Circle of Life Hospice

“Based on interview and document review, the agency failed to ensure their emergency preparedness plan was reviewed and updated every two years. This failure has the potential of not maintaining an integrated response during a disaster or emergency, which could lead to delays in medical treatment, misallocation of resources, and inconsistent care, for the patients’ safety and well-being. A review of the agency’s undated policies and procedures titled Emergency Management Plan did not show when the emergency preparedness plan was last reviewed or updated. During a concurrent interview and record review on 6/30/25 at 2:30 PM, with the CEO (Chief Executive Officer), the hospice’s Emergency Management Plan was reviewed. The CEO stated their Emergency Preparedness Plan was last updated in 2025, however was unable to provide documentation of when the Emergency Preparedness Plan was last updated in the prior years.”

“Based on interview and document review, the agency failed to ensure their emergency preparedness plan policies and procedures (P&Ps) was reviewed and updated every two years. This failure has the potential of not maintaining an integrated response during a disaster or emergency, which could lead to delays in medical treatment, misallocation of resources, and inconsistent care, for the patients’ safety and well-being. A review of the agency’s undated Policy and Procedures titled Emergency Management Plan did not show when the emergency preparedness plan’s policies and procedures were last reviewed or updated. During a concurrent interview and record review on 6/30/25 at 2:30 PM, with the CEO (Chief Executive Officer), the hospice’s Emergency Management Plan was reviewed. The CEO stated their Emergency Preparedness Plan was last updated in 2025, however was unable to provide documentation of when the Emergency Preparedness Plan was last updated in the prior years.”

“Based on interview and document review, the agency failed to ensure their emergency preparedness plan included procedures to follow up with staff they are unable to contact in the event of an emergency. This failure has the potential of not maintaining an integrated response during a disaster or emergency, which could lead to delays in medical treatment, misallocation of resources, and inconsistent care, for the patients’ safety and well-being. A review of the agency’s undated policies and procedures titled Emergency Management Plan, indicated, the hospice will maintain an emergency preparedness communication. Further review of the emergency plan failed to show procedures on how the hospice will inform State and local officials of any on- duty staff they are unable to contact in the event of an emergency. During a concurrent interview and record review on 6/30/25 at 2:30 PM, with the CEO (Chief Executive Officer), the hospice’s Emergency Management Plan was reviewed. The CEO was unable to provide documentation for how the hospice will inform the State and local officials of any on- duty staff they are unable to contact. The CEO verified and acknowledged the finding.”

“Based on interview and document review, the agency failed to ensure their emergency preparedness plan communication plan was reviewed and updated every two years. This failure has the potential of not maintaining an integrated response during a disaster or emergency, which could lead to delays in medical treatment, misallocation of resources, and inconsistent care, for the patients’ safety and well-being. A review of the agency’s undated policies and procedures titled Emergency Management Plan did not show when the emergency preparedness plan’s communication plan was last reviewed or updated. During a concurrent interview and record review on 6/30/25 at 2:30 PM, with the CEO (Chief Executive Officer), the hospice’s Emergency Management Plan was reviewed. The CEO stated their Emergency Preparedness Plan was last updated in 2025, however was unable to provide documentation of when the Emergency Preparedness Plan was last updated in the prior years.”

“Based on interview and document review, the agency failed to ensure their emergency preparedness plan training and testing was reviewed and updated every two years. This failure has the potential of not maintaining an integrated response during a disaster or emergency, which could lead to delays in medical treatment, misallocation of resources, and inconsistent care, for the patients’ safety and well-being. A review of the agency’s undated policies and procedures titled Emergency Management Plan did not show when the emergency preparedness plan’s training and testing section was last reviewed or updated. During a concurrent interview and record review on 6/30/25 at 2:30 PM, with the CEO (Chief Executive Officer), the hospice’s Emergency Management Plan was viewed. The CEO stated their Emergency Preparedness Plan was last updated in 2025, however was unable to provide documentation of when the Emergency Preparedness Plan was last updated in the prior years.”

“Based on interview and clinical record review, the hospice failed to ensure the initial bereavement assessment was completed properly as evidenced by the lack of the primary bereaved’s information for one of two sampled patients (Patient 7). This failure had the potential to delay communication with the bereaved which could result in emotional distress. A review of Patient 7’s admission record (a document that contains a summary of basic information about the patient) indicated Patient 7’s start of care was on 3/11/25.A review of Patient 7’s “CTI” (Certification of Terminal Illness - a document indicating that a patient has a prognosis of six months or less to live if the illness runs its normal course) dated 3/11/25 indicated the patient was certified for hospice services during the certification period from 3/11/25 to 6/8/25. A review of Patient 7’s “Bereavement Assessment” dated 3/13/25 indicated the Chaplain completed an initial bereavement assessment. However, the assessment was not completed properly as it did not include the primary bereaved’s name and contact information.During a concurrent interview and clinical record review on 7/1/25 at 09:04 AM with the Chief Executive Officer (CEO), Patient 7’s “Bereavement Assessment” dated 3/13/25 was reviewed. The CEO verified the initial bereavement assessment was not completed properly and should have included the primary bereaved’s information. The CEO stated if the primary bereaved’s information was not included in the initial bereavement assessment, the staff would need to find the information from the admission record. If the contact information was not included in the admission record, the staff would need to ask the assigned registered nurse to find out who signed the election of benefit, which would delay the communication process.”

“Based on interview and clinical record review, the hospice failed to ensure the care and services were provided in accordance with the plan of care (POC - the plans showing specific interventions to provide effective and person-centered care to meet the patient’s needs) as evidenced by missed Registered Nurse (RN) visits for two of 14 sampled patients (Patients 3 and 14).These failures had the potential for the patients to not receive appropriate, consistent, and quality care. 2. A review of Patient 14’s admission record indicated Patient 14’s start of care was 3/10/25. The clinical record indicated the patient was certified for hospice services during the period from 3/10/25 to 5/8/25.A review of Patient 14’s physician’s order dated 3/10/25, indicated LVN visits every other week for changes in condition to promote comfort and symptom management. A review of Patient 14’s IDG/ POC Review dated 5/30/25, failed to show the LVN’s frequency of visits. Additionally, during a review of Patient 14’s RN (Registered Nurse) and LVN visit notes, the clinical record failed to show a visit was conducted for Patient 14 during the week of 4/27/25 to 5/3/25. During a concurrent interview and record review on 7/1/25 at 09:34 AM, with the Office Manager, Patient 14’s RN and LVN visit notes were reviewed. The OM verified there was no RN or LVN visit during the week of 4/27/25 to 5/23/25. The OM acknowledged the finding. Findings: 1. A review of Patient 3’s admission record (a document that contains a summary of basic information about the patient) indicated Patient 3’s start of care (SOC) was on 8/5/24.A review of Patient 3’s “CTIs” (Certification of Terminal Illness - a document indicating that a patient has a prognosis of six months or less to live if the illness runs its normal course) dated 4/2/25 and 6/1/25 indicated the patient was certified for hospice services during the certification periods from 4/2/25 to 5/31/25 and 6/1/25 to 7/30/25.A review of the “POC/IDG [Plan of Care/Interdisciplinary Group – a document outlining the plan of care and physician orders as determined through collaborative discussions by the team responsible for the patient’s care] Review” dated 4/4/25, 4/18/25, 5/2/25, 5/16/25, and 5/30/25 indicated the physician’s order for the registered nurse (RN) to visit once a week.A review of Patient 3’s “History of Visit Notes” indicated the RN visited the patient on 4/30/25, 5/20/25, 5/27/25, and 6/20/25. There was no documented evidence indicating the RN visited the patient for Weeks 1 to 4 (4/2/25 to 4/26/25) and Weeks 6 to 7 (5/4/25 to 5/17/25) for the certification period from 4/2/25 to 5/31/25. In addition, there was no documented evidence indicating the RN visited the patient for Weeks 1 and 2 (6/1/25 to 6/14/25) for the certification period from 6/1/25 to 7/30/25. Further review of Patient 3’s “Communication Log” indicated no documented evidence explaining why the visits were missed and if the IDG was informed.During a concurrent interview and clinical record review on 7/1/25 at 09:30 AM with the Chief Executive Officer (CEO), Patient 3’s “History of Visit Notes” for the certification periods from 4/2/25 to 5/31/25 and 6/1/25 to 7/30/25 were reviewed. The CEO verified the above findings. When asked why the RN missed the visits, the CEO stated she did not know why the visit notes were not available as she was certain the RN visited the patient weekly. The CEO was asked to provide the RN’s route sheet (a document that outlines the staff’s schedule and visit location) during the weeks when the missed visits occurred; however, the CEO was unable to provide any documentation by the time the survey team exited.”

“Based on interview and record review, the hospice failed to develop the individualized POC (Plan of Care, a written individualized document that outlines the care and services provided to a patient with a terminal illness and their family) that reflected the patient and family goals and interventions related to the pain necessary to meet the patient’s needs for one of 14 sampled patients (Patient 8). This failure had the potential for the patients’ pain needs to not be addressed. A review of Patient 8’s admission record (a document that contains a summary of basic information about the patient) indicated the SOC (Start of Care, the date hospice care started) was 3/10/25. The patient was certified for hospice services during the certification period from 6/8/25 to 9/5/25.A review of the clinical record indicated a physicians order dated 4/25/25 for oxycodone 20mg (a medication use to manage severe pain) by mouth, every eight hours, as needed for pain.During a review of the POC/ IDG (Plan of Care/ Interdisciplinary Group, the plan of care developed and overseen by the interdisciplinary group) dated 6/13/25, the POC/ IDG indicated a plan of care for pain, with interventions including the use of Norco 5-325mg (milligrams, a medication use to treat moderate to severe pain), by mouth every six hours as needed for pain.However, further review of the patient’s clinical record, failed to show documented evidence the care plan were updated to include the use of oxycodone per MD order. In addition, the patient’s clinical record also indicated that Patient 8 was no longer taking Norco 20mg for pain. During a concurrent interview and record review on 7/1/25 at 09:17 AM, with the Office Manager (OM), the POC/ IDG dated 6/13/25 and the physician’s order was reviewed. The OM stated the POC/ IDG should have been updated to include oxycodone. The OM verified and acknowledged the findings.”

“Based on interview and clinical record review, the hospice failed to ensure the updated plan of care (POC - the plans showing specific interventions to provide effective and person-centered care to meet the patient’s needs) included the discipline visit frequencies for two of 14 sampled patients (Patients 12 and 14) when:1. Patient 12’s POC/IDG (Plan of Care/Interdisciplinary Group - a document outlining the plan of care and physician orders as determined through collaborative discussions by the team responsible for the patient’s care) Review notes did not include the visit frequencies for the registered nurse (RN) and medical social worker (MSW).2. Patient 14’s POC/IDG Review notes did not include the visit frequency for the licensed vocational nurse (LVN).These failures had the potential for the patients to not receive the necessary care and services they need. 2. A review of Patient 14’s admission record indicated Patient 14’s SOC was on 3/10/25.A review of Patient 14’s “CTI” dated 5/9/25 indicated the patient was certified for hospice services during the certification period from 5/9/25 to 7/7/25. Review of Patient 14’s History of Visit Notes showed the LVN visited the patient on 4/12, 4/19, 4/26, 5/10, 5/17, 5/24, 5/31 and the RN visits on 6/7/25. A review of the “POC/IDG Review” dated 4/4, 4/18, 5/2, 5/16, and 5/30 indicated the physician’s orders for the for the Chaplain and MSW to visit once a month. However, there was no documented evidence indicating the visit frequencies for the RN and the LVN. On 7/1/25 at 9:34 AM, an interview and concurrent clinical record review was conducted with the Office Manager (OM). The OM verified the LVN visit frequencies were not updated on the POC/IDG. A review of the hospice’s policy and procedure titled, “The Plan of Care”, with a revised date of 4/2020, indicated “The plan of care… must state, in detail, the scope and frequency of services needed to meet the patient’s and family/ caregiver’s needs, goals and outcome achievement”. Findings:1. A review of Patient 12’s admission record (a document that contains a summary of basic information about the patient) indicated Patient 12’s start of care was on 9/12/24.A review of Patient 12’s “CTI” (Certification of Terminal Illness - a document indicating that a patient has a prognosis of six months or less to live if the illness runs its normal course) dated 9/12/24 indicated the patient was certified for hospice services during the certification period from 9/12/24 to 12/10/24. A review of Patient 12’s “History of Psychosocial Assessment” indicated the medical social worker (MSW)visited the patient on 9/14/24.A review of Patient 12’s “History of Visit Notes” indicated the RN visited the patient on 9/17/24, 9/24/24, 10/2/24, 10/9/24, 10/11/24, 10/16/24, 10/23/24, 10/30/24, and 11/1/24.A review of the “POC/IDG Review” dated 9/12/24, 9/20/24, 10/4/24, 10/18/24, and 11/1/24 indicated a physician’s orders for the hospice aide to visit two times a week and for the Chaplain to visit once a month. There was no documented evidence indicating the visit frequencies for the RN and the MSW.During a concurrent interview and clinical record review on 7/1/25 at 09:19 AM with the Chief Executive Officer (CEO), Patient 12’s “POC/IDG Review” dated 9/12/24, 9/20/24, 10/4/24, 10/18/24, and 11/1/24 were reviewed. The CEO verified the visit frequencies for the RN and MSW were missing and should have been included in the IDGs. The CEO stated the RN who was assigned to the patient was responsible for ensuring that the visit frequencies were captured in the IDG.”

“Based on interview and clinical record review, the hospice failed to ensure that the plan of care (POC - the plans showing specific interventions to provide effective and person-centered care to meet the patient’s needs) included measurable outcomes for five of 14 sampled patients (Patients 1, 3, 5, 6, and 10) when:1. Patient 3’s nutrition POC did not have a measurable goal for the patient’s fluid intake.2. Patient 5’s gastrointestinal (GI - a continuous pathway in the body where food travels) system POC did not have a measurable goal for the patient’s nausea.3. Patient 1’s cardiovascular (refers to anything related to the heart and blood vessels) POC did not have a measurable goal for the patient’s peripheral circulation.4. Patient 6 and 10’s spiritual POC did not have a measurable goal for the bereavement process.5. Patient 10’s Endocrine (tissue that makes and releases hormones that travel into the bloodstream and control the actions of other cells or organs.) POC did not have a measurable goal for blood sugar management.These failures had the potential for untimely, inconsistent and inaccurate assessment of the patients’ progress, which could result in inappropriate or ineffective care. 3. A review of Patient 1’s admission record indicated Patient 1’s start of care was on 4/16/25. The patient was certified for hospice services during the certification period from 6/15/25 to 8/13/25. A review of the POC/ IDG Review dated 6/13/25, indicated the patients’ identified problems included cardiovascular related atrial fibrillation, with the goal for the patient to maintain optimum peripheral circulation. However, there was no documented evidence of a measurable outcome and what the “optimum peripheral circulation” would be. During a concurrent interview and clinical record review on 7/1/25 at 8:43 AM, with the Office Manager (OM), Patient 1’s POC/ IDG was reviewed. The OM verified that the word “optimal” was not measurable and acknowledged the findings. 4. a. A review of Patient 6’s admission record indicated Patient 6’s SOC was on 5/7/25. The patient was certified for hospice services during the certification period from 2/28/25 to 4/28/25 and 4/29/25 to 6/27/25.The POC/ IDG Review dated 6/13/25, indicated a spiritual problem of loneliness with goals including to facilitate an optimal spiritual environment to begin the bereavement process, and healing road to peace. However, there was no documented evidence of a measurable outcome and what the optimum spiritual environment, or healing road to peace would be. During a concurrent interview and clinical record review on 7/1/25 at 9:17 AM, with the OM. The OM verified that the word “optimal” was not measurable and would not be able to measure the healing road to peace. The OM acknowledged the findings. b. A Review of Patient 10’s admission record indicated Patient 10’s SOC was on 1/25/25. The patient was certified for hospice services during the certification period from 5/25/25 to 7/23/25. A review of the POC/ IDG Review dated 6/13/25, indicated a spiritual care plan problem addressing the patient’s loneliness with goals including to facilitate an optimal spiritual environment to being the bereavement process and healing road to peace. However, there was no documented evidence of a measurable outcome and what the optimum spiritual environment, or healing road to peace would be. During a concurrent interview and clinical record review on 7/1/25 at 9:23 AM, with the OM, the POC/ IDG was reviewed. The OM verified that “optimum spiritual environment” was not measurable. The OM acknowledged the finding. 5. A Review of Patient 10’s admission record indicated Patient 10’s SOC was on 1/25/25. The patient was certified for hospice services during the certification period from 5/25/25 to 7/23/25.A review of the POC/ IDG Review dated 6/13/25, indicated a care plan problem addressing the patient’s history of diabetes with goals including “optimal blood sugar management for the patient’s comfort”. However, there was no documented evidence of a measurable outcome and what the optimal blood sugar management would be. During a concurrent interview and clinical record review on 7/1/25 at 10:30 AM, with the OM, Patient 10’s POC/ IDG dated 6/13/25 was reviewed. The OM verified that “optimal” blood sugar was not measurable. The OM was acknowledged the findings. A review of the facility’s policy and procedure titled “The Plan of Care,” revised on 4/2020, indicated “…12. The written plan of care will contain, but will not be limited to, the following:…W. Measurable outcomes anticipated from implementing and coordinating the plan of care…” Findings:1. A review of Patient 3’s admission record (a document that contains a summary of basic information about the patient) indicated Patient 3’s start of care (SOC) was on 8/5/24.A review of Patient 3’s “CTIs” (Certification of Terminal Illness - a document indicating that a patient has a prognosis of six months or less to live if the illness runs its normal course) dated 4/2/25 and 6/1/25 indicated the patient was certified for hospice services during the certification periods from 4/2/25 to 5/31/25 and 6/1/25 to 7/30/25.A review of the “POC/IDG [Plan of Care/Interdisciplinary Group - a document outlining the plan of care and physician orders as determined through collaborative discussions by the team responsible for the patient’s care] Review” dated 4/4/25 and 6/13/25 indicated a POC for nutrition was developed. The goal included “Patient will have adequate food and fluids as tolerated or desired and be able to eat 2-3 full meals per day with no incidence of aspiration within the next 2 weeks and will re-evaluate on the next IDT [interdisciplinary team] meeting.” There was no documented evidence showing the measurable goal for Patient 3’s fluid intake.During a concurrent interview and clinical record review on 7/1/25 at 09:30 AM with the Chief Executive Officer (CEO), Patient 3’s “POC/IDG Review” dated 4/4/25 and 6/13/25 were reviewed. The CEO verified the goals should have been measurable and specified what adequate meant for Patient 3. 2. A review of Patient 5’s admission record indicated Patient 5’s start of care was on 4/18/25.A review of Patient 5’s “CTI” dated 4/18/25 indicated the patient was certified for hospice services during the certification period from 4/18/25 to 6/16/25.A review of the “POC/IDG Review” dated 6/13/25 indicated a POC for the GI system was developed. The goal included “Patient will have decreased severity of nausea within the next 2 weeks and will re-evaluate on the next IDT meeting.” There was no documented measurable goal specifying the intended reduction in the severity of Patient 5’s nausea.During a concurrent interview and clinical record review on 7/1/25 at 08:52 AM with the CEO, Patient 5’s “POC/IDG Review” dated 6/13/25 was reviewed. The CEO verified the POC should have identified a measurable goal to help assess whether the patient’s nausea was improving.”

“Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for one of 14 sampled patients (Patient 14). This failure had the potential to cause inconsistent delivery of care which can result in the decline or lack of improvement of the patients’ health condition. A review of Patient 14’s admission record (a document that contains a summary of basic information about the patient) indicated the SOC (Start of Care, the date hospice care started) was 3/10/25. The patient was certified for hospice services during the certification period from 3/10/25 to 5/8/25. A review of the clinical record indicated a physician’s order dated 6/30/25, for Carbidopa/ Levodopa 25-100mg (a medication used to treat symptoms of Parkinson’s disease) by mouth, twice a day for Parkinson’s disease.However, review of the POC/ IDG (Plan of Care/ Interdisciplinary Group, written individualized document that outlines the care and services provided to a patient with a terminal illness and their family that is developed and overseen by the interdisciplinary group) dated 5/30/25, indicated no documented evidence the care plan were developed to address the use of Carbidopa/ Levodopa 25- 100mg.During a concurrent interview and record review with the Office Manager (OM) on 7/1/25 at 09:34 AM, Patient 14’s POC/ IDG dated 5/30/25 was reviewed. The OM verified the Carbidopa/ Levodopa was not included in the patients’ POC/ IDG. The OM acknowledged the findings.”

“Based on interview and record review, the hospice IDG (Interdisciplinary Group, a team responsible for developing and implementing a patients plan of care) failed to ensure the care and services were provided in accordance with the POCs (Plan of Care, a written individualized document that outlines the care and services provided to a patient with a terminal illness and their family) for two of 14 sampled patients (Patients 2 and 6).This failure had the potential for patients to receive inappropriate, inconsistent, and substandard quality care. 1. A Review of Patient 2’s admission record (a document that contains a summary of basic information about the patient) indicated the SOC (Start of Care, the date hospice care started) was on 5/7/25. The patient was certified for hospice services during the certification period from 5/7/25 to 8/4/25. A Review of Patient 2’s POC/ IDG (Plan of Care/ Interdisciplinary Group, the plan of care developed and overseen by the interdisciplinary group) Review dated 6/13/25, indicated a respiratory problem to address dyspnea (shortness of breath) with interventions including,”To assess and record respiratory rate, depth, check oxygen saturation (the measure of how much hemoglobin in your blood is carrying oxygen) via pulse oximeter (a non-invasive medical device used to measure oxygen saturation levels in the blood) as needed for any signs of respiratory distress; Provide oxygen inhalation at two liters per minute via nasal cannula/facemask as needed for mild dyspnea (shortness of breath) with respiratory rate of 21-22 breaths per minute.”A review of Patient 2’s clinical record, indicated the following physician’s orders dated 5/7/25, “May check oxygen saturation at each SN (Skilled Nurse) or as needed visit for shortness of breath/congestion/respiratory crisis. Notify hospice and hospice MD if O2 sat is below 89%”.A Review of the Visit Note RN (Registered Nurse) dated 6/9/25, indicated vital signs including respiratory rate of 22, and oxygen saturation of 88%. However, there was no documented evidence indicating the RN notified the hospice and the hospice MD (Medical Doctor) of the patients’ low O2 sat, as noted in the POC/IDG. During a concurrent interview and clinical record review on 7/1/25 at 8:55 AM, with the Office Manager (OM), the OM stated the RN should have documented what they did for the patient. 2. A review of Patient 6’s admission record showed the SOC was 2/28/25. The patient was certified for hospice services during the certification period 2/28/25 to 4/28/25 and 4/29/25 to 6/27/25. A review of Patient 6’s clinical record, indicated the following physician’s orders dated 2/28/25, “Skilled Nurse to assessment vital signs during every assessment and notify if the systolic blood pressure is greater than 160 mm/Hg (millimeters of mercury) and less than 90mm/Hg. Diastolic Blood pressure is greater than 90mmHg and less than 50mm/Hg; or if heart rate is greater than 110 beats per minute and less than 50 beats per min.” A review of Patient 6’s Comprehensive Nursing Assessment dated 2/28/25, indicated vital signs including blood pressure 88/54 and pulse 97. However, there was no documented evidence indicating the RN notified the MD about the patients’ vital signs which were below parameters, as noted in the physician orders. During a concurrent interview and clinical record review on 7/1/25 at 10:00 AM, with the Office Manager (OM). The OM stated the RN should have documented the interventions provided to the patient. A review of the hospice’s P&P (policies and procedures) titled “The Plan of Care”, with a revised date of 4/2020 indicated, “a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care”.”

“Based on observation and interview, the hospice failed to implement proper infection control practices when Registered Nurse (RN) 1 failed to perform hand hygiene during a skin assessment for one of three sampled patients (Patient 3). This failure had the potential for cross contamination and spread of infection which could adversely affect the health and well-being of the patient and staff. Findings:On 6/25/25 at 12:45 PM, a joint home visit with RN 1 to Patient 3’s residence was conducted.During a concurrent observation and interview with RN1 on 6/25/25 at 1:00 PM, RN 1 stated he will be assessing Patient 3’s sacrum (the triangular-shaped bone at the bottom of the spine) and buttocks due to a new skin tear (a traumatic wound caused by friction when the upper layer of the skin becomes torn from the underlying layers) that was reported. Prior to assessing Patient 3’s skin, RN 1 washed his hands with soap and water. Afterwards, RN 1 donned (wore) a clean pair of gloves and lowered Patient 3’s pants to assess the skin on the sacrum and buttocks. After assessing and touching the surrounding skin, RN 1 removed his right glove and retrieved the phone from his pocket to photograph the skin tear. RN 1 then placed the phone back in his pocket and doffed (removed) the left glove. RN 1 continued to don a new pair of gloves, without performing hand hygiene, and proceeded to clean Patient 3’s sacrum and buttocks using an incontinence wipe.During an interview with RN1 on 6/25/25 at 01:25 PM, RN 1 was informed of the observation. RN 1 verified he should have washed his hands after assessing and touching Patient 3’s skin and before donning a new pair of gloves.A review of the facility’s policy and procedure titled “Hand Hygiene,” revised on 4/2020, indicated “…3. Hand decontamination using an alcohol-based hand rub should be performed:…C. After contact with a patient’s intact skin (when taking a pulse, blood pressure or lifting a patient)…D. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, if hands are not visibly contaminated. E. When moving from a contaminated body site to a clean body site during patient care. F. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. G. After removing gloves…””

“Based on interview and clinical record review, the hospice failed to ensure the bereavement plan of care (POC - the plans showing specific interventions to provide effective and person-centered care to meet the patient’s needs) was implemented when the scheduled bereavement mailings were not sent and the planned condolence calls to the bereaved were not made for two of two sampled patients (Patients 11 and 12). These failures created the risk of compromising the emotional and psychosocial needs of the patients’ bereaved. Findings:a. A review of Patient 11’s admission record (a document that contains a summary of basic information about the patient) indicated Patient 11’s start of care (SOC) was on 11/2/24.A review of Patient 11’s “Visit Note Death Visit” dated 11/17/24 indicated the patient passed away on 11/17/24. A review of Patient 11’s “Bereavement POC” dated 11/23/24, indicated a check mark next to the following interventions and action plans:-post-death sympathy card-post-death bereavement assessment-provide standard post-death bereavement mailings-encourage/support expression of grief-two month bereavement staff call-condolence card, after the IDT (interdisciplinary team meeting)-one month letter-three month letter-six month letter The narrative portion of the “Bereavement POC” dated 11/23/24 indicated “…According to the hospice care plan, a condolence card will be sent by the hospice, bereavement letters and material will be sent every three months, and a 2 and 8 month supportive phone call will be made…”A review of Patient 11’s “POC/IDG [Plan of Care/Interdisciplinary Group – a document outlining the plan of care and physician orders as determined through collaborative discussions by the team responsible for the patient’s care] Review” dated 11/29/24 indicated an IDG meeting was completed following the patient’s death. Further review of Patient 11’s clinical record indicated the bereavement letters were sent to the primary bereaved on 12/17/24, 2/17/25, and 5/17/25. However, there was no documented evidence indicating a post-death sympathy card and condolence card after the IDG meeting were mailed. There was also no documented evidence indicating the two-month bereavement staff call was completed.b. A review of Patient 12’s admission record indicated Patient 12’s SOC was on 9/12/24.A review of Patient 12’s “Visit Note Death Visit” dated 11/2/24 indicated the patient passed away on 11/2/24. A review of Patient 12’s “Bereavement POC” dated 11/8/24, indicated a check mark next to the following interventions and action plans:-post-death sympathy card-post-death bereavement assessment-provide standard post-death bereavement mailings-encourage/support expression of grief-two month bereavement staff call-condolence card, after the IDT -one month letter-three month letter-six month letter The narrative portion of the “Bereavement POC” dated 11/8/24 indicated “…Chaplain and the bereavement support group will continue to provide bereavement support and grief counseling throughout the year by following the care plan, which consists of a condolence card, and bereavement letters sent every three months, and a 2 and 8 month supportive phone call.”A review of Patient 12’s “POC/IDG Review” dated 11/15/24 indicated an IDG meeting was completed following the patient’s death. Further review of Patient 12’s clinical record indicated the bereavement letters were sent to the primary bereaved on 12/2/24, 2/2/25, and 5/2/25. However, there was no documented evidence indicating a post-death sympathy card and condolence card after the IDG meeting were mailed. There was also no documented evidence indicating the two-month bereavement staff call was completed.During a concurrent interview and clinical record review on 6/30/25 at 02:00 PM with the Bereavement Coordinator (BC), the “Bereavement POCs” for Patient 11 dated 11/23/24 and Patient 12 dated 11/8/24 were reviewed. The BC verified he was in charge of ensuring the bereavement POC was implemented, including sending all mailings. The BC verified that the interventions and action plans with a check mark in the “Bereavement POC” meant that these items needed to be implemented. When asked to locate the documented evidence indicating the staff completed a two-month bereavement call and mailed the post-death sympathy and condolence cards for Patients 11 and 12, the BC verified he was unable to find them. The BC stated he called and sent the cards, but he may have forgotten to document.A review of the facility’s policy and procedure titled “Bereavement Assessment,” revised on 4/2020, indicated “…4. The Bereavement Coordinator will develop a plan for intervention based on the findings of the bereavement follow-up assessment…5. The Bereavement Coordinator or Volunteer will document the family bereavement interventions…6. Upon completion all bereavement documentation will be filed.””

“Based on interview and clinical record review, the hospice failed to ensure the Hospice Aide (HA) assignments were developed during the recertification period for two of four sampled patients (Patients 1 and 3). This failure created the risk for the HAs to provide inappropriate or insufficient care as the outdated assignments may not reflect the patient’s current condition. 3. Test HA failed. Findings:1. A review of Patient 3’s admission record (a document that contains a summary of basic information about the patient) indicated Patient 3’s start of care was on 8/5/24.A review of Patient 3’s “CTIs” (Certification of Terminal Illness - a document indicating that a patient has a prognosis of six months or less to live if the illness runs its normal course) dated 4/2/25 and 6/1/25 indicated the patient was certified for hospice services during the certification periods from 4/2/25 to 5/31/25 and 6/1/25 to 7/30/25.A review of Patient 3’s “POC/IDG [Plan of Care/Interdisciplinary Group – a document outlining the plan of care and physician orders as determined through collaborative discussions by the team responsible for the patient’s care] Review” dated 4/4/25, 4/18/25, 5/2/25, 5/16/25, 5/30/25, and 6/13/25 indicated the physician’s order for the HA to visit two times per week. A review of Patient 3’s “HA Assignment” indicated an HA assignment was completed on 8/5/24. However, there was no documented evidence indicating the HA assignments were developed when the patient’s hospice services were recertified. During a concurrent interview and clinical record review on 7/1/25 at 09:30 AM with the Chief Executive Officer (CEO), Patient 3’s “HA Assignment” dated 8/5/24 was reviewed. When asked to show the updated HA assignments for each certification period, the CEO verified there were no HA assignments developed. The CEO stated the registered nurses only developed the HA assignments upon admission and will only update them if there were any changes. A review of the facility’s policy and procedure titled “Hospice Aide Services,” revised on 4/2020, indicated “…3. Hospice aide assignments, plan of care, and interventions will be documented and included in the patient’s clinical record…””

“Based on interview and clinical record review, the hospice failed to ensure the care and services were provided in accordance with the plan of care (POC) as evidenced by missed hospice aide (HA) visits for one of 14 sampled patients (Patient 3). This failure created the risk of not providing appropriate, consistent, and quality care to the patient. A review of Patient 3’s admission record (a document that contains a summary of basic information about the patient) indicated Patient 3’s start of care (SOC) was on 8/5/24. A review of Patient 3’s “CTIs” (Certification of Terminal Illness - a document indicating that a patient has a prognosis of six months or less to live if the illness runs its normal course) dated 4/2/25 indicated the patient was certified for hospice services during the certification period from 4/2/25 to 5/31/25. A review of Patient 3’s “POC/IDG [Plan of Care/Interdisciplinary Group - a document outlining the plan of care and physician orders as determined through collaborative discussions by the team responsible for the patient’s car] Review” dated 5/16/25 indicated the physician’s order for the HA to visit twice a week. A review of Patient 3’s “History of HA Notes” indicated the HA visited the patient on 5/13/25, 5/16/25, and 5/23/25. However, the HA only visited the patient once for Week 8 (5/18/25 to 5/24/25).Further review of Patient 3’s “Communication Log” indicated no documented evidence explaining why the visits were missed or if an attempt to reschedule the visit was made. During a concurrent interview and clinical record review on 7/1/25 at 09:30 AM with the Chief Executive Officer (CEO), Patient 3’s “History of HA Notes” was reviewed. The CEO verified the above findings. When asked why the HA missed the visit, the CEO replied she did not know. The CEO stated the hospice would usually send another staff to visit the patient or will try to reschedule the visit within the week. The CEO stated the missed visits should be communicated to the hospice and the reasons or attempts to reschedule should be documented. A review of the facility’s policy and procedure titled “Hospice Aide Services,” revised on 4/2020, indicated “…3. Hospice aide assignments, plan of care, and interventions will be documented and included in the patient’s clinical record…””

“Based on interview and clinical record review, the hospice failed to ensure the Registered Nurse (RN) provided proper supervision to assess the quality of care and services provided for one of four sampled patients (Patients 3), when the RN did not:a. conduct supervisory visits every 14 days and b. identify that the Hospice Aide (HA) did not follow the visit frequency as per the plan of care (POC - the plans showing specific interventions to provide effective and person-centered care to meet the patient’s needs). a. A review of Patient 3’s admission record (a document that contains a summary of basic information about the patient) indicated Patient 3’s start of care was on 8/5/24.A review of Patient 3’s “CTIs” (Certification of Terminal Illness - a document indicating that a patient has a prognosis of six months or less to live if the illness runs its normal course) dated 4/2/25 and 6/1/25 indicated the patient was certified for hospice services during the certification periods from 4/2/25 to 5/31/25 and 6/1/25 to 7/30/25.A review of Patient 3’s “POC/IDG [Plan of Care/Interdisciplinary Group – a document outlining the plan of care and physician orders as determined through collaborative discussions by the team responsible for the patient’s care] Review” dated 4/4/25, 4/18/25, 5/2/25, 5/16/25, 5/30/25, and 6/13/25 indicated the physician’s order for the HA to visit twice a week.A review of Patient 3’s “History of HA Notes” indicated the HA visited the patient twice a week from 4/4/25 to 5/16/25 and 5/27/25 to 6/20/25. A review of Patient 3’s “Visit Notes RN” dated 4/30/25, 5/20/25, and 6/20/25 indicated the RN conducted HA supervisory visits on these days. However, the supervisory visits were inconsistent and were not conducted every 14 days. b. A review of Patient 3’s “History of HA Notes” indicated the HA visited the patient on 5/13/25, 5/16/25, and 5/23/25. However, the HA only visited the patient once for Week 8 (5/18/25 to 5/24/25). Cross reference to L626.A review of Patient 3’s “Re-Cert Assessment” dated 5/27/25 indicated the RN visited the patient. However, there was no documented evidence indicating the RN conducted an HA supervisory visit on this day. In addition, there was no documented evidence indicating the RN identified that the HA did not follow the POC and missed a visit on Week 8 (5/18/25 to 5/24/25).During a concurrent interview and clinical record review on 7/1/25 at 09:30 AM with the Chief Executive Officer (CEO), Patient 3’s “POC/IDG Review,” “History of HA Notes,” “Visit Notes RN,” and “Re-Cert Assessment” during the certification periods from 4/2/25 to 5/31/25 and 6/1/25 to 7/30/25 were reviewed. The CEO verified the above findings. The CEO confirmed the RN should have identified that the HA missed a visit and conducted supervisory visit every 14 days. The CEO stated she was certain that the RN visited the patient but was unable to provide documentation. A review of the facility’s policy and procedure titled “Hospice Aide Supervisory Visits,” revised on 4/2020, indicated “…1. The Frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days…3. The Case Manager will be responsible for:…B. Supervision of all services provided for in the plan of care…4. Supervisory visits and overall supervision will be documented in the clinical record…A. Supervisory visits will be documented on a supervisory form. B. Ongoing supervision will be documented within the plan of care, aide assignment sheet, and clinical notes. 5. During an onsite supervisory visit, if the appropriate supervising personnel identifies an area of concern, the supervising personnel with follow-up with an on-site supervisory visit…””

“Based on interview and record review, the hospice failed to implement ongoing volunteer recruitment efforts. This failure created the risk to restrict the hospice’s ability meet the required cost-savings. A review of the hospice’s volunteer program binder for 2024 and 2025 indicated the hospice had a current volunteer services program. Further record review indicated the hospice had one active volunteer. However, there was no documented evidence indicating the hospice implemented an ongoing volunteer recruitment effort. During an interview with the Chief Executive Officer (CEO) on 6/30/25 at 01:34 PM, the CEO was asked how the hospice advertised and recruited volunteers. The CEO replied that the hospice recruited volunteers through word of mouth. The CEO stated she preferred to recruit volunteers whom she or the other staff knew to ensure that the volunteers were trustworthy and behaved properly while visiting a patient. When asked to show any documentation regarding the hospice’s volunteer recruitment, the CEO verified the hospice did not document their efforts. A review of the hospice’s policy and procedure titled “Volunteer Services,” revised on 4/2020, indicated “…The Volunteer Coordinator will document ongoing efforts to recruit, train, and retain volunteers of all ages and ethnic backgrounds…””

“Based on interview and record review, the hospice’s Administrator failed to oversee the overall operations of the hospice and maintain administrative and supervisory responsibility for all care provided when:1. The written agreements for two of five contractors (Contractors 1 and 2) did not include the procedures for charges and reimbursement and the required elements related to bereavement follow-up as per the Hospice Standards.2. The facility failed to ensure the health examinations were completed for 6 of 11 employees, 6 months prior or within 14 days of hired date. These failures placed the patients at a potential risk for receiving care from individuals whose qualifications, roles, and health status had not been properly verified, compromising the hospice’s ability to ensure the safety, quality, and consistency of care provided. 2a. A review of the hospice’s Bereavement Counselor/ Chaplain’s personnel file indicated a hire date of 10/1/22. Further review of the personnel file indicated a health examination dated 7/29/24. b. A review of the Medical Director’s personnel file indicated a hire date of 1/1/22. Further review of the personnel file indicated a health examination dated 12/23/24. c. A review of the RN (Registered Nurse) 1’s personnel file indicated a hire date of 1/1/22. Further review of the personnel file indicated a health examination dated 3/7/22. d. A review of the MSW’s (Master in Social Work’s) personnel file indicated a hire date of 1/1/22. Further review of the personnel file indicated a health examination dated 5/11/23. e. A review of the DPCS’(Director of Patient Care Services’) personnel file indicated a hire date of 1/1/22. Further review of the personnel file indicated a health examination dated 1/15/25. f. A review of the CEO’s (Chief Executive Officer’s) personnel file indicated a hire date of 1/1/22. Further review of the personnel file indicated a health examination dated 8/15/22. During a concurrent interview and hospice document review, on 7/1/25 at 9:39 AM, with the Office Manager (OM), the hospice’s personnel files were reviewed. The OM verified and acknowledged the above findings. No additional documents were provided at the time of exit. A review of the Hospice Standards Article 6, Section 6.3 Record- keeping Requirements, indicated, “all persons providing physician, nursing or home health aide services shall have a health examination by a physician, nurse practitioner or physicians assistant six months prior to employment or within 14 days of the date of employment.” Findings:1a. A review of the written agreement dated 2/1/23 between Contractor 1 and the hospice indicated, Contractor 1 provided laboratory services. However, the written agreement with Contractor 1 did not address the procedure for charges and reimbursement.b. A review of the written agreement dated 1/11/22 between Contractor 2 and the hospice indicated, Contractor 2 provided medical services. However, the written agreement with Contractor 2 did not address the roles and responsibilities of the hospice and contractor regarding bereavement follow-up.During a concurrent interview and record review on 7/1/25 at 10:00 AM with the Chief Executive Officer (CEO), the written agreements for Contractor 1 dated 2/1/23, and Contractor 2 dated 1/11/22 were reviewed. The CEO read the written agreements and verified they did not include the required elements as per the Hospice Standards.A review of the Hospice Standards Article 6, Section 6.2 B Contractual Services, “…1. When program services are not provided directly by employees there shall be a written agreement defining the nature and scope of services provided. 2. The agreement shall address but not be limited to:… c. Roles and responsibilities of the program and contracted individual or organization in the following:…(7) Bereavement follow-up…f… Procedure for charges and reimbursement...””

“Based on interview and clinical record review, the hospice failed to ensure the staff conducted a comprehensive pain assessment for two of 14 sampled patients (Patients 5 and 8).This failure had the potential of providing inappropriate or ineffective pain management and treatment for the patients. 2. A review of Patient 8’s admission record indicated the start of care was 3/10/25. The patient was certified for hospice services during the certification period from 3/10/25 to 5/8/25. During a review of the RN (Registered Nurse) and LVN (Licensed Vocational Nurse) visit notes dated 4/7, 4/14, 4/21, 4/28, 5/5, 5/12, and 5/19/25, the visit notes indicated the patient had reported pain level between 4-6. Further review of the clinical record failed to show a complete pain assessment was documented. During a concurrent interview and clinical record review on 7/1/25 at 9:17 AM, with the Office Manager (OM), Patient 8’s RN and LVN visit notes were reviewed. The OM stated the visiting nurse is supposed to document and complete a pain assessment. The OM verified and acknowledged the findings.A review of the hospice’s P&P titled “Pain Assessment,” revised on 4/2020, indicated “…When pain is identified, a more comprehensive pain assessment will be completed when warranted by the patient’s condition…2. When the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained whenever zpossible: A…The patient will be reassessed every visit for the existence and intensity of pain and the effectiveness of interventions to relieve pain…C. Pain quality, patterns of radiation, and character. Use the patient’s own words whenever possible. D. Pain onset, duration, variations, and patterns. E. Alleviating and aggravating factors. F. Present pain management regimen and effectiveness G. Pain management history, to include a medication history, presence of common barriers to reporting pain and using analgesics, past interventions and response, and manner of expressing pain. H Effects of pain. These include impact on daily life, function, sleep, appetite, relationship with others, emotions, concentration, etc…J. Physical exam or observation of the site of pain…K. Secondary symptoms related to pain such as nausea, vomiting, respiratory distress, or nutritional compromise…5. Pain assessments will be part of the comprehensive assessment and will be updated if significant changes occur…” Findings:1. A review of Patient 5’s admission record (a document that contains a summary of basic information about the patient) indicated Patient 5’s start of care (SOC) was on 4/18/25.A review of Patient 5’s “CTI” (Certification of Terminal Illness - a document indicating that a patient has a prognosis of six months or less to live if the illness runs its normal course) dated 4/18/25 indicated the patient was certified for hospice services during the certification period from 4/18/25 to 6/16/25.A review of the “POC/IDG (Plan of Care/Interdisciplinary Group – a document outlining the plan of care and physician orders as determined through collaborative discussions by the team responsible for the patient’s care) Review” dated 5/2/25, 5/16/25, 5/30/25, and 6/13/25 indicated a POC was developed for pain. The interventions included to “…Instruct PCG (patient caregiver) and assess non-verbal signs of pain such as moaning, restlessness and body language indicative of pain…Instruct PCG on non-pharmacological methods of pain and symptom relief such as repositioning, music therapy and/or calm quiet environment…Monitor vital signs, especially pulse and blood pressure, every 5 minutes until the pain subsides…Monitor/assess effectiveness of current medication…”A review of Patient 5’s “Visit Note LVN (Licensed Vocational Nurse)” on the following dates indicated: -On 5/9/25, the LVN documented that the patient reported a pain level of “5” to the lower back. The notes indicated “…Tramadol Hydrochloride (a pain medication used to relieve moderate to severe pain) 50 mg (milligram) tablet was given for pain orally (by mouth)…”-On 5/16/25, the LVN documented that the patient reported a pain level of “5” to the lower back and hip. The notes indicated “…If pain is present the patient takes Tramadol Hydrochloride 50 mg.”-On 5/22/25, the LVN documented that the patient reported a pain level of “4” to the shoulder.-On 5/29/25, the LVN documented that the patient reported a pain level of “5” to the lower back. The notes indicated “…Medication was tolerated without issues…” The notes did not indicate which medication was administered and if the medication administered was for the patient’s pain. -On 6/5/25, the LVN documented that the patient reported a pain level of “4” to the upper back. The notes indicated “…No visible signs of distress noted following medication administration…” The notes did not indicate which medication was administered and if the medication administered was for the patient’s pain.-On 6/12/25, the LVN documented that the patient reported a pain level of “4” to the lower back, radiating slightly to the left hip.There was no documented evidence showing the LVN completed a comprehensive pain assessment as per Patient 5’s POC and the hospice’s policy and procedure (P&P). There was also no documented evidence showing the LVN reassessed the patient when pain medication was administered on 5/9/25.During a concurrent interview and clinical record review on 7/1/25 at 08:52 AM with the Chief Executive Officer (CEO), Patient 5’s “Visit Note LVN” dated 5/9/25, 5/16/25, 5/22/25, 5/29/25, and 6/5/25 were reviewed. The CEO verified the findings and confirmed a comprehensive pain assessment and reassessment should have been documented.”

“Based on interview and clinical record review, the hospice failed to ensure the clinical records were properly authenticated and completed timely, accurately, and consistently for five of 14 sampled patients (Patients 2, 3, 4, 5, and 6) when:1. The registered nurse (RN) failed to electronically sign the interdisciplinary group (IDG) meetings conducted for Patient 3.2. The RN failed to consistently document Patient 4’s pain level.3. The RN and licensed vocational nurse (LVN) failed to authenticate the assessments properly and timely for Patient 5.4. The Physician and RN failed to electronically sign the interdisciplinary (IDG) meetings conducted for Patient 25. The RN and LVN failed to authenticate the assessments properly and timely for Patient 6.These failures had the potential to compromise the continuity of care and undermine accountability in the patient assessment process. 4. A review of Patient 2’s admission record indicated the start of care was 5/7/25. The patient was certified for hospice services during the certification period from 5/7/25 to 8/4/25. A review of the POC/ IDG Review dated 5/7/25, failed to show the physician had signed the clinical record. A review of the POC/ IDG Review dated 5/16/25, failed to show the physician and RN had signed the clinical record. A review of the POC/ IDG Review dated 5/30/25, failed to show the physician had signed the clinical record. A review of the POC/ IDG Review dated 6 /13/25, failed to show the physician had signed the clinical record. During a concurrent interview and clinical record review on 7/1/25 at 8:55 AM, with the Office Manager (OM), Patient 2’s POC/ IDGs were reviewed. The OM stated the members of the IDG should have signed the POC/ IDG after each review. The OM verified and acknowledged the findings.5. A review of Patient 6’s admission record indicated the start of care was 5/7/25. The patient was certified for hospice services during the certification period from 4/29/25 to 6/27/25. A review of the Visit Note LVN dated 5/2/25 indicated the RN closed the note on behalf of staff assigned on 6/25/25. A Review of the Visit Note LVN dated 5/16/25 indicated the RN closed note on behalf of staff assigned on 6/25/25. During a concurrent interview and clinical record review on 7/1/25 at 10:30 AM, with the OM, Patient 6’s visit notes were reviewed. The OM stated the visiting nurse had two days to complete and sign their assessments after the visit. The OM stated she was unsure why the RN signed the LVN’s note. The OM verified the RN signed the LVN’s note a month after the visit. The OM verified and acknowledged the findings.A review of the hospice’s P&P titled “Completion and Accuracy of Clinical Records,” revised on 4/2020, indicated “…Clinical records for each hospice patient must be complete, accurate, legible, and promptly updated…A. Documentation must be made contemporaneously with the care delivered-ideally at the point of care or within 24 hours…B. Electronic entries must reflect secure use authentication and time stamps…” Findings:1. A review of Patient 3’s admission record (a document that contains a summary of basic information about the patient) indicated Patient 3’s start of care (SOC) was on 8/5/24.A review of Patient 3’s “CTIs” (Certification of Terminal Illness - a document indicating that a patient has a prognosis of six months or less to live if the illness runs its normal course) dated 4/2/25 and 6/1/25 indicated the patient was certified for hospice services during the certification periods from 4/2/25 to 5/31/25 and 6/1/25 to 7/30/25.A review of the “POC/IDG (Plan of Care/Interdisciplinary Group – a document outlining the plan of care and physician orders as determined through collaborative discussions by the team responsible for the patient’s care) Review” dated 4/4/25, 4/18/25, 5/2/25, 5/16/25, 5/30/25, and 6/13/25 indicated the IDG meetings were conducted. The “Nursing” section indicated there were notes documented. However, there was no documented evidence to confirm the RN’s participation in the IDG meetings as evidenced by the absence of the RN’s signature.During a concurrent interview and clinical record review on 7/1/25 at 09:30 AM with the Chief Executive Officer (CEO), Patient 3’s “POC/IDG Review” dated 5/9/25, 5/16/25, 5/22/25, 5/29/25, and 6/5/25 were reviewed. The CEO verified there were missing signatures from the RN on the IDG meetings and confirmed attendance was only documented electronically in the POC/IDG Review forms. The CEO stated the RN must have forgotten to sign them electronically.A review of the hospice’s policy and procedure (P&P) titled “Interdisciplinary Group Meeting,” revised on 4/2020, indicated “…1. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor…”2. A review of Patient 4’s admission record indicated Patient 4’s start of care was on 10/24/24.A review of Patient 4’s “CTIs” dated 3/13/25 and 5/22/25 indicated the patient was certified for hospice services during the certification periods from 3/24/25 to 5/22/25 and 5/23/25 to 7/21/25.A review of Patient 4’s “Visit Note RN” dated 3/27/25 indicated the RN documented that the patient reported a generalized body pain level of “2.” The narrative section of the form indicated the RN documented that the patient reported a pain level of “1” which was inconsistent. A review of Patient 4’s “Visit Note RN” dated 6/19/25 indicated the RN documented that the patient reported pain level of “3” to both knees. The narrative section of the form indicated the RN documented that the patient reported a pain level of “1” which was inconsistent. During a concurrent interview and clinical record review on 7/1/25 at 08:44 AM with the CEO, Patient 4’s “Visit Note RN” dated 3/27/25 and 6/19/25 were reviewed. The CEO verified the documentation of the pain levels was inconsistent.A review of the hospice’s P&P titled “Completion and Accuracy of Clinical Records,” revised on 4/2020, indicated “…Clinical records for each hospice patient must be complete, accurate, legible, and promptly updated…”3. A review of Patient 5’s admission record indicated Patient 5’s start of care was on 4/18/25.A review of Patient 5’s “CTI” (Certification of Terminal Illness - a document indicating that a patient has a prognosis of six months or less to live if the illness runs its normal course) dated 4/18/25 indicated the patient was certified for hospice services during the certification period from 4/18/25 to 6/16/25.A review of Patient 5’s “Comprehensive Nursing Assessment” dated 4/18/25 indicated the RN visited the patient on this day. A review of the signature section indicated the form was electronically signed by a different RN on 6/24/25, approximately two months after the visit was conducted.A review of Patient 5’s “Visit Note LVN” dated 4/25/25 indicated the LVN visited the patient on this day. A review of the signature section indicated the form was signed on behalf of the LVN by the RN on 6/25/25, two months after the visit was conducted.During a concurrent interview and clinical record review on 7/1/25 at 08:52 AM with the CEO, Patient 5’s “Comprehensive Nursing Assessment” dated 4/18/25 and “Visit Note LVN” dated 4/25/25 were reviewed. The CEO verified the findings. The CEO stated all notes should be completed and signed as soon as possible, but no more than three days from the visit date. The CEO stated the staff collaborated and agreed to sign the forms on behalf of each other, but that the person who completed the visit should be the one signing the document.”

“Based on record review and interview, the hospice failed to ensure the discharge summary was sent to the physician for two of 14 sampled patients (Patient 13 and 14). This failure had the potential of not providing the necessary patient information for aftercare. 1. A review of Patient 13’s closed admission record (a document that contains a summary of basic information about the patient) indicated the start of care was 3/18/25. The patient was certified for hospice services during the certification period from 3/18/25 to 5/16/25. A review of the Discharge Summary dated 4/25/25, indicated the patient revoked hospice to pursue other treatment options.However, further review of the clinical record indicated no documented evidence the discharge summary was sent to the physician.During a concurrent interview and clinical record review on 7/1/25 at 12:30 PM, with the Office Manager (OM), Patient 13’s Discharge Summary was reviewed. The OM stated when a patient is discharged, they send the discharge summary, physicians orders, the plan of care, and medication list to the physician. When asked for documentation to show the hospice had sent the summary to the attending physician, the OM was unable to provide evidence of the discharge summary being sent to the physician. The OM verified and acknowledged the findings.2. A review of Patient 14’s closed admission record indicated the SOC was 3/10/25. The patient was certified for hospice services during the certification period from 3/18/25 to 5/16/25. A review of Patient 14’s Discharge Summary dated 6/10/25, indicated the patient revoked hospice services to explore additional treatment options. However, further review of the clinical record indicated no documented evidence the discharge summary was sent to the physician.During a concurrent interview and record review on 7/1/25 at 1:30 PM with the Office Manager (OM), Patient 14’s Discharge Summary dated 6/10/25 was reviewed. The OM was unable to show documented evidence the Discharge Summary was sent to the attending physician. OM verified and acknowledged the findings.”