Calmedix Hospice, Inc.

“Based on observation, interview and record review, the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Conditions of Participations (COP - conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people 65 years of age or more and for certain younger people with disabilities]) for initial and Comprehensive Assessments of Patients was met as follows: Based on interview and record review, the Hospice Agency (HA) failed to ensure compliance with the Condition of Participation for Initial and Comprehensive Assessment as evidenced by the following: 1. The HA failed to ensure staff conducted and documented a comprehensive assessment identifying the need for hospice care and services for one of fourteen sampled patients (Patient 7). (Refer to L522).2. The HA failed to ensure the interdisciplinary group (IDG) (a team consisting of a Registered Nurse [RN], Medical Social Worker [MSW], Chaplain, and Physician responsible for coordinating individualized patient care) completed the comprehensive assessment no later than five (5) calendar days after hospice election for three of fourteen sampled patients (Patient 6, Patient 9, and Patient 10). (Refer to L523).3. The HA failed to ensure all medications were reviewed and the medication profile was updated to reflect currently prescribed and administered medications for three of fourteen sampled patients (Patient 1, Patient 2, and Patient 8). This deficient practice placed patients at risk for medication errors and adverse drug reactions. (Refer to L530).4. The HA failed to ensure the interdisciplinary group (IDG) reviewed and updated the comprehensive assessment at least every fifteen (15) days for six of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). (Refer to L533). The cumulative effect of these systemic practices resulted in the Hospice Agency’s failure to ensure compliance with federal regulations governing the Initial and Comprehensive Assessment of patients, which has the potential to adversely affect the health, safety, and well-being of patients receiving hospice services.”

“Based on observation, interview, and record review, the Hospice Agency failed to meet the Condition of Participation for compliance with Interdisciplinary Group Care Planning, and Coordination of Services for Patients as follows: 1). The Hospice Agency (HA) failed to ensure that the plan of care was followed for eight of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 8, and Patient 9).This deficient practice had the potential to result in a failure to identify and communicate changes in patients’ conditions to the registered nurse, which could lead to delayed interventions, unmanaged symptoms, and further deterioration in patients’ health status. (Refer to L543). 2). The HA failed to ensure that an individualized plan of care was developed for four of fourteen sampled patients (Patient 7, Patient 9, Patient 10, and Patient 13).This deficient practice resulted in a lack of clear, individualized direction for patient care, placing patients at risk for unmet needs, ineffective symptom management, and diminished quality of end-of-life care, including the inability to ensure patients pass with dignity. (Refer to L545). The cumulative effect of these systemic practices resulted in the failure of the Hospice Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Interdisciplinary Group, Care Planning, and Coordination of Services to ensure quality of care is provided to patients certified to receive hospice benefits.”

“Based on observation, interview and record review, the Hospice Agency failed to ensure the Conditions of Participation for Organization and administration of services was met as follows: 1. The HA failed to ensure a qualified Administrator was appointed by the Governing body for two of 14 sampled selected Patients (Patient 7 and Patient 8). This deficient practice resulted in the HA not adhering to federal standards for Hospice care. (Refer to L651). 2. The HA failed to ensure staffs’ skills and competency were checked, for one of fourteen sample selected patients (Patient 8). This failure had the potential to result in further health deterioration by not ensuring staff were competent to care for patients. (Refer to L663). The cumulative effect of these systemic practices resulted in the failure of the Hospice Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Organization and administration of services.”

“Based on interview, and record review, the Hospice Agency failed to ensure the Condition of Participation for Medical Director was met as evidenced by: The HA failed to ensure the medical director and/or physician designee (who is a hospice employee or under the contract with the hospice) reviewed patients clinical information to determine hospice (health care that focuses on the palliation of a terminally ill patient’s pain and symptoms and attending to their emotional and spiritual needs at the end of life) care criteria is met and/or provide an initial written certification that the patient had six months or less to live if the illness runs its normal course for one of fourteen sample patients (Patient 7). (Refer to L 667). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services.”

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Clinical Records was met as follows: 1. The HA failed to ensure twelve of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 13) medical records included visit notes, plan of care, and assessments. (Refer to L672). 2. The HA failed to ensure one of fourteen sample selected patients (Patient 7) medical record included physician orders. (Refer to L678). 3. The HA failed to ensure clinical records were appropriately authenticated for two of fourteen sample selected patients (Patient 6 and Patient 7). (Refer to L679). The cumulative effect of these systemic practices resulted in the failure of the Hospice Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Clinical Records.”

“Based on interview and record review, the Hospice Agency (HA - an agency that provides care and services to terminally ill patients with a prognosis of six months or less to live, if the illness runs it’s normal course) staff failed to ensure staff conducted and documented a comprehensive assessment that identified the patient’s need for hospice care and services for one of fourteen sample selected patients (Patient 7). This deficient practice resulted in the provision of hospice services without a complete and individualized assessment of the patient’s physical, psychosocial, and spiritual needs, which had the potential to adversely affect the patient’s quality of life and the delivery of appropriate, coordinated care. During a record review of Patient 7’s medical record form titled “Personal Information,” the form indicated a referral date of 11/19/2025, with a primary diagnosis of acute respiratory failure with hypoxia (insufficient oxygen to the body). During a concurrent interview and record review on 3/5/2026 at 12:40 p.m. with Licensed Vocational Nurse 1 (LVN1) of an undated form titled “Outlook,” LVN1 stated the Medical Director 1 (MD1) sent an email to Licensed Vocational Nurse 2 (LVN2) containing Patient 7’s face to face on 11/13/2025. The Outlook form indicated MD1 had a face to face with Patient 7 on 11/13/2025 with the assistance of nursing. The form also indicated that Patient 7’s plan was to “Begin hospice care”. During a record review of Patient 7’s medical record form titled “(HA) Hospice Election of Benefits” dated 11/19/2026, the form indicated Patient 7’s legal representative signed the form on 11/19/2025, electing hospice care under Medicare Hospice Benefit for Patient 7. During a record review of Patient 7s’ medical record, the record indicated the sections for History of nursing assessment, and History of Visit Notes were empty. During a record review of Patient 7’s undated medical record form titled “Physicians Orders,” indicated “Admit to (HA) with primary diagnosis of acute respiratory failure with hypoxia, for the 1st 90 days hospice benefit period from 11/19/25 through 2/16/26, routine level of care.” The form also indicated “Send Registered Nurse to evaluate for hospice eligibility & admission.” During a record review of Patient 7’s undated medical record form titled “Communication Log” the log indicated LVN1 entered four communication notes all dated 11/19/2025. The Communication log timed at 3:37 p.m. indicated “RN to complete admission 7-8pm.” The Communication log timed at 5:30 p.m. indicated LVN2 administered Morphine (pain medication) and was going to wait for the registered nurse arrival. During a record review of Patient 7’s medical record form titled “Audit Log (Module ID 2744982)” dated from 11/19/2025 through 3/6/2026, the log indicated Registered Nurse 2 (RN2) entered Patient 7’s comprehensive nursing assessment dated 11/19/2025 on 11/24/2025. The comprehensive assessment included the following vital signs: 110/67, 20 respirations, 91 pulse rate, 97.2 temperature. The form also indicated that License Vocational Nurse 1 deleted the comprehensive nursing assessment dated 11/19/2025, entered by RN2, on 11/26/2025. During a concurrent interview and record review on 3/6/2026 at 9:26 a.m. with the Medical Director 1 (MD1) of Patient 7’s medical record, MD1 stated that he (MD1) conducted a facetime session with Licensed Vocational Nurse 2 (LVN2) of Patient 7 on 11/13/2025. MD1 stated he (MD1) did not actually see Patient 7 but did hear LVN2’s assessment/report. MD1 stated that he (MD1) admitted Patient 7 for hospice services. MD1 stated “I believe it should be an RN (Registered Nurse) that should do the patients admission comprehensive assessment, I am 90% sure that it should be an RN. An RN would provide better assessment skills due to more education.” During an interview on 3/6/2026 at 11:48 a.m. with Registered Nurse 2 (RN2), RN2 stated she (RN2) did not have any involvement with Patient 7’s care. RN2 stated that she (RN2) never met Patient 7 or his family. RN2 stated that she (RN2) did not assess Patient 7. RN2 stated that LVN2 was the hospice nurse that contacted MD1, and Patient 7’s family. RN2 stated that she (RN2) did not speak with LVN2 regarding Patient 7’s admission. RN2 stated that LVN2 “assessed the patient for me.” RN2 stated “We are allowed to work with LVNs and accept their assessment.” RN2 stated that “Because the patient died, I never had a chance to do a real assessment. I thought we were able to use the LVN assessment.” Lastly, RN2 stated she (RN2) documented Patient 7’s assessment because she (RN2) thought the HA needed to finish the visit but believes LVN1 deleted her (RN2) assessment. During an interview on 3/6/2026 at 12:13 p.m. with License Vocational Nurse 1 (LVN1), LVN1 stated that she (LVN1) deleted Patient 7’s comprehensive nursing assessment documented by RN2, because she (LVN1) was told by a consultant. LVN1 stated that she (LVN1) was told that since Patient 7 was not seen or had a full assessment by a registered nurse, Patient 7 was a non-admit. During a concurrent interview and record review on 3/6/2026 at 2 p.m. with the Director of Nurses (DON) of Patient 7’s medical record, the DON stated that Patient 7’s medical record did not contain an RN assessment. During a record review of the HA’s document titled, Initial Assessment, dated 4/2019, the policy indicated, “An initial assessment will be performed by a registered nurse within 48 hours after election of hospice care unless otherwise specified by the physician, patient or representative to be completed in less than 48 hours... The admitting registered nurse will document interventions and teaching performed.””

“Based on interview and record review, the Hospice Agency failed to ensure the interdisciplinary group completed the comprehensive assessment no later than five calendar days after hospice election for three of fourteen sample selected patients (Patient 6, Patient 9, Patient 10 ). This deficient practice had the potential to result in failure to identify the patient’s comprehensive care needs, leading to inappropriate or delayed interventions, increased risk of unmet needs, and potential decline in the patient’s health status and quality of life. During a record review of Patient 6’s undated medical record form titled “Personal Information” the form indicated a start of care date of 11/1/2025 and an end of care date of 11/29/2025 with an admitting diagnosis of end stage renal disease (kidney not functioning). During a record review of Patient 6’s medical record form titled “Audit Log – IDG” dated from 11/2/2025 through 3/6/2026, the log indicated Patient 6‘s initial IDG dated 11/3/2025 was signed by the Medical Director (MD1) on 12/8/2025, the Medical Social Worker (MSW) on 1/2/2026, Registered Nurse 2 (RN2) on 12/13/2025, and the Spiritual Counselor (SC) on 1/3/2026. 2. During a record review of Patient 9’s record document titled, Personal Information, the record indicated a start of care of 2/6/2026, with a terminal diagnosis of heart failure (heart is unable to pump blood to the body effectively). During a concurrent interview and record review on 3/6/2026, at 12:45 p.m., with the Director of Nurses (DON), the DON reviewed Patient 9’s plan of care titled, POC Summary, dated 3/6/2026. The DON stated the POC summary was incomplete because it was missing Patient 9’s issues, frequency of visits, and nursing interventions. The DON stated the IDG group was supposed to complete the POC by the 5th day of admission. The DON stated the IDG group met late to discuss the comprehensive assessment and develop the plan of care on 2/20/2026. The importance of meeting on the 5th day to discuss the assessment findings and develop the plan of care was to ensure the nurses and visiting staff were aware of what interventions were required. 3. During a record review of Patient 10’s record document titled, Personal Information, indicated a start of care on 2/28/2026, with a terminal diagnosis of senile degeneration of the brain (age related decline in cognitive status, resulting in brain cell death). During a concurrent interview and record review on 3/6/2026, at 12:53 p.m., with the DON, the DON reviewed Patient 10’s medical records. The DON stated Patient 10’s spiritual assessment had not been done. The spiritual assessment was supposed to be completed within 5 days of admission, by 3/5/2026. The purpose of the spiritual assessment was to assess the spiritual needs of the patient and family, to determine further interventions for spiritual needs. The risk of not having a spiritual assessment if the patient died, the patient would not have the last rights, or any other spiritual service required. The DON stated he was not aware the spiritual assessment had not been done. During a record review of the HA’s document titled, Comprehensive Assessment, dated 4/2019, the policy indicated, a comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with the attending physician. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s clinical record, including at least the following information, as relevant. An assessment of the patient’s and family/caregivers spiritual orientation. Specific, individualized patient needs/problems pertinent to the hospice care being provided. Type of services, frequency, and duration needed to meet patient care needs.””

“Based on observation, interview and record review, the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) staff failed to review all medications the patients were taking and update their medication profiles with the currently used medications for three of fourteen sample selected patients (Patient 1, Patient 2, and Patient 8). The patients were at risk for medication errors and adverse drug reactions. This deficient practice had the potential to place the patient at risk for medication errors and adverse drug reactions. 1. During a record review of Patient 1’s undated medical record form titled “Personal Information” the record indicated a start of care date of 10/31/2025 with a primary diagnosis of Alzheimer’s Disease (slow progressive memory decline). During a record review of Patient 1’s undated medical record form provided by Patient 1’s living facility and titled “Physician Order Review COGIR” the form indicated Patient 1 was receiving acetaminophen 1-2 tablets as needed; Bisacodyl every third day as needed; Strawberry meal replacement twice daily if needed; Milk of Magnesia (constipation medication) as needed; Tylenol cold and flu medication as needed; and was using Calmoseptine (moisture barrier cream). During a record review of Patient 1’s undated medical record form titled “Current Treatment/Medication/DME List” the form indicated that Patient 1 was prescribed the following medications:Acetaminophen (pain medication) two tablets as needed; Bisacodyl (constipation medication) once daily as needed; and Mucinex (cold medication) for five days (with an order date of 12/27/2025). The form did not indicate Patient 1 was prescribed Calmoseptine, Milk of Magnesium, or Tylenol cold and flu. During a joint home visit on 3/4/2026 at 11:15 a.m. with Registered Nurse 1 (RN1) at Patient 1’s living facility, RN1 stated that the Licensed Vocational Nurse (LVN), who conducts weekly visits, is responsible for completing medication reconciliation. 2. During a record review of Patient 2’s undated medical record form titled “Personal Information” the form indicated a start of care date of 12/27/2025 with a primary diagnosis of Alzheimer’s Disease. During a record review of Patient 2’s undated medical record form provided by Patient 2’s living facility and titled “Physician Order Review COGIR” the order indicated Patient 2 was receiving Ezetimibe (high cholesterol medication) and chocolate meal replacement three times daily if needed. The form indicated Patient 2 was prescribed Olanzapine 10 milligrams (mg – unit of measurement) at 6 p.m. and 2.5 mg at 12 p.m. During a record review of Patient 2’s undated medical record form titled “Current Treatment/Medication/DME List” the form indicated Patient 2 was prescribed Olanzapine 2.5 mg twice a day as needed, 2.5 mg at 12 p.m. and 10 mg at 6 p.m. The form indicated “Hold Lisinopril (high blood pressure medication) table for seven days” which was ordered on 1/12/2026. The form did not indicate Patient 2 was currently prescribed Lisinopril. During a joint home visit on 3/4/2026 at 10:40 a.m. with Registered Nurse 1 (RN1) at Patient 2’s living facility, RN1 did not perform medication reconciliation, stating she was focused on completing the home visit. RN1 further stated that the Licensed Vocational Nurse (LVN), who conducts weekly visits, is responsible for completing the medication reconciliation conducts the medication reconciliation. During an interview on 3/4/2026 at 11:33 a.m. with Registered Nurse 1 (RN1), RN1 stated that patients’ medications should be reconciled during every skilled nurse (SN) visit to ensure medications are not expired, patients are taking the correct dose, and to know what parameters, if any, to follow. 3. During a record review of Patient 8’s document titled Personal Information, the form indicated a start of care on 11/1/2025, with a terminal diagnosis of Alzheimer’s disease (slow progressive memory decline). During a concurrent observation, interview and record review, on 3/4/2026, at 10:45 a.m. and 11:15 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 reviewed the medications Patient 8 was taking using Patient 8’s document titled, Current Treatment/Medication/DME List, printed on 3/3/2026. An observation of LVN 2’s medication list indicated a missing first page. LVN 2 stated Licensed Vocational Nurse 1 (LVN 1) came the night of 3/3/2026 to deliver an updated medication list to the assisted living facility, where Patient 8 lived. LVN 2 used the surveyor’s medication list to review Patient 8’s medications. Continued review of the medications at 11:15 a.m., indicated medication Carbamide Peroxide (ear drops) were listed but LVN 2 stated Patient 8 was no longer taking. During an interview on 3/4/2026, at 11:16 a.m., with LVN 2, LVN 2 stated medications were supposed to be reviewed, and medication list updated every visit. This was important to make sure the medication is there or to check if there were any changes with the order of the medications. During a record review of the HA’s document titled, Medication Profile, dated 4/2019, indicated, “Patients receiving medications administered by the organization will have a current, accurate, medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.””

“Based on interview and record review, the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for six of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). This deficient practice resulted in the failure to consistently evaluate and address changes in patient’s conditions, which had the potential to delay necessary modifications to the plan of care and adversely affect patients’ comfort, symptom management, and overall quality of life. During an interview on 3/4/2026 at 12:30 p.m. with Registered Nurse 1 (RN1), RN1 stated if a patient’s plan of care is incomplete, she (RN1) checks for condition changes, overall patient health, performs a head to toe assessment, and any noted or reported distress. RN1 stated that a patients plan of care is meant to address individual treatments and make sure all concerns are addressed. RN1 stated when there is no plan of care, there is nothing to go by, not knowing if a patient is having a change of condition. During an interview on 3/5/2026 at 11:54 a.m. with the Medical Director 1 (MD1), MD1 stated that he (MD1) attends the HAs IDG meetings every two weeks on different days by phone or in person. MD1 stated that during the IDG meeting License Vocational Nurse 2 (LVN2) gives him (MD1) a rundown of all the patients and any problems. MD1 stated that he does not write on the patients’ plan of care, but just conducts reviews and if everything looks “good” he (MD1) signs. MD1 stated that he (MD1) signs the IDG meeting notes the same day of the meeting or a “little after that.” During a record review of Patient 1’s undated medical record form titled “Personal Information” the record indicated a start of care date of 10/31/2025 with a primary diagnosis of Alzheimer’s Disease (slow progressive memory decline). During a record review of Patient 1’s medical record form titled POC/IDG (Plan of care/Interdisciplinary group) Review” dated 11/28/2025, indicated the “other/physician” section was left blank. The form did not indicate the Medical Director (MD1) signed the form. During a record review of Patient 1’s medical record form titled POC/IDG Review” dated 12/12/2025, the record indicated the “other/physician” section was left blank. The form did not indicate MD1 signed the form. During a record review of Patient 1’s medical record form titled POC/IDG Review” dated 12/26/2025, indicated the “other/physician” section was left blank. The form did not indicate MD1 signed the form. During a record review of Patient 1’s medical record form titled POC/IDG Review” dated 1/9/2026, the form indicated the “other/physician” section was left blank. The form did not indicate MD1 signed the form. During a record review of Patient 1’s medical record form titled POC/IDG Review” dated 1/23/2026, the form indicated the “other/physician” section was left blank. The form did not indicate MD1 signed the form. During a record review of Patient 1’s medical record form titled POC/IDG Review” dated 2/6/2026, the record indicated the “other/physician” section was left blank. The form did not indicate MD1 signed the form. During a record review of Patient 1’s medical record form titled POC/IDG Review” dated 2/20/2026, the record indicated the “other/physician” section was left blank. The form did not indicate MD1 signed the form. During a concurrent interview and record review on 3/4/2026 at 12:05 p.m. with Registered Nurse 1 (RN1) of Patient 1’s medical record, RN1 stated that Patient 1’s plan of care did not list any treatments. RN1 stated that Patient 1’s was missing interventions and goals for Alzheimer’s Disease, gastrointestinal, safety, pain, activities of daily living, and risk for skin breakdown. RN1 stated Patient 1’s plan of care was incomplete. During a concurrent interview and record review on 3/6/2026 at 8:59 a.m. with the Medical Director 1 (MD1) of Patient 1’s medical record, MD1 stated that he (MD1) signed “a lot” of Patient 1’s IDT (interdisciplinary team) yesterday (3/5/2026). MD1 stated that it was best practice to sign the IDG meeting the day of the meeting because “it is fresh on the mind”. 2. During a record review of Patient 2’s undated medical record form titled “Personal Information” indicated a start of care date of 12/27/2025 with a primary diagnosis of Alzheimer’s Disease. During a record review of Patient 2’s medical record form titled POC/IDG Review” dated 1/9/2026, the record indicated the “other/physician” section was left blank. The form did not indicate MD1 signed the form. During a record review of Patient 2’s medical record form titled POC/IDG Review” dated 1/23/2026, the record indicated the “other/physician” section was left blank. The form did not indicate the MD1 or a Registered Nurse signed the form. During a record review of Patient 2’s medical record form titled POC/IDG Review” dated 2/6/2026, the record indicated the “other/physician” section was left blank. The form did not indicate the MD1 or a Registered Nurse signed the form. During a record review of Patient 2’s medical record form titled POC/IDG Review” dated 2/20/2026, the form indicated the “other/physician” section was left blank. The form did not indicate the MD1 or a Registered Nurse signed the form. During a concurrent interview and record review on 3/4/2026 at 12:15 p.m. with RN1 of Patient 2’s medical records, RN1 stated Patient 2’s plan of care was incomplete. RN1 stated that Patient 2’s plan of care only addressed her (Patient 2) spiritual needs and was missing “many” other issues, such as Alzheimer’s disease, anxiety, depression, sleep, risk factors, pain, skin breakdown, medication, and diabetes. During a concurrent interview and record review on 3/6/2026 at 1:40 p.m. with the DON of Patient 2’s medical record, the DON stated Patient 2’s plan of care was incomplete. The DON stated that it was important to complete the care plan based on a patient’s diagnosis, “so that the nurse is providing safe care and assessing the patient properly.” 3. During a record review of Patient 3’s medical record form titled “Comprehensive Nursing Assessment (HOPE Admission) dated 2/5/2026, the record indicated a start of care date of 2/5/2026, with a primary diagnosis of Alzheimer’s disease. During a record review of Patient 3’s medical record form titled POC/IDG Review” dated 2/6/2026, the record indicated the “other/physician” and “Psychosocial” sections were left blank. The form did not indicate MD1 had signed the form. During a record review of Patient 3’s medical record form titled POC/IDG Review” dated 2/20/2026, the record indicated the “other/physician” section was left blank. The form did not indicate that MD1 signed the form During a concurrent interview and record review on 3/6/2026 at 1:46 p.m. with the DON of Patient 3’s medical record, the DON stated Patient 3’s plan of care did not consist of nursing and was incomplete. The DON stated Patient 3 had a history of blood clotting disorder. The DON stated it was important for Patient 3 to have a completed plan of care so that the nurses could be aware of Patient 3’s bleeding risk. 4. During a record review of Patient 4’s undated medical record form titled “Personal Information” the record indicated a start of care date of 11/14/2025 and an end care of date of 11/30/2025, with a primary diagnosis of Alzheimer’s Disease. During a record review of Patient 4’s medical record form titled POC/IDG Review” dated 11/17/2025, the record indicated the “other/physician” section was left blank. The form did not indicate the Spiritual Counselor (SC) signed the form. During a record review of Patient 4’s medical record form titled POC/IDG Review” dated 11/28/2025, the record indicated the “other/physician” section was left blank. The form did not indicate the SC signed the form. 5. During a record review of Patient 5’s undated medical record form titled “Personal Information” the record indicated a start of care date of 11/7/2025 and an end care of date of 1/15/2026, with a primary diagnosis of Alzheimer’s Disease. During a record review of Patient 5’s medical record form titled “POC/IDG Review” dated 1/9/2026, the record indicated the “other/physician” section was left blank. During a record review of Patient 5’s medical record form titled “Audit Log – IDG” dated from 11/6/2025 to 3/6/2026, the form indicated Patient 5’s IDG dated 1/9/2026 was signed by MD1 on 3/5/2026. The SC, Registered Nurse 2 (RN2), and the Medical Social Worker (MSW) signed on 3/3/2026. During a record review of Patient 5’s medical record form titled “Audit Log – IDG” dated from 11/6/2025 to 3/6/2026, the record indicated Patient 5 ‘s IDG dated 11/14/2025, 11/28/2025, 12/12/2025, 12/26/2025, and 1/9/2026 were accessed by Licensed Vocational Nurse 1 (LVN1) on 3/3/2026. The form indicated LVN1 signed and documented the start date and time for IDG team members on 3/3/2026. During a concurrent interview and record review on 3/6/2026 at 1:50 p.m. with the DON of Patient 5’s medical record, the DON stated that Patient 5’s care plan was not complete. The DON stated Patient 5’s kidney and diabetes were not care planned. The DON stated Patient 5 could run the risk of not being assessed properly, having missed treatment, that could put him (Patient 5) at risk for hospitalization. 6. During a record review of Patient 6’s undated medical record form titled “Personal Information” the record indicated a start of care date of 11/1/2025 and an end of care date of 11/29/2025 with an admitting diagnosis of end stage renal disease (kidney not functioning). During a record review of Patient 6’s medical record form titled POC/IDG Review” dated 11/14/2025, the record indicated the “other/physician” section was left blank. During a record review of Patient 6’s medical record form titled “Audit Log – IDG” dated from 11/2/2025 to 3/6/2026, the record indicated Patient 6 ‘s initial IDG dated 11/14/2025 was signed by the Medical Director (MD1) on 12/8/2025, the Medical Social Worker (MSW) on 1/2/2026, Registered Nurse 2 (RN2) on 12/13/2025, and the Spiritual Counselor (SC) on 1/3/2025. During a record review of the HA’s document titled, Interdisciplinary Group Plan of Care, dated 4/2019, indicated, “Procedure...Written evidence of care coordination will be found in the plan of care and/or interdisciplinary team meeting forms in the patient’s clinical record, and will involve the hospice patient’s attending physician...The interdisciplinary group (in collaboration with the attending physician, if any will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of every 15 calendar days.” During a record review of the HA’s policy titled, Interdisciplinary Group Meeting, dated 4/2019, the policy indicated, “Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor.””

“Based on observation, interview, and record review, the Hospice Agency failed to ensure that the plan of care was followed for eight of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 8 and Patient 9).This deficient practice had the potential to result in further health deterioration, as changes in the patients’ condition were not communicated to the registered nurse, preventing timely assessment and appropriate intervention. 1. During a record review of Patient 1’s undated medical record form titled “Personal Information” the record indicated a start of care date of 10/31/2025 with a primary diagnosis of Alzheimer’s Disease (slow progressive memory decline). During a record review of Patient 1’s medical record titled “POC/IDG (plan of care/interdisciplinary group) Review” dated 11/28/2025, the record indicated Patient 1 was to have Certified Home Health Aide (CHHA) visit twice a week. During a record review of Patient 1’s medical record titled “Plan of Care” dated 3/4/2026, the record indicated Patient 1 was to have CHHA visits twice a week. During a record review on 3/4/2026 at 8:23 a.m. of Patient 1’s undated medical record titled “History of HA (home aide) Visits” the record indicated Patient 1 did not have documented CHHA visit notes from 11/1/2025 to 1/17/2026. During a concurrent interview and record review on 3/6/2026 at 1:08 p.m. with the Director of Nurses (DON) of Patient 1’s medical record, the DON stated that Patient 1 was to have twice a week CHHA visits. The DON stated that Patient 1’s first documented CHHA visit was on 1/20/2026. The DON stated that it was important to have visits notes as proof that care was provided. The DON stated that the CHHA was to document the visit notes, seven days after the visit. 2. During a record review of Patient 2’s undated medical record form titled “Personal Information” the record indicated a start of care date of 12/27/2025 with a primary diagnosis of Alzheimer’s Disease. During a record review of Patient 2’s medical record titled “POC/IDG Review” dated 1/9/2026, the record indicated Patient 2 was to have CHHA visits three times per week. During a record review of Patient 2’s medical record titled “Plan of Care” dated 3/4/2026, indicated Patient 2 was to have CHHA visits three times per week. During a record review on 3/4/2026 at 8:57 a.m. of Patient 2’s undated medical record titled “History of HA Visits” the record indicated Patient 2 did not have documented CHHA visit notes from 12/30/2025 to 1/17/2026. During a concurrent interview and record review on 3/6/2026 at 1:40 p.m. with the DON of Patient 2’s medical record, the DON stated that Patient 2 was to have CHHA visits three times per week. The DON stated that Patient 2’s first documented CHHA visit was on 1/20/2026. The DON stated that there was no documented proof Patient 2 received CHHA visits, and that it was important to document so that the HA is aware the orders are being followed. 3. During a record review of Patient 3’s medical record form titled “Comprehensive Nursing Assessment (HOPE Admission) dated 2/5/2026, the record indicated a start of care date of 2/5/2026, with a primary diagnosis of Alzheimer’s disease. During a record review of Patient 3’s medical record titled “POC/IDG Review” dated 2/6/2026, the record indicated Patient 3 was to have CHHA visits three times per week. During a record review of Patient 3’s medical record titled “Plan of Care” dated 3/4/2026, the record indicated Patient 3 was to have CHHA visits three times per week. During a record review on 3/4/2026 at 9:25 a.m. of Patient 3’s undated medical record titled “History of HA Visits” the record indicated Patient 3 did not have any documented CHHA visit notes. During a concurrent interview and record review on 3/6/2026 at 1:46 p.m. with the DON of Patient 3’s medical record, the DON stated that he (DON) does not know why the CHHA visit notes are not being documented. 4. During a record review of Patient 4’s undated medical record form titled “Personal Information” the record indicated a start of care date of 11/14/2025 and an end care of date of 11/30/2025, with a primary diagnosis of Alzheimer’s Disease. During a record review of Patient 4’s medical record titled “POC/IDG Review” dated 11/17/2025, indicated Patient 4 was to have CHHA visits twice per week. During a record review of Patient 4’s medical record titled “Plan of Care” dated 3/6/2026, the record indicated Patient 4 was to have CHHA visits twice per week. During a record review on 3/6/2026 at 5:55 a.m. of Patient 4’s undated medical record titled “History of HA Visits” the record indicated Patient 4 did not have any documented CHHA visit notes from 11/15/2025 to 11/29/2025. During a concurrent interview and record review on 3/6/2026 at 1:49 p.m. with the DON of Patient 4’s medical record, the DON stated that he (DON) does not know why the CHHAs are not documenting. 5. During a record review of Patient 5’s undated medical record form titled “Personal Information” the record indicated a start of care date of 11/7/2025 and an end care of date of 1/15/2026, with a primary diagnosis of Alzheimer’s Disease. During a record review of Patient 5’s medical record titled “POC/IDG Review” dated 1/9/2026, the record indicated Patient 5 was to have CHHA visits twice per week. During a record review of Patient 5’s medical record titled “Plan of Care” dated 3/6/2026, the record indicated Patient 5 was to have CHHA visits twice per week. During a record review on 3/6/2026 at 6:25 a.m. of Patient 5’s undated medical record titled “History of HA Visits” the record indicated Patient 5 did not have any documented CHHA visit notes from 11/10/2025 to 1/14/2026. During a concurrent interview and record review on 3/6/2026 at 1:50 p.m. with the DON of Patient 5’s medical record, the DON stated Patient 5 was to have CHHA visits twice per week. The DON stated that Patient 5 did not have any CHHA visit documented. 6. During a record review of Patient 6’s undated medical record form titled “Personal Information” indicated a start of care date of 11/1/2025 and an end of care date of 11/29/2025 with an admitting diagnosis of end stage renal disease (kidney not functioning). During a record review of Patient 6’s medical record titled “POC/IDG Review” dated 11/3/2025, indicated the section for “frequency of visit” was left blank. During a record review on 3/6/2026 at 6:37 a.m. of Patient 6’s undated medical record titled “History of HA Visits” the record indicated Patient 6 did not have any documented CHHA visit notes from 11/4/2025 to 11/29/2025. 7. During a record review of Patient 8’s document titled Personal Information, the record indicated a start of care on 11/1/2025, with a terminal diagnosis of Alzheimer’s disease (slow progressive memory decline). During an interview at the home visit on 3/4/2026, at 10:15 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated the Certified Home Health Aide (CHHA) had given Patient 8 a bath on the morning of 3/4/2026. During a concurrent observation and interview at the home visit on 3/4/2026, at 10:25 a.m., with LVN 2, LVN 2 assessed Patient 8’s skin. During the observation of Patient 8’s skin in the buttocks area, a visible half dimed size opening, with a red base, was visible. LVN 2 stated the opening was a Stage 2 pressure wound (loss of the top layer of the skin exposing the second layer). LVN 2 stated the buttocks area had redness only in the previous visit. During an interview on 3/4/2026, at 10:42 a.m., with LVN 2, LVN 2 stated if the CHHA noticed the presence of the wound, the CHHA would have notified the office. The office would have notified LVN 2. LVN 2 stated, “Nobody notified me”. During an interview on 3/4/2026, at 11:10 a.m., with LVN 2, LVN 2 stated it was important for the LVN 2 to have been aware of the wound so LVN 2 could have prepared on what to do such as wound care and education. LVN 2 stated LVN 2 should have been notified right away. LVN 2 stated the protocol of the HA was for the CHHA to notify the office, and the office was supposed to notify the nurse. During an interview on 3/5/2026, at 11:44 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the CHHA had notified her of the presence of a wound yesterday, 3/4/2026, at around noon. During a concurrent interview and record review on 3/6/2026, at 12:29 p.m., with the Director of Nurses (DON), the DON reviewed Patient 8’s document titled, HA (Hospice Aide) Assignment, dated 11/1/2025. The DON stated this was the plan of care the CHHA was supposed to follow. The record indicated, “If Patient is experiencing pain/change in condition notify RN” (registered nurse). The DON stated the CHHA was supposed to notify the RN because the presence of a wound was considered a change of condition. The RN needed to be notified because it was the RN who could call the doctor, get and change the order, and change the level of care if needed. The risk of not notifying the RN was that the patient could suffer because of lack of response to the care. 8. During a record review of Patient 9’s record document titled, Personal Information, the record indicated a start of care on 2/6/2026, with a terminal diagnosis of heart failure (heart is unable to pump blood to the body effectively). During a record review of Patient 9’s document titled, POC Summary, dated 3/6/2026, the record indicated the CHHA was to visit Patient 9 twice weekly. During a concurrent interview and record review on 3/6/2026, at 12:42 p.m., with the DON, the DON reviewed Patient 9’s record titled, HA Assignment, dated 2/6/2026. The record indicated instructions for care during each visit. The DON further reviewed Patient 9’s medical records and the review indicated the absence of CHHA visit notes. The DON was asked how the DON ensured the CHHA was following the plan of care. The DON stated the only way to verify if the POC was being followed was if the CHHA was documenting the visits. The DON stated he could not say the CHHA was following the POC because there was not documentation of the visits. During a record review of the HA’s policy titled, “The Plan of Care,” dated 4/2019, indicated, “Any change in the patient’s condition must result in a change in the plan of care...Care provided to the patient will be in accordance with the plan of care.””

“Based on interview and record review, the Hospice Agency (HA) failed to develop an individualized care plan for four of fourteen sample selected patients (Patient 7, Patient 9, Patient 10, Patient 13). This failure resulted in patients, caregivers, and nurses to not be aware of the individualize hospice care the patients required and needed, placing the patients at risk of not passing with dignity. 1. During a record review of Patient 7’s medical record form titled “Personal Information” the record indicated a referral date of 11/19/2025, with a primary diagnosis of acute respiratory failure with hypoxia (insufficient oxygen to the body). During a record review of Patient 7s’ medical record indicated the sections for “History of nursing assessment”, and “History of Visit Notes” were empty. During a record review of Patient 7’s undated medical record form titled “Physicians Orders” the record indicated “Admit to (HA) with primary diagnosis of acute respiratory failure with hypoxia, for the 1st 90 days hospice benefit period from 11/19/25 through 02/16/26, routine level of care.” During a record review of Patient 7’s medical record form titled “Plan of Care” dated 3/5/2026, the record indicated there were three issues with their interventions and goals written. The form indicated the three issues were “created by (Registered Nurse 2 - RN2)”. The three issues were cardiovascular, imminently dying, and respiratory. The form was not signed by the author. During an interview on 3/6/2026 at 11:48 a.m. with Registered Nurse 2 (RN2), RN2 stated she (RN2) did not have any involvement with Patient 7’s care. RN2 stated that she (RN2) never met Patient 7 or his family. RN2 stated that she (RN2) did not assess Patient 7. RN2 stated that Licensed Vocational Nurse 2 (LVN2) was the hospice nurse that contacted the Medical Director 1 (MD1), and Patient 7’s family. RN2 stated that she (RN2) did not speak with LVN2 regarding Patient 7’s admission. RN2 stated that LVN2 “assessed the patient for me.” RN2 stated “We are allowed to work with LVNs and accept their assessment.” RN2 stated that “because the patient died, I never had a chance to do a real assessment. I thought we were able to use the LVN assessment.” Lastly, RN2 stated she (RN2) documented Patient 7’s assessment because she (RN2) thought the HA needed to finish the visit but believes License Vocational Nurse 1 (LVN1) deleted her (RN2) assessment. 2. During a record review of Patient 9’s record document titled, Personal Information, the record indicated a start of care on 2/6/2026, with a terminal diagnosis of heart failure (heart is unable to pump blood to the body effectively). During a concurrent interview and record review on 3/6/2026, at 12:45 p.m., with the Director of Nurses (DON), the DON reviewed Patient 9’s plan of care titled, POC Summary, dated 3/6/2026. The DON stated the POC summary was incomplete because it was missing Patient 9’s issues, frequency of visits, and nursing interventions. The DON stated the IDG group was supposed to complete the POC by the 5th day of admission. The DON stated the IDG group met late to discuss the comprehensive assessment and develop the plan of care on 2/20/2026. The importance of meeting on the 5th day is to discuss the assessment findings and develop the plan of care o ensure the nurses and visiting staff were aware of what interventions were required. 3. During a record review of Patient 10’s record document titled, Personal Information, the record indicated a start of care on 2/28/2026, with a terminal diagnosis of senile degeneration of the brain (age related decline in cognitive status, resulting in brain cell death). During a concurrent interview and record review on 3/6/2026, at 12:57 p.m., with the DON, the DON reviewed Patient 10’s plan of care titled, POC Summary, dated 3/4/2026. The DON stated the POC summary was incomplete because it was missing Patient 10’s nursing interventions, frequency of visits, treatments, issues, DME (durable medical equipment). The DON stated the only thing he read on the POC was the medications. The POC also did not have interventions or goals. The DON stated he did not know what the needs of Patient 10 was because the POC was blank. The DON was asked what services were being provided to Patient 10, since there was no POC. The DON stated he assumed a physical assessment and assessment of needs was being done. 4. During a record review of Patient 13’s record document titled, Personal Information, indicated a start of care on 2/23/2026, with a terminal diagnosis of chronic kidney disease stage 5 (kidneys do not work properly and are unable to remove waste from the body). The record also indicated Patient 13 died on 2/24/2026. During a concurrent interview and record review on 3/6/2026, at 2:03 p.m., with the DON, the DON reviewed Patient 13’s plan of care titled, POC Summary, dated 3/6/2026. The DON stated the POC was not completed; the only items listed were the medications. There were no interventions, treatment, patient goals, patient issues, frequency of visits listed, DME, listed. During a record review of the HA’s document titled, The Plan of Care, dated 4/2019, indicated, “A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care.”

“Based on interview and record review, the HA failed to ensure a qualified Administrator was appointed by the Governing body for two of 14 sampled selected Patients (Patient 7 and Patient 8). This deficient practice resulted in the HA not adhering to federal standards for Hospice care. During an interview on 3/3/2026 at 1:05 p.m., at the entrance conference with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she was the owner of the HA. LVN 1 stated Licensed Vocational Nurse 2 (LVN 2) was the current administrator. During an interview on 3/5/2026, at 1:32 p.m., LVN 1 stated the members of the governing body were LVN 1, the Director of Nurses (DON) and the Medical Director (MD 1). LVN 1 was asked to provide the appointment letter for the Administrator (LVN 2). LVN 1 stated she did not remember if the HA had an appointment letter for the administrator. LVN 1 stated she was told that due to LVN 1’s and LVN 2’s experience as nurses, this was considered experience to manage a hospice agency. LVN 1 stated LVN 2 was originally supposed to be in the office. LVN 2 was unable to be in the office anymore, which is why the HA was in the process of changing the administrator role to LVN 1. LVN 1 stated she did not have experience as a hospice administrator. LVN 1 stated, “This is my first time, I’m learning.” During a concurrent interview and record review on 3/5/2026, at 1:50 p.m., with LVN 1, LVN 1 provided the HA’s document titled, Minutes of Governing Body Meeting, dated 1/6/2026. The record indicated LVN 2 was the Chief Financial Officer. The record indicated the DON was appointed to the position of Director of Patient Care Services (DPCS), there was no mention of an administrator on the document. LVN 1 was informed that the document did not specify LVN 2 was appointed to the administrator role. LVN 1 stated, she would look for the document. LVN 1 did not provide additional documents to support LVN 2 was appointed as the administrator. During a record review of the HA’s document titled, Minutes of Governing Body Meeting, dated 1/22/2026 indicated LVN 2 was the Chief Executive Officer and CFO. The record also indicated LVN 1 was the secretary. Continued review of the record did not indicate who the administrator was. During a record review of the HA’s document titled, Governing Body, dated 5/2024, the record indicated, “The Governing Body will appoint a qualified Executive Director/Administrator and establish procedures of systematic communication between the two...All actions taken by the Governing Body will be documented in meeting minutes, which will be retained by the organization for a minimum of five (5) years.” During a record review of the HA’s policy titled, “Job Descriptions Executive Director/Administrator,” dated 5/2024, indicated, “The Executive Director/Administrator is responsible for the overall direction of the hospice services...is responsible for establishing standards of care to comply with federal and state regulations and guidelines...Position Qualifications...A Bachelor’s degree in Business Administration, Master’s Degree in health care or related field preferred...Three (3) to five (5) years’ experience in health care management.” 1. During a record review of Patient 7’s medical record form titled “Personal Information” indicated a referral date of 11/19/2025, with a primary diagnosis of acute respiratory failure with hypoxia (insufficient oxygen to the body). During a concurrent interview and record review on 3/5/2026 at 12:40 p.m. with LVN1 of an undated form titled “Outlook” LVN1 stated the Medical Director 1 (MD1) sent email to LVN2 containing Patient 7’s face to face on 11/13/2025. The Outlook form indicated MD1 had a face to face with Patient 7 on 11/13/2025 with the assistance of nursing. The form also indicated that Patient 7’s plan was to “Begin hospice care.” During a record review of Patient 7’s medical record for titled “(HA) Hospice Election of Benefits” dated 11/19/2026, indicated Patient 7’s legal representative signed the form on 11/19/2025, electing hospice care under Medicare Hospice Benefit for Patient 7. During a record review of Patient 7s’ medical record indicated sections “History of nursing assessment”, and “History of Visit Notes” were empty. During a record review of Patient 7’s undated medical record form titled “Physicians Orders” the physician orders indicated “Admit to (HA) with primary diagnosis of acute respiratory failure with hypoxia, for the 1st 90 days hospice benefit period from 11/19/25 - 02/16/26, routine level of care.” The form also indicated “Send Registered Nurse to evaluate for hospice eligibility & admission”. During a record review of Patient 7’s undated medical record form titled “Communication Log” the log indicated LVN1 entered four communication notes all dated 11/19/2025. The Communication log timed at 3:37 p.m. indicated “RN to complete admission 7-8pm.” The Communication log timed at 5:30 p.m. indicated LVN2 administered Morphine (pain medication) and was going to wait for the registered nurses arrival. During a record review of Patient 7’s medical record form titled “Audit Log (Module ID 2744982)” dated from 11/19/2025 to 3/6/2026, the record indicated Registered Nurse 2 (RN2) entered Patient 7’s comprehensive nursing assessment dated 11/19/2025 on 11/24/2025. The comprehensive assessment included the following vital signs: 110/67, 20 respirations, 91 pulse rate, 97.2 temperature. The form also indicated that License Vocational Nurse 1 deleted the comprehensive nursing assessment dated 11/19/2025, entered by RN2, on 11/26/2025. During a concurrent interview and record review on 3/6/2026 at 9:26 a.m. with the MD1 of Patient 7’s medical record, the MD1 stated that he (MD1) conducted a facetime session with Licensed Vocational Nurse 2 (LVN2) assistance of Patient 7 on 11/13/2025. MD1 stated he (MD1) did not actually see Patient 7 but did hear LVN2’s assessment/report. MD1 stated that he (MD1) admitted Patient 7 for hospice services. MD1 stated “I believe it should be an RN (Registered Nurse)) that should do the patients admission comprehensive assessment. I am 90% sure that is should be an RN. An RN would provide better assessment skills due to more education.” During an interview on 3/6/2026 at 11:48 a.m. with Registered Nurse 2 (RN2), RN2 stated she (RN2) did not have any involvement with Patient 7’s care. RN2 stated that she (RN2) never met Patient 7 or his family. RN2 stated that she (RN2) did not assess Patient 7. RN2 stated that LVN2 was the hospice nurse that contacted the MD1, and Patient 7’s family. RN2 stated that she (RN2) did not speak with LVN2 regarding Patient 7’s admission. RN2 stated that LVN2 “assessed the patient for me.” RN2 stated “We are allowed to work with LVNs and accept their assessment.” RN2 stated that “Because the patient died, I never had a chance to do a real assessment. I thought we were able to use the LVN assessment.” RN2 stated she (RN2) documented Patient 7’s assessment because she (RN2) thought the HA needed to finish the visit but believes LVN1 deleted her (RN2) assessment. During an interview on 3/6/2026 at 12:13 p.m. with LVN1, LVN1 stated that she (LVN1) deleted Patient 7’s comprehensive nursing assessment documented by RN2, because she (LVN1) was told to do so by a consultant. LVN1 stated that she (LVN1) was told that since Patient 7 was not seen or had a full assessment by a registered nurse, he (Patient 7) was a non-admit. During a concurrent interview and record review on 3/6/2026 at 2 p.m. with the Director of Nurses (DON) of Patient 7’s medical record, the DON stated that Patient 7’s medical record did not contain an RN assessment. 2. During a record review of Patient 8’s document titled Personal Information, indicated a start of care on 11/1/2025, with a terminal diagnosis of Alzheimer’s disease (slow progressive memory decline). During an interview at the home visit on 3/4/2026, at 10:15 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated the Certified Home Health Aide (CHHA) had given Patient 8 a bath on the morning of 3/4/2026. During a concurrent observation and interview at the home visit on 3/4/2026, at 10:25 a.m., with LVN 2, LVN 2 assessed Patient 8’s skin. During the observation of Patient 8’s skin in the buttocks area, a visible half dimed size opening, with a red base, was visible. LVN 2 stated the opening was a Stage 2 pressure wound (loss of the top layer of the skin exposing the second layer). LVN 2 stated the buttocks area had redness only in the previous visit. During the observation of the assessment of Patient 8’s wound, LVN 2 did not measure the wound. During an interview on 3/4/2026, at 10:42 a.m., with LVN 2, LVN 2 stated had the CHHA noticed the presence of the wound, the CHHA would have notified the office. The office would have notified LVN 2. LVN 2 stated, “Nobody notified me”. During an interview on 3/4/2026, at 11:05 a.m., with LVN 2, LVN 2 stated the wound should have been measured. LVN 2 stated she did not measure the wound because she got nervous. LVN 2 was supposed to measure the wound to notify the doctor of the size, as this will determine the type of treatment. During an interview on 3/4/2026, at 11:10 a.m., with LVN 2, LVN 2 stated it was important for LVN 2 to have been aware of the wound, then LVN 2 could have been prepared regarding wound care and education. LVN 2 stated LVN 2 should have been notified right away. LVN 2 stated the protocol of the HA was for the CHHA to notify the office, and the office was required to notify the nurse. During an interview on 3/5/2026, at 11:44 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the CHHA had notified her of the presence of a wound yesterday, 3/4/2026, at around noon. During a concurrent interview and record review conducted on 3/6/2026 at 12:29 p.m. with the Director of Nurses (DON), the DON reviewed Patient 8’s document titled “HA (Hospice Aide) Assignment,” dated 11/1/2025. The DON stated this document represented the plan of care the Certified Home Health Aide (CHHA) was expected to follow. The record indicated, “If the patient is experiencing pain or a change in condition, notify the RN (Registered Nurse).” The DON confirmed that the CHHA was required to notify the RN, as the presence of a wound constituted a change in the patient’s condition. The DON further stated that the RN is responsible for notifying the physician, obtaining and implementing new or revised orders, and adjusting the level of care as necessary. Failure to notify the RN had the potential to result in a delay in assessment, intervention, and treatment, placing the patient at risk for unmet care needs, worsening condition, and avoidable harm due to lack of timely clinical response.During a concurrent interview and record review on 3/5/2026, at 12:40 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 reviewed the employee files of the Licensed Vocational Nurses, CHHA’s and RN’s. LVN 1 stated there were no competency verification documents present. LVN 1 stated, “We just go over a list and ask them if they know how to do it.” LVN 1 stated the HA verifies the knowledge of the items listed based on the staff response of Yes or No. LVN 1 stated the HA was a new agency and did not know staff were required to have someone sign off the skills of the nurses. LVN 1 stated the importance of skill competency is to ensure we know the skills staff are proficient in.”

“Based on observation, interview, and record review, the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure staffs’ skills and competency were checked, for one of fourteen sample selected patients (Patient 8). This failure had the potential to result in further health deterioration by not ensuring staff were competent to care for patients. During a record review of Patient 8’s document titled Personal Information, indicated a start of care on 11/1/2025, with a terminal diagnosis of Alzheimer’s disease (slow progressive memory decline). During an interview at the home visit on 3/4/2026, at 10:15 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated the Certified Home Health Aide (CHHA) had given Patient 8 a bath on the morning of 3/4/2026. During a concurrent observation and interview at the home visit on 3/4/2026, at 10:25 a.m., with LVN 2, LVN 2 assessed Patient 8’s skin. During the observation of Patient 8’s skin in the buttocks area, a visible half dimed size opening, with a red base, was visible. LVN 2 stated the opening was a stage 2 pressure wound (loss of the top layer of the skin exposing the second layer). LVN 2 stated the buttocks area had redness only in the previous visit. During the observation of the assessment of Patient 8’s wound, LVN 2 did not measure the wound. During an interview on 3/4/2026, at 10:42 a.m., with LVN 2, LVN 2 stated had the CHHA noticed the presence of the wound, the CHHA would have notified the office. The office would have notified LVN 2. LVN 2 stated, “nobody notified me”. During an interview on 3/4/2026, at 11:05 a.m., with LVN 2, LVN 2 stated the wound should have been measured. LVN 2 stated she did not measure the wound because she got nervous. LVN 2 was supposed to measure the wound to notify the doctor of the size, as this will determine the type of treatment. During an interview on 3/4/2026, at 11:10 a.m., with LVN 2, LVN 2 stated it was important for the LVN 2 to have been aware of the wound so LVN 2 could have prepared on what to do such as wound care and education. LVN 2 stated LVN 2 should have been notified right away. LVN 2 stated the protocol of the HA was for the CHHA to notify the office, and the office was supposed to notify the nurse. During an interview on 3/5/2026, at 11:44 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the CHHA had notified her of the presence of a wound yesterday, 3/4/2026, at around noon. ===== During a concurrent interview and record review on 3/5/2026, at 12:40 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 reviewed the employee files of the Licensed Vocational Nurses, CHHA’s and RN’s. LVN 1 stated there were no competency verification documents present. LVN 1 stated, “we just go over a list and ask them if they know how to do it”. LVN 1 stated the HA verifies the knowledge of the items listed based on the staff response of yes or no. LVN 1 stated the HA was a new agency and did not know staff were supposed to have someone sign off the skills of the nurses. LVN 1 stated the importance of a skill competency was to know what skills staff are proficient at. During a concurrent interview and record review conducted on 3/6/2026 at 12:29 p.m. with the Director of Nurses (DON), the DON reviewed Patient 8’s document titled “HA (Hospice Aide) Assignment,” dated 11/1/2025. The DON stated this document represented the plan of care the Certified Home Health Aide (CHHA) was expected to follow. The record indicated, “If the patient is experiencing pain or a change in condition, notify the RN (Registered Nurse).” The DON confirmed that the CHHA was required to notify the RN, as the presence of a wound constituted a change in the patient’s condition. The DON further stated that the RN is responsible for notifying the physician, obtaining and implementing new or revised orders, and adjusting the level of care as necessary. Failure to notify the RN had the potential to result in a delay in assessment, intervention, and treatment, placing the patient at risk for unmet care needs, worsening condition, and avoidable harm due to lack of timely clinical response.During a record review of the HA’s undated documents titled, “Butterfly Hospice Nursing Competency List, Butterfly Hospice Director of Nursing (DON) Job Description, Butterfly Hospice Registered Nurse (RN) Job description, Butterfly Hospice Licensed Vocational Nurse (LVN) Job Description, Butterfly Hospice Hospice Home Health Aide (HHA) Job description, Butterfly Hospice Medical Socil Worker (MSW) Job Description, Butterfly Hospice Spiritual (SC) Job Description”, indicated titles of skills. The document did not specif criteria for competency. During a record review of the HA’s undated policy titled, Competency Program, indicated, “Procedure...The organization will clearly identify and define the skills, which are essential to observe for the determination of competence, for each category...A preceptor will be assigned to each new staff member as part of the orientation process. The preceptor/supervisor will observe and deem proficient the indicated skills and core competencies...Organization personnel will not provide the care or service independently until satisfactory completion of required skills competency. During a record review of the HA’s undated policy titled, Competency Assessment, indicated, Procedure...Using a Competency Skills Performance Checklist, and the Orientation Checklist, the preceptor/Clinical Supervisor will observe the new personnel performing the required skills and activities.””

“Based on observation, interview and record review, the Hospice Agency failed to ensure the medical director and/or physician designee reviewed patients clinical information to determine hospice care criteria is met and/or provide an initial written Certification of Terminal Illness (CTI) that the patient had six months or less to live if the illness runs its normal course for one of fourteen sample patients (Patient 7). These deficient practices resulted in the hospice medical director and/or the designee certified patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses. It also resulted in patients not being certified by a medical doctor for hospice care, which can result in lack of and inappropriate care being provided to the patients. During an interview on 3/6/2026 at 9:10 a.m. with the Medical Director 1 (MD1), MD1 stated that it was important to sign patients CTI at the time of hospice admission, or two days at most after hospice admission to ensure it is the appropriate way for the patient. MD1 stated that his (MD1) signature on patients CTIs indicate the patient was appropriate for hospice admission, where the patient had six months or less to live. During an interview on 3/6/2026, at 9:21 a.m., with MD 1, MD 1 stated the certification of terminal illness was to justify hospice admission. 1. During a record review of Patient 7’s medical record form titled “Personal Information” indicated a referral date of 11/19/2025, with a primary diagnosis of acute respiratory failure with hypoxia (insufficient oxygen to the body). During a record review on 3/5/2026 at 6:47 a.m. of Patient 7’s undated medical record titled “Certification List” and F2F (face to face) Visit Notes List” indicated both did not contain documentation. During a record review of undated form titled “Outlook” the form indicated the Medical Director 1 (MD1) sent an email to Licensed Vocational Nurse 2 (LVN2) containing Patient 7’s facetime (videotelephony) conducted on 11/13/2025. The Outlook form indicated MD1 had a face to face with Patient 7 on 11/13/2025 with the assistance of nursing. The form also indicated that Patient 7’s plan was to “Begin hospice care.” During a concurrent interview and record review on 3/6/2026 at 9:26 a.m. with the Medical Director 1 (MD1) of Patient 7’s medical record, the MD1 stated that he (MD1) conducted a facetime session with Licensed Vocational Nurse 2 (LVN2) assistance of Patient 7 on 11/13/2025. MD1 stated he (MD1) did not actually see Patient 7 but did hear LVN2s assessment/report. MD1 stated that he (MD1) admitted Patient 7 for hospice services. MD1 stated that he does not remember if he (MD1) wrote a CTI for Patient 7. MD1 stated that CTIs are important “because the physician needs to certify that the patient is terminally ill and appropriate for hospice care.” During an interview on 3/6/2026 at 11:48 a.m. with Registered Nurse 2 (RN2), RN2 stated she (RN2) did not have any involvement with Patient 7’s care. RN2 stated that she (RN2) never met Patient 7 or his family. RN2 stated that she (RN2) did not assess Patient 7. RN2 stated that LVN2 was the hospice nurse that contacted the MD1, and Patient 7’s family. RN2 stated that she (RN2) did not speak with LVN2 regarding Patient 7’s admission. RN2 stated that LVN2 “assessed the patient for me”. RN2 stated “we are allowed to work with LVNs and accept their assessment.” RN2 stated that “because the patient died, I never had a chance to do a real assessment, I thought we were able to use the LVN assessment.” Lastly, RN2 stated she (RN2) documented Patient 7’s initial comprehensive nursing assessment because she (RN2) thought the HA needed to finish the visit but believes License Vocational Nurse 1 (LVN1) deleted her (RN2) assessment. During a record review of the HA’s policy titled, Hospice Medical Director, dated 5/2024, indicated, “Essential Job Functions/Responsibilities...Reviewing patients’ medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care written certification of terminal illness.” During a record review of the HA’s document titled, Certification of Terminal Illness”, dated 4/2019, indicated, “At the time of admission to hospice, the hospice Medical Director or the patient’s attending physician will complete a certification narrative that reflects the patient’s individual circumstances based on: his/her review of the patient’s medical record or, if applicable, examination of the patients...The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election...Clinical information and other documentation that supports the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification.””

“Based on interview and record review, the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure twelve of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 13) medical records included visit notes, plan of care, and assessments. This failure resulted in an incomplete medical record and had the potential to result in harm to the patient by not having medical records documented to monitor their plan of care and response to treatment, to determine if a change of care was needed. 1. During a record review of Patient 1’s undated medical record form titled “Personal Information” the record indicated a start of care date of 10/31/2025 with a primary diagnosis of Alzheimer’s Disease (slow progressive memory decline). During a record review on 3/4/2026 at 8:23 a.m. of Patient 1’s undated medical record titled “History of HA (home aide) Visits” indicated Patient 1 did not have documented CHHA (Certified Home Health Aide) visit notes from 11/1/2025 to 1/17/2026. During a concurrent interview and record review on 3/6/2026 at 1:08 p.m. with the Director of Nurses (DON) of Patient 1’s medical record, the DON stated that Patient 1 was to have twice a week CHHA visits. The DON stated that Patient 1’s first documented CHHA visit was on 1/20/2026. The DON stated that it was important to have visits notes as proof that care was provided. The DON stated that the CHHA was to document the visit notes, 7 days at most after the visit. 2. During a record review of Patient 2’s undated medical record form titled “Personal Information” the record indicated a start of care date of 12/27/2025 with a primary diagnosis of Alzheimer’s Disease. During a record review on 3/4/2026 at 8:57 a.m. of Patient 2’s medical record titled “History of HA Visits” undated, indicated Patient 2 did not have documented CHHA visit notes from 12/30/2025 to 1/17/2026. During a concurrent interview and record review on 3/6/2026 at 1:40 p.m. with the DON of Patient 2’s medical record, the DON stated that Patient 2 was to have CHHA visits three times per week. The DON stated that Patient 2’s first documented CHHA visit was on 1/20/2026. The DON stated that there was no documented proof Patient 2 received CHHA visits, and that it was important to document so that the HA is aware the orders were being followed. 3. During a record review of Patient 3’s medical record form titled “Comprehensive Nursing Assessment (HOPE Admission) dated 2/5/2026, the record indicated a start of care date of 2/5/2026, with a primary diagnosis of Alzheimer’s disease. During a record review of Patient 3’s medical record titled “POC/IDG Review” dated 2/6/2026, the record indicated Patient 3 was to have CHHA visits three times per week. During a record review of Patient 3’s medical record titled “Plan of Care” dated 3/4/2026, the POC indicated Patient 3 was to have CHHA visits three times per week. During a record review on 3/4/2026 at 9:25 a.m. of Patient 3’s undated medical record titled “History of HA Visits” the record indicated Patient 3 did not have any documented CHHA visit notes. During a concurrent interview and record review on 3/6/2026 at 1:46 p.m. with the DON of Patient 3’s medical record, the DON stated that he (DON) does not know why the CHHA visit notes are not being documented. 4. During a record review of Patient 4’s undated medical record form titled “Personal Information” the form indicated a start of care date of 11/14/2025 and an end care of date of 11/30/2025, with a primary diagnosis of Alzheimer’s Disease. During a record review on 3/6/2026 at 5:55 a.m. of Patient 4’s undated medical record titled “History of HA Visits” the record indicated Patient 4 did not have any documented CHHA visit notes from 11/15/2025 to 11/29/2025. During a concurrent interview and record review on 3/6/2026 at 1:49 p.m. with the DON of Patient 4’s medical record, the DON stated that he (DON) does not know why the CHHAs are not documenting. 5. During a record review of Patient 5’s undated medical record form titled “Personal Information” indicated a start of care date of 11/7/2025 and an end care of date of 1/15/2026, with a primary diagnosis of Alzheimer’s Disease. During a record review on 3/6/2026 at 6:25 a.m. of Patient 5’s undated medical record titled “History of HA Visits” the history indicated Patient 5 did not have any documented CHHA visit notes from 11/10/2025 to 1/14/2026. During a concurrent interview and record review on 3/6/2026 at 1:50 p.m. with the DON of Patient 5’s medical record, the DON stated Patient 5 was to have CHHA visits twice per week. The DON stated that Patient 5 did not have any CHHA visit documented. 6. During a record review of Patient 6’s undated medical record form titled “Personal Information” the record indicated a start of care date of 11/1/2025 and an end of care date of 11/29/2025 with an admitting diagnosis of end stage renal disease (kidney not functioning). During a record review on 3/6/2026 at 6:37 a.m. of Patient 6’s undated medical record titled “History of HA Visits” the record indicated Patient 6 did not have any documented CHHA visit notes from 11/4/2025 to 11/29/2025. 7. During a record review of Patient 7’s medical record form titled “Personal Information” indicated a referral date of 11/19/2025, with a primary diagnosis of acute respiratory failure with hypoxia (insufficient oxygen to the body). During a record review of Patient 7s’ medical record, the record indicated the sections for History of nursing assessment, History of POC/IDG (plan of care/interdisciplinary group), History of Visit Notes, F2F (face to face) Visit Notes List, and Certification List were empty. During a concurrent interview and record review on 3/5/2026 at 12:40 p.m. with Licensed Vocational Nurse 1 (LVN1) of an undated form titled “Outlook” LVN1 stated the Medical Director 1 (MD1) sent an email to Licensed Vocational Nurse 2 (LVN2) containing Patient 7’s face to face on 11/13/2025. The Outlook form indicated MD1 had a face to face with Patient 7 on 11/13/2025 with the assistance of nursing. The form also indicated that Patient 7’s plan was to “Begin hospice care.” During a concurrent interview and record review on 3/6/2026 at 9:26 a.m. with the Medical Director 1 (MD1) of Patient 7’s medical record, the MD1 stated that he (MD1) conducted a facetime session with assistance from Licensed Vocational Nurse 2 (LVN2) of Patient 7 on 11/13/2025. MD1 stated that he (MD1) admitted Patient 7 for hospice services. MD1 stated that he does not remember if he (MD1) wrote a CTI for Patient 7. MD1 stated he did not recall if he signed physician orders for Patient 7. During an interview on 3/6/2026 at 11:48 a.m. with Registered Nurse 2 (RN2), RN2 stated she (RN2) did not have any involvement with Patient 7’s care. RN2 stated that she (RN2) never met Patient 7 or his family. RN2 stated that she (RN2) did not assess Patient 7. RN2 stated that LVN2 was the hospice nurse that contacted the MD1, and Patient 7’s family. RN2 stated that she (RN2) did not speak with LVN2 regarding Patient 7’s admission. RN2 stated that LVN2 “assessed the patient for me”. RN2 stated “we are allowed to work with LVNs and accept their assessment.” RN2 stated that “because the patient died, I never had a chance to do a real assessment, I thought we were able to use the LVN assessment.” Lastly, RN2 stated she (RN2) documented Patient 7’s assessment because she (RN2) thought the HA needed to finish the visit but believes LVN1 deleted her (RN2) assessment. During an interview on 3/6/2026 at 12:13 p.m. with License Vocational Nurse 1 (LVN1), LVN1 stated that she (LVN1) deleted Patient 7’s comprehensive nursing assessment documented by RN2, because she (LVN1) was told to do so by a consultant. LVN1 stated that she (LVN1) was told that since Patient 7 was not seen or had a full assessment by a registered nurse, he (Patient 7) was a non-admit. During a concurrent interview and record review on 3/6/2026 at 2 p.m. with the Director of Nurses (DON) of Patient 7’s medical record, the DON stated that Patient 7’s medical record did not contain an RN assessment or skilled nurse visit notes. 8. During a record review of Patient 8’s document titled Personal Information, indicated a start of care on 11/1/2025, with a terminal diagnosis of Alzheimer’s disease (slow progressive memory decline). During a concurrent interview and record review on 3/6/2026, at 12:21 p.m., with the DON, the DON reviewed Patient 8’s CHHA visit notes. The DON stated the last CHHA visit note documented was on 2/2/2026. The DON stated Patient 8 was receiving CHHA services twice a week. The DON stated the visit notes were required to be in the medical record within 5-7 days from the visit. The purpose of the note was to document the patients progress or any change of condition. The DON stated he was not sure why the visit notes had not been documented since 2/2/2026. The DON stated clinical notes documentation was important because it gave a picture of the patient condition, response to treatment. Any deviation to the plan of care, deterioration of the patient was not documented. The DON stated if it was not documented, it did not happen. During a concurrent interview and record review on 3/6/2026, at 12:35 p.m., with the DON, the DON reviewed Patient 8’s skilled nurse (SN) visit notes for 2/16/2026, 2/19/2026, 2/23/2026, 2/26/2026. The record indicated LVN 1 was the visiting nurse for all these dates. The DON stated the notes were not complete and were missing vital signs, assessment details, narrative, and care provided. During an interview on 3/6/2026, at 12:36 p.m., with LVN 1, LVN 1 stated the reason the SN visit notes were not documented because LVN 1 had a lot going on and she had been behind. LVN 1 stated it was not acceptable nursing practice to not document nursing visit notes. 9. a. During a record review of Patient 9’s record document titled, Personal Information, indicated a start of care on 2/6/2026, with a terminal diagnosis of heart failure (heart is unable to pump blood to the body effectively). During a concurrent interview and record review on 3/6/2026, at 12:42 p.m., with the DON, the DON reviewed Patient 9’s record titled, HA Assignment, dated 2/6/2026. The record indicated instructions for care during each visit. The DON further reviewed Patient 9’s medical records and the review indicated the absence of CHHA visit notes. b. During a concurrent interview and record review on 3/6/2026, at 12:45 p.m., with the DON, the DON reviewed Patient 9’s plan of care titled, POC Summary, dated 3/6/2026. The DON stated the POC summary was incomplete because it was missing Patient 9’s issues, frequency of visits, and nursing interventions. The DON stated the IDG group was supposed to complete the POC by the 5th day of admission. 10. a. During a record review of Patient 10’s record document titled, Personal Information, indicated a start of care on 2/28/2026, with a terminal diagnosis of senile degeneration of the brain (age related decline in cognitive status, resulting in brain cell death). During a concurrent interview and record review on 3/6/2026, at 12:53 p.m., with the DON, the DON reviewed Patient 10’s medical records. The DON stated Patient 10’s spiritual assessment had not been done. The spiritual assessment was supposed to be completed within 5 days of admission, by 3/5/2026. The purpose of the spiritual assessment was to assess the spiritual needs of the patient and family, to determine further interventions for spiritual needs. The risk of not having a spiritual assessment was if patient died, the patient would not have the last rights, or any other spiritual service required. The DON stated he was not aware the spiritual assessment had not been done. b. During a concurrent interview and record review on 3/6/2026, at 12:57 p.m., with the DON, the DON reviewed Patient 10’s plan of care titled, POC Summary, dated 3/4/2026. The DON stated the POC summary was incomplete because it was missing Patient 10’s nursing interventions, frequency of visits, treatments, issues, DME (durable medical equipment). The DON stated the only thing he read on the POC was the medications. The POC also did not have interventions or goals. The DON stated he did not know what the needs of Patient 10 was because POC was blank. The DON was asked what services were being provided to Patient 10, since there was no POC. The DON stated he assumed a physical assessment and assessment of needs was being done. c. During a concurrent interview and record review on 3/6/2026, at 12:57 p.m., with the DON, the DON reviewed Patient 10’s medical records. The DON stated there was no nursing notes in Patient 10’s medical records. 11. During a record review of Patient 11’s record document titled, Personal Information, indicated a start of care on 12/8/2026, with a terminal diagnosis of Alzheimer’s disease (slow progressive memory decline). During a concurrent interview and record review on 3/6/2026, at 1:03 p.m., with the DON, the DON reviewed Patient 11’s CHHA visit notes. The DON stated the last CHHA note documented was on 2/2/2026. The DON stated Patient 11 was currently being seen twice a week. 12. During a record review of Patient 13’s record document titled, Personal Information, indicated a start of care on 2/23/2026, with a terminal diagnosis of chronic kidney disease stage 5 (kidneys do not work properly and are unable to remove waste from the body). The record also indicated Patient 13 died on 2/24/2026. During a concurrent interview and record review on 3/6/2026, at 2:03 p.m., with the DON, the DON reviewed Patient 13’s plan of care titled, POC Summary, dated 3/6/2026. The DON stated the POC was not completed; the only items listed were the medications. There were no interventions, treatment, patient goals, patient issues, frequency of visits listed, DME, listed. The DON continued to review Patient 13’s medical records and stated there was no nursing notes for Patient 13. During an interview on 3/6/2026, at 2:07 p.m., with LVN 1, LVN 1 stated the nurse visited Patient 13 for the initial start of care visit and no additional visits were done. A nurse went to visit Patient 13 the following day for a death visit, but the nurse did not document the death visit. During a record review of the HA’s document titled, Clinical/Service Data Collection, dated 5/2024, indicated, “A clinical/service record will be initiated and maintained for each patient receiving care or services according to organization policies found in this manual and will include at a minimum...Physician...orders and evidence of physician oversight activities...dates, times, and types of interventions, assessments, and coordination of care/services...Entries into the clinical/service will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday.””

“Based on interview and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure one of fourteen sample selected patients (Patient 7) medical record included physician orders. This failure resulted in HA staff not knowing what services were ordered for the patients. During a record review of Patient 7’s medical record form titled “Personal Information” indicated a referral date of 11/19/2025, with a primary diagnosis of acute respiratory failure with hypoxia (insufficient oxygen to the body). During a concurrent interview and record review on 3/5/2026 at 12:40 p.m. with Licensed Vocational Nurse 1 (LVN1) of an undated form titled “Outlook” LVN1 stated the Medical Director 1 (MD1) sent an email to Licensed Vocational Nurse 2 (LVN2) containing Patient 7’s face to face on 11/13/2025. The form also indicated that Patient 7’s plan was to “Begin hospice care”. During a concurrent interview and record review on 3/6/2026 at 9:26 a.m. with the Medical Director 1 (MD1) of Patient 7’s medical record, the MD1 stated that he (MD1) admitted Patient 7 for hospice services. MD1 stated while reviewing Patient 7’s physician orders, “Yes, I seemed to remember giving some kind of comfort kit order. These look like my orders. I don’t see that I have signed these orders. Orders are supposed to be signed by a physician, you want to make sure that everything is correct, and the physician is aware of what was given. I guess it is missing a signature, in a sense it wouldn’t be valid order.” During an interview on 3/6/2026 at 12:13 p.m. with License Vocational Nurse 1 (LVN1), LVN1 stated that she (LVN1) deleted Patient 7’s comprehensive nursing assessment documented. LVN1 stated that she (LVN1) was told that since Patient 7 was not seen or had a full assessment by a registered nurse, he (Patient 7) was a non-admit. During a concurrent interview and record review on 3/6/2026 at 2 p.m. with the Director of Nurses (DON) of Patient 7’s medical record, the DON stated that Patient 7 did have admission and comfort medications dated 11/19/2025 in his (Patient 7) medical record, but that the orders did contain a physicians signature. During a record review of the HA’s document titled, Clinical/Service Data Collection, dated 5/2024, indicated, “A clinical/service record will be initiated and maintained for each patient receiving care or services according to organization policies found in this manual and will include at a minimum...Physician...orders and evidence of physician oversight activities...”.”

“Based on interview and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure clinical records were appropriately authenticated for two of fourteen sample selected patients (Patient 6 and Patient 7). This failure has the potential to result in an unauthorized and inaccurate patient information or assessment will be entered in the patients’ clinical record that could affect the patient’s quality of care and well-being. 1. During a record review of Patient 6’s undated medical record form titled “Personal Information” indicated a start of care date of 11/1/2025 and an end of care date of 11/29/2025 with an admitting diagnosis of end stage renal disease (kidney not functioning). During a record review of Patient 6’s medical record form titled “Audit Log – IDG” dated from 11/2/2025 to 3/6/2026, indicated Patient 6 ‘s initial IDG dated 11/3/2025 was signed by the Medical Director (MD1) on 12/8/2025, the Medical Social Worker (MSW) on 1/2/2026, Registered Nurse 2 (RN2) on 12/13/2025, and the Spiritual Counselor (SC) on 1/3/2026. 2. During a record review of Patient 7’s medical record form titled “Personal Information” indicated a referral date of 11/19/2025, with a primary diagnosis of acute respiratory failure with hypoxia (insufficient oxygen to the body). During a record review of Patient 7’s medical record form titled “Plan of Care” dated 3/5/2026, the form did not indicate who the author was. During a record review of Patient 7’s undated medical record form titled “Physicians Orders” the form did not indicate who the author was. During a concurrent interview and record review on 3/6/2026 at 9:26 a.m. with the Medical Director 1 (MD1) of Patient 7’s medical record, the MD1 stated while reviewing Patient 7’s physician orders, “Yes, I seemed to remember giving some kind of comfort kit order. These look like my orders. I don’t see that I have signed these orders. Orders are supposed to be signed by a physician, you want to make sure that everything is correct, and the physician is aware of what was given. I guess it is missing a signature, in a sense it wouldn’t be valid order.” 3. During a record review of Patient 8’s document titled Personal Information, indicated a start of care on 11/1/2025, with a terminal diagnosis of Alzheimer’s disease (slow progressive memory decline). During a record review of Patient 8’s record titled, POC/IDG Review, dated 1/9/2026, 1/23/2026, 2/6/2026, and 2/20/2026 did not indicate a signature to validate that Medical Director 1 (MD 1) had attended the IDG meetings. 4. During a record review of Patient 9’s record document titled, Personal Information, indicated a start of care on 2/6/2026, with a terminal diagnosis of heart failure (heart is unable to pump blood to the body effectively). During a record review of Patient 9’s record titled, POC/IDG Review, dated 2/20/2026 did not indicate a signature to validate that Medical Director 1 (MD 1) had attended the IDG meetings. 5. During a record review of Patient 11’s record document titled, Personal Information, the record indicated a start of care on 12/8/2026, with a terminal diagnosis of Alzheimer’s disease (slow progressive memory decline). During a record review of Patient 11’s record titled, POC/IDG Review, dated 1/9/2026, 1/23/2026, 2/6/2026, and 2/20/2026, the records did not indicate a signature to validate Medical Director 1 (MD 1) had attended the IDG meetings. During a record review of the HA’s policy titled, Clinical/Service Data Collection, 5/2024, indicated “ The clinical/service note will include: A. What care/service was provided...E. Signature of clinician/technician and his/her credentials.” During a record review of the HA’s policy titled, Interdisciplinary Group Meeting, dated 4/2019, the policy indicated, “Members of the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor.””

“Upon home visits and patient record review, 2 of 14 (Patient #2,4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2 resides in a Board and Care home and was a home visit. The facility MAR did not “mirror” the medications on the HSP POC and med profile dated 8/21/24. The facility MAR included the following meds that were not on the HSP POC: Triamcinolone 0.1% ointment, apply to affected area topically after each incontinence. Diclofenac Sodium apply topically to affected area 3x daily as needed for pain. The HSP POC included the following meds that were not on the facility MAR: Triple antibiotic ointment apply topically daily and as needed and prn for soiled or dislodged dressing . (proper wound care orders in instruction), Oxygen 2L/min via N/C as needed for shortness of breath. The following medications on the HSP POC had discrepancies in the dose &/or frequency on the facility MAR as follows: Ipratropium Bromide/Albuterol sulfate 0.5mg-3mg/3ml for inhalation, one vial via nebulizer every 4 hours as needed for wheezing. The facility order stated every 6 hours as needed. Lorazepam 2mg/ml give 0.25ml (0.5mg) Sublingual every 4 hours as needed for anxiety. Facility order stated every 6 hours as needed. Morphine Sulfate 20mg/ml give 0.25ml (5mg) every 2 hours as needed for pain or dyspnea. Facility order stated every 4 hours as needed. Ondansetron 8mg ODT every 6 hours as needed for N/V. Facility order stated 4mg . Amlodipine Besylate 5mg tablet oral once daily. Facility order states 10mg daily. Docusate Sodium 50mg/5ml give 5ml oral twice daily. Facility order states 10ml twice daily. corrected on site Patient #4 resides in a Board and care home and was a home visit. Facility MAR did not “mirror” the medications on the HSP POC and med profile. HSP POC included the following meds that were not on the facility MAR: Ipratropium Bromide/ Albuterol Sulfate0.5mg-3mg/3ml solution for inhalation 1 vial per nebulizer every 4 hours as needed for wheezing. The following medications on the HSP POC had discrepancies in the dose &/or frequency on the facility MAR as follows: Lactulose solution 10G/15ml give 15ml oral once daily as needed for constipation. Facility order states to give 30ml oral twice daily as needed. Lorazepam 2mg/ml give 0.25ml (0.5mg) Sublingual every 4 hours as needed for anxiety. Facility order stated take 0.5mg (0.25mg) every 2 hours as needed. Morphine Sulfate 20mg/ml give 0.25ml (5mg) every 4 hours as needed for pain or dyspnea. Facility order stated every 2 hours as needed. Ondansetron 8mg ODT every 6 hours as needed for N/V. Facility order stated 4mg every 4 hours as needed. Acetaminophen Suppository 650mg Rectal every 6 hours as needed for pain or fever > 100 degrees F. Facility order stated every 4 hours as needed. corrected on site”

“Upon home visits and patient record review, 2 of 14 (Patient #2,4) 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 #2 resides in a Board and Care home and was a home visit. The facility MAR did not “mirror” the medications on the HSP POC and med profile dated 8/21/24. The facility MAR included the following meds that were not on the HSP POC: Triamcinolone 0.1% ointment, apply to affected area topically after each incontinence. Diclofenac Sodium apply topically to affected area 3x daily as needed for pain. The HSP POC included the following meds that were not on the facility MAR: Triple antibiotic ointment apply topically daily and as needed and prn for soiled or dislodged dressing . (proper wound care orders in instruction), Oxygen 2L/min via N/C as needed for shortness of breath. The following medications on the HSP POC had discrepancies in the dose &/or frequency on the facility MAR as follows: Ipratropium Bromide/Albuterol sulfate 0.5mg-3mg/3ml for inhalation, one vial via nebulizer every 4 hours as needed for wheezing. The facility order stated every 6 hours as needed. Lorazepam 2mg/ml give 0.25ml (0.5mg) Sublingual every 4 hours as needed for anxiety. Facility order stated every 6 hours as needed. Morphine Sulfate 20mg/ml give 0.25ml (5mg) every 2 hours as needed for pain or dyspnea. Facility order stated every 4 hours as needed. Ondansetron 8mg ODT every 6 hours as needed for N/V. Facility order stated 4mg . Amlodipine Besylate 5mg tablet oral once daily. Facility order states 10mg daily. Docusate Sodium 50mg/5ml give 5ml oral twice daily. Facility order states 10ml twice daily. corrected on site Patient #4 resides in a Board and care home and was a home visit. Facility MAR did not “mirror” the medications on the HSP POC and med profile. HSP POC included the following meds that were not on the facility MAR: Ipratropium Bromide/ Albuterol Sulfate0.5mg-3mg/3ml solution for inhalation 1 vial per nebulizer every 4 hours as needed for wheezing. The following medications on the HSP POC had discrepancies in the dose &/or frequency on the facility MAR as follows: Lactulose solution 10G/15ml give 15ml oral once daily as needed for constipation. Facility order states to give 30ml oral twice daily as needed. Lorazepam 2mg/ml give 0.25ml (0.5mg) Sublingual every 4 hours as needed for anxiety. Facility order stated take 0.5mg (0.25mg) every 2 hours as needed. Morphine Sulfate 20mg/ml give 0.25ml (5mg) every 4 hours as needed for pain or dyspnea. Facility order stated every 2 hours as needed. Ondansetron 8mg ODT every 6 hours as needed for N/V. Facility order stated 4mg every 4 hours as needed. Acetaminophen Suppository 650mg Rectal every 6 hours as needed for pain or fever > 100 degrees F. Facility order stated every 4 hours as needed. corrected on site”

“Upon personnel record review, 1 of 13 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- (C) Shampoo, sink, tub, and bed The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #5 only demonstrated “Shampoo”. The list did not include “Shampoo, sink,tub,bed.”