Hospice of Oc, Inc.

“Based on interview and record review, the hospice failed to ensure the comprehensive assessment included the imminence of death for one of three sampled patients (Patient 3). This failure had the potential risk of not appropriately addressing the patient’s needs.Findings: Review of the hospice’s P&P titled Comprehensive Assessment revised 5/2024 showed during the comprehensive assessment, all baseline data and other relevant information will be documented in the patient’s clinical record, including imminence of death.Review of Patient 3’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 6/4/25. The patient was certified for hospice services during the certification periods from 6/4/25 to 9/1/25, 9/2/25 to 11/30/25, 12/1/25 to 1/29/26, 1/30/26 to 3/30/26, and 3/31/26 to 5/29/26. The patient was discharged on 5/17/26.Review of the initial comprehensive nursing assessment dated 6/4/25, showed RN 1 had assessed the patient’s communication and body system (head-to-toe).* However, the initial comprehensive assessment did not include the imminence of death for Patient 3.On 7/9/26 at 1010 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.”

“Based on interview and record review, the hospice failed to ensure the medication profile was reviewed to include all current medications for two of three sampled patients (Patients 2 and 3). This failure had the potential for the patients not receiving the appropriate care and necessary services that could negatively affect the patients’ well-being.Findings: The hospice’s P&P titled Medication Profile revised 5/2024 showed patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect the current medications and new medications.1. Review of Patient 2’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 4/22/26. The patient was certified for hospice services during the certification period from 4/22/26 to 6/20/26. The patient was discharged on 6/13/26.a. Review of the Nursing Updated Assessment dated 5/8/26, showed the patient had cancer-related tunnel wound. Documentation showed the surrounding skin was cleansed with normal saline. Documentation showed metronidazole (antibiotic) ointment was applied around wound opening for odor management.b. Review of the LVN Visit Note dated 5/22/26, showed the patient had recent history of throbbing pain on the head and had used CBD (cannabidiol, a non-psychoactive compound ) oil three times since returning from vacation.c. Review of RN 2’s Visit Note dated 6/9/26, showed the patient had mild constipation and the last bowel movement was 6/6/26. The family member gave the patient Miralax (laxative). Documentation showed the patient had a podiatrist visit and was prescribed Cipro (antibiotic) cream to the toes.* However, there was no documented evidence the medication profile was reviewed and updated to show the metronidazole, CBD, and Cipro.On 7/9/26 at 0914 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer stated the medication reconciliation should be done every visit. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.2. Review of Patient 3’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 6/4/25. The patient was certified for hospice services during the certification periods from 6/4/25 to 9/1/25, 9/2/25 to 11/30/25, 12/1/25 to 1/29/26, 1/30/26 to 3/30/26, and 3/31/26 to 5/29/26. The patient was discharged on 5/17/26.Review of the DPCS Designee Visit Note dated 4/9/26, showed a family member requested for an IV hydration due to concern for dehydration. The DPCS Designee carried out a new order for 0.9% sodium chloride (a type of IV fluid) at 60 ml per hour IV for a total of one liter.* However, there was no documented evidence the medication profile was reviewed and updated to show the abovementioned IV fluid.On 7/9/26 at 1010 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.”

“Based on interview and record review, the hospice failed to ensure the comprehensive assessment included the initial bereavement assessment to address the needs of the patient’s family and other individuals/PCG focusing on the social, religious, and cultural factors which may impact their ability to cope with patient’s death for one of three sampled patients (Patient 2). This failure had the potential of not addressing the bereavement needs of Patient 2.Findings: Review of the hospice’s P&P titled Bereavement Assessment revised 5/2024 showed on admission, the social worker or hospice registered nurse will complete a bereavement risk assessment. The hospice bereavement plan of care will be developed based on an initial assessment of the patient and family/caregiver needs, during course of care, and the time of the patient’s death as part of the comprehensive assessment.Review of Patient 2’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 4/22/26. The patient was certified for hospice services during the certification period from 4/22/26 to 6/20/26. The patient was discharged on 6/13/26.The Release of Information and Consent for Treatment dated 4/22/26, showed the family member authorized for hospice services.* However, there was no documented evidence an initial bereavement risk assessment was completed at the time of admission.On 7/9/26 at 0914 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.”

“Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments included the changes that occurred since the initial assessments, information on the patients’ progress, and reassessment of the patients’ responses for two of three sampled patients (Patients 2 and 3). This failure had the potential of not addressing the care needs for these patients.Findings: Review of the hospice’s P&P titled The Plan of Care revised 5/2024 showed the plan of care will be based on the initial comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than 15 days. This plan of care must be initiated at start of care.1. Review of Patient 2’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 4/22/26. The patient was certified for hospice services during the certification period from 4/22/26 to 6/20/26. The patient was discharged on 6/13/26.Review of RN 2’s Visit Note dated 5/15/26, showed the physician was notified of the patient’s itchiness in the forehead and top of the head. Documentation showed the family member was applying cortisone 1 % (anti-itch cream) regularly; however, the itching still occured on and off. Documentation showed would wait for the physician’s advice and would continue with cortisone mixed with vitamin A and D cream (skin protectant).Review of the POC/IDG Review dated 5/20/26, showed a new order dated 5/16/26, for hydroxyzine hydrochloride (antihistamine medication) 25 mg one tablet as needed for itching. However, there was no documented evidence the IDG had discussed and updated the comprehensive assessment to include the changes that had occurred regarding the patient’s itchiness in the forehead and top of the head.On 7/9/26 at 0914 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.2. Review of Patient 3’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 6/4/25. The patient was certified for hospice services during the certification periods from 6/4/25 to 9/1/25, 9/2/25 to 11/30/25, 12/1/25 to 1/29/26, 1/30/26 to 3/30/26, and 3/31/26 to 5/29/26. The patient was discharged on 5/17/26.a. Review of the DPCS Designee Visit Note dated 4/9/26, showed the family member requested for an IV hydration due to concern for dehydration. The DPCS Designee carried out a new order for 0.9% sodium chloride at 60 ml per hour via IV for a total of one liter.However, the POC/IDG review dated 4/22/26, showed no documented evidence the IDG discussed and updated the comprehensive assessment to include the changes that had occurred regarding the family member’s request for an IV hydration and a new order for 0.9% sodium chloride at 60 ml per hour IV for a total of one liter.b. Review of the Re-Cert Assessment dated 3/26/26, showed the DPCS Designee performed the comprehensive assessment.However, the Re-Cert Assessment was not updated as the section for imminently dying was blank.On 7/9/26 at 1010 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.”

“Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POCs for two of three sampled patients (Patients 2 and 3). This failure had the potential for not providing appropriate, consistent, and quality care to these patients.Findings: Review of the hospice’s P&P titled The Plan of Care revised 5/2024 showed the written plan of care will contain, but will not be limited to, which include among others:-Diagnosis-Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, and counseling-Detailed statement of scope and frequency of services-Drugs and treatments-Physician ordersIn addition to the plan of care, if a patient is accepted into the organization’s telemedicine program (if applicable), and the plan of care will incorporate elements of the telemedicine program. The telehealth plan of care will include the telehealth encounter frequency and how the patient will be monitored should there be a discontinuation of the telehealth program.Review of the hospice’s P&P titled Missed Visit revised 5/2024 showed a missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit.1. Review of Patient 2’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 4/22/26. The patient was certified for hospice services during the certification period from 4/22/26 to 6/20/26. The patient was discharged on 6/13/26.a. Review of Patient 2’s POC/IDG Review dated 4/22/26, showed an order for HA visits two per week for personal hygiene and ADL care.Review of the clinical records showed the HA had conducted one visit for Week 1 (4/22/26 to 4/25/26) and one visit for Week 3 (5/3/26 to 5/9/26). However, further review of the clinical record showed no documented evidence a physician was notified of the missed visit and there was no attempt to reschedule the visits for the above weeks.b. Review of Patient 2’s POC/IDG Review dated 5/20/26, showed an MSW one visit per month.Review of the MSW 2’s Visit Note dated 5/28/26, showed the MSW completed a monthly routine visit via telephone. However, there was no documented evidence the physician had ordered telehealth visits for the patient.In addition, the POC/IDG Review dated 5/20/26, showed SN visits two times per week and one PRN visit for symptom management.Review of the clinical record showed the SN had conducted one visit for Week 7 (5/31/26 to 6/6/26), instead of two visits as cited in the POC. Further review of the clinical record showed no documented evidence the physician was notified of the missed visit and there was no attempt to reschedule the visit for Week 7.c. Review of the Physician’s Order dated 4/23/26, showed an order for erythromycin (antibiotic) 0.5% ophthalmic solution ointment to be applied four times a day for seven days for the left eye infection. The ophthalmic ointment started on 4/23/26, with a stop date of 4/30/26.Review of the SN Visit Notes dated 5/1, 5/5, 5/19, and 5/29/26, showed erythromycin ophthalmic ointment was applied in the left eye. However, there was no documented evidence of the physician’s order to continue with the application of the ophthalmic ointment after 4/30/26.On 7/9/26 at 0914 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.2. Review of Patient 3’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 6/4/25. The patient was certified for hospice services during the certification periods from 6/4/25 to 9/1/25, 9/2/25 to 11/30/25, 12/1/25 to 1/29/26, 1/30/26 to 3/30/26, and 3/31/26 to 5/29/26. The patient was discharged on 5/17/26.Review of Patient 3’s POC/IDG Review dated 4/22 and 5/6/26, showed an order for HA visits two times per week.Review of the clinical record showed the HA did not conduct a visit during Week 6 (5/3/26 to 5/9/26) and Week 7 (5/10/26 to 5/16/26). In addition, further review of the clinical record showed no documented evidence the physician was notified of the missed visits and there was no attempt to reschedule the visits for Weeks 6 and 7.Furthermore, the POC/IDG Review dated 5/6/26, showed SN visit one time per week plus two PRN visits for pain and symptom management. Review of the SN missed visit note dated 5/14/26 showed the family had declined the visit for the day and the hospice IDG was updated. However, there was no documented evidence an attempt was made to reschedule the visit.On 7/9/26 at 1010 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.”

“Based on interview and record review, the hospice failed to ensure individualized care plans were developed for three of three sampled patients (Patients 1, 2, and 3). This failure had the potential to cause inconsistent delivery of care which could result in the decline or lack of improvement in the patients’ health condition.Findings: Review of the hospice’s P&P titled Plan of Care revised 5/2024 showed the written plan of care will contain, but not limited to, the following:-Diagnosis-Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, and counseling.-Reduction in risk-Nutritional requirements-Prognosis-Individualized interventions to assist with end-of-life care.-Statement of treatment goals and documentation of the progress of outcomes-Interdisciplinary group assessment of needs-Drugs and treatments (including allergies)1. Review of Patient 1’s closed clinical record was initiated on 7/7/26. The clinical record showed the SOC was 3/6/26. The patient was certified for hospice services during the certification period from 3/6/26 to 6/3/26. The patient was discharged on 4/13/26.Review of the POC/IDG Review dated 4/8/26, showed the following medications were ordered:-On 4/6/26, Eliquis (blood thinner) 5 mg tablet one tablet twice a day.-On 4/7/26, Creon (pancreatic enzyme replacement therapy) lipase 24,000 unit minimicrospheres delayed-release capsule one capsule taken with meal three times and as needed.However, there was no documented evidence the IDG had developed an individualized POC to address the use of Eliquis and Creon.On 7/9/26 at 0847 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.2. Review of Patient 2’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 4/22/26. The patient was certified for hospice services during the certification period from 4/22/26 to 6/20/26. The patient was discharged on 6/13/26.Review of the patient’s clinical record showed the Letter of Agreement for Provision of Temporary Core Hospice Services between the hospice and another hospice agency signed on 4/29/26, by both parties to cover hospice services that may be provided while Patient 2 was on out of state vacation from 5/7/26 to 5/14/26.The POC/IDG Review dated 5/6/26, showed IDG had discussed the planned vacation.However, there was no documented evidence the IDG had developed an individualized POC to address the patient’s upcoming out of state travel.Review of RN 2’s Visit Note dated 6/9/26, showed the patient had a podiatrist visit and was prescribed Cipro (antibiotic) cream to the toes.However, there was no documented evidence the IDG had developed an individualized POC to address the patient’s use of the antibiotic cream on the toes.On 7/9/26 at 0914 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.3. Review of Patient 3’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 6/4/25. The patient was certified for hospice services during the certification periods from 6/4/25 to 9/1/25, 9/2/25 to 11/30/25, 12/1/25 to 1/29/26, 1/30/26 to 3/30/26, and 3/31/26 to 5/29/26. The patient was discharged on 5/17/26.Review of the DPCS Designee Visit Note dated 4/9/26, showed a family member requested for an IV hydration due to concern for dehydration. Documentation showed the DPCS Designee carried out the new order for 0.9% sodium chloride at 60 ml per hour IV for a total of one liter.However, there was no documented evidence the IDG had developed an individualized POC to address the family member’s concern regarding hydration.On 7/9/26 at 1010 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.”

“Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for two of three sampled patients (Patients 1 and 2). This failure had the potential risk of not evaluating the POC and providing appropriate care and services to these patients.Findings: 1. Review of Patient 1’s closed clinical record was initiated on 7/726. The clinical record showed the SOC was 3/6/26. The patient was certified for hospice services during the certification period from 3/6/26 to 6/3/26. The patient was discharged on 4/13/26.The POC/IDG Review dated 3/11, 3/25, and 4/8/26, showed the patient’s identified problems with the established goals and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example, Patient 1 had a care plan addressing activity intolerance. Documentation showed one of the goals was for the patient to reduce activities that will cause fatigue and shortness of breath and performed activities as tolerated throughout hospice care. There was no documented evidence as to what were the activities that can cause fatigue and shortness of breath to the patient.On 7/9/26 at 0847 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.2. Review of Patient 2’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 4/22/26. The patient was certified for hospice services during the certification period from 4/22/26 to 6/20/26. The patient was discharged on 6/13/26.The POC/IDG Review dated 4/22, 5/6, 5/20, and 6/3/26, showed the patient’s identified problems with established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example, Patient 2 had a care plan addressing deficit in self-care. Documentation showed one of the goals was the caregiver will verbalize understanding of functional limitations as part of the terminal condition and disease process. There was no documented evidence as to what was the functional limitation of the patient the caregiver would verbalize and understand.On 7/9/26 at 0914 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.”

“Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patients’ POC no less frequently than every 15 calendar days for two of three sampled patients (Patients 2 and 3). This failure had the potential for not providing appropriate, consistent, and quality care to these patients.Findings: The hospice’s P&P titled Interdisciplinary Group Membership and Responsibilities revised 5/2024, showed the hospice interdisciplinary group membership includes at a minimum:A. PhysicianB. Registered NurseC. Social Worker/Marriage and Family Counselor/Mental Health TherapistD. Pastoral or other counselor(s)The hospice’s P&P titled Interdisciplinary Group Meeting revised 5/2024 showed the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires.1. Review of Patient 2’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 4/22/26. The patient was certified for hospice services during the certification period from 4/22/26 to 6/20/26. The patient was discharged on 6/13/26.Review of RN 2’s Visit Note dated 6/2/26, showed the patient reported losing balance and incurred a small scratch on the inner wrist and right arm.The POC/IDG Review dated 6/3/26, showed a care plan problem regarding environment/safety opened on 4/22/26, for potential for harm and increased risk related to fall due to poor coordination, weakness and unsteady gait.* However, there was no documented evidence the identified care plan problem was updated to include the loss of balance and injuries incurred by the patient on 6/2/26.On 7/9/26 at 0914 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.2. Review of Patient 3’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 6/4/25. The patient was certified for hospice services during the certification periods from 6/4/25 to 9/1/25, 9/2/25 to 11/30/25, 12/1/25 to 1/29/26, 1/30/26 to 3/30/26, and 3/31/26 to 5/29/26. The patient was discharged on 5/17/26.a. The POC/IDG Review dated 2/11, 2/25, 3/11, 3/25, 4/8, 4/22, and 5/6/26, showed the patient’s identified care plan problem included risk for infection related to indwelling urinary catheter as evidenced by prior UTIs. Intervention included monitoring catheter output, color, and odor at every RN visit. The identified problem was opened on 6/4/25.On 7/9/26 at 1010 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer. The QAPI Coordinator/Compliance Officer was asked if the patient still had an indwelling urinary catheter. The QAPI Coordinator/Compliance Officer stated the indwelling urinary catheter was removed in 2025.* However, the care plan for risk of infection related to indwelling urinary catheter was not updated for the patient.b. The POC/IDG Review dated 2/11, 2/25, 3/11, 3/25, 4/8, and 4/22/26, showed the patient’s identified care plan problem for a foul smelling, slightly bloody urine post indwelling urinary catheter removal. The identified problem was opened on 9/8/25.However, further review of the SN visit notes dated 2/11/, 2/12, 2/19, 2/26, 3/5, 3/12, 3/19, 4/2, 4/4, 4/6, 4/9, 4/16, and 4/23/26, showed the SN assessed the patient’s genitourinary reproductive and there were no issues reported.* There was no documented evidence the identified care plan problem was updated for the patient.c. The POC/IDG Review dated 2/11, 2/25, and 3/11/26, showed the patient’s identified care plan problem included recent unwitnessed fall at home on 11/17/25. The identified problem was opened on 11/20/25, with a target date of 11/30/25.* There was no documented evidence the identified care plan problem was updated for the patient.On 7/9/26 at 1010 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the findings.”

“Based on interview and record review, the hospice failed to ensure the revised POCs included the patient’s progress toward goals as specified in the POCs for two of three sampled patients (Patients 1 and 2). This failure had the potential of not identifying the care needs and providing necessary care and services for these patients.Findings: Review of the hospice’s P&P titled Interdisciplinary Group Membership and Responsibilities revised 5/2024, showed the interdisciplinary group will collaborate with the patient’s attending physician to develop an individualized written plan of care. The interdisciplinary group responsibilities included among others participation in the establishment of the plan of care for each patient admitted to the hospice service.1. Review of Patient 1’s closed clinical record was initiated on 7/726. The clinical record showed the SOC was 3/6/26. The patient was certified for hospice services during the certification period from 3/6/26 to 6/3/26. The patient was discharged on 4/13/26.The POC/IDG Review dated 3/11, 3/25 and 4/8/26 showed the patient’s identified care plan problems opened on the following dates and a target date of 6/3/26:-On 3/6/26, the care plan problems included deficit in self-care, activity intolerance, at risk for injury, potential for altered bowel elimination, potential for altered urinary elimination, at risk for impaired skin integrity, potential harm due to alteration in posture, potential for altered neurological status, potential for altered nutritional status, potential for pain, potential for altered respiratory status, and altered sleep pattern-On 3/9/26, the care plan problem included funeral planning-On 3/10/26, the care plan problem included spiritual distress * However, there was no documentation showing the patient’s progress toward outcome and goals specified in the plan of care.Moreover, the POC/IDG Review dated 4/22/26, showed the abovementioned plan of care with a status of pending. * However, further review of the clinical records showed Patient 1 was discharged on 4/13/26.On 7/9/26 at 0847 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.2. Review of Patient 2’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 4/22/26. The patient was certified for hospice services during the certification period from 4/22/26 to 6/20/26. The patient was discharged on 6/13/26.The POC/IDG Review dated 4/22, 5/6, 5/20 and 6/3/26, showed the patient’s identified care problem included a target date. The identified care problems were self-care deficit, new admission to hospice care in need of initial bereavement assessment, diabetes, potential for harm and increased risk related to fall, history of bowel obstruction, nasal wound, bed chair transfer status, generalized weakness, impaired balance, reduced appetite, new admission to hospice care in need of psychosocial assessment, dyspnea with exertion, somnolence, and new admission to hospice care in need of spiritual assessment. The identified problems showed a target date of 6/20/26.* However, there was no documentation showing the patient’s progress towards the outcome and goals specified in the plan of care.On 7/9/26 at 0914 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.”

“Based on interview and record review, the hospice failed to ensure the IDG had maintained responsibility for coordination and supervising the care and services related to CTIs, clinical records, RN supervisory visit, face to face encounter, and discharge summary for three of three sampled patients (Patients 1, 2, and 3). These failure had the potential of not addressing the care needs for these patients.Findings: The hospice’s P&P titled Interdisciplinary Group Membership and Responsibilities revised 5/2024 showed the interdisciplinary group responsibilities include but are not limited to the provision or supervision of hospice services.1. The hospice’s P&P titled Certification of Terminal Illness revised 5/2024, showed at the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient’s attending physician, if any, will certify the patient’s terminal illness. Both the attending physician’s and Medical Director’s signed and dated initial certification forms must be on file prior to billing the first claim.a. Review of Patient 1’s closed clinical record was initiated on 7/726. The clinical record showed the SOC was 3/6/26. The patient was certified for hospice services during the certification period from 3/6/26 to 6/3/26. The patient was discharged on 4/13/26.The Physician’s Certification for Hospice Benefit for Statement for the First 90-day period effective 3/6/26 to 6/3/26, showed the referring/attending physician’s attestation included this patient had a life expectancy of six months or less, if the terminal illness runs its normal course and had been encouraged to participate in the IDG Meetings and Plan of Care if chosen to follow the patient.* However, it did not include the physician’s signature and date.Documentation showed an instruction to “check one” on the section for “Patient Follow-Up.” The “Patient Follow-Up” included if the referring/attending physician “DO wish to be contacted directly should the need arise for a change in the current plan of care, if the hospice physician can be designated in the absence of the referring physician, to sign the death certificate, if the hospice physician can follow for pain and symptom management.” The “Patient Follow-Up” also included if the referring/attending physician “DO NOT want to follow the patient and/or sign the death certificate. * However, the boxes to mark with a check were both blank.On 7/9/26 at 0847 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the findings.b. Review of Patient 2’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 4/22/26. The patient was certified for hospice services during the certification period from 4/22/26 to 6/20/26. The patient was discharged on 6/13/26.The Physician’s Certification for Hospice Benefit for Re-Certification Statement for the next 60-day period effective 4/22/26 to 6/20/26, showed the referring/attending physician’s attestation that this patient had a life expectancy of six months or less, if the terminal illness runs its normal course and had been encouraged to participate in the IDG Meetings and Plan of Care if chosen to follow the patient.* However, it did not include the physician’s signature and date.Documentation showed an instruction to “check one” on the section for “Patient Follow-Up.” The “Patient Follow-Up” included if the referring/attending physician “DO wish to be contacted directly should the need arise for a change in the current plan of care, if the hospice physician can be designated in the absence of the referring physician, to sign the death certificate, if the hospice physician can follow for pain and symptom management.” The “Patient Follow-Up” also included if the referring/attending physician “DO NOT want to follow the patient and/or sign the death certificate. * However, the boxes to mark with a check were both blank.On 7/9/26 at 0914 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the findings.The IDG failed to maintain responsibility for supervising the care and services related to the completion of the CTIs.2. The hospice’s P&P titled Clinical/Service Data Collection revised 5/2024, showed documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care of services provided.a. Review of Patient 1’s closed clinical record was initiated on 7/726. The clinical record showed the SOC was 3/6/26. The patient was certified for hospice services during the certification period from 3/6/26 to 6/3/26. The patient was discharged on 4/13/26.Review of the SN visit note dated 3/8/26, showed the HA supervisory visit was completed for Patient 1.* However, there was no documented evidence of an HA visit from 3/6/26 to 3/8/26.The POC/IDG Review dated 3/11 and 3/25/26, showed the Spiritual IDG Discussion/Updated Comprehensive Assessment Review. * However, the Spiritual IDG Discussion/Updated Comprehensive Assessment Review showed the same information for the mentioned POC/IDG Review dates (3/11 and 3/25/26).On 7/9/26 at 0847 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the findings.b. Review of Patient 2’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 4/22/26. The patient was certified for hospice services during the certification period from 4/22/26 to 6/20/26. The patient was discharged on 6/13/26.The POC/IDG Review dated 5/6/26, showed the POC was discussed during the IDT meeting. Documentation showed the Medical Director, MSW, and SC electronically signed the attendance form.* However, the section for the RN electronic signature was left blank.Review of the patient’s clinical record showed the Letter of Agreement for Provision of Temporary Core Hospice Services between the hospice and another hospice agency signed 4/29/26, by both parties to cover hospice services that may be provided while Patient 2 was on an out-of-state vacation from 5/7/26 to 5/14/26.Review of RN 3’s Nursing Updated Assessment dated 5/8/26, showed a routine visit was completed.* However, the patient was on an out-of-state visit which started on 5/7/26.On 7/9/26 at 0914 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the findings.c. Review of Patient 3’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 6/4/25. The patient was certified for hospice services during the certification periods from 6/4/25 to 9/1/25, 9/2/25 to 11/30/25, 12/1/25 to 1/29/26, 1/30/26 to 3/30/26 and 3/31/26 to 5/29/26. The patient was discharged on 5/17/26.Review of the Re-Cert Assessment dated 3/26/25, showed the DPCS Designee completed a Body System (Head-to-Toe) assessment. The genitourinary reproductive system was assessed; however, the options in the section for “Catheter” were both checked as “None” and “Foley. “On 7/9/26 at 1010 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.The IDG failed to maintain responsibility for supervising the care and services related to the accuracy and completeness of the patient’s clinical record.3. The hospice’s P&P titled Responsibilities/Supervision of Clinical Services revised 5/2024 showed Hospice Aide supervisory visits will be conducted on site at least every two weeks by a hospice registered nurse.a. Review of Patient 2’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 4/22/26. The patient was certified for hospice services during the certification period from 4/22/26 to 6/20/26. The patient was discharged on 6/13/26.The POC/IDG review dated 5/20 and 6/3/26, showed HA visits two times a week.Review of the clinical record showed the HA conducted the visits for the weeks of 5/31/26 to 6/6/26 and 6/7/26 to 6/13/26. * However, there was no documented evidence the RN conducted HA supervision for these weeks.On 7/9/26 at 0914 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.The IDG failed to maintain responsibility for supervising the care and services related to RN Supervisory Visit.4. The hospice’s P&P titled Face-to-Face Encounter revised 5/2024, showed the hospice director or a hospice employed nurse practitioner will perform a face-to-face encounter within 30 days prior to the hospice recertification for the third and all subsequent benefit periods.Review of Patient 2’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 4/22/26. The patient was certified for hospice services during the certification period from 4/22/26 to 6/20/26. The patient was discharged on 6/13/26.Review of the Physician’s Certification for Hospice Benefit for Re-Certification Statement for the next 60-day period effective 4/22/26 to 6/20/26, showed the certification was based on face-to-face encounter.However, the face-to-face encounter visit was dated 4/25/26, which was after the start of the benefit period.On 7/9/26 at 0914 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.The IDG failed to maintain responsibility for supervising the care and services related face to face encounter.5. The hospice’s P&P titled Discharge from Hospice Program revised 5/2024 showed when a patient is discharged, transferred, or referred to another organization, relevant information will include among others: reason for transfer or discharge and the date of discharge, which is the date of the last visit made.Review of Patient 2’s closed clinical record was initiated on 7/8/26. The clinical record showed the SOC was 4/22/26. The patient was certified for hospice services during the certification period from 4/22/26 to 6/20/26. The patient was discharged on 6/13/26.Review of the Discharge Summary dated 6/13/26, showed the reason for transfer/discharged from current hospice services on 6/13/26, was due to the transfer of hospice care to another hospice agency.* However, there was no documented evidence why the patient was transferred to another hospice agency.Further review of the clinical records showed the SN last visit was on 6/12/26.* However, the transfer and end of care was completed on 6/13/26, which was inconsistent on the SN last visit dated 6/12/26.The IDG failed to maintain responsibility for supervising the care and services related to the discharge summary.On 7/9/26 at 0914 hours, an interview and concurrent clinical record review were conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the findings.6. The hospice’s P&P titled Care/Service Coordination dated 05/2024, timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patients, and relevant to the care/service provided. The clinician will be responsible for facilitating communications about changes in the patient’s status among the assigned personnel.Review of Patient 1’s closed clinical record was initiated on 7/7/26. The clinical record showed the SOC was 3/6/26. The patient was certified for hospice services during the certification period from 3/6/26 to 6/3/26. The patient was discharged on 4/13/26.Review of Patient 1’s POC/IDG Review dated 3/25/26, showed MSW visit one time per month and two PRN visits for psychosocial and emotional support or family requests.Review of MSW 1’s Visit Note Declined Visit dated 4/6/26, showed the family was contacted to schedule the monthly visit. The patient’s family member declined the visit for the month and requested for a visit next month. * However, there was no documented evidence the physician was informed of the visit not conducted due to the patient’s family member declined.On 7/9/26 at 0847 hours, an interview and concurrent clinical record review was conducted with the QAPI Coordinator/Compliance Officer and Operations Manager. The QAPI Coordinator/Compliance Officer acknowledged and confirmed the finding.The IDG failed to maintain responsibility for coordinating the care and services related to informing the physician of the missed visit.”

“It is required that the hospice conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. This standard was not met as evidenced by document review and interview. On July 10th, 2024, a review of the Agency’s Emergency Preparedness Plan with the Administrator and Director of Patient Care Services revealed an in-service had been conducted regarding emergency preparedness on 05/24/2023. An emergency preparedness drill was conducted on 05/10/2024. The Agency did not have evidence of a drill, tabletop exercise, or community-based exercise in 2022. The Administrator stated he acquired the hospice in July of 2022. He did not know if there was a community-based exercise completed in 2022 before the acquisition. On July 10th, 2024 a review of the Agency’s Emergency Preparedness Plan with the Administrator and Director of Patient Care Services revealed an in-service had been conducted regarding emergency preparedness on 05/24/2023. An emergency preparedness drill was conducted on 05/10/2024. The Agency did not have evidence of a drill, tabletop exercise, or community-based exercise in 2022. The Administrator stated he acquired the hospice in July of 2022. He did not know if there was a community based exercise completed in 2022 before the acquisition.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over the counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 3 (33%) home visits performed revealed the agency did not ensure the drug profile contained the patient’s current prescription and over the counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Home Visit 1/Clinical Record 1: During Home Visit 1 on 07/10/2024 to observe Staff 5 (SW), the Site Visitor compared the hospice medication list to the assisted living facility medication list. The facility medication list contained 2 medications not listed on the hospice medication list: Promethazine every 6 hours as needed for cough and hydroxyzine every 6 hours as needed for itching. The hospice medication list contained 7 medications not listed on the facility list. These were the comfort kit medications: Tylenol, Albuterol, Bisacodyl, Levsin, Ativan, Morphine, and Zofran. The facility Alternative Administrator was working as the medication nurse during the site visit and reviewed the medications with the site visitor. During the review and interview, she stated “Usually didn’t list the comfort kit on their medication list until they used it” but did confirm they had them in the patient’s medications. During an interview and joint record review with the Director of Patient Care Services on 07/10/2024, it was confirmed the medication lists had not been reconciled. The Director of Patient Care Services stated she knew the facility “didn’t list the comfort kit meds until they had called hospice.””

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure the clinical record contained an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Clinical Record 12: The patient elected the hospice benefit on 04/17/2024 for malignant neoplasm of the rectum. A clinical record review on 07/10/2024 revealed the comprehensive assessment did not include documentation of an initial bereavement assessment. During an interview and joint record review with the Director of Patient Care Services on 07/10/2024, it was confirmed this clinical record did not contain an initial bereavement assessment. The Director of Patient Care Services did not “understand why this had not been completed.””

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure the individualized plan of care was reviewed and revised as frequently as the patient’s condition required. Clinical Record 8: The patient elected the hospice benefit on 03/21/2024 for the diagnosis of senile degeneration of the brain. On 05/12/2024 there was an on-call nursing visit for “a fall and confusion,” On 05/13/2024 there was an on-call nursing visit for “follow up for wound care after fall”. On 05/15/2024 there was an on-call nursing visit for “patient becoming more confused and hallucinating.” The plan of care (POC) dated 3/21/2024 included the following: “Problem: Neurological/Mental Potential risk of harm r/t (related to) senile degeneration. Goal: Patient to remain in a safe environment. Intervention: Assess alteration in mobility.” The POC was not revised to account for the increased agitation, hallucinations, medication changes, falls, wounds noted during the on-call visits that occurred in May 2024. During an interview and joint record review with the Director of Patient Care Services on 07/10/2024, she stated the Plan of Care should have been updated to include “more robust goals and interventions after those visits.””

“It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties. This standard was not met as evidenced by interview and personnel record review. In 3 of 10 (30%) personnel records reviewed revealed the agency did not ensure the skills and competence of all individuals furnishing care, including volunteers furnishing services were assessed. Document 2: Agency Policy titled Scope of the Program/Process Methodology. Policy No 3-001.1 Revised Jan 2021 stated in the relevant part: “3. Hospice will clearly identify and define the skills which are essential to observe for the determination of competencies for each job category. In the identification of core competencies, the essential skills will be demonstrated upon hire” Personnel Record 4: An employee who has direct patient contact (Alternate Director of Patient Care Services) transitioned into the Alternative Director of Patient Care Services role in March 2023. A review of the personnel file 07/09/2024 revealed it did not contain competencies for that role. Personnel Record 8: An employee who has direct patient contact (Social Worker/Bereavement Coordinator) was hired on 03/04/2024. A review of the personnel file 07/09/2024 revealed it did not contain competencies for the role of bereavement coordinator. Personnel Record 9: An employee who has direct patient contact (Volunteer Coordinator) was hired on 01/08/2024. The initial competencies are signed on the date of hire however none of the boxes are checked off as completed. During an interview and joint record review with the Director of Patient Care Services and Human Resources on 07/10/2024 they stated they did not realize that personnel with “two job descriptions needed two competencies.” They confirmed the competency on Staff 9 had not been completed and only had been signed.”