New Path Hospice Care Inc.

“Based on interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (CoP, refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Initial & Comprehensive Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process) of Patient was met as follows: 1. The HA failed to ensure the Interdisciplinary Group (IDG, a group of health care professionals with various areas of expertise who work together toward the goals of the patients and families) completed the comprehensive assessment no later than five calendar days after hospice election for six of nine sampled patients (Patient 2, Patient 4, Patient 6, Patient 7, Patient 8 and Patient 9). This failure had the potential to result in patient needs not identified, timely support and services of patients’ needs not being provided that could result in decline of patient health and quality of life. (Refer to L523).2. The HA failed to complete and update a comprehensive assessment for two of nine sampled patients (Patient 3 and Patient 4), to reflect their current health condition, pain status, response to treatment and current medications.This failure of inaccurate assessment of Patient 3 and Patient 4 had the potential to cause a disruption in their continuity of care amongst the hospice care staff which could result patients needs, treatment and services not provided to the patients, discomfort, decline of patient health, and affect the patients’ quality of life. (Refer to L524).3. The HA failed to complete and submit an initial bereavement assessment, to provide bereavement counseling in accordance with the patient/family’s needs, within five days of Start of Care for four of nine sampled patients (Patient 2, Patient 6, Patient 7 and Patient 9).This failure had the potential to delay the individualized support the family/caregivers required that could impact their ability to cope with the patients’ death. (Refer to L531). 4. The HA failed to ensure the Registered Nurse (RN) completed an updated comprehensive assessment that reflected the patient’s current health status every 15 days as per their policy, for one of nine sampled patients (Patient 1).This deficient practice resulted in the late submission and reporting of the patient’s current health status, which could have resulted in a delay in Patient 1’s 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 Patient to ensure the highest quality of care were being provided to patients certified to receive the hospice benefits.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (CoP, refers to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Medical Director was met as follows: 1. The HA failed to ensure the Medical Director reviewed past medical history /physical, or diagnostic, and laboratory results that indicated the patients met the hospice criteria to be admitted into the hospice patient care program for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, and Patient 9).This failure resulted in patients being enrolled to the HA without oversight of the implementation of the hospice services and could affect the patients’ and patient’s family’s needs not being met that could result in in decline patients’ health and quality of life. (Refer to L669).2. The HA failed to ensure the Medical Director conducted an accurate assessment, reviewed, and verified the patient’s clinical information, necessary for Initial Certification of Terminal Illness (CTI, formal document signed by physicians declaring a patient has a life expectancy of six months or less, making them eligible for Medicare/Medicaid-funded hospice care focused on comfort, not cure) to support the diagnosis of the patients’ terminal illnesses and to qualify for hospice care for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8 and Patient 9).This deficient practice resulted in patient’s being enrolled in hospice and receiving care without a proper verification of the patient eligibility and had the potential for the Patients’ to not receive necessary care and healthcare resources to meet their care goals. (Refer to L667).The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory (written law) mandated compliance with Federal regulation for Medical Director services to ensure quality of patient care were provided to the patients certified to receive hospice services.”

“Based on interview and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Clinical Records was met as follows: 1. The HA failed to ensure the clinical records for six of nine sampled patients (Patient 2, Patient 4, Patient 6, Patient 7, Patient 8, and Patient 9) included the plan of care, initial assessment, comprehensive assessments, and/or clinical notes that reflected the patients’ current health status, correct and updated assessments:This failure of incomplete clinical record could lead to misinformation and non-continuity of care. This failure has a potential to result in patients’ needs and services not provided to the patients that could result to patient’s health status to decline, and not have good quality of life. (Refer to L672). 2. The HA failed to ensure complete and accurate patient health records were documented for nine of nine sampled patients (Patients 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8 and Patient 9), by failing to:Ensure all members of the interdisciplinary group (IDG, a group of health care professionals with various areas of expertise who work together toward the goals of the patients and families) who attended the interdisciplinary group meeting documented and signed in the Plan of Care/Interdisciplinary Group Review (POC/IDG, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) after the meeting for six of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 7, and Patient 8).Ensure that the licensed nurses complete, sign and date all nursing visit notes for one of nine sampled patients (Patient 1).Ensure that the Discharge Summary’s for three of nine sampled patients (Patient 7, Patient 8, and Patient 9) were completed with signature and date.These failures could result in inaccurate records, patient not receiving appropriate high-quality care, disrupt the patients’ continuity of care, patients not receiving the necessary care and services that could result in the decline of patient health condition, or not having quality of life. (Refer to L679).3. The HA failed to ensure that the Discharge Summaries (medical document that wraps up a patient’s hospital stay, detailing their diagnosis, treatments, and condition, serving as a vital roadmap for smooth care transitions to home or another facility) for three of nine sampled patients (Patient 7, Patient 8 and Patient 9) were completed and validated with date and signature, by the licensed nurse.This failure had a potential to increase risks of patient safety, medication errors, missed follow-up care, and patients not receiving the necessary care and services. (Refer to L684).”

“Based on interview and record review the Hospice Agency (HA, agency that provides /care and support for people with a serious illness and nearing the end of life) failed to ensure the Interdisciplinary Group (IDG, a group of health care professionals with various areas of expertise who work together toward the goals of the patients and families) completed the comprehensive assessment no later than five calendar days after hospice election for six of nine sampled patients (Patient 2, Patient 4, Patient 6, Patient 7, Patient 8 and Patient 9). This failure had the potential to result in patient needs not identified, timely support and services of patients’ needs not being provided that could result in decline of patient health and quality of life. During a review of Patient 4’s “Personal Information”, indicated a start of care (SOC) date of 12/11/2025, with a primary diagnosis arteriosclerotic heart disease of coronary artery disease without angina pectoris, (is a buildup of plaque in the hearts arteries, narrowing them and reducing blood flow , without chest pain) aphasia following cerebral infarct(Aphasia after a stroke or cerebral infarct is a language problem caused by brain damage it makes it hard to speak, understand read, and write. During a review of Patient 4’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 12/11/2025, indicated the frequency of visits for skilled nurse (SN) one to two visits per week plus two PRN (pro re nata, “as needed”) visits to promote comfort and symptom management., Mater of Social Work (MSW )initial assessment within 5 days, Spiritual Counsel(SC), initial assessment within 5 days and for the Rn initial evaluation and then every 14 days thereafter for supervisory visits.During a Review of Patient 4’s Electronic Medical Record on 12/16/2025, indicated there was no psychosocial completed by the Medical Social Worker within the comprehensive assessment timeframe after the SOC.The absence of the psychosocial assessment indicated the comprehensive assessment was not completed by all required IDG disciplines within the required timeframe.c. During a review of patient ’s “Personal Information”, indicated a start of care (SOC) date of 12/08/2025, with a primary diagnosis arteriosclerotic heart disease of coronary artery disease without angina pectoris, (is a buildup of plaque in the hearts arteries, narrowing them and reducing blood flow, without chest pain). During a review of Patient 6’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 12/08/2025, indicated the frequency of visits for skilled nurse (SN) one to two visits per week plus two PRN (pro re nata, “as needed”) visits to promote comfort and symptom management., Mater of Social Work (MSW )initial assessment within 5 days, Spiritual Counsel(SC), initial assessment within 5 days and for the Rn initial evaluation and then every 14 days thereafter for supervisory visits.During a Review of Patient 6’s Electronic Medical Record on 12/16/2025, indicated there was no psychosocial assessment completed by the Medical Social Worker within the comprehensive assessment timeframe after the SOC.Review of patient 6’s EMR on 12/16/2025, indicated there was no bereavement assessment completed, and the initial Spiritual Assessment contained multiple blank sections and was incomplete, indicating the chaplain did not complete the spiritual component of the comprehensive assessment within the required time frame.d. During a review of patient 9’s “Personal Information”, indicated a start of care (SOC) date of 08/01/2025 and end of care (EOC) date of 11/30/2025, with a primary diagnosis of Chronic Obstructive Heart Disease (COPD-is a progressive lung disease that makes breathing difficult due to air flow obstruction is characterized by inflammation coughing wheezing and shortness of breath).During a review of Patient 9’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 11/11/2025, and 11/30/2025, indicated the frequency of visits for skilled nurse (SN) one to two visits per week plus two PRN (pro re nata, “as needed”) visits to promote comfort and symptom management., Mater of Social Work (MSW )initial assessment within 5 days, Spiritual Counsel(SC), initial assessment within 5 days and for the Rn initial evaluation and then every 14 days thereafter for supervisory visits. Review of the EMR indicated there was no initial psychosocial assessment and no initial spiritual assessment completed during the patients entire episode of care. Continued review of the EMR indicated there was no skilled nursing notes in Patient 9’s record, the discharge summary did not have the signature of the discipline completing the form.During an interview with the DPCS in the HA’s office on 12/19/2025, at 12pm. She stated that she was new and would have to train staff.The absence of these assessments demonstrates the comprehensive assessment was not completed within the required time frame Findings:During an interview on 12/19/2025 at 10:45 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated comprehensive assessments initial and on recertification are to be completed and submitted within 5 days of the patient’s admission. The DPCS stated it is important to complete comprehensive assessments within the 5 days of SOC to understand the patient’s care needs and provide it to them.During a telephone interview on 12/19/2025 at 12:10 p.m. with the MSW, the MSW stated she is responsible for completing the initial psychosocial assessment and initial bereavement assessment within 5 days of the patient’s admission. The MSW stated it is important to complete a psychosocial assessment for a patient because it provides well-rounded information on the patient that is apart from the medical diagnosis, like who they are, how they are feeling, what makes them feel better and makes them feel more connected to the care team. The MSW stated the importance of completing an initial bereavement assessment on a patient is to initiate the end-of-life conversation with the patient and family and see where they are at and how they feel about it. The MSW stated if an initial bereavement assessment is not completed, then a negative outcome can be that the patient and/or family can be left dealing with feelings of distress or negativity and can cause mental health issues which can also affect their grieving process. The MSW also stated if a newly admitted patient does not want to meet with a social worker she will reach out to the patient and educate them on why she is part of the care team and how she can help the patient and if the patient still declines the visit then the MSW will follow up with the patient the following month or on recertification. The MSW stated she documents the patient declining the visit in a communication note in the patient’s Electronic Medical Record (EMR). a. During a review of Patient 2’s Patient Information Sheet (face sheet, admission record). The Patient Information Sheet indicated a Start of Care (SOC) date of 12/7/2025, with a primary diagnosis of Hypertensive heart disease with heart failure (heart problems caused by long term, uncontrolled high blood pressure, forcing the heart to work harder, leading to muscle thickening, stiffness and damage, potentially progressing to heart failure).During a review of Patient 2’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 12/7/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visits once per week for changes in condition to promote comfort and symptom management, Medical Social Worker (MSW) to evaluate and assess for needs initial evaluation within 5 days of admission, recertification and as needed for psycho-social counseling and support, Bereavement Coordinator (BC) visit within 5 days of admission to assess and evaluate bereavement and grieving risk factors, and Spiritual care Coordinator (SC) for spiritual initial assessment within5 days of admission, recertification and as needed to identify spiritual needs to support patient/family and primary caregiver.During a concurrent interview and record review on 12/19/2025 at 11:30 a.m. with the Director of Patient Care Services (DPCS), Patient 2’s Electronic Medical Record (EMR) was reviewed. Patient 2’s EMR, under the section History of Psychosocial assessment, indicated there was no completed or submitted assessment since the SOC of 12/7/2025. The DPCS stated and confirmed Patient 2’s Assessment section in his EMR did not include documented evidence that a Psychosocial Assessment was completed or submitted. The DPCS stated it is the responsibility of the MSW to complete the home visit within 5 days of the patient’s admission and complete and submit the assessment. The DPCS stated the psychosocial assessment should have been completed by 12/12/2025.b. During a review of Patient 7’s Patient Information Sheet (face sheet, admission record), the Patient Information Sheet indicated a Start of Care (SOC) date of 11/3/2025 and an End of Care (EOC) date of 11/30/2025, with a primary diagnosis of Atherosclerotic heart disease of native artery without angina pectoris (a condition where atherosclerosis [buildup of plaque in the artery walls] occurs in the coronary arteries, which supply blood to the heart, without chest pain).During a review of Patient 7’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 11/25/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visits once per week and one as needed (PRN) visit to promote comfort and symptom management, Bereavement Coordinator (BC) visit within 5 days of admission to assess and evaluate bereavement and grieving risk factors, Medical Social Worker (MSW) visit within 5 days of admission for initial assessment and Spiritual Coordinator (SC) visit within 5 days of admission for initial assessment.During a concurrent interview and record review on 12/19/2025 at 10:50 a.m. with the DPCS, patient 7’s the Electronic Medical Record (EMR) was reviewed. Patient 7’s EMR, under the section, Assessment indicated there was no completed or submitted Psychosocial assessment since the SOC date of 11/3/2025. Patient 7’s EMR under section Assessment also indicated there was no completed or submitted Spiritual Assessment since the SOC date of 11/3/2025. The DPCS stated and confirmed that Patient 7’sd EMR did not have documented evidence of a psychosocial assessment submitted. The DPCS stated the psychosocial assessment is the responsibility of the MSW and should have been completed and submitted within 5 days from the SOC date. The DPCS stated and confirmed that Patient 7’s EMR also did not have documented evidence of a Spiritual Assessment submitted. The DPCS stated the spiritual assessment is the responsibility of the Chaplain and should also be submitted within 5 days from the patient’s SOC date.c. During a review of Patient 8’s Patient Information Sheet (face sheet, admission record), the Patient Information Sheet indicated a Start of Care (SOC) date of 11/8/2025 and an End of Care (EOC) date of 11/30/2025, with a primary diagnosis of Heart Failure (a condition when the heart muscle does not pump blood as well as it should causing blood to back up and fluid can build up in the lungs, causing shortness of breath).During a review of Patient 8’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 11/11/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visit once per week for changes in condition to promote comfort and symptom management, Bereavement Coordinator (BC) visit within 5 days of admission to assess and evaluate bereavement and grieving risk factors, Medical Social Worker (MSW) to evaluate and assess for needs initial evaluation within 5 days of admission, recertification and as needed for psycho-social counseling and support, and Spiritual care Coordinator (SC) visit for spiritual initial assessment within 5 days of admission, recertification and as needed to identify spiritual needs to support patient/family and primary caregiver.During a concurrent interview and record review on 12/19/2025 at 10:57 a.m. with the Director of Patient Care Services (DPCS), Patient 8’s Electronic Medical Record (EMR) was reviewed. Patient 8’s EMR, under the section Assessment, indicated there was no completed or submitted Spiritual Assessment since the patient’s SOC of 11/8/2025. The DPCS stated and confirmed that Patient 8’s EMR did not have documented evidence of a Spiritual Assessment completed or submitted. The DPCS stated it was the responsibility of the Chaplain to contact the patient and schedule a home visit within 5 days of the admission date to conduct, complete and submit the Spiritual assessment. The DPCS stated Patient 8 has been discharged from the HA, and a spiritual assessment was not done.During a review of the HA’s Policy and Procedure (P&P) titled Comprehensive Assessment, revised on October 2015, the P&P indicated that a patient comprehensive assessment will be performed by the hospice IDG no later than 5 calendar says after the election of hospice care in consultation with the attending physician. The P&P also indicated that the comprehensive patient assessment will at least include the following: an assessment of pain, a physical assessment, patient’s functional status, evaluation of home environment, review of current and past medication, the patient’s psychosocial status, patient and/or family/caregiver support system, assessment of the patient’s and family/caregiver spiritual orientation, and a bereavement assessment.”

“Based on interview and record review the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to complete and update a comprehensive assessment for two of nine sampled patients (Patient 3 and Patient 4), to reflect their current health condition, pain status, response to treatment and current medications.This failure of inaccurate assessment of Patient 3 and Patient 4 had the potential to cause a disruption in the patients continuity of care amongst the hospice care staff which could result patients’ needs, treatment and services not provided to the patients, discomfort, decline of patient health, and affect the patients’ quality of life. Findings:a. During a review of Patient 3’s Personal Information, undated, indicated Patient 3 had a start of care (SOC) date of 10/31/2025, with a primary diagnosis of Heart failure (the heart muscle is too weak or stiff to pump enough blood that can cause fluid buildup in the lungs, legs and other areas leading to fatigue and shortness of breath).During a review of Patient 3’s initial comprehensive Assessment dated 10/31/2025, under the section, Nature & Conditions of Terminal Illness/LCD (Local Coverage Determination) Eligibility, Illness Trajectory (typical path or pattern a specific illness follows over time, describing its progression, potential for recovery, and eventual outcome) and Reasons for Hospice Admission, indicated that the patient’s condition existed as evidenced by medical history , patient, and caregiver/family; however no individualized supporting details were documented. The comprehensive assessment also failed to include baseline weight, height and mid-arm circumference (MAC), (simple measurement of the upper arm’s grit (middle of) at its midpoint between the shoulder and elbow).During a concurrent interview and record review on 12/19/2025 at 10:05 a.m. with the Director of Patient Care Services (DPCS), Patient 3’s comprehensive assessment dated 10/31/2025 was reviewed. The DPCS stated and confirmed Patient 3’s comprehensive assessment was incomplete, and had missing information about the patient’s baseline weight, height and mid-are circumference (MAC). b. During a review of Patient 4’s Personal Information, it indicated a SOC date of 12/11/2025, with a primary diagnosis arteriosclerotic heart disease of coronary artery disease without angina pectoris (arteriosclerotic heart disease of coronary artery disease without angina pectoris (is a buildup of plaque in the hearts arteries, narrowing them and reducing blood flow , without chest pain) aphasia (a language problem caused by brain damage from a stroke, making it hard to speak, understand, read and write) following cerebral infarct (brain tissue death from a lack of blood flow, stroke, caused by a blocked artery in the brain, depriving cells of oxygen and nutrients). During a review of Patient 4’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 12/11/2025, indicated the frequency of visits for skilled nurse (SN) was one to two visits per week plus two as needed visits to promote comfort and symptom management and for the Registered Nurse (RN) to visit for initial evaluation and then every 14 days thereafter for supervisory visits.During a review of Patient 4’s initial comprehensive Assessment dated 12/11/2025, under the Nature & Conditions of Terminal Illness/LCD Eligibility, Illness Trajectory and Reasons for Hospice Admission documented that conditions existed as evidence by medical history, patient, and caregiver/family; however, there was no documented medical history /physical indicating the patient’s need for hospice services. Continued review of Patient 4’s initial comprehensive assessment dated 12/11/2025, documented “moderate pain” however, the comprehensive assessment failed to include pain location, description, duration, or additional signs and symptoms in the pain assessment tool.During a concurrent interview and record review on 12/19/2025 at 10:10 a.m. with the Director of Patient Care Services, Patient 4’s comprehensive assessment dated 10/31/2025 was reviewed. The DPCS stated and confirmed Patient 4’s comprehensive assessment was incomplete, had missing information describing the pain location, description, duration, or additional signs and symptoms in the pain assessment tool. During a review of the Hospice Agency’s (HA) Policy and Procedure (P&P) titled Comprehensive Assessment, revised October 2015, the P&P indicated that during the comprehensive assessment all baseline date and other relevant information will be documented to include, pain its origin, duration, severity and relief measures, nature and condition of admission, current treatment and patient response, physical assessment, patient’s functional status, home environment, review of medications, patient’s psychosocial status and spiritual orientation and support system.”

“Based on interview and record review the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to complete and submit an initial bereavement assessment, to provide bereavement counseling in accordance with the patient/family’s needs, within five days of Start of Care for four of nine sampled patients (Patient 2, Patient 6, Patient 7 and Patient 9).This failure had the potential to delay the individualized support the family/caregivers required that could impact their ability to cope with the patients’ death. a. During a review of Patient 3’s “Personal Information”, indicated a start of care (SOC) date of 10/31/2025, with a primary diagnosis of Heart failure (heart failure means the heart muscle is too weak or stiff to pump enough blood this can cause fluid buildup in the lungs, legs and other areas leading to fatigue and shortness of breath, it’s a chronic condition where the heart can’t keep up) advice or a diagnosis consult a professional ).Review of Patient 3’s initial comprehensive Assessment dated 10/31/2025, under the” Nature & Conditions of Terminal Illness/LCD Eligibility, Illness Trajactory and Reasons for Hospice Admission documented that conditions existed as evidence by medical history ,patient, and caregiver/family; however no individualized supporting details were documented. The comprehensive assessment also failed to include baseline weight, height and mid-are circumference (MAC). b. During a review of Patient 4’s “Personal Information”, indicated a start of care (SOC) date of 12/11/2025, with a primary diagnosis arteriosclerotic heart disease of coronary artery disease without angina pectoris, (is a buildup of plaque in the hearts arteries, narrowing them and reducing blood flow , without chest pain) aphasia following cerebral infarct(Aphasia after a stroke or cerebral infarct is a language problem caused by brain damage it makes it hard to speak, understand read, and write. During a review of Patient 4’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 12/11/2025, indicated the frequency of visits for skilled nurse (SN) one to two visits per week plus two PRN (pro re nata, “as needed”) visits to promote comfort and symptom management., Mater of Social Work (MSW )initial assessment within 5 days, Spiritual Counsel(SC), initial assessment within 5 days and for the Rn initial evaluation and then every 14 days thereafter for supervisory visits.Review of Patient 4’s initial comprehensive Assessment dated 12/11/2025, under the” Nature & Conditions of Terminal Illness/LCD Eligibility, Illness Trajectory and Reasons for Hospice Admission documented that conditions existed as evidence by medical history ,patient, and caregiver/family; however no individualized supporting details were documented.Continued review of Patient 4’s initial comprehensive assessment dated 12/11/2025, documented “moderate pain” however, failed to include pain location, description, duration, or additional signs and symptoms in the pain assessment tool. c. During a Review of Patient 6’s Electronic Medical Record on 12/16/2025, indicated there was no initial psychosocial, bereavement assessment and the initial Spiritual Assessment contained multiple blank sections and was incomplete, indicating that multiple disciplines of the IDG did not complete the spiritual, psychosocial and bereavement component of the comprehensive assessment. d. . During a review of patient 9’s “Personal Information”, indicated a start of care (SOC) date of 08/01/2025, and a End of Care (EOC) date with a primary diagnosis of Chronic Obstructive Heart Disease (COPD-is a progressive lung disease that makes breathing difficult due to air flow obstruction is characterized by inflammation coughing wheezing and shortness of breath). e. During a review of Patient 9’s Electronic Medical Record on 12/16/2025, indicated there was no initial psychosocial and bereavement assessment, indicating that multiple disciplines of the IDG did not complete the psychosocial and bereavement component of the comprehensive assessment. During an interview with the DPCS in the HA’s office on 12/19/2025, at 12p.m., she stated she was hired on 12/1/2025, and would have to train staff. Findings:During a telephone interview on 12/19/2025 at 12:10 p.m. with the MSW, the MSW stated she is responsible for completing the initial psychosocial assessment and initial bereavement assessment within 5 days of the patient’s admission. The MSW stated it is important to complete a psychosocial assessment for a patient because it provides well-rounded information on the patient that is apart from the medical diagnosis, like who they are, how they are feeling, what makes them feel better and makes them feel more connected to the care team. The MSW stated the importance of completing an initial bereavement assessment on a patient is to initiate the end-of-life conversation with the patient and family and see where they are at and how they feel about it. The MSW stated if an initial bereavement assessment is not completed, then a negative outcome can be that the patient and/or family can be left dealing with feelings of distress or negativity and can cause mental health issues which can also affect their grieving process. The MSW stated if a newly admitted patient does not want to meet with a social worker she will reach out to the patient and educate them on why she is part of the care team and how she can help the patient and if the patient still declines the visit then the MSW will follow up with the patient the following month or on recertification. The MSW stated she documents the patient declining the visit in a communication note in the patient’s Electronic Medical Record (EMR). The MSW also stated and verified if the patient’s EMR does not indicate that a psychosocial assessment or an initial bereavement assessment was submitted and there was no documented communication note indicating the patient refused the visit, then it means that she (MSW) did not complete the visit. a. During a review of Patient 2’s Patient Information Sheet (face sheet, admission record). The Patient Information Sheet indicated a Start of Care (SOC) date of 12/7/2025, with a primary diagnosis of Hypertensive heart disease with heart failure (heart problems caused by long term, uncontrolled high blood pressure, forcing the heart to work harder, leading to muscle thickening, stiffness and damage, potentially progressing to heart failure).During a review of Patient 2’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 12/7/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visits once per week for changes in condition to promote comfort and symptom management, Medical Social Worker (MSW) to evaluate and assess for needs initial evaluation within 5 days of admission, recertification and as needed for psycho-social counseling and support, Bereavement Coordinator (BC) visit within 5 days of admission to assess and evaluate bereavement and grieving risk factors, and Spiritual care Coordinator (SC) for spiritual initial assessment within5 days of admission, recertification and as needed to identify spiritual needs to support patient/family and primary caregiver.During a review of Patient 2’s Bereavement section in his Electronic Medical record (EMR), the Bereavement section indicated there was no completed or submitted Initial Bereavement Assessment for Patient 2 since her SOC date of 12/7/2025.During a concurrent interview and record review on 12/19/2025 at 11:35 a.m. with the Director of Patient Care Services (DPCS), Patient 2’s Bereavement section in the Electronic Medical Record (EMR) was reviewed. Patient 2’s Bereavement section indicated there was no completed or submitted Initial Bereavement Assessment for Patient 2 since her SOC date of 12/7/2025. The DPCS stated and confirmed Patient 2’s Bereavement section in his EMR did not include documented evidence that an Initial Bereavement assessment was completed or submitted. The DPCS stated it is the responsibility of the BC to complete the initial bereavement assessment within 5 days of admission and it is only submitted under the bereavement section in the EMR. The DPCS stated the initial bereavement assessment should have been completed and submitted by 12/12/2025.b. During a review of Patient 7’s Patient Information Sheet (face sheet, admission record), the Patient Information Sheet indicated a Start of Care (SOC) date of 11/3/2025 and an End of Care (EOC) date of 11/30/2025, with a primary diagnosis of Atherosclerotic heart disease of native artery without angina pectoris (a condition where atherosclerosis [buildup of plaque in the artery walls] occurs in the coronary arteries, which supply blood to the heart, without chest pain).During a review of Patient 7’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 11/25/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visits once per week and one as needed (PRN) visit to promote comfort and symptom management, Bereavement Coordinator (BC) visit within 5 days of admission to assess and evaluate bereavement and grieving risk factors, Medical Social Worker (MSW) visit within 5 days of admission for initial assessment and Spiritual Coordinator (SC) visit within 5 days of admission for initial assessment.During a review of Patient 7’s Electronic Medical record (EMR), under the section Bereavement, it indicated there was no completed or submitted Initial Bereavement Assessment for Patient 7 since his SOC date of 11/3/2025.During a concurrent interview and record review on 12/19/2025 at 10:50 a.m. with the Director of Patient Care Services (DPCS), Patient 7’s EMR was reviewed. Patient 7’s EMR under the section, Bereavement, indicated there was no completed or submitted Initial Bereavement Assessment for Patient 7 since his SOC date of 11/3/2025. The DPCS stated and confirmed Patient 7’s EMR did not have documented evidence that an Initial Bereavement assessment was completed or submitted. The DPCS stated it was the responsibility of the Bereavement Coordinator to complete the initial bereavement assessment within 5 days of the patient’s admission. During a review of the HA’s Policy and Procedure titled Bereavement Services, with no revised date, the P&P indicated that the HA will provide an organized bereavement program that will provide bereavement services to the family/caregiver of hospice patients before and after the patient’s death, that will facilitate a normal grieving process and prepare the individual to function independently of hospice and identify a support system with the individual. The P&P also indicated that a bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice, and information gathered will be incorporated into the plan of care. During a review of the HA’s Policy and Procedure (P&P) titled Comprehensive Assessment, revised on October 2015, the P&P indicated that a patient comprehensive assessment will be performed by the hospice IDG no later than 5 calendar says after the election of hospice care in consultation with the attending physician. The P&P also indicated that the comprehensive patient assessment will at least include the following: an assessment of pain, a physical assessment, patient’s functional status, evaluation of home environment, review of current and past medication, the patient’s psychosocial status, patient and/or family/caregiver support system, assessment of the patient’s and family/caregiver spiritual orientation, and a bereavement assessment.”

“Based on interview and record review the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Registered Nurse (RN) complete an updated comprehensive assessment that reflected the patient’s current health status every 15 days as per their policy, for one of nine sampled patients (Patient 1). This deficient practice resulted in the late submission and reporting of the patient’s current health status, which could have resulted in a delay in Patient 1’s care. Findings:During a review of Patient 1’s Patient Information Sheet (face sheet, admission record). The Patient Information Sheet indicated a Start of Care (SOC) date of 11/5/2025, with a primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a heart condition where plaque buildups in the arteries causes chest pain that is not specifically described as stable or unstable, which indicates reduced blood flow to the heart muscle). During a review of Patient 1’s clinical record form titled Plan of Care/ Interdisciplinary Group Review (POC/IDG, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) dated 12/9/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visit once per week and one as needed (PRN) visit to promote comfort and symptom management. During a review of Patient 1’s clinical record form titled Nursing updated Assessment dated 11/18/2025, the updated assessment indicated a visit date of 11/18/2025 by the Director of Patient Care Services Designee (DPCSD), and an electronic signature from the DPCSD dated 12/17/2025. During a review of Patient 1’s clinical record titled Nursing updated Assessment dated 12/2/2025, the updated assessment indicated a visit date of 12/2/2025 by the DPCSD, and an electronic signature from the DPCSD dated 12/17/2025. During a concurrent interview and record review on 12/19/2025 at 1:12 p.m. with the Director of Patient Care Services (DPCS), Patient 1’s Electronic Medical Record (EMR)for certification period # 1 was reviewed. Patient 1’s EMR under the section Assessment, indicated the following: Nursing Updated Assessment with a documented visit date of 11/18/2025 assigned to the DPCSD, and an electronic signature from the DPCSD dated 12/17/2025. Nursing Updated Assessment with a documented visit date of 12/2/2025 assigned to the DPCSD, and an electronic signature from the DPCSD dated 12/17/2025. The DPCS stated and confirmed that Patient 1’s updated assessment dated 11/18/2025 was completed, signed and dated by the DPCSD on 12/17/2025. The DPCS confirmed that the DPCSD submitted the updated assessment 29 days after the documented visit date of 11/18/2025. The DPCS also stated and confirmed that Patient 1’s updated assessment dated 12/2/2025 was completed, signed and dated by the DPCSD on 12/17/2025. The DPCS confirmed that the DPCSD submitted the updated assessment 15 days after the documented visit date of 12/2/2025. The DPCS stated that the assessments were to be completed by the assigned nurse, with date and signature, within five days from the visit date. The DPCS confirmed that Patient 1’s updated assessment dated 11/18/2025 and 12/2/2025 were submitted late by the DPCSD and did not follow policy. During a review of the HA’s Policy and Procedure (P&P) titled Comprehensive Assessment, revised on October 2015, the P&P indicated that a patient comprehensive assessment will be performed by the hospice IDG no later than 5 calendar days after the election of hospice care in consultation with the attending physician. The P&P also indicated that the comprehensive assessment is to be updated by the interdisciplinary group as frequently as the patient’s condition requires but at a minimum of every 15 days. During a review of the HA’s P&P titled Entries into the clinical record revised October 2015, the P&P indicated that documentation into a patient’s clinical record will be timely, detailed, accurate and reflect the care or services provided. The P&P indicated that entries made into the clinical record will be made on the day care is provided to the patient with all documentation to be turned in to the office at the end of the workday, and clinical notes will include the date and signature of the clinician and his/her credentials. The P&P also indicated that late entries and amendments will be documented stating “late entry or amendment for visit of (date and time of visit)” and include the date the entry is made and the date and documentation that was originally omitted or amended with the signature and title of the staff member.”

“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 conducted an accurate assessment, reviewed, and verified the patient’s clinical information, necessary for Initial Certification of Terminal Illness (CTI, formal document signed by physicians declaring a patient has a life expectancy of six months or less, making them eligible for Medicare/Medicaid-funded hospice care focused on comfort, not cure) to support the diagnosis of the patients’ terminal illnesses and to qualify for hospice care for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8 and Patient 9).This deficient practice resulted in patient’s being enrolled in hospice and receiving care without a proper verification of the patient eligibility and had the potential for the Patients’ to not receive necessary care and healthcare resources to meet their care goals. a. During a review of Patient 3’s “Personal Information”, indicated a start of care (SOC) date of 10/31/2025, with a primary diagnosis of Heart failure (heart failure means the heart muscle is too weak or stiff to pump enough blood this can cause fluid buildup in the lungs, legs and other areas leading to fatigue and shortness of breath, it’s a chronic condition where the heart can’t keep up) advice or a diagnosis consult a professional ).The HA had no documentation of clinical information that included the patient’s history and physicals, laboratory and imaging data, biopsy results, et cetera, necessary for initial certification of hospice care and services. a. During a review of Patient 4’s “Personal Information”, indicated a start of care (SOC) date of 12/11/2025, with a primary diagnosis arteriosclerotic heart disease of coronary artery disease without angina pectoris, (is a buildup of plaque in the hearts arteries, narrowing them and reducing blood flow , without chest pain) aphasia following cerebral infarct(Aphasia after a stroke or cerebral infarct is a language problem caused by brain damage it makes it hard to speak, understand read, and write. During a review of Patient 4’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 12/11/2025, indicated the frequency of visits for skilled nurse (SN) one to two visitsweek plus two PRN (pro re nata, “as needed”) visits to promote comfort and symptom management., Mater of Social Work (MSW )initial assessment within 5 days, Spiritual Counsel(SC), initial assessment within 5 days and for the Rn initial evaluation and then every 14 days thereafter for supervisory visits.The HA had no documentation of clinical information that included the patient’s history and physicals, laboratory and imaging data, biopsy results, et cetera, necessary for initial certification of hospice care and services. During a review of Patient 5’s “Personal Information”, indicated a start of care (SOC) date 10/31/2025, of with a primary diagnosis arteriosclerotic heart disease of coronary artery disease without angina pectoris, (is a buildup of plaque in the hearts arteries, narrowing them and reducing blood flow , without chest pain) aphasia following cerebral infarct(Aphasia after a stroke or cerebral infarct is a language problem caused by brain damage it makes it hard to speak, understand read, and write. During a review of Patient 5’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 10/31/2025, indicated the frequency of visits for skilled nurse (SN) one to two visitsper week plus two PRN (pro re nata, “as needed”) visits to promote comfort and symptom management., Mater of Social Work (MSW )initial assessment within 5 days, Spiritual Counsel(SC), initial assessment within 5 days and for the Rn initial evaluation and then every 14 days thereafter for supervisory visits.The HA had no documentation of clinical information that included the patient’s history and physicals, laboratory and imaging data, biopsy results, et cetera, necessary for initial certification of hospice care and services. During a Review of Patient 6’s Electronic Medical Record on 12/16/2025, indicated there was no initial psychosocial, bereavement assessment and the initial Spiritual Assessment contained multiple blank sections and was incomplete, indicating that multiple disciplines of the IDG did not complete the spiritual, psychosocial and bereavement component of the comprehensive assessment.The HA had no documentation of clinical information that included the patient’s history and physicals, laboratory and imaging data, biopsy results, et cetera, necessary for initial certification of hospice care and services. During a review of patient 9’s “Personal Information”, indicated a start of care (SOC) date of 08/01/2025, and a End of Care (EOC) date with a primary diagnosis of Chronic Obstructive Heart Disease (COPD-is a progressive lung disease that makes breathing difficult due to air flow obstruction is characterized by inflammation coughing wheezing and shortness of breath).The HA had no documentation of clinical information that included the patient’s history and physicals, laboratory and imaging data, biopsy results, et cetera, necessary for initial certification of hospice care and services. This deficient practice resulted in patient’s being enrolled in hospice and receiving care without a proper verification of the patient eligibility and had the potential for Patient 1, Patient 11 and Patient 12 to not receive necessary care and healthcare resources to meet their care goalsDuring a concurrent interview and record review with the Administrator (ADM) on12/19/2025 at 10:30 a.m., the ADM the ADM stated she owned HA and the agency gets the referrals and the DPCS reviews them and notfy’s the MD.The ADM was unable to find the admitting order or any documents regarding all patients history and physical. During a telephone interview with the Medical Director (MD) on 12/19/2025, at 11:20 a.m. in the HA’s office, the MD stated he certified a patient for hospice based on the LCD (Local Coverage Determination) criteria, History and Physical from the hospital, and the Registered Nurse’s narrative because they saw the patient first. When the MD was asked how Patient 1 was admitted to the hospice agency when the HA’s has no history/physical for the patients receiving hospice services form the HA’s, the MD stated he was not aware that the HA’s had not gotten the documents and that he based his assessment and Certification of Terminal Illness form on the RN. The MD stated he would base his narrative on what was verbally reported to him by the HA’s Registered Nurse, who saw the patients. Findings:a. During a review of Patient 1’s Patient Information Sheet (face sheet, admission record). The Patient Information Sheet indicated a Start of Care (SOC) date of 11/5/2025, with a primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a heart condition where plaque buildups in the arteries causes chest pain that is not specifically described as stable or unstable, which indicates reduced blood flow to the heart muscle).During a review of Patient 1’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 12/9/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visit once per week and one as needed (PRN) visit to promote comfort and symptom management, Bereavement Coordinator (BC) visit within 5 days of admission to assess and evaluate bereavement and grieving risk factors, and Spiritual Coordinator (SC) for initial assessment within 5 days of admission.During a concurrent interview and record review on 12/19/2025 at 10:15 a.m. with the Director of Patient Care Services (DPCS), Patient 1’s Electronic Medical Record (EMR) was reviewed. Patient 1’s EMR, under the section Document/image, did not include any documents about the patient’s History and physical (H&P), physician progress notes or any recent hospitalization records. The DPCS stated and confirmed that Patient 1’s EMR did not include the patient’s H&P, physicians notes or hospital records. The DPCS stated the H&P should be in the patient’s EMR. b. During a review of Patient 2’s Patient Information Sheet (face sheet, admission record). The Patient Information Sheet indicated a Start of Care (SOC) date of 12/7/2025, with a primary diagnosis of Hypertensive heart disease with heart failure (heart problems caused by long term, uncontrolled high blood pressure, forcing the heart to work harder, leading to muscle thickening, stiffness and damage, potentially progressing to heart failure).During a review of Patient 2’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 12/7/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visits once per week for changes in condition to promote comfort and symptom management, Medical Social Worker (MSW) to evaluate and assess for needs initial evaluation within 5 days of admission, recertification and as needed for psycho-social counseling and support, Bereavement Coordinator (BC) visit within 5 days of admission to assess and evaluate bereavement and grieving risk factors, and Spiritual care Coordinator (SC) for spiritual initial assessment within5 days of admission, recertification and as needed to identify spiritual needs to support patient/family and primary caregiver.During a concurrent interview and record review on 12/19/2025 at 10:20 a.m. with the DPCS, Patient 2’s EMR was reviewed. Patient 2’s EMR, under the section Document/image, did not include the patient’s H&P, physician progress notes or any recent hospital records. The DPCS stated and confirmed that Patient 2’s EMR did not include the patient’s H&P, physicians notes or hospital records. The DPCS stated the H&P should be in the patient’s EMR. g. During a review of Patient 7’s Patient Information Sheet (face sheet, admission record), the Patient Information Sheet indicated a Start of Care (SOC) date of 11/3/2025 and an End of Care (EOC) date of 11/30/2025, with a primary diagnosis of Atherosclerotic heart disease of native artery without angina pectoris (a condition where atherosclerosis [buildup of plaque in the artery walls] occurs in the coronary arteries, which supply blood to the heart, without chest pain).During a review of Patient 7’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 11/25/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visits once per week and one as needed (PRN) visit to promote comfort and symptom management, Bereavement Coordinator (BC) visit within 5 days of admission to assess and evaluate bereavement and grieving risk factors, Medical Social Worker (MSW) visit within 5 days of admission for initial assessment and Spiritual Coordinator (SC) visit within 5 days of admission for initial assessment.During a concurrent interview and record review on 12/19/2025 at 10:25 a.m. with the DPCS, Patient 7’s EMR was reviewed. Patient 7’s EMR, under the section Document/image, did not include the patient’s H&P, physician notes notes or any hospital records. The DPCS stated and confirmed that Patient 7’s EMR did not include the patient’s H&P, physician notes or hospital records. The DPCS stated those records should be in the patient’s EMR. h. During a review of Patient 8’s Patient Information Sheet (face sheet, admission record), the Patient Information Sheet indicated a Start of Care (SOC) date of 11/8/2025 and an End of Care (EOC) date of 11/30/2025, with a primary diagnosis of Heart Failure (a condition when the heart muscle does not pump blood as well as it should causing blood to back up and fluid can build up in the lungs, causing shortness of breath).During a review of Patient 8’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 11/11/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visit once per week for changes in condition to promote comfort and symptom management, Bereavement Coordinator (BC) visit within 5 days of admission to assess and evaluate bereavement and grieving risk factors, Medical Social Worker (MSW) to evaluate and assess for needs initial evaluation within 5 days of admission, recertification and as needed for psycho-social counseling and support, and Spiritual care Coordinator (SC) visit for spiritual initial assessment within 5 days of admission, recertification and as needed to identify spiritual needs to support patient/family and primary caregiver.During a concurrent interview and record review on 12/19/2025 at 10:30 a.m. with the DPCS, Patient 8’s EMR was reviewed. Patient 8’s EMR, under the section Document/image, did not include any uploaded documents like the H&P, physician progress notes or any recent hospitalization records. The DPCS stated and confirmed that Patient 8’s EMR did not include the patient’s H&P, physicians notes or hospital records, and stated those records should be in the patient’s EMR. During a review of the HA ‘s Policy and Procedure (P&P) titled Admission criteria and process, revised October 2015, the P&P indicated that the agency will admit any patient with a life-limiting illness that meets the admission criteria. The P&P further indicates that referral information provided by family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician’s offices will assist in the determination of eligibility for admission to the program.”

“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 reviewed past medical history /physical, or diagnostic, and laboratory results that indicated the patients met the hospice criteria to be admitted into the hospice patient care program for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8,and Patient 9).This failure resulted in patients being enrolled to the HA without oversight of the implementation of the hospice services and could affect the patients’ and patient’s family’s needs not being met that could result in in decline patients’ health and quality of life. . During a review of Patient 3’s “Personal Information”, indicated a start of care (SOC) date of 10/31/2025, with a primary diagnosis of Heart failure (heart failure means the heart muscle is too weak or stiff to pump enough blood this can cause fluid buildup in the lungs, legs and other areas leading to fatigue and shortness of breath, it’s a chronic condition where the heart can’t keep up) advice or a diagnosis consult a professional ).The HA had no documentation of clinical information that included the patient’s history and physicals, laboratory and imaging data, biopsy results, et cetera, necessary for initial certification of hospice care and services. a. During a review of Patient 4’s “Personal Information”, indicated a start of care (SOC) date of 12/11/2025, with a primary diagnosis arteriosclerotic heart disease of coronary artery disease without angina pectoris, (is a buildup of plaque in the hearts arteries, narrowing them and reducing blood flow , without chest pain) aphasia following cerebral infarct(Aphasia after a stroke or cerebral infarct is a language problem caused by brain damage it makes it hard to speak, understand read, and write. During a review of Patient 4’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 12/11/2025, indicated the frequency of visits for skilled nurse (SN) one to two visitsweek plus two PRN (pro re nata, “as needed”) visits to promote comfort and symptom management., Mater of Social Work (MSW )initial assessment within 5 days, Spiritual Counsel(SC), initial assessment within 5 days and for the Rn initial evaluation and then every 14 days thereafter for supervisory visits.The HA had no documentation of clinical information that included the patient’s history and physicals, laboratory and imaging data, biopsy results, et cetera, necessary for initial certification of hospice care and services. During a review of Patient 5’s “Personal Information”, indicated a start of care (SOC) date 10/31/2025, of with a primary diagnosis arteriosclerotic heart disease of coronary artery disease without angina pectoris, (is a buildup of plaque in the hearts arteries, narrowing them and reducing blood flow , without chest pain) aphasia following cerebral infarct(Aphasia after a stroke or cerebral infarct is a language problem caused by brain damage it makes it hard to speak, understand read, and write. During a review of Patient 5’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 10/31/2025, indicated the frequency of visits for skilled nurse (SN) one to two visitsper week plus two PRN (pro re nata, “as needed”) visits to promote comfort and symptom management., Mater of Social Work (MSW )initial assessment within 5 days, Spiritual Counsel(SC), initial assessment within 5 days and for the Rn initial evaluation and then every 14 days thereafter for supervisory visits.The HA had no documentation of clinical information that included the patient’s history and physicals, laboratory and imaging data, biopsy results, et cetera, necessary for initial certification of hospice care and services. During a Review of Patient 6’s Electronic Medical Record on 12/16/2025, indicated there was no initial psychosocial, bereavement assessment and the initial Spiritual Assessment contained multiple blank sections and was incomplete, indicating that multiple disciplines of the IDG did not complete the spiritual, psychosocial and bereavement component of the comprehensive assessment.The HA had no documentation of clinical information that included the patient’s history and physicals, laboratory and imaging data, biopsy results, et cetera, necessary for initial certification of hospice care and services. During a review of patient 9’s “Personal Information”, indicated a start of care (SOC) date of 08/01/2025, and a End of Care (EOC) date with a primary diagnosis of Chronic Obstructive Heart Disease (COPD-is a progressive lung disease that makes breathing difficult due to air flow obstruction is characterized by inflammation coughing wheezing and shortness of breath).The HA had no documentation of clinical information that included the patient’s history and physicals, laboratory and imaging data, biopsy results, et cetera, necessary for initial certification of hospice care and services. Findings: a. During a review of Patient 1’s Patient Information Sheet (face sheet, admission record). The Patient Information Sheet indicated a Start of Care (SOC) date of 11/5/2025, with a primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a heart condition where plaque buildups in the arteries causes chest pain that is not specifically described as stable or unstable, which indicates reduced blood flow to the heart muscle).During a review of Patient 1’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 12/9/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visit once per week and one as needed (PRN) visit to promote comfort and symptom management, Bereavement Coordinator (BC) visit within 5 days of admission to assess and evaluate bereavement and grieving risk factors, and Spiritual Coordinator (SC) for initial assessment within 5 days of admission.During a concurrent interview and record review on 12/19/2025 at 10:15 a.m. with the Director of Patient Care Services (DPCS), Patient 1’s Electronic Medical Record (EMR) was reviewed. Patient 1’s EMR, under the section Document/image, did not include any documents about the patient’s History and physical (H&P), physician progress notes or any recent hospitalization records. The DPCS stated and confirmed that Patient 1’s EMR did not include the patient’s H&P, physicians notes or hospital records. The DPCS stated the H&P should be in the patient’s EMR. b. During a review of Patient 2’s Patient Information Sheet (face sheet, admission record). The Patient Information Sheet indicated a Start of Care (SOC) date of 12/7/2025, with a primary diagnosis of Hypertensive heart disease with heart failure (heart problems caused by long term, uncontrolled high blood pressure, forcing the heart to work harder, leading to muscle thickening, stiffness and damage, potentially progressing to heart failure).During a review of Patient 2’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 12/7/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visits once per week for changes in condition to promote comfort and symptom management, Medical Social Worker (MSW) to evaluate and assess for needs initial evaluation within 5 days of admission, recertification and as needed for psycho-social counseling and support, Bereavement Coordinator (BC) visit within 5 days of admission to assess and evaluate bereavement and grieving risk factors, and Spiritual care Coordinator (SC) for spiritual initial assessment within5 days of admission, recertification and as needed to identify spiritual needs to support patient/family and primary caregiver.During a concurrent interview and record review on 12/19/2025 at 10:20 a.m. with the DPCS, Patient 2’s EMR was reviewed. Patient 2’s EMR, under the section Document/image, did not include the patient’s H&P, physician progress notes or any recent hospital records. The DPCS stated and confirmed that Patient 2’s EMR did not include the patient’s H&P, physicians notes or hospital records. The DPCS stated the H&P should be in the patient’s EMR. g. During a review of Patient 7’s Patient Information Sheet (face sheet, admission record), the Patient Information Sheet indicated a Start of Care (SOC) date of 11/3/2025 and an End of Care (EOC) date of 11/30/2025, with a primary diagnosis of Atherosclerotic heart disease of native artery without angina pectoris (a condition where atherosclerosis [buildup of plaque in the artery walls] occurs in the coronary arteries, which supply blood to the heart, without chest pain).During a review of Patient 7’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 11/25/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visits once per week and one as needed (PRN) visit to promote comfort and symptom management, Bereavement Coordinator (BC) visit within 5 days of admission to assess and evaluate bereavement and grieving risk factors, Medical Social Worker (MSW) visit within 5 days of admission for initial assessment and Spiritual Coordinator (SC) visit within 5 days of admission for initial assessment.During a concurrent interview and record review on 12/19/2025 at 10:25 a.m. with the DPCS, Patient 7’s EMR was reviewed. Patient 7’s EMR, under the section Document/image, did not include the patient’s H&P, physician notes notes or any hospital records. The DPCS stated and confirmed that Patient 7’s EMR did not include the patient’s H&P, physician notes or hospital records. The DPCS stated those records should be in the patient’s EMR. h. During a review of Patient 8’s Patient Information Sheet (face sheet, admission record), the Patient Information Sheet indicated a Start of Care (SOC) date of 11/8/2025 and an End of Care (EOC) date of 11/30/2025, with a primary diagnosis of Heart Failure (a condition when the heart muscle does not pump blood as well as it should causing blood to back up and fluid can build up in the lungs, causing shortness of breath).During a review of Patient 8’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 11/11/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visit once per week for changes in condition to promote comfort and symptom management, Bereavement Coordinator (BC) visit within 5 days of admission to assess and evaluate bereavement and grieving risk factors, Medical Social Worker (MSW) to evaluate and assess for needs initial evaluation within 5 days of admission, recertification and as needed for psycho-social counseling and support, and Spiritual care Coordinator (SC) visit for spiritual initial assessment within 5 days of admission, recertification and as needed to identify spiritual needs to support patient/family and primary caregiver.During a concurrent interview and record review on 12/19/2025 at 10:30 a.m. with the DPCS, Patient 8’s EMR was reviewed. Patient 8’s EMR, under the section Document/image, did not include any uploaded documents like the H&P, physician progress notes or any recent hospitalization records. The DPCS stated and confirmed that Patient 8’s EMR did not include the patient’s H&P, physicians notes or hospital records, and stated those records should be in the patient’s EMR. During a review of the HA ‘s Policy and Procedure (P&P) titled Admission criteria and process, revised October 2015, the P&P indicated that the agency will admit any patient with a life-limiting illness that meets the admission criteria. The P&P further indicates that referral information provided by family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician’s offices will assist in the determination of eligibility for admission to the program.”

“Based on interview and record review the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the clinical records for six of nine sampled patients (Patient 2, Patient 4, Patient 6, Patient 7, Patient 8, and Patient 9) contained completed initial assessment, and/or comprehensive assessments that reflected the patients’ current health status, correct and updated assessments, by failing to:Ensure that the bereavement coordinator completed an initial bereavement assessment within five days of the patient’s Start of care (SOC) date for Patient 2, Patient 6, Patient 7 and Patient 9.Ensure the Master of Social Work (MSW) completed an initial psychosocial assessment within five days of the patient’s SOC date for Patient 2, Patient 4, Patient 6, Patient 7, and Patient 9.Ensure the Chaplain completed an initial spiritual assessment within five days of the patient’s SOC date for Patient 6 and Patient 8.This failure of incomplete clinical record could lead to misinformation and non-continuity of care and patients’ needs and services not provided to the patients that could result to patient’s health status to decline, and not have good quality of life. a. During a review of Patient 3’s “Personal Information”, indicated a start of care (SOC) date of 10/31/2025, with a primary diagnosis of Heart failure (heart failure means the heart muscle is too weak or stiff to pump enough blood this can cause fluid buildup in the lungs, legs and other areas leading to fatigue and shortness of breath, it’s a chronic condition where the heart can’t keep up) advice or a diagnosis consult a professional ).Review of Patient 3’s initial comprehensive Assessment dated 10/31/2025, under the” Nature & Conditions of Terminal Illness/LCD Eligibility, Illness Trajactory and Reasons for Hospice Admission documented that conditions existed as evidence by medical history ,patient, and caregiver/family; however no individualized supporting details were documented. The comprehensive assessment also failed to include baseline weight, height and mid-are circumference (MAC). b. During a review of Patient 4’s “Personal Information”, indicated a start of care (SOC) date of 12/11/2025, with a primary diagnosis arteriosclerotic heart disease of coronary artery disease without angina pectoris, (is a buildup of plaque in the hearts arteries, narrowing them and reducing blood flow , without chest pain) aphasia following cerebral infarct(Aphasia after a stroke or cerebral infarct is a language problem caused by brain damage it makes it hard to speak, understand read, and write. During a review of Patient 4’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 12/11/2025, indicated the frequency of visits for skilled nurse (SN) one to two visits per week plus two PRN (pro re nata, “as needed”) visits to promote comfort and symptom management., Mater of Social Work (MSW )initial assessment within 5 days, Spiritual Counsel(SC), initial assessment within 5 days and for the Rn initial evaluation and then every 14 days thereafter for supervisory visits.Review of Patient 4’s initial comprehensive Assessment dated 12/11/2025, under the” Nature & Conditions of Terminal Illness/LCD Eligibility, Illness Trajectory and Reasons for Hospice Admission documented that conditions existed as evidence by medical history ,patient, and caregiver/family; however no individualized supporting details were documented.Continued review of Patient 4’s initial comprehensive assessment dated 12/11/2025, documented “moderate pain” however, failed to include pain location, description, duration, or additional signs and symptoms in the pain assessment tool. c. During a Review of Patient 6’s Electronic Medical Record on 12/16/2025, indicated there was no initial psychosocial, bereavement assessment and the initial Spiritual Assessment contained multiple blank sections and was incomplete, indicating that multiple disciplines of the IDG did not complete the spiritual, psychosocial and bereavement component of the comprehensive assessment. d. . During a review of patient 9’s “Personal Information”, indicated a start of care (SOC) date of 08/01/2025, and a End of Care (EOC) date with a primary diagnosis of Chronic Obstructive Heart Disease (COPD-is a progressive lung disease that makes breathing difficult due to air flow obstruction is characterized by inflammation coughing wheezing and shortness of breath). e. During a review of Patient 9’s Electronic Medical Record on 12/16/2025, indicated there was no initial psychosocial and bereavement assessment, indicating that multiple disciplines of the IDG did not complete the psychosocial and bereavement component of the comprehensive assessment. Findings:During an interview on 12/19/2025 at 10:45 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated comprehensive assessments initial and on recertification are to be completed and submitted within 5 days of the patient’s admission. The DPCS stated it is important to complete comprehensive assessments within the 5 days of SOC to understand the patient’s care needs and provide it to them.During a telephone interview on 12/19/2025 at 12:10 p.m. with the MSW, the MSW stated she is responsible for completing the initial psychosocial assessment and initial bereavement assessment within 5 days of the patient’s admission. The MSW stated it is important to complete a psychosocial assessment for a patient because it provides well-rounded information on the patient that is apart from the medical diagnosis, like who they are, how they are feeling, what makes them feel better and makes them feel more connected to the care team. The MSW stated the importance of completing an initial bereavement assessment on a patient is to initiate the end-of-life conversation with the patient and family and see where they are at and how they feel about it. The MSW stated if an initial bereavement assessment is not completed, then a negative outcome can be that the patient and/or family can be left dealing with feelings of distress or negativity and can cause mental health issues which can also affect their grieving process. The MSW also stated if a newly admitted patient does not want to meet with a social worker she will reach out to the patient and educate them on why she is part of the care team and how she can help the patient and if the patient still declines the visit then the MSW will follow up with the patient the following month or on recertification. The MSW stated she documents the patient declining the visit in a communication note in the patient’s Electronic Medical Record (EMR). a. During a review of Patient 2’s Patient Information Sheet (face sheet, admission record). The Patient Information Sheet indicated a Start of Care (SOC) date of 12/7/2025, with a primary diagnosis of Hypertensive heart disease with heart failure (heart problems caused by long term, uncontrolled high blood pressure, forcing the heart to work harder, leading to muscle thickening, stiffness and damage, potentially progressing to heart failure).During a review of Patient 2’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 12/7/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visits once per week for changes in condition to promote comfort and symptom management, Medical Social Worker (MSW) to evaluate and assess for needs initial evaluation within 5 days of admission, recertification and as needed for psycho-social counseling and support, Bereavement Coordinator (BC) visit within 5 days of admission to assess and evaluate bereavement and grieving risk factors, and Spiritual care Coordinator (SC) for spiritual initial assessment within5 days of admission, recertification and as needed to identify spiritual needs to support patient/family and primary caregiver.During a concurrent interview and record review on 12/19/2025 at 11:30 a.m. with the Director of Patient Care Services (DPCS), Patient 2’s Electronic Medical Record (EMR) was reviewed. Patient 2’s EMR, under the section History of Psychosocial assessment, indicated there was no completed or submitted assessment since the SOC of 12/7/2025. The DPCS stated and confirmed Patient 2’s Assessment section in his EMR did not include documented evidence that a Psychosocial Assessment was completed or submitted. The DPCS stated it is the responsibility of the MSW to complete the home visit within 5 days of the patient’s admission and complete and submit the assessment. The DPCS stated the psychosocial assessment should have been completed by 12/12/2025.During a review of Patient 2’s Bereavement section in his Electronic Medical record (EMR), the Bereavement section indicated there was no completed or submitted Initial Bereavement Assessment for Patient 2 since her SOC date of 12/7/2025.During a concurrent interview and record review on 12/19/2025 at 11:35 a.m. with the Director of Patient Care Services (DPCS), Patient 2’s Bereavement section in the Electronic Medical Record (EMR) was reviewed. Patient 2’s Bereavement section indicated there was no completed or submitted Initial Bereavement Assessment for Patient 2 since her SOC date of 12/7/2025. The DPCS stated and confirmed Patient 2’s Bereavement section in his EMR did not include documented evidence that an Initial Bereavement assessment was completed or submitted. The DPCS stated it is the responsibility of the BC to complete the initial bereavement assessment within 5 days of admission and it is only submitted under the bereavement section in the EMR. The DPCS stated the initial bereavement assessment should have been completed and submitted by 12/12/2025. b. During a review of Patient 7’s Patient Information Sheet (face sheet, admission record), the Patient Information Sheet indicated a Start of Care (SOC) date of 11/3/2025 and an End of Care (EOC) date of 11/30/2025, with a primary diagnosis of Atherosclerotic heart disease of native artery without angina pectoris (a condition where atherosclerosis [buildup of plaque in the artery walls] occurs in the coronary arteries, which supply blood to the heart, without chest pain).During a review of Patient 7’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 11/25/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visits once per week and one as needed (PRN) visit to promote comfort and symptom management, Bereavement Coordinator (BC) visit within 5 days of admission to assess and evaluate bereavement and grieving risk factors, Medical Social Worker (MSW) visit within 5 days of admission for initial assessment and Spiritual Coordinator (SC) visit within 5 days of admission for initial assessment.During a concurrent interview and record review on 12/19/2025 at 10:50 a.m. with the DPCS, patient 7’s the Electronic Medical Record (EMR) was reviewed. Patient 7’s EMR, under the section, Assessment indicated there was no completed or submitted Psychosocial assessment since the SOC date of 11/3/2025. Patient 7’s EMR under section Assessment also indicated there was no completed or submitted Spiritual Assessment since the SOC date of 11/3/2025. The DPCS stated and confirmed that Patient 7’sd EMR did not have documented evidence of a psychosocial assessment submitted. The DPCS stated the psychosocial assessment is the responsibility of the MSW and should have been completed and submitted within 5 days from the SOC date. The DPCS stated and confirmed that Patient 7’s EMR also did not have documented evidence of a Spiritual Assessment submitted. The DPCS stated the spiritual assessment is the responsibility of the Chaplain and should also be submitted within 5 days from the patient’s SOC date.During a review of Patient 7’s Electronic Medical record (EMR), under the section Bereavement, it indicated there was no completed or submitted Initial Bereavement Assessment for Patient 7 since his SOC date of 11/3/2025.During a concurrent interview and record review on 12/19/2025 at 10:50 a.m. with the Director of Patient Care Services (DPCS), Patient 7’s EMR was reviewed. Patient 7’s EMR under the section, Bereavement, indicated there was no completed or submitted Initial Bereavement Assessment for Patient 7 since his SOC date of 11/3/2025. The DPCS stated and confirmed Patient 7’s EMR did not have documented evidence that an Initial Bereavement assessment was completed or submitted. The DPCS stated it was the responsibility of the Bereavement Coordinator to complete the initial bereavement assessment within 5 days of the patient’s admission. c. During a review of Patient 8’s Patient Information Sheet (face sheet, admission record), the Patient Information Sheet indicated a Start of Care (SOC) date of 11/8/2025 and an End of Care (EOC) date of 11/30/2025, with a primary diagnosis of Heart Failure (a condition when the heart muscle does not pump blood as well as it should causing blood to back up and fluid can build up in the lungs, causing shortness of breath).During a review of Patient 8’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 11/11/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visit once per week for changes in condition to promote comfort and symptom management, Bereavement Coordinator (BC) visit within 5 days of admission to assess and evaluate bereavement and grieving risk factors, Medical Social Worker (MSW) to evaluate and assess for needs initial evaluation within 5 days of admission, recertification and as needed for psycho-social counseling and support, and Spiritual care Coordinator (SC) visit for spiritual initial assessment within 5 days of admission, recertification and as needed to identify spiritual needs to support patient/family and primary caregiver.During a concurrent interview and record review on 12/19/2025 at 10:57 a.m. with the Director of Patient Care Services (DPCS), Patient 8’s Electronic Medical Record (EMR) was reviewed. Patient 8’s EMR, under the section Assessment, indicated there was no completed or submitted Spiritual Assessment since the patient’s SOC of 11/8/2025. The DPCS stated and confirmed that Patient 8’s EMR did not have documented evidence of a Spiritual Assessment completed or submitted. The DPCS stated it was the responsibility of the Chaplain to contact the patient and schedule a home visit within 5 days of the admission date to conduct, complete and submit the Spiritual assessment. The DPCS stated Patient 8 has been discharged from the HA, and a spiritual assessment was not done. During a review of the HA’s Policy and Procedure (P&P) titled Contents of the clinical record revised October 2015, the P&P indicated that a patient’s clinical record will contain sufficient information to identify the patient, describe patient problems/needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care amongst hospice IDG members. The P&P also indicated that the clinical record will include but not be limited to record and findings of initial, comprehensive and updated comprehensive assessments.”

“Based on interview and record review the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure complete and accurate patient health records were documented for nine of nine sampled patients (Patients 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8 and Patient 9), by failing to:Ensure all members of the interdisciplinary group (IDG, a group of health care professionals with various areas of expertise who work together toward the goals of the patients and families) who attended the interdisciplinary group meeting documented and signed in the Plan of Care/Interdisciplinary Group Review (POC/IDG, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) after the meeting for six of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 7, and Patient 8).Ensure that the licensed nurses complete, sign and date all nursing visit notes for one of nine sampled patients (Patient 1).Ensure that the Discharge Summary’s for three of nine sampled patients (Patient 7, Patient 8, and Patient 9) were completed with signature and date.These failures could result in inaccurate records, patient not receiving appropriate high-quality care, disrupt the patients’ continuity of care, patients not receiving the necessary care and services that could result in the decline of patient health condition, or not having quality of life. Findings:1. During an interview on 12/19/2025 at 11:15 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated the HA’s IDG meetings were every 14 days, and the meetings were either in person or via video conference. The DPCS stated the IDG members consisted of the Medical Director (MD), the social worker (MSW), the DPCS, and the Chaplain and the Administrator (ADM), and licensed vocational nurse (LVN) also do attend the meetings as well. The DPCS stated the IDG member’s signature on the Plan of Care/Interdisciplinary Group Review (POC/IDG, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) were used as a sign in sheet to validate their attendance in the meeting. The DPCS stated that the IDG members should have completed and signed the IDG/POC Review right away after the meeting, and if it was not signed then it meant that the member was not present during the meeting. The DPCS stated it was important that all IDG members attended every meeting to be current with any new regulations set, receive any education needed, review information on patient’s medications, and for each discipline to provide the necessary information and/or concerns on the patient’s condition to better care for them.During a telephone interview on 12/19/2025 at 11:32 a.m. with the MD, the MD stated he does attend the IDG meetings for the HA, every two weeks. The MD stated he attended the IDG meetings via telephone call. The MD stated it was important to attend the IDG meetings and fill out the portion of the POC/IDG Review, participate in the patient’s care and be aware of what was going on with the patient. The MD stated he signed his part of the POC/IDG Review electronically the same day as the meeting or the day after, and it was important not to wait too long to complete and sign it, so the information was not forgotten or incomplete. During a telephone interview on 12/19/2025 at 11:56 a.m. with the Chaplain, the Chaplain stated he attended the IDG meetings via telephone call every 14 days, as his schedule is busy to join in person. The Chaplain stated he completed and signed his part of the POC/IDG Review electronically, either on the same day as the meeting or the next day. The Chaplain stated he has forgotten to sign his part of the POC/IDG Review, at times, and has been reminded by either the HA office staff or the Electronic Medical Record (EMR) dashboard when he signed in.During a telephone interview on 12/19/2025 at 12:10 p.m. with the MSW, the MSW stated she attends the IDG meetings were every two weeks in person. The MSW stated that because she was a member of the IDG it was important for her to attend all meetings to inform the care team on the patient’s psychosocial status and needs and assist in putting together the patient’s comprehensive assessment. The MSW stated she completed and signed her portion of the patient’s POC/IDG Review right after the IDG meeting or a day or two after the meeting. The MSW stated the signatures on the POC/IDG Review validated a member’s attendance and participation, and if the signature was missing then the member was not present.a. During a review of Patient 1’s Patient Information Sheet (face sheet, admission record), the Patient Information Sheet indicated a Start of Care (SOC) date of 11/5/2025, with a primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a heart condition where plaque buildups in the arteries causes chest pain that is not specifically described as stable or unstable, which indicates reduced blood flow to the heart muscle).During a review of Patient 1’s clinical record form titled POC/IDG Review dated 12/9/2025 for certification period #1, the POC/IDG Review indicated an order for the next POC/IDG review to be done no later than 14 days from today’s date.During a concurrent interview and record review on 12/19/2025 at 12:20 p.m. with the DPCS, Patient 1’s EMR section for Interdisciplinary Group (IDG) was reviewed. Patient 1’s EMR section for IDG indicated the following:POC/IDG Review dated 11/5/2025 for certification period #1, with electronic signatures from the Medical Director Designee (MDD), the DPCSD and MSW dated 11/5/2025, and missing signature from the Chaplain.POC/IDG Review dated 11/11/2025 for certification period #1, with electronic signatures from the MDD, the DPCSD and MSW dated 11/11/2025, and missing signature from the Chaplain.POC/IDG Review dated 11/25/2025 for certification period #1, with electronic signatures from the MD) and the DPCSD dated 11/25/2025, and missing signature from the MSW and Chaplain.POC/IDG Review dated 12/9/2025 for certification period #1, with electronic signatures from the MDD and the DPCSD dated 12/9/2025, and missing signature from the MSW and Chaplain. The DPCS stated and confirmed that Patient 1’s POC/IDG Review dated 11/5/2025, 11/11/2025, 11/25/2025 and 12/9/2025 did not have documented evidence of an electronic signature from the Chaplain, and the POC/IDG Review dated 11/25/2025 and 12/9/2025 did not have documented evidence of an electronic signature from the Chaplain and MSW. The DPCS stated both MSW and Chaplin were IDG members and should have been present at all IDG meetings and should have signed the IDG right away. The DPCS stated the IDG members’ signature on the POC/IDG Review validated their participation and attendance in the meeting, and if the signature was not there then the member was not present.b. During a review of Patient 2’s Patient Information Sheet, the Patient Information Sheet indicated a SOC date of 12/7/2025, with a primary diagnosis of Hypertensive heart disease with heart failure (heart problems caused by long term, uncontrolled high blood pressure, forcing the heart to work harder, leading to muscle thickening, stiffness and damage, potentially progressing to heart failure).During a review of Patient 2’s clinical record form titled POC/IDG Review dated 12/7/2025 for certification period #1, the POC/IDG Review indicated an order for Interdisciplinary team to review patient’s status every 14 days and as needed to evaluate changes in condition.During a review of Patient 2’s clinical record form titled POC/IDG Review dated 12/7/2025 for certification period #1, the POC/IDG Review indicated electronic signatures from the MDD dated 12/7/2025, the DPCSD dated 12/7/2025, and had missing signatures from the MSW, under the MSW signature section and from the Chaplain, under the Chaplain signature section.During a concurrent interview and record review on 12/19/2025 at 11:45 a.m. with the DPCS, Patient 2’s EMR section for IDG was reviewed. Patient 2’s EMR section for IDG indicated the following:POC/IDG Review dated 12/7/2025 for certification period #1, with electronic signatures from the MDD, DPCSD dated 12/7/2025, and no signatures from the MSW and the Chaplain.The DPCS stated and confirmed that Patient 2’s POC/IDG Review dated 12/7/2025 did not have documented evidence of an electronic signature from the MSW and the Chaplain. The DPCS stated both MSW and Chaplin were IDG members and should have been present at all IDG meetings and should have signed the IDG right away. The DPCS stated signing the POC/IDG Review is used as a sign in sheet for the members attending the meeting, therefore if there is a missing signature from the MSW and Chaplain then it can mean they did not attend the meeting.c. During a review of Patient 3’s Personal Information sheet, it indicated a SOC date of 10/31/2025, with a primary diagnosis of Heart failure (heart failure means the heart muscle is too weak or stiff to pump enough blood this can cause fluid buildup in the lungs, legs and other areas leading to fatigue and shortness of breath, it’s a chronic condition where the heart can’t keep up) advice or a diagnosis consult a professional). During a review of Patient 3’s POC/IDG form dated 10/31/2025, it indicated the frequency of visits for skilled nurse (SN) one to two visits per week plus two as needed visits to promote comfort and symptom management, MSW for initial assessment within five days, Spiritual Counselor (SC) for initial assessment within five days.During a concurrent interview and record review on 12/19/2025 at 11:50 a.m. with the DPCS, Patient 3’s clinical record form titled POC/IDG Review dated 10/31/2025, 11/11/2025, and 11/25/2025 were reviewed. Patient 3’s POC/IDG Review dated 10/31/2025 indicated electronic signatures from the MD, the DPCSD, the MSW, and indicated missing signature from the Chaplain. Patient 3’s POC/IDG Review dated 11/11/2025 indicated electronic signatures from the MD, the DPCSD, the MSW, and missing signature from the Chaplain. Patient 3’s POC/IDG Review dated 11/25/2025 indicated electronic signatures from the DPCSD, and missing signature from the MSW, the MD and from the Chaplain. The DPCS stated and confirmed that Patient 3’s POC/IDG Review dated 10/31/2025 and 11/11/2025 were missing the signature from IDG member the Chaplain, and the POC/IDG Review dated 11/25/2025 was missing signatures from IDG members the chaplain, the MSW and MD. d. During a review of Patient 4’s Personal Information sheet, it indicated a SOC date of 12/11/2025, with a primary diagnosis arteriosclerotic heart disease of coronary artery disease without angina pectoris (is a buildup of plaque in the hearts arteries, narrowing them and reducing blood flow , without chest pain) aphasia (a language problem caused by brain damage from a stroke, making it hard to speak, understand, read and write) following cerebral infarct (brain tissue death from a lack of blood flow, stroke, caused by a blocked artery in the brain, depriving cells of oxygen and nutrients). During a review of Patient 4’s POC/IDG form dated 12/11/2025, it indicated the frequency of visits for skilled nurse (SN) one to two visits per week plus two as needed visits to promote comfort and symptom management, MSW initial assessment within five days, and the SC for initial assessment within five days.During a concurrent interview and record review on 12/19/2025 at 12:05 p.m. with the DPCS, Patient 4’s clinical record form titled POC/IDG Review dated 12/11/2025 was reviewed. Patient 4’s POC/IDG Review dated 12/11/2025 indicated electronic signatures from the MD, the DPCSD, and missing signatures from the Chaplain and MSW. The DPCS stated and confirmed that Patient 4’s POC/IDG Review dated 12/11/2025 were missing signatures from the chaplain and MSW, and not all IDG members signed the form. e. During a review of Patient 7’s Personal Information Sheet, the Personal Information sheet indicated a SOC date of 11/3/2025 and an End of Care (EOC) date of 11/30/2025, with a primary diagnosis of Atherosclerotic heart disease of native artery without angina pectoris (a condition where atherosclerosis [buildup of plaque in the artery walls] occurs in the coronary arteries, which supply blood to the heart, without chest pain).During a review of Patient 7’s clinical record form titled POC/IDG Review dated 11/25/2025 for certification period #1, the POC/IDG Review indicated an order for the next POC/IDG review to be done no later than 14 days from today’s date.During a concurrent interview and record review on 12/19/2025 at 12:30 p.m. with the DPCS, Patient 7’s EMR section for IDG was reviewed. Patient 7’s EMR section for IDG indicated the following:POC/IDG Review dated 11/3/2025 for certification period #1, with electronic signatures from the MDD and the DPCSD dated 11/3/2025, and missing signature from the MSW and Chaplain.POC/IDG Review dated 11/11/2025 for certification period #1, with electronic signatures the MDD and the DPCSD dated 11/11/2025, and missing signature from the MSW and Chaplain.POC/IDG Review dated 11/25/2025 for certification period #1, with electronic signatures from the MDD and the DPCSD dated 11/25/2025, and missing signature from the MSW and Chaplain.The DPCS stated and confirmed that Patient 7’s POC/IDG Review dated 11/3/2025, 11/11/2025 and 11/25/2025 did not have documented evidence of an electronic signature from the Chaplain and MSW. The DPCS stated both the MSW and Chaplin were IDG members and should have been present at all IDG meetings. The DPCS stated the IDG members should have signed the IDG right after the meeting or the next day, because their signature on the POC/IDG Review validated their participation and attendance, and if the signature was not there then the member was not present. f. During a review of Patient 8’s Personal Information Sheet, the Patient Information Sheet indicated a SOC date of 11/8/2025 and an EOC date of 11/30/2025, with a primary diagnosis of Heart Failure (a condition when the heart muscle does not pump blood as well as it should causing blood to back up and fluid can build up in the lungs, causing shortness of breath).During a review of Patient 8’s clinical record form titled POC/IDG Review dated 11/11/2025 for certification period #1, the POC/IDG Review indicated an order for the interdisciplinary team to review patient’s status every 14 days and as needed to evaluate changes in condition.During a concurrent interview and record review on 12/19/2025 at 12:46 p.m. with the DPCS, Patient 8’s EMR section for IDG was reviewed. Patient 8’s EMR section for IDG indicated the following:POC/IDG Review dated 11/8/2025 for certification period #1, with electronic signatures from the MDD, the DPCSD and the MSW dated 11/8/2025, and missing signature from the Chaplain.POC/IDG Review dated 11/11/2025 for certification period #1, with electronic signatures the MDD, the DPCSD and the MSW dated 11/11/2025, and missing signature from the Chaplain.POC/IDG Review dated 11/25/2025 for certification period #1, with electronic signatures from the MDD and the DPCSD dated 11/25/2025, and missing signature from the MSW and Chaplain.The DPCS stated and confirmed that Patient 8’s POC/IDG Review dated 11/8/2025, and 11/11/2025 did not have documented evidence of an electronic signature from the Chaplain, and the POC/IDG Review dated 11/25/2025 did not have documented evidence of an electronic signature from the MSW and Chaplain. The DPCS stated both the MSW and Chaplin were IDG members and should have been present at all IDG meetings. The DPCS stated the IDG members’ signature on the POC/IDG Review was important because it validated their participation and attendance in the meeting. The DPCS also stated if a POC/IDG Review document was missing a signature from one of the IDG members, then it meant that member was not present. During a review of the HA’s P&P titled Entries into the clinical record revised October 2015, the P&P indicated that documentation into a patient’s clinical record will be timely, detailed, accurate and reflect the care or services provided. The P&P indicated that entries made into the clinical record will be made on the day care is provided to the patient with all documentation to be turned into the office at the end of the workday, and clinical notes will include the date and signature of the clinician and his/her credentials. The P&P also indicated that late entries and amendments will be documented stating “late entry or amendment for visit of (date and time of visit)” and include the date the entry is made and the date and documentation that was originally omitted or amended with the signature and title of the staff member. During a review of the HA’s P&P titled Interdisciplinary Group (IDG) members, undated, the P&P indicated that the IDG shall include at a minimum the hospice physician, the registered nurse, the social worker and the pastoral or spiritual care counselor and have IDG meetings at least every 15 calendar days, either in person or via telecommunication methods. The P&P also indicated that the IDG is responsible for addressing changes in patient’s condition and ensuring continuity of care across settings, and IDG meeting notes are documented to include date, summary of their discussion and plan of care changes. The P&P indicated that the documentation is maintained in the patient’s medical record.2. During an interview on 12/19/2025 at 11:53 a.m. with the DPCS, the DPCS stated nurse visit notes were to be completed and submitted within five days from the visit date. The DPCS stated any clinical document, including a visit note, was considered complete if it was filled out entirely, signed and dated by the prospective nurse. The DPCS stated if the clinical document was not signed then it is not valid because the document does not indicate who the author was to validate that all that was documented was correct.During a review of Patient 1’s Patient Information Sheet (face sheet, admission record). The Patient Information Sheet indicated a Start of Care (SOC) date of 11/5/2025, with a primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a heart condition where plaque buildups in the arteries causes chest pain that is not specifically described as stable or unstable, which indicates reduced blood flow to the heart muscle).During a review of Patient 1’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 12/9/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visit once per week and one as needed (PRN) visit to promote comfort and symptom management, Bereavement Coordinator (BC) visit within five days of admission to assess and evaluate bereavement and grieving risk factors, and Spiritual Coordinator (SC) for initial assessment within five days of admission.During a concurrent interview and record review on 12/19/2025 at 12:08 p.m. with the DPCS, Patient 1’s EMR was reviewed. Patient 1’s EMR, under the section visit notes, indicated the following were submitted:Visit Note LVN dated 11/8/2025 with no electronic signature from the nurse.Visit note LVN dated 11/15/2025 with no electronic signature from the nurse.Visit note LVN dated 11/22/2025 with no electronic signature from the nurse. Visit note LVN dated 11/29/2025 with no electronic signature from the nurse.Visit note LVN dated 12/6/2025 with no electronic signature from the nurse.The DPCS stated and confirmed that Patient 1’s visit notes dated 11/8/2025, 11/15/2025, 11/22/2025, 11/29/2025 and 12/6/2025 did not have documented evidence of an electronic signature from the visiting nurse. The DPCS stated that the visit notes were considered complete when it had a date and signature. The DPCS stated Patient 1’s visit notes dated 11/8/2025, 11/15/2025, 11/22/2025, 11/29/2025 and 12/6/2025 are not considered complete as they were missing the nurse’s signature to validate the information.3a. During a review of Patient 7’s Patient Information Sheet (face sheet, admission record), the Patient Information Sheet indicated a Start of Care (SOC) date of 11/3/2025 and an End of Care (EOC) date of 11/30/2025, with a primary diagnosis of Atherosclerotic heart disease of native artery without angina pectoris (a condition where atherosclerosis [buildup of plaque in the artery walls] occurs in the coronary arteries, which supply blood to the heart, without chest pain).During a review of Patient 7’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 11/25/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visits once per week and one as needed (PRN) visit to promote comfort and symptom management, Bereavement Coordinator (BC) visit within five days of admission to assess and evaluate bereavement and grieving risk factors, Medical Social Worker (MSW) visit within five days of admission for initial assessment and Spiritual Coordinator (SC) visit within five days of admission for initial assessment.During a review of Patient 7’s clinical record form titled Discharge Summary dated 11/30/2025, the Discharge summary indicated no signature from the licensed nurse.During a concurrent interview and record review on 12/19/2025 at 12:40 p.m. with the DPCS, Patient 7’s clinical record form titled Discharge Summary dated 11/30/2025 was reviewed. The DPCS stated that the Discharge summary was incomplete because it did not have the signature from the nurse who discharged the patient, as well as not include the patient’s medical history, diagnosis, active medications when discharged and the services received under hospice care. b. During a review of Patient 8’s Patient Information Sheet (face sheet, admission record), the Patient Information Sheet indicated a Start of Care (SOC) date of 11/8/2025 and an End of Care (EOC) date of 11/30/2025, with a primary diagnosis of Heart Failure (a condition when the heart muscle does not pump blood as well as it should causing blood to back up and fluid can build up in the lungs, causing shortness of breath).During a review of Patient 8’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 11/11/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visit once per week for changes in condition to promote comfort and symptom management, Bereavement Coordinator (BC) visit within five days of admission to assess and evaluate bereavement and grieving risk factors, Medical Social Worker (MSW) to evaluate and assess for needs initial evaluation within five days of admission, recertification and as needed for psycho-social counseling and support, and Spiritual care Coordinator (SC) visit for spiritual initial assessment within five days of admission, recertification and as needed to identify spiritual needs to support patient/family and primary caregiver.During a review of Patient 8’s clinical record form titled Discharge Summary dated 11/30/2025, the Discharge summary indicated no signature from the licensed nurse.During a concurrent interview and record review on 12/19/2025 at 1 p.m. with the DPCS, Patient 8’s clinical record form titled Discharge Summary dated 11/30/2025 was reviewed. The DPCS stated that the Discharge summary was inco mplete because it did not have the signature from the prospective nurse who discharged the patient, and it did not include pertinent information like the patient’s medical history and medications, and what care and services the patient received while on hospice care. c. During a review of patient 9’s Personal Information, it indicated a SOC date of 08/01/2025 and an EOC date of 11/30/2025, with a primary diagnosis of Chronic Obstructive Heart Disease (COPD-is a progressive lung disease that makes breathing difficult due to air flow obstruction is characterized by inflammation coughing wheezing and shortness of breath).During a review of Patient 9’s POC/IDG Review form dated 11/11/2025, it indicated the frequency of visits for skilled nurse (SN) one to two visits per week plus two as needed visits to promote comfort and symptom management, MSW initial assessment within five days of admission, SC to visit for initial assessment within five days of admission and for the Rn to visit for initial evaluation and then every 14 days thereafter for supervisory visits.During a review of Patient 9’s EMR, the EMR indicated a discharge summary dated 11/30/2025 that indicated reason for discharge was, “change in payer” with no signature from the licensed nurse.During a concurrent interview and record review on 12/19/2025 at 1:15 p.m. with the DPCS, Patient 9’s clinical record form titled Discharge Summary dated 11/30/2025 was reviewed. The DPCS stated that the Discharge summary was incomplete because it did not have the signature from the discharge nurse.During a review of the HA’s P&P titled Entries into the clinical record revised October 2015, the P&P indicated that documentation into a patient’s clinical record will be timely, detailed, accurate and reflect the care or services provided. The P&P indicated that entries made into the clinical record will be made on the day care is provided to the patient with all documentation to be turned into the office at the end of the workday, and clinical notes will include the date and signature of the clinician and his/her credentials. The P&P also indicated that late entries and amendments will be documented stating “late entry or amendment for visit of (date and time of visit)” and include the date the entry is made and the date and documentation that was originally omitted or amended with the signature and title of the staff member. During a review of the HA’s P&P titled Interdisciplinary Group (IDG) members, with no revised date, the P&P indicated that the IDG shall include at a minimum the hospice physician, the registered nurse, the social worker and the pastoral or spiritual care counselor and have IDG meetings at least every 15 calendar days, either in person or via telecommunication methods. The P&P also indicated that the IDG is responsible for addressing changes in patient’s condition and ensuring continuity of care across settings, and IDG meeting notes are documented to include date, summary of their discussion and plan of care changes. The P&P indicated that the documentation is maintained in the patient’s medical record.”

“Based on interview and record review the Hospice Agency (HA) failed to ensure that the Discharge Summaries for three of nine sampled patients (Patient 7, Patient 8 and Patient 9) were completed and validated by the licensed nurse.This failure caused the patients discharge summary to be incomplete therefore possibly causing a change in the patients care with future clinical care teams that could affect their over health and comfort. . During a review of patient 9’s “Personal Information”, indicated a start of care (SOC) date of 08/01/2025 and end of care (EOC) date of 11/30/2025, with a primary diagnosis of Chronic Obstructive Heart Disease (COPD-is a progressive lung disease that makes breathing difficult due to air flow obstruction is characterized by inflammation coughing wheezing and shortness of breath).During a review of Patient 9’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 11/11/2025, and 11/30/2025, indicated the frequency of visits for skilled nurse (SN) one to two visits per week plus two PRN (pro re nata, “as needed”) visits to promote comfort and symptom management., Mater of Social Work (MSW )initial assessment within 5 days, Spiritual Counsel(SC), initial assessment within 5 days and for the Rn initial evaluation and then every 14 days thereafter for supervisory visits.Review of the EMR of Patient 9’s discharge summary dated 11/30/2025, on 12/16/2025, indicated reason for discharge was ,”change in payor”.The discharge summary failed to have the following;A summary of the patient’s stay including treatments, symptoms and pain management; The patient’s current plan of care; The patient’s latest physician orders; and any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility or the signature of the discipline who created the discharge summary.During an interview in the HA’s office with the ADM on 12/19/2025, at 10:30 a.m., she stated the patients was discharge due to the insurance changing and no longer cover hospice services. Findings:a. During a review of Patient 7’s Patient Information Sheet (face sheet, admission record), the Patient Information Sheet indicated a Start of Care (SOC) date of 11/3/2025 and an End of Care (EOC) date of 11/30/2025, with a primary diagnosis of Atherosclerotic heart disease of native artery without angina pectoris (a condition where atherosclerosis [buildup of plaque in the artery walls] occurs in the coronary arteries, which supply blood to the heart, without chest pain).During a review of Patient 7’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 11/25/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visits once per week and one as needed (PRN) visit to promote comfort and symptom management, Bereavement Coordinator (BC) visit within 5 days of admission to assess and evaluate bereavement and grieving risk factors, Medical Social Worker (MSW) visit within 5 days of admission for initial assessment and Spiritual Coordinator (SC) visit within 5 days of admission for initial assessment.During a review of Patient 7’s clinical record form titled Discharge Summary dated 11/30/2025, the Discharge summary indicated no signature from the licensed nurse.During a concurrent interview and record review on 12/19/2025 at 12:40 p.m. with the DPCS, Patient 7’s clinical record form titled Discharge Summary dated 11/30/2025 was reviewed. The DPCS stated that the Discharge summary was incomplete because it did not have the signature from the nurse who discharged the patient, as well as not include the patient’s medical history, active medications when discharged and the services received under hospice care. b. During a review of Patient 8’s Patient Information Sheet (face sheet, admission record), the Patient Information Sheet indicated a Start of Care (SOC) date of 11/8/2025 and an End of Care (EOC) date of 11/30/2025, with a primary diagnosis of Heart Failure (a condition when the heart muscle does not pump blood as well as it should causing blood to back up and fluid can build up in the lungs, causing shortness of breath).During a review of Patient 8’s clinical record form titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 11/11/2025 for certification period #1, the POC/IDG Review indicated an order for Licensed vocational nurse (LVN) visit once per week for changes in condition to promote comfort and symptom management, Bereavement Coordinator (BC) visit within 5 days of admission to assess and evaluate bereavement and grieving risk factors, Medical Social Worker (MSW) to evaluate and assess for needs initial evaluation within 5 days of admission, recertification and as needed for psycho-social counseling and support, and Spiritual care Coordinator (SC) visit for spiritual initial assessment within 5 days of admission, recertification and as needed to identify spiritual needs to support patient/family and primary caregiver.During a review of Patient 8’s clinical record form titled Discharge Summary dated 11/30/2025, the Discharge summary indicated no signature from the licensed nurse, no documentation of the patient’s medical history, treatments received or current medication.During a concurrent interview and record review on 12/19/2025 at 1 p.m. with the DPCS, Patient 8’s clinical record form titled Discharge Summary dated 11/30/2025 was reviewed. The DPCS stated that the Discharge summary was incomplete because it did not have the signature from the prospective nurse who discharged the patient, and it did not include pertinent information like the patient’s medical history, current medications, and what care and services the patient received while on hospice care. During a review of the HA ‘s Policy and Procedure (P&P) titled Discharge from hospice program, with no revised date, the P&P indicated that when a patient is discharged the relevant information included will be the reason for discharge or transfer, physical and psychosocial status of the patient at time of discharge, summary of care provided and progress toward achieving goals, copy of current plan of care, cope of medication profile, latest physician orders, continuing symptom management, any labs, any instructions or referrals to the patient and any advance directives.”