Golden Time Hospice, Inc.

“Based on interview, observation, and record review, the Hospice Agency (HA) failed to meet the Condition of Participation for Initial and Comprehensive Assessment of Patient as follows: 1. The HA failed to ensure the interdisciplinary group (IDG – a Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians) completed and documented the initial comprehensive assessment no later than 5 calendar days after hospice election for one of fourteen sample patients (Patient 9). (Refer to L523). 2. The Hospice Agency (HA) failed to review all medications the patients are taking and update the medication profiles with the currently used medications for three of fourteen sample selected patients (Patient 1, Patient 8 and Patient 9). (Refer to L 530). 3. Hospice Agency (HA) failed to ensure hospice patient’s identified need for spiritual counseling was provided as requested by the patient’s family member for one of 14 sample patients (Patient 8). (Refer to L532). 4. The HA failed to ensure the interdisciplinary group (IDG) met and updated the comprehensive assessment at least every 15 days for three out of 14 sample selected patients (Patient 1, Patient 8, and Patient 11). (Refer to L533). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with Federal regulations for Initial & Comprehensive Assessment of Patient to ensure highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.”

“Based on interview and record review, the Hospice Agency (HA) failed to meet the Condition of Participation for Interdisciplinary group, Care planning, Coordination of services as follows: 1. The HA failed to ensure two of 14 sample patients (Patient 1 and Patient 12) treatments for the wounds were included in the plan of care. (Refer to L549). 2. The HA failed to ensure all care services furnished, followed individualized Plan of Care (POC - an individualize care plan, indicating what interventions are needed for patient care) established be the interdisciplinary group (IDG – Registered Nurse, Physician, Medical Social Worker, and Chaplain) for two of 14 sampled patients (Patient 1 and Patient 11). (Refer to L555). 3. The HA failed to ensure three out of 14 sampled patients (Patient 1, Patient 8, and Patient 9) care giver be provided with the patient’s Plan of Care (POC - an individualized care plan, indicating what interventions are needed for patient care) which provided information on the services/care being provided by the HA. (Refer to L558). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with Federal regulations for Interdisciplinary group, care planning, and coordination of services to ensure the highest quality of care are provided to patients certified to receive the hospice benefits.”

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation on Clinical Records was met as follows: 1. The HA failed to ensure clinical records for one of 14 sample patients (Patient 11) included an updated comprehensive assessment. (Refer to 672). 2. The HA failed to ensure the clinical records for two of 14 sample patients (Patient 11 and Patient 12) included a Recertification of terminal illness. (Refer to L676). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients’ clinical records contained the completed and accurate hospice patient information.”

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – a Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians) completed and documented the initial comprehensive assessment no later than 5 calendar days after hospice election for one of fourteen sample patients (Patient 9). This deficient practice had the potential to result in the delay in identifying the hospice patient’s care needs and delay in the development of these needs in the plan of care. During a record review of Patient 9’s medical record form titled “Personal Information” indicated a start of care date of 8/1/2025 with a primary diagnosis of malignant neoplasm of colon (colon cancer).During a record review of Patient 9’s medical record form titled “POC (plan of care) Summary” dated as of 8/11/2025, indicated “MSW (Medical Social Worker): initial assessment within 5 days of admission for psychosocial needs/emotional support for patient/family/caregiver.”During a record review of Patient 9’s medical record form titled “Current Treatment/Medication/DME List” undated, indicated “MSW (Medical Social Worker): initial assessment within 5 days of admission for psychosocial needs/emotional support for patient/family/caregiver.”During a record review of Patient 9’s medical record form titled “POC (plan of care)/IDG (interdisciplinary group) Review” dated 8/1/2025, indicated under section “psychosocial – MSW (Medical Social Worker) was informed and will follow up. The POC/IDG Review did not indicate it was signed by a Medical Social Worker (MSW).During a record review of Patient 9’s Electronic Medical Record (EMR) section titled “History of Psychosocial Assessment” indicated there was one entry made on 8/3/2025 with a red “X” under “status”. During a record review of Patient 9’s medical record form titled “Psychosocial Assessment” dated 8/3/2025, did not indicate it was signed by the author. During a concurrent interview and record review on 8/13/2025 at 11:38 a.m. with the Administrator/Director of Patient Care Services (DPCS) of Patient 9’s Electronic Medical Record (EMR), the DPCS stated there was one entry made for Patient 9’s History of Psychosocial Assessment dated 8/3/2025. The DPCS stated the red “X” under the status section indicated the note was not complete or the author did not sign the note. The DPCS stated that patient’s psychosocial assessment should be completed within 5 days of admission. The DPCS stated that a psychosocial assessment was important to identify patients’ frustration, emotions, financial status, and their living conditions. During a record review of the agency’s form titled “IDG (interdisciplinary group) Care Planning Process” revised 2/2021, indicated “The care of plan specifies the care and services necessary to meet the patient and family specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions.”During a record review of the agency’s form titled “initial Assessment/Comprehensive Assessment” revised 2/2021, indicated “The hospice IDG, in consultation with the patients attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after patients’ election of hospice care.””

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to review all medications the patients are taking and update the medication profiles with the currently used medications for three of fourteen sample selected patients (Patient 1, Patient 8 and Patient 9). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. 1. During record review of Patient 1’s Personal Information sheet indicated a start of care date on 6/10/2024, with a terminal diagnosis of heart failure (when the heart cannot pump oxygen and blood effectively). Patient 1 residence was at the Board and Care facility.1a. During a concurrent observation, interview, and record review on 8/12/2025, at 10:05 a.m., the Case Manager (CM 1) reviewed Patient 1’s medications being taken, using the record titled Current treatment/Medication/DME form. The following medications were not found at Patient 1’s residence:Bisacodyl (stool softener) 10 mg (mg-milligram, unit of measurement). CM 1 stated medication was refilled on 8/11/25.Cranberry Concentrate soft gel (supplement). CM 1 stated medication was refilled on 8/11/25.Tramadol Hydrochloride (pain reliever) 50 mg. Zofran (for nausea) 8 mg tablet. CM 1 stated medication was refilled on 8/11/25.The following medications had the wrong dose listed and/or instructions on the medication record:Docusate Sodium (or constipation) label indicated 100 mg capsule, to take 1 capsule in the morning and 1 capsule in the evening as needed. The record indicated 250 mg capsule once a day as needed for constipation.Vitamin B 12 (supplement). The medication label indicated Super B-complex, with no dosage indicated. The label on the bottle indicated the capsule contained different supplements, each with their own dosages. The record indicated Vitamin B 12 dosage of 1000 mcg (mcg-micrograms, unit of measurement).Vitamin C (supplement). The medication label indicated 500 mg. The record indicated a dosage of 1000 mg.1b. During a concurrent observation, interview, and record review on 8/12/2025, at 10:05 a.m., CM 1 reviewed Patient 1’s medications being taken, using the record titled Current treatment/Medication/DME form. The medication Seroquel (controls symptoms of mental illness) 25 mg tablet medication bottle was empty at Patient 1’s residence. CM 1 stated medication was refilled on 8/11/25. Further review of the record indicated the medication was to be taken in the morning as needed. The medication record indicated a frequency of every morning. CM 1 stated she did not remember when the medication schedule changed to as needed.CM 1 stated the nurse should check the medications and update the medication record at least every 2 weeks. The importance of this is to prevent medication errors. Medication errors can cause deaths.1c. During a concurrent observation, interview, and record review on 8/12/2025, at 10:05 a.m., CM 1 reviewed Patient 1’s medications being taken, using the record titled Current treatment/Medication/DME form. The medication Lorazepam (for anxiety) 0.5 mg tablet was not in Patient 1’s residence. CM 1 stated medication was refilled on 8/11/25.During an interview on 8/12/2025, at 10:20 a.m., Patient 1’s caregiver (CG 2) stated the last time Patient 1 took the medication was in July 2025. CG 2 stated there was no medication administration records.During an interview on 8/13/2025, at 10:15 a.m., CM 1 stated CG2 had found the medication. CM 1 stated the last refill obtained for this medication was on 7/22/2025. CM 1 stated the medication was not present during the medication review process on 8/12/2025.During a concurrent interview and record review on 8/13/2025, at 11:55 a.m., the Administrator Designee (AD) reviewed Patient 1’s pharmacy delivery receipt, titled Waybil. The AD stated Lorazepam 0.5 mg tablet, a quantity of 30 tablets was delivered to Patient 1’s residence on 7/22/2025.During an interview on 8/14/2025, at 11:11 a.m., DPCS stated Lorazepam was a controlled substance. If the medication was delivered on 7/22/2025, Patient 1 should have run out of the medication by 8/22/2025. The DPCS stated she was concerned the medication was not present during the review on 8/12/2025, and she needed to investigate to see what happened to ensure the medication was not being taken by somebody else. During an interview on 8/14/2025, at 11:11 a.m., the Administrator/Director of Patient Care Services (DPCS) stated she talked to caregivers about medications. The DPCS stated the last time she reviewed medication administration records at Patient 1’s board and care facility (BC) was in March 2025. The DPCS stated the BC facility sometimes had medication administration record and sometimes they did not have it. The DPCS stated the importance of reviewing records at the BC was because she could not depend on words alone. To make sure patient was not over or under medicated. Dosages and medications affect the condition of the patient; that is why medications needed to be monitored. 2. During a record review of Patient 8’s medical record form titled “Personal Information” indicated a start of care date of 9/1/2024 with a primary diagnosis of Alzheimer’s disease (progressive brain loss resulting in forgetfulness). During a record review of Patient 8’s medical record form titled “POC (plan of care) Summary” dated as of 8/11/2025, indicated Patient 8 was prescribed Albuterol (medication for shortness of breath) and Atropine (medication for the treatment of excessive secretions), each to be used every four hours as needed. During a record review of Patient 8’s medical record form titled “Current Treatment/Medication/DME List” undated, indicated Patient 8 was prescribed Albuterol (medication for shortness of breath) and Atropine (medication for the treatment of excessive secretions), each to be used every four hours as needed. During a concurrent observation and interview on 8/12/2025 at 12 p.m. with the Administrator/Director of Patient Care Services (DPCS) at Patient 8’s home, the DPCS conducted a home visit but did not include medication reconciliation until requested to. The DPCS requested Patient 8’s home staff to provide all Patient 8’s medications. During a concurrent observation, interview, and record review on 8/12/2025 at 12 p.m. with the DPCS of Patient 8’s medication list and medications, Patient 8’s medications were placed inside a plastic container. Three, 2 ml (milliliters) small bottles were noted inside Patient 8’s medication container. The three bottles were labeled “Atropine 1.5% suspension, and had different expiration dates, 10/2/2025, 11/6/2025, and 12/12/2025. The DPCS stated the Atropine bottles should be labeled with Patient 8’s name, frequency, and dosage. The DPCS stated if given improperly, Patient 8’s heart rate can increase causing a medication error. The DPCS or Patient 8’s home staff were unable to locate Patient 8’s Albuterol medication. 3. During a record review of Patient 9’s medical record form titled “Personal Information” indicated a start of care date of 8/1/2025 with a primary diagnosis of malignant neoplasm of colon (colon cancer).During a record review of Patient 9’s medical record form titled “POC (plan of care) Summary” dated as of 8/11/2025, indicated Patient 9 was prescribed Albuterol (medication for shortness of breath) every four hours as needed and Midodrine (medication to increase blood pressure) to be taken three times a day as needed. During a record review of Patient 9’s medical record form titled “Current Treatment/Medication/DME List” undated, indicated Patient 9 was prescribed Albuterol (medication for shortness of breath) every four hours as needed and Midodrine (medication to increase blood pressure) to be taken three times a day as needed.During a concurrent observation and interview on 8/12/2025 at 12 p.m. with the DPCS at Patient 9’s home, the DPCS conducted a home visit but did not include medication reconciliation until requested to. The DPCS requested Patient 9’s home staff to provide all Patient 9’s medications. During a concurrent observation, interview, and record review on 8/12/2025 at 12:30 p.m. with the DPCS of Patient 9’s medication list and medications, Patient 9’s medications were placed inside a plastic container. Patient 9’s Midodrine label stated to give one tablet by mouth three times per day. The DPCS stated that even though the label did not state to give Midodrine as needed, it did have indications to hold medicine if systolic blood pressure was above 120. The DPCS stated that the medication label should match what was written on Patient 9’s hospice medication profile to ensure patients name, dosage, time, and route to prevent a medication error. The DPCS stated if Patient 9 were to receive Midodrine three times per day, as the label indicated, Patient 9’s blood pressure would be high, and Patient 9 has a history of having DVTs (dep vein thrombosis – blood clot in veins). The DPCS or Patient 9’s home staff were unable to locate Patient 9’s Albuterol medication.During an interview on 8/12/2025 at 12:40 p.m. with the DPCS, the DPCS stated that patients’ medications receive a “full medication reconciliation” during their admission and readmission visits. The DPCS stated a full medication reconciliation included, gathering all their medications and going one by one matching them with the records. The DPCS stated all patients should have their medications reconciled every Skilled Nurse (SN) visit to ensure patients receive the right medication intended for their needs to be able to manage their signs and symptoms. During a record review of agency’s form titled “Medication Reconciliation” revised 6/2019, indicated “Hospice will reconcile patients’ medications at time of admission and an ongoing basis. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication.””

“Based on interview and record review the Hospice Agency (HA) failed to ensure hospice patient’s identified need for spiritual counseling was provided as requested by the patient’s family member for one of 14 sample patients (Patient 8).This failure had the potential to affect the patient’s family member’s abilities to cope with the patient’s terminal illness and or death. During a record review of Patient 8’s medical record form titled “Personal Information” indicated a start of care date of 9/1/2024 with a primary diagnosis of Alzheimer’s disease (progressive brain loss resulting in forgetfulness). During a record review of Patient 8’s medical record form titled “POC (plan of care) Summary” dated as of 8/11/2025, indicated an order with a start date of 9/18/2024 and no stop date that read “Per family request, SC (Spiritual Counselor) visit in person this month and follow up once a month….”. The POC Summary also indicated “MSW 1 per month – initial assessment, monthly, then every recertification period.”During a record review of Patient 8’s medical record form titled “Visit Note SC” dated 9/19/2024, indicated Patient 8’s wife/caregiver (CG1) requested monthly SC visits. During a record review of Patient 8’s Electronic Medical Record (EMR) on 8/11/2025 at 12:49 p.m., Patient 8’s EMR indicated there was one SC note documented on 9/2/2024.During a record review of Patient 8’s medical record form titled “Communication Log” undated, indicated that on 9/17/2024, Patient 8’s wife (CG1) accepted a visit from the Chaplain (SC – Spiritual Counselor) for 9/19/2024. The Communication Log also indicated the SC sent CG1 a note expressing an enjoyable visit on 9/19/2024. During a concurrent interview and record review on 8/13/2025 at 10:30 a.m., with the DPCS of Patient 8’s EMR, the DPCS stated that during Patient 8’s initial Spiritual Counselor (SC) assessment on 9/2/2024, Patient 8’s wife/caregiver (CG1) refused SC services. The DPCS stated that on 9/19/2024, CG1 received SC services and requested monthly visits. The DPCS stated that for the last five of Patient 8’s comprehensive nursing recertification assessment, the nurse did not refer Patient 8 for SC or MSW (Medical Social Worker) services, which indicates “we did not provide the services”. The DPCS stated the HA offers SC services to every patient during every recertification period. The DPCS stated that SC services are important because during the end stages of life the patients look for their creator, God.”

“Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG) met and update the comprehensive assessment at least every 15 days for three out of 14 sample selected patients (Patient 1, Patient 8, and Patient 11). This deficient practice had the potential for patients’ progress toward desired outcomes, including their responses to care will not be identified causing delay of treatment, intervention, update of the plan of care, and management of needs of the terminally ill patients. 1. During record review of Patient 1’s Personal Information sheet indicated a start of care date on 6/10/2024, with a terminal diagnosis of heart failure (when the heart cannot pump oxygen and blood effectively). During an observation of the home visit on 8/12/2025, at 9:50 a.m., Case Manager 1 (CM 1), provided wound care to Patient 1’s mid buttocks area (sacrum). CM 2 stated Patient 1 had a stage 2 wound (loss of skin affecting the dermis and epidermis layers of the skin). During the wound care, CM 1 did not perform the complete assessment of the wound that included measurements, size, color, drainage, odor, and status of the wound (improving or worsening).During an interview on 8/14/2025, at 11:40 a.m., the Administrator/Director of Patient Care Services (DPCS) stated a complete wound assessment included: level of wound, presence of infection, type of wound, how long it has been, presence of pain, presence of discharge, wound bed, color, size, odors, what relieves the pain, and wound measurements. The DPCS stated the wound measurements were required when the wound was stage 2 or more. The wound should be measured at least every recertification period. DPCS recommended for the wound to be measured every visit. The DPCS stated nurses were expected to monitor the wound every visit. Monitoring meant looking at the wound, examine it and check all the factors are getting better or worse. If the wound was smaller, and the wound discharge was less, that meant you don’t do a full assessment. If wound was getting worse, we needed to change the plan of care to make sure the wound healed.During a concurrent interview and record review on 8/14/2025, at 11:44 a.m., the DPCS reviewed Patient 1’s record titled, Re-Cert Assessment, dated 6/2/2025. The DPCS stated this was the recertification assessment for period 6/5/2025 to 8/3/2025. The record indicated the presence of a stage 2 wound on the right and left buttocks, but there was no complete wound assessment. The DPCS stated the wound assessment was missing elements including measurements, size, color, drainage, odor, and status of the wound (improving or worsening).During a concurrent interview and record review on 8/14/2025, at 11:52 a.m., the DPCS reviewed Patient 1’s record titled, Visit Note RN dated 6/9/2025. The record did not indicate a wound assessment. The DPCS stated without documentation, the care team did not know if the wound was getting better or worse.During a concurrent interview and record review on 8/14/2025, at 11:54 a.m., the DPCS reviewed Patient 1’s record titled, Visit Note RN dated 6/19/2025. The record did not indicate a wound assessment. The DPCS stated there was no wound assessment for Patient 1’s stage 2 wound.During a concurrent interview and record review on 8/14/2025, at 11:55 a.m., the DPCS reviewed Patient 1’s record titled, Visit Note RN dated 6/26/2025. The record did not indicate a wound assessment. The DPCS stated there was no wound assessment for Patient 1’s stage 2 wound.During a concurrent interview and record review on 8/14/2025, at 11:56 a.m., the DPCS reviewed Patient 1’s record titled, Visit Note RN dated 7/3/2025. The record did not indicate a wound assessment. The DPCS stated there was no wound assessment for Patient 1’s stage 2 wound.During a concurrent interview and record review on 8/14/2025, at 11:58 a.m., the DPCS reviewed Patient 1’s record titled, Visit Note RN dated 7/10/2025. The record did not indicate a wound assessment. The DPCS stated there was no wound assessment for Patient 1’s stage 2 wound.During a concurrent interview and record review on 8/14/2025, at 12:00 p.m., the DPCS reviewed Patient 1’s record titled, Visit Note RN dated 7/17/2025. The record did not indicate a wound assessment. The DPCS stated there was no wound assessment for Patient 1’s stage 2 wound.During a concurrent interview and record review on 8/14/2025, at 12:01 p.m., the DPCS reviewed Patient 1’s record titled, Visit Note RN dated 7/24/2025. The record did not indicate a complete wound assessment. The DPCS stated the record only indicated mild. There were no other indications of the wound.During a concurrent interview and record review on 8/14/2025, at 12:02 p.m., the DPCS reviewed Patient 1’s record titled, Re-Cert Assessment, dated 7/31/2025. The DPCS stated this was the recertification assessment for period 8/4/2025 to 10/2/2025. The record indicated the presence of a stage 2 wound on the right and left buttocks, but there was no complete wound assessment. The DPCS stated the wound was not completely assessed. The DPCS stated the last time the wound was completely assessed was on 3/30/2025. The DPCS continued to review Patient 1’s records titled, Visit Note RN for visit dates 7/24/2025 and 8/7/2025. The DPCS stated there was no wound assessment for these dates. The DPCS stated due to the lack of wound assessments, the plan of care was not updated with patient changes. Patient may experience pain, discomfort. If wound gets worse, wound can get infected. Infection accelerates the death process. 2a. During a record review of Patient 8’s medical record form titled “Personal Information” indicated a start of care date of 9/1/2024 with a primary diagnosis of Alzheimer’s disease (progressive brain loss resulting in forgetfulness). During a record review of Patient 8’s medical record form titled “POC (plan of care)/IDG (interdisciplinary group) Review” dated 8/5/2025, indicated the physician discussion section was left blank. The POC/IDG Review form did not indicate it was signed by a Medical Social Worker (MSW).During a concurrent interview and record review on 8/13/2025 at 10:30 a.m. with the Administrator/Director of Patient Care Services (DPCS) of Patient 8’s Electronic Medical Record (EMR) form titled POC/IDG Review dated 8/5/2025, the DPCS stated the physician discussion section was left blank. The DPCS stated that the physician’s responsibility was to review Patient 8’s record to be able to guide Patient 8’s care. During a concurrent interview and record review on 8/13/2025 at 10:30 a.m. with the DPCS of Patient 8’s EMR form titled POC/IDG Review dated 8/5/2025, the DPCS stated she did not attend the IDG meeting for on 8/5/2025 due to not being available. The DPCS stated she signed Patient 8’s IDG meeting at a later date and was not able to recall when she signed. The DPCS stated she did not change the date on their EMR system when she signed and did not indicate it was a late entry. 2b. During a record review of Patient 8’s medical record form titled “POC (plan of care) Summary” dated as of 8/11/2025, indicated an order with a start date of 9/18/2024 and no stop date that read “Per family request, SC (Spiritual Counselor) visit in person this month and follow up once a month….”. The POC Summary also indicated “MSW 1 per month – initial assessment, monthly, then every recertification period.”During a record review of Patient 8’s medical record form titled “Visit Note SC” dated 9/19/2024, indicated Patient 8’s wife/caregiver (CG1) requested monthly SC visits. During a record review of Patient 8’s Electronic Medical Record (EMR) on 8/11/2025 at 12:49 p.m., Patient 8’s EMR indicated there was one SC note documented on 9/2/2024.During a record review of Patient 8’s medical record form titled “Communication Log” undated, indicated that on 9/17/2024, Patient 8’s wife (CG1) accepted a visit from the Chaplain (SC – Spiritual Counselor) for 9/19/2024. The Communication Log also indicated the SC sent CG1 a note expressing an enjoyable visit on 9/19/2024. During a concurrent interview and record review on 8/13/2025 at 10:30 a.m. with the DPCS of Patient 8’s EMR, the DPCS stated that during Patient 8’s initial Spiritual Counselor (SC) assessment on 9/2/2024, Patient 8’s wife/caregiver (CG1) refused SC services. The DPCS stated that on 9/19/2024, CG1 received SC services and requested monthly visits. The DPCS stated that for the last five of Patient 8’s comprehensive nursing recertification assessment, the nurse did not refer Patient 8 for SC or MSW (Medical Social Worker) services, which indicates “we did not provide the services”. The DPCS stated the HA offers SC services to every patient during every recertification period. The DPCS stated that SC services are important because during the end stages of life the patients look for their creator, God. 3. During a record review of Patient 11’s medical record form titled “Personal Information” indicated a start of care date of 4/18/2024 with a primary diagnosis of carcinoma in situ of prostate (prostate cancer). During a record review of Patient 11’s medical record form titled “POC/IDG Review” dated 8/5/2025, did not indicate it was signed by an MSW.During an interview on 8/13/2025 at 10:30 a.m. with the DPCS, stated the HA hold IDG meetings every 14 days to discuss patients’ status. The DPCS stated during the meeting the members (Registered Nurse (RN), Spiritual Counselor (SC), Medical Social Worker (MSW), and Physician (MD)) of the IDG sign in on the patients Electronic Medical Record (EMR). The DPCS stated each discipline fills out their indicated section to communicate patients updated status with the team. The DPCS stated, “It benefits the patients because our focus, purpose, goal is to provide physical, emotional, psychosocial, and spiritual. At the end of life, it is important not just to treat them as their physical body.” The DPCS stated that each discipline’s signature indicates their presence and participation. The DPCS stated when a member does not sign a patients IDG meeting it indicates the member forgot to sign, they were negligent, or they were not present for the meeting. During a record review of agency’s form titled “IDG (interdisciplinary group) Care Planning Process” revised 2/2021, indicated “All care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any), the patient or representative and the primary caregiver in accordance with the patient’s needs.””

“Based on observation, interview and record review the Hospice Agency (HA) failed to ensure two of 14 sample patients (Patient 1 and Patient 12) treatments for the wounds were included in the plan of care. This failure had the potential to result in missed treatments which had the possibility of worsening the patient’s health and status. During an interview on 8/14/2025, at 11:40 a.m., the Administrator/Director of Patient Care Services (DPCS) stated a complete wound assessment included: level of wound, presence of infection, type of wound, how long it has been, presence of pain, presence of discharge, wound bed, color, size, odors, what relieves the pain, and wound measurements. The DPCS stated the wound measurements were required when the wound was stage 2 or more. The wound should be measured at least every recertification period. DPCS recommended for the wound to be measured every visit. The DPCS stated nurses were expected to monitor the wound every visit. Monitoring meant looking at the wound, examine it and check all the factors are getting better or worse. If the wound was smaller, and the wound discharge was less, that meant you don’t do a full assessment. If wound was getting worse, we needed to change the plan of care to make sure the wound healed.1. During record review of Patient 1’s Personal Information sheet indicated a start of care date on 6/10/2024, with a terminal diagnosis of heart failure (when the heart cannot pump oxygen and blood effectively). During a record review of Patient 1’s record titled, POC (Plan of Care) Summary. Dated 8/11/2025, indicated a doctor’s order placed on 3/30/2025, for treatment to the Stage 2 pressure injury to the right and left buttocks. During a record review of Patient 1’s record titled, Plan of Care, dated 8/11/2025, did not include the treatment order prescribed by the doctor for Patient 1’s Stage 2 pressure injury to the right and left buttocks. 2. During a record review of Patient 12’s medical record form titled “Personal Information” indicated a start of care date of 12/14/2023 with a primary diagnosis of senile degeneration of brain (progressive memory loss). During a record review of Patient 12’s medical record form titled “Current Treatment /Medication/DME List” undated, indicated Patient 12 was prescribed treatments to bilateral stage II elbow with a start date of 6/2/2025 and stage II left buttocks with a start date of 6/23/2025. During a record review of Patient 12’s medical record form titled “Re-Cert Assessment” dated 6/2/2025, indicated Patient 12’s skin was assessed and found to have a pressure injury on left heel. The Re-Cert Assessment also indicated under the narrative section that Patient 12 also had a stage II on right and left elbows. During a record review of Patient 12’s medical record form titled “Skin Impairment Assessment” dated 6/2/2025, indicated Patient 12’s list of current skin impairment location was located on his (Patient 12) left and right lower leg, left heel, and right and left elbow.During a record review of Patient 12’s medical record form titled “Re-Cert Assessment” dated 8/4/2025, indicated Patient 12’s skin was assessed and found to have a pressure injury on left heel. The Re-Cert Assessment also indicated under the narrative section: “Skin: stage II left heel. Stage II right 2nd toe.During a record review of Patient 12’s medical record form titled “Skin Impairment Assessment” dated 8/4/2025, indicated Patient 12’s list of current skin impairment locations were located on his (Patient 12) left and right lower leg, and right toe.During a record review of Patient 12’s medical record form titled “Physician Orders” indicated that on 6/23/2025, there was an ordered placed for Patient 12 to treat his (Patient 12) stage II on left buttocks. The Physician Orders also indicated Patient 12 has wound treatments order for his (Patient 12) right posterior leg skin tear, left heel, right arm redness, left temporal, and skin tear on left leg. During a record review on Patient 12’s medical record form titled “POC (plan of care) / IDG (interdisciplinary group) Review” dated 8/5/2025, indicated there was one skin impairment care planned with an open date of 7/27/2025, for Patient 12’s stage II right second toe. Patient 12’s skin impairment did not list the goals or interventions required to assess and treat Patient 12’s stage II right second toe wound. During a record review on Patient 12’s medical record form titled “POC/ IDG Review” dated 8/14/2025, indicated there was one skin impairment care planned with an open date of 7/27/2025, for Patient 12’s stage II right second toe. Patient 12’s skin impairment did not list the goals or interventions required to assess and treat Patient 12’s stage II right second toe wound. During a record review of Patient 12’s medical record form titled “Visit Note RN (Registered Nurse)” dated 6/23/2025, indicated under the narrative section, “Stage II on left buttocks…”. During a record review of Patient 12’s medical record form titled “Visit Note RN” dated 7/14/2025, indicated “Skin has multiple wounds requiring daily wound care.”During a record review of Patient 12’s medical record form titled “Visit Note RN” dated 7/20/2025, indicated “Skin: patient continues to have various wounds and stages of healing. Newest wound on right toe. Left heel almost healed… bilateral elbows”.During a record review of Patient 12’s medical record form titled “Visit Note RN” dated 7/27/2025, indicated Patient 12’s wounds were located on his (Patient 12) second right toe, and left heel stage II.During a record review of Patient 12’s medical record form titled “Visit Note RN” dated 8/11/2025, indicated Patient 12’s wounds were located on his (Patient 12) second right toe, and left heel stage II.During a record review of Patient 12’s medical record form titled “Communication Log” undated, indicated the last communication note entry was made on 2/21/2025.During a record review of Patient 12’s medical record form titled “F2F (face to face) Visit Note” dated 8/2/2025, indicated Patient 12’s stage II sacral wound was treated. During a concurrent interview and record review on 8/14/2025 at 1:47 p.m. with the Administrator/Director of Patient Care Services (DPCS) of Patient 12’s Electronic Medical Record (EMR), the DPCS stated Patient 12’s EMR indicated he (Patient 12) had several wounds that did not have care plans developed. The DPCS stated Patient 12’s wound care plan was initiated on 7/27/2025, but that it was not complete because it lacked interventions and goals. The DPCS stated Patient 12’s other wounds did not have care plans. During a record review of agency’s form titled “IDG (interdisciplinary group) Care Planning Process” revised 2/2021, indicated “The care of plan specifies the care and services necessary to meet the patient and family specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions. An individualized written plan of care is developed for each patient. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments.” During a record review of agency’s form titled “Wound Assessment” undated, indicted “Wound assessments will be completed at admission, when new wounds are identified, and during each visit then a wound is present. All wound care will be provided according to evidence based practice, the patients individualized plan of care…”.”

“Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure all care services furnished, followed individualized Plan of Care (POC - an individualize care plan, indicating what interventions are needed for patient care) established be the interdisciplinary group (IDG – Registered Nurse, Physician, Medical Social Worker, and Chaplain) for two of 14 sampled patients (Patient 1 and Patient 11). This deficient practice resulted in the patient not receiving care/services from home visits and placed the patient at risk by not being provided with care/services when they needed. 1. During record review of Patient 1’s Personal Information sheet indicated a start of care date on 6/10/2024, with a terminal diagnosis of heart failure (when the heart cannot pump oxygen and blood effectively). During an observation of the home visit on 8/12/2025, at 9:50 a.m., Case Manager 1 (CM 1), provided wound care to Patient 1’s mid buttocks area (sacrum). CM 2 stated Patient 1 had a stage 2 wound (loss of skin affecting the dermis and epidermis layers of the skin). During the wound care, CM 1 did not measure the wound.During a record review of Patient 1’s record titled, Plan of Care, dated 8/11/2025, indicated in the Integumentary/Skin section to assess alteration in skin integrity every visit.During an interview on 8/14/2025, at 11:40 a.m., the Administrator/Director of Patient Care Services (DPCS) stated a complete wound assessment included: level of wound, presence of infection, type of wound, how long it has been, presence of pain, presence of discharge, wound bed, color, size, odors, what relieves the pain, and wound measurements. The DPCS stated the wound measurements were required when the wound was stage 2 or more. The wound should be measured at least every recertification period. However, the DPCS recommended for the wound to be measured every visit. The DPCS stated nurses were expected to monitor the wound every visit. Monitoring meant looking at the wound, examine it and check all the factors are getting better or worse. If the wound was smaller, and the wound discharge was less, that meant you don’t do a full assessment. If the wound was getting worse, we needed to change the plan of care to make sure the wound healed.During a concurrent interview and record review on 8/14/2025, at 11:44 a.m., the DPCS reviewed Patient 1’s record titled, Re-Cert Assessment, dated 6/2/2025. The DPCS stated this was the recertification assessment for period 6/5/2025 to 8/3/2025. The record indicated the presence of a stage 2 wound on the right and left buttocks, but there was no complete wound assessment. The DPCS stated the wound assessment was missing elements including measurements, size, color, drainage, odor, and status of the wound (improving or worsening).During a concurrent interview and record review on 8/14/2025, at 11:52 a.m., the DPCS reviewed Patient 1’s record titled, Visit Note RN dated 6/9/2025. The record did not indicate a wound assessment. The DPCS stated without documentation, the care team did not know if the wound was getting better or worse.During a concurrent interview and record review on 8/14/2025, at 11:54 a.m., the DPCS reviewed Patient 1’s record titled, Visit Note RN dated 6/19/2025. The record did not indicate a wound assessment. The DPCS stated there was no wound assessment for Patient 1’s stage 2 wound.During a concurrent interview and record review on 8/14/2025, at 11:55 a.m., the DPCS reviewed Patient 1’s record titled, Visit Note RN dated 6/26/2025. The record did not indicate a wound assessment. The DPCS stated there was no wound assessment for Patient 1’s stage 2 wound.During a concurrent interview and record review on 8/14/2025, at 11:56 a.m., the DPCS reviewed Patient 1’s record titled, Visit Note RN dated 7/3/2025. The record did not indicate a wound assessment. The DPCS stated there was no wound assessment for Patient 1’s stage 2 wound.During a concurrent interview and record review on 8/14/2025, at 11:58 a.m., the DPCS reviewed Patient 1’s record titled, Visit Note RN dated 7/10/2025. The record did not indicate a wound assessment. The DPCS stated there was no wound assessment for Patient 1’s stage 2 wound.During a concurrent interview and record review on 8/14/2025, at 12:00 p.m., the DPCS reviewed Patient 1’s record titled, Visit Note RN dated 7/17/2025. The record did not indicate a wound assessment. The DPCS stated there was no wound assessment for Patient 1’s stage 2 wound.During a concurrent interview and record review on 8/14/2025, at 12:01 p.m., the DPCS reviewed Patient 1’s record titled, Visit Note RN dated 7/24/2025. The record did not indicate a complete wound assessment. The DPCS stated the record only indicated mild. There were no other indications of the wound.During a concurrent interview and record review on 8/14/2025, at 12:02 p.m., the DPCS reviewed Patient 1’s record titled, Re-Cert Assessment, dated 7/31/2025. The DPCS stated this was the recertification assessment for period 8/4/2025 to 10/2/2025. The record indicated the presence of a stage 2 wound on the right and left buttocks, but there was no complete wound assessment. The DPCS stated the wound was not completely assessed. The DPCS stated the last time the wound was completely assessed was on 3/30/2025. The DPCS continued to review Patient 1’s records titled, Visit Note RN for visit dates 7/24/2025 and 8/7/2025. The DPCS stated there was no wound assessment for these dates. The DPCS stated due to the lack of wound assessments, the plan of care was not updated with patient changes. The HA loses the opportunity to provide better care to the patient. Patient may experience pain, discomfort. If wound gets worse, wound can get infected. Infection accelerates the death process. 1. During a record review of Patient 11’s medical record form titled “Personal Information” indicated a start of care date of 4/18/2024 with a primary diagnosis of carcinoma in situ of prostate (prostate cancer). During a record review of Patient 11’s medical record form titled “POC (Plan of Care) Summary” dated as of 8/11/2025, indicated Patient 11 was prescribed to receive Skilled Nurse (SN) visits once per week. During a record review of Patient 11’s medical record form titled “Visit Note RN” dated 8/13/2025, indicated the form and the author signature section were left blank. During a concurrent interview and record review on 8/14/2025 at 10:20 a.m., with the Administrator/Director of Patient Care Services (DPCS) of Patient 11’s Electronic Medical Record (EMR) the DPCS stated Patient 11’s SN visit frequency was once a week. The DPCS stated the last SN visit note was on 8/13/2025, but that note was left blank. The DPCS stated the last completed documented SN visit was on 7/31/2025. The DPCS stated that she (DPCS) was the one that conducted the SN visit during the week of 8/3/2025 to 8/9/2025, but that she (DPCS) forgot to document the visit. During a record review of agency’s form titled “IDG (interdisciplinary group) Care Planning Process” revised 2/2021, indicated “All care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any), the patient or representative and the primary caregiver in accordance with the patient’s needs.””

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure three out of 14 sampled patients (Patient 1, Patient 8, and Patient 9) caregivers were provided the patient’s Plan of Care (POC - an individualized care plan, indicating what interventions are needed for patient care) which provided information on the services/care being provided by the HA. This failure had the potential to result in placing the patients at risk for not receiving the services/care as indicated in their individualized POC. 1. During record review of Patient 1’s Personal Information sheet indicated a start of care date on 6/10/2024, with a terminal diagnosis of heart failure (when the heart cannot pump oxygen and blood effectively).During a concurrent observation, interview, and record review at the home visit on 8/12/2025, at 9:40 a.m., the Case Manager (CM 1) reviewed Patient 1’s HA binder. Inside the binder was the presence of a plan of care: the record was titled, POC, dated 8/11/2025. CM 1 stated “I know, I know”, when asked if this was the most recent plan of care provided. Continued review of the records indicated a document titled, POC, dated 9/26/2024. CM 1 stated this was the last time, prior to 8/11/2025, when the patient received a copy of the plan of care. 2. During a record review of Patient 8’s medical record form titled “Personal Information” indicated a start of care date of 9/1/2024 with a primary diagnosis of Alzheimer’s disease (progressive brain loss resulting in forgetfulness). During a concurrent interview and record review on 8/12/2025 at 11 a.m. with the Administrator/Director of Patient Care Services (DPCS) of Patient 8’s home hospice record, the DPCS stated that Patient 8’s plan of care with a recertification period starting on 6/23/2025, was provided to the patient and family/caregiver on 8/11/2025.During an observation on 8/12/2025 at 11 a.m., at Patient 8’s residence, Patient 8’s resides in a Board and Care (BC1), where there are 24-hour staff available for assistance. 3. During a record review of Patient 9’s medical record form titled “Personal Information” indicated a start of care date of 8/1/2025 with a primary diagnosis of malignant neoplasm of colon (colon cancer).During a concurrent interview and record review on 8/12/2025 at 10 a.m. with the DPCS of Patient 9’s home hospice record, the DPCS stated that Patient 9’s plan of care with a recertification period starting on 8/1/2025, was provided to the patient and family/caregiver on 8/11/2025.During an observation on 8/12/2025 at 10 a.m. at Patient 9’s residence, Patient 9’s resides in a BC1, where there are 24-hour staff available for assistance. During an interview on 8/14/2025 at 12:25 p.m. with the Administrator/Director of Patient Care Services (DPCS), the DPCS stated patients’ plans of care (POC) are used to describe patients’ issues, how to relieve those issues, patients’ responses, what nurses need to do, communicate, and re-evaluate. The DPCS stated that patient POCs also detail the equipment and supplies needed to relieve patients’ issues. The DPCS stated that the HA does not take patients POC to their home. The DPCS stated that it was important to provide patients and their caregivers with the patients POC to communicate the patients plan of care and to communicate their care and goals. During a record review of the agency’s form titled “IDG (interdisciplinary group) Care Planning Process” revised 2/2021, indicated “The RN (Registered Nurse) ensures that the plan of care is individualized, updated and relevant to the needs of patient/family by: Easing exchange of information among the IDG staff and patient/caregiver.” During a record review of the agency’s form titled “Coordination of Patient Care” revised 6/2019, indicated “Hospice has developed and maintains a system of communication and integration to: Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Coordination of Hospice’s internal resources includes Assuring all involved staff members are aware of patient’s IDG (interdisciplinary) plan of care.””

“Based on interview and record review, the Hospice Agency (HA) failed to ensure clinical records for one of 14 sample patients (Patient 11) included an updated comprehensive assessment. This failure had the potential to result in the lack of or missed coordination and continuity of care and services due to patients missing or incomplete clinical information. During a record review of Patient 11’s medical record form titled “Personal Information” indicated a start of care date of 4/18/2024 with a primary diagnosis of carcinoma in situ of prostate (prostate cancer). During a record review of Patient 11’s medical record form titled “Updated Assessment” dated 8/7/2025, indicated the form and the author signature section were left blank. During a record review of Patient 11’s medical record form titled “Visit Note RN” dated 8/13/2025, indicated the form and the author signature section were left blank. During a concurrent interview and record review on 8/14/2025 at 10:20 a.m., with the Administrator/Director of Patient Care Services (DPCS) of Patient 11’s Electronic Medical Record (EMR) the DPCS stated the last completed documented SN visit was on 7/31/2025. The DPCS stated that Patient 11 was an active patient on his (Patient 11) 8th recertification period which started on 8/11/2025. The DPCS stated Patient 11’s updated nursing comprehensive assessment was to be completed at each recertification period. The DPCS stated that Patient 11’s last documented nursing comprehensive assessment was documented on 6/11/2025. The DPCS stated it was important to complete a recertification assessment because there could be changes in the patient. The DPCS stated without a nursing recertification assessment the HA cannot provide the proper care for the patients’ needs. During a record review of agency’s form titled “IDG Care Planning Process” revised 2/2021, indicated “In order to assure that care provided is appropriately planned to meet each patient’s specific needs and problems, hospice will utilize data/information gathered during the comprehensive assessment, updates to the comprehensive assessment and reassessment…”.”

“Based on interview and record review the Hospice Agency (HA) failed to ensure the clinical records for two of 14 sample patients (Patient 11 and Patient 12) included a completed recertification assessment of the hospice patients’ terminal illness (CTI). This failure had the potential for lack of or missed coordination and continuity of care and services due to patients missing or incomplete clinical information. 1. During a record review of Patient 11’s medical record form titled “Personal Information” indicated a start of care date of 4/18/2024 with a primary diagnosis of carcinoma in situ of prostate (prostate cancer). During a record review of Patient 11’s medical record form titled “Updated Assessment” dated 8/7/2025, indicated the form and the author signature section were left blank. During a record review of Patient 11’s medical record form titled “Physician Certification for Hospice Benefit” dated from 8/11/2025 to 10/9/2025, indicated sections “RN (Registered Nurse) Assessment and Physician Narrative were left blank. The Physician Certification for Hospice Benefit form did not indicate it was signed by a physician. During a concurrent interview and record review on 8/14/2025 at 10:20 a.m., with the Administrator/Director of Patient Care Services (DPCS) of Patient 11’s Electronic Medical Record (EMR) the DPCS stated that Patient 11 was an active patient on his (Patient 11) 8th recertification period which started on 8/11/2025. The DPCS stated Patient 8’s current CTI dated from 8/11/2025 to 10/9/2025, was not filled out or signed by the physician. The DPCS stated that a physician’s involvement and signature on patients CTIs indicates the patient continues to be eligible for hospice services. The DPCS stated that if patient CTIs lack physicians’ signatures, the patient is not eligible for hospice services. 2. During a record review of Patient 12’s medical record form titled “Personal Information” indicated a start of care date of 12/14/2023 with a primary diagnosis of senile degeneration of brain (progressive memory loss). During a review on 8/11/2025 at 1:10 p.m., of Patient 12’s Electronic Medical Record (EMR) medical record form titled “F2F (face to face) Visit Notes List” indicate the last entry was made on 6/1/2025. During a record review of Patient 12’s medical record form titled “Physician Certification for Hospice Benefit” dated from 8/5/2025 to 10/3/2025, indicated the section Physician Narrative was left blank. The Physician Certification for Hospice Benefit form did not indicate it was signed by a physician. During a record review of agency’s form titled “Certification/Recertification of Terminal Illness, Brief Narrative, Statement and Face to Face Evaluations” revised 2/2021, indicated “In order to be eligible to elect hospice care under Medicare, a patient must be certified as being terminally ill. Hospice will obtain written certification of terminal illness for each of the periods… Recertification is completed no later than two (2) calendar days after the first day of each benefit period. A hospice physician or nurse practitioner (NP) must have a face-to-face encounter with every hospice patient prior to the patient’s third recertification and each subsequent recertification. A hospice physician or hospice nurse practitioner who performs the encounter must attest in writing that he or she had a face-to-face encounter with the patient, including the date of the encounter.””

“Upon patient record review, 6 of 14 (Patient #1, #2, #5, #6, #8, #9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1, #5, #8 Aide care plan has aspiration precautions documented, there are no interventions or goals regarding aspiration precautions on plan of care. Patient #1: The aide care plan has 02 therapy documented, there are no interventions or goals regarding oxygen needs on plan of care. Patient #2: There is no evidence of psychosocial problems, goals or interventions reflected on plan of care. Patient #6: The medical record contained documentation on admission identifying patient as a high risk for skin breakdown, there is no evidence of problems, goals or interventions regarding integumentary system on plan of care. Patient #9: The medical record contained documentation on admission identifying patient as a fall and aspiration risk, there are no problems, interventions or goals to address this risk on plan of care.”

“Upon patient record review, 6 of 14, (Patient #4, #6, #7, #8, #9, #10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #8: Medication order indicated to apply Nystatin to affected area BID without clear instruction for location of application. Corrected on site. Patient #4: Medication order indicated order for Miralax 17 gm oral, but did not include mixing instructions. Corrected on site. Patients #4, #6, #7, #8, #9, #10: Medication orders indicated oxygen PRN but did not include delivery method. Corrected on site”

“Upon patient record review, 5 of 15 (Patient #2, #3, #6, #7, #9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #2: Plan of care did not list following DME that was documented in nursing assessment: bed, walker, wheelchair, shower chair, commode. Patient #3: Plan of care did not list following DME that was documented in nursing assessment: bed, air mattress, wheel chair, shower chair, commode. Patient #6: Plan of care did not list following DME that was documented in nursing assessment: wheel chair, shower chair, Geri chair, Hoyer lift. Patient #7: Plan of care did not list following DME that was documented in nursing assessment: wheel chair. Patient #9: Plan of care did not list following DME that was documented in nursing assessment: oxygen concentrator, walker, wheel chair.”

“Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 Corrected on site. Agency was able to calculate cost savings for 2023 and 2024.”

“Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. Upon observation, there was no evidence the hospice that is using contract personnel for core services met the following exception: The hospice may use contracted personnel, if necessary, to supplement hospice personnel in order to meet the needs of patients under extraordinary or other non-routine circumstances. A hospice may also enter into a written arrangement with another Medicare certified hospice program for the provision of core services to supplement hospice personnel to meet the needs of patients. Circumstances under which a hospice may enter into a written arrangement for the provision of core services include: unanticipated periods of high patient loads, staffing shortages due to illness or other short-term temporary situations that interrupt patient care; and temporary travel of a patient outside of the hospice’s service area. During patient chart reviews, it was identified that the agency was using WoundPros for ongoing treatment of wounds for two patients. Upon further investigation, the agency stated that WoundPros is directly billing Medicare Part B, however there was no documentation to indicate the wounds were unrelated to the terminality of the patients. Also, the agency was unable to provide a contract written to outline responsibilities as required.”