit on 9/9/2025, at 10:35 a.m. the Administrator/Director of Patient Care Services Designee (DD) asked Patient 1 if he was in pain. An observation of Patient 1 indicated Patient 1 was grimacing as he stated that his right foot was painful and felt as if his rods (medical tool placed to hold the bone) were coming out. Patient 1 stated to the DD that he had fallen 2 weeks ago and someone was supposed to come to his home to x-ray (a medical picture) his foot. Patient 1 stated he had had an operation done previously on his foot. Patient 1 stated he fell often. During a concurrent interview and record review on 9/10/2025, at 12:15 p.m., the DD reviewed Patient 1’s medical records. The DD stated patient had reported pain on 8/25/2025 but Patient 1 did not want a nurse visit. The DD reviewed Patient 1’s record titled, Visit Note RN, dated 8/26/2025. The record indicated, “Patient c/o (complain of) pain to his RLE (right lower extremity-leg) at 8/10 (using a 10-point scale. 8 is considered a lot of pain) ...Office staff was notified at time of visit-possible consult with supervising physician (doctor) and need to order x-ray to RLE. Patient was advised to have caregiver take him to Urgent Care or ER (Emergency room) if symptoms persist or worsen.” The DD stated the nurse visited the patient, assessed Patient 1’s pain, and the note indicated patient needed an x-ray. The DD continued to review Patient 1’s records and stated there was no mention the nurse notified the doctor, and an x-ray was ordered. The DD stated the order for x-ray was placed on 9/10/2025. During an interview on 9/10/2025, at 12:23 p.m., Licensed Vocational Nurse 3 (LVN 3) stated she had initially placed the x-ray order on 8/25/2025, but cancelled the order because there was no order from the doctor. LVN 3 stated Patient 1 was supposed to go to the ER to have his leg checked. LVN 3 stated she spoke to Patient 1 on 8/26/2025 who reported his pain was better. LVN 3 stated she had not documented the communication between Patient 1 and herself (LVN 3) because she was used to talking to Patient 1 all the time. LVN 3 stated in reference to nursing documentation, if it was not documented, it was not done. LVN 3 stated she placed the order for x-ray today, 9/10/2025, because the doctor ordered it today (9/20/2025). During an interview on 9/10/2025, at 12:31 p.m., the DD stated the x-ray was delayed. Patient 1 had requested it on 8/26/2025. Patient 1 was in pain, and the HA did not know why. Maybe there was a fracture (break). The HA needed to confirm it. 2. During a record review of Patient 13’s medical record form titled “Personal Information”, undated, indicated a start of care date of 4/12/2024 and an end of care date of 6/3/2025 with a primary diagnosis of malignant neoplasm of prostate. During a record review of Patient 13’s electronic medical record (EMR), the EMR indicated Patient 13 complaint of low back pain, 10 out of 10 on 4/12/2024. Patient 13 complaint of right leg pain, 6 out of 10 on 5/22/2025. During a record review of Patient 13’s medical record form titled “POC (plan of care)/ IDG (interdisciplinary group) Review” dated 4/12/2024, indicated there were no problems/ interventions/ goals/status or issues care planned for Patient 13. During a record review of Patient 13’s medical record form titled “POC/IDG Review” dated 4/16/2024, indicated there were no problems/ interventions/ goals/status or issues care planned for Patient 13. During a record review of Patient 13’s medical record form titled “POC/IDG Review” dated 4/30/2024, indicated there was no problems/ interventions/ goals/status or issues care planned for Patient 13’s pain. During a concurrent interview and record review on 9/11/2025 at 11:20 a.m. with the Director of Patient Care Services (DPCS) of Patient 13’s EMR, the DPCS stated that Patient 13’s pain should have been addressed, taken care of, and care planned to prevent from suffering. The DPCS stated that the Medical Director (MD1) needed to be made aware of Patient 13’s pain, to be able to order medications and make adjustments as needed. During a record review of the HA’s document titled Patient Rights and Responsibilities, dated 2019, indicated the patient had the right to receive effective pain management and symptom control from the hospice for conditions related to the 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 one of twenty-eight sample patients (Patient 1) was informed of his right to choose a primary care physician. This failure resulted in violation of patient rights. Findings: During a record review of Patient 1’s Personal Information sheet indicated a start of care date of 8/13/2025, with a terminal diagnosis of prostate cancer (a cancer of a male organ). During an interview at the home visit on 9/9/2025, at 11:21 a.m., Patient 1 stated he currently did not have a primary care doctor because he was told he could not have one while in hospice. Patient 1 stated, “I can’t get blood drawn, can’t get nothing…I haven’t seen a doctor, but I fall all the time.” During an interview at the home visit on 9/9/2025, at 11:37 a.m., the Director of Patient Care Services Designee (DD) stated he did not know who told Patient 1 he could not have a primary care doctor while on hospice care. The DD stated Patient 1 could have a primary care doctor. During a record review of the HA’s document titled Patient Rights and Responsibilities, dated 2019, indicated the patient had the right to choose a health care provider including choosing an attending physician.”

“Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to inform two of 28 sampled patients (Patient 16 and Patient 22) about the services the HA provides and the limitations of these services. This deficient practice has the potential for patients not being informed about the purpose of the hospice care services. Findings: 1. During a review of Patient 16’s Personal Information, the Personal Information indicated a start of care (SOC) date of 3/21/2025, with a terminal diagnosis of dysarthria (a speech disorder characterized by difficulty in producing clear and intelligible speech due to damage or dysfunction in the muscles or nerves that control speech production) following other cerebrovascular (relating to the brain and its blood vessels) disease. During a review of Patient 16’s POC/IDG Review (Plan of Care/Interdisciplinary Group Review, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), dated 9/2/2025, the POC/IDG Review indicated the visit frequency as follows: Hospice Aide twice per week, MSW (Master of Social Work – a professional social worker with a master’s degree who provides specialized psychosocial and emotional support to patients with life-limiting illnesses and their families) every recertification and as needed, RN (Registered Nurse) once a week for clinical care and support of patient’s condition, SC (Spiritual Counselor) every recertification and as needed. During a joint home visit with Registered Nurse 2 (RN 2) on 9/9/2025 at 10:40 a.m., Patient 16 was observed alert and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 16 was sitting on a recliner. Caregiver 1 (CG 1) was present at Patient 16’s home. During an interview with Patient 16 on 9/9/2025 at 11:56 a.m., Patient 16 stated that he was never told by a physician that he had terminal illness or that he was dying. Patient 16 stated that the HA explained to him that they were going to send a nurse to check on his conditions, to help him with medication refills. Patient 16 stated that the HA also sent a staff to help him with shower. During a phone interview with FM 1 on 9/9/2025 at 2:06 p.m., FM 1 stated that Patient 16 did not have terminal illness with 6 months or less life expectancy. FM 1 stated that he had never been contacted by anybody from the HA, that he had never received explanation regarding what the hospice service provided and its limitations. 2. During a review of Patient 22’s Personal Information, the Personal Information indicated a start of care date of 3/26/2025, with a terminal diagnosis (any condition expected to end in death) of heart disease, unspecified. During a review of Patient 22’s clinical record titled, Plan of Care (POC, a detailed, personalized, written document that outlines an individual’s specific health and care needs, preferences, and goals, developed in collaboration with the person receiving care and their healthcare team) Summary, the POC Summary indicated an order dated 3/26/2025, for the skilled nurse (SN) to visit the patient once a week for clinical care and support of patient’s condition. Social worker, spiritual counselor and volunteer services was offered but declined. During a joint home visit at Patient 22’s residence, on 9/9/2025 at 1:40 p.m. with licensed vocational nurse (LVN 2), Patient 22 was observed to be awake, alert, oriented x 3 (to person, place and time), ambulatory with a cane, and showing no shortness of breath (SOB), edema, palpitations (irregular, fast heartbeat), or chest pain. Vital signs (measurements of the body’s most basic functions, providing crucial information about a person’s general health) were normal. During an interview, Patient 22 stated that no one from the HA explained to her regarding what hospice care was, that she does not have terminal illness and was not dying, and that she signed up for hospice care because she was told by HA staff that they can supervised and checked on her health condition, be visited by a nurse once a week to monitor her blood pressure. During an interview, on 9/11/2025 at 10:45 a.m., with the Administrator/Director of Patient Care Services Designee (DD), the DD stated the agency’s visiting nurse during the initial visit and subsequent recertification visits should explain to the patient and patient family what hospice care is and the services that they can provide to prevent confusion. The DD stated and acknowledged the findings. During a review of the agency’s policy and procedure (P&P) titled, Patient Rights and Responsibilities, dated 2019, the P&P indicated Hospice and Palliative Care of California, Inc has a patient Bill of Rights that is designed to recognize, protect and promote the right of each patient to be treated with dignity and respect. The patient has the right to be fully informed of the care/services to be provided, including the disciplines that will furnish care/services, including the frequency of visits as well as any modifications to the plan of care. Receive information about the scope of services the hospice provides as well as any limitation on those 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 interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after election of hospice care for four of twenty eight sampled patients (Patient 1, Patient 11, Patient 17 and Patient 22). This failure had the potential to result in patients identified needs are not evaluated necessary to address all areas of the identified needs related to the terminal illness and related conditions. Findings: 1a. During a record review of Patient 1’s Personal Information sheet indicated a start of care date of 8/13/2025, with a terminal diagnosis of prostate cancer (a cancer of a male organ). During a record review of Patient 1’s medical records on 9/8/2025, there was no indication that the MSW had done a psychosocial assessment. 1b. During a record review of Patient 1’s medical records on 9/8/2025, there was no indication that the SC had done a spiritual assessment. 2. During a record review of Patient 11’s medical record form titled “Personal Information”, undated, indicated a start of care date of 8/5/2024 and an end of care date of 1/7/2025 with a primary diagnosis of chronic obstructive pulmonary disease (COPD – lung disease causing breathing problems). During a record review of Patient 11’s electronic medical record (EMR), the EMR indicated Patient 11 had one spiritual assessment dated 9/2/2024 and one psychosocial assessment dated 10/22/2024. During a concurrent interview and record review on 9/10/2025 at 2:35 p.m. with the Administrator/ Director of Patient Care Services Designee (DD) of Patient 11’s EMR, the DD stated that Patient 11’s psychosocial and spiritual assessments should have been completed within 5 days of his (Patient 11) start of care date. The DD stated that Patient 11 could have benefited from a psychosocial assessment because he (Patient 11) might need community help, referrals, and/or outreach. The DD stated that a spiritual assessment was part of the hospice, and that counseling and prayer helps. The DD stated that there was no documented reason as to why Patient 11 was assessed late. 3. During a review of Patient 17’s Personal Information, the Personal Information indicated a start of care (SOC) date of 1/28/2025, with a terminal diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat). During a review of Patient 17’s History of Spiritual Assessment, the record indicated the comprehensive spiritual assessment was done on 2/4/2025, which was 7 days after the patient was admitted to hospice. During a concurrent interview and record review with Registered Nurse Case Manager (RN 1) on 9/10/2025 at 2:37 p.m., RN 1 reviewed Patient 17’s spiritual assessments. RN 1 stated the spiritual comprehensive assessment was part of the comprehensive assessment that needed to be completed within 5 calendar days following patient’s admission to hospice. RN 1 stated that Patient 17’s spiritual assessment was done late. RN 1 stated there was no communication note that explained why it was done late. When RN 1 was asked why it was important to complete the comprehensive assessment within 5 days, RN 1 stated, “Because that’s what the regulation says.” 4. During a review of Patient 22’s Personal Information, the Personal Information indicated a start of care date of 3/26/2025, with a terminal diagnosis (any condition expected to end in death) of heart disease (a group of conditions that affect the heart and its blood vessels), unspecified. During a review of Patient 22’s document titled, History of Psychosocial Assessment, the History of Psychosocial Assessment indicated there was no documented evidence a psychosocial assessment was conducted within 5 days from the SOC date. During a concurrent interview and record review, on 9/15/2025 at 2:30 p.m., with the DD, the DD reviewed Patient 22’s document titled History of Psychosocial Assessment. The DD stated and confirmed the agency’s social worker did not conduct an initial assessment within 5 days from the patient’s SOC. The DD stated an initial psychosocial assessment should be conducted within 5 days of admission to hospice care to identify the social/emotional needs and assess potential safety risks of the patient at home. During a review of the HA’s policy and procedure (P&P) titled “Comprehensive Assessment - Timing”, dated 2019, the P&P indicated the HA would perform a comprehensive assessment within the accepted timeframe set forth by CMS (Centers for Medicare and Medicaid – a part of the U.S. Department of Health and Human Services and works to improve healthcare quality and outcomes by implementing quality initiatives, developing innovative payment and service delivery models, and overseeing standards for long-term care facilities and clinical laboratories). The procedure part of the P & P indicated the following: - The comprehensive assessment of the patient is completed by designated members of the IDG, in consultation with the patient’s attending physician, no later than five (5) calendar days after the patient elects the hospice benefit. - The hospice nurse coordinates the comprehensive assessment process and ensures that the patient’s physical, emotional, psychosocial, spiritual, and bereavement needs are assessed. During a review of the agency’s P&P titled Social Work Services, dated 2019, the P&P indicated the comprehensive assessment of the patient includes a psychosocial assessment conducted by the social worker to evaluate the patient/caregiver’s emotional, social, financial, and environmental resources and identify appropriate psychosocial problems, interventions and goals for the patient’s plan of care. A thorough psychosocial assessment is initiated at the time of admission and continued throughout the course of care. Interventions to assist the patient are based on assessment data. During a review of the agency’s P&P titled Spiritual Care Services, dated 2019, the P&P indicated Hospice and Palliative Care of California, Inc provides counseling or arranges for counseling to meet the spiritual needs of patients/caregivers in a manner consistent with their beliefs and desires and in accordance with the patient’s plan of care. An initial spiritual assessment for all consenting patients and/or documentation supporting attempts to make such an assessment shall be completed within 5 days.”

“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 comprehensive assessments accurately reflected the patients current health condition related to hospice eligibility, management of terminal illness, and identified the patients’ need for hospice care (a specialized care that provides comfort and emotional, social, and spiritual support for people nearing the end of life) and services for seven of 11 active sample patients (Patient 1, Patient 10, Patient 16, Patient 17, Patient 22, Patient 23, and Patient 24).As a result of the noncompliance described above, Patient 1, Patient 10, Patient 16, Patient 17, Patient 22, Patient 23, and Patient 24 were at increased risk to experience a decline in health that could lead to serious harm, hospitalization, and death due to not having proper medical oversight and access to needed specialist, medications, and medically necessary treatments; and have the potential to lose their hospice eligibility/hospice benefits and not receive hospice care when needed and eligible in the future. On 9/12/2025, at 4:05 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the Administrator (ADM) and Director of Patient Care Services (DPCS) related to the hospice agency’s failure to ensure the comprehensive assessments accurately reflected the patients current health condition related to hospice eligibility and management of terminal illness and identified the patients need for hospice care and services for seven of eleven active sample patients (Patient 1, Patient 10, Patient 16, Patient 17, Patient 22, Patient 23, and Patient 24), of 28 total sample patients. On 9/15/2025, at 10:13 a.m., the hospice agency submitted an IJ removal plan (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), reviewed and was not accepted by the Department. On 9/16/2025, at 1 p.m., the hospice agency was unable to submit an acceptable IJ removal plan. On 9/16/2025, at 1:30 pm, the survey team completed the survey tasks and conducted an exit conference in the presence of the ADM, DPCS, DPCS Designee and Registered nurse case manager with the IJ situation not removed. Findings: 1.During a review of Patient 1’s Personal Information sheet, the Personal Information sheet indicated a start of care (SOC) date of 8/13/2025, with a terminal diagnosis (any condition expected to end in death) of prostate cancer (a cancer of a male organ). Patient 1’s Personal Information sheet indicated that it was Patient 1’s 5th certification period in the hospice program. During a review of Patient 1’s General Acute Care Hospital (GACH) records, titled Final Report, History and Physical, dated 7/12/2025, the Final Report, History and Physical records, indicated Patient 1’s prostate cancer (type of cancer where cells in the prostate gland, a small gland in the male reproductive system, grow abnormally and multiply out of control), was in remission (a temporary or permanent disappearance of signs and symptoms). The Final Report, History and Physical records, indicated Patient 1 had reported to the hospital doctor history of prostate cancer, high blood pressure, and Chronic Obstructive Pulmonary Disease (COPD -an illness that makes breathing difficult). The Final Report, History and Physical records, indicated Patient 1 respiratory system was examined and the doctor documented the following, “Review of symptoms…no shortness of breath, cough, or sputum production…Physical exam: Clear to auscultation and percussion. No wheezing, rales or rhonchi.” The Final Report, History and Physical records indicated Patient 1’s active medical problems were asthma (a condition that makes breathing difficult), gallstone (stones in the liver) and hypertensive disorder (high blood pressure). During an observation of the joint home visit on 9/9/2025 at 10:35 a.m., with the Administrator/Director of Patient Care Services Designee (DD), Patient 1 greeted DD at the door. Patient 1 was walking, using a cane, and was breathing normally. During a concurrent observation and interview on 9/9/2025, at 10:38 a.m., the DD checked Patient 1’s blood pressure, temperature, oxygen saturation (the amount /percentage of oxygen in the blood), heart rate. The DD stated Patient 1’s oxygen saturation was 99% on room air (breathing without oxygen, breathing ambient air). During an interview at the home visit on 9/9/2025, at 11:21 a.m., with Patient 1, Patient 1 stated he was taking medication for prostate cancer. Patient 1 stated the prostate cancer had not spread. Patient 1 stated he did not need Spiritual Care services because he goes to church. Patient 1 stated he currently did not have a primary care doctor because he was told he could not have one while in hospice. Patient 1 stated, “I can’t get blood drawn, can’t get nothing…I haven’t seen a doctor, but I fall all the time.” During a concurrent interview and record review on 9/9/2025, at 11:42 a.m., with DD, DD reviewed Patient 1’s Comprehensive Nursing Assessment, dated 8/13/2025. The Comprehensive Nursing Assessment indicated Patient 1 had a Palliative Performance Scale (PPS, a tool used in palliative care to assess a patient’s functional status and prognosis), indicated a score of 40 (unable to do any work, mainly in bed). Patient 1’s Comprehensive Nursing Assessment indicated that Patient 1 was hospice eligible due to the Local Coverage Determination (LCD, a tool that describes the qualifying criteria for hospice care) indicated as follows: Patient 1’s cancer had metastasized (spread to other parts of the body) regardless of therapy, Patient 1 had been ruled out as a candidate or declines further curative therapy. The DD stated during the visit (unknown), Patient 1 reported the cancer had not spread. The DD stated he (DD) had read Patient 1’s history and physical (a medical document that describes all the medical problems and treatment plan) prior to the visit and the document indicated Patient 1’s cancer was in remission (stabilized). The DD stated the LCD was not done correctly. The DD stated based on Patient1 report and the LCD, Patient 1 did not meet eligibility for hospice care. During an interview on 9/11/2025, at 1:54 p.m., with the Medical Director (MD 1), MD1 reviewed Patient 1’s medical records (in general). MD 1 stated the only evidence he had of Patient 1’s metastatic prostate cancer was Patient1’s report, and the prophylactic (prevention) medication Patient1’s was currently taking. MD 1 stated he could not find the name of the medication, as the medication was not listed in Patient1’s medical record (in general). MD 1 stated he (MD1) did not have any medical records to support Patient 1’s terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure), of prostate cancer metastasis. During an interview on 9/11/2025 at 1:58 p.m., MD 1 stated Patient 1’s real problem was COPD, and the HA was going to change his diagnosis on the records. During a review of Patient 1’s Communication/Progress log, dated 9/14/2025, MD 1 documented as follows, “...71-year-old male admitted to GACH on 7/12/2025 for multiple falls and generalized weakness. Patient1 has documented the history of COPD. Primary Terminal Diagnosis for Hospice Admission End-Stage Chronic Obstructive Pulmonary Disease (COPD)... the Registered Nurse (RN) reported from the prior week highlights a rapid deterioration in the patient’s condition. Patient1’s pulmonary function indicated has declined significantly, with severe dyspnea noted upon minimal exertion. Patient1’s Communication/Progress log, indicated Patient1 became short of breath by merely standing up or taking one to two steps, at which point his oxygen saturations drop to below 90%...Criterion Met: Dyspnea with Minimal Exertion or at Rest. The record state he gets “easily fatigues needing extra time to perform ADL’s and rest breaks. His inability to ambulate more than 15 feet, about one or two steps, and shaking when standing which requires maximum support are classic physical manifestation of severe dyspnea from end-stage lung disease.” During a review of Patient 1’s “Visit Note RN”, dated 9/9/2025, indicated, dyspnea (short of breath) light difficulty, oxygen saturation of 97% room air, a respiratory rate of 18 breaths per minute (normal finding). During a review of Patient 1’s “Visit Note LVN”, dated 9/10/2025, indicated, dyspnea (short of breath) light difficulty, oxygen saturation of 94% room air, a respiratory rate of 20 breaths per minute (normal finding). The Visit Note LVN record indicated lung sounds clear with shortness of breath (SOB) upon exertion, Patient1 was able to ambulate about 15-20 steps before having to sit to catch his breath. The Visit Note LVN record indicated Patient 1 required walker or care to ambulate. 2.During a review of Patient 10’s “Personal Information”, undated, indicated Patient1’s start of care (SOC) date was 1/11/2025 with a primary diagnosis of hypertensive heart disease (a condition where the heart muscle is damaged or weakened due to long-term high blood pressure) without heart failure. During a review of Patient 10’s Re-Cert Assessment (a recertification assessment, required evaluation to confirm that a patient continues to be eligible for hospice care after the initial eligibility period has ended), dated 9/1/2025, the Re-Cert Assessment indicated Patient 10 had normal blood pressure, regular pulse, no cardiac-related pain, and normal skin color. However, Patient 10’s nursing assessment indicated Patient 10 met the criteria for New York Heart Association for Class IV heart failure (the most severe form of heart failure, characterized by an inability to perform any physical activity without discomfort and the presence of symptoms, such as shortness of breath, even at rest). During a record review of Patient 10’s “Local Coverage Determination (LCD, a tool that describes the qualifying criteria for hospice care) Hospice Eligibility Determination” dated 6/30/2025 and 9/1/2025, indicated heart disease was used to determine hospice eligibility. The LCD Hospice Eligibility Determination form indicated a “Yes” was marked for the following sections, has patient been ruled out as a candidate for surgical procedures, is patient optimally treated for heart disease with diuretics and vasodilators, does this CHF (congestive heart failure) or angina patient meet the criteria for NYHA class IV level, and hx (history) of unexplained syncope/fainting.” During an interview on 9/9/2025 at 2:46 p.m., with Patient 10’s caregiver/daughter (FM4), FM4 stated Patient 10 has a primary physician (MD3) which she (Patient 10) saw last month. FM4 stated Patient 10 requested to be full code, “she (Patient 10) wants everything done if she has a full code.” FM4 stated that Patient 10 is active at home and uses her walker to go out to the porch by herself. FM4 stated Patient 10 is healthy despite having high blood pressure, vertigo and high cholesterol. During an interview on 9/9/2025 at 3:08 p.m., with Patient 10’s primary physician (MD3), MD3 stated that he did not discuss or refer Patient 10 for hospice services. MD3 stated Patient 10 did not mention she (Patient 10) was receiving hospice services. MD3 stated he saw Patient 10 for the first time in 2016, and the last time was on 6/17/2025. During a concurrent interview and record review on 9/10/2025 at 1:30 p.m., with the Administrator/Director of Patient Care Services Designee (DD) of Patient 10’s electronic medical record (EMR), DD stated Patient 10 was on certification period number eight from 9/8/2025 to 11/6/25, and was not signed by the Medical Director (MD1). During a concurrent interview and record review on 9/10/2025 at 1:30 p.m., with the DD of Patient 10’s medical record form titled “LCD Hospice Eligibility Determination” dated 6/30/2025 and 9/1/2025, the DD stated Patient 10 did not have heart failure or documentation to support both LCDs. The DD stated he (DD) relied on Patient 10’s medical record for information and was not able to find documented evidence to support Patient 10’s hospice diagnosis. During a concurrent interview and record review on 9/11/2025 at 3:25 p.m., with the Medical Director (MD1) of Patient 10’s EMR, MD1 stated Patient 10’s hospice diagnosis of hypertensive heart disease without heart failure, was an unacceptable diagnosis. MD1 stated unless Patient 10 had “something else” besides hypertensive heart disease without heart failure, she (Patient 10) was not a hospice candidate. MD1 stated Patient 10’s heart was not failing. MD1 stated it was a mistake on his (MD1) part by not signing Patient 10’s current Certification of Terminal Illness (CTI, is the narrative summary, a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician). MD1 stated he (MD1) did not recall who referred Patient 10 for hospice services. MD1 stated Patient 10’s hospice admission was based on her “old age, history of cancer and falls, multiple visits to the emergency department, broken ankle, brain degeneration, and poor scores on her (Patient 10) activities of daily livings. MD1 stated Patient 10 looked like she was dying. MD1 stated that he (MD1) was certain Patient 10 had a primary physician, and that he was not in contact with him (Patient 10’s primary physician). 3.During a review of Patient 16’s GACH records dated 3/20/2025, Patient 16’s H & P (history and physical, a formal, comprehensive medical document a physician creates after gathering a patient’s health information through an interview and performing a thorough physical examination), there was no evidence of documentation in Patient 16’s H & P regarding a history of stroke. Patient 16’s H & P indicated a history of spinal cerebral ataxia (a group of inherited neurological disorders characterized by progressive loss of coordination and balance [ataxia]), failure to thrive, and dysphagia (difficulty swallowing). Patient 16 was saturating 100% on room air, with respiratory that was clear to auscultation. Cardiovascular (relating to the heart and blood vessels) was documented as regular in rate and rhythm. During a review of Patient 16’s Personal Information, the Personal Information indicated Patient 16’s start of care (SOC) date was 3/21/2025, with a terminal diagnosis of dysarthria (a speech disorder characterized by difficulty in producing clear and intelligible speech due to damage or dysfunction in the muscles or nerves that control speech production), following other cerebrovascular (relating to the brain and its blood vessels) disease. Patient 16’s Personal Information record indicated Patient 16 was on 5th certification period in the hospice program. During a review of Patient 16’s face-to-face (F2F) Visit Note List, indicated there was one face-to-face visit conducted by MD 1 on 3/21/2025. During a review of Audit Log (a detailed record containing details of who performed an action, what was done, when it happened, and which resources were affected) conducted on 9/9/2025, the Audit Log indicated that MD 1 documented the face-to-face visit note on 9/8/2025. During a review of Patient 16’s Local Coverage Determination, (LCD, a tool that describes the qualifying criteria for hospice care), the LCD Hospice Eligibility Determination dated 3/21/2025, indicated Patient 16 was qualified to receive hospice services due to stroke (a medical emergency that occurs when blood flow to the brain is interrupted) and coma (a prolonged state of unconsciousness where a person is unresponsive to their environment and unable to communicate). The LCD indicated Patient 16’s KPS (Karnofsky Performance Scale, a tool used to assess the functional status of terminally ill patients in hospice care, helping predict survival and guide treatment decisions; a score of 40 indicated inability to care for self, requiring equivalent of institutional or hospital care) or PPS (Palliative Performance Scale, a standardized tool used by clinicians to assess a patient’s functional decline and overall ability to perform daily activities; a score of 40 indicated inability to do most activities) was less than 40. The LCD indicated that Patient 16 had weight loss of more than 10% in the last 6 months or more than 7.5% in the last 3 months. During a review of Patient 16’s Comprehensive Nursing Assessment, dated 3/21/2025, the Comprehensive Nursing Assessment indicated Patient 16’s KPS was 50 and PPS was 50. The Comprehensive Nursing Assessment indicated Patient 16 had NYHA IV (a classification of heart failure by the New York Heart Association – class IV indicates the most severe form of heart failure, characterized by an inability to perform any physical activity without discomfort and the presence of symptoms, such as shortness of breath, even at rest). The Comprehensive Nursing Assessment indicated Patient 16’s oxygen saturation (the amount of oxygen circulating in a person’s blood) was 95% on room air, respiration rate 17 per minute. Patient 16’s Comprehensive Nursing Assessment narrative section indicated Patient 16’s lung sounds were clear, breathing was even and unlabored. There was no documentation regarding how much weight Patient 16 had lost in the past 3 months or 6 months. MAC (mid-arm circumference, a measurement taken around the arm, midway between the bony tip of the shoulder and the point of the elbow) was not documented. During a review of Patient 16’s LCD, dated 5/16/2025, the LCD indicated Patient 16 was qualified to receive hospice services due to stroke and coma. The LCD indicated that Patient 16’s KPS or PPS was less than 40. The LCD indicated Patient 16 had weight loss of more than 10% in the last 6 months or more than 7.5% in the last 3 months. During a review of Patient 16’s Recert Assessment (recertification assessment, a process to confirm a patient’s continued eligibility for hospice care, which requires a physician to re-evaluate their condition to ensure the terminal illness is still life-limiting with a prognosis of six months or less), dated 5/16/2025, the Recert Assessment indicated KPS was 50 and PPS was 50. Patient 16’s oxygen saturation was 95% on room air, respiration rate 17 per minute. Patient 16’s Recert Assessment, narrative section indicated Patient 16’s lung sounds were clear, breathing was even and unlabored with shortness of breath noted on mild exertion. There was no documentation regarding how much weight Patient 16 had lost in the past 3 months or 6 months. MAC was 23 cm. During a review of Patient 16’s LCD, dated 7/5/2025, the LCD indicated Patient 16 was qualified to receive hospice services due to stroke and coma. The LCD indicated Patient 16’s KPS or PPS was less than 40. The LCD indicated Patient 16 had weight loss of more than 10% in the last 6 months or more than 7.5% in the last 3 months. During a review of Patient 16’s Recert Assessment, dated 7/5/2025, the Recert Assessment indicated that KPS was 50 and PPS was 50. Patient 16’s O2 saturation was 95% on room air, respiration rate 17 per minute, with clear lung sounds and normal respiration documented. Patient 16’s Recert Assessment, narrative section indicated Patient 16 denied shortness of breath but appeared more fatigued (tired) and mildly dyspneic (short of breath). There was no documentation regarding how much weight Patient 16 had lost in the past 3 months or 6 months. MAC was 21 cm. During a review of Audit Log for Patient 16, for Nursing Assessment, it indicated, on 8/13/2025, RN 1 modified the MAC from 23 cm to 22 cm and then modified it again from 22 cm to 21 cm, for Patient 1’s Recert Assessment, dated 7/5/2023. During a joint home visit with RN 2 on 9/9/2025 at 10:40 a.m., at Patient 16’s home, Patient 16 was observed alert and oriented to person, place, and time. Patient 16 was sitting on a recliner. Patient 16’s Caregiver 1 (CG 1) was present at Patient 16’s home. During the observation, RN 2 took Patient 16’s vital signs. Per RN 2, O2 saturation was 97% on room air, respiration rate was 20 per minute. RN 2 stated lung sounds were clear to auscultation (listening to the internal sounds of the body). Observed Patient 16’s breathing unlabored. When asked by the surveyor if he sometimes had shortness of breath, Patient 16 stated he (Patient 16) had never experienced shortness of breath. Patient 16 stated he had been visited by RN 2 once a week, every Monday. Patient 16 stated he had not been visited by MD1. During an interview with CG 1 on 9/9/2025 at 11:50 a.m., CG 1 stated that since she (CG1) started caring for Patient 16 three months ago, Patient 16 had improved appetite. CG 1 stated she believed that Patient 16 had gained weight, since he now needed a large pull-up. CG 1 stated Patient 16 was wearing a size medium pull-up before. During a telephone interview with Patient 16’s Family Member 1 (FM 1) on 9/9/2025 at 2:06 p.m., FM 1 stated Patient 16 did not have a history of stroke. FM 1 stated that Patient 16 had had spinal cerebellar ataxia (uncoordinated and unsteady movements) type 2 since he (Patient 16) was in his forties. FM 1 stated that Patient 16 did not have a history of heart failure. FM 1 stated Patient 16’s appetite had improved. FM 1 stated Patient 16 was never diagnosed with a terminal illness with 6 months or less life expectancy. FM 1 stated he (FM1) did not know who referred Patient 16 to hospice. During a telephone interview with Patient 16’s former Primary Care Physician (MD 4) on 9/9/2025 at 3:47 p.m., MD 4 stated Patient 16 was his long-time patient. MD 4 stated Patient 16 was not terminally ill. MD 4 stated that Patient 16 had a neurological condition called spinal cerebellar ataxia, which was not the same as stroke. MD 4 stated he (MD4) referred Patient 16 to be admitted to a nursing home, because it was not safe for Patient 16 to live by himself at his apartment. MD 4 stated Patient 16 needed to be in a facility because he needed constant assistance. MD 4 stated he did not know who referred Patient 16 to hospice. During a concurrent interview and record review with RN 1 on 9/10/2025 at 1:15 p.m., RN 1 reviewed Patient 16’s H & P records, Comprehensive Nursing Assessment, dated 3/21/2025, Recert Assessments, dated 5/16/2025 and 7/5/2025, F2F visit note list. RN 1 reviewed the LCD dated 3/21/2025, 5/16/2025, and 7/5/2025. RN 1 stated Patient 1 was transferred from another hospice agency. RN 1 was not able to provide information on the physician who referred Patient 16 to hospice. RN 1 stated there was no documentation regarding the history of stroke for Patient 16. RN 1 stated since Patient 16 was mostly bed bound, the hospice was using MAC as an indicator of weight. RN 1 stated MAC did not transcribe to a percentage of weight loss or weight gain, but it could indicate that a person had lost or gained weight. RN 1 stated there was no documented weight to indicate if Patient 16 had lost more than 10% of weight in the last 6 months. RN 1 stated a face-to-face visit by the hospice physician or physician designee was required before the 3rd certification and prior to each subsequent recertification after. RN 1 confirmed there was only one face-to-face visit documented for Patient 16. RN 1 stated there were no face-to-face visit completed for recertification #6 and #7. RN 1 stated it was very important to have a complete and accurate comprehensive assessment and face-to-face visit to ensure the patient was still eligible to receive hospice services. RN 1 was asked to provide documentation or clinical records regarding Patient 16’s history of stroke. RN 1 stated there was no documentation or clinical records that indicated Patient 16 had a history of stroke. During the same interview, when RN 1 was asked if he visited Patient 16 on 7/5/2025 and measured his MAC, RN 1 stated she had never visited Patient 16. RN 1 stated she asked the DPCS to remeasure Patient 16’s MAC on 8/13/2025. When RN 1 was asked for documented evidence of the DPCS’ assessment of Patient 16 on 8/13/2025, RN 1 was not able to provide the requested documentation. 4.During a review of Patient 17’s Personal Information, the Personal Information indicated Patient 17’s start of care (SOC) date of 1/28/2025, with a terminal diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat). Patient 17’s Personal Information record indicated this was Patient 17’s first certification period in the hospice program. During a review of Patient 17’s GACH records, H & P dated 1/31/2025, there was no documentation in the record regarding a history of heart disease or heart failure in Patient 17’s H & P. The H & P indicated that Patient 17’s chief complaint was abdominal pain. During a review of Patient 17’s LCD, dated 1/29/2025, the LCD indicated that Patient 17 was qualified to receive hospice services due to heart disease. The LCD indicated that Patient 17 met the criteria for NYHA IV and had an ejection fraction (EF – the percentage of blood that the left ventricle pumps out with each heartbeat, providing a measure of the heart’s pumping efficiency; a normal EF for a healthy heart is typically between 55% and 70%) of less than 20. During a review of Patient 17’s Comprehensive Nursing Assessment, dated 1/29/2025, the Comprehensive Nursing Assessment indicated that the KPS was 50 and PPS was 40, NYHA IV. The Comprehensive Nursing Assessment indicated Patient 17’s oxygen saturation was 98% on room air, with clear lung sounds, and normal respiration. Heart rate was documented as regular. Per Comprehensive Nursing Assessment, Patient 17 had no edema (swelling). The Comprehensive Nursing Assessment was not signed. During a review of Patient 17’s LCD, dated 1/29/2025, the LCD was not completed. The LCD indicated that Patient 17 was not qualified to receive hospice services. During a review of Patient 17’s Recert Assessment, dated 4/21/2025, the Recert Assessment indicated that the KPS was 50 and PPS was 40, NYHA III. The assessment indicated Patient 17’s O2 saturation was 96% on room air, with clear lung sounds, and normal respiration. Heart rate was documented as regular, and the patient did not have edema. During a review of Patient 17’s LCD, dated 7/14/2025, the LCD indicated that Patient 17 was not qualified to receive hospice services. The LCD was not completed. During a review of Patient 17’s Recert Assessment, dated 7/14/2025, the Recert Assessment indicated that the KPS was 50 and PPS was 40, NYHA III. The assessment further indicated Patient 17’s O2 saturation was 96% on room air, with clear lung sounds, and normal respiration. Heart rate was documented as regular, and the patient did not have edema. During a review of Patient 17’s F2F Visit Note List, the record indicated there was no face-to-face visit conducted. Patient 17 was in the 3rd certification period as of 7/14/2025. During a telephone interview with Patient 17 and FM 2 on 9/9/2025 at 4:23 p.m., FM 2 stated Patient 17 did not have heart disease or heart failure. Patient 2 stated he (Patient 17) had hypertension (a condition in which the blood force against the artery walls is consistently too high), but not heart failure. When Patient 17 was asked if he was able to ambulate, Patient 17 stated he and FM 2 walked their dog around the neighborhood for 30 minutes daily. Patient 17 stated he was never told by his doctor that he had 6 months or less to live. FM 2 stated that Patient 17’s PCP did not refer him to hospice. During a concurrent interview and record review with RN 1 on 9/10/2025 at 1:15 p.m., RN 1 reviewed the hospital records, dated 1/31/2025, Comprehensive Nursing Assessment, dated 1/29/2025, Recert Assessments, dated 4/21/2025 and 7/14/2025. RN 1 also reviewed the LCD dated 1/29/2025, 4/21/2025, and 7/14/2025. RN 1 stated there was no history of heart disease or heart failure documented in the hospital records. RN 1 stated that the Comprehensive Nursing Assessment was considered incomplete since it was not signed. RN 1 confirmed that the LCD for the second and third certification period were not done. RN 1 stated that LCD was an important part of the Comprehensive Assessment and Recert Assessment to determine if the patient was still eligible for hospice. RN 1 stated the Recert Assessments were considered incomplete since the LCDs were not done. RN 1 stated there was no physician face-to-face visit documented for Patient 17. RN 1 stated a face-to-face visit prior to the third certification period was required to ensure the patient was still eligible to receive hospice services. When RN 1 was asked to provide diagnostics that showed Patient 17’s EF was less than 20, RN 1 stated there was no documentation of any diagnostics, such as echocardiogram (a test of the action of the heart using ultrasound waves to produce a visual display, used for the diagnosis or monitoring of heart disease), that showed Patient 17’s EF was less than 20. 5.During a review of Patient 22’s Personal Information, the Personal Information indicated Patient 22’s SOC date was 3/26/2025, with a terminal diagnosis of heart disease, unspecified. During a review of Patient 22’s Comprehensive Nursing Assessment, dated 3/26/2025, the Comprehensive Nursing Assessment indicated Patient 22 had normal blood pressure, regular pulse (the number of times the heart beats per minute), no cardiac-related pain (heart-related chest pain), no edema (swelling caused by the accumulation of excess fluid in the body’s tissues), normal skin color, clear lung sounds, and normal respiration. However, the nursing assessment indicated Patient 22 met the criteria for New York Heart Association for Class IV level for heart failure and was optimally treated for heart disease with diuretics (medications used to treat a variety of conditions, including high blood pressure, heart failure and edema) and vasodilators (medications that increase blood flow and reduce blood pressure). During a review of Patient 22’s Re-Cert Assessment, dated 6/17/2025, the Re-Cert Assessment indicated Patient 22 had normal blood pressure, regular pulse, no cardiac-related pain, no edema, normal skin color, clear lung sounds, and normal respiration. However, the Re-Cert assessment indicated Patient 22 met the criteria for New York Heart Association for Class IV heart failure, was optimally treated for heart disease with diuretics and vasodilators and was recertified for hospice care for another benefit period. During an observation and an interview, on a joint home visit at Patient 22’s residence, on 9/9/2025 at 1:40 p.m. with licensed vocational nurse (LVN 2), Patient 22 was observed to be awake, alert, oriented times three (to person, place and time), ambulatory with a cane, and showing no shortness of breath (SOB), edema, palpitations (irregular, fast heartbeat), or chest pain. Vital signs (measurements of the body’s most basic functions, providing crucial information about a person’s general health) were normal. During an interview with Patient 22, Patient 22 stated that no one from the HA explained to her regarding what hospice care was, and she (Patient 22) has no terminal illness and was not dying. Patient 22 stated she (Patient 22) signed up for hospice care because she was told by HA staff (unknown) that they (HA staff) could supervise and check on her (Patient 22) health condition, be visited by a nurse once a week to monitor her blood pressure. Patient 22 stated she was not referred by her own physician to hospice care, was independent with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and is concerned about potential denial of necessary treatment and medications due to her enrollment in hospice care. During an interview and joint record review, on 9/11/2025, at 10:45 a.m., with the DD, the DD reviewed Patient 22’s comprehensive nursing assessment dated 3/26/2025, recertification assessment dated 6/17/2025, and LCD assessment dated 6/17/2025. The DD stated that the agency used LCD assessment to determine patient’s hospice eligibility. The DD stated the initial, recertification and LCD assessments indicated Patient 22 met NYHA Class IV heart failure criteria and was optimally treated with diuretics and vasodilators, thus admitted to hospice care. However, the DD could not provide documented evidence supporting these criteria or treatments. 6.During a review of Patient 23’s Personal Information, the Personal Information indicated Patient 23’s SOC date was 1/1/2025, with a terminal diagnosis of heart disease, unspecified. During a review of Patient 23’s Re-Cert Assessment, dated 6/23/2025, the Re-Cert Assessment indicated Patient 23 had normal blood pressure, no cardiac-related pain, no edema, normal skin color, had normal respiration, and had mild dyspnea only with mild exertion. However, the Re-Cert assessment indicated Patient 23 met the criteria for New York Heart Association for Class IV level, was optimally treated with diuretics and vasodilators, and was recertified for hospice care for another benefit period (3rd). During a review of Patient 23’s Re-Cert Assessment, dated 8/18/2025, the Re-Cert Assessment indicated Patient 23 had normal blood pressure, no cardiac-related pain, no pitting edema, normal skin color, had normal respiration, and had mild dyspnea only with mild exertion. However, the Re-Cert assessment indicated Patient 23 met the criteria for New York Heart Association for Class IV level, was optimally treated for heart disease with diuretics and vasodilators and was recertified for hospice care for another benefit period (4th). Durin g a joint home visit at Patient 23’s residence, on 9/10/2025 at 10:00 a.m. with the DD, Patient 23 was observed to be awake, alert, oriented times three (to person, place and time), ambulatory with a cane, and showing no SOB, edema, palpitations, or chest pain. Vital signs were normal. During an interview, Patient 23 stated she was not referred to hospice by her own attending physician, still want curative treatment, was not optimally treated with diuretics or vasodilators for heart disease and will be devastated if she will face potential denials of necessary medical treatment if needed right now because she is enrolled in hospice care. During an interview and joint record review, on 9/11/2025, at 10:45 a.m., with the DD, the DD reviewed Patient 23’s recertification assessment dated 6/23/2025 and 8/18/2025, and LCD assessment dated 8/18/2025. The DD stated the recertification and LCD assessments indicated Patient 23 met NYHA Class IV heart failure criteria, was optimally treated with diuretics and vasodilators and had an ejection fraction (EF- is the percentage of blood pumped out of the left ventricle with each heartbeat) of less than 20, thus admitted to hospice care. However, the DD could not provide documented evidence supporting these criteria or treatments. 7.During a review of Patient 24’s Personal Information, the Personal Information indicated Patient 24’s SOC date of 2/25/2025, with a terminal diagnosis of heart disease, unspecified. During a review of Patient 24’s Re-Cert Assessment, dated 5/20/2025, the Re-Cert Assessment indicated Patient 24 had normal blood pressure, regular pulse, no cardiac-related pain, no edema, normal skin color, had normal respirations, had mild dyspnea only with mild exertion, had a steady gait and was able to ambulate with any assistive devices. However, the Re-Cert assessment indicated Patient 24 met the criteria for New York Heart Association for Class IV level and was recertified for hospice care for another benefit period (2nd). During a review of Patient 24’s Re-Cert Assessment, dated 8/18/2025, the Re-Cert Assessment indicated Patient 24 had normal blood pressure, regular pulse, no cardiac-related pain, no pitting edema, normal skin color, had normal respirations, had mild dyspnea only with mild exertion, and was able to ambulate with assistive devices cane or walker when heading out. However, the Re-Cert assessment indicated Patient 24 met the criteria for New York Heart Association for Class IV level and was recertified for hospice care for another benefit period (3rd). During a joint home visit at Patient 24’s residence, on 9/9/2025 at 2:30 p.m., with RN 1, Patient 24 was observed sitting in a wheelchair, awake, alert, and oriented times three (to person, place and time), and has no SOB, edema, palpitations, or chest pain. Vital signs were normal. During an interview with Patient 24’s family member (FM 3), FM 3 stated Patient 24’s blood pressure was always normal, has not complained of any chest pain, has no SOB when in bed or chair, and was not sure if Patient 24 really has terminal illness. FM 3 further stated it will be bad and concerning if Patient 24 will face potential denials of necessary medical treatment or medications if needed right now because she is enrolled in hospice care. During an interview and joint record review, on 9/11/2025, at 10:45 a.m., with the DD, the DD reviewed Patient 24’s recertification assessment dated 5/20/2025 and 8/18/2025, and LCD assessment dated 8/18/2025. The DD stated Patient 24’s recertification assessment, and LCD assessment indicated Patient 24 met the criteria for NYHA Class IV level, was optimally treated for heart disease with diuretics and vasodilators, thus was admitted to hospice. However, the DD was unable to provide any documented evidence to support Patient 24 met NYHA IV criteria for heart failure or was optimally treated for heart disease with diuretics and vasodilators. During a record review of the HA’s document titled, Comprehensive Assessment-Content, dated 2019, it indicated that the comprehensive assessment must include physical health components that included diagnosis and terminal illness. During an interview on 9/11/2025, at 10:20 a.m., the Director of Patient Care Services (DPCS) stated the Local Coverage Determination (LCD, a tool that describes the qualifying criteria for hospice care) carried a lot of weight in the admission process. The DPCS stated the patient needed to be qualified based on the LCD guidelines in order to be admitted to hospice. If the patient did not meet the LCD qualification, the patient was not admitted. During an interview on 9/11/2025 at 3 p.m. with the Medical Director (MD1), MD1 stated that he (MD1) would not look (check) at the LCD to determine if patients were eligible. The MD1 stated the Administrator/Director of Patient Care Services Designee (DD) and the Registered Nurse/Case Manager (RN1) ensure LCD compliance are met. During an interview on 9/12/2025 at 11:42 a.m., with MD1, MD1 stated nurses (in general) document patients’ (in general) LCD forms. MD1 stated, he (MD1) relied on the nurse’s (in general) documentation on the LCD to fill out the CTI. During a record review of the HA’s document titled, Admission Orders, dated 2019, indicated, “...Procedure...the hospice nurse is responsible for confirming the admission orders with the patient’s attending physician and the hospice physician. 5. The admission orders are sent to the physician’s office for signature and upon receipt by the hospice, placed in the patient’s clinical record.” During a record review of the HA’s document titled, Admission to Hospice Care and Initial Assessment, dated 2019, indicated, “...Information documenting the patient’s terminal illness is obtained at the time of the referral for hospice care. The attending physician shall provide information regarding the admitting diagnosis, current medical findings...information about medical management of patient conditions unrelated to the terminal illness and designation of an alternate physician to contact in case the attending physician is unavailable during a patient information...In reaching a decision to certify that the patient is terminally ill, the hospice medical director must consider at least the following information: a. Diagnosis of the terminal condition of the patient. B. Other health conditions, whether related or unrelated to the terminal condition. C. Current clinically relevant information supporting all diagnoses.””

“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 HA staff review all the medications and update the medication profile with currently used medications for three of twenty-eight sampled patients (Patient 1, Patient 16, and Patient 22). This failure put Patient 1, Patient 16, and Patient 22 at risk for medication errors and adverse drug reactions. Findings: During an interview on 9/11/2025 at 1:53 p.m. with the Medical Director 1 (MD1), the MD1 stated that he (MD1) reviews patient medications during the interdisciplinary meetings. 1. During a record review of Patient 1’s Personal Information sheet indicated a start of care date of 8/13/2025, with a terminal diagnosis of prostate cancer (cancer of a male organ). During a concurrent observation, interview, and record review on 9/9/2025, at 10:45 a.m., with the Administrator/Director of Patient Care Services Designee (DD), the DD reviewed Patient 1’s medications during the home visit, using Patient 1’s record titled, POC summary, dated 9/8/2025. The following medications were listed but not at home: Amlodipine Besylate (for high blood pressure) 10 mg (mg-milligram, unit of measurement). Patient 1 stated the last time he took this medication was more than 1 month ago. Atorvastatin Calcium (treats high cholesterol) 40 mg. Patient 1 stated ran out of this medication a couple days ago. Benzonatate (treats cough) 200 mg capsule. Patient 1 stated he had run out of the medication. Clonidine Hydrochloride (for high blood pressure) 0.1 mg tablet. Guaifenesin (treats congestion/cough) 400 mg tablet. Patient 1 stated he needed a refill. Losartan Potassium (for high blood pressure) 25 mg. Patient 1 stated to DD, “I told you, there are many meds I need.” Norco (pain reliever) 10 mg-325 mg tablet. Patient 1 stated he ran out of the medication. Oxycodone (pain reliever) 30 mg tablet. Patient 1 stated he ran out of the medication. During an interview on 9/10/2025, at 11:55 a.m., with the DD, the DD stated the nurse was supposed to review the medication Patient 1 was taking at every visit. This was important to do so the HA can avoid problems. Medications are also a safety concern. The medications Patient 1 was taking were considered high risk because all the blood pressure medications can increase the chances of the blood pressure dropping too much (hypotension). 2. During a review of Patient 16’s Personal Information, the Personal Information indicated a start of care (SOC) date of 3/21/2025, with a terminal diagnosis of dysarthria (a speech disorder characterized by difficulty in producing clear and intelligible speech due to damage or dysfunction in the muscles or nerves that control speech production) following other cerebrovascular (relating to the brain and its blood vessels) disease. During a review of Patient 16’s POC (Plan of Care – Summary, as of 9/8/2025, the POC (a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) Summary indicated the HA’s IDT (Interdisciplinary Team – team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions, share resources and responsibilities) was responsible for medical care management that included skilled assessments and interventions, and coordination with pharmacy for medications/supplies and DME supplier for DMEs/supplies. During a joint home visit with Registered Nurse 2 (RN 2) on 9/9/2025 at 10:40 a.m., Patient 16 was observed alert and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 16 was sitting on a recliner. Caregiver 1 (CG 1) was present at Patient 16’s home. During the joint home visit, a review of Patient 16’s available medications at home and the Current Treatment/Medication/DME List (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes) was conducted with RN 2. The following medications and/or treatments were observed at Patient 16’s residence but not listed in the Current Treatment/ Medication/ DME List: - Tums (a medication to treat heartburn and upset stomach) 1000 mg tablet. - Lidocaine 2% viscous solution, swish and spit 15 ml by mouth three times daily as needed for mouth sore. The following medications were listed in the Current Treatment/Medication/DME List, but not available at the patient’s home: - Buprenorphine/Naloxone (a medication used to treat opioid [a class of powerful pain-relieving drugs] use disorder) 4 mg (milligram – a unit measurement) - 1 mg sublingual (under the tongue) film, one film once at bedtime routinely for pain. - Mylanta (a medication used to treat heartburn and upset stomach) 200 mg – 200 mg – 20 mg/ 5 ml (milliliter – a unit measurement), 30 ml by mouth two times a day as needed for heartburn. - Ativan (a medication to treat anxiety) 0.5 mg, one tablet by mouth three times a day as needed for agitation. The following medication was available at the patient’s home in a different dose than what was listed in the Current Treatment/Medication/DME List: - Megace (an appetite stimulant) 40 mg tablet, take ½ tablet by mouth every day. The Current Treatment/Medication/DME List indicated the one ordered by the physician was Megace 20 mg tablet, take one tablet once a day for appetite stimulant. During an interview with RN 2 on 9/9/2025 at 11:25 a.m., RN 2 stated she had never seen Patient 16 before, so she did not know how long Patient 16 had not had the ordered medications. RN 2 stated the visiting RN needed to go over the patient’s medications with each visit, so if the patient was running out of medications the nurse could help reordering from the pharmacy. RN 2 stated if the patient had new medications that were not listed, the physician needed to be notified, and the medication list needed to be updated. RN 2 stated that a current medication list was very important so that the nurse would be able to monitor side effects, provide appropriate teaching, and monitor effectiveness of the medications. During an interview with CG 1 on 9/9/2025 at 11:50 a.m., CG 1 stated she had been providing care for Patient 16 for the past three months. CG 1 stated her responsibilities included preparing and administering medications, preparing food, assisting Patient 16 with personal hygiene, and some clean up. CG 1 stated she followed the instructions on each medication label, but she was not aware that Patient 16 was missing some medications. 3. During a review of Patient 22’s Personal Information, the Personal Information indicated a start of care (SOC) date of 3/26/2025, with a terminal diagnosis (any condition expected to end in death) of heart disease (a group of conditions that affect the heart and its blood vessels), unspecified. During a review of Patient 22’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 9/2/2025, the POC/IDG Review form indicated the frequency of visits of the registered nurse (RN) to one visit a week plus 3 prn (pro re nata, or as needed) visits for clinical care and support o patient’s condition, to assess medications each visit, instruct on new use of medication, and monitor effectiveness of medications. During a joint home visit at Patient 22’s residence, on 9/9/2025 at 1:40 p.m., with licensed vocational nurse (LVN 2), Patient 22 was observed to be awake, alert, oriented x 3 (to person, place and time), and ambulatory with a cane. During a review of Patient 22’s current medication, on 9/9/2025 at 1:56 p.m., with LVN 2, a bottle of Pyridium (pain reliever that works on the lower part of the urinary tract) 100 mg (milligram, a unit of measurement) 1 tablet oral twice daily could not be found. However, the patient’s current medication profile list provided by the HA indicated Patient 22 was still on this medication. During an interview with Patient 22, Patient 22 stated she was only prescribed to take Pyridium for two days in mid-July and completed the course. During an interview, on 9/15/2025 at 2:30 p.m., with the Administrator/Director of Patient Care Services Designee (DD), the DD stated the HA’s nursing staff should check and reconcile patient’s medication on every visit. The DD stated there will be an increased risk of medication errors if medication reconciliation was not being conducted frequently or on every nurse’s visit. During a review of the hospice agency’s policy and procedure (P&P) titled Medication Profile, dated 2019, the P&P indicated when a patient is admitted to hospice, a medication profile is initiated to document all of the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. The patient’s medication profile is reviewed by the IDG whenever there is a significant change and, at a minimum, every fifteen days. The patient’s medication profile review includes but is not limited to… determining accuracy and completeness of the profile. During a review of the HA’s P&P titled “Medication - Management”, dated 2019, the P&P indicated that medications related to the palliation and management of the patient’s terminal illness and related conditions are provided in accordance with the patient’s plan of care and State and Federal laws and regulations. The procedure part of the P & P indicated the following: - A Medication Profile is maintained for every patient including a listing of the current medication orders for each patient and specifies whether the medication is or is not related to the patient’s terminal illness. - The Medication Profile includes all prescription medications, over the counter drugs, vitamins, and herbal and alternative supplements.”

“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 five of twenty-eight sample patients (Patient 1, Patient 8, Patient 9, Patient 11, and Patient 14) families/caregivers were provided with a bereavement assessment. This failure had the potential to result in patient family/caregivers having pain and suffering due to the grief and/or loss of their loved one. Findings: During an interview on 9/12/2025 at 10:08 a.m., with the Spiritual Counselor (SC), the SC stated his (SC) job was to conduct the bereavement assessments on all the patients at time of diagnosis. The SC stated that it was important to provide bereavement services to assess how the patient and their family are doing. The SC stated that all humans’ experience grief, and that some families feel lost and alone. The SC stated that he (SC) informs the family about the hospice process. 1. During a record review of Patient 1’s Personal Information sheet indicated a start of care date of 8/13/2025, with a terminal diagnosis of prostate cancer (a cancer of a male organ). During a record review of Patient 1’s medical records on 9/8/2025, there was no indication an initial bereavement assessment was done. 2. During a record review of Patient 8’s medical record form titled “Personal Information”, undated, indicated a start of care date of 2/16/2024 with a primary diagnosis of human immunodeficiency virus (HIV – virus that attacks the immune system). During a record review of Patient 8’s medical record form titled “POC (plan of care) Summary” dated as of 9/8/2025, indicated that on 2/16/2024 Patient 8’s orders included “Medical care management by Hospice IDT (interdisciplinary team), skilled assessments and interventions by RN (Registered Nurse), LVN (License Vocational Nurse), MSW (Medical Social Worker), SC (Spiritual Counselor), BC (Bereavement Counselor), CHHA (Certified Home Health Aide)…….” During a record review of Patient 8’s medical record form titled “Comprehensive Nursing Assessment” dated 2/18/2024, indicated Patient 8 had multiple loses under the bereavement screening. During a record review of Patient 8’s medical record form titled “Bereavement Assessment” dated 5/24/2024, indicated it was filled out and signed by the Medical Social Worker 2 (MSW2) on 5/24/2024. During a concurrent interview and record review on 9/10/2025 at 10:20 a.m., with the Registered Nurse Case Manager (RN1) of Patient 8’s electronic medical record (EMR), RN1 stated Patient 8’s bereavement assessment was conducted late and that it should have been completed within 5 days of admission. RN1 stated Patient 8’s mother was the bereaved (people in deep sorrow at the loss of a loved one). RN1 stated “The assessment is important because we need to find out if the bereaved are ready for death and dying and to see if they have arrangement.” 3. During a record review of Patient 9’s medical record form titled “Personal Information”, undated, indicated a start of care date of 8/6/2024 with a primary diagnosis of heart disease (a group of conditions that affect the heart and its blood vessels), unspecified. During a record review of Patient 9’s medical record form titled “POC Summary” dated as of 9/8/2025, indicated that on 8/6/2024 Patient 9’s orders included “Medical care management by Hospice IDT (interdisciplinary team), skilled assessments and interventions by RN, LVN, MSW, SC, BC, CHHA…….” During a record review of Patient 9’s medical record form titled “Re-Cert Assessment” dated 7/24/2025, did not indicate Patient 9 was referred to spiritual care or social worker. During a record review of Patient 9’s EMR form titled “History of Bereavement Assessment” indicated there were no entries documented. During a concurrent interview and record review on 9/10/2025 at 11:45 a.m., with the RN1 of Patient 9’s EMR, RN1 stated Patient 9 did not have a bereavement assessment. RN1 stated the assessment should have been completed within five days of Patient 9’s start of care. RN1 stated the HA had to ensure Patient 9’s bereaved were accepting the hospice process. 4. During a record review of Patient 11’s medical record form titled “Personal Information”, undated, indicated a start of care date of 8/5/2024 and an end of care date of 1/7/2025 with a primary diagnosis of chronic obstructive pulmonary disease (COPD – lung disease causing breathing problems). During a record review of Patient 11’s electronic medical record (EMR), the EMR indicated there were no entries made in section “History of Bereavement Assessment.” During a concurrent interview and record review on 9/10/2025 at 2:35 p.m., with the Administrator/ Director of Patient Care Services Designee (DD) of Patient 11’s EMR, the DD stated Patient 11 did not have an initial bereavement assessment documented. The DD stated the initial bereavement assessment helps patients emotionally. The DD stated patients’ families also benefit from the assessment because it provides a holistic approach. 5. During a record review of Patient 14’s medical record form titled “Personal Information”, undated, indicated a start of care date of 7/10/2024 and an end of care date of 6/23/2025 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure (weak heart that does not pump blood correctly). During a record review of Patient 14’s medical record form titled “POC Summary” dated as of 9/9/2025, indicated that on 10/7/2024 Patient 14’s orders included “Medical care management by Hospice IDT (interdisciplinary team), skilled assessments and interventions by RN, LVN, MSW, SC, BC, CHHA…….” During a record review on 9/9/2025 at 5:39 p.m., of Patient 14’s EMR, medical record form titled “History of Bereavement Assessment” indicated there were no entries. During a concurrent interview and record review on 9/11/2025 at 12 p.m., with the Director of Patient Care Services (DPCS) of Patient 14’s EMR, the DPCS stated Patient 14 does not have an initial bereavement documented. The DPCS stated it was important to conduct an initial bereavement assessment to determine if there were any recent deaths in the family, if there are any risk or stressors, how they feel about death, suicidal ideations, mental health issues, or substance abuse. During a record review of the HAs form titled “Comprehensive Assessment – Timing” undated, indicated “The hospice nurse coordinates the comprehensive assessment process and ensures that the patients physical, emotional, psychosocial, spiritual and bereavement needs are assessed.” During a record review of the HAs form titled “Bereavement – Risk Assessment” undated, indicated “During the comprehensive assessment of the patient, an initial bereavement assessment is conducted to determine the cultural, social and spiritual factors that may impact the ability of family members or other involved individuals to cope with the patient’s death.””

“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 interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for four of twenty eight sampled patients (Patient 1, Patient 8, Patient 9, and Patient 17). This failure resulted in patients progress toward desired outcomes including the patient’s response to care were not identified, causing delay of treatment, intervention, and management of needs of the terminally ill patient. During an interview on 9/10/2025 at 9:30 a.m., with the Registered Nurse Case Manager (RN1), RN1 stated she runs the IDG meetings at the HA on Tuesdays at 10 a.m. RN1 stated the HA alternates patients to ensure all patients are assessed. RN1 stated patient changes, new orders, physical and emotional health are discussed, and their plans of care are updated. RN1 stated the MSW1 was responsible for the psychosocial assessment on admission, recertification and as needed. RN1 stated the MSW1 was responsible for documenting and signing patients’ IDGs but does not have a timeline. RN1 stated the SC was responsible for the spiritual assessment on admission, recertification and as needed. RN1 stated the SC was responsible for documenting and signing patients’ IDGs but does not have a timeline. RN1 stated that the disciplines were to document under their discussion section regardless of patient changes or not. RN1 stated the MD1 does not document on the discussion section if there were no changes. During an interview on 9/11/2025 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated one of her roles was to audit patient charts. The DPCS stated, herself and RN1 run the IDG meetings. The DPCS stated that everyone should document and sign the IDG meetings within 24 hours, but that it usually takes longer. The DPCS stated IDG meetings are conducted to update the patients’ plan of care. During an interview on 9/12/2025 at 10:08 a.m., with the Spiritual Counselor (SC), the SC stated he was part of the HA’s IDG and attends weekly meetings at the HA. The SC stated he documents patients’ narrative on the discussion section and signs the IDG the day of the meeting or the next day, but sometimes later. The SC stated his signature on patients IDG indicates that he agrees with the discussion. 1.During a record review of Patient 1’s Personal Information sheet indicated a start of care date of 8/13/2025, with a terminal diagnosis of prostate cancer (a cancer of a male organ).During a concurrent observation, interview, and record review on 9/9/2025, at 10:45 a.m., with the Administrator/Director of Patient Care Services Designee (DD), reviewed Patient 1’s medications during the home visit, using Patient 1’s record titled, POC summary, dated 9/8/2025. The following medications were listed:Amlodipine Besylate (for high blood pressure) 10 mg (mg-milligram, unit of measurement) 1 tablet by mouth once day routinely. Hold the medication if the systolic blood pressure is less than 110. Patient 1 stated the last time he took this medication was over a month ago.Clonidine Hydrochloride (high blood pressure) 0.1 mg 1 tablet by mouth once day as needed for systolic blood pressure greater than 160. Patient 1 stated he took the medication twice a day, only if his blood pressure was high. Losartan Potassium (high blood pressure) 25 mg 1 tablet by mouth one a day. Hold the medication if the systolic blood pressure is less than 110.Metoprolol Tartrate (high blood pressure) 25 mg tablet by mouth. Two times a day routinely. Hold the medication if the heart rate is less than 55.Hydrochlorothiazide (for high blood pressure) 25 mg 1 tablet by mouth. Once a day routinely.During an interview on 9/9/2025, at 11:12 a.m., Patient 1 stated he took all the blood pressure medications prescribed by the doctor.During an interview on 9/9/2025 at 11:37 a.m., Patient 1 stated he took his blood pressure every morning and would write them in a log. During an interview on 9/9/2025, at 11:57 a.m., with the DD, stated he did not review Patient 1’s blood pressure logs. The DD stated it was important to review Patient 1’s blood pressure reading to make sure his blood pressures were not too low. Patient 1 had been hospitalized for falling after excessive alcohol consumption. By taking all the blood pressure medications, in addition to pain medication and alcohol, all increased his chances of falling. The DD stated the IDG group reviewed Patient 1’s medications every meeting and had to see if the IDG group had reviewed Patient 1’s medications. The DD stated Patient 1 needed more education on blood pressure medication management because a lot of those medications needed to be taken or stopped based on the blood pressure readings.During a concurrent interview and record review on 9/10/2025, at 11:35 a.m., with the DD, reviewed Patient 1’s Comprehensive Assessment, dated 8/13/2025. The DD stated the record did not specifically indicate Patient 1 was taught about the blood pressure parameters, to take his blood pressure daily, and to log the blood pressure readings. The DD stated the importance for Patient 1 taking his blood pressure daily and recording it was for the nurses to review the information. If there were changes with the blood pressure, it should have been identified and reported to the Medical Director (MD1) to see if a change of medication was needed.During a concurrent interview and record review on 9/10/2025, at 11:56 a.m., with the DD reviewed Patient 1’s record titled, POC/IDG, dated 8/13/2025. The DD stated Patient 1’s blood pressure readings and medications were not addressed with the IDG group. The DD stated the record did not mention the teaching Patient 1 needed and what side effects to monitor for. During a concurrent interview and record review on 9/10/2025, at 11:59 a.m., DD reviewed Patient 1’s record titled, POC/IDG, dated 8/26/2025. The DD stated the record indicated the same narratives and entries as of the POC/IDG document, dated 8/13/2025. There was no update about Patient 1’s blood pressure and medication effectiveness. The DD stated the purpose of the IDG meeting was to update the team of any changes in the care, to determine if patient required a change in the plan of care. 2.During a record review of Patient 8’s medical record form titled “Personal Information”, undated, indicated a start of care date of 2/16/2024 with a primary diagnosis of human immunodeficiency virus (HIV – virus that attacks the immune system).During a record review of Patient 8’s medical record form titled “POC (plan of care) Summary” dated as of 9/8/2025, indicated orders were written on 8/8/2025, 6/9/2025, 4/10/2025, 2/9/2025, 12/11/2024, 10/12/2024, 7/30/2024, 5/15/2024, and 2/16/2024 for “Medical care management by Hospice IDT (interdisciplinary team).”During a record review of Patient 8’s medical record form titled “POC/IDG (interdisciplinary group) Review” dated 7/22/2025, indicated the physician discussion section was left blank.During a record review of Patient 8’s medical record form titled “Audit Log - IDG” dated from 2/16/2024 to 9/15/2025, indicated Patient 8’s POC/IDG Review form dated 7/22/2025 was signed by the Spiritual Counselor (SC) on 9/8/2025. The POC/IDG Review form also indicated the Registered Nurse Case Manager (RN1) documented in the nursing discussion section and signed the form on 8/29/2025. Lastly, the POC/IDG Review form was signed by the Medical Doctor 1 (MD1) and the Medical Social Worker (MSW1) on 8/17/2025.During a record review of Patient 8’s medical record form titled “POC/IDG Review” dated 9/2/2025, indicated the physician and psychosocial discussion sections were left blank. The POC/IDG Review form indicated the MSW did not sign the form. During a record review of Patient 8’s medical record form titled “Audit Log - IDG” dated from 2/16/2024 to 9/15/2025, indicated Patient 8’s POC/IDG Review form dated 9/2/2025 was signed by the MD1 and SC on 9/8/2025. The Audit Log -IDG form also indicated it was signed by the RN1 on 9/3/2025. During a concurrent interview and record review on 9/10/2025 at 10:20 a.m., with RN1 of Patient 8’s electronic medical record (EMR), RN1 stated she did not know why the MSW1’s discussion or signature was not on Patient 8’s POC/IDG Review form dated 9/2/2025. RN1 stated that it was MSW1’s responsibility to document and sign the form, because her signature would indicate her (MSW1) involvement in Patient 8’s IDG meeting. RN1 stated Patient 8’s last SC assessment was on 6/5/2025. RN1 stated by not having a spiritual assessment, Patient 8 was at risk of stress. 3.During a record review of Patient 9’s medical record form titled “Personal Information”, undated, indicated a start of care date of 8/6/2024 with a primary diagnosis of heart disease (a group of conditions that affect the heart and its blood vessels), unspecified.During a record review of Patient 9’s medical record form titled “POC Summary” dated as of 9/8/2025, indicated orders were written on 7/31/2025, 6/1/2025, 4/2/2025, 2/1/2025, 11/3/2024, and 8/6/2024 for “Medical care management by Hospice IDT (interdisciplinary team).”During a record review of Patient 9’s EMR indicated there were five psychosocial assessments documented, the last one dated 5/22/2025.During a record review of Patient 9’s EMR indicated there was one spiritual assessment documented on 8/10/2024. The spiritual assessment indicated “Plan: spiritual care visits 1x per month, recertification and as needed”During a record review of Patient 9’s medical record form titled “Audit Log” dated from 9/8/2025 to 9/9/2025, indicated the SC singed and documented the spiritual discussion on Patient 9’s IDG dated 9/2/2025, 8/19/2025, and 8/5/2025 on 9/8/2025. The Audit Log also indicated the MD1 signed Patient 9’s IDG dated 9/2/2025 on 9/8/2025. During a concurrent interview and record review on 9/10/2025 at 11:45 a.m. with RN1 of Patient 9’s EMR stated Patient 9 was to be evaluated by the MSW1 and SC per a physician order dated 7/31/2025. RN1 stated Patient 8 had one SC assessment documented dated 8/10/2024. RN1 stated Patient 9 has an SC visit on 9/29/2024, but it was not an assessment. RN1 stated SC assessments are needed to assess if there has been a spiritual decline. RN1 stated there was documentation on 9/9 and 9/10/2024, indicating Patient 9 refused SC services, but does not know if Patient 9 was offered services after that. RN1 stated Patient 9’s last psychosocial assessment was documented on 5/22/2025. RN1 stated that there was no documentation that states Patient 9 refused psychosocial services. RN1 stated psychosocial assessments are needed to assess if there has been a psychosocial decline and to assess for needs. 4.During a review of Patient 17’s Personal Information, the Personal Information indicated a start of care (SOC) date of 1/28/2025, with a terminal diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat).During a review of Patient 17’s History of Spiritual Assessment, the History of Spiritual Assessment indicated that Patient 17 had spiritual assessment completed on 2/4/2025 and 7/22/2025.During a review of Patient 17’s Recert Assessment (recertification assessment – a process to confirm a patient’s continued eligibility for hospice care, which requires a physician to re-evaluate their condition to ensure the terminal illness is still life-limiting with a prognosis of six months or less), dated 4/21/2025, the Recert Assessment indicated that Patient 17 was recertified for a second certification period. During a concurrent interview and record review with Registered Nurse Case Manager (RN 1) on 9/10/2025 at 2:37 p.m., RN 1 reviewed Patient 17’s History of Spiritual Assessment. RN 1 confirmed there was no spiritual assessment done for Patient 17 for the second certification period. RN 1 stated patients were supposed to have a spiritual assessment upon admission, on every recertification, and as needed, unless the patient or family refused. RN 1 stated that after reviewing the Communication Note Log for Patient 17, she did not find any communication note that indicated Patient 17 refused the assessment and there was no note that explained why it was not done. RN 1 stated the reason to have the spiritual assessment done with every recertification was to identify if the patient had different or new issues that require different interventions. RN 1 stated that without an updated spiritual assessment, the HA would not know if the patient had changing needs and therefore could not address those needs. During a review of the HA’s policy and procedure (P&P) titled “Comprehensive Assessments - Updates”, copyrighted 2019, the P&P indicated the hospice’s IDG updates the comprehensive assessment and reassesses the patient’s response to care on a regular basis. The procedure part of the P & P indicated that information from the updated comprehensive assessment is reviewed by the IDG at care planning meetings and is used to revise the patient’s plan of care as needed.”

“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 three of twenty eight sampled patients (Patient 1, Patient 8, and Patient 22) received services as indicated in the plan of care (POC, an individualized, written roadmap developed by a hospice team to meet the holistic needs of a terminally ill patient and their family, focusing on comfort and quality of life rather than a cure). This failure had resulted in not meeting the palliative (managing physical pain, emotional distress, and social challenges) and comfort needs of the patients during the terminal stage of their illness. 1. During a record review of Patient 1’s Personal Information sheet indicated a start of care date of 8/13/2025, with a terminal diagnosis of prostate cancer (a cancer of a male organ).1a. During a record review of Patient 1’s medical records on 9/8/2025, there was no indication that the MSW had done a psychosocial assessment. During a record review of Patient 1’s document titled, POC Summary, dated 9/8/2025, indicated, “Social Worker initial: +2 PRN (as needed) initial evaluation and to develop plan of care and every recertification.”1b. During a record review of Patient 1’s medical records on 9/8/2025, there was no indication that the SC had done a spiritual assessment.During a record review of Patient 1’s document titled, POC Summary, dated 9/8/2025, indicated, “Spiritual Counselor initial: +2 PRN initial evaluation and to develop plan of care and every recertification.”1c. During a record review of Patient 1’s document titled, POC summary, dated 9/8/2025, indicated, “Certified Home Health (CHHA) Aide twice per week to perform ADL (activities of daily living) care…”.During a concurrent interview and record review with Registered Nurse Case Manager (RN 1) on 9/11/2025, at 9:55 a.m., RN 1 reviewed Patient 1’s medical records. RN 1 stated Patient 1 had declined the CHHA visit of 8/18/2025. RN 1 stated she should have followed up after that declined visit. However, there was no follow-up. RN 1 stated Patient 1 did not get any CHHA visits, there was nothing documented about the reason why the visits were not made, and there was no discussion documented among the IDG group. The plan of care was not followed.1d. During a record review of Patient 1’s document titled, POC Summary, dated 9/8/2025, indicated, “Family/caregiver may administer all medication after instructions given for use”.During a record review of Patient 1’s document titled, POC/IDG Review, dated 8/26/2025, indicated that Patient 1’s goals would be able to demonstrate the ability to monitor blood pressure and give medications exactly as ordered and to report to hospice if medication is not effective in maintaining systolic blood pressure below 160 throughout the benefit period. Further review of the record indicated the skilled nurse (SN) was to assess medications each visit, instruct primary care giver (PCG) when to notify hospice related to blood pressure reading, assess patient’s blood pressure and home monitor log, as well as teach PCG how to properly check blood pressure. During a concurrent observation, interview, and record review on 9/9/2025, at 10:45 a.m., with the Administrator/Director of Patient Care Services Designee (DD), the DD reviewed Patient 1’s medications during the home visit, using Patient 1’s record titled, POC summary, dated 9/8/2025. The following medications were listed:Amlodipine Besylate (for high blood pressure) 10 mg (mg-milligram, unit of measurement) 1 tablet by mouth once day routinely. Hold the medication if the systolic blood pressure is less than 110. Patient 1 stated the last time he took this medication was over a month ago.Clonidine Hydrochloride (high blood pressure) 0.1 mg 1 tablet by mouth once day as needed for systolic blood pressure greater than 160. Patient 1 stated he took the medication twice a day, only if his blood pressure was high. Losartan Potassium (high blood pressure) 25 mg 1 tablet by mouth one a day. Hold the medication if the systolic blood pressure is less than 110.Metoprolol Tartrate (high blood pressure) 25 mg tablet by mouth. Two times a day routinely. Hold the medication if the heart rate is less than 55.Hydrochlorothiazide (for high blood pressure) 25 mg 1 tablet by mouth. Once a day routinely.During an interview on 9/9/2025, at 11:12 a.m., Patient 1 stated he took all the blood pressure medications prescribed by the doctor.During an interview on 9/9/2025 at 11:37 a.m., Patient 1 stated he took his blood pressure every morning and would write them in a log.During an interview on 9/9/2025, at 11:57 a.m., with the DD, the DD stated Patient 1 needed more education on blood pressure medication management because a lot of those medications needed to be taken or stopped based on the blood pressure readings. During a concurrent interview and record review on 9/10/2025, at 11:35 a.m., with the DD, the DD reviewed Patient 1’s Comprehensive Assessment, dated 8/13/2025. The DD stated the record did not specifically indicate Patient 1 was taught about the blood pressure parameters, to take his blood pressure daily, and to log the blood pressure readings. The DD stated the importance for Patient 1 taking his blood pressure daily and recording it was for the nurses to review the information. If there were changes with the blood pressure, it should have been identified and reported to the Medical Director to see if a change of medication was needed. 2. During a record review of Patient 8’s medical record form titled “Personal Information”, undated, indicated a start of care date of 2/16/2024 with a primary diagnosis of human immunodeficiency virus (HIV – virus that attacks the immune system).During a record review of Patient 8’s medical record form titled “POC Summary” dated as of 9/8/2025, indicated a registered nurse was to conduct a home visit once per week. During a concurrent interview and record review on 9/10/2025 at 10:20 a.m., with the Registered Nurse Case Manager (RN1) of Patient 8’s electronic medical record (EMR), RN1 stated that Patient 8 skilled nurse visit was to be conducted once a week. RN1 stated that the last skilled nurse visit note was documented on 8/13/2025 and does not know if Patient 8 was visited after that. RN1 stated that patients’ plans of care are patient oriented and need to be followed. RN1 stated that she (RN1) does not know Patient 8’s health status at this time. During a concurrent interview and record review on 9/11/2025 at 2:23 p.m. with the Medical Director (MD1) of Patient 8’s EMR, MD1 stated he (MD1) was unaware that Patient 8 had any missed skilled nurse visits. MD1 stated that it was the nurses’ job to inform him (MD1) of the missed visits. MD1 stated that it was important for him (MD1) to be aware of the missed visits because he (MD1) is following the laws and regulations. 3. During a review of Patient 22’s Personal Information, the Personal Information indicated a start of care date of 3/26/2025, with a terminal diagnosis (any condition expected to end in death) of heart disease, unspecified.During a review of Patient 22’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 6/3/2025, the POC/IDG Review form indicated the frequency of visits of the registered nurse (RN) to one visit per week plus 3 prn (pro re nata, or as needed) visits for clinical care and support of patient’s condition, to assess patient’s pain status and effectiveness of current pain management, and to teach patient caregiver on medications uses and side effects (unintended and often unwanted effects that occur when taking a medicine). During a review of Patient 22’s document titled History of Visit Notes, the History of Visit Notes showed no RN visit occurred from 6/8/2025 to 6/14/2025. During a concurrent interview and record review, on 9/15/2025 at 2:30 p.m., with the DD, the DD reviewed Patient 22’s History of Visit Notes. The DD confirmed that no RN visit occurred for Patient 22 from 6/8/2025 to 6/14/2025, and there was no note explaining the missed visit. The DD stated all nursing visits should follow the plan of care. During a review of the hospice agency’s policy and procedure (P&P) titled Plan of Care, dated 2019, the P&P indicated each patient will have a written plan of care. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. All services furnished to patients must follow a written plan of care established by the interdisciplinary team in collaboration with the attending physician. Care provided to an individual patient is in accordance with the plan of care. During a record review of the HAs form titled “Admission to Hospice Care and Initial Assessment” undated, indicated “The plan of care is based on the initial assessment and is updated as appropriate with input from the patient/family, attending physician and the hospice IDG. The care plan will be appropriate for the type of care that is needed and is directed toward driving positive patient outcomes.””

“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 plan of care included goals and interventions based on the problems identified in the initial comprehensive and updated comprehensive assessments for two of twenty-eight sampled patients (Patient 8 and Patient 16). This failure had the potential to result in patients not receiving services necessary for the palliation (reducing the severity of symptoms or suffering without curing the underlying disease; aims to provide comfort and improve quality of life) and management of the terminal illness and related conditions. 1. During a record review of Patient 8’s medical record form titled “Personal Information”, undated, indicated a start of care date of 2/16/2024 with a primary diagnosis of human immunodeficiency virus (HIV – virus that attacks the immune system).During a record review of Patient 8’s medical record form titled “POC/IDG Review” dated 9/2/2025, indicated the Registered Nurse Case Manager (RN1) was the nurse who documented in the nursing discussion section and signed the form. RN1 documented that Patient 8 was seen at an urgent care on 8/25 and was prescribed Amoxicillin/Clavulanate Potassium for a perineal abscess. The POC/IDG Review form also indicated Patient 8’s perineal abscess had not been care planned, there were no goals, interventions, or monitoring ordered. During a record review of Patient 8’s medical record form titled “POC (plan of care) Summary” dated as of 9/8/2025, did not indicate Patient 8’s perineal abscess was care planned. During a concurrent interview and record review on 9/10/2025 at 10:20 a.m. with the RN1 of Patient 8’s electronic medical record (EMR), RN1 stated the last nursing visit note for Patient 8 was documented on 8/13/2025. RN1 stated there was no documentation as to why Patient 8 has not been seen since 8/13/2025. RN1 stated “At this moment I don’t know the status of the patient, because there is no documentation. I don’t know her (Patient 8) status.” 2. During a review of Patient 16’s Personal Information, the Personal Information indicated a start of care (SOC) date of 3/21/2025, with a terminal diagnosis of dysarthria (a speech disorder characterized by difficulty in producing clear and intelligible speech due to damage or dysfunction in the muscles or nerves that control speech production) following other cerebrovascular (relating to the brain and its blood vessels) disease.During a review of Patient 16’s the Current Treatment/Medication/DME List (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List listed Vitamin A & D ointment (a skin protectant that works by creating a thick, protective barrier over the skin to seal out wetness), one big tub/jar, and Calmoseptine (a topical ointment that acts as a moisture barrier to protect and help heal irritated skin), one big tube. The dosage, route, frequency, and indication for Vitamin A & D ointment and Calmoseptine were left blank.During a review of Patient 16’s Recert Assessment (recertification assessment – a process to confirm a patient’s continued eligibility for hospice care, which requires a physician to re-evaluate their condition to ensure the terminal illness is still life-limiting with a prognosis of six months or less), dated 7/5/2025, the Recert Assessment, under Integumentary-Skin, indicated as follows: Patient has a pressure ulcer (a localized area of skin damage that develops when prolonged pressure is applied to a specific area of the body) stage 1 (the earliest stage of pressure sore development) to the sacral area (the region of the lower back where the sacrum bone [a triangular-shaped bone that forms the base of the spine] is located), education provided to caregiver regarding keeping patient clean and dry and to make sure to have patient reposition every 2 hours. There was no treatment indicated for the stage 1 pressure ulcer/sore. During a review of Patient 16’s POC/IDG Review (Plan of Care/Interdisciplinary Group Review, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), dated 9/2/2025, the POC/IDG Review did not identify and include the problem, intervention, goals, and status related to integumentary/skin. During a joint home visit with Registered Nurse 2 (RN 2) on 9/9/2025 at 10:40 a.m., Patient 16 was observed alert and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 16 was sitting on a recliner. Caregiver 1 (CG 1) was present at Patient 16’s home. Observed RN 2 conducted skin assessment on Patient 16. Observed a minimally blanching redness on the sacral area. Did not observe RN 2 measure the redness. During an interview with CG 1 on 9/9/2025 at 11:50 a.m., CG 1 stated she had been providing care for Patient 16 for the past three months. CG 1 stated her responsibilities included preparing and administering medications, preparing food, assisting Patient 16 with personal hygiene, and some clean up. CG 1 stated she applied Vitamin A & D ointment and Calmoseptine on the sacral area daily.During a concurrent interview and record review with the Director of Patient Care Services (DPCS) and RN 1 on 9/15/2025 at 2:37 p.m., the DPCS reviewed Patient 16’s Comprehensive Nursing Assessment, dated 3/21/2025, Recert Assessments, dated 5/16/2025 and 7/5/2025, POC/IDG Review, dated 9/2/2025, and the Current Treatment/Medication/DME List. The DPCS stated the POC/IDG for Patient 16 was incomplete because it did not include the stage 1 pressure ulcer and it did not include the necessary interventions, goals, and expected outcomes. The DPCS stated that since the pressure ulcer was not addressed in the plan of care, the HA had not monitored it. The DPCS stated that without monitoring, it would be difficult to know if the pressure ulcer was improving or not, which could affect the interventions for Patient 16. The DPCS stated that for every medication or treatment ordered, the dosage, route, frequency, and indication needed to be included. When the DPCS was asked for the HA’s policy on pressure ulcer, the DPCS stated the HA did not currently have a policy on pressure ulcer/sore. During a review of the HA’s policy and procedure (P&P) titled “Plan of Care - Content”, copyrighted 2019, the P&P indicated the plan of care specifies the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions. During a record review of the HAs form titled “Admission to Hospice Care and Initial Assessment” undated, indicated “The outcome of the comprehensive assessment forms the basis for the goals and interventions contained in 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 provide one of twenty-eight sampled patients (Patient 16) with drugs and treatment necessary to meet the needs of the patient. This failure had the potential to result in uncontrolled symptoms, which could affect the patient’s quality of life. During a review of Patient 16’s Personal Information, the Personal Information indicated a start of care (SOC) date of 3/21/2025, with a terminal diagnosis of dysarthria (a speech disorder characterized by difficulty in producing clear and intelligible speech due to damage or dysfunction in the muscles or nerves that control speech production) following other cerebrovascular (relating to the brain and its blood vessels) disease.During a joint home visit with Registered Nurse 2 (RN 2) on 9/9/2025 at 10:40 a.m., Patient 16 was observed alert and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 16 was sitting on a recliner. Caregiver 1 (CG 1) was present at Patient 16’s home.During the joint home visit, a review of Patient 16’s available medications at home and the Current Treatment/Medication/DME List (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes) was conducted with RN 2.During the joint home visit, a review of Patient 16’s available medications at home and the Current Treatment/Medication/DME List (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes) was conducted with RN 2. The following medications were listed in the Current Treatment/Medication/DME List, but not available at the patient’s home:- Buprenorphine/Naloxone (a medication used to treat opioid [a class of powerful pain-relieving drugs] use disorder) 4 mg (milligram – a unit measurement) - 1 mg sublingual (under the tongue) film, one film once at bedtime routinely for pain.- Mylanta (a medication used to treat heartburn and upset stomach) 200 mg – 200 mg – 20 mg/ 5 ml (milliliter – a unit measurement), 30 ml by mouth two times a day as needed for heartburn. - Ativan (a medication to treat anxiety) 0.5 mg, one tablet by mouth three times a day as needed for agitation. During an interview with RN 2 on 9/9/2025 at 11:25 a.m., RN 2 stated she had never seen Patient 16 before, so she did not know how long Patient 16 had not had the ordered medications.During a phone interview with RN 4 on 9/10/2025 at 12:52 p.m., RN 4 stated she had been visiting Patient 16 weekly for approximately two to three months. RN 4 stated she checked Patient 16’s medications with each visit. RN 4 stated she did not remember seeing Buprenorphine/Naloxone sublingual film, Mylanta, or Ativan. RN 4 stated that Patient 16 and CG 1 did not report pain during her visits. RN 4 stated even though those were as needed medications, they needed to be available. During a concurrent interview and record review with RN 1 on 9/10/2025 at 1:15 p.m., RN 1 reviewed Patient 16’s Current Treatment/Medication/DME List. RN 1 stated that the visiting RN should have checked with every visit to make sure the patient had all the medications ordered. RN 1 stated that as needed medications had to be available in case the patient needed it. RN 1 stated that if the medications were ordered by the physician, then they were conserved necessary for the patient. During a review of the HA’s policy and procedure (P&P) titled “Medication - Management”, copyrighted 2019, the P&P indicated that medications related to the palliation and management of the patient’s terminal illness and related conditions are provided in accordance with the patient’s plan of care and State and Federal laws and regulations. The procedure section of the P & P indicated that medications are provided on a timely basis and are available 24 hours a day and seven days a week as needed.”

“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 provide one of twenty-eight sampled patients (Patient 16) with medical supplies and appliances necessary to meet the needs of the patient. This failure had the potential to result in patient’s comfort, safety, and quality of life being compromised. During a review of Patient 16’s Personal Information, the Personal Information indicated a start of care (SOC) date of 3/21/2025, with a terminal diagnosis of dysarthria (a speech disorder characterized by difficulty in producing clear and intelligible speech due to damage or dysfunction in the muscles or nerves that control speech production) following other cerebrovascular (relating to the brain and its blood vessels) disease. During a review of Patient 16’s Current Treatment/Medication/DME List (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List indicated that on 3/22/2025 the physician the following for Patient 16:- Oxygen concentrator (a medical device that provides supplemental, concentrated oxygen to people with low blood oxygen levels) 5 liters (a unit measurement for volumes).- Oxygen E tank (a common, portable, lightweight metal cylinder, approximately 3 feet tall, that stores compressed medical oxygen for patients who need it for breathing assistance).- Suction machine (a medical device that uses a vacuum to remove fluids, blood, mucus, saliva, and other secretions from a patient’s airway or body).Patient 16’s Current Treatment/Medication/DME List, oxygen inhalation at 2 liters per minute via nasal cannula (a lightweight, tube-like device with two prongs that fit into the nostrils to deliver supplemental oxygen to patients with respiratory conditions) was to be administered as needed for shortness of breath, may titrate to 3 liters per minute to 5 liters per minute as needed.A review of POC Summary (Plan of Care Summary – a document that summarizes a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) for Patient 16, as of 9/11/2025, indicated the oxygen concentrator, oxygen tank, and suction machine in the DME section. During a joint home visit with Registered Nurse 2 (RN 2) on 9/9/2025 at 10:40 a.m., Patient 16 was observed alert and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 16 was sitting on a recliner. Caregiver 1 (CG 1) was present at Patient 16’s home.During the joint home visit, at 11:17 a.m., a man arrived at Patient 16’s residence to deliver oxygen concentrator, nasal cannula, and oxygen tank. The man stated that he was a staff of the DME company who was assigned to deliver the oxygen concentrator, nasal cannula, and oxygen tank. When the DME company staff was asked if his company had previously delivered the oxygen concentrator, nasal cannula, and oxygen tank to Patient 16, he stated that there was no prior delivery made since the HA had just ordered the oxygen concentrator and oxygen tank. Patient 16 refused the delivery. Patient 16 stated the HA had never sent oxygen before. During the home visit, an inspection on DMEs ordered for Patient 16 was conducted. It was noted that there was no suction machine available at the residence. It was also noted that Patient 16’s hospital bed mattress’ covering was torn in multiple places. Observed tapes applied on the mattress that held the mattress together. CG 1 stated, “The mattress broke a while ago. I put tape to fix it. I told the nurse several times but still no new mattress.” CG 1 stated that she had never seen a suction machine in the apartment. CG 1 also stated that she had never seen an oxygen concentrator and an oxygen tank prior to the delivery today. During an interview with RN 2 on 9/9/2025 at 11:25 a.m., RN 2 stated she had never seen Patient 16 before. RN 2 stated that since oxygen concentrator, oxygen tank, and suction machine were ordered for Patient 16, the HA needed to provide those. RN 2 stated that according to the HA, oxygen concentrator and oxygen tank were ordered and delivered but the patient refused.During a phone interview with RN 4 on 9/10/2025 at 12:52 p.m., RN 4 stated she had been visiting Patient 16 weekly for approximately two to three months. When RN 4 was asked if she was aware that Patient 16 had not been provided with oxygen concentrator, oxygen tank, and suction machine, RN 4 stated that she was not aware. RN 4 stated, “I don’t look at the DME that much. I just inspect the DMEs at the patient’s house, such as the walker and the bed.” When RN 4 was asked if she had reported that Patient 16’s bed covering was torn apart, RN 4 stated she had never inspected the mattress and therefore did not know about this issue. During a concurrent interview and record review with RN 1 on 9/10/2025 at 1:15 p.m., RN 1 reviewed Patient 16’s Current Treatment/Medication/DME List and POC Summary. RN 1 stated that oxygen concentrator, oxygen tank, and suction machine were still listed as active physician orders for Patient 16, which means they were considered necessary by the physician. RN 1 stated that DMEs were ordered based on patient assessment, it was determined the patient needed those DMEs. RN 1 stated the HA was required to provide all DMEs ordered for the patient. RN 1 stated, “Even though the order is as needed, oxygen and suction machine should be available to use anytime the patient needs it.” The HA was not able to provide proof of delivery prior to 9/9/2025 for the oxygen concentrator, oxygen tank, and suction machine by the DME company as requested by the survey team on 9/10/2025. During a review of the HA’s policy and procedure (P&P) titled “Plan of Care”, copyrighted 2019, the P&P indicated that the care and services provided/delivered to patients and their families are in accordance with an individualized, written plan of care established by the hospice IDG in collaboration with the patient’s attending physician, the patient and/or his or her representative and the primary caregiver in accordance with the patient’s needs if any of them so desire.”

“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 interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) review, revise, and document the individualized plan of care as the patient’s condition requires, at least every 15 days for five of twenty eight sampled patients (Patient 1, Patient 2, Patient 8, Patient 9, and Patient 17). This failure resulted in patient’s hospice needs are not being evaluated and will not be met which could impact their quality of life. During an interview on 9/10/2025 at 9:30 a.m., with the Registered Nurse Case Manager (RN1), RN1 stated she runs the HA’s IDG meetings at the HA on Tuesdays at 10 a.m. RN1 stated the HA alternates patients to ensure all patients are assessed. RN1 stated patient changes, new orders, physical and emotional health are discussed, and their plan of care are updated. RN1 stated the MSW1 was responsible for the psychosocial assessment on admission, recertification and as needed. RN1 stated the MSW1 was responsible for documenting and signing patients’ IDGs but does not have a timeline. RN1 stated the SC was responsible for the spiritual assessment on admission, recertification and as needed. RN1 stated the SC was responsible for documenting and signing patients’ IDGs but does not have a timeline. RN1 stated that the disciplines were to document under their discussion section regardless of patient changes or not. RN1 stated the MD1 does not document on the discussion section if there were no changes. During an interview on 9/11/2025 at 10 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated one of her roles was to audit patient charts. The DPCS stated that herself and RN1 run the IDG meetings. The DPCS stated that everyone should be documenting and signing the IDG meetings within 24 hours, but that it usually takes longer. The DPCS stated IDG meetings are conducted to update the patients’ plan of care. During an interview on 9/12/2025 at 10:08 a.m. with the Spiritual Counselor (SC) he was part of the HA’s IDG and attends weekly meetings at the HA. The SC stated he documents patients’ narrative on the discussion section and signs the IDG the day of the meeting or the next day, but sometimes later. The SC stated that his signature on patients IDG indicate that he agrees with the discussion. 1a. During a record review of Patient 1’s Personal Information sheet indicated a start of care date of 8/13/2025, with a terminal diagnosis of prostate cancer (a cancer of a male organ). During a concurrent observation and interview at the home visit on 9/9/2025, at 10:35 a.m. the Administrator/Director of Patient Care Services Designee (DD) asked Patient 1 if he was in pain. An observation of Patient 1 indicated Patient 1 was grimacing as he stated that his right foot was painful and felt as if his rods (medical tool placed to hold the bone) were coming out. Patient 1 stated to the DD that he had fallen 2 weeks ago and someone was supposed to come to his home to x-ray (a medical picture) his foot. Patient 1 stated he had had an operation done previously on his foot. Patient 1 stated he fell often.During a concurrent interview and record review on 9/10/2025, at 12:15 p.m., the DD reviewed Patient 1’s medical records titled, Visit Note RN, dated 8/26/2025. The record indicated, “Patient c/o (complain of) pain to his RLE (right lower extremity-leg) at 8/10 (using a 10-point scale. 8 is considered a lot of pain) ...Office staff was notified at time of visit-possible consult with supervising physician (doctor) and need to order x-ray to RLE. Patient was advised to have caregiver take him to Urgent Care or ER (Emergency room) if symptoms persist or worsen.” The DD stated the nurse visited the patient, assessed Patient 1’s pain, and the note indicated patient needed an x-ray. The DD continued to review Patient 1’s records and stated there was no mention the nurse notified the doctor, and an x-ray was ordered. The DD stated the order for x-ray was placed on 9/10/2025.During an interview on 9/10/2025, at 12:31 p.m., the DD stated the x-ray was delayed. Patient 1 had requested it on 8/26/2025. Patient 1 was in pain, and the HA did not know why. Maybe there was a fracture (break). The HA needed to confirm it.1b. During a concurrent observation, interview, and record review on 9/9/2025, at 10:45 a.m., with the Director of Patient Care Services Designee (DD), the DD reviewed Patient 1’s medications during the home visit, using Patient 1’s record titled, POC summary, dated 9/8/2025. The following medications were listed:Amlodipine Besylate (for high blood pressure) 10 mg (mg-milligram, unit of measurement) 1 tablet by mouth once day routinely. Hold the medication if the systolic blood pressure is less than 110. Patient 1 stated the last time he took this medication was over a month ago.Clonidine Hydrochloride (high blood pressure) 0.1 mg 1 tablet by mouth once day as needed for systolic blood pressure greater than 160. Patient 1 stated he took the medication twice a day, only if his blood pressure was high. Losartan Potassium (high blood pressure) 25 mg 1 tablet by mouth one a day. Hold the medication if the systolic blood pressure is less than 110.Metoprolol Tartrate (high blood pressure) 25 mg tablet by mouth. Two times a day routinely. Hold the medication if the heart rate is less than 55.Hydrochlorothiazide (for high blood pressure) 25 mg 1 tablet by mouth. Once a day routinely.During an interview on 9/9/2025, at 11:12 a.m., Patient 1 stated he took all the blood pressure medications prescribed by the doctor.During an interview on 9/9/2025 at 11:37 a.m., Patient 1 stated he took his blood pressure every morning and would write them in a log. During an interview on 9/9/2025, at 11:57 a.m., with the DD, the DD stated he did not review Patient 1’s blood pressure logs. The DD stated it was important to review Patient 1’s blood pressure reading to make sure his blood pressures were not too low. Patient 1 had been hospitalized for falling after excessive alcohol consumption. By taking all the blood pressure medications, in addition to pain medication and alcohol, all increased his chances of falling. The DD stated the IDG group reviewed Patient 1’s medications every meeting and had to see if the IDG group had reviewed Patient 1’s medications. The DD stated Patient 1 needed more education on blood pressure medication management because a lot of those medications needed to be taken or stopped based on the blood pressure readings.During a concurrent interview and record review on 9/10/2025, at 11:56 a.m., with the DD, the DD reviewed Patient 1’s record titled, POC/IDG, dated 8/13/2025. The DD stated Patient 1’s blood pressure readings and medications were not addressed with the IDG group. The DD stated the record did not mention the teaching Patient 1 needed and what side effects to monitor for. During a concurrent interview and record review on 9/10/2025, at 11:59 a.m., with the DD, the DD reviewed Patient 1’s record titled, POC/IDG, dated 8/26/2025. The DD stated the record indicated the same narratives and entries as of the POC/IDG document, dated 8/13/2025. The record was not updated for Patient 1. There was no update about Patient 1’s blood pressure and medication effectiveness. The DD stated the purpose of the IDG meeting was to update the team of any changes in the care, to determine if patient required a change in the plan of care. The DD continued to review the record and stated there was no update regarding Patient 1’s right leg pain and need of an x-ray either. 2. During a record review of Patient 2’s Personal Information, indicated a start of care date of 7/12/2025, with a terminal diagnosis of Chronic Obstructive Pulmonary disease (COPD, an illness that makes breathing difficult). During concurrent interview and record review on 9/10/2025, at 3:25 p.m., with Registered Nurse 1 (RN 1), RN 1 reviewed Patient 2’s record titled, POC Summary, dated 9/8/2025. The record indicted Patient 2 had a stage 2 pressure ulcer (an opening of the skin, extending to the outer layer of the skin). RN 1 reviewed Patient 2’s medical records and stated the stage 2 wound had improved to redness only as of 8/4/2025. The wound was no longer open. RN 1 stated the POC had not been updated, and it should have because the POC is the guide for nursing care.During a concurrent interview and record review on 9/10/2025, at 3:41 p.m., with RN 1, RN 1 reviewed Patient 2’s document titled, POC/IDG Review, dated 8/5/2025, 8/19/2025, and 9/2/2025. RN 1 stated the documents did not indicate any discussion about the progress of the wound. There was no mention about Patient 2’s wound. RN 1 stated the IDG group should have mentioned the wound because there was progress. There was a positive change of condition. The interventions needed to be changed. The POC needed to be updated. 3. During a record review of Patient 8’s medical record form titled “Personal Information”, undated, indicated a start of care date of 2/16/2024 with a primary diagnosis of human immunodeficiency virus (HIV – virus that attacks the immune system).During a record review of Patient 8’s medical record form titled “POC (plan of care) Summary” dated as of 9/8/2025, indicated orders were written on 8/8/2025, 6/9/2025, 4/10/2025, 2/9/2025, 12/11/2024, 10/12/2024, 7/30/2024, 5/15/2024, and 2/16/2024 for “Medical care management by Hospice IDT (interdisciplinary team).”During a record review of Patient 8’s medical record form titled “POC/IDG (interdisciplinary group) Review” dated 7/22/2025, indicated the physician discussion section was left blank.During a record review of Patient 8’s medical record form titled “Audit Log - IDG” dated from 2/16/2024 to 9/15/2025, indicated Patient 8’s POC/IDG Review form dated 7/22/2025 was signed by the Spiritual Counselor (SC) on 9/8/2025. The POC/IDG Review form also indicated the Registered Nurse Case Manager (RN1) documented in the nursing discussion section and signed the form on 8/29/2025. Lastly, the POC/IDG Review form was signed by the Medical Doctor 1 (MD1) and the Medical Social Worker (MSW1) on 8/17/2025.During a record review of Patient 8’s medical record form titled “POC/IDG Review” dated 9/2/2025, indicated the physician and psychosocial discussion sections were left blank. The POC/IDG Review form indicated the MSW did not sign the form. During a record review of Patient 8’s medical record form titled “Audit Log - IDG” dated from 2/16/2024 to 9/15/2025, indicated Patient 8’s POC/IDG Review form dated 9/2/2025 was signed by the MD1 and SC on 9/8/2025. The Audit Log -IDG form also indicated it was signed by the RN1 on 9/3/2025. During a concurrent interview and record review on 9/10/2025 at 10:20 a.m. with RN1 of Patient 8’s electronic medical record (EMR), RN1 stated that she did not know why the MSW1’s discussion or signature was not on Patient 8’s POC/IDG Review form dated 9/2/2025. RN1 stated that it was MSW1’s responsibility to document and sign the form, because her signature would indicate her (MSW1) involvement in Patient 8’s IDG meeting. RN1 stated that Patient 8’s last SC assessment was on 6/5/2025. RN1 stated by not having a spiritual assessment, Patient 8 was at risk of stress. 4. During a record review of Patient 9’s medical record form titled “Personal Information”, undated, indicated a start of care date of 8/6/2024 with a primary diagnosis of heart disease (a group of conditions that affect the heart and its blood vessels), unspecified.During a record review of Patient 9’s medical record form titled “POC Summary” dated as of 9/8/2025, indicated orders were written on 7/31/2025, 6/1/2025, 4/2/2025, 2/1/2025, 11/3/2024, and 8/6/2024 for “Medical care management by Hospice IDT (interdisciplinary team).”During a record review of Patient 9’s EMR, the EMR indicated there were five psychosocial assessments documented, the last one dated 5/22/2025.During a record review of Patient 9’s EMR, the EMR indicated there was one spiritual assessment documented on 8/10/2024. The spiritual assessment indicated “Plan: spiritual care visits 1x per month, recertification and as needed”. During a record review of Patient 9’s medical record form titled “Audit Log” dated from 9/8/2025 to 9/9/2025, indicated the SC singed and documented the spiritual discussion on Patient 9’s IDG dated 9/2/2025, 8/19/2025, and 8/5/2025 on 9/8/2025. The Audit Log also indicated the MD1 signed Patient 9’s IDG dated 9/2/2025 on 9/8/2025.During a concurrent interview and record review on 9/10/2025 at 11:45 a.m. with RN1 of Patient 9’s EMR, RN1 stated Patient 9 was to be evaluated by the MSW1 and SC per a physician order dated 7/31/2025. RN1 stated Patient 8 had one SC assessment documented dated 8/10/2024. RN1 stated Patient 9 has an SC visit on 9/29/2024, but it was not an assessment. RN1 stated SC assessments are needed to assess if there has been a spiritual decline. RN1 stated there was documentation on 9/9 and 9/10/2024, indicating Patient 9 refused SC services, but does not know if Patient 9 was offered services after that. RN1 stated Patient 9’s last psychosocial assessment was documented on 5/22/2025. RN1 stated that there is no documentation that states Patient 9 refused psychosocial services. RN1 stated psychosocial assessments are needed to assess if there has been a psychosocial decline and to assess for needs. 5. During a review of Patient 17’s Personal Information, the Personal Information indicated a start of care (SOC) date of 1/28/2025, with a terminal diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat).During a review of Patient 17’s History of Spiritual Assessment, the History of Spiritual Assessment indicated that Patient 17 had spiritual assessment completed on 2/4/2025 and 7/22/2025.During a review of Patient 17’s Recert Assessment (recertification assessment – a process to confirm a patient’s continued eligibility for hospice care, which requires a physician to re-evaluate their condition to ensure the terminal illness is still life-limiting with a prognosis of six months or less), dated 4/21/2025, the Recert Assessment indicated that Patient 17 was recertified for a second certification period. During a concurrent interview and record review with Registered Nurse Case Manager (RN 1) on 9/10/2025 at 2:37 p.m., RN 1 reviewed Patient 17’s History of Spiritual Assessment. RN 1 confirmed there was no spiritual assessment done for Patient 17 for the second certification period. RN 1 stated that patients were supposed to have a spiritual assessment upon admission, on every recertification, and as needed, unless the patient or family refused. RN 1 stated that after reviewing the Communication Note Log for Patient 17, she did not find any communication note that indicated Patient 17 refused the assessment and there was no note that explained why it was not done. RN 1 stated the reason to have the spiritual assessment done with every recertification was to identify if the patient had different or new issues that require different interventions. RN 1 stated that without an updated spiritual assessment, the HA would not know if the patient had changing needs and therefore could not address those needs. During a review of the HA’s policy and procedure (P&P) titled “Comprehensive Assessments - Updates”, copyrighted 2019, the P&P indicated the hospice’s IDG updates the comprehensive assessment and reassesses the patient’s response to care on a regular basis. The procedure part of the P & P indicated that information from the updated comprehensive assessment is reviewed by the IDG at care planning meetings and is used to revise the patient’s plan of care as needed.”

“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 medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications for eight of twenty eight sampled patients (Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10) to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patient’s pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. The hospice agency failed to ensure there was documentation of clinical information that included patient’s history and physicals, laboratory, and imaging data, biopsy results, etc., necessary for initial certification of hospice are and services. This failure resulted in the hospice medical director and/or the designee certifying these patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses. During an interview on 9/11/2025 at 2:05 p.m., with the Nurse Practitioner (NP), the NP stated that sometimes she (NP) personally visits patients and sometimes she (NP) conducts a telehealth. The NP stated nurses conduct the patients’ assessments and report it back to her (NP). The NP stated she (NP) bases her (NP) assessment on the nurses’ assessments. The NP stated she (NP) reports to the Medical Director (MD1) when there are abnormalities or medications that need to be ordered. During an interview on 9/12/2025 at 11:05 a.m., with the Medical Director (MD1), the MD1 stated he (MD1) does not see all the patients personally. MD1 stated he saw Patient 8 and Patient 16 from the twenty-eight sample patients personally. MD1 stated he (MD1) composes patients CTIs (Certification of Terminal Illness) based on the assessment and information provided by the nurses’ notes, the interdisciplinary group (IDG) meetings, and “specially” the face-to-face physical assessment documentation of the NP. During an interview on 9/16/2025 at 11:12 a.m., with MD1 stated he does not review patients’ records. MD1 stated patients are discussed during the IDG meetings. 1. During a record review of Patient 3’s Personal Information sheet, indicated a start of care date of 7/30/2024. The record also indicated an end of care date of 4/37/2025 for the reason of hospitalized. A record review of Patient 3’s CTI, for certification period #1, dated 7/30/2024 to 10/27/2024, indicated Patient 3’s terminal diagnosis of Malignant neoplasm of prostate (prostate cancer). During an interview on 9/10/2025, at 1:23 p.m., Patient 3’s son (FM 6) stated Patient 3 was never in hospice. FM 6 stated Patient 3 was never terminal. FM 6 stated no one told Patient 3 and FM 6 that Patient 3 had 6 months or less to live. FM 6 stated, “you said his care was on 7/30/2024? If he was passing away, don’t you think he would be dead now?”. FM 6 stated Patient 3 goes to his doctor and is doing fine. During a concurrent interview and record review on 9/11/2025, at 10:18 a.m., Registered Nurse 1 (RN 1) reviewed Patient 3’s medical records from his primary care doctor, dated 2023 and 2024. RN 1 stated the records indicated that Patient 3 had a suspicion that the cancer had spread, but further studies still needed to be done. RN 1 stated the documents did not confirm the cancer had spread. RN 1 further reviewed the records and stated Patient 3 had been referred to orthopedics and oncology. During an interview on 9/11/2025, at 10:20 a.m., the Director of Patient Care Services (DPCS) stated the LCD (Local Coverage Determination-a tool used to determine if patient qualifies for hospice care) carried a lot of weight in the admission process. The patient needed to qualify based on the LCD guidelines in order to admit to hospice. If the patient did not meet the LCD qualifications, the HA should not admit. During a concurrent interview and record review on 9/11/2025, at 10:22 a.m., RN 1 reviewed Patient 3’s LCD, included in the Comprehensive Assessment, dated 7/30/2024. The LCD had the word “select” under the question: Disease with metastasis (spread) at presentation (a must be met). RN 1 stated “select” meant the question was not answered. The LCD also indicated Patient 3 had been ruled out as a candidate or declines further curative therapy: RN 1 stated there was nothing documented to support this. RN 1 stated the agency did not have any supporting documentation to admit Patient 3 into hospice care. 2. During a record review of Patient 4’s Personal Information, indicated a start of care date of 8/20/2025. A record review of Patient 4’s CTI, for certification period #1, dated 8/20/2024 to 11/17/2024, indicated Patient 4’s terminal diagnosis of Malignant neoplasm of cervix (cervical cancer). During a concurrent interview and record review with the Director of Patient Care Services designee (DD), on 9/15/2025, at 10:22 a.m., the DD reviewed Patient 4’s LCD, included in the Comprehensive Assessment, dated 8/20/2024. The record indicated Patient 4 met criteria due to cancer metastasis. The DD reviewed Patient 4’s medical records, including the History and Physical (H&P, a document that lists the patients’ medical problems, and treatment plan) dated 7/17/2018. The record indicated, “History of cervical carcinoma (cancer): the patient is in remission (temporary or permanent disappearance of symptoms) at this time status post radiation therapy (XRT) and chemotherapy”. The DD stated there was no documentation to support Patient 4’s cancer had metastasized (spread). The DD stated based on what was documented on the LCD, the LCD was not done correctly. The DD stated, he was the visiting nurse, and he did not recall what information he used to answer the LCD. At the time, the DD did not have the H&P. 3. During a record review of Patient 5’s Personal Information, indicated a start of care of 1/1/2025. A record review of Patient 5’s CTI, for certification period #1, dated 1/1/2025 to 3/31/2025, indicated Patient 5’s terminal diagnosis of hypertensive heart disease with heart failure. During a concurrent interview and record review with Registered Nurse 4 (RN 4), on 9/11/2025, at 10:48 a.m., RN 4 reviewed Patient 5’s H&P records. RN 4 stated the most recent H&P records were dated 6/30/2022 and these did not have any evidence of heart failure. RN 4 stated the document indicated Patient 5 was to be referred to the cardiologist (a doctor who specializes in the heart). During a concurrent interview and record review with RN 4, on 9/11/2025, at 11:04 a.m., the RN 4 reviewed Patient 5’s LCD, included in the Comprehensive Assessment, dated 1/1/2025. The LCD indicated Patient 5 met hospice criteria due evidence of heart failure, an ejection fraction of less than 20 (a test that shows the function of the heart) and history of fainting. RN 4 reviewed Patient 5’s medical records and stated there was no evidence to support any of the forementioned. 4. During a record review of Patient 6’s Personal Information, indicated a start of care of 10/24/2023. A record review of Patient 6’s CTI, for certification period #1, dated 10/24/2023 to 1/21/2024, indicated Patient 6’s terminal diagnosis of Chronic obstructive pulmonary disease (COPD-an illness that makes breathing difficult). During a concurrent interview and record review with RN 4, on 9/11/2025, at 12:05 p.m., the RN 4 reviewed Patient 6’s LCD, included in the Comprehensive Assessment, dated 10/24/2023. The document indicated the comprehensive assessment was done by MD 1. The LCD indicated Patient 6 met hospice criteria due to decreased functional capacity, increasing emergency room visits, hospitalization for lung infections, oxygen saturations less than or equal to 86% determined either by arterial blood gases or O2 (oxygen) saturation monitors. RN 4 reviewed Patient 6’s medical records and stated there was no evidence to support any of the forementioned. RN 4 stated Patient 6’s O2 saturation on admission was 95% on room air. 5. During a record review of Patient 7’s Personal Information, indicated a start of care on 12/21/2023. A record review of Patient 7’s CTI, for certification period 12/21/2023 to 3/19/2024, indicated Patient 7’s terminal diagnosis of COPD. During a concurrent interview and record review with RN 4, on 9/11/2025, at 12:45 p.m., the RN 4 reviewed Patient 7’s LCD, included in the Comprehensive Assessment, dated 12/21/2023. The LCD indicated Patient 7 met hospice criteria due to decreased functional capacity, increasing emergency room visits, oxygen saturations less than or equal to 86% determined either by arterial blood gases or O2 (oxygen) saturation monitors and unintentional weight loss. RN 4 reviewed Patient 7’s medical records and stated there was no H&P documents to support Patient 7’s COPD diagnosis. There was no evidence to support the criteria indicated in the LCD. 6. During a record review of Patient 8’s medical record form titled “Personal Information”, undated, indicated a start of care date of 2/16/2024 with a primary diagnosis of human immunodeficiency virus (HIV). During a record review of Patient 8’s medical record form titled “Audit Log” dated from 2/16/2024 to 9/11/2025, indicated MD1 added the following documentation on Patient 8’s CTI (Certification of Terminal Illness – a physician’s written statement confirming a patient has a life expectancy of six months or less, if the illness runs its natural course, which is required for the patient to be eligible for hospice benefits) dated 2/16/2024 on 10/30/2024, “I certified that this patient is under my care and based on my medical knowledge and data available has a life expectancy of 6 months or less if the terminal illness runs its normal course.” During a concurrent interview and record review on 9/10/2025 at 10:20 a.m. with Registered Nurse Case Manager (RN1) of Patient 8’s electronic medical record (EMR), RN1 stated she (RN1) does not know how or who referred Patient 8 for hospice services. RN1 stated the Medical Director (MD1) wrote Patient 8’s admission order. During a concurrent interview and record review on 9/11/2025 at 2:23 p.m. with MD1 of Patient 8s’ EMR, MD1 stated Patient 8 was a patient at his (MD1) pain clinic. MD1 stated he (MD1) referred Patient 8 for hospice services because Patient 8 was underweight, counts were up and down, was having pain, had multiple bacterial infections, was depressed, was using multiple illegal substances, had heart failure, and she (Patient 8) looked like she (Patient 8) was dying. MD1 stated all the above issues were reported by Patient 8. 7. During a record review of Patient 9’s medical record form titled “Personal Information”, undated, indicated a start of care date of 8/6/2024 with a primary diagnosis of heart disease unspecified. During an interview on 9/9/2025 at 12:55 p.m. with Patient 9’s daughter (FM5), FM5 stated Patient 9 was able to ambulate with a walker and a four-legged cane. FM5 stated “She (Patient 9) does have heart issues, but she has a pacemaker. She does not have chest pain or anything like that. Nothing major.” FM5 stated Patient 9 was referred to the hospice agency by a friend who worked there (HA). During an interview on 9/9/2025 at 1:16 p.m. with Patient 9’s primary physicians nurse (PPN), PPN stated that Patient 9 was not referred by her (Patient 9) primary physician (MD2). PPN stated Patient 9 saw MD2, via telehealth, on 11/8/2024. PPN stated Patient 9 had an imaging appointment on 11/8/2024 but was cancelled because her (Patient 9) insurance did not cover it. During a concurrent interview and record review on 9/10/2025 at 11:45 a.m. with the Registered Nurse Case Manager (RN1) of Patient 9’s EMR, RN1 stated Patient 9’s terminal diagnosis was heart disease, unspecified. RN1 stated she (RN1) does not know how or who referred Patient 9 for hospice services. RN1 stated the Medical Director (MD1) wrote Patient 9’s admission order. RN1 stated there were no objectives findings in Patient 9’s EMR to verify she (Patient 9) had heart failure. RN1 stated Patient 9 had chest pain. During a concurrent interview and record review on 9/11/2025 at 3 p.m. with MD1 of Patient 9’s EMR, the MD1 stated Patient 9’s terminal diagnosis was heart disease unspecified. MD1 stated he (MD1) referred Patient 9 for hospice services. MD1 stated he (MD1) did not recall how he (MD1) knew Patient 9. MD1 stated he (MD1) determined Patient 9 was eligible to receive hospice services due to her (Patient 9) activity level, function level, comorbidities, pacemaker, syncopal episodes, she (Patient 9) smokes, and drinks, blood pressure problems, palpitations, urinary problems, abdominal pain and an ejection fraction (percentage of blood pumped by the heart with each contraction) of 60% (low normal range). MD1 stated he (MD1) does not use the Local Coverage Determination (LCD – reasonable and necessary criteria for services) to determine if Patient 9 was eligible for hospice services. MD1 stated RN1 and the Director of Patient Care Services (DPCS) fill out the patients LCD and ensure all compliance are met. MD1 stated he (MD1) was aware Patient 9 has a primary physician and that there is no coordination of care between them (MD1 and MD2). MD1 stated he (MD1) did not need to coordinate with MD2. 8. During a record review of Patient 10’s medical record form titled “Personal Information”, undated, indicated a start of care date of 1/11/2025 with a primary diagnosis of hypertensive heart disease without heart failure. During an interview on 9/9/2025 at 2:46 p.m. with Patient 10’s daughter (FM4), FM4 stated Patient 10 sees her primary physician (MD3) every three months, saw him (MD3) last month on 8/11/2025 and was prescribed Lasix (medication for water retention). FM4 stated “She is healthy, she does have high blood pressure, vertigo, high cholesterol. It is pretty much control with her medication. They (HA) do come over and look out for her (Patient 10) and make sure she (Patient 10) has her (Patient 10) medical supplies.” During an interview on 9/9/2025 at 3:08 p.m. with Patient 10’s primary physician (MD3), MD3 stated that he (MD3) did not discuss or refer Patient 10 for hospice services. MD3 stated Patient 10 did not mention she (Patient 10) was receiving hospice services. MD3 stated he (MD3) saw Patient 10 for the first time in 2016, and the last time was on 6/17/2025. During a concurrent interview and record review on 9/10/2025 at 1:30 p.m. with the Administrator/Director of Patient Care Services Designee (DD) of Patient 10’s EMR, the DD stated Patient 10 did not have heart failure or documentation to support it. The DD stated he (DD) relies on patients’ medical record for information and was not able to find documented evidence to support Patient 10’s hospice diagnosis. During a concurrent interview and record review on 9/11/2025 at 3:25 p.m. with the Medical Director (MD1) of Patient 10’s EMR, MD1 stated Patient 10’s hospice diagnosis of hypertensive heart disease without heart failure, was an unacceptable diagnosis. MD1 stated that unless Patient 10 had “something else” besides hypertensive heart disease without heart failure, she (Patient 10) was not a hospice candidate. MD1 stated Patient 10’s heart was not failing. MD1 stated he (MD1) did not recall who referred Patient 10 for hospice services. MD1 stated Patient 10’s hospice admission was based on her “old age, history of cancer and falls, multiple visits to the emergency department, broken ankle, brain degeneration, and poor scores on her (Patient 10) activities of daily livings (basic personal task of everyday life). MD1 stated Patient 10 looked like she was dying. MD1 stated that he (MD1) was certain Patient 10 had a primary physician, and that he (MD1) was not in contact with him (Patient 10’s primary physician).”

“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) Medical Director 1 (MD1) failed to document an accurate Certification of Terminal Illness (CTI, is the narrative summary, a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician), that reflected the patient’s current health status and identify patients’ need for hospice care and services related to hospice eligibility and management of terminal illness for seven of eleven sampled active patients (Patient 1, Patient 10, Patient 16, Patient 17, Patient 22, Patient 23, and Patient 24). As a result, of the noncompliance above, Patient 1, Patient 10, Patient 16, Patient 17, Patient 22, Patient 23, and Patient 24 were placed at increased risk for losing their hospice eligibility/hospice benefits, not receiving hospice care when needed in the future, and had the potential to not receive the necessary care and services that could lead to potential hospitalization and death. On 9/15/2025, at 4:38 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the Administrator (ADM) and Director of Patient Care Services (DPCS) related to failure to ensure MD1 documented an accurate Certification of Terminal Illness (CTI) that reflected the patient’s current health status and identified patients’ need for hospice care and services related to hospice eligibility and management of terminal illness for seven of eleven sampled active patients (Patient 1, Patient 10, Patient 16, Patient 17, Patient 22, Patient 23, and Patient 24). On 9/16/2025, at 1:00 p.m., the hospice agency was unable to submit an acceptable IJ removal plan (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 9/16/2025, at 1:30 pm, the survey team completed the survey tasks and conducted an exit conference in the presence of the ADM, DPCS, DPCS Designee and Registered nurse case manager, with the IJ situation not removed. Findings:1.During a review of Patient 1’s Personal Information sheet indicated a start of care (SOC) date of 8/13/2025, with a terminal diagnosis (any condition expected to end in death) of prostate cancer (a cancer of a male organ). Patient 1’s Personal Information sheet indicated Patient 1’s 5th certification period in the hospice program. During a review of Patient 1’s record titled, certification of terminal illness (CTI, is the narrative summary, a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician), for re-certification period #5, dated 8/13/2025 to 10/11/2025, indicated Patient 1 was admitted to hospice due to physical decline and the progression of disease process. The CTI indicated the terminal diagnosis was malignant neoplasm of prostate. The CTI record indicated, “He (Patient1) gets mild SOB during ambulation around his home and needs to rest in between activities related to his asthma. He, (Patient 1) uses 2 inhalers (a medication given by breathing through the nose) to manage SOB.” During a review of Patient 1’s General Acute Care Hospital (GACH) records, titled Final Report, History and Physical, dated 7/12/2025, the Final Report, History and Physical records, indicated Patient 1’s prostate cancer (type of cancer where cells in the prostate gland, a small gland in the male reproductive system, grow abnormally and multiply out of control), was in remission (a temporary or permanent disappearance of signs and symptoms). The Final Report, History and Physical records, indicated Patient 1 had reported to the hospital doctor history of prostate cancer, high blood pressure, and Chronic Obstructive Pulmonary Disease (COPD -an illness that makes breathing difficult). The Final Report, History and Physical records, indicated Patient 1 respiratory system was examined and the doctor documented the following, “Review of symptoms…no shortness of breath, cough, or sputum production…Physical exam: Clear to auscultation and percussion. No wheezing, rales or rhonchi.” The Final Report, History and Physical records indicated Patient 1’s active medical problems were asthma (a condition that makes breathing difficult), gallstone (stones in the liver) and hypertensive disorder (high blood pressure). During an observation of the home visit on 9/9/2025 at 10:35 a.m., with the Administrator/Director of Patient Care Services designee (DD), Patient 1 greeted DD at the door. Patient 1 was walking, using a cane, and was breathing normally. During a concurrent observation and interview on 9/9/2025, at 10:38 a.m., the DD checked Patient 1’s blood pressure, temperature, oxygen saturation (the amount /percentage of oxygen in the blood), heart rate. The DD stated Patient 1’s oxygen saturation was 99% on room air (breathing without oxygen, breathing ambient air). During an interview at the home visit on 9/9/2025, at 11:21 a.m., with Patient 1, Patient 1 stated he (Patient 1) was taking medication for prostate cancer. Patient 1 stated the prostate cancer had not spread. Patient 1 stated he (Patient1) did not need Spiritual Care services because he goes to church. Patient 1 stated he (Patient1) currently did not have a primary care doctor because he was told he could not have one while in hospice. Patient 1 stated, “I can’t get blood drawn, can’t get nothing…I haven’t seen a doctor, but I fall all the time.” During a concurrent interview and record review on 9/9/2025, at 11:42 a.m., with DD, DD reviewed Patient 1’s Comprehensive Nursing Assessment, dated 8/13/2025. The Comprehensive Nursing Assessment indicated Patient 1 had a Palliative Performance Scale (PPS, a tool used in palliative care to assess a patient’s functional status and prognosis), indicated a score of 40 (unable to do any work, mainly in bed). Patient 1’s Comprehensive Nursing Assessment indicated that Patient 1 was hospice eligible due to the Local Coverage Determination (LCD, a tool that describes the qualifying criteria for hospice care) indicated as follows:Patient 1’s cancer had metastasized (spread to other parts of the body) regardless of therapy, Patient 1 had been ruled out as a candidate or declines further curative therapy. The DD stated during the visit (unknown), Patient 1 reported the cancer had not spread. The DD stated he (DD) had read Patient 1’s history and physical (a medical document that describes all the medical problems and treatment plan) prior to the visit and the document indicated Patient 1’s cancer was in remission (stabilized). The DD stated the LCD was not done correctly. The DD stated based on Patient1 report and the LCD, Patient 1 did not meet eligibility for hospice care. During an interview on 9/11/2025, at 1:54 p.m., with the Medical Director (MD 1), MD1 reviewed Patient 1’s medical records (in general). MD 1 stated the only evidence he had of Patient 1’s metastatic prostate cancer was Patient1’s report, and the prophylactic (prevention) medication Patient1’s was currently taking. MD 1 stated he could not find the name of the medication, as the medication was not listed in Patient1’s medical record (in general). MD 1 stated he (MD1) did not have any medical records to support Patient 1’s terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure), of prostate cancer metastasis. During an interview on 9/11/2025 at 1:58 p.m., MD 1 stated Patient 1’s real problem was COPD, and the HA was going to change his diagnosis on the records. During an interview on 9/11/2025, at 2:05 p.m., the HA’s Nurse Practitioner (NP) stated she saw Patient 1, on admission, on 8/13/2025 through a telehealth (using a camera/audio tool) visit during the nurse’s visit. The NP stated she used the nurse’s physical assessment as the medical assessment and only reported abnormalities to MD 1. During a review of Patient 1’s Communication/Progress log, dated 9/14/2025, MD 1 documented as follows, “...71-year-old male admitted to GACH on 7/12/2025 for multiple falls and generalized weakness. Patient1 has documented the history of COPD. Primary Terminal Diagnosis for Hospice Admission End-Stage Chronic Obstructive Pulmonary Disease (COPD)... the Registered Nurse (RN) reported from the prior week highlights a rapid deterioration in the patient’s condition. Patient1’s pulmonary function indicated has declined significantly, with severe dyspnea noted upon minimal exertion. Patient1’s Communication/Progress log, indicated Patient1 became short of breath by merely standing up or taking one to two steps, at which point his oxygen saturations drop to below 90%...Criterion Met: Dyspnea with Minimal Exertion or at Rest. The record state he gets “easily fatigues needing extra time to perform ADL’s and rest breaks. His inability to ambulate more than 15 feet, about one or two steps, and shaking when standing which requires maximum support are classic physical manifestation of severe dyspnea from end-stage lung disease.”During a review of Patient 1’s “Visit Note RN”, dated 9/9/2025, indicated, dyspnea (short of breath) light difficulty, oxygen saturation of 97% room air, a respiratory rate of 18 breaths per minute (normal finding). During a review of Patient 1’s “Visit Note LVN”, dated 9/10/2025, indicated, dyspnea (short of breath) light difficulty, oxygen saturation of 94% room air, a respiratory rate of 20 breaths per minute (normal finding). The Visit Note LVN record indicated lung sounds clear with shortness of breath (SOB) upon exertion, Patient1 was able to ambulate about 15-20 steps before having to sit to catch his breath. The Visit Note LVN record indicated Patient 1 required walker or care to ambulate. 2.During a review of Patient 10’s “Personal Information”, undated, indicated Patient1’s start of care (SOC) date was 1/11/2025 with a primary diagnosis of hypertensive heart disease (a condition where the heart muscle is damaged or weakened due to long-term high blood pressure) without heart failure. During a record review of Patient 10’s “Local Coverage Determination (LCD, a tool that describes the qualifying criteria for hospice care) Hospice Eligibility Determination” dated 6/30/2025 and 9/1/2025, indicated heart disease was used to determine hospice eligibility. The LCD Hospice Eligibility Determination form indicated a “Yes” was marked for the following sections, has patient been ruled out as a candidate for surgical procedures, is patient optimally treated for heart disease with diuretics and vasodilators, does this CHF (congestive heart failure) or angina patient meet the criteria for NYHA class IV level, and hx (history) of unexplained syncope/fainting.” During a record review of Patient 10’s medical record form titled “CTI”, for re-certification period #7 7/10/2025 to 9/7/2025 indicated it was signed by the Medical Director (MD1) on 7/10/2025. During a record review of Patient 10’s medical record form titled “CTI”, for re-certification period #8 9/8/2025 to 11/6/2025 indicated it was not signed by the MD1. During a record review of Patient 10’s medical record form titled “Re-Cert Assessment” dated 6/30/2025, the Re-Cert Assessment indicated Patient 10 had normal blood pressure, no cardiac-related pain, and normal skin color. However, the nursing assessment indicated Patient 10 met the criteria for New York Heart Association for Class IV heart failure. During a record review of Patient 10’s medical record form titled “Re-Cert Assessment” dated 9/1/2025, the Re-Cert Assessment indicated Patient 10 had normal blood pressure, regular pulse, no cardiac-related pain, and normal skin color. However, the nursing assessment indicated Patient 10 met the criteria for New York Heart Association for Class IV heart failure. During an interview on 9/9/2025 at 2:46 p.m., with Patient 10’s caregiver/daughter (FM4), FM4 stated Patient 10 has a primary physician (MD3) which she (Patient 10) saw last month. FM4 stated Patient 10 requested to be full code, “she (Patient 10) wants everything done if she has a full code.” FM4 stated that Patient 10 is active at home and uses her walker to go out to the porch by herself. FM4 stated Patient 10 is healthy despite having high blood pressure, vertigo and high cholesterol. During an interview on 9/9/2025 at 3:08 p.m., with Patient 10’s primary physician (MD3), MD3 stated that he (MD3) did not discuss or refer Patient 10 for hospice services. MD3 stated Patient 10 did not mention she (Patient 10) was receiving hospice services. MD3 stated he (MD3) saw Patient 10 for the first time in 2016, and the last time was on 6/17/2025. During a concurrent interview and record review on 9/10/2025 at 1:30 p.m., with the Administrator/Director of Patient Care Services Designee (DD) of Patient 10’s electronic medical record (EMR), DD stated Patient 10 was on certification period number eight from 9/8/2025 to 11/6/25, but it was not signed by the Medical Director (MD1). During a concurrent interview and record review on 9/10/2025 at 1:30 p.m. with the DD of Patient 10’s medical record form titled “LCD Hospice Eligibility Determination” dated 6/30/2025 and 9/1/2025, the DD stated Patient 10 did not have heart failure or documentation to support both LCDs. The DD stated he (DD) relies on patients’ medical record for information and was not able to find documented evidence to support Patient 10’s hospice diagnosis. During a concurrent interview and record review on 9/11/2025 at 3:25 p.m. with the Medical Director (MD1) of Patient 10’s EMR, MD1 stated Patient 10’s hospice diagnosis of hypertensive heart disease without heart failure, was an unacceptable diagnosis. MD1 stated that unless Patient 10 had “something else” besides hypertensive heart disease without heart failure, she (Patient 10) was not a hospice candidate. MD1 stated Patient 10’s heart was not failing. MD1 stated it was a mistake on his (MD1) part by not signing Patient 10’s current CTI. MD1 stated he (MD1) did not recall who referred Patient 10 for hospice services. MD1 stated Patient 10’s hospice admission was based on her “old age, history of cancer and falls, multiple visits to the emergency department, broken ankle, brain degeneration, and poor scores on her (Patient 10) activities of daily livings. MD1 stated Patient 10 looked like she was dying. MD1 stated that he (MD1) was certain Patient 10 had a primary physician, and that he (MD1) was not in contact with him (Patient 10’s primary physician). 3.During a review of Patient 16’s Personal Information, the Personal Information indicated Patient 16’s start of care (SOC) date was 3/21/2025, with a terminal diagnosis of dysarthria (a speech disorder characterized by difficulty in producing clear and intelligible speech due to damage or dysfunction in the muscles or nerves that control speech production), following other cerebrovascular (relating to the brain and its blood vessels) disease. Patient 16’s Personal Information record indicated Patient 16 was on 5th certification period in the hospice program. During a review of hospital records for Patient 16, dated 3/20/2025, Patient 16’s H & P indicated a history of spinal cerebral ataxia, failure to thrive, and dysphagia. There was no documented history of stroke. During a review of Patient 16’s F2F Visit Note List, the record indicated there was one face-to-face visit conducted by MD 1 on 3/21/2025, which was the date Patient 16 entered the fifth certification period. There was no face-to-face visit documented prior to the sixth and seventh certification periods. During a review of Patient 16’s CTI (Certification of Terminal Illness – a physician’s written statement confirming a patient has a life expectancy of six months or less, if the illness runs its natural course, which is required for the patient to be eligible for hospice benefits) for the sixth certification period, from 5/20/2025 to 7/18/2025, the physician narrative indicated that Patient 16 was eligible to receive hospice services. The CTI indicated that MD 1 signed it on 6/1/2025. During a review of Patient 16’s LCD, dated 5/16/2025, the LCD indicated that Patient 16 was qualified to receive hospice services due to stroke and coma. The LCD indicated that Patient 16’s KPS or PPS was less than 40. The LCD also indicated that Patient 16 had weight loss of more than 10% in the last 6 months or more than 7.5% in the last 3 months. During a review of Patient 16’s Recert Assessment (recertification assessment – a process to confirm a patient’s continued eligibility for hospice care, which requires a physician to re-evaluate their condition to ensure the terminal illness is still life-limiting with a prognosis of six months or less), dated 5/16/2025, the Recert Assessment indicated that KPS was 50 and PPS was 50. Patient 16’s oxygen saturation was 95% on room air, respiration rate 17 per minute. The narrative section indicated that lung sounds were clear, breathing was even and unlabored with shortness of breath noted on mild exertion. There was no documentation regarding how much weight Patient 16 had lost in the past 3 months or 6 months. MAC (mid-arm circumference, a measurement taken around the arm, midway between the bony tip of the shoulder and the point of the elbow) was 23 cm. During a review of Patient 16’s CTI (Certification of Terminal Illness – a physician’s written statement confirming a patient has a life expectancy of six months or less, if the illness runs its natural course, which is required for the patient to be eligible for hospice benefits) for the seventh certification period, from 7/19/2025 to 9/16/2025, the physician narrative indicated that Patient 16 continued to be eligible to receive hospice services. The face-to-face narrative was blank. The CTI indicated that MD 1 signed it on 7/19/2025. During a review of Patient 16’s LCD, dated 7/5/2025, the LCD indicated that Patient 16 was qualified to receive hospice services due to stroke and coma. The LCD indicated that Patient 16’s KPS or PPS was less than 40. The LCD also indicated that Patient 16 had weight loss of more than 10% in the last 6 months or more than 7.5% in the last 3 months. MAC was 23 cm. During a review of Patient 16’s Recert Assessment, dated 7/5/2025, the Recert Assessment indicated that KPS was 50 and PPS was 50. Patient 16’s O2 saturation was 95% on room air, respiration rate 17 per minute, with clear lung sounds and normal respiration documented. The narrative section indicated that patient denies shortness of breath but appeared more fatigued and mildly dyspneic. There was no documentation regarding how much weight Patient 16 had lost in the past 3 months or 6 months. MAC was 21 cm. During a joint home visit with RN 2 on 9/9/2025 at 10:40 a.m., Patient 16 was observed alert and oriented to person, place, and time. Patient 16 was sitting on a recliner. Caregiver 1 (CG 1) was present at Patient 16’s home. RN 2 took Patient 16’s vital signs. Per RN 2, O2 saturation was 97% on room air, respiration rate was 20 per minute. RN 2 stated lung sounds were clear to auscultation. Observed Patient 16’s breathing unlabored. When asked by the surveyor if he sometimes had shortness of breath, Patient 16 stated he had never experienced shortness of breath. Patient 16 stated he had been visited by RN 4 once a week, every Monday. Patient 16 stated he had not been visited by MD 1. During an interview with CG 1 on 9/9/2025 at 11:50 a.m., CG 1 stated that since she started caring for Patient 16 three months ago, Patient 16 had shown improved appetite. CG 1 stated she believed that Patient 16 had gained weight, since he now needed a size large pull-up. CG 1 stated Patient 16 was wearing a size medium pull-up before. During a phone interview with FM 1 on 9/9/2025 at 2:06 p.m., FM 1 stated that Patient 16 did not have a history of stroke. FM 1 stated that Patient 16 had had spinal cerebellar ataxia type 2 since he was in his forties. FM 1 stated that Patient 16 did not have a history of heart failure. FM 1 also stated that Patient 16’s appetite had improved. According to FM 1, Patient 16 was never diagnosed with a terminal illness with 6 months or less life expectancy. FM 1 stated he did not know who referred Patient 16 to hospice. During a phone interview with Patient 16’s former PCP (MD 4) on 9/9/2025 at 3:47 p.m., MD 4 stated Patient 16 was his long-time patient. MD 4 stated Patient 16 was not terminally ill. MD 4 stated that Patient 16 had a neurological condition called spinal cerebellar ataxia, which was not the same as stroke. MD 4 stated that he referred Patient 16 to be admitted to a nursing home, because it was not safe for Patient 16 to live by himself at his apartment. MD 4 stated he did not know who referred Patient 16 to hospice. During a concurrent interview and record review with RN 1 on 9/10/2025 at 1:15 p.m., RN 1 reviewed Patient 16’s H & P records, Recert Assessments, dated 5/16/2025 and 7/5/2025, F2F visit note list. RN 1 also reviewed the LCDs dated 3/21/2025, 5/16/2025, and 7/5/2025 and CTIs for certification period #6 and #7. RN 1 stated that a face-to-face visit by the hospice physician or physician designee was required before the 3rd certification and prior to each subsequent recertification after. RN 1 confirmed there was only one face-to-face visit documented for Patient 16. RN 1 stated there were no face-to-face visit completed for recertification #6 and #7. RN 1 stated it was very important to have a complete and accurate comprehensive assessment and face-to-face visit to ensure the patient was still eligible to receive hospice services. During a concurrent interview and record review with MD 1 on 9/16/2025 at 11:12 a.m. a.m., MD 1 reviewed Patent 16’s CTIs, LCDs, and F2F Visit Note for the fifth through the seventh certification periods. MD 1 stated that Patient 16’s terminal diagnosis was not dysarthria as listed in his CTIs. MD 1 stated that dysarthria was a symptom and not an illness. MD 1 stated, “It should be rearranged.” MD 1 stated he saw Patient 16 on 3/21/2025 but did not document the visit until 9/8/2025. 4.During a review of Patient 17’s Personal Information, the Personal Information indicated a start of care (SOC) date of 1/28/2025, with a terminal diagnosis of (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat). The record indicated this was Patient 17’s first certification period in the hospice program.During a review of Patient 17’s hospital records, dated 1/31/2025, there was no documentation in the record regarding a history of heart disease or heart failure in Patient 17’s H & P. The H & P indicated that Patient 17’s chief complaint was abdominal pain. During a review of Patient 17’s CTI for the second certification period, from 4/28/2025 to 7/26/2025, the physician narrative indicated that Patient 17 was still appropriate to receive hospice services. The CTI indicated that MD 1 signed it on 5/15/2025. During a review of Patient 17’s Recert Assessment, dated 4/21/2025, the Recert Assessment indicated that the KPS was 50 and PPS was 40, NYHA III. The assessment further indicated Patient 17’s O2 saturation was 96% on room air, with clear lung sounds, and normal respiration. Heart rate was documented as regular, and the patient did not have edema. During a review of Patient 17’s LCD, dated 7/14/2025, the LCD indicated that Patient 17 was not qualified to receive hospice services. The LCD was not completed. During a review of Patient 17’s CTI for the third certification period, from 7/27/2025 to 9/24/2025, the physician narrative indicated that Patient 17 was appropriate to receive hospice services. The CTI indicated that MD 1 signed it on 7/27/2025. During a review of Patient 17’s Recert Assessment, dated 7/14/2025, the Recert Assessment indicated that the KPS was 50 and PPS was 40, NYHA III. The assessment further indicated Patient 17’s O2 saturation was 96% on room air, with clear lung sounds, and normal respiration. Heart rate was documented as regular and the patient did not have edema. During a review of Patient 17’s LCD, dated 7/14/2025, the LCD indicated that Patient 17 was not qualified to receive hospice services. The LCD was not completed.During a review of Patient 17’s F2F Visit Note List on 9/10/2025, the record indicated there was no face-to-face visit conducted. Patient 17 was in the third certification period as of 7/14/2025.During a phone interview with Patient 17 and FM 2 on 9/9/2025 at 4:23 p.m., FM 2 stated that Patient 2 did not have heart disease or heart failure. Patient 2 stated he had hypertension (a condition in which the force of blood against the artery walls is consistently too high), but not heart failure. When the survey team called Patient 17 previously, at 3:47 p.m., FM 2 stated that Patient 17 was taking a shower by himself. When Patient 17 was asked if he was able to ambulate, Patient 17 stated he and FM 2 walked their dog around the neighborhood for 30 minutes daily. Patient 17 stated he was never told by his doctor that he had 6 months or less to live. FM 2 stated that Patient 17’s PCP did not refer him to hospice. During a concurrent interview and record review with RN 1 on 9/10/2025 at 1:15 p.m., RN 1 reviewed the hospital records, dated 1/31/2025, Comprehensive Nursing Assessment, dated 1/29/2025, Recert Assessments, dated 4/21/2025 and 7/14/2025. RN 1 also reviewed the LCD dated 1/29/2025, 4/21/2025, and 7/14/2025. RN 1 stated there was no history of heart disease or heart failure documented in the hospital records. RN 1 stated that the Comprehensive Nursing Assessment was considered incomplete since it was not signed. RN 1 confirmed that the LCD for the second and third certification period were not done. RN 1 stated that LCD was an important part of the Comprehensive Assessment and Recert Assessment to determine if the patient was still eligible for hospice. RN 1 stated the Recert Assessments were considered incomplete since the LCDs were not done. RN 1 stated there was no physician face-to-face visit documented for Patient 17. RN 1 stated a face-to-face visit prior to the third certification period was required to ensure the patient was still eligible to receive hospice services. When RN 1 was asked to provide diagnostics that showed Patient 17’s EF was less than 20, RN 1 stated there was no documentation of any diagnostics, such as echocardiogram (a test of the action of the heart using ultrasound waves to produce a visual display, used for the diagnosis or monitoring of heart disease), that showed Patient 17’s EF was less than 20. During a concurrent interview and record review with MD 1 on 9/16/2025 at 10:38 a.m., MD 1 reviewed Patent 17’s CTIs, LCDs, and F2F Visit Note for the second and third certification periods. MD 1 confirmed the LCDs indicated that Patient 17 did not qualify for hospice services. MD 1 stated, “It is a critical deficiency that LCD is not appropriate.” MD 1 stated that besides terminal diagnosis, comorbidities (two or more medical conditions that occur simultaneously in the same patient) and symptom burdens also needed to be considered. MD 1 stated the Nurse Practitioner (NP) visited Patient 17 on 7/14/2025 but the visit was not documented as of 9/10/2025. 5.During a review of Patient 22’s Personal Information, the Personal Information indicated a start of care (SOC) date of 3/26/2025, with a terminal diagnosis (any condition expected to end in death) of heart disease, unspecified. During a review of Patient 22’s Re-Cert Assessment (the process of re-evaluating a patient’s eligibility for continued hospice care and providing detailed clinical documentation to support it), dated 6/17/2025, the Re-Cert Assessment indicated Patient 22 had normal blood pressure, regular pulse, no cardiac-related pain, no edema, normal skin color, clear lung sounds, and normal respiration. However, the Re-Cert assessment indicated Patient 22 met the criteria for New York Heart Association for Class IV heart failure, was optimally treated for heart disease with diuretics and vasodilators and was recertified for hospice care for another benefit period. During a record review of Patient 22’s CTI form for certification #2 from 6/24/2025 to 9/21/2025, the CTI form indicated Patient 22 terminal diagnosis was heart disease, unspecified. The Medical Director indicated Patient 22 had a life expectancy of six months or less if the terminal illness runs its normal course. However, there was no documented evidence MD 1 communicated with Patient 22’s attending physician to certify Patient 22 to hospice care. The “Certifying Physician Narrative” section did not indicate any documented evidence and supporting narrative from the Medical Director that Patient 22 met NYHA IV criteria for heart failure and was optimally treated for heart disease with diuretics and vasodilators. During a joint home visit at Patient 22’s residence, on 9/9/2025 at 1:40 p.m. with licensed vocational nurse (LVN 2), Patient 22 was observed to be awake, alert, oriented x 3 (to person, place and time), ambulatory with a cane, and showing no shortness of breath (SOB), edema, palpitations (irregular, fast heartbeat), or chest pain. Vital signs (measurements of the body’s most basic functions, providing crucial information about a person’s general health) were normal. During an interview, Patient 22 stated that no one from the HA explained to her regarding what hospice care was, that she does not have terminal illness and was not dying, and that she signed up for hospice care because she was told by HA staff that they can supervised and checked on her health condition, be visited by a nurse once a week to monitor her blood pressure. Patient 22 stated she was not referred by her own physician to hospice care, was independent with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and is concerned about potential denial of necessary treatment and medications due to her enrollment in hospice care. During an interview and joint record review, on 9/11/2025, at 10:45 a.m., with the DD, the DD reviewed Patient 22’s recertification assessment dated 6/17/2025, LCD assessment dated 6/17/2025 and CTI form for certification #2 from 6/24/2025 to 9/21/2025. The DD stated that the agency used LCD assessment to determine patient’s hospice eligibility. The DD stated the recertification, LCD assessments and CTI form indicated Patient 22 met NYHA Class IV heart failure criteria and was optimally treated with diuretics and vasodilators, thus admitted to hospice care. However, the DD could not provide documented evidence supporting these criteria or treatments. 6.During a review of Patient 23’s Personal Information, the Personal Information indicated a SOC date of 1/1/2025, with a terminal diagnosis of heart disease, unspecified. During a record review of Patient 23’s CTI form for certification #4 starting from 8/29/2025 to 10/27/2025, the CTI form indicated it was unsigned by the Medical Director and missing the Certifying Physician Narrative section. During a review of Patient 23’s Re-Cert Assessment, dated 6/23/2025, the Re-Cert Assessment indicated Patient 23 had normal blood pressure, no cardiac-related pain, no edema, normal skin color, had normal respiration, and had mild dyspnea only with mild exertion. However, the Re-Cert assessment indicated Patient 23 met the criteria for New York Heart Association for Class IV level, was optimally treated with diuretics and vasodilators, and was recertified for hospice care for another benefit period (3rd). During a review of Patient 23’s Re-Cert Assessment, dated 8/18/2025, the Re-Cert Assessment indicated Patient 23 had normal blood pressure, no cardiac-related pain, no pitting edema, normal skin color, had normal respiration, and had mild dyspnea only with mild exertion. However, the Re-Cert assessment indicated Patient 23 met the criteria for New York Heart Association for Class IV level, was optimally treated for heart disease with diuretics and vasodilators and was recertified for hospice care for another benefit period (4th). During a joint home visit at Patient 23’s residence, on 9/10/2025 at 10:00 a.m. with the DD, Patient 23 was observed to be awake, alert, oriented x 3 (to person, place and time), ambulatory with a cane, and showing no SOB, edema, palpitations, or chest pain. Vital signs were normal. During an interview, Patient 23 stated she was not referred to hospice by her own attending physician, still want curative treatment, was not optimally treated with diuretics or vasodilators for heart disease and will be devastated if she will face potential denials of necessary medical treatment if needed right now because she is enrolled in hospice care. During a concurrent interview and record review, on 9/11/2025, at 10:45 a.m., with the DD, the DD reviewed Patient 23’s recertification assessment dated 6/23/2025 and 8/18/2025, and LCD assessment dated 8/18/2025. The DD stated the recertification and LCD assessments indicated Patient 23 met NYHA Class IV heart failure criteria, was optimally treated with diuretics and vasodilators and had an ejection fraction (EF- is the percentage of blood pumped out of the left ventricle with each heartbeat) of less than 20, thus admitted to hospice care. However, the DD could not provide documented evidence supporting these criteria or treatments. During a concurrent interview and record review, on 9/11/2025 at 11:15 a.m. with the DD, the DD reviewed Patient 23’s CTI form for certification #4 dated starting from 8/29/2025 to 10/27/2025. The DD stated and confirmed the CTI form for certification #4 was not signed by the hospice Medical Director and there was no documentation under the section “Face to Face Narrative” and “Certifying Physician Narrative”. The DD stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director which included face to face visit narrative and certifying physician narrative. The DD further stated if the CTI form was not signed and completed by the Medical Director, the patient should not have been readmitted to hospice care. 7.During a review of Patient 24’s Personal Information, the Personal Information indicated a SOC date of 2/25/2025, with a terminal diagnosis of heart disease, unspecified. During a record review of Patient 24’s CTI form for certification #3 starting from 8/24/2025 to 10/22/2025, the CTI form indicated it was unsigned by the Medical Director and missing the Certifying Physician Narrative section. During a review of Patient 24’s Re-Cert Assessment, dated 5/20/2025, the Re-Cert Assessment indicated Patient 24 had normal blood pressure, regular pulse, no cardiac-related pain, no edema, normal skin color, had normal respirations, had mild dyspnea only with mild exertion, had a steady gait and was able to ambulate with any assistive devices. However, the Re-Cert assessment indicated Patient 24 met the criteria for New York Heart Association for Class IV level and was recertified for hospice care for another benefit period (2nd). During a review of Patient 24’s Re-Cert Assessment, dated 8/18/2025, the Re-Cert Assessment indicated Patient 24 had normal blood pressure, regular pulse, no cardiac-related pain, no pitting edema, normal skin color, had normal respirations, had mild dyspnea only with mild exertion, and was able to ambulate with assistive devices cane or walker when heading out. However, the Re-Cert assessment indicated Patient 24 met the criteria for New York Heart Association for Class IV level and was recertified for hospice care for another benefit period (3rd). During a joint home visit at Patient 24’s residence, on 9/9/2025 at 2:30 p.m. with RN 1, Patient 24 was observed sitting in a wheelchair, awake, alert, and oriented x 3 (to person, place and time), and showing no SOB, edema, palpitations, or chest pain. Vital signs were normal. During an interview with Patient 24’s family member (FM 3), FM 3 stated Patient 24’s blood pressure was always normal, has not complained of any chest pain, has no SOB when in bed or chair, and was not sure if Patient 24 really has terminal illness. FM 3 further stated it will be bad and concerning if Patient 24 will face potential denials of necessary medical treatment or medications if needed right now because she is enrolled in hospice care. During an interview and joint record review, on 9/11/2025, at 10:45 a.m., with the DD, the DD reviewed Patient 24’s recertification assessment dated 5/20/2025 and 8/18/2025, and LCD assessment dated 8/18/2025. The DD stated Patient 24’s recertification assessment, and LCD assessment indicated Patient 24 met the criteria for NYHA Class IV level, was optimally treated for heart disease with diuretics and vasodilators, thus was admitted to hospice. However, the DD was unable to provide any documented evidence to support Patient 24 met NYHA IV criteria for heart failure or was optimally treated for heart disease with diuretics and vasodilators. During a concurrent interview and record review, on 9/11/2025 at 11:15 a.m. with the DD, the DD reviewed Patient 24’s CTI form for certification #3 dated from 8/24/2025 to 10/22/2025. The DD stated and confirmed the CTI form for certification #3 was not signed by the hospice Medical Director and there was no documentation under the section “Face to Face Narrative” and “Certifying Physician Narrative”. The DD stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director which included face to face visit narrative and certifying physician narrative. The DD further stated if the CTI form was not signed and completed by the Medical Director, the patient should not have been readmitted to hospice care. During an interview on 9/11/2025 at 2:05 p.m. with the Nurse Practitioner (NP), the NP stated that sometimes she (NP) personally visits patients and sometimes she (NP) conducts a telehealth. The NP stated nurses conduct the patients assessments and report it back to her (NP). The NP stated she (NP) bases her (NP) assessment on the nurses assessments. The NP stated she (NP) reports to the Medical Director (MD1) when there are abnormalities or medications that need to be ordered. During an interview on 9/12/2025 at 11:05 a.m. with the Medical Director (MD1), the MD1 stated he (MD1) does not see all the patients personally. MD1 stated he saw Patient 8 and Patient 16, from the twenty-eight sample patients personally. MD1 stated he (MD1) composes patients CTIs (Certification of Terminal Illness) based on the assessment and information provided by the nurses’ notes, the interdisciplinary group (IDG) meetings, and “specially” the face-to-face physical assessment documentation of the NP. During an interview, on 9/15/2025 at 3:10 p.m. with MD 1, MD 1 stated he was not the attending physician, and he does not know who the attending physician for Patient 22, Patient 23, and Patient 24. MD 1 was asked if he needs to discuss and collaborate with the patient’s attending physician regarding their medical condition and health status before certifying them to hospice care, MD 1 stated, “I can but I don’t have to.” MD 1 stated he certified patients to hospice based on the assessment and information provided by the nurses’ notes, thru IDG meetings, and NP face to face assessment report. MD 1 was asked what it means if the patient’s CTI form was not signed by him and there was missing documentation under the Certifying Physician Narrative section, MD 1 stated, “I always signed the CTI.” During an interview on 9/16/2025 at 11:12 a.m. with MD1, MD1 stated that he (MD1) does not review patients’ records. MD1 stated that patients are discussed during the IDG meetings. During a record review of the HA’s document titled, Admission to Hospice Care and Initial Assessment, dated 2019, indicated, “...Information documenting the patient’s terminal illness is obtained at the time of the referral for hospice care. The attending physician shall provide information regarding the admitting diagnosis, current medical findings...information about medical management of patient conditions unrelated to the terminal illness and designation of an alternate physician to contact in case the attending physician is unavailable during a patient information...In reaching a decision to certify that the patient is terminally ill, the hospice medical director must consider at least the following information: a. Diagnosis of the terminal condition of the patient. B. Other health conditions, whether related or unrelated to the terminal condition. C. Current clinically relevant information supporting all diagnoses.” During a record review of the HA’s document titled, Certification of Terminal Illness, dated 2019, indicated, ...Recertification may be completed no more than 15 days prior to the start of the subsequent benefit period. A hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient whose total stay across all hospices is anticipated to reach the 3rd benefit period. The face-to-face encounter must occur prior to, but no more than 30 calendar days prior to, the 3rd benefit period recertification, and every benefit period recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care. The physician must consider the following when making this determination...Current subjective and objective medical findings...Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification...All certifications and recertifications must be signed by the physician(s) and must include the benefit period dates to which the certification or recertification applies.”

“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 medical director oversaw the implementation of the entire hospice program, to include nursing services, to ensure that these areas consistently met patient needs, for one of 28 sampled selected patients (Patient 1). This failure resulted in delay of care, and potential health decline by not meeting the needs of the patient. 1. During a record review of Patient 1’s Personal Information sheet indicated a start of care date of 8/13/2025, with a terminal diagnosis of prostate cancer (a cancer of a male organ). 1a. During a concurrent observation and interview at the home visit on 9/9/2025, at 10:35 a.m. the Administrator/Director of Patient Services Designee (DD) asked Patient 1 if he was in pain. An observation of Patient 1 indicated Patient 1 was grimacing as he stated that his right foot was painful and felt as if his rods (medical tool placed to hold the bone) were coming out. Patient 1 stated to the DD that he had fallen 2 weeks ago and someone was supposed to come to his home to x-ray (a medical picture) his foot. Patient 1 stated he had had an operation done previously on his foot. Patient 1 stated he fell often. During a concurrent interview and record review on 9/10/2025, at 12:15 p.m., the DD reviewed Patient 1’s medical records. The DD stated patient had reported pain on 8/25/2025. The DD reviewed Patient 1’s record titled, Visit Note RN, dated 8/26/2025. The record indicated, “Patient c/o (complain of) pain to his RLE (right lower extremity-leg) at 8/10 (using a 10-point scale. 8 is considered a lot of pain) ...Office staff was notified at time of visit-possible consult with supervising physician (doctor) and need to order x-ray to RLE. Patient was advised to have caregiver take him to Urgent Care or ER (Emergency room) if symptoms persist or worsen.” The DD stated the nurse visited the patient, assessed Patient 1’s pain, and the note indicated patient needed an x-ray. The DD continued to review Patient 1’s records and stated there was no mention the nurse notified the doctor, and an x-ray was ordered. The DD stated the order for x-ray was placed on 9/10/2025. During an interview on 9/10/2025, at 12:23 p.m., Licensed Vocational Nurse 3 (LVN 3) stated she had initially placed the x-ray order on 8/25/2025, but cancelled the order because there was no order from the doctor. LVN 3 stated Patient 1 was supposed to go to the ER to have his leg checked. LVN 3 stated she spoke to Patient 1 on 8/26/2025 who reported his pain was better. LVN 3 stated she had not documented the communication between Patient 1 and herself (LVN 3) because she was used to talking to Patient 1 all the time. LVN 3 stated in reference to nursing documentation, if it was not documented, it was not done. LVN 3 stated she placed the order for x-ray today, 9/10/2025, because the doctor ordered it today (9/20/2025). During an interview on 9/10/2025, at 12:31 p.m., the DD stated the x-ray was delayed. Patient 1 had requested it on 8/26/2025. Patient 1 was in pain, and the HA did not know why. Maybe there was a fracture (break). The HA needed to confirm it. During a concurrent interview and record review on 9/10/2025, at 11:59 a.m., with the DD, the DD reviewed Patient 1’s record titled, POC/IDG, dated 8/26/2025. The stated there was no update regarding Patient 1’s right leg pain and need of an x-ray. 1b. During a record review of Patient 1’s document titled, POC/IDG Review, dated 8/26/2025, indicated that Patient 1’s goals would be able to demonstrate the ability to monitor blood pressure and give medications exactly as ordered and to report to hospice if medication is not effective in maintaining systolic blood pressure below 160 throughout the benefit period. Further review of the record indicated the skilled nurse (SN) was to assess medications each visit, instruct primary care giver (pcg) when to notify hospice related to blood pressure reading, assess patient’s blood pressure and home monitor log, as well as teach pcg how to properly check blood pressure. During a concurrent observation, interview, and record review on 9/9/2025, at 10:45 a.m., with the DD, the DD reviewed Patient 1’s medications during the home visit, using Patient 1’s record titled, POC summary, dated 9/8/2025. The following medications were listed: Amlodipine Besylate (for high blood pressure) 10 mg (mg-milligram, unit of measurement) 1 tablet by mouth once day routinely. Hold the medication if the systolic blood pressure is less than 110. Patient 1 stated the last time he took this medication was over a month ago. Clonidine Hydrochloride (high blood pressure) 0.1 mg 1 tablet by mouth once day as needed for systolic blood pressure greater than 160. Patient 1 stated he took the medication twice a day, only if his blood pressure was high. Losartan Potassium (high blood pressure) 25 mg 1 tablet by mouth one a day. Hold the medication if the systolic blood pressure is less than 110. Metoprolol Tartrate (high blood pressure) 25 mg tablet by mouth. Two times a day routinely. Hold the medication if the heart rate is less than 55. Hydrochlorothiazide (for high blood pressure) 25 mg 1 tablet by mouth. Once a day routinely. During an interview on 9/9/2025, at 11:12 a.m., Patient 1 stated he took all the blood pressure medications prescribed by the doctor. During an interview on 9/9/2025 at 11:37 a.m., Patient 1 stated he took his blood pressure every morning and would write them in a log. During an interview on 9/9/2025, at 11:57 a.m., with the DD, the DD stated he did not review Patient 1’s blood pressure logs. The DD stated it was important to review Patient 1’s blood pressure reading to make sure his blood pressures were not too low. Patient 1 had been hospitalized for falling after excessive alcohol consumption. By taking all the blood pressure medications, in addition to pain medication and alcohol, all increased his chances of falling. The DD stated Patient 1 needed more education on blood pressure medication management because a lot of those medications needed to be taken or stopped based on the blood pressure readings. During a concurrent interview and record review on 9/10/2025, at 11:35 a.m., with the DD, the DD reviewed Patient 1’s Comprehensive Assessment, dated 8/13/2025. The DD stated the record did not specifically indicate Patient 1 was taught about the blood pressure parameters, to take his blood pressure daily, and to log the blood pressure readings. The DD stated the importance for Patient 1 taking his blood pressure daily and recording it was for the nurses to review the information. If there were changes with the blood pressure, it should have been identified and reported to the Medical Director to see if a change of medication was needed. During a concurrent interview and record review with Registered Nurse 1 (RN 1) on 9/10/2025 at 2:20 p.m., RN 1 reviewed Patient 1’s medical records. RN 1 stated there was no documentation of the face-to-face visit for Patient 1’s 5th recertification period. During an interview with the Medical Director (MD 1) on 9/11/2025, at 1:45 p.m., MD 1 initially stated he was not aware Patient 1 was on all the blood pressure medications as listed in the POC summary, dated 9/8/2025. MD 1 stated high blood pressure was a silent killer and needed to be managed. MD 1 stated medication Clonidine had effects such as really low blood pressure (severe hypotension) and death, if the doubled the dose. MD 1 later stated he was aware Patient 1 was on blood pressure medications, he had approved it, and his previous statement of not being aware, was misunderstood. MD 1 stated Patient 1’s blood pressure medications were part of his medical management. During an interview on 9/11/2025, at 2:05 p.m., the Nurse Practitioner (NP) stated) stated she saw Patient 1, on admission, on 8/13/2025 through a telehealth (using a camera/audio tool) visit during the nurse’s visit. The NP stated she was not aware of Patient 1’s blood pressure medications and could not recall if she reviewed the medications with the visiting nurse. The NP stated she notified MD 1 of the visit, only if there were abnormalities. The NP stated there was nothing to report to MD 1 regarding Patient 1’s telehealth visit. During an interview with MD 1 on 9/11/2025, at 1:45 p.m., MD 1 stated it was not fair to ask Patient 1 to take his blood pressure and keep a log. Patient 1 had alcoholism, liver failure, and had too many issues to keep a blood pressure log. MD 1 stated the blood pressure medications with parameters, were for the nurses. MD 1 was then asked if nurses were administering his medications daily: MD 1 stated no. MD 1 stated the nurses should give the medication to Patient 1 when they visit him. MD 1 stated Patient 1 should be taking his medications without taking his blood pressure. During further record review of Patient 1’s document titled, Visit Note LVN, dated 9/10/2025, indicated a blood pressure of 169/102 (high reading). The record indicated “High BP (blood pressure) waited 15 minutes after BP medication given 149/92 (high reading)”. The record did not indicate further blood pressure interventions after obtaining the second high BP reading.”

“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 four of twenty -eight sampled patients (Patient 1, Patient 9, Patient 11, and Patient 14) patients’ records included the comprehensive assessments and completed clinical notes. This failure resulted in the lack of coordination among hospice staff in reference to patients’ clinical information and continuity of care services provided to patients certified to receive the hospice benefits. 1a. During a record review of Patient 1’s Personal Information sheet indicated a start of care date of 8/13/2025, with a terminal diagnosis of prostate cancer (a cancer of a male organ). During a record review of Patient 1’s medical records on 9/8/2025, indicated there was no MSW (Medical Social Worker) documented evidence the psychosocial assessment was done. During a record review of Patient 1’s document titled, POC/IDG Review, dated 8/13/2025, indicated the social worker would create a plan of care once the initial assessment was completed. During a concurrent interview and record review with the Administrator/Director of Patient Care Services Designee (DD), on 9/10/2025, at 11:59 a.m., the DD reviewed Patient 1’s document titled, POC/IDG Review, dated 8/26/2025. The DD stated the psychosocial discussion indicated Patient 1 did not have any psychosocial (interrelation of social factors and individual thought and behavior) issues. During a concurrent interview and record review with the DD, on 9/10/2025, at 12:10 p.m., the DD reviewed Patient 1’s Audit Log (a document that records all entries and changes made in a medical record), dated 9/10/2025. The record indicated the Medical Social Worker (MSW 1), documented the initial psychosocial assessment for visit date 8/17/2025 on 9/8/2025. The DD stated the record indicated the MSW 1 documented psychosocial issues. DD was asked, how the IDG team determined there was no psychosocial issues on 8/26/2025, if there was no psychosocial assessment documented at that time, the DD stated, “I don’t know what happened.” 1b. During a record review of Patient 1’s medical records on 9/8/2025, there was no indication that the SC had done a spiritual assessment. During a record review of Patient 1’s document titled, POC/IDG Review, dated 8/13/2025, indicated the social worker would create a plan of care once the initial assessment was completed. During a concurrent interview and record review with the DD, on 9/10/2025, at 11:59 a.m., the DD reviewed Patient 1’s document titled, POC/IDG Review, dated 8/26/2025. The DD stated the spiritual discussion indicated there was no spiritual issues during the period. When the DD was asked how that was determined if no spiritual assessment was documented, the DD stated the Spiritual Counselor (SC) needed to be asked about it. The DD stated the SC probably did not document the spiritual assessment. During a record review of Patient 1’s Audit Log, dated 9/10/2025, indicated the SC documented the spiritual assessment on 9/10/2025. 1c. During a record review on 9/8/2025, Patient 1’s medical record indicated two documented, nursing visits: 8/18/2025 and 8/15/2025. During a record review of Patient 1’s document titled, Communication log, dated 9/9/2025, the record indicated, “Upon checking the SN’s notes for the week of August 31-September 06, there was none submitted. Per SN (skilled nurse), he had a death in the family and needed to take some days off.” 1d. During a record review on 9/8/2025, Patient 1’s medical record did not indicate an initial bereavement assessment. During a record review of Patient 1’s Audit Log, dated 9/10/2025, indicated the SC documented in the initial bereavement assessment for 8/16/2025 on 9/10/2025. 2. During a record review of Patient 9’s medical record form titled “Personal Information”, undated, indicated a start of care date of 8/6/2024 with a primary diagnosis of heart disease (a group of conditions that affect the heart and its blood vessels), unspecified. During a record review of Patient 9’s electronic medical record (EMR) form titled “History of Bereavement Assessment” indicated there were no entries documented. During a concurrent interview and record review on 9/10/2025 at 11:45 a.m. with the Registered Nurse Case manager (RN1) of Patient 9’s EMR, RN1 stated that Patient 9 did not have a bereavement assessment. RN1 stated that the assessment should have been completed within five days of Patient 9’s start of care. 3. During a record review of Patient 11’s medical record form titled “Personal Information”, undated, indicated a start of care date of 8/5/2024 and an end of care date of 1/7/2025 with a primary diagnosis of chronic obstructive pulmonary disease (COPD – lung disease causing breathing problems). During a record review of Patient 11’s electronic medical record (EMR), the EMR indicated there were no entries made in section “History of Bereavement Assessment.” During a concurrent interview and record review on 9/10/2025 at 2:35 p.m., with the DD of Patient 11’s EMR, the DD stated Patient 11 did not have an initial bereavement assessment documented. 4. During a record review of Patient 14’s medical record form titled “Personal Information”, undated, indicated a start of care date of 7/10/2024 and an end of care date of 6/23/2025 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure (weak heart that does not pump blood correctly). During a record review on 9/9/2025 at 5:39 p.m., of Patient 14’s EMR, medical record form titled “History of Bereavement Assessment” indicated there were no entries. During a concurrent interview and record review on 9/11/2025 at 12 p.m. with the Director of Patient Care Services (DPCS) of Patient 14’s EMR, the DPCS stated that Patient 14 did not have an initial bereavement documented. A review of the Hospice Agency (HA) document titled, Clinical Records, dated 2019, indicated, “Policy: A clinical record is established and maintained for very patient receiving care and services...The record is complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval...Each patient’s clinical record contains...Initial assessment...signed and dated clinical notes and progress notes...”.”

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the Physician’s Certification for Hospice Benefit (or CTI, a document signed by a physician certifying that a patient is terminally ill with a life expectancy of six months or less) was completed and signed by the Medical Director, for nine of twenty-eight sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 10, Patient 16, Patient 17, Patient 23, and Patient 24). This deficient practice had the potential to result in denial of Medicare (federal health insurance program in the United States for people age 65 or older, and for younger individuals with certain disabilities) coverage, loss of hospice services and disruptions in care that could lead to unnecessary suffering and a diminished quality of life during the final months of a terminal illness. 1. During a record review of Patient 1’s Personal Information sheet indicated a start of care date of 8/13/2025, with a terminal diagnosis of prostate cancer (a cancer of a male organ). During a record review of Patient 1’s Audit Log, dated 1/1/2025 to 9/11/2025, indicated the Medical Director 1 (MD 1) documented the Certificate of Terminal Illness (CTI) for certification period #5, dated 8/13/2025 to 10/11/2025, on 9/4/2025. Further review of the record indicated the CTI was signed on 9/8/2025. 2. During a record review of Patient 2’s Personal Information, indicated a start of care date of 7/12/2025, with a terminal diagnosis of Chronic Obstructive Pulmonary disease (COPD, an illness that makes breathing difficult). During a record review of Patient 2’s Audit Log, dated 7/10/2024 to 9/11/2024, indicated the CTI for certification period 7/7/2025 to 9/4/2025 physician narrative, was documented and edited by Registered Nurse 1 (RN 1), on 8/8/2025 and 8/16/2025, and not by the MD 1. Further review of the record indicated, the Nurse Practitioner (NP) also documented on the physician’s narrative on 8/11/2025. 3. During a record review of Patient 3’s Personal Information sheet, indicated a start of care date of 7/30/2024, with a terminal diagnosis of Malignant neoplasm of prostate (prostate cancer). During a record review of Patient 3’s Audit Log, dated 7/1/2024 to 9/11/2025, indicated the CTI for certification period 7/30/2024 to 10/27/2024, was documented by MD 1 on 8/7/2024. During a record review of Patient 3’s Audit Log, dated 7/1/2024 to 9/11/2025, indicated the CTI for certification period 3/27/2025 to 5/25/2025, was documented by MD 1 on 5/7/2025. 4. During a record review of Patient 4’s Personal Information, indicated a start of care date of 8/20/2025, with a terminal diagnosis of malignant neoplasm of cervix (cancer of the cervix). During a record review of Patient 4’s Audit Log, dated 8/20/2024 to 9/11/2025, indicated the CTI for certification period 8/20/2024 to 9/11/2024, was documented by MD 1 on 9/3/2024. 5. During a record review of Patient 10’s medical record form titled “Personal Information”, undated, indicated a start of care date of 1/11/2025 with a primary diagnosis of hypertensive heart disease without heart failure. During a record review of Patient 10’s medical record form titled “CTI”, for re-certification period #8 9/8/2025 to 11/6/2025 indicated it was not signed by the MD1. During a concurrent interview and record review on 9/10/2025 at 1:30 p.m., with the Administrator/Director of Patient Care Services Designee (DD) of Patient 10’s electronic medical record (EMR), DD stated Patient 10 was on certification period number eight from 9/8/2025 to 11/6/25, but it was not signed by the Medical Director (MD1). 6. During a review of Patient 16’s Personal Information, the Personal Information indicated a start of care (SOC) date of 3/21/2025, with a terminal diagnosis of dysarthria (a speech disorder characterized by difficulty in producing clear and intelligible speech due to damage or dysfunction in the muscles or nerves that control speech production) following other cerebrovascular (relating to the brain and its blood vessels) disease. During a review of Patient 16’s CTI (Certification of Terminal Illness – a physician’s written statement confirming a patient has a life expectancy of six months or less, if the illness runs its natural course, which is required for the patient to be eligible for hospice benefits) for the seventh certification period, from 7/19/2025 to 9/16/2025, the physician narrative indicated that Patient 16 continued to be eligible to receive hospice services. The face-to-face narrative was blank. The CTI indicated that MD 1 signed it on 7/19/2025. During a review of Audit Log (a detailed record containing details of who performed an action, what was done, when it happened, and which resources were affected) conducted on 9/9/2025, the Audit Log indicated the Medical Director (MD 1) signed it on 8/13/2025. During a concurrent interview and record review with RN 1 on 9/11/2025 at 10:54 a.m., RN 1 reviewed Patient 16’s CTI for the certification period of 7/19/2025 to 9/16/2025 and Audit Log (a detailed record containing details of who performed an action, what was done, when it happened, and which resources were affected) for Certification MD/CTI, from 8/13/2025 to 9/10/2025. RN 1 confirmed that the CTI for the certification period of 7/19/2025 to 9/16/2025 was not signed by MD 1 until 8/13/2025, or 25 days after the certification period started. 7. During a review of Patient 17’s Personal Information, the Personal Information indicated Patient 17’s start of care (SOC) date of 1/28/2025, with a terminal diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat). During a review of Patient 17’s CTI for the third certification period, from 7/27/2025 to 9/24/2025, the physician narrative indicated that Patient 17 was appropriate to receive hospice services. The CTI indicated that MD 1 signed it on 7/27/2025. During a review of Audit Log conducted on 9/9/2025, the Audit Log indicated that MD 1 signed it on 8/12/2025. During a concurrent interview and record review with RN 1 on 9/11/2025 at 10:54 a.m., RN 1 reviewed Patient 17’s CTI for the certification period of 7/27/2025 to 9/24/2025 and Audit Log for Certification MD/CTI from 8/11/2025 to 9/10/2025. RN 1 stated that the CTI for the certification period of 7/27/2025 to 9/24/2025 was not signed by MD 1 until 8/12/2025, or 16 days after the certification period started. 8. During a review of Patient 23’s Personal Information, the Personal Information indicated a start of care (SOC) date of 1/1/2025, with a terminal diagnosis of heart disease, unspecified. During a record review of Patient 23’s CTI form for certification #4 starting from 8/29/2025 to 10/27/2025, the CTI form indicated it was unsigned by the Medical Director and missing the Certifying Physician Narrative section. During a concurrent interview and record review, on 9/11/2025 at 11:15 a.m., with the Administrator/Director of Patient Care Services Designee (DD), the DD reviewed Patient 23’s CTI form for certification #4 dated starting from 8/29/2025 to 10/27/2025. The DD stated and confirmed Patient 23’s CTI form for certification #4 was not signed by the hospice Medical Director and there was no documentation under the section “Face to Face Narrative” and “Certifying Physician Narrative”. The DD stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director which included face to face visit narrative and certifying physician narrative. The DD further stated if the CTI form was not signed and completed by the Medical Director, the patient should not have been readmitted to hospice care. 9. During a review of Patient 24’s Personal Information, the Personal Information indicated a SOC date of 2/25/2025, with a terminal diagnosis of heart disease, unspecified. During a record review of Patient 24’s CTI form for certification #3 starting from 8/24/2025 to 10/22/2025, the CTI form indicated it was not signed by the Medical Director and missing the Certifying Physician Narrative section. During a concurrent interview and record review, on 9/11/2025 at 11:15 a.m., with the DD, the DD reviewed Patient 24’s CTI form for certification #3 dated from 8/24/2025 to 10/22/2025. The DD stated and confirmed Patient 24’s CTI form for certification #3 was not signed by the hospice Medical Director and there was no documentation under the section “Face to Face Narrative” and “Certifying Physician Narrative”. The DD further stated if the CTI form was not signed and completed by the Medical Director, the patient should not have been readmitted to hospice care. During a review of the agency’s policy and procedure (P&P) titled, Clinical Records, dated 2019, the P&P indicated a clinical record is established and maintained for every patient receiving care and services from Hospice and Palliative Care of California, Inc. All entries must be legible, clear, complete, and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice. Each entry is dated and signed, including title and credential, by the person providing the care/services. During a review of the agency’s P&P titled, Certification of Terminal Illness, dated 2019, the P&P indicated that the hospice would obtain written certification of terminal illness for each benefit period. If the hospice cannot obtain the written certification within 2 calendar days, after a period begins, it must obtain an oral certification within 2 calendar days and the written certification before it submits a claim for payment. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. All certifications and recertifications must be signed by the physician(s) and must include the benefit period dates to which the certification or recertification applies.”

“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 any amendments, correction or late entries within an electronic health record must clearly identify the original content, the modified content, date, and authorship of each record modification for six of twenty-eight sampled patients (Patient1, Patient 2, Patient 3, Patient 14, Patient 16, and Patient 17). This failure had the potential to result in an inaccurate patient information or assessment being entered in the patients’ clinical record, which could affect the patient’s quality of care and well-being. 1. During a record review of Patient 1’s Personal Information sheet indicated a start of care date of 8/13/2025, with a terminal diagnosis of prostate cancer (a cancer of a male organ). During concurrent interview and record review on 9/10/2025, at 2:23 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 reviewed Patient 1’s Audit Log (a document that recorded all entries and changes made in a medical record), dated 9/10/2025. The Audit Log indicated LVN 1 had made changes to the nursing narrative, documented by Registered Nurse 5 (RN 5). When LVN 1 was asked the reason for making changes to RN 5’s nursing note, LVN 1 stated she made the changes because the agency could not get a hold of RN 5. LVN 1 stated she received information about Patient 1’s medical information and these needed to be added to the record for billing purposes. LVN 1 stated she did not visit and did not assess Patient 1. LVN 1 stated she received permission from Registered Nurse 1 (RN 1) to input the information into the record. 2. During a record review of Patient 2’s Personal Information, indicated a start of care date of 7/12/2025, with a terminal diagnosis of Chronic Obstructive Pulmonary disease (COPD, an illness that makes breathing difficult). During concurrent interview and record review on 9/10/2025, at 3:25 p.m., with RN 1, RN 1 reviewed Patient 2’s Audit Log, dated 7/10/2024 to 9/10/2025. The record indicated changes were made to the face-to-face note made by the Nurse Practitioner (NP), for the visit dated 3/7/2025. RN 1 stated she removed the entry that indicated the presence of a pressure wound on the note by the NP because the information was incorrect. RN 1 stated she should have returned the record to the NP, so the NP could make the correction. During concurrent interview and record review on 9/10/2025, at 3:58 p.m., with LVN 1, LVN 1 reviewed Patient 2’s Audit Log, dated 7/10/2024 to 9/10/2025. The record indicated LVN 1 had made changes to the nursing narrative for Patient 2’s record titled, Recert Assessment, dated 8/25/2025. LVN 1 stated she added missing information to the narrative. LVN 1 stated she should have not done that and should have asked the nurse who saw the patient to add the missing information. 3. During a record review of Patient 3’s Personal Information sheet, indicated a start of care date of 7/30/2024, with a terminal diagnosis of Malignant neoplasm of prostate (prostate cancer). During a record review of Patient 3’s Audit Log, dated 7/23/2024 to 9/11/2025, the record indicated that RN 1 had made changes to the nursing narrative made by Registered Nurse 6 (RN 6) on the record titled, Re-Cert Assessment, dated 3/28/2025. 4. During a record review of Patient 14’s medical record form titled “Personal Information”, undated, indicated a start of care date of 7/10/2024 and an end of care date of 6/23/2025 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure (weak heart that does not pump blood correctly). During a record review of Patient 14’s medical record form titled “Discharge Summary” dated 6/23/2025, indicated the reason for discharge was due to moved out of area. The Discharge Summary did not indicate who the author was. During a concurrent interview and record review on 9/11/2025 at 12 p.m., with the DPCS of Patient 14s’ EMR, the DPCS stated that according to Patient 14’s EMR she (DPCS) did not know if Patient 14 was provided with one month worth of medications or that if he (Patient 14) received his medical records because it was not documented in his (Patient 14) EMR. The DPCS stated that she (DPCS) did not know who documented Patient 14’s discharge summary because the form was not signed. 5. During a review of Patient 16’s Personal Information, the Personal Information indicated a start of care (SOC) date of 3/21/2025, with a terminal diagnosis of dysarthria (a speech disorder characterized by difficulty in producing clear and intelligible speech due to damage or dysfunction in the muscles or nerves that control speech production) following other cerebrovascular (relating to the brain and its blood vessels) disease. During a review of Patient 16’s CTI (Certification of Terminal Illness – a physician’s written statement confirming a patient has a life expectancy of six months or less, if the illness runs its natural course, which is required for the patient to be eligible for hospice benefits) for the seventh certification period, from 7/19/2025 to 9/16/2025, the physician narrative indicated that Patient 16 continued to be eligible to receive hospice services. The face-to-face narrative was blank. The CTI indicated that MD 1 signed it on 7/19/2025. During a review of Audit Log (a detailed record containing details of who performed an action, what was done, when it happened, and which resources were affected) conducted on 9/9/2025, the Audit Log indicated the Medical Director (MD 1) signed it on 8/13/2025. During a concurrent interview and record review with RN 1 on 9/11/2025 at 10:54 a.m., RN 1 reviewed Patient 16’s CTI for the certification period of 7/19/2025 to 9/16/2025, Recert Assessment dated 7/5/2025, Audit Logs for Certification MD/CTI, Nursing Assessment, and Visit Note, from 8/13/2025 to 9/10/2025. During the concurrent interview and record review, RN 1 stated that only a physician or physician designee was supposed to document the CTI, including the Physician Narrative/Certifying Physician Summary. RN 1 stated she was not a physician or physician designee. When RN 1 was asked if she visited and assessed Patient 16’s MAC on 7/5/2025, RN 1 stated she did not. RN 1 stated that on 8/13/2025 she asked the DPCS to reassess Patient 16’s MAC; per RN 1 after the DPCS reassessed Patient 16 DPCS reported that Patient 16’s MAC was 21 cm. RN 1 stated that on 8/13/2025 she changed the MAC for the visit date that occurred on 7/5/2025. When RN 1 was asked to provide the documentation of the assessment that she stated was done by the DPCS on 8/13/2025, RN 1 stated there was no documentation. When RN 1 was asked to provide the route sheet (a document that provides a detailed plan for one or more appointments, typically in a healthcare setting or for field services) or any other evidence of the DPCS visit on 8/13/2025, RN 1 stated there was none. 6. During a review of Patient 17’s Personal Information, the Personal Information indicated Patient 17’s start of care (SOC) date of 1/28/2025, with a terminal diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat). During a review of Patient 17’s CTI for the third certification period, from 7/27/2025 to 9/24/2025, the physician narrative indicated that Patient 17 was appropriate to receive hospice services. The CTI indicated that MD 1 signed it on 7/27/2025. During a review of Audit Log conducted on 9/9/2025, the Audit Log indicated that MD 1 signed it on 8/12/2025. During a concurrent interview and record review with RN 1 on 9/11/2025 at 10:54 a.m., RN 1 reviewed Patient 17’s CTI for the certification period of 7/27/2025 to 9/24/2025 and Audit Log for Certification MD/CTI from 8/11/2025 to 9/10/2025. RN 1 restated that only a physician or physician designee was supposed to document the CTI, including the Physician Narrative/Certifying Physician Summary. RN 1 stated she was not supposed to document or modify the physician narrative for Patient 16’s and Patient 17’s CTIs. During a review of the HA’s policy and procedure (P&P) titled “Certification of Terminal Illness”, copyrighted 2019, the P&P indicated that the hospice would obtain written certification of terminal illness for each benefit period. If the hospice cannot obtain the written certification within 2 calendar days, after a period begins, it must obtain an oral certification within 2 calendar days and the written certification before it submits a claim for payment.”

“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 a discharge summary for three of twenty-eight sample patients (Patient 12, Patient 14, and Patient 21). This failure had the potential to impair continuity of care and smooth transition of care for the discharged patients. 1. During a record review of Patient 12’s medical record form titled “Personal Information”, undated, indicated a start of care date of 4/23/2024 and an end of care date of 12/31/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD). During a record review of Patient 12’s medical record form titled “Discharge Summary” dated 12/31/2024, indicated the reason for discharge was due to change in payer. The Discharge Summary did not indicate any other information was documented on Patient 12s’ discharge status. During a concurrent interview and record review on 9/11/2025 at 10:20 a.m., with the Director of Patient Care Services (DPCS) of Patient 12s’ electronic medical records (EMR), the DPCS stated there was no discharge note documented for Patient 12. The DPCS stated it was important to document a discharge note, to be able to know why, where, and what happened to the patient. The DPCS stated there was no discharge order written for Patient 12. The DPCS stated a physician discharge order was required to ensure that the patient was ready to be discharge. The DPCS stated when patients are to be discharged the HA supplies patients with one month supply of medications and communicate with their primary physician. The DPCS stated Patient 12s’ EMR did not have documentation that she (Patient 12) was supplied with medications or that the HA spoke with Patient 12s’ physician. During a concurrent interview and record review on 9/12/2025 at 11:42 a.m., with the Medical Director (MD1) of Patient 12’s EMR, the MD1 stated Patient 12’s EMR did not have discharge information. The MD1 stated patients need to be informed of their discharge, provide arrangements, be supplied with at least 30 days worth of medications and durable medical equipment. 2. During a record review of Patient 14’s medical record form titled “Personal Information”, undated, indicated a start of care date of 7/10/2024 and an end of care date of 6/23/2025 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure (weak heart that does not pump blood correctly). During a record review of Patient 14’s medical record form titled “Discharge Summary” dated 6/23/2025, indicated the reason for discharge was due to moved out of area. The Discharge Summary did not indicate who the author was. During a concurrent interview and record review on 9/11/2025 at 12 p.m., with the DPCS of Patient 14s’ EMR, the DPCS stated that according to Patient 14’s EMR she (DPCS) did not know if Patient 14 was provided with one month worth of medications or that if he (Patient 14) received his medical records because it was not documented in his (Patient 14) EMR. The DPCS stated that she (DPCS) did not know who documented Patient 14’s discharge summary because the form was not signed. 3. During a review of Patient 21’s Personal Information, the Personal Information indicated a start of care (SOC) date of 9/7/2024, with a terminal diagnosis of heart disease (a group of conditions that affect the heart and blood vessels), unspecified. During a review of Physicians Order, dated 6/3/2025, the Physicians Order indicated that Patient 21 was discharged from the HA due to extended prognosis (a situation where a patient, originally given a short life expectancy (often under six months), outlives that prediction and remains eligible for hospice care or is discharged from it because their condition has stabilized or improved). During a review of Patient 21’s Discharge Summary, with the End of Care (EOC) date 6/3/2025, the Discharge Summary was blank. The Discharge Summary was not signed and dated. During a review of the HA’s policy and procedure (P&P) titled “Discharge from Hospice”, copyrighted 2019, the P&P indicated the following: When the patient is discharged from hospice (by discharge, transfer or revocation), the hospice provides a copy of the clinical record (if requested) and the hospice discharge summary to the patient’s attending physician and any new agency providing care (home care agency, skilled nursing facility, assisted living facility), if applicable. This discharge summary is filed in the clinical record and includes: a. Any instructions or referral information given to the patient or family; b. Patient identifying information; c. Hospice diagnosis;…n. Any third party revocation or terminations.”

“Upon patient record review, 1 of 14 (Patient #9) 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 #9: IDG Meetings/POC Reviews documented 5/28 and not again until 6/24/24, and then no other documentation of review to date. which is greater than 15 days between each review. No additional information provided by end of survey.”

“Upon patient record review, 2 of 14 (Patient #1,10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: Recent history of bowel obstruction requiring surgical intervention and history of gastric bypass. Admitted with surgical wound with sutures intact. RN did wound care to surgical incision wound. But there were no related problem/goals interventions Patient #10: 4/17/24 MD order left hand surgical wound with tx order to cleanse with NS pat dry with gauze. Apply triple antibiotic then cover with non-adherent dressing then wrap with kerlix roll daily until healed. SN to do day of visits and caregiver remainder of week. No problems, goals or interventions included in IDG POC related to wound.”

“Upon patient record review, 4 of 14 (Patient #5, 6, 7, 10) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #5: MSW frequency 1/recert period and PRN. PRN is not quantified. Patient #6: HA 2x/week and PRN. PRN is not quantified. MSW 1/recert period and PRN. PRN is not quantified. Patient #7: MSW initial visit to evaluate to develop POC, recert and PRN. PRN is not quantified. Patient #10: MSW and SC frequencies are to evaluate to develop POC, recert and PRN. PRN is not quantified.”

“Upon client record review, 3 of 14 (Patient #1, 10, 12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: SN Visit notes 5/13, 5/20, 5/27, 6/4, 6/15/24 documented wound care done on abdominal incision wound. Cleansed with wound cleanser, pat dry, covered with dressing. There was no documented wound treatment order. Patient #10: 6/10/24 order for PT consult. No evidence the PT assessment occurred. Patient #12: SC order initial evaluation to develop plan of care, recertification and as needed. Visits made 2/20, 3/20, 4/24, 5/24/24, but there was no orders for the extra visits.”

“Upon patient record review, 2 of 14 (Patient #3, 7) did not have evidence that Social work services are based on the patient’s psychosocial assessment and the patient/family’s needs and acceptance of these services. Patient #3: Upon record review, it was noted in MSW psychosocial assessment that 24 year old patient’s complex social history includes living with great grandmother, dad and girlfriend currently, while mother lives in in a “shanty at back of property” and anticipates eviction by grandmother. It was further noted that the patient shared that her mother has caused many problems in family related to drug abuse. Also noted that patient saw her uncle murdered when she was 10. She became tearful during visit. MSW appropriately coordinated with MD regarding referral to outside psychologist, and documented MSW will make one follow up 5/16/24, and then only one visit per cert period. There was no order obtained for 5/16 MSW visit and no documentation of communication with patient for follow up and no mention in IDG of documented plan to see patient that day for follow up. There is no documentation that additional visits were offered and/or declined. Patient #7: Upon patient record review MSW psychosocial assessment noted that patient is estranged from family, was addicted to cocaine for 15 years, but sober since 1995. He was very talkative and engaged during interview. MSW planned visits every recert and prn. Planned intervention that visit was to provide emotional support and validate feelings re estranged relationship with family. IDG 6/4/24, MSW referenced use of DBT techniques to address feelings related to estranged relationship with family. There is no documentation that additional visits were offered and/or declined.”

“Upon patient record review, 1 of 14 (Patient # 12) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #12: Pt admitted 1/12/23-6/17/24. HA assignment created/signed by LVN, not RN, although in EMR, visit appeared to have been assigned to RN. The frequency noted on the assignment sheet was “HA declined but will continue to offer”, but there are assigned tasks on the form.”

“Upon patient record review 3 of 14 (Patient #6, 9, 12) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #6: Pt admitted 5/14/24. HA Assignment CP 5/14/24 includes HA frequency of 2x/week and order in place. The only HA visit note documented is 6/13/24. HA documentation same note 6/13/24 narrative says “patient completed” in narrative, but there are tasks checked off as completed, including but not limited to: tub bath, comb/brush hair, shampoo, blow dry, clean nails. During the home visit, the patient verified she had declined aide services. Patient #9: Pt. admitted 5/26/24. HA Assignment and POC ordered frequency of 3x wk. effective 5/26/24. Only documented visits were 6/13 and 6/21/24. There were no visits for first 2 weeks and only one each for subsequent weeks. There was no subsequent order change to update frequency/POC. 6/13 NOTE HA Assignment included for HA to record bowel movement. The HA note included a check for BM, but space allocated for date said 5/21/2024, but the date of visit was 6/21/24. Narrative says “reported to case manager” but no details. Also, there was no documentation that patient did not want additional visits, although none were provided. Patient #12: Pt. admitted 1/12/23. HA assignment documented frequency is that HA declined but will continue to offer, but there are assigned tasks on the form. There was a duplicate of the same HA assignment sheet in EMR also. Physician order, POC, IDG Meetings and Care Plan all list HA frequency as declined. Visits provided 1-2x weekly, for example HA visits documented May 7, 9, 14, 16, 22, 28, 30 of 2024.”

“Upon patient record review 3 of 14 (Patient #6, 9, 12) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient #6, 9: There was no documented evidence of HA Supervisory visit q 14 days. Patient #12: There was documentation of supervisory visit every 14 days, but during multiple supervisory visits, the nurse did not effectively identify error in frequency assigned/ordered and update hospice POC accordingly to reflect frequency of the visits being made.”

“Upon contract review, 1 of 5 (contract) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient’s plan of care There was no contractual arrangement of any kind documented with Wound Pro for wound treatment and consultation services provided to patient #1.”

“Upon patient client record review, 3 of 14 (Patient #4, 8, 9) 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 #4: Patient admissions consents, election of hospice benefit forms all signed with signature date of 4/21/24. However, the effective date for hospice Medicare benefit is documented as 5/17/24. MSW initial assessment 5/17/24 documents patient is full code. However, there is a POLST with DNR uploaded to record and dated 4/21/24. Patient #8: Initial comprehensive assessment narrative includes educated all related teachings to PCG regarding wound care. However, there is no documented evidence that patient had wounds. Integumentary status documented as normal, cool, warm, dry, fair turgor, wound/skin impairment - no and identified as low risk for skin impairment. Patient #9: CTI narrative by physician begins with Entering hospice cert 4 for 97 year old female with primary dx of heart disease without heart failure. Further states that Face to Face was completed 5/20/24. There is no specific documentation related to Face to Face as referenced. (No documents uploaded. Admission information and EMR identify 5/26/24-8/23/24 as second 90 day benefit period and CTI header identifies 2nd 90 day period.”