Carebest Hospice

“Based on interview and record review, the hospice failed to ensure the emergency preparedness plan was reviewed and updated at least every two years. This failure created the risk of not providing the necessary care and services to the patients during an emergency.Findings: Review of the hospice’s emergency preparedness P&P titled Emergency Management Plan (undated) was initiated on 7/23/25. The hospice’s Emergency Preparedness Plan showed the organization will comply with all applicable Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meet those regulations.Review of the hospice’s emergency disaster preparedness plan showed an approval date of 1/2/23. However, there was no documented evidence when the plan was reviewed and updated for the year of 2025, which was more than two years from the approval date of 1/2/23.On 7/24/25 at 0920 hours, an interview and concurrent hospice document review was conducted with the Administrator. The Administrator confirmed the emergency preparedness plan was not reviewed nor updated for the current year 2025.”

“Based on interview and record review, the hospice failed to ensure the emergency prepared program included the procedures to inform the State and local officials in the event the hospice was unable to contact any on-duty staff and patients during an emergency. This failure created the risk of not providing the necessary care and services during an emergency.Findings: Review of the hospice’s emergency preparedness program was initiated on 7/23/25. The documents did not include the procedures to inform the State and local officials of any on-duty staff or patients that they were unable to contact during an emergency.On 7/24/25 at 0920 hours, an interview and concurrent hospice document review was conducted with the Administrator. The Administrator was unable to provide documentation and confirmed the findings.”

“Based on interview and record review, the hospice failed to ensure the emergency preparedness program included the procedures to inform the State and local emergency preparedness officials about the patients in need of evacuation from their residences due to an emergency. This failure created the risk of not providing the necessary care and services to the patients during emergency.Findings: Review of the hospice’s emergency preparedness program was initiated on 7/23/25. The documents did not include the procedures on informing the State and local emergency preparedness officials about the patients in need of evacuation from their residences due to an emergency.On 7/24/25 at 0920 hours, an interview and concurrent hospice document review was conducted with the Administrator. The Administrator was unable to provide documentation and confirmed the findings.”

“Based on interview and record review, the hospice failed to ensure the hospice’s emergency preparedness program addressed the use of other emergency staffing strategies to address the surge needs during an emergency. This failure had the potential of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Findings: Review of the hospice’s emergency preparedness P&P titled Emergency Management Plan (undated) was initiated on 7/23/25. The Emergency Preparedness Plan showed the Administrator has been designated as key leadership who is responsible for all emergency activities and makes the decision to implement the emergency plan upon becoming aware of an emergency situation. Patients will be placed in one of three categories for triaging patient care in the event the emergency management plan (operations) is implemented.Review of the hospice’s Emergency Disaster Preparedness Plan approved on 1/2/23, showed the Administrator or designee will initiate the Pyramid Phone Communication Plan to notify personnel and community authorities.However, the hospice’s emergency management P&P and plan did not include the use of other emergency staffing strategies to address the surge needs, including which external staffing agencies to be used, or the role for the integration of the State and Federal designated health care professionals to address the surge needs during an emergency.On 7/24/25 at 0920 hours, an interview and concurrent hospice document review was conducted with the Administrator. The Administrator acknowledged the finding.”

“Based on interview and record review, the hospice failed to provide the patient or representative with the written notice of the patient’s rights and responsibilities in a language and manner that the patient understands for two of 15 sampled patients (Patients 1 and 4). This failure had the potential to negatively impact the quality of care provided to these patients. Findings: Review of Patient 1’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/23/25. The patient was certified for hospice services during the certification period from 4/5/25 to 7/3/25 and 7/4/25 to 10/1/25. The patient was transferred from another hospice on 5/23/25.Review of the face sheet showed Patient 1 was Hispanic. The primary language was left blank. Review of the patients admission packet included the Patient Handbook. The Patient Handbook included information related to the agency policies, criteria for admission, hospice concept, services, hospice team, Medicare level of hospice care, Medicare hospice benefits, advance directives and education materials. However, the documents were written in English instead of the language the patient understand. In addition, review of the informed consent and treatment authorization, advance directives, release of patient records, Medicare election statement, and the Patients /Family Rights and Responsibilities. Those documents were signed and dated on 5/23/25. However, the documents were written in English instead of the language the patient understand. On 7/16/25 at 1000 hours, a joint home visit with RN 1 was conducted to Patient 1’s home. Introductions were made. The patient and the PCG was observed to be Hispanic speaking. The patient and PCG had a family member to interpret the RN assessment and the conversation. On 7/16/25 at 1058 hours, an interview was conducted with the patient and the PCG. They were asked if they were able to understand the documents included on the admission packet. The PCG replied, No, preferred Spanish documents. The RN 1 was asked if they needed to provide the documents in the language the patient/PCG understands. The RN 1 reviewed the documents and stated all of the documents including the consent should be in Spanish. The RN 1 was informed and acknowledged the finding.On 7/24/25 at 1030 hours, an interview and concurrent document review was conducted with the Consultant. The Consultant was informed and acknowledged the finding. Review of the hospice’s P&P titled Patient Bill of Rights/Responsibilities revised April 2024 showed upon admission, the admitting clinician will provide each patient or his/her representative with a written copy of the Patient Bill of Rights/Responsibilities in advance of furnishing care. The Patient Bill of Rights/Responsibilities will be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services. This explanation will be in a language and manner he/she can reasonably be expected to understand. Written information will be provided to patients in the predominant languages of the population.1. Review of Patient 4’s clinical record was initiated on 7/16/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25.Review of the face sheet showed Patient 4 was Hispanic and his primary language was Spanish.Review of the patient’s admission packet included the following: the patient handbook, the informed consent and treatment authorization, advance directives, release of patient records, Medicare election statement, and the Patients /Family Rights and Responsibilities. Those documents were signed and dated on 5/20/25. *However, the documents were written in English instead of the language the patient understood. On 7/16/25 at 0951 hours, a joint home visit with LVN 1 was conducted to Patient 4’s home. Introductions were made and Patient 4 was observed speaking in Spanish to LVN 1. Patient 4 stated he did not speak English. LVN 1 was Spanish speaking. On 7/16/25 at 1048 hours, an interview was conducted with Patient 4. Patient 4 was shown the hospice binder and the documents printed in English; and was asked if he understood what was written in the documents. Patient 4 replied he did not understand English and would prefer the written documents in Spanish.On 7/16/25 at 1050 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the above finding. Review of the hospice’s P&P titled Patient Bill of Rights/Responsibilities revised April 2024 showed upon admission, the admitting clinician will provide each patient or his/her representative with a written copy of the Patient Bill of Rights/Responsibilities in advance of furnishing care. The Patient Bill of Rights/Responsibilities will be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services. This explanation will be in a language and manner he/she can reasonably be expected to understand. Written information will be provided to patients in the predominant languages of the population.1. Review of Patient 4’s clinical record was initiated on 7/16/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25.Review of the face sheet showed Patient 4 was Hispanic and his primary language was Spanish.Review of the patient’s admission packet included the following: the patient handbook, the informed consent and treatment authorization, advance directives, release of patient records, Medicare election statement, and the Patients /Family Rights and Responsibilities. Those documents were signed and dated on 5/20/25. *However, the documents were written in English instead of the language the patient understood. On 7/16/25 at 0951 hours, a joint home visit with LVN 1 was conducted to Patient 4’s home. Introductions were made and Patient 4 was observed speaking in Spanish to LVN 1. Patient 4 stated he did not speak English. LVN 1 was Spanish speaking. On 7/16/25 at 1048 hours, an interview was conducted with Patient 4. Patient 4 was shown the hospice binder and the documents printed in English; and was asked if he understood what was written in the documents. Patient 4 replied he did not understand English and would prefer the written documents in Spanish.On 7/16/25 at 1050 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the above finding.2. Review of Patient 1’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/23/25. The patient was certified for hospice services during the certification periods from 4/5/25 to 7/3/25 and 7/4/25 to 10/1/25. The patient was transferred from another hospice on 5/23/25.Review of the face sheet showed Patient 1 was Hispanic. The primary language was left blank. Review of the patient’s admission packet included the Patient Handbook. The Patient Handbook included information related to the agency’s policies, criteria for admission, hospice concept, services, hospice team, Medicare level of hospice care, Medicare hospice benefits, advance directives and education materials. In addition, review of the informed consent and treatment authorization, advance directives, release of patient records, Medicare election statement, and the Patients /Family Rights and Responsibilities was conducted. Those documents were signed and dated on 5/23/25. On 7/16/25 at 1000 hours, a joint home visit with RN 1 was conducted to Patient 1’s home. Introductions were made. The patient and the PCG was observed to be Hispanic speaking. The patient and PCG had a family member to interpret the RN assessment and the conversation. On 7/16/25 at 1058 hours, an interview was conducted with the patient and the PCG. They were asked if they were able to understand the documents included in the admission packet. The PCG stated no and preferred Spanish written documents. RN 1 was asked if they needed to provide the documents in the language the patient/PCG understands. RN 1 reviewed the documents and stated all of the documents including the consent should be in Spanish. RN 1 was informed and acknowledged the finding.* The documents were written in English instead of the language the patient understood. On 7/24/25 at 1030 hours, an interview and concurrent document review was conducted with the Consultant. The Consultant was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to provide the accurate information for filing a complaint for one of 15 sampled patients (Patient 1). This failure had the potential for complaints to not be investigated timely as the information was inaccurate.Findings: Review of Patient 1’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/23/25. The patient was certified for hospice services during the certification periods from 4/5/25 to 7/3/25 and 7/4/25 to 10/1/25. The patient was transferred from another hospice on 5/23/25.Review of the patient’s admission packet included the Patients Handbook. The Patients Handbook included a section related to the Complaint/Grievance Process. However, the telephone contact information for the CDPH, L&C Program was 1-800 -228-1019 which was for LA county instead of Orange County where the hospice was located.On 7/16/25 at 1000 hours, a joint home visit with RN 1 was conducted to Patient 1’s home. The patient and PCG were Spanish speaking. The patient and PCG had a family member to interpret the RN assessment and conversation. On 7/16/25 at 1058 hours, an interview was conducted with the patient and PCG. They were asked if they knew how to contact the CDPH, L&C Program in case they needed to file the complaint. The PCG replied no. RN 1 reviewed the admission packet and showed the telephone number listed on how to file a complaint. RN 1 was asked to call the telephone number listed. RN 1 called the telephone number and verified the telephone number was for the CDPH, LA county and not for Orange County where the hospice was located. RN 1 was informed and acknowledged the findings.On 7/24/25 at 1030 hours, an interview and concurrent record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the comprehensive assessments were completed no later than five calendar days after the election of hospice care for four of 15 sampled patients (Patients 2, 4, 11, and 15). This failure had the potential for not addressing the care needs for these patients.Findings: Review of the hospice’s P&P titled Comprehensive Assessment revised April 2020 showed 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 attending physician. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient’s clinical record.1. Review of Patient 2’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/22/25. The patient was certified for hospice services during the certification period from 5/22/25 to 8/1/25.The election of hospice benefit form dated 5/22/25, showed Patient 2 signed for hospice services.Review of the physician’s orders dated 5/22/25, showed to administer Tradjenta (antidiabetic drug) 5 mg on tablet oral daily, glipizide (antidiabetic drug) 10 mg one tablet oral daily, and pioglitazone hydrochloride (antidiabetic drug) 30 mg one tablet oral daily for patient’s diabetes.The initial comprehensive nursing assessment dated 5/22/25, showed no documented evidence the SN completed the assessment for the need for volunteer and comorbidities for diabetes mellitus.The initial comprehensive psychosocial assessment dated 5/25/25, showed no documented evidence the MSW assessed for the patient’s mortuary information.The initial comprehensive spiritual assessment dated 5/26/25, showed no documented evidence the SC completed the PCG Faith Community Information or the PCG-Spiritual Distress/Concern Information.In addition, there was no documented evidence the comprehensive physical, psychosocial, and spiritual assessments were completed no later than 5 calendar days after the election of hospice care.On 7/24/25 at 1035 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS was informed and acknowledged the findings. 2. Review of Patient 4’s clinical record was initiated on 7/16/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25.The election of hospice benefit form dated 5/20/25, showed Patient 4 signed for hospice services.The Physician’s Certification for Hospice Benefit dated 5/20/25, showed a secondary diagnosis of Diabetes Mellitus Type 2.The initial comprehensive nursing assessment dated 5/20/25, showed no documented evidence the SN completed the assessment for the comorbidities for diabetes mellitus.The initial comprehensive psychosocial assessment dated 5/21/25, showed no documented evidence the MSW assessed the patient’s mortuary information.* The comprehensive physical and psychosocial assessments were not completed within 5 calendar days after the election of hospice care.On 7/24/25 at 0958 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS was informed and acknowledged the findings. 3. Review of Patient 11’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and revoked hospice services on 5/20/25.The election of hospice benefit form dated 3/6/25, showed Patient 11 signed for hospice services.The initial comprehensive psychosocial assessment dated 3/6/25, showed no documented evidence the MSW assessed for the patient’s mortuary information.In addition, there was no documented evidence the comprehensive psychosocial assessment was completed no later than 5 calendar days after the election of hospice care.On 7/24/25 at 1520 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS was informed and acknowledged the findings. 4. Review of Patient 15’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/22/24. The patient was certified for hospice services during the certification period from 3/22/24 to 6/19/24. The patient expired on 4/13/24.The election of hospice benefit form dated 3/20/24, showed Patient 15’s PCG signed for hospice services.The initial comprehensive spiritual assessment dated 3/22/24, showed no documented evidence the SC completed the Spiritual Circumstances, Patient/PCG Faith Community Information, or the PCG-Spiritual Distress/Concern Information.The initial comprehensive psychosocial assessment dated 3/26/24, showed no documented evidence the MSW assessed the patient’s need for volunteer.* However, there was no documented evidence the comprehensive psychosocial and spiritual assessments were completed no later than 5 calendar days after the election of hospice care.On 7/24/25 at 1451 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the comprehensive assessments identified the emotional, psychosocial, and spiritual needs for eight of 15 sampled patients (Patients 2, 3, 4, 8, 9, 11, 12, and 15). This failure had the potential risk of not providing care and services to meet the care needs for these patients.Findings: #. Review of Patient 2’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/22/25. The patient was certified for hospice services during the certification period from 5/22/25 to 8/1/25.The initial comprehensive nursing assessment dated 5/22/25, showed the RN assessment for the need for volunteer and comorbidities for diabetes mellitus were left blankThe initial comprehensive psychosocial assessment dated 5/25/25, showed the MSW assessment for the patient’s mortuary information was left blank.The initial comprehensive spiritual assessment dated 5/26/25, showed SC assessment for the PCG Faith Community Information or the PCG-Spiritual Distress/Concern Information was incomplete.On 7/24/25 at 1035 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the findings. #. Review of Patient 4’s clinical record was initiated on 7/16/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25.The initial comprehensive nursing assessment dated 5/20/25, showed the SN assessment for the comorbidities for diabetes mellitus was left blank.The initial comprehensive psychosocial assessment dated 5/21/25, showed the MSW assessment for the patient’s mortuary information was left blank.On 7/24/25 at 0958 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the findings. #. Review of Patient 11’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and revoked hospice services on 5/20/25.The initial comprehensive psychosocial assessment dated 3/6/25, showed the MSW assessment for the patient’s mortuary information was left blankOn 7/24/25 at 1520 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the findings. #. Review of Patient 15’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/22/24. The patient was certified for hospice services during the certification period from 3/22/24 to 6/19/24. The patient expired on 4/13/24.The initial comprehensive spiritual assessment dated 3/22/24, showed the SC assessment for the Spiritual Circumstances, Patient/PCG Faith Community Information or the PCG-Spiritual Distress/Concern Information was incomplete.The initial comprehensive psychosocial assessment dated 3/26/24, showed the MSW assessment for the patient’s need for volunteer was left blankOn 7/24/25 at 1451 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the findings. #. Review of Patient 8’s clinical record review was initiated on 7/17/24. The clinical record showed the SOC was 2/7/25. The patient was certified for hospice services during the certification periods from 2/7/25 to 5/7/25 and 5/8/25 to 8/5/25.a.The initial comprehensive nursing assessment dated 2/7/25, showed no documented evidence RN 2 completed the assessment for the patient’s MAC, stool, frequency of BM, last BM and sleep duration.b.The initial comprehensive psychosocial assessment completed by RN 2 on 2/7/25 showed the mortuary info as pending. However, the MSW 1 had completed a comprehensive psychosocial assessment of the patient on 5/7/25 still showing no documented evidence for mortuary info. On 7/24/25 at 0953 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. #.Review of Patient 9’s clinical record review was initiated on 7/17/25. The clinical record showed the SOC was 2/4/25. The patient was certified for hospice services during the certification period from 2/4/25 to 5/4/25 and 5/5/25 to 8/2/25.The initial comprehensive nursing assessment dated 2/4/25, showed no documented evidence RN 5 completed the MAC.On 7/24/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. #. Review of Patient 1’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/23/25. The patient was certified for hospice services during the certification periods from 4/5/25 to 7/3/25 and 7/4/25 to 10/1/25. The patient was transferred from another hospice on 5/23/25.Review of the Comprehensive Nursing Assessment dated 5/23/25, showed the RN 1 had had performed the initial comprehensive assessment. The assessment included a section for the Primary/Secondary diagnosis and Comorbidities. The secondary diagnoses includes essential hypertension - related, hyperlipidemia, unspecified- related; constipation, unspecified-unrelated and type 2 diabetes mellitus without complications- unrelated.Further review of the initial comprehensive assessment on the section of Nature & Condition of Terminal Illness/LCD Eligibility included a list of co-morbidities. The comorbidities included diabetes mellitus. However, the section where to check for diabetes mellitus as one of the comorbidities was left blank. On 7/24/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was asked if the section for the co-morbidities, needed to be filled out. The Consultant reviewed the clinical record and replied, it should have been filled out. The Consultant was informed and acknowledged the finding. #. Review of Patient 3’s clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25. a. Review of the Physician H&P dated 5/20/25 showed the list of patients comorbidities. The comorbidities included hypertension, diabetes mellitus, depression, diffuse joint degenerative disease and generalized weakness.Review of the Comprehensive Nursing Assessment dated 5/20/25, showed the RN 1 had performed the initial comprehensive assessment. The assessment included a section for the Primary/Secondary diagnosis and Comorbidities. However, the section for comorbidities was left blank.Further review of the initial comprehensive assessment included the section for Nature & Condition of Terminal Illness/LCD Eligibility. The section included comorbidities. However, the section where to check for diabetes mellitus as one of the comorbidities was left blank.b. Review of the Psychosocial Assessment dated 5/21/25 showed the MSW 1 had performed the initial assessment. The comprehensive assessment included the section for mortuary information. However, the section for the mortuary information was left blank. On 7/24/25 at 0920 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. #. Review of Patient 12’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and transferred to another hospice on 4/30/25.Review of the Psychosocial Assessment dated 3/6/25 showed the RN 3 had performed the initial assessment. The comprehensive assessment included the section for mortuary information. However, the section for the mortuary information was left blank. On 7/24/25 at 1102 hours, an interview and concurrent closed clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the comprehensive assessment identified the imminence of death for eight of 14 sampled patients (Patients 5, 6, 7, 10, 11,12, 14, and 15). This failure had the potential risk of not appropriately addressing the care needs for these patients.Findings: #. Review of Patient 10’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 1/6/25. The patient was certified for hospice services during the certification period from 5/25/25 to 7/23/25. The Comprehensive Nursing Assessment dated 1/6/25, showed the RN 3 had performed the initial comprehensive assessment. The assessment included a section for Imminently Dying. However, the section was left blank.On 7/24/25 at 1008 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was asked if they needed to complete the section for imminently dying . The Consultant reviewed the clinical record and replied yes, it should have been completed. The Consultant was informed and acknowledged the finding. #. Review of Patient 6’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/9/25. The patient was certified for hospice services during the certification periods from 3/9/25 to 6/6/25 and 6/7/25 to 9/4/25.The Comprehensive Nursing Assessment dated 3/9/25, showed the RN 1 had performed the initial comprehensive assessment. The assessment included a section for Imminently Dying. However, the section was left blank.On 7/24/25 at 1146 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the finding. #. Review of Patient 12’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and transferred to another hospice on 4/30/25.The Comprehensive Nursing Assessment dated 3/6/25, showed the RN 3 had performed the initial comprehensive assessment. The assessment included a section for Imminently Dying. However, the section was left blank.On 7/24/25 at 1102 hours, an interview and concurrent closed clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the finding. #. Review of Patient 14’s closed clinical record was initiated on 7/22/25. The clinical record showed the SOC was on 4/17/25. The patient was certified for hospice services during the certification period from 4/17/25 to 6/15/25. The patient was discharged and transferred to another hospice on 5/20/25.The Comprehensive Nursing Assessment dated 4/17/25, showed the RN 4 had performed the initial comprehensive assessment. The assessment included a section for Imminently Dying. However, the section was left blank.On 7/24/25 at 0942 hours, an interview and concurrent closed clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the finding. Review of the hospice’s P&P titled Comprehensive Assessment revised April 2020 showed 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 attending physician. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient’s clinical record, including at least the following information as relevant: under section H, imminence of death.#. Review of Patient 5’s clinical record was initiated on was initiated on 7/17/25. The clinical record showed the SOC was on 5/13/25. The patient was certified for hospice services during the certification period from 5/13/25 to 8/10/25.The initial comprehensive nursing assessment dated 5/13/25, showed no documented evidence the SN completed the assessment for imminence of death.On 7/24/25 at 1102 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 7’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/2/25. The patient was certified for hospice services during the certification period from 5/31/25 to 8/28/25.The initial comprehensive nursing assessment dated 3/2/25, showed no documented evidence the SN completed the assessment for imminence of death.On 7/24/25 at 1124 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 11’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and revoked hospice services on 5/20/25.The initial comprehensive nursing assessment dated 3/6/25, showed no documented evidence the SN completed the assessment for imminence of death.On 7/24/25 at 1525 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 15’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/22/24. The patient was certified for hospice services during the certification period from 3/22/24 to 6/19/24. The patient expired on 4/13/24.The initial comprehensive nursing assessment dated 3/22/24, showed no documented evidence the SN completed the assessment for imminence of death.On 7/24/25 at 1359 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding.”

“Based on observation, interview, and record review, the hospice failed to include all current medications’ side effects and actual or potential drug interaction in the comprehensive assessments; ensure the medication profile was reviewed and updated to reflect the current medications; and include specific indications and parameters for its use for seven of 15 sampled patients (Patients 1, 4, 5, 11, 12, 13, and 15). This failure had the potential risk for the patients to not receive the appropriate care and necessary services and negatively affect the patients’ well-being. Findings: Review of Patient 13’s closed clinical record was initiated on 7/18/25. The closed clinical record showed the SOC was 6/30/24. The patient was certified for hospice services during the certification period from 6/30/24 to 8/28/24.The Comfort Kit Medication Orders showed the patient’s medication included the following medications:-lorazepam (antianxiety) 0.5 ml sublingual every four hours as needed for agitation/anxiety.-morphine sulfate (opioid analgesic) 0.25 ml sublingual every four hours as needed for mild pain of one to three.-morphine sulfate 0.5 ml sublingual every four hours as needed for moderate pain of four to six.-morphine sulfate 0.75 ml sublingual every four hours as needed for severe pain of six to eight.-morphine sulfate 1.0 ml sublingual every four hours as needed for severe pain of nine to ten.According to Lexi-Comp’s pharmacology website, the US Boxed Warning for lorazepam included concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma and death.*However, there was no documented evidence the IDG had identified the potential drug interactions between lorazepam and morphine sulfate medications.On 7/24/25 at 1124 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the finding. #. Review of Patient 1’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/23/25. The patient was certified for hospice services during the certification period from 4/5/25 to 7/3/25 and 7/4/25 to 10/1/25. The patient was transferred from another hospice on 5/23/25.A joint home visit with RN 1 was conducted on 7/16/25 at 1000 hours, to Patient 1’s home.Review of the Patient Current/Treatment/Medication/DME List included the following: -Metamucil (constipation) 5.8 g Clear and Natural Powder for suspension, mix one teaspoon powder into 8 oz water, mix well and drink daily. However, the medication was not available.-metformin hydrochloride (anti -diabetic) 850 mg tablet, one tablet PO BID. However, the medication bottle was empty.In addition, the patient and the PCG reported patient was taking Tylenol for pain. The RN 1 was observed instructing the patient and the PCG to continue taking Tylenol for pain. However, the medication list was not updated to reflect the use of Tylenol to address pain. On 7/16/25 at 1058 hours, an interview and concurrent clinical record review was conducted with the PCG and the RN 1. The PCG was asked if the Metamucil was given to the patient. The PCG reported, the medication was never given as it was not delivered to their home. The PCG was also asked about the last time the patient was given metformin. The PCG replied, the last tablet was given this morning and needed refills. The RN 1 was asked as to the frequency of checking the medication profile. The RN 1 replied, every SN visit. The RN 1 was informed and acknowledged the findings. On 7/24/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. #. Review of Patient 12’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and transferred to another hospice on 4/30/25.The POC/Review dated 3/6 and 3/19/25, showed the patient’s medication included lorazepam (antianxiety)2mg/ml 0.5 ml SL Q six hours PRN for anxiety or agitation and morphine sulfate 20 mg 0.25 ml SL Q four hours PRN for pain or respiratory distress.According to lorazepam’s prescribing information, the concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death.However, review of the POC/IDG dated 3/6, 3/19, 4/2, 4/16 and 4/30/25 failed to show documented evidence the IDG identified the potential drug interactions between the lorazepam and morphine sulfate medications.On 7/24/25 at 1102 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. Review of the hospice’s P&P titled Medication Profile revised April 2020 showed patients receiving medications administered by the organization will have a current and 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. A drug regimen review will be performed by a registered nurse at the time of initial and comprehensive assessment, when updates to the comprehensive assessment are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. The review will identify: effectiveness; actual or potential side effects; toxic effects; allergic reactions; immediate desired effects; unusual and unexpected effects; changes in the patient’s condition that contraindicates continue administration of the new medication; drug related laboratory results; actual and potential drug interactions; duplicate drug therapy; and the need for pharmacological or non-pharmacological interventions for pain and other symptom management as applicable to the patient.#. Review of Patient 5’s clinical record was initiated on was initiated on 7/17/25. The clinical record showed the SOC was on 5/13/25. The patient was certified for hospice services during the certification period from 5/13/25 to 8/10/25.The POC Summary dated 7/15/25, showed the patient’s medications included the following:- naproxen (pain medication) 600 mg tablet one tablet orally three times a day as needed for mild pain.- Tylenol Extra Strength (pain medication) 500 mg two tablets orally twice a day PRN for pain.*However, there was no specific instruction as to which pain medication to give first for moderate to severe pain, naproxen vs Tylenol Extra Strength medication.On 7/24/25 at 1113 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 4’s clinical record was initiated on 7/16/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25.The Medication Profile showed the patient’s medications included the following:- metformin hydrochloride (antidiabetic drug) 1000 mg one tablet orally twice a day.- nifedipine extended release (antihypertensive drug) 60 mg one tablet orally daily.- omeprazole delayed release (a drug that decreases acid in the stomach) 20 mg one tablet orally daily.- Aspirin (blood thinner) 81 mg tablet one tablet orally daily.- glipizide (antidiabetic drug) 10 mg tablet one tablet orally twice daily.- hydrochlorothiazide (diuretic drug) 25 mg one tablet orally daily.- ibuprofen (pain medication) 800 mg one tablet orally every 8 hours a needed.- losartan potassium (antihypertensive drug) 100 mg one tablet orally daily.- baclofen (muscle relaxant drug) 10 mg one tablet orally daily.On 7/16/25 at 0951 hours, a joint home visit was conducted with LVN 1 to the patient’s residency. The Medication Profile was reviewed with LVN 1 and the patient. The patient showed all the medication he had which consisted of the above medications. *However, the patient showed a medication bottle for docusate sodium 100 mg tablet one tablet two times daily as need which was not included in the patient’s medication profile and patient stated he used the medication sometimes. On 7/16/25 at 1040 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the finding. #. Review of Patient 11’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and revoked hospice services on 5/20/25.The Current Medication List showed the patient’s medication included the following:- acetaminophen 500 mg one tablet orally every 8 hours as needed for pain.- Norco (opioid medication)10-325 mg one tablet orally every 8 hours as needed for severe pain.*However, there was no specific instruction as to which pain medication to give first for moderate to severe pain, acetaminophen vs Norco medication.On 7/24/25 at 1519 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 15’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/22/24. The patient was certified for hospice services during the certification period from 3/22/24 to 6/19/24. The patient expired on 4/13/24.Review of the Telephone Order dated 3/22/24, showed the patient medications included the following:- lorazepam (antianxiety medication) 2 mg/ml 0.5 ml sublingually every four hours as needed for anxiety/agitation- morphine sulfate (opioid medication) 20 mg/ml 0.25 ml sublingually every 4 hours as needed for mild pain- morphine sulfate 20 mg/ml 0.5 ml sublingually every 4 hours as needed for moderate pain- morphine sulfate 20 mg/ml 0.75 ml sublingually every 4 hours as needed for severe painAccording to lorazepam’s prescribing information, the concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death.* Further review of the POC Summary showed no documented evidence the orders/medication profile have been reviewed for contraindication, side effects, interactions, duplications and lab therapy drugs.On 7/24/25 at 1402 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the initial bereavement assessment was completed for four of 15 sampled patients (Patients 4, 5, 7, and 14). This failure had the potential risk of not providing appropriate, consistent, and quality care to these patients. Findings: #. Review of Patient 14’s closed clinical record was initiated on 7/22/25. The clinical record showed the SOC was on 4/17/25. The patient was certified for hospice services during the certification period from 4/17/24 to 6/15/24. The patient was discharged and transferred to another hospice on 5/20/25.Review of the Comprehensive Nursing Assessment dated 4/17/24 showed the RN 4 had performed the initial comprehensive assessment. The assessment included the section for bereavement screening. However the section for bereavement screening was left blank. On 7/24/25 at 0942 hours, an interview and concurrent closed clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the finding. Review of the hospice’s P&P titled Comprehensive Assessment revised April 2020 showed 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 attending physician. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient’s clinical record, including at least the following information as relevant: under section W, a bereavement assessment of the needs of the patient’s family and other individuals focusing on: the nature of the relationship of the patient; circumstances surrounding the illness/prognosis; behaviors prior to and after the illness/prognosis; survivor needs (social, spiritual, and cultural) that may impact coping skills; and potential for pathological grief reactions.#. Review of Patient 4’s clinical record was initiated on 7/16/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25.Further review of the clinical record showed no documented evidence the initial bereavement assessment was completed.On 7/24/25 at 1021 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 5’s clinical record was initiated on was initiated on 7/17/25. The clinical record showed the SOC was on 5/13/25. The patient was certified for hospice services during the certification period from 5/13/25 to 8/10/25.Review of the clinical record showed the initial bereavement assessment was completed on 3/2/25. *However, further review of the clinical record showed no documented evidence the bereavement assessment was incorporated in the patient’s POC.On 7/24/25 at 1103 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 7’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/2/25. The patient was certified for hospice services during the certification period from 5/31/25 to 8/28/25.Review of the clinical record showed the initial bereavement assessment was completed on 3/2/25. *However, further review of the clinical record showed no documented evidence the bereavement assessment was incorporated in the patient’s POC.On 7/24/25 at 1126 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the updated comprehensive assessment was completed no less than every 15 days and included the changes that had occurred since the initial assessment, information on the patient’s progress, and reassessment of the patient’s responses for one of 15 sampled patients (Patients 7). This failure created the potential risk of not addressing the care needs to this patient.Findings: Review of the hospice’s P&P titled The Plan of Care revised April 2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen days. Review of Patient 7’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/2/25. The patient was certified for hospice services during the certification period from 5/31/25 to 8/28/25.Review of the Visit Note-RN dated 6/22/25, showed under the narrative notes, “Wound care is continued to open wound left posterior thigh.”The POC/IDG Review dated 6/25/25, did not show documented evidence the IDG discussed the patient’s open wound on the left posterior thigh.On 7/24/25 at 1148 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS was informed and acknowledged the finding.”

“Based on record review and interview, the hospice failed to ensure care and services were provided in accordance with the POC for 11 of 15 sampled patients (Patients 1, 2, 3, 4, 7, 8, 9, 10, 11, 14, and 15 ). This failure had the potential risk of not providing appropriate, consistent, and quality care to these patients. Findings: #. Review of Patient 8’s clinical record review was initiated on 7/17/24. The clinical record showed the SOC was 2/7/25. The patient was certified for hospice services during the certification periods from 2/7/25 to 5/7/25 and 5/8/25 to 8/5/25.Review of the POC/IDG for 4/30/25, 5/14/25 and 5/28/25, showed the MSW visit frequency was declined.*However, the MSW 1 visited the patient on 5/7/25 and 6/6/25.On 7/24/25 at 0953 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. #.Review of Patient 9’s clinical record review was initiated on 7/17/25. The clinical record showed the SOC was 2/4/25. The patient was certified for hospice services during the certification period from 2/4/25 to 5/4/25 and 5/5/25 to 8/2/25.Review of the POC/IDG for 4/30/25 and 5/14/25 showed the MSW visit frequency was declined.*However, the MSW 1 visited the patient on 5/4/25.On 7/24/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. #. Review of Patient 2’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/22/25. The patient was certified for hospice services during the certification period from 5/22/25 to 8/1/25. The POC/IDG Review dated 5/28, 6/11, 6/25, and 7/9/25, showed the LVN visit cited once weekly.Review of the Visit Notes showed there was no documented evidence of an LVN visit for the week of 7/6 to 7/12/25 for the patient instead of one visit per week as per the POC. * In addition, review of the clinical record failed to show documented evidence of the LVN had documented an attempt to re-schedule the visit for the week or the IDG was notified of the missed visit as per the hospice’s P&P.On 7/24/25 at 1036 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 4’s clinical record was initiated on 7/16/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25.The POC/IDG Review dated 5/28, 6/11, 6/25, and 7/9/25, showed the LVN visit cited once weekly.Review of the Visit Notes showed there was no documented evidence of an LVN visit for the week of 7/6 to 7/12/25 for the patient instead of one visit per week as per the POC. In addition, there were documented evidence to show there were missed visits on 6/5/25 for the week of 6/1 to 6/7/25 and on6 6/20/25 for the week of 6/15 to 6/21/25.* However, review of the clinical record failed to show documented evidenced of the LVN had documented an attempt to re-schedule the visit for the week or the IDG was notified of the missed visit as per the hospice’s P&P.On 7/24/25 at 1007 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 7’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/2/25. The patient was certified for hospice services during the certification period from 5/31/25 to 8/28/25.The POC dated 7/15/25, showed the care plan problem for gastrointestinal had an intervention to assess bowel status every visit.Review of the SN notes dated 6/7, 6/8, 6/13, 6/20, 6/22, 6/27, 7/4, 7/6, and 7/11/24, showed under Gastro-Intestinal Digestive section a checked box that SN “assessed and no issue reported” for the gastrointestinal assessment. *However, there was no documented evidence the SN assessed for the patient’s last bowel movement.On 7/24/25 at 1133 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS stated the assessment of bowel status included bowel sounds, last bowel movement, and episodes of constipation. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 11’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and revoked hospice services on 5/20/25. The POC/IDG Review dated 3/6, 3/19, 4/2, 4/16, 4/30, and 5/14/25, showed the RN visit cited once every two weeks.Review of the Visit Notes showed there was no documented evidence of an RN visit for the week of 3/16 to 3/22/25 for the patient instead of one visit every two weeks as per the POC. * In addition, review of the clinical record failed to show documented evidenced of the RN had documented an attempt to re-schedule the visit for the week or the IDG was notified of the missed visit as per the hospice’s P&P.On 7/24/25 at 1514 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 15’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/22/24. The patient was certified for hospice services during the certification period from 3/22/24 to 6/19/24. The patient expired on 4/13/24.The POC/IDG Review dated 5/23 and 4/3/24, showed the HA visit cited as twice per week.Review of the 2024 Full Year Weekly Calendar showed the HA conducted one visit for the weeks of 3/31-4/6/24 and 4/7-4/13/24 instead of two visits weekly as ordered in the POC.Further review of the closed clinical record failed to show documented evidence of the HA had documented an attempt to re-schedule the visit for the week or the IDG was notified of the missed visit as per the hospice’s P&P.On 7/24/25 at 1455 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS stated there were HA visits completed based on the calendar and verified HA conducted a visit to the patient once weekly during the week mentioned above. The Administrator Designee/ DPCS was informed and acknowledged the finding. The hospice’s P&P titled The Plan of Care revised 4/2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted in the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The procedure includes the plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs, goals, and outcome achievement.The hospice’s P&P titled Missed Visit revised 4/2020, showed missed visit will be communicated to the Interdisciplinary Group at the IDG Meeting. Missed visit will documented in the clinical record. If a visit is missed for any reason, the clinician should attempt to reschedule for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If a visit is missed and not reschedule the clinician will notify the IDG and the clinical supervisor of the missed visit.#. Review of Patient 1’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/23/25. The patient was certified for hospice services during the certification period from 4/5/25 to 7/3/25 and 7/4/25 to 10/1/25. The patient was transferred from another hospice on 5/23/25.* The POC/IDG Review for the certification period from 4/5/25 to 7/3/25 dated 5/23/25 showed the frequency of visit. The SC visit cited as 1 per month.Review of the clinical record showed the BC/SC had performed a telephone visits on 5/27 and 7/16/25.However, review of the clinical record failed to show documented evidenced of an SC visit for the month of June as ordered in the POC. In addition, there was no documented evidenced of the SC missed visit was discussed in the IDG as per P&P. *The POC/IDG Review for the certification period from 7/4/25 to 10/1/25 dated 6/25/25 showed the frequency of visit. The LVN visit cited as 1 visit per week.However, on Week 2 (from 7/6 to 7/12/25) failed to show documented evidenced of the LVN had visited the patient as ordered in the POC.Further review of the clinical record failed to show documented evidenced of the LVN had documented an attempt to re-schedule the visit for the week as per P&P.In addition, there was no documented evidenced of the IDG was notified of the missed visit as per P&P.On 7/24/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was asked if they needed to re-schedule the visit. The Consultant replied, there was no documentation of the re-scheduled visit. The Consultant was informed and acknowledged the finding. #. Review of Patient 3’s clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25. *The POC/IDG Review for the certification period from 5/20/25 to 8/17/25 dated 5/23/25 showed the frequency of visit. The LVN visit cited as weekly.However, on Week 8 (from 7/6 to 7/12/25) failed to show documented evidenced of the LVN had visited the patient as ordered in the POC.Further review of the clinical record failed to show documented evidenced of the LVN had documented an attempt to re-schedule the visit for the week as per P&P.In addition, there was no documented evidenced of the IDG was notified of the missed visit as per P&P.*Review of the Physicians Order dated 5/21/25 showed a diet order. The order for diet was regular.Review of the SN visit notes dated 5/28, 5/31, 6/6, 6/13, 6/19 and 6/26/25 showed the SN had performed the nutrition assessment. On the section of the narrative notes showed the SN had documented the patients diet as low salt. However, the physicians order for diet was regular instead of low salt. On 7/24/25 at 0920 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. #. Review of Patient 10’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 1/6/25. The patient was certified for hospice services during the certification period from 5/25/25 to 7/23/25. a. Review of the Current Treatment/Medication/DME list showed a diet order dated 1/6/25. The diet order was NAS (no added salt). Review of the SN visit notes dated 5/26, 5/31, 6/7, 6/9, 6/13, 6/20, 6/23, 6/27, 7/2, 7/7 and 7/14/25 showed the SN had performed a nutrition assessment. The SN documented the diet as regular. However, review of the clinical record failed to show documented evidenced of a physicians order for regular diet. Further review of the SN visit notes dated 5/31, 6/7, 6/9, 6/13, 6/20, 6/27, 7/2, 7/7 and 7/14/25, on the section of narrative showed the SN documented patients diet was low salt instead of NAS as ordered by the physician. b. The POC/IDG Review dated 5/24, 5/28, 6/11, 6/26 and 7/9/25 showed a care plan for pain. The goal was to bring down pain level to less than 3 or stated comfort level of pain by patient after nursing intervention/medication. The intervention includes SN to assess/monitor pain and severity every visit and to monitor and assess effectiveness of current and new medication/treatment.Review of the SN visit notes dated 5/31, 6/20, 6/27, and 7/14/25- showed the SN had documented the patient reported pain level of 7, the comment showed moderate to severe bilateral knee pain.However, review of the clinical record failed to show documented evidenced of the SN had provided an intervention to address the patients moderate to severe bilateral knee pain as ordered in the POC. On 7/24/25 at 1008 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was asked if the physicians order for diet was followed. The Consultant reviewed the clinical record and replied no. The Consultant was also asked if there was an intervention provided to address the patients moderate to severe bilateral knee pain. The Consultant replied no interventions documented. The Consultant was further asked if they needed to re-check the patients pain level. The Consultant replied, yes, they should. The Consultant was informed and acknowledged the findings. #. Review of Patient 14’s closed clinical record was initiated on 7/22/25. The clinical record showed the SOC was on 4/17/25. The patient was certified for hospice services during the certification period from 4/17/24 to 6/15/24. The patient was discharged and transferred to other hospice on 5/20/25.The POC/IDG Review dated 5/1/24 showed the services and frequency of visits. The services included RN visit cited as one per two weeks and one PRN. Review of the closed clinical record showed on Week 3 (4/28 to 5/4/24) showed the patient declined visit on 5/1/24. However, there was no documented evidenced of an RN attempted to re-schedule the visit for the week to maintained the visit frequency as ordered in the POC. On 7/24/25 at 0942 hours, an interview and concurrent closed clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for 13 of 15 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 14, and 15). This failure had the potential risk to cause an inconsistent delivery of care which can result in the decline or lack of improvement of the patients’ health conditions.Findings: #. Review of Patient 8’s clinical record review was initiated on 7/17/24. The clinical record showed the SOC was 2/7/25. The patient was certified for hospice services during the certification periods from 2/7/25 to 5/7/25 and 5/8/25 to 8/5/25.a.The POC/IDG Review dated 7/9/25, showed it was discussed in the IDG that the MSW will continue monthly follow-up visits to provide ongoing counseling interventions and monitor the patient and family’s psychosocial status.*However, there was no documented evidence the IDG developed an individualized POC to address the patient’s psychosocial status.b.The physician’s order with start date of 5/9/25, showed to administer Ketorolac Tromethamine 60 mg intramuscular and then repeat in two weeks. Give omeprazole 40 mg daily for three days upon administering ketorolac.The SN visit note dated 5/24/25 showed the SN had administered Ketorolac Tromethamine 60 mg/2 ml intramuscularly. However, there was no documented evidence the IDG had developed an individualized POC to address the side effects of the Ketorolac Tromethamine.On 7/24/25 at 0953 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. #.Review of Patient 9’s clinical record review was initiated on 7/17/25. The clinical record showed the SOC was 2/4/25. The patient was certified for hospice services during the certification period from 2/4/25 to 5/4/25 and 5/5/25 to 8/2/25.a.The POC/IDG Review dated 7/9/25, showed it was discussed in the IDG that the MSW will continue to make monthly follow-up visits to resume the counseling interventions and to monitor the patient/family psychosocial status. *However, there was no documented evidence the IDG had developed an individualized POC to address the patient’s psychosocial status.b.The POC/IDG review dated 5/28/25, showed it was discussed in the IDG that the SC will continue to provide spiritual and emotional support according to the patient’s POC.*However, there was no documented evidence the IDG had developed an individualized POC to address the patient’s spiritual needs.c. The RN visit note dated 3/18/25 showed in the narrative that patient complained of clogged nose during the night. The MD prescribed Sudafed.*However, there was no documented evidence the IDG had developed an individualized POC to address the patient’s clogged nose and effectiveness of prescribed medication. On 7/24/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. #. Review of Patient 2’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/22/25. The patient was certified for hospice services during the certification period from 5/22/25 to 8/1/25.Review of the initial Comprehensive Nursing Assessment dated 5/22/25, showed under the narrative notes the patient on azithromycin 500 mg to manage upper respiratory infection.*However, there was no documented evidence the IDG developed an individualized POC to address the patient’s use of antibiotic or infection.On 7/24/25 at 1031 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 4’s clinical record was initiated on 7/16/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25.On 7/16/25 at 0951 hours, a joint home visit with LVN 1 was conducted to Patient 4’s home. During the visit, the patient showed LVN 1 the azithromycin medication (antibiotic) supply and stated his primary physician prescribed this antibiotic for possible stomach infection. Then, LVN 1 stated he will notify the patient’s hospice physician about the antibiotic medication.On 7/23/25 at 1640 hours, an observation of the hospice’s IDG meeting was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS had the Medical Director, BC/SC, and MSW 1 on speaker on a cellphone. The Administrator Designee/ DPCS was observed facilitating the meeting and providing the IDG report of the patient’s conditions. *However, when the Administrator Designee/ DPCS was providing report about Patient 4, she did not notify the team that the patient was prescribed azithromycin for possible stomach infection from his primary physician as observed during the joint home visit on 7/16/25.*In addition, further review of the clinical record showed there was no documented evidence the IDG developed an individualized POC to address the patient’s stomach infection or the use of an antibiotic.On 7/24/25 at 0938 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS stated she forgot to mention the prescribed azithromycin of the patient, but LVN 1 did notify her. The Administrator Designee/ DPCS further stated LVN 1 should have initiated a POC to address the antibiotic use and infection. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 5’s clinical record was initiated on was initiated on 7/17/25. The clinical record showed the SOC was on 5/13/25. The patient was certified for hospice services during the certification period from 5/13/25 to 8/10/25.a. Review of the initial Comprehensive Nursing Assessment dated 5/13/25, showed under the narrative notes that the patient walking short distances inside her room with the assistance of a walker.*However, there was no documented evidence the IDG developed an individualized POC to address the patient’s risk for falls.b. The POC/IDG Review dated 5/28/25, showed it was discussed in the IDG that the MSW will continue monthly follow-up visits to provide ongoing counseling interventions and monitor the patient and family’s psychosocial status.*However, there was no documented evidence the IDG developed an individualized POC to address the patient’s psychosocial status.On 7/24/25 at 1107 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 7’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/2/25. The patient was certified for hospice services during the certification period from 5/31/25 to 8/28/25.The POC/IDG Review dated 6/25/25, showed it was discussed in the IDG that the MSW will continue monthly follow-up visits to provide ongoing counseling interventions and monitor the patient and family’s psychosocial status.*However, there was no documented evidence the IDG developed an individualized POC to address the patient’s psychosocial status.On 7/24/25 at 1130 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 11’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and revoked hospice services on 5/20/25.The POC/IDG Review dated 3/19/25, showed it was discussed in the IDG that the MSW visits were declined by the patient, but MSW will continue to provide ongoing counseling interventions will remain available on as needed basis and during recertification period.*However, there was no documented evidence the IDG developed an individualized POC to address the patient’s psychosocial status or interventions.On 7/24/25 at 1537 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 15’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/22/24. The patient was certified for hospice services during the certification period from 3/22/24 to 6/19/24. The patient expired on 4/13/24.Review of the Physician’s Telephone Orders showed a physician order dated 3/22/24, to administer Novolog Pen (antidiabetic) 100 units/ml per sliding scale subcutaneously as follows for diabetes: 200-250 mg/dl= 2 units, 251-300 mg/dl=3 units, 301-350 mg/dl= 4 units, 351-400 mg/dl=5 units, and more than 400 mg/dl, to call the physician.* However, there was no documented evidence of the frequency for the insulin administration as per the sliding scale was included in the POC or if the SN or the patient/PCG will perform the patient’s blood sugar testing and administer the medication.On 7/24/25 at 1348 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. The hospice’s P&P titled The Plan of Care revised 4/2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted in the hospice program. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by the members of the interdisciplinary group and will be reviewed on the regular basis but no less than (15) fifteen days. This plans will focus on the identified problems, goals and interventions. The plan of care must be initiated at the start of care. Review of Patient 1’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/23/25. The patient was certified for hospice services during the certification period from 4/5/25 to 7/3/25 and 7/4/25 to 10/1/25. The patient was transferred from another hospice on 5/23/25.a. Review of the Comprehensive Nursing Assessment dated 5/23/25, showed the RN had performed psychosocial screening. The psychosocial distress rating was identified as “mild” and the need for Social Worker visit was documented as “Yes”. However, review of the POC/IDG Meeting dated 5/23, 5/28, 6/11, 6/26 and 7/9/25 failed to show documented evidenced of a psychosocial care plan was developed to address the patients’ psychosocial needs. Further review of the Comprehensive Nursing Assessment dated 5/23/25, showed the RN had performed bereavement screening. The screening showed the bereavement coordinator visit was documented as “Yes”. However, review of the POC/IDG Meeting dated 5/23/25 failed to show documented evidenced of a spiritual care plan was developed to address the patients’ spiritual needs. b. Moreover on the section of Narrative & Disease Trajectory section, showed the patient was assessed to be alert only to person, disoriented, reports of generalized pain, exhibits total body weakness and mostly chairbound. The patient had history of stroke four years ago which led to a persistent left sided weakness requiring full assistance with ADLs. The patient was hard of hearing bilaterally with poor vision. The PCG reports patient appears to be confused and withdrawn and had signs of depression. The patient had poor appetite and experienced significant unintentional weight loss. The patient was also constipated. The skin had mild flaking and overall dryness on both lower extremities. However, review of the POC/IDG Meeting dated 5/23, 5/28, 6/11, 6/26 and 7/9/25 failed to show documented evidenced of a care plan was developed to address the patients’ identified care needs. On 7/24/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. #. Review of Patient 10’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 1/6/25. The patient was certified for hospice services during the certification period from 5/25/25 to 7/23/25. Review of the clinical record showed the MSW 1 visited the patient on 6/22/25. The narrative notes showed a “monthly social services counselling interventions will continue to be available for ongoing support”.However, review of the POC/IDG Meeting Review dated 6/25/25 failed to show documented evidenced of a psychosocial care plan was developed to reflect the MSW 1 assessment dated 6/22/25. On 7/24/25 at 1008 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. #. Review of Patient 6’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/9/25. The patient was certified for hospice services during the certification periods from 3/9/25 to 6/6/25 and 6/7/25 to 9/4/25.Review of the Comprehensive Nursing Assessment dated 3/9/25, showed the RN 1 had documented the patients co morbidities. The co-morbidities included diabetes mellitus.Review of the POC/IDG Review dated 3/9, 3/19, 4/2, 4/16, 4/30, 5/14, 5/28, 6/11, 6/25 and 7/9/25, showed a care plan problem and intervention created for endocrine. The problem includes diabetes - NIDDM. The interventions included to assess endocrine status, educate on the medication use and side effects for diabetes, educate on the signs and symptoms of hypo/hyperglycemia and signs and symptoms of complications related to diabetes. Review of the SN notes dated 4/6/25 the endocrine assessment showed the blood sugar level was documented as 140 to 200. The comments include the random blood sugar was 162 mg/dl as reported by the PCG. Further review of the SN visit notes dated 5/4/25 the endocrine assessment showed the blood sugar level was documented as 140 to 200. The comments include the blood glucose levels reportedly range between 140 to 180 mg/dl. In addition, review of the SN notes dated 5/26, 6/2, 6/16, 6/23, 6/30, 7/7 and 7/14/25 showed the SN had documented the patients blood sugar level. The endocrine assessment showed the blood sugar level was documented as 140 to 200 mg/dl. However, review of the POC/IDG Review dated 3/9, 3/19, 4/2, 4/16, 4/30, 5/14, 5/28, 6/11, 6/25 and 7/9/25 failed to show documented evidenced of care plan was developed related to the frequency of blood sugar monitoring by the PCG. On 7/24/25 at 1146 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was asked if the care plan was developed to address the frequency of the blood sugar monitoring. The Consultant replied, none documented. The Consultant was informed and acknowledged the findings. crossed ref. L-552 #. Review of Patient 3’s clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25. *The POC/IDG Review for the certification period from 5/20/25 to 8/17/25 dated 5/20, 5/28, 6/11, 6/25, and 7/9/25 showed the frequency of visit. The MSW visit cited as one per month. Further review of the POC/IDG Review dated 5/20, 5/28, 6/11, 6/25, and 7/9/25 showed the IDG discussion for nursing, spiritual and psychosocial needs. However, the care plan for psychosocial services was not developed as discussed in the IDG. *The POC/IDG Review for the certification period from 5/20/25 to 8/17/25 dated 5/20/25 showed the frequency of visit. The SC visit cited as one per month. Further review of the POC/IDG Review dated 5/20/25 showed the IDG discussion for nursing, spiritual and psychosocial needs. However, the care plan for spiritual services was not developed as discussed in the IDG. On 7/24/25 at 0920 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. 5. Review of Patient 14’s closed clinical record was initiated on 7/22/25. The clinical record showed the SOC was on 4/17/25. The patient was certified for hospice services during the certification period from 4/17/24 to 6/15/24. The patient was discharged and transferred to another hospice on 5/20/25.a. The POC/IDG Review dated 4/18, 5/1, 5/15 and 5/20/25 showed the frequency of visit included SW one per month plus one PRN. The POC/ IDG also showed the patients’ psychosocial needs. However, there was no documented evidenced of a care plan was developed to address the patients’ psychosocial needs.b. The POC/IDG Review dated 5/1, 5/15, and 5/20/24 showed the IDG discussed the patients spiritual needs.However, there was no documented evidenced of a care plan was developed to address the patients’ spiritual needs.c. The Comprehensive Nursing Assessment dated 4/17/24, showed the RN 4 had performed the initial comprehensive assessment. The assessment included the genitourinary reproductive system. The section for other observations showed “self cath”. Further review of the Comprehensive Nursing Assessment dated 4/17/24 on the section of Narrative & Disease Trajectory showed the patient was admitted to the acute hospital with a diagnosis of ALOC and UTI. The patient was discharged with antibiotic prescription of levofloxacin 750 mg daily for seven days. The documentation also showed the patient performs “self cath” three times a day.However, review of the POC/IDG dated 4/18/24 failed to show documented evidenced of a care plan was developed to address the patients genitourinary needs and the use of the prescribed antibiotic. On 7/24/25 at 0942 hours, an interview and concurrent closed clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. Review of the hospice’s P&P titled The Plan of Care revised 4/2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted in the hospice program. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by the members of the interdisciplinary group and will be reviewed on the regular basis but no less than (15) fifteen days. This plans will focus on the identified problems, goals and interventions. The plan of care must be initiated at the start of care. 1. Review of Patient 1’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/23/25. The patient was certified for hospice services during the certification periods from 4/5/25 to 7/3/25 and 7/4/25 to 10/1/25. The patient was transferred from another hospice on 5/23/25.a. Review of the Comprehensive Nursing Assessment dated 5/23/25, showed the RN had performed the psychosocial screening. The psychosocial distress rating was identified as “mild” and the need for Social Worker visit was documented as “Yes.” However, review of the POC/IDG Meeting dated 5/23, 5/28, 6/11, 6/26, and 7/9/25, failed to show documented evidence a psychosocial care plan was developed to address the patients’ psychosocial needs. Further review of the Comprehensive Nursing Assessment dated 5/23/25, showed the RN had performed the bereavement screening. The screening showed the bereavement coordinator visit was documented as “Yes.” However, review of the POC/IDG Meeting dated 5/23/25, failed to show documented evidence a spiritual care plan was developed to address the patients’ spiritual needs. b. Review of the Narrative & Disease Trajectory section of the assessment showed the patient was assessed to be alert only to person, disoriented, reports of generalized pain, exhibits total body weakness and mostly chairbound. The patient had history of stroke four years ago which led to a persistent left sided weakness requiring full assistance with ADL care. The patient was hard of hearing bilaterally with poor vision. The PCG reported that the patient appeared to be confused and withdrawn and had signs of depression. The patient had poor appetite and experienced significant unintentional weight loss. The patient was also constipated. The skin had mild flaking and overall dryness on both lower extremities. However, review of the POC/IDG Meeting dated 5/23, 5/28, 6/11, 6/26, and 7/9/25, failed to show documented evidence a care plan was developed to address the patients’ identified care needs. On 7/24/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. 2. Review of Patient 10’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 1/6/25. The patient was certified for hospice services during the certification period from 5/25/25 to 7/23/25. Review of the clinical record showed MSW 1 visited the patient on 6/22/25. The narrative notes showed a “monthly social services counselling interventions will continue to be available for ongoing support.”However, review of the POC/IDG Meeting Review dated 6/25/25, failed to show documented evidence a psychosocial care plan was developed to reflect the MSW 1 assessment dated 6/22/25. On 7/24/25 at 1008 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. 3. Review of Patient 6’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/9/25. The patient was certified for hospice services during the certification periods from 3/9/25 to 6/6/25 and 6/7/25 to 9/4/25.Review of the Comprehensive Nursing Assessment dated 3/9/25, showed RN 1 had documented the patient’s co-morbidities including diabetes mellitus.Review of the POC/IDG Review dated 3/9, 3/19, 4/2, 4/16, 4/30, 5/14, 5/28, 6/11, 6/25 and 7/9/25, showed a care plan problem and intervention created for endocrine. The problem includes diabetes - NIDDM. The interventions included to assess endocrine status, educate on the medication use and side effects for diabetes, educate on the signs and symptoms of hypo/hyperglycemia and signs and symptoms of complications related to diabetes. Review of the SN notes dated 4/6/25, showed the blood sugar level was documented as 140 to 200 mg/dl. The comments included the random blood sugar was 162 mg/dl as reported by the PCG. Further review of the SN visit notes dated 5/4/25, showed the blood sugar level was documented as 140 to 200 mg/dl. The comments included the blood glucose levels reportedly range between 140 to 180 mg/dl. In addition, review of the SN notes dated 5/26, 6/2, 6/16, 6/23, 6/30, 7/7 and 7/14/25, showed the SN had documented the patient’s blood sugar level. The endocrine assessment showed the blood sugar level was documented as 140 to 200 mg/dl. However, review of the POC/IDG Review dated 3/9, 3/19, 4/2, 4/16, 4/30, 5/14, 5/28, 6/11, 6/25, and 7/9/25, failed to show documented evidence a care plan was developed related to the frequency of blood sugar monitoring by the PCG. On 7/24/25 at 1146 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was asked if the care plan was developed to address the frequency of the blood sugar monitoring. The Consultant replied, none documented. The Consultant was informed and acknowledged the findings. crossed ref. L-5524. Review of Patient 3’s clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25. *The POC/IDG Reviews dated 5/20, 5/28, 6/11, 6/25, and 7/9/25, showed MSW visit one time per month. Further review of the POC/IDG Review dated 5/20, 5/28, 6/11, 6/25, and 7/9/25, showed the IDG discussion for nursing, spiritual, and psychosocial needs. However, the care plan for psychosocial services was not developed as discussed in the IDG. *The POC/IDG Review dated 5/20/25, showed SC visit one time per month. Further review of the POC/IDG Review dated 5/20/25, showed the IDG discussion for nursing, spiritual, and psychosocial needs. However, the care plan for spiritual services was not developed as discussed in the IDG. On 7/24/25 at 0920 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings.5. Review of Patient 14’s closed clinical record was initiated on 7/22/25. The clinical record showed the SOC was on 4/17/25. The patient was certified for hospice services during the certification period from 4/17/24 to 6/15/24. The patient was discharged and transferred to another hospice on 5/20/24.a. The POC/IDG Review dated 4/18, 5/1, 5/15, and 5/20/24, showed SW visit one time per month and one PRN visit. The POC/IDG also showed the patient’s psychosocial needs. However, there was no documented evidence a care plan was developed to address the patient’s psychosocial needs.b. The POC/IDG Reviews dated 5/1, 5/15, and 5/20/24, showed the IDG discussed the patients spiritual needs.However, there was no documented evidenced of a care plan was developed to address the patients’ spiritual needs.c. The Comprehensive Nursing Assessment dated 4/17/24, showed RN 4 had performed the initial comprehensive assessment. The assessment included the genitourinary reproductive system. The section for other observations showed, “self cath.” Further review of the Comprehensive Nursing Assessment dated 4/17/24, showed the patient was admitted to the acute hospital with diagnosis of ALOC and UTI. The patient was discharged with antibiotic prescription of levofloxacin 750 mg daily for seven days. The documentation also showed the patient performed “self cath” three times a day.However, review of the POC/IDG dated 4/18/24, failed to show documented evidence a care plan was developed to address the patient’s genitourinary needs and use of the prescribed antibiotic. On 7/24/25 at 0942 hours, an interview and concurrent closed clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. 6. Review of Patient 2’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/22/25. The patient was certified for hospice services during the certification period from 5/22/25 to 8/1/25.Review of the initial Comprehensive Nursing Assessment dated 5/22/25, showed the patient was on azithromycin 500 mg to manage upper respiratory infection.*However, there was no documented evidence the IDG developed an individualized POC to address the patient’s use of antibiotic or infection.On 7/24/25 at 1031 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS was informed and acknowledged the finding.7. Review of Patient 4’s clinical record was initiated on 7/16/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25.On 7/16/25 at 0951 hours, a joint home visit with LVN 1 was conducted to Patient 4’s home. During the visit, the patient showed the azithromycin medication (antibiotic) supply and stated his primary physician prescribed this antibiotic for possible stomach infection. Then, LVN 1 stated he would notify the patient’s hospice physician about the antibiotic medication.On 7/23/25 at 1640 hours, an observation of the hospice’s IDG meeting was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS had the Medical Director, BC/SC, and MSW 1 on a speaker of cellphone. The Administrator Designee/DPCS was observed facilitating the meeting and providing the IDG report of the patient’s conditions. *However, when the Administrator Designee/DPCS was providing report about Patient 4, she did not notify the team that the patient was prescribed azithromycin for possible stomach infection from his primary physician as observed during the joint home visit on 7/16/25.*In addition, further review of the clinical record showed there was no documented evidence the IDG developed an individualized POC to address the patient’s stomach infection or the use of an antibiotic.On 7/24/25 at 0938 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS stated she forgot to mention the prescribed azithromycin of the patient, but LVN 1 did notify her. The Administrator Designee/DPCS further stated LVN 1 should have initiated a POC to address the antibiotic use and infection. The Administrator Designee/DPCS was informed and acknowledged the finding.8. Review of Patient 5’s clinical record was initiated on was initiated on 7/17/25. The clinical record showed the SOC was on 5/13/25. The patient was certified for hospice services during the certification period from 5/13/25 to 8/10/25.a. Review of the initial Comprehensive Nursing Assessment dated 5/13/25, showed the patient was able to walk short distances inside her room with the assistance of a walker.*However, there was no documented evidence the IDG developed an individualized POC to address the patient’s risk for falls.b. The POC/IDG Review dated 5/28/25, showed it was discussed in the IDG that the MSW will continue monthly follow-up visits to provide ongoing counseling interventions and monitor the patient and family’s psychosocial status.*However, there was no documented evidence the IDG developed an individualized POC to address the patient’s psychosocial status.On 7/24/25 at 1107 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS was informed and acknowledged the finding.9. Review of Patient 7’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/2/25. The patient was certified for hospice services during the certification period from 5/31/25 to 8/28/25.The POC/IDG Review dated 6/25/25, showed it was discussed in the IDG that the MSW will continue monthly follow-up visits to provide ongoing counseling interventions and monitor the patient and family’s psychosocial status.*However, there was no documented evidence the IDG developed an individualized POC to address the patient’s psychosocial status.On 7/24/25 at 1130 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS was informed and acknowledged the finding.10. Review of Patient 11’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and revoked hospice services on 5/20/25.The POC/IDG Review dated 3/19/25, showed it was discussed in the IDG that the MSW visits were declined by the patient, but the MSW would continue to provide ongoing counseling interventions remain available on as needed basis and during the recertification period.*However, there was no documented evidence the IDG developed an individualized POC to address the patient’s psychosocial status or interventions.On 7/24/25 at 1537 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS was informed and acknowledged the finding.11. Review of Patient 15’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/22/24. The patient was certified for hospice services during the certification period from 3/22/24 to 6/19/24. The patient expired on 4/13/24.Review of the Physician’s Telephone Orders showed a physician order dated 3/22/24, to administer Novolog Pen (antidiabetic) 100 units/ml per sliding scale subcutaneously as follows: BS 200-250 mg/dl= 2 units, 251-300 mg/dl=3 units, 301-350 mg/dl= 4 units, 351-400 mg/dl=5 units, and more than 400 mg/dl, to call the physician.* However, there was no documented evidence of the frequency for the insulin administration as per the sliding scale was included in the POC or if the SN or the patient/PCG will perform the patient’s blood sugar testing and administer the medication.On 7/24/25 at 1348 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding.12. Review of Patient 8’s clinical record review was initiated on 7/17/24. The clinical record showed the SOC was 2/7/25. The patient was certified for hospice services during the certification periods from 2/7/25 to 5/7/25 and 5/8/25 to 8/5/25.a. The POC/IDG Review dated 7/9/25, showed it was discussed in the IDG that the MSW will continue monthly follow-up visits to provide ongoing counseling interventions and monitor the patient and family’s psychosocial status.*However, there was no documented evidence the IDG developed an individualized POC to address the patient’s psychosocial status.b. The physician’s order with start date of 5/9/25, showed to administer Ketorolac Tromethamine 60 mg intramuscular and then repeat in two weeks. Give omeprazole 40 mg daily for three days upon administering ketorolac.The SN visit note dated 5/24/25 showed the SN had administered Ketorolac Tromethamine 60 mg/2 ml intramuscularly.However, there was no documented evidence the IDG had developed an individualized POC to address the side effects of the Ketorolac Tromethamine.On 7/24/25 at 0953 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings.13. Review of Patient 9’s clinical record review was initiated on 7/17/25. The clinical record showed the SOC was 2/4/25. The patient was certified for hospice services during the certification period from 2/4/25 to 5/4/25 and 5/5/25 to 8/2/25.a. The POC/IDG Review dated 7/9/25, showed it was discussed in the IDG that the MSW will continue to make monthly follow-up visits to resume the counseling interventions and to monitor the patient/family psychosocial status.*However, there was no documented evidence the IDG had developed an individualized POC to address the patient’s psychosocial status.b. The POC/IDG review dated 5/28/25, showed it was discussed in the IDG that the SC will continue to provide spiritual and emotional support according to the patient’s POC.*However, there was no documented evidence the IDG had developed an individualized POC to address the patient’s spiritual needs.c. The RN visit note dated 3/18/25 showed in the narrative that patient complained of clogged nose during the night. The MD prescribed Sudafed.*However, there was no documented evidence the IDG had developed an individualized POC to address the patient’s clogged nose and effectiveness of prescribed medication.On 7/24/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the revised POCs included the indication for the PRN discipline visits for one of 15 sampled patients (Patients 15). This failure had the potential of not providing necessary services for these patients.Findings: Review of Patient 15’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/22/24. The patient was certified for hospice services during the certification period from 3/22/24 to 6/19/24. The patient expired on 4/13/24.The POC/IDG Review dated 4/3/25, showed HA visits two times per week, MSW visit one time per month, SC visit one time per month, and SN visits two times per week and three PRN visits.* However, the revised POC did not include the indication for the PRN SN visits.On 7/24/25 at 1352 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for 15 of 15 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15). This failure had the potential risk of not evaluating the POC and providing appropriate care and services to these patients. Findings: #. Review of Patient 8’s clinical record review was initiated on 7/17/24. The clinical record showed the SOC was 2/7/25. The patient was certified for hospice services during the certification periods from 2/7/25 to 5/7/25 and 5/8/25 to 8/5/25.*The POC showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:-Review of patient’s medication list showed the following pain medication: a.Tylenol (over the counter medication for relieving mild to moderate pain) 500 mg every six hours as needed for pain; and b.Ibuprofen (medication used to relieve pain) 600 mg every eight hours as needed for pain.The intervention for alteration in comfort symptoms related to chronic back pain was to assess/monitor pain and severity every visit and to resolve pain with medications ordered. However, there was no documented evidence as to what medication will be given on the severity of pain. -The goal for the spiritual was patient will verbalize receiving desired spiritual support, However, there was no documented evidence as to what kind of spiritual support does the patient desired. On 7/24/25 at 0953 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. #.Review of Patient 9’s clinical record review was initiated on 7/17/25. The clinical record showed the SOC was 2/4/25. The patient was certified for hospice services during the certification period from 2/4/25 to 5/4/25 and 5/5/25 to 8/2/25.The Plan of Care Items – Active showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:-The goal for potential for altered cardiac status related to edema was to prevent discomfort due to edema. However, there was no documented evidence as to what grade of edema that will provide discomfort was. -The goal for alteration in comfort due to pain was patient to be comfortable during level of care. However, there was no documented evidence as to the comfortable level was.On 7/24/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 showed no documented evidence the POCs included measurable outcomes. For example:#. Review of Patient 1’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/23/25. The patient was certified for hospice services during the certification period from 4/5/25 to 7/3/25 and 7/4/25 to 10/1/25. The patient was transferred from another hospice on 5/23/25.The POC/IDG Review dated 5/23, 5/28, 6/11 and 6/25/25 showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:-The goal for cardiovascular related to hypertension was for the PCG to be knowledgeable in medications for hypertension. However, there was no documented evidenced as to what a knowledgeable in medications for hypertension was.-The goal for endocrine related to NIDDM was for the PCG to be knowledgeable in medications for diabetes, its side effects and signs and symptoms of diabetes mellitus. However, there was no documented evidenced as to what a knowledgeable in medications for diabetes, its side effects and signs and symptoms was.-The goal for environment/safety related to fall precautions was for the PCG to be knowledgeable in fall prevention. However, there was no documented evidenced as what a knowledgeable in fall prevention was.-The goal for nutrition related to aspiration precaution was for the PCG to be knowledgeable in aspiration precaution . However, there was no documented evidenced as what a knowledgeable in aspiration precaution was.On 7/24/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings.#. Review of Patient 10’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 1/6/25. The patient was certified for hospice services during the certification period from 5/25/25 to 7/23/25. The POC/IDG Review dated 5/24, 5/28, 6/11, 6/25 and 7/9/25 showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:-for cardiovascular: potential for altered cardiac status related to irregular blood pressure level (hypertension). The goal was to achieve and maintain peripheral circulation for patient comfort. However, there was no documented evidenced as to what to achieved and maintain peripheral circulation for patient comfort was. -for respiratory : potential for altered respiratory status related to increased shortness of breath. The goal includes oxygen treatment to achieve and maintain patient comfort. However, there was no documented evidenced as to what oxygen level to achieved and maintain for patient comfort was. On 7/24/25 at 1008 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. Review of the hospice P&P titled The Plan of Care revised April 2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen days. This plan will focus on identified problems, goals, and interventions. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. The written plan of care will contain, but not limited to, the following: under letter W, measurable outcomes anticipated from implementing and coordinating the plan of care. #. Review of Patient 2’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/22/25. The patient was certified for hospice services during the certification period from 5/22/25 to 8/1/25.The POC/IDG Review dated 5/28, 6/11, 6/25, and 7/9/25 showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:- The goal for cardiovascular related to aspirin use-bleeding precautions was for the PCG to be knowledgeable in signs and symptoms of bleeding and proper usage of aspirin (an anti-inflammatory drug) and its side-effects.- The goal for endocrine related to diabetes was for the PCG to be knowledgeable in medication usage, side-effects, and signs and symptoms for diabetes.- The goal for environment/safety related to fall risk was for the PCG to be knowledgeable in fall prevention. - The goal for nutrition related to aspiration precaution was for the PCG to be knowledgeable in aspiration precaution.- The goal for respiratory related to potential alteration in respiratory status due to asthma was for PCG to be knowledgeable in medication use for asthma.On 7/24/25 at 1039 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 4’s clinical record was initiated on 7/16/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25.The POC/IDG Review dated 5/28, 6/11, 6/25, and 7/9/25 showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:- The goal for cardiovascular related to hypertension and bleeding precautions was for the PCG to be knowledgeable in medication usage of hypertension and aspirin, bleeding precautions, and management of edema- The goal for endocrine related to diabetes was for the PCG to be knowledgeable in medication usage for diabetes and its signs and symptoms of complications.- The goal for musculoskeletal related to fall risk was for the PCG to be knowledgeable in fall prevention.- The goal for nutrition related to aspiration precaution and poor appetite was for the PCG to be knowledgeable in aspiration precaution.- The goal for pain related to chronic pain was for the PCG to be knowledgeable in pain medication usage and its side-effects.On 7/24/25 at 1000 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 5’s clinical record was initiated on was initiated on 7/17/25. The clinical record showed the SOC was on 5/13/25. The patient was certified for hospice services during the certification period from 5/13/25 to 8/10/25.The POC/IDG Review dated 5/28, 6/11, 6/25, and 7/9/25 showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:- The goal for cardiovascular related to altered cardiac status due to hypertension was for the PCG to be knowledgeable in hypertensive medication and side-effects.On 7/24/25 at 1104 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 7’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/2/25. The patient was certified for hospice services during the certification period from 5/31/25 to 8/28/25.The POC/IDG Review dated 6/11, 6/25, and 7/9/25 showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:- The goal for cardiovascular related to altered cardiac status due to unstable blood pressure level and edema was for the PCG to achieve and maintain peripheral circulation for patient comfort and PCG to be knowledgeable in how to manage and prevent edema.- The goal for mobility related to bed-bound and bed and chair transfer was to maintain mobility and independence.- The goal for gastrointestinal related to hyperactive bowel sounds was to facilitate bowel elimination and comfort.- The goal for pain related to alteration in comfort due to pain was for the PCG to be knowledgeable in pain medication use and its side-effects and remain comfortable during care.- The goal for respiratory related to altered respiratory status due to increased shortness of breath was for the PCG to be knowledgeable in oxygen usage and precautions.On 7/24/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 11’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and revoked hospice services on 5/20/25.The POC/IDG Review dated 3/19, 4/16, 4/30, 5/11, and 5/28/25 showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:- The goal for pain related to alteration in comfort due to pain was for the PCG to be knowledgeable in pain medication use and its side-effects and remain comfortable during care.- The goal for respiratory related to altered respiratory status due to shortness of breath was for the patient not to develop any episodes of respiratory crisis.On 7/24/25 at 1528 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 15’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/22/24. The patient was certified for hospice services during the certification period from 3/22/24 to 6/19/24. The patient expired on 4/13/24.The POC/IDG Review dated 3/23 and 4/3/24 showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:- The goal for ADL related to the deficit in self- care was for the patient to have a level of independence with personal care and effective POC.- The goal for cardiovascular related to potential altered cardiac status was for the patient to maintain optimum peripheral circulation.- The goal for endocrine related to diabetes was for blood sugar management for patient comfort.- The goal for gastrointestinal related to constipation was to facilitate bowel elimination and comfort.- The goal for respiratory related to altered respiratory status due to shortness of breath at rest and continuous oxygen therapy was for the patient to have optimum level of oxygen.On 7/24/25 at 1343 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. Review of the hospice’s P&P titled The Plan of Care revised April 2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen days. This plan will focus on identified problems, goals, and interventions. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. The written plan of care will contain, but not limited to, the following: under letter W, measurable outcomes anticipated from implementing and coordinating the plan of care.Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15 showed no documented evidence the POCs included measurable outcomes. For example:1. Review of Patient 1’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/23/25. The patient was certified for hospice services during the certification period from 4/5/25 to 7/3/25 and 7/4/25 to 10/1/25. The patient was transferred from another hospice on 5/23/25.The POC/IDG Review dated 5/23, 5/28, 6/11 and 6/25/25 showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:-The goal for cardiovascular related to hypertension was for the PCG to be knowledgeable in medications for hypertension. However, there was no documented evidenced as to what a knowledgeable in medications for hypertension was.-The goal for endocrine related to NIDDM was for the PCG to be knowledgeable in medications for diabetes, its side effects and signs and symptoms of diabetes mellitus. However, there was no documented evidenced as to what a knowledgeable in medications for diabetes, its side effects and signs and symptoms was.-The goal for environment/safety related to fall precautions was for the PCG to be knowledgeable in fall prevention. However, there was no documented evidenced as what a knowledgeable in fall prevention was.-The goal for nutrition related to aspiration precaution was for the PCG to be knowledgeable in aspiration precaution . However, there was no documented evidenced as what a knowledgeable in aspiration precaution was.On 7/24/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings.2. Review of Patient 10’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 1/6/25. The patient was certified for hospice services during the certification period from 5/25/25 to 7/23/25. The POC/IDG Review dated 5/24, 5/28, 6/11, 6/25 and 7/9/25 showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:-for cardiovascular: potential for altered cardiac status related to irregular blood pressure level (hypertension). The goal was to achieve and maintain peripheral circulation for patient comfort. However, there was no documented evidenced as to what to achieved and maintain peripheral circulation for patient comfort was. -for respiratory : potential for altered respiratory status related to increased shortness of breath. The goal includes oxygen treatment to achieve and maintain patient comfort. However, there was no documented evidenced as to what oxygen level to achieved and maintain for patient comfort was. On 7/24/25 at 1008 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings.3. Review of Patient 2’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/22/25. The patient was certified for hospice services during the certification period from 5/22/25 to 8/1/25.The POC/IDG Review dated 5/28, 6/11, 6/25, and 7/9/25 showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:- The goal for cardiovascular related to aspirin use-bleeding precautions was for the PCG to be knowledgeable in signs and symptoms of bleeding and proper usage of aspirin (an anti-inflammatory drug) and its side-effects.- The goal for endocrine related to diabetes was for the PCG to be knowledgeable in medication usage, side-effects, and signs and symptoms for diabetes.- The goal for environment/safety related to fall risk was for the PCG to be knowledgeable in fall prevention. - The goal for nutrition related to aspiration precaution was for the PCG to be knowledgeable in aspiration precaution.- The goal for respiratory related to potential alteration in respiratory status due to asthma was for the PCG to be knowledgeable in medication use for asthma.On 7/24/25 at 1039 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS was informed and acknowledged the finding.4. Review of Patient 4’s clinical record was initiated on 7/16/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25.The POC/IDG Reviews dated 5/28, 6/11, 6/25, and 7/9/25, showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:- The goal for cardiovascular related to hypertension and bleeding precautions was for the PCG to be knowledgeable in medication usage of hypertension and aspirin, bleeding precautions, and management of edema- The goal for endocrine related to diabetes was for the PCG to be knowledgeable in medication usage for diabetes and its signs and symptoms of complications.- The goal for musculoskeletal related to fall risk was for the PCG to be knowledgeable in fall prevention.- The goal for nutrition related to aspiration precaution and poor appetite was for the PCG to be knowledgeable in aspiration precaution.- The goal for pain related to chronic pain was for the PCG to be knowledgeable in pain medication usage and its side effects.On 7/24/25 at 1000 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding.5. Review of Patient 5’s clinical record was initiated on was initiated on 7/17/25. The clinical record showed the SOC was on 5/13/25. The patient was certified for hospice services during the certification period from 5/13/25 to 8/10/25.The POC/IDG Review dated 5/28, 6/11, 6/25, and 7/9/25 showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:- The goal for cardiovascular related to altered cardiac status due to hypertension was for the PCG to be knowledgeable in hypertensive medication and side-effects.On 7/24/25 at 1104 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding.6. Review of Patient 7’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/2/25. The patient was certified for hospice services during the certification period from 5/31/25 to 8/28/25.The POC/IDG Review dated 6/11, 6/25, and 7/9/25 showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:- The goal for cardiovascular related to altered cardiac status due to unstable blood pressure level and edema was for the PCG to achieve and maintain peripheral circulation for patient comfort and PCG to be knowledgeable in how to manage and prevent edema.- The goal for mobility related to bed-bound and bed and chair transfer was to maintain mobility and independence.- The goal for gastrointestinal related to hyperactive bowel sounds was to facilitate bowel elimination and comfort.- The goal for pain related to alteration in comfort due to pain was for the PCG to be knowledgeable in pain medication use and its side-effects and remain comfortable during care.- The goal for respiratory related to altered respiratory status due to increased shortness of breath was for the PCG to be knowledgeable in oxygen usage and precautions.On 7/24/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding.7. Review of Patient 11’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and revoked hospice services on 5/20/25.The POC/IDG Review dated 3/19, 4/16, 4/30, 5/11, and 5/28/25 showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:- The goal for pain related to alteration in comfort due to pain was for the PCG to be knowledgeable in pain medication use and its side-effects and remain comfortable during care.- The goal for respiratory related to altered respiratory status due to shortness of breath was for the patient not to develop any episodes of respiratory crisis.On 7/24/25 at 1528 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding.8. Review of Patient 15’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/22/24. The patient was certified for hospice services during the certification period from 3/22/24 to 6/19/24. The patient expired on 4/13/24.The POC/IDG Review dated 3/23 and 4/3/24 showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:- The goal for ADL related to the deficit in self- care was for the patient to have a level of independence with personal care and effective POC.- The goal for cardiovascular related to potential altered cardiac status was for the patient to maintain optimum peripheral circulation.- The goal for endocrine related to diabetes was for blood sugar management for patient comfort.- The goal for gastrointestinal related to constipation was to facilitate bowel elimination and comfort.- The goal for respiratory related to altered respiratory status due to shortness of breath at rest and continuous oxygen therapy was for the patient to have optimum level of oxygen.On 7/24/25 at 1343 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding.9. Review of Patient 8’s clinical record review was initiated on 7/17/24. The clinical record showed the SOC was 2/7/25. The patient was certified for hospice services during the certification periods from 2/7/25 to 5/7/25 and 5/8/25 to 8/5/25.*The POC showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:-Review of patient’s medication list showed the following pain medication: a. Tylenol (over the counter medication for relieving mild to moderate pain) 500 mg every six hours as needed for pain; and b. Ibuprofen (medication used to relieve pain) 600 mg every eight hours as needed for pain.The intervention for alteration in comfort symptoms related to chronic back pain was to assess/monitor pain and severity every visit and to resolve pain with medications ordered. However, there was no documented evidence as to what medication will be given on the severity of pain.-The goal for the spiritual was patient will verbalize receiving desired spiritual support, However, there was no documented evidence as to what kind of spiritual support does the patient desired.On 7/24/25 at 0953 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings.10. Review of Patient 9’s clinical record review was initiated on 7/17/25. The clinical record showed the SOC was 2/4/25. The patient was certified for hospice services during the certification period from 2/4/25 to 5/4/25 and 5/5/25 to 8/2/25.The Plan of Care Items – Active showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:-The goal for potential for altered cardiac status related to edema was to prevent discomfort due to edema. However, there was no documented evidence as to what grade of edema that will provide discomfort was.-The goal for alteration in comfort due to pain was patient to be comfortable during level of care. However, there was no documented evidence as to the comfortable level was.On 7/24/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patients’ POCs no less frequently than every 15 calendar days for six of 15 sampled patients (Patients 6, 8, 9, 10, 12, and 14). This failure had the potential risk for not providing appropriate, consistent, and quality care to these patients. Findings: #. Review of Patient 8’s clinical record review was initiated on 7/17/24. The clinical record showed the SOC was 2/7/25. The patient was certified for hospice services during the certification periods from 2/7/25 to 5/7/25 and 5/8/25 to 8/5/25.a.The POC/IDG review dated 3/5/25, 4/2/25, 5/14/25, 5/28/25, 6/11/25, 6/25/25, 7/9/25 and 7/15/25 showed the same problem/intervention/goals/status for the plan of care. There was no documented evidence the plan of care was revised and updated. All issues were opened on 2/7/25 with target date of 8/5/25. All issues have a status of pending.b.Review of the POC/IDG for 4/30/25, 5/14/25 and 5/28/25, showed the MSW visit frequency was declined.The Psychosocial Assessment date 5/7/25 and MSW Visit Note dated 6/6/25, showed MSW 1 conducted a home visit.However, the POC/IDG Review was not updated with the MSW’s visit frequency. On 7/24/25 at 0953 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. #.Review of Patient 9’s clinical record review was initiated on 7/17/25. The clinical record showed the SOC was 2/4/25. The patient was certified for hospice services during the certification period from 2/4/25 to 5/4/25 and 5/5/25 to 8/2/25.a.Review of the POC/IDG for 4/30/35 and 5/14/25, showed the MSW visit frequency was declined.The Psychosocial Assessment dated 5/4/25 showed the MSW 1 conducted a home visit.However, the POC/IDG Review was not updated with the MSW’s visit frequency.b.The POC/IDG review dated 4/30/25, 5/14/25, 5/28/25, 6/11/25 and 6/25/25 showed the same problem/intervention/goals/status for the plan of care. There was no documented evidence the plan of care was revised and updated. All issues were opened on 2/4/25 with target date of 7/4/25. All issues have a status of pending.Likewise, the POC/IDG review dated 7/9/25 and 7/17/25, showed the same problem/intervention/goals/status for the plan of care. There was no documented evidence the plan of care was revised and updated. All issues were opened on 2/4/25 with target date of 8/2/25. All issues have a status of pending.On 7/24/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. #. Review of Patient 10’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 1/6/25. The patient was certified for hospice services during the certification period from 5/25/25 to 7/23/25. Review of the POC/IDG Review dated 5/28, 6/11, 6/25 and 7/9/25 showed the frequency of visit for MSW was declined. Review of the clinical record showed the MSW 1 visited the patient on 6/22/25. The narrative notes showed a “monthly social services counselling interventions will continue to be available for ongoing support”.However, review of the POC/IDG Meeting Review dated 6/25/25 failed to show documented evidenced of the MSW visit frequency was revised to reflect the MSW 1 visit dated 6/22/25. On 7/24/25 at 1008 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. #. Review of Patient 6’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/9/25. The patient was certified for hospice services during the certification periods from 3/9/25 to 6/6/25 and 6/7/25 to 9/4/25.Review of the Comprehensive Nursing Assessment dated 3/9/25, showed the RN 1 had documented the patients co morbidities. The co-morbidities included diabetes mellitus.Review of the POC/IDG Review dated 3/9, 3/19, 4/2, 4/16, 4/30, 5/14, 5/28, 6/11, 6/25 and 7/9/25, showed a care plan problem and intervention created for endocrine. The problem includes diabetes - NIDDM. The interventions included to assess endocrine status, educate on the medication use and side effects for diabetes, educate on the signs and symptoms of hypo/hyperglycemia and signs and symptoms of complications related to diabetes. Review of the SN notes dated 4/6/25 the endocrine assessment showed the blood sugar level was documented as 140 to 200. The comments include the random blood sugar was 162 mg/dl as reported by the PCG. Further review of the SN visit notes dated 5/4/25 the endocrine assessment showed the blood sugar level was documented as 140 to 200. The comments include the blood glucose levels reportedly range between 140 to 180 mg/dl. In addition, review of the SN notes dated 5/26, 6/2, 6/16, 6/23, 6/30, 7/7 and 7/14/25 showed the SN had documented the patients blood sugar level. The endocrine assessment showed the blood sugar level was documented as 140 to 200 mg/dl. However, review of the POC/IDG Review dated 4/16, 4/30, 5/14, 5/28, 6/11/25 failed to show documented evidenced of care plan was revised to show the frequency and the monitoring of the patients blood sugar by the PCG. On 7/24/25 at 1146 hours, an interview and concurrent clinical record review was conducted with the Consultant The Consultant was informed and acknowledged the findings. #. Review of Patient 12’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and transferred to another hospice on 4/30/25.Review of the POC/IDG Review dated 3/6 and 3/19/25 included the physicians orders. The Other order for services included SN visit cited as weekly and three PRN per month for symptom management and any changes in condition. However, on the section for the frequency of visits failed to show the visit was revised to include the LVN three PRN visits per month as ordered. Further review of the POC/IDG dated 3/6/25 showed an order for CHHA visits. The CHHA visit cited as three times a week.However, on the section for the frequency of visits failed to show the visit was revised to include the CHHA visit of three times a week as ordered. On 7/24/25 at 1102 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was asked if the frequency in the POC needed to be revised. The Consultant reviewed the closed clinical record and replied, there was no PRN visit order. The Consultant was also asked to review the physicians order. The Consultant was informed and acknowledged the finding. #. Review of Patient 14’s closed clinical record was initiated on 7/22/25. The clinical record showed the SOC was on 4/17/25. The patient was certified for hospice services during the certification period from 4/17/24 to 6/15/24. The patient was discharged and transferred to other hospice on 5/20/25.a. Review of the Comprehensive Spiritual dated 4/25/24, showed the MSW 3/SC had performed the initial spiritual comprehensive assessment. The note showed an SC visit one time monthly and one to two PRN.The POC/IDG Review dated 5/1/24 showed the disciplines and frequency of visits. The disciplines included RN, SN and SW services.However, the POC/IDG dated 5/1/24 failed to be revised to reflect the SC services and the visit frequency as assessed on the initial spiritual comprehensive assessment. b. Review of the SN visit notes dated 4/18/24 showed the SN had performed an assessment. The assessment included genitourinary/reproductive system. The patient was assessed to have severe (7 to 10) urinary problems. The comment showed “self cath” five times a day.Further review of the SN visit notes dated 4/20/24 showed the patient was assessed to have severe (7 to 10) urinary problems. The comment showed “self cath” five to six times a day.However, the POC/IDG Review dated 5/1/24 failed to show documented evidenced of the care plan was revised to reflect the use of straight catheter for self catheterization. On 7/24/25 at 0942 hours, an interview and concurrent closed clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. 1. Review of Patient 10’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 1/6/25. The patient was certified for hospice services during the certification period from 5/25/25 to 7/23/25. Review of the POC/IDG Reviews dated 5/28, 6/11, 6/25, and 7/9/25 showed the MSW visit was declined. Review of the clinical record showed MSW 1 visited the patient on 6/22/25. The narrative notes showed a “monthly social services counselling interventions will continue to be available for ongoing support.”However, review of the POC/IDG Meeting Review dated 6/25/25, failed to show documented evidence of the MSW visit frequency revised to reflect the MSW visit conducted on 6/22/25. On 7/24/25 at 1008 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. 2. Review of Patient 6’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/9/25. The patient was certified for hospice services during the certification periods from 3/9/25 to 6/6/25 and 6/7/25 to 9/4/25.Review of the Comprehensive Nursing Assessment dated 3/9/25, showed RN 1 had documented the patient’s co-morbidities including diabetes mellitus.Review of the POC/IDG Reviews dated 3/9, 3/19, 4/2, 4/16, 4/30, 5/14, 5/28, 6/11, 6/25, and 7/9/25, showed a care plan problem and intervention created for endocrine. The problem included diabetes - NIDDM. The interventions included to assess endocrine status, educate on the medication use and side effects for diabetes, educate on the signs and symptoms of hypo/hyperglycemia and signs and symptoms of complications related to diabetes. Review of the SN note dated 4/6/25, showed the blood sugar level was documented as 140 to 200 mg/dl. The comments included the random blood sugar was 162 mg/dl as reported by the PCG. Further review of the SN visit notes dated 5/4/25, showed the blood sugar level was documented as 140 to 200 mg/dl. The comments included the blood glucose levels reportedly range between 140 to 180 mg/dl. In addition, review of the SN notes dated 5/26, 6/2, 6/16, 6/23, 6/30, 7/7 and 7/14/25, showed the SN had documented the patient’s blood sugar level. The endocrine assessment showed the blood sugar level was documented as 140 to 200 mg/dl. However, review of the POC/IDG Reviews dated 4/16, 4/30, 5/14, 5/28, 6/11/25, failed to show documented evidenced the care plan was revised to show the frequency and the monitoring of the patient’s blood sugar levels by the PCG. On 7/24/25 at 1146 hours, an interview and concurrent clinical record review was conducted with the Consultant The Consultant was informed and acknowledged the findings. 3. Review of Patient 12’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and transferred to another hospice on 4/30/25.Review of the POC/IDG Reviews dated 3/6 and 3/19/25, included the physicians orders. The Other order for services included SN visit cited as weekly and three PRN per month for symptom management and any changes in condition. However, on the section for the frequency of visits failed to show the visit was revised to include the LVN three PRN visits per month as ordered. Further review of the POC/IDG dated 3/6/25 showed an order for CHHA visits. The CHHA visit cited as three times a week.However, on the section for the frequency of visits failed to show the visit was revised to include the CHHA visit of three times a week as ordered. On 7/24/25 at 1102 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was asked if the frequency in the POC needed to be revised. The Consultant reviewed the closed clinical record and replied, there was no PRN visit order. The Consultant was also asked to review the physicians order. The Consultant was informed and acknowledged the finding. 4. Review of Patient 14’s closed clinical record was initiated on 7/22/25. The clinical record showed the SOC was on 4/17/25. The patient was certified for hospice services during the certification period from 4/17/24 to 6/15/24. The patient was discharged and transferred to other hospice on 5/20/25.a. Review of the Comprehensive Spiritual dated 4/25/24, showed the MSW 3/SC had performed the initial spiritual comprehensive assessment. The note showed an SC visit one time monthly and one to two PRN.The POC/IDG Review dated 5/1/24 showed the disciplines and frequency of visits. The disciplines included RN, SN and SW services.However, the POC/IDG dated 5/1/24 failed to be revised to reflect the SC services and the visit frequency as assessed on the initial spiritual comprehensive assessment. b. Review of the SN visit notes dated 4/18/24 showed the SN had performed an assessment. The assessment included genitourinary/reproductive system. The patient was assessed to have severe (7 to 10) urinary problems. The comment showed “self cath” five times a day.Further review of the SN visit notes dated 4/20/24 showed the patient was assessed to have severe (7 to 10) urinary problems. The comment showed “self cath” five to six times a day.However, the POC/IDG Review dated 5/1/24 failed to show documented evidenced of the care plan was revised to reflect the use of straight catheter for self catheterization. On 7/24/25 at 0942 hours, an interview and concurrent closed clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. 5. Review of Patient 8’s clinical record review was initiated on 7/17/24. The clinical record showed the SOC was 2/7/25. The patient was certified for hospice services during the certification periods from 2/7/25 to 5/7/25 and 5/8/25 to 8/5/25.a. The POC/IDG review dated 3/5/25, 4/2/25, 5/14/25, 5/28/25, 6/11/25, 6/25/25, 7/9/25 and 7/15/25 showed the same problem/intervention/goals/status for the plan of care. There was no documented evidence the plan of care was revised and updated. All issues were opened on 2/7/25 with a target date of 8/5/25. All issues have a status of pending.b. Review of the POC/IDG for 4/30/25, 5/14/25 and 5/28/25, showed the MSW visit frequency was declined.The Psychosocial Assessment date 5/7/25 and MSW Visit Note dated 6/6/25, showed MSW 1 conducted a home visit.However, the POC/IDG Review was not updated with the MSW’s visit frequency.On 7/24/25 at 0953 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings.6. Review of Patient 9’s clinical record review was initiated on 7/17/25. The clinical record showed the SOC was 2/4/25. The patient was certified for hospice services during the certification period from 2/4/25 to 5/4/25 and 5/5/25 to 8/2/25.a. Review of the POC/IDG for 4/30/35 and 5/14/25, showed the MSW visit frequency was declined.The Psychosocial Assessment dated 5/4/25 showed the MSW 1 conducted a home visit.However, the POC/IDG Review was not updated with the MSW’s visit frequency.b. The POC/IDG review dated 4/30/25, 5/14/25, 5/28/25, 6/11/25 and 6/25/25 showed the same problem/intervention/goals/status for the plan of care. There was no documented evidence the plan of care was revised and updated. All issues were opened on 2/4/25 with a target date of 7/4/25. All issues have a status of pending.Likewise, the POC/IDG review dated 7/9/25 and 7/17/25, showed the same problem/intervention/goals/status for the plan of care. There was no documented evidence the plan of care was revised and updated. All issues were opened on 2/4/25 with a target date of 8/2/25. All issues have a status of pending.On 7/24/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the revised POCs included the patients’ progress toward goals specified in the POCs for four of 15 sampled patients (Patients 2, 11, 12, and 15). This failure had the potential risk for not addressing the care needs for these patients.Findings: #. Review of Patient 12’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharge and transferred to another hospice on 4/30/25.The POC/IDG Review dated 4/30/25, showed the hospice identified patient care problems included cardiovascular- potential for altered cardiac status related to unstable blood pressure level; endocrine - diabetes- NIDDM uncontrolled blood sugar level (hyperglycemia; gastrointestinal -bowel sounds - hyperactive related to over secretion of gastric acid content as evidence by belching sour taste substance, potential for bowel elimination related to constipation; mobility - ambulatory with fall risk poor balance with left sided weakness; musculoskeletal- potential for harm due to alteration in posture related to right CVA with left sided weakness; neurological/mental- potential for altered neurological status related to right CVA with left sided weakness, seizure, anxiety and depression; pain- alteration in comfort symptoms related to generalized body pain; respiratory -potential for altered respiratory status related to increase shortness of breath; sleep -altered sleep patterns related to inability to sleep. The goals were established for these identified problems. Documentation showed the status for these care plan problems were pending. However, the POC failed to include the updated patient’s progress towards the goals for each of the care plan problem identified after the patient was discharged from hospice. On 7/24/25 at 1102 hours, an interview and concurrent closed clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the finding. Review of the hospice P&P titled The Plan of Care revised April 2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen days. This plan will focus on identified problems, goals, and interventions. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to evaluate progress toward goals.#. Review of Patient 2’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/22/25. The patient was certified for hospice services during the certification period from 5/22/25 to 8/1/25.The POC/IDG Review dated 6/11, 6/25, and 7/9/25, showed the hospice identified patient care problems included cardiovascular- hypertension; endocrine- diabetes; environment/safety- fall risk; nutrition- aspiration precaution; respiratory- potential altered respiratory status; and spiritual- alienation from the Catholic church faith community. The goals were established for these identified problems. Documentation showed the status for these care plan problems were controlled.* However, there was no documented evidence the POCs included the patient’s progress towards the goals for each of the care plan problem identified.On 7/24/25 at 1039 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 11’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and revoked hospice services on 5/20/25.The POC/IDG Review dated 5/28/25, showed the hospice identified patient care problems included cardiovascular- hypertension; gerourinary- potential altered bladder elimination; integumentary/skin- skin lesions; neurological/mental- potential for altered neuro status; pain- alteration in comfort; respiratory- potential altered respiratory status; and spiritual- faith support. The goals were established for these identified problems. Documentation showed the status for these care plan problems were pending. * However, there was no documented evidence the POCs included the patient’s progress towards the goals for each of the care plan problem identified.On 7/24/25 at 1542 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 15’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/22/24. The patient was certified for hospice services during the certification period from 3/22/24 to 6/19/24. The patient expired on 4/13/24.The POC/IDG Review dated 4/3/25, showed the hospice identified patient care problems included self-care deficit; altered cardiac status; impaired pancreas; potential for altered bowel elimination; potential for altered bladder elimination; impaired mobility; potential harm due to alteration in posture; potential for altered nutritional status; potential for increasing pain with disease process; knowledge deficit; and potential for altered respiratory status. The goals were established for these identified problems. Documentation showed the status for these care plan problems were controlled.* However, there was no documented evidence the POCs included the patient’s progress towards the goals for each of the care plan problem identified.On 7/24/25 at 1359 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing, coordinating, and supervising the care and services provided for 12 of 15 sampled patients (Patients 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, and 15). This failure had the potential risk of not addressing the care needs for these patients. Findings: #. Review of Patient 8’s clinical record review was initiated on 7/17/24. The clinical record showed the SOC was 2/7/25. The patient was certified for hospice services during the certification periods from 2/7/25 to 5/7/25 and 5/8/25 to 8/5/25.The SC’s visits dated 5/28/25, 6/6/25 and 7/15/25, showed SC was completing a telehealth visit with the patient. The patient’s family returned SC’s phone call and responded positively. *However, there was no documented evidence for the reason why the visits were conducted through telehealth or if the patient or the patient’s family requested for a telehealth visit.On 7/24/25 at 0953 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. The Administrator stated the SC should visit the patient personally to provide emotional and spiritual support. #.Review of Patient 9’s clinical record review was initiated on 7/17/25. The clinical record showed the SOC was 2/4/25. The patient was certified for hospice services during the certification period from 2/4/25 to 5/4/25 and 5/5/25 to 8/2/25.a.The SC’s visit dated 6/6/25 and 7/15/25, showed SC was completing a telehealth visit with the patient. The patient returned the SC’s phone call and responded positively. *However, there was no documented evidence for the reason why the visits were conducted through telehealth or if the patient requested for a telehealth visit.b.The RN 5 visit note dated 3/18/25 showed in the narrative that patient complained of clogged nose during the night. The MD prescribed Sudafed (medication for stuffy nose).*However, there was no documented evidence the Sudafed was in the recent order and medication list. On 7/24/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. Review of Patient 13’s closed clinical record was initiated on 7/18/25. The closed clinical record showed the SOC was 6/30/24. The patient was certified for hospice services during the certification period from 6/30/24 to 8/28/24.The POC/IDG review dated 7/3/24 showed an SC service order for initial evaluation and PRN thereafter. Furthermore, the spiritual narrative showed patient was unresponsive but daughter would like her mother to continue to receive spiritual counselling care.*However, there was no documented evidence the SC had visited the patient.On 7/24/25 at 1124 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the finding. #. Review of Patient 1’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/23/25. The patient was certified for hospice services during the certification period from 4/5/25 to 7/3/25 and 7/4/25 to 10/1/25. The patient was transferred from another hospice on 5/23/25.a. The POC/IDG Review for the certification period from 7/4/25 to 10/1/25 dated 5/23/25 showed the frequency of visit. The MSW visit cited as 1 per month.Review of the clinical record showed the MSW 4 had performed the psychosocial assessment on 5/26/25. The assessment included on the section of narrative showed the active issues was for food bank resources. MSW 4 to follow-up once monthly to provide psychosocial support to patient and family.Further review of the MSW 4 visit note dated 6/23/25, under the section of narrative showed the active issue was for the need of food resources. MSW to provide one time visit monthly for ongoing support and as needed.However, review of the clinical record failed to show documented evidenced of the MSW 4 had coordinated with the physician for the need of the PRN visit as documented on the MSW visit notes. b. The POC/IDG Review for the certification period from 7/4/25 to 10/1/25 dated 5/23/25 showed the frequency of visit. The SC visit cited as one per month.Review of the clinical record showed the BC/SC had performed a telephone visits on 5/27 and 7/16/25.However, there was no documented evidence for the reason why the BC/SC conducted the visits thru telehealth or if the patient or PCG requested for a telehealth visits. c. The POC/IDG Review for the certification period from 7/4/25 to 10/1/25 dated 5/23/25 showed the frequency of visit. The LVN visit cited as one per week and RN visit cited as one per two weeks.Review of the Comprehensive Nursing Assessment dated 5/23/25, showed the RN 1 had performed the initial comprehensive assessment. The assessment includes on the section of the narrative note showed the patient had generalized body pain rated at 4/10 on the pain scale.In addition review of the LVN 1 notes showed on the following: -on 6/10/25 patient was assessed to have pain level of 4. On the narrative note showed the patient complaints of mild to moderate pain to bilateral lower extremities due to disease progression.-on 6/23/25 patient was assessed to have pain level of 3. On the narrative note showed the patient reported mild generalized joint pain and-on 6/30/25 patient was assessed to have pain level of 5. On the narrative note showed the patient complaints of mild to moderate pain to bilateral lower extremities due to disease progression.Further, review of the LVN 1 notes dated 6/10, 6/23 and 6/30/25 showed on the section on the visit check list where to update CM or MD on patient status showed N/A.However, the LVN 1 failed to coordinate with the CM or MD the patients pain to the bilateral lower extremities as the section was documented as N/A. On 7/24/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was asked if the assessed PRN visit was coordinated with the physician. The Consultant replied, there was no documentation. The Consultant was also asked as to the reason for the SC telehealth visits. The Consultant replied, the visit should have been in person and the SC was already informed. The Consultant was further asked if the need for pain medication was coordinated with the physician. The Consultant reviewed the clinical record and replied yes, but was not documented. The Consultant was informed and acknowledged the findings. #. Review of Patient 10’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 1/6/25. The patient was certified for hospice services during the certification period from 5/25/25 to 7/23/25. The POC/IDG Review dated 5/28, 6/11, 6/25, and 7/9/25 showed the frequency of visit. The SC visit cited as one per month.Review of the clinical record showed the BC/SC had performed a telephone visits on 5/28, 6/6 and 7/15/25. However, there was no documented evidence for the reason why the BC/SC conducted the visits thru telehealth or if the patient or PCG requested for a telehealth visits.On 7/24/25 at 1008 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the finding. #. Review of Patient 3’s clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25. Review of the Psychosocial Assessment dated 5/21/25 showed the MSW 1 had performed the initial comprehensive assessment. The comprehensive assessment included the section for mortuary information. However, the section for the mortuary information was left blank. In addition, review of the MSW 1 visit note dated 6/20/25 showed the MSW had performed a follow up visit. The narrative section showed the discussion included the patient and family needs for community resources. However, review of the clinical record failed to show documented evidenced of the coordination of services related to mortuary information. On 7/24/25 at 0920 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the finding. #. Review of Patient 12’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and transferred to another hospice on 4/30/25.Review of the Comprehensive Nursing Assessment dated 3/6/25 showed the RN 3 performed the initial comprehensive assessment. The assessment included the diet type. The diet type was documented as regular, no salt, low fat, NCS. However, review of the closed clinical record failed to show documented evidenced of the diet order was coordinated with the physician. On 7/24/25 at 1102 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the finding. Review of the facility’s P&P titled Coordination of Patient Care revised March 2013 showed hospice staff members regularly communicate to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the IDG plan of care. Hospice has developed and maintains a system of communication and integration to:- Ensure that the IDG maintains responsibility directing, coordinating, and supervising the care and services provided.- Ensure that care and services are provided in accordance with the plan of care and are based on all assessment of the patient and family need.- Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement.- Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. #. Review of Patient 2’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/22/25. The patient was certified for hospice services during the certification period from 5/22/25 to 8/1/25.a. The POC/IDG Review dated 5/22, 5/28, 6/11, 6/25 and 7/9/25, showed the frequency of visit for the SC was cited as one visit per month.Review of the clinical record showed the SC had performed telephone visits on 5/26 and 6/9/25. * However, there was no documented evidence for the reason why the SC conducted the visits thru telehealth or if the patient or PCG requested for a telehealth visits. On 7/24/25 at 1056 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS stated home visit should be in person unless otherwise requested by the family or PCG. The Administrator Designee/ DPCS was informed and acknowledged the finding.b. Review of the Visit Note-MSW dated 6/22/25, showed under the narrative section, for a MSW recommendation of MSW to provide 1x monthly visit prn for ongoing support and as needed.* However, review of the clinical record failed to show documented evidence MSW 4 had coordinated with the physician for the need of the PRN visit as documented on the MSW visit notes.On 7/24/25 at 1058 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS stated the MSW should have coordinated with the physician to get an order and discussed in the IDG meeting. The Administrator Designee/ DPCS was informed and acknowledged the finding.c. Review of the SN notes dated 6/5, 6/16, and 6/19/25, showed under the narrative notes the patient reports of diffuse musculoskeletal discomfort, primarily in the legs and lower back rated 4 out of 10 numerical pain scale, or pain in bilateral lower extremities or both knees.*However, review of the Physician’s Orders failed to show documented evidence the patient had medication for pain. In addition, further review of the clinical records failed to show the physician was notified and coordinated of the patient’s complaints of pain.On 7/24/25 at 1054 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS stated the SNs should have coordinated with the physician to get an order for pain medications and discussed in the IDG meeting. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 4’s clinical record was initiated on 7/16/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25.The POC/IDG Review dated 5/28, 6/11, 6/25, and 7/9/25, showed the frequency of visit for the SC was cited as one visit per month.Review of the clinical record showed the SC had performed telephone visits on 5/24 and 6/9/25. * However, there was no documented evidence for the reason why the SC conducted the visits thru telehealth or if the patient or PCG requested for a telehealth visits. On 7/24/25 at 0956 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 5’s clinical record was initiated on was initiated on 7/17/25. The clinical record showed the SOC was on 5/13/25. The patient was certified for hospice services during the certification period from 5/13/25 to 8/10/25.The POC/IDG Review dated 5/28, 6/11, 6/25 and 7/9/25 showed the frequency of visit for the SC was cited as one visit per month.Review of the clinical record showed the SC had performed telephone visits on 5/17, 6/9, and 7/16/25. * However, there was no documented evidence for the reason why the SC conducted the visits thru telehealth or if the patient or PCG requested for a telehealth visits. On 7/24/25 at 1117 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 7’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/2/25. The patient was certified for hospice services during the certification period from 5/31/25 to 8/28/25.a. The POC/IDG Review dated 6/11, 6/25 and 7/9/25 showed the frequency of visit for the SC was cited as one visit per month.Review of the clinical record showed the SC had performed telephone visits on 5/28 and 6/9/25. * However, there was no documented evidence for the reason why the SC conducted the visits thru telehealth or if the patient or PCG requested for a telehealth visits. On 7/24/25 at 1127 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding.b. Review of the SN notes dated 5/31, 6/7, 6/20, and 6/27/25, showed under the narrative notes the patient struggles to check her glucose regularly due to left sided weakness.* However, further review of the clinical records failed to show the physician was notified or discussed in the IDG meetings.On 7/24/25 at 1145 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS stated the SNs should have coordinated with the physician with the patient’s left side weakness and discussed in the IDG meeting. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 11’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and revoked hospice services on 5/20/25.Review of the initial Comprehensive Nursing Assessment dated 3/6/24, showed the patient was on a regular diet.However, review of the physician’s orders and POC/IDG Review dated 3/6, 3/19, 4/2, 4/16, 4/30, 5/14, and 5/28/25 did not show there was a physician’s order for the patient’s diet.On 7/24/25 at 1540 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS stated the SN should have coordinated with the physician to get a diet order. The Administrator Designee/ DPCS was informed and acknowledged the finding.”

“Based on record review and interview, the hospice failed to ensure care and services were provided in accordance with the POC for 11 of 15 sampled patients (Patients 1, 2, 3, 4, 7, 8, 9, 10, 11, 14, and 15 ). This failure had the potential risk of not providing appropriate, consistent, and quality care to these patients. Review of the hospice’s P&P titled The Plan of Care revised 4/2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted in the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The procedure includes the plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs, goals, and outcome achievement.Review of the hospice’s P&P titled Missed Visit revised 4/2020 showed missed visit will be communicated to the Interdisciplinary Group at the IDG Meeting. Missed visit will be documented in the clinical record. If a visit is missed for any reason, the clinician should attempt to reschedule for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If a visit is missed and not reschedule the clinician will notify the IDG and the clinical supervisor of the missed visit.1. Review of Patient 1’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/23/25. The patient was certified for hospice services during the certification period from 4/5/25 to 7/3/25 and 7/4/25 to 10/1/25. The patient was transferred from another hospice on 5/23/25.* The POC/IDG Review for the certification period from 4/5/25 to 7/3/25 dated 5/23/25, showed SC visit one time per month.Review of the clinical record showed the SC had performed a telephone visits on 5/27 and 7/16/25.However, review of the clinical record failed to show documented evidence of an SC visit for the month of June as ordered in the POC. *The POC/IDG Review dated 6/25/25, showed LVN visit one time per week.However, for Week 2 (from 7/6 to 7/12/25), there was documented evidenced of the LVN visit as ordered in the POC.Further review of the clinical record failed to show documented evidence of the attempt to reschedule the visit for the week as per the hospice’s P&P.On 7/24/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was asked if they needed to reschedule the visit. The Consultant replied, there was no documentation of the rescheduled visit. The Consultant was informed and acknowledged the finding. 2. Review of Patient 3’s clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25. *The POC/IDG Review for the certification period from 5/20/25 to 8/17/25 dated 5/23/25, showed the LVN visit weekly.However, for Week 8 (from 7/6 to 7/12/25), there was no documented evidence of the LVN visit as ordered in the POC.Further review of the clinical record failed to show documented evidence of the attempt to reschedule the visit for the week as per the hospice’s P&P.On 7/24/25 at 0920 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. 3. Review of Patient 10’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 1/6/25. The patient was certified for hospice services during the certification period from 5/25/25 to 7/23/25. The POC/IDG Review dated 5/24, 5/28, 6/11, 6/26 and 7/9/25, showed a care plan for pain. The goal was to bring down pain level to less than 3 or stated comfort level of pain by patient after nursing intervention/medication. The intervention included the SN to assess/monitor pain and severity every visit and to monitor and assess effectiveness of current and new medication/treatment.Review of the SN visit notes dated 5/31, 6/20, 6/27, and 7/14/25, showed the SN had documented the patient reported a pain level of 7. The comment section showed moderate to severe bilateral knee pain.However, review of the clinical record failed to show documented evidence the SN had provided an intervention to address the patient’s moderate to severe bilateral knee pain as ordered in the POC. On 7/24/25 at 1008 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant reviewed the clinical record and replied no. The Consultant was also asked if there was an intervention provided to address the patient’s moderate to severe bilateral knee pain. The Consultant replied no interventions documented. The Consultant was further asked if they needed to recheck the patient’s pain level. The Consultant replied, yes, they should. The Consultant was informed and acknowledged the findings. 4. Review of Patient 14’s closed clinical record was initiated on 7/22/25. The clinical record showed the SOC was on 4/17/25. The patient was certified for hospice services during the certification period from 4/17/24 to 6/15/24. The patient was discharged and transferred to other hospice on 5/20/24.The POC/IDG Review dated 5/1/24, showed RN visit one time per two weeks and one PRN visit. Review of the closed clinical record showed for Week 3 (4/28 to 5/4/24), the patient declined the visit on 5/1/24. However, there was no documented evidence of an RN attempting to reschedule the visit for the week to maintain the visit frequency as ordered in the POC. On 7/24/25 at 0942 hours, an interview and concurrent closed clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the finding. 5. Review of Patient 2’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/22/25. The patient was certified for hospice services during the certification period from 5/22/25 to 8/1/25. The POC/IDG Review dated 5/28, 6/11, 6/25, and 7/9/25, showed the LVN visits once weekly.Review of the Visit Notes showed there was no documented evidence of LVN visit for the week of 7/6 to 7/12/25, for the patient instead of one visit per week as per the POC. In addition, review of the clinical record failed to show documented evidence of an attempt to reschedule the visit for the week as per the hospice’s P&P.On 7/24/25 at 1036 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS was informed and acknowledged the finding.6. Review of Patient 4’s clinical record was initiated on 7/16/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25.The POC/IDG Review dated 5/28, 6/11, 6/25, and 7/9/25, showed the LVN visits once weekly.Review of the Visit Notes showed there was no documented evidence of LVN visit for the week of 7/6 to 7/12/25, for the patient instead of one visit per week as per the POC. In addition, there were documented evidence to show missed visits on 6/5/25, for the week of 6/1 to 6/7/25, and on 6/20/25, for the week of 6/15 to 6/21/25.* However, review of the clinical record failed to show documented evidence of the attempt to reschedule the visit for the week as per the hospice’s P&P.On 7/24/25 at 1007 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS was informed and acknowledged the finding.7. Review of Patient 7’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/2/25. The patient was certified for hospice services during the certification period from 5/31/25 to 8/28/25.The POC dated 7/15/25, showed the care plan problem for gastrointestinal had an intervention to assess bowel status every visit.Review of the SN notes dated 6/7, 6/8, 6/13, 6/20, 6/22, 6/27, 7/4, 7/6, and 7/11/24, showed under Gastro-Intestinal Digestive section, a check box for SN “assessed and no issue reported” for the gastrointestinal assessment. However, there was no documented evidence the SN assessed for the patient’s last bowel movement.On 7/24/25 at 1133 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS stated the assessment of bowel status included bowel sounds, last bowel movement, and episodes of constipation. The Administrator Designee/DPCS was informed and acknowledged the finding.8. Review of Patient 11’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and revoked hospice services on 5/20/25. The POC/IDG Review dated 3/6, 3/19, 4/2, 4/16, 4/30, and 5/14/25, showed the RN visit once every two weeks.Review of the Visit Notes showed there was no documented evidence of an RN visit for the week of 3/16 to 3/22/25, instead of one visit every two weeks as per the POC. In addition, review of the clinical record failed to show documented evidence of the attempt to reschedule the visit for the week as per the hospice’s P&P.On 7/24/25 at 1514 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS was informed and acknowledged the finding.9. Review of Patient 15’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/22/24. The patient was certified for hospice services during the certification period from 3/22/24 to 6/19/24. The patient expired on 4/13/24.The POC/IDG Review dated 5/23 and 4/3/24, showed the HA visits twice per week.Review of the 2024 Full Year Weekly Calendar showed the HA conducted one visit for the weeks of 3/31-4/6/24 and 4/7-4/13/24, instead of two visits weekly as ordered in the POC.Further review of the closed clinical record failed to show documented evidence of the HA had documented an attempt to reschedule the visit for the week as per the hospice’s P&P.On 7/24/25 at 1455 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS stated there were HA visits completed based on the calendar and verified the missed visit finding. The Administrator Designee/DPCS was informed and acknowledged the finding.10. Review of Patient 8’s clinical record review was initiated on 7/17/24. The clinical record showed the SOC was 2/7/25. The patient was certified for hospice services during the certification periods from 2/7/25 to 5/7/25 and 5/8/25 to 8/5/25.Review of the POC/IDG for 4/30/25, 5/14/25 and 5/28/25, showed the MSW visit was declined.*However, MSW 1 visited the patient on 5/7/25 and 6/6/25.On 7/24/25 at 0953 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings.11. Review of Patient 9’s clinical record review was initiated on 7/17/25. The clinical record showed the SOC was 2/4/25. The patient was certified for hospice services during the certification period from 2/4/25 to 5/4/25 and 5/5/25 to 8/2/25.Review of the POC/IDG for 4/30/25 and 5/14/25 showed the MSW visit was declined.*However, MSW 1 visited the patient on 5/4/25.On 7/24/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings.”

“Based on interview and document review, the hospice failed to document the measurable progress achieved on their performance improvement projects. This failure created the risk of not effectively evaluating the outcomes of the PIPs to improve the care and services provided by the hospice’s staff. Findings: Review of the hospice’s P&P titled Improving Organizational Performance revised April 2020 showed senior management, as designated by the Governing Body, will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance in governance, management, clinical, and support activities; to define expectations of hospice’s performance improvement activities; and to generate the pain and processes hospice will utilize to assess, improve and maintain quality of care and services including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will be active participants in the organization’s quality assessment and performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the QAPI program is defined, implemented, and maintained, and is evaluated annually. Trends identified through quality assessment and performance improvement measurement and analysis will be reported to the Governing Body on a quarterly basis. Results of QAPI activities will be communicated with all staff via intranet, newsletters, email, etc. Quarterly, results and care implications will be provided at in-service programs for patient care staff and volunteers. Review of the hospice’s QAPI program for 2023 and 2024 was conducted on 7/23/25. a. The 2023 Clinical QAPI Plan for Wound Care reviewed 3/1/24, showed in section, “collaboration and coordination of QAPI activities,” that the hospice would hold regular meetings (at least quarterly) to discuss QAPI initiatives, review data, and identify areas for improvement. Communication would be facilitated through email, phone calls, and in-person meetings. *However, there was no documented evidence to show the quarterly meetings were held to discuss QAPI initiatives, review data, and identify areas for improvement. b. The 2023 QAPI Annual Review of Fall Risk/Incidence dated 3/20/24, showed the agenda, summary, recommendations and action items, and conclusion. The recommendations and action items section included the quarterly meeting to reassess processes and incorporate any necessary improvements. *However, there was no documented evidence the quarterly meetings were held to reassess processes and incorporate any necessary improvements. c. The 2023 QAPI Report for Wound Care dated 4/17/24, showed the agenda, summary, recommendations and action items, and conclusion. The recommendations and action items section included the quarterly meetings to reassess processes and incorporate any necessary improvements. *However, there was no documented evidence quarterly meetings were held to reassess the processes and incorporate any necessary improvements. d. The 2024 Annual Corporate Meeting Minutes with subject of QAPI Annual Review for Fall Risk Incident Report dated 3/7/25, showed the agenda, summary, recommendations and action items, and conclusion. The recommendations and action items section included the quarterly meetings would continue to support ongoing monitoring with updates to protocols implemented as needed. *However, there was no documented evidence the quarterly meetings were held to continue to support ongoing monitoring with updates to protocols implemented as needed. e. The 2024 QAPI Report- Comfortable Dying Measure dated 3/7/25, showed the measure focus was comfortable dying, data summary, performance outcome, analysis, recommendations and action item, and conclusion. The recommendations and action items section included quarterly monitoring of this measure and will continue to ensure sustained quality outcomes. *However, there was no documented evidence to show the quarterly monitoring of the measure of comfortable dying to continue ensuring sustained quality outcomes. f. The 2024 QAPI Report -Antibiotics Without Care Plan dated 3/10/25, showed the measure focus was antibiotic without a documented care plan, data summary, performance outcome, analysis, recommendations and action item, and conclusion. The recommendations and action items section included maintaining quarterly audits to monitor compliance and identify trends or educational needs. *However, there was no documented evidence to show the quarterly audit reports of the hospice’s monitoring for compliance and identifying trends or educational needs. e. The 2024 QAPI Report for Wound Care dated 4/28/25, showed the agenda, summary, recommendations and action items, and conclusion. The recommendation and action items section included quarterly meetings to reassess processes and incorporate any necessary improvement. *However, there was no documented evidence to show the quarterly meetings were held to reassess processes and incorporate any necessary improvement. On 7/24/25 at 1340 hours, an interview and concurrent facility document review was conducted with the Administrator/Volunteer Coordinator/Owner. The Administrator/Volunteer Coordinator/Owner stated the information data for the QAPI can be generated through their electronic health record software based on the topic of the focused QAPI plan and filtered through specific dates. The Administrator/Volunteer Coordinator/Owner regular meetings were held quarterly. When the Administrator/Volunteer Coordinator/Owner was asked to provide documented evidence of the quarterly meeting minutes for 2023 and 2024, she verified there were no documented quarterly meetings. The Administrator/Volunteer Coordinator/Owner was informed and acknowledged the above findings.”

“Based on interview and record review, the hospice failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention control, and investigation of infectious and communicable disease. This failure had the potential risk of the spread of infections and not improving the infection control program. Findings: Review of the hospice’s P&P titled Infection Control Plan revised April 2020 showed the hospice is committed to reducing the risk of acquisition and transmission of health care associated infections. Recognized prevention and control mechanisms will be implemented for planning, surveillance, identification, prevention/controls, and reporting procedures. To determine the effectiveness of the infection control plan, the hospice will measure, assess, improve, and redesign (as appropriate) the surveillance, identification, prevention, and control function annually through its performance improvement program.Review of the hospice’s P&P titled Infection Surveillance System: Prioritized Risk Defined revised 2014 showed at least quarterly, the Director and infection control and QAPI committees will review and assess the infection control log. Data will be aggregated and analyzed on the Infection Control Quarterly Data Aggregation and Analysis: Patients and Employees form.Review of the QAPI and infection control documents for 2023, 2024, and 2025 was conducted on 7/23/25, and showed the following:a. Review of the 2024 QAPI Report -Antibiotics Without Care Plan dated 3/10/25, showed the measure focus was antibiotic without a documented care plan, data summary, performance outcome, analysis, recommendations and action item, and conclusion. The recommendations and action items section included maintaining quarterly audits to monitor compliance and identify trends or educational needs.* However, there was no documented evidence of quarterly audit reports to show the hospice was monitoring for compliance and identifying trends or educational needs.b. Review of the Infection Control Logs for 2023, 2024, and 2025 showed zero cases of infection for each month.* However, during the patients’ clinical records review, there were documented evidence showing the patients were currently taking antibiotics for infections, for example:- Review of Patient 2’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/22/25. The patient was certified for hospice services during the certification period from 5/22/25 to 8/1/25.The Comprehensive Nursing Assessment dated 5/22/25, showed under the narrative notes, “Patient currently has an upper respiratory infection managed by azithromycin (an antibiotic) 500 mg tablet.”* However, there was no documented evidence the RN included the azithromycin in the patient’s admitting orders, reported to the DPCS of the patient’s use of antibiotic for an infection, nor an infection log completed to include the patient’s infection for the infection tracking purposes.-Review of Patient 14’s closed clinical record was initiated on 7/22/25. The clinical record showed the SOC was on 4/17/24. The patient was certified for hospice services during the certification period from 4/17/24 to 6/15/24. The patient was discharged and revoked hospice services on 5/20/24.The Comprehensive Nursing Assessment dated 4/17/24, showed under the narrative notes, “(Patient 14) had revocation of hospice and now re-admitting S/p fall and signs/ symptoms of UTI… (Patient 14) was discharges with Rx for Levofloxacin 750 mg daily x’s 7 days.”* However, there was no documented evidence the RN included the levofloxacin (antibiotic) in the patient’s admitting orders, reported to the DPCS of the patient’s use of antibiotic for an infection, nor an infection log completed to include the patient’s infection for the infection tracking purposes.On 7/23/25 at 1050 hours, an interview, clinical record review, closed record review, and concurrent facility document review was conducted with the Consultant. The Consultant was asked how the hospice screened for infections. The Consultant stated the nurses would assess the patients for signs and symptoms of infection, review the patient’s medications if they were currently taking antibiotics, or the patient/patient’s caregiver reports to hospice. The Consultant stated the nurses had the responsibility to report if the patient had infection to the DPCS, and the DPCS would document the infection in the tracking log in the hospice’s electronic software. The Consultant was informed, acknowledged the findings, and verified the data in the monthly Infection Control Log was inaccurate.On 7/24/25 at 0924 hours, a follow-up interview was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS was asked what the hospice did with the infection data. The Administrator Designee/DPCS stated the infection data was analyzed to see trends to determine goals and interventions to decrease the number of infections. The Administrator Designee/DPCS further stated the data collection was also reported in the QAPI meeting. The Administrator Designee/DPCS was asked if a quarterly meeting was conducted to discuss infection control data. The Administrator Designee/DPCS replied she was unsure and unable to provide documented evidence a quarterly meeting was conducted to discuss infection control data.”

“Based on interview and record review, the hospice failed to implement the bereavement program as per the hospice’s P&P to address the needs of the bereaved family members for two of 15 sampled patients (Patients 13 and 15) who was deceased. This failure has the potential to not address the bereavement needs of the bereaved family members of the patients.Findings: 2.Review of Patient 13’s closed clinical record was initiated on 7/18/25. The closed clinical record showed the SOC was 6/30/24. The patient was certified for hospice services during the certification period from 6/30/24 to 8/28/24. The patient expired on 7/14/24.Review of the bereavement tracking log showed the sympathy card was sent on 7/15/25. *However, there was no documented evidence of the copy of the sympathy card sent.In addition, further review of Patient 13’s closed clinical record did not show an updated bereavement assessment completed as per the hospice’s P&P. On 7/24/25 at 1124 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the finding. Review of the hospice’s P&P titled Bereavement Services revised April 2020 showed the hospice will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for up to one year following the death of the patient. The program will provide bereavement services to the family/caregiver of hospice patients before and after the patient’s death, in accordance with the plan of care. Within two weeks after the death of a patient, a sympathy card will be sent to the bereaved. After three weeks, a bereavement letter will be sent to the bereaved; offering support and outlining the hospice bereavement services. Within three to five weeks after the patient’s death, a bereavement assessment will be completed by the bereavement counselor following the family/caregiver. This assessment will identify grief issues. The bereavement counselor will render a professional judgment as to whether the bereaved is experiencing normal grief, moderate grief, or severe grief. If a person is noted as experiencing normal grief, the bereavement counselor will contact the bereaved person for an ongoing assessment and support for three, six, and nine months after the patient’s death and at the anniversary of the patient’s death.1. Review of Patient 15’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/22/24. The patient was certified for hospice services during the certification period from 3/22/24 to 6/19/24. The patient expired on 4/13/24.Review of the bereavement binder showed a photocopy of a bereavement letter sent to the patient’s family/caregiver dated 5/13/24. *However, the bereavement letter was sent more than 21 days instead of less than 21 days as per the hospice’s P&P.In addition, further review of Patient 15’s closed clinical record did not show an updated bereavement assessment was completed as per the hospice’s P&P.On 7/24/25 at 1511 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the HA provided the HA services in accordance with the POC for one of 15 sampled patients (Patient 15). This failure had the potential for not providing the appropriate, consistent, and quality care to Patient 15.Findings: Review of Patient 15’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/22/24. The patient was certified for hospice services during the certification period from 3/22/24 to 6/19/24. The patient expired on 4/13/24.The POC/IDG Review dated 3/23 and 4/3/24, showed HA frequency of visits was two times per week.The HA Assignment dated 3/23/24, showed the HA tasks included bed bath, shaving facial hair, brushing teeth, cleaning/filing nails, applying deodorant and lotion, visualizing condition of skin and reporting to the RN, providing peri-care, and housekeeping tasks every visit.Review of the 2024 Full Year Weekly Calendar showed the HA conducted visits on 4/1 and 4/8/24.* However, further review of the HA Visit Notes did not show documented evidence of the HA’s services provided to the patient as per the POC.* In addition, further review of the 2024 Full Year Calendar showed the HA conducted one visit per week to the patient during the weeks of 3/31/24 to 4/6/24 and 4/7/24 to 4/13/24, instead of two visits per week as per the POC.On 7/24/25 at 1455 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS was informed and acknowledged the findings. The Administrator Designee/DPCS verified the calendar showed the actual scheduled and conducted visit of the hospice’s personnel to the patient.”

“Based on interview and record review, the hospice failed to ensure the volunteers the time spent and services provided by the volunteers were completed. This failure had the potential of not providing the adequate volunteer services.Findings: Review of the hospice’s P&P titled Volunteer Services revised April 2020 showed volunteers will document their activities/type of service and time worked on volunteer activity/clinical notes and submit this documentation for the patient’s clinical records. The Volunteer Coordinator will track the use of volunteers, the cost of savings achieved, and that the hours of volunteer services will exceed the 5% of the total patient care hours of paid and contracted hospice personnel. Review of the hospice’s volunteer programs for the years of 2023, 2024, and 2025 were conducted on 7/23/25. The following was identified:- Review of the hospice’s volunteer program binder failed to show documented evidence the Volunteer Saving Report and Cost savings through Use of Volunteers Report was completed from May to August of 2023.- The Volunteer Savings Report for November 2023 showed 66.42 hours of total direct patient care hours. The Cost Savings through Use of Volunteers Report showed the volunteer spent five hours of administrative office tasks. The Volunteer Documentation-Ancillary dated 11/14/23, showed the volunteer did administrative type assignments. *However, there was no documented evidence of the specific hours that the volunteer worked.- The Volunteer Savings Report for February 2024 showed 35.5 hours of total direct patient care hours. The Cost Savings through Use of Volunteers Report showed the volunteer spent three hours of administrative office tasks. The Volunteer Documentation-Ancillary dated 2/7/24, showed the volunteer’s task were filing and interpreting for Spanish-speaking patients. *However, there was no documented evidence of the specific hours the volunteer worked.- The Volunteer Savings Report for April 2024 showed 17.75 hours of total direct patient care hours. The Cost Savings through Use of Volunteers Report showed the volunteer spent two hours of administrative office tasks. *However, there was no documented evidence of the volunteer’s documentation of detail of the tasks completed and the date and time the volunteer worked.-Review of the hospice’s volunteer program binder failed to show documented evidence the Volunteer Saving Report and Cost Savings through Use of Volunteers Report were completed for August of 2024.On 7/24/25 at 1340 hours, an interview and concurrent facility document review was conducted with the Administrator/Volunteer Coordinator/Owner. The Administrator/Volunteer Coordinator/Owner was informed and acknowledged the above findings.”

“Based on interview and record review, the hospice Administrator failed to be responsible for the day-to-day operations of the organization and maintain the administrative and supervisory responsibility for all care provided as evidenced by:-The written agreement for three of five contractors (Contractor 1, 2, and 3) failed to include the rights and responsibilities related to coordination and supervision of the care services. -The written agreement for two of five contractors (Contractor 3 and 4) failed to include the roles and responsibilities related to patient/family admission process, development , review, revision and management of the plan of care, interdisciplinary team conferences, scheduling visit hours, bereavement follow up and submission of documentation.-The written agreement for one of five contractors (Contractor 4) failed to include the procedure for charge and reimbursements.-The Administrator failed to ensure wound care policy was implemented for one of 15 sampled patients (Patient 7).-The Administrator failed to ensure the supervision for the LVN policy was implemented for one for 15 sampled patients (Patient 4).These failures had the potential risk to negatively impact the hospice’s operational performance. Findings: #. Review of the hospice’s Administrator Job Description (undated) the Administrator ensures quality and safe delivery of Hospice services; coordinates services that reflect Hospice’s philosophy and standard of care; and plans, develops, implements and evaluates Hospice services, programs and activities.Review of the hospice’s Wound Care Policy (undated) the nurse will provide wound care per physician orders and continue to implement and evaluate the plan of care based on the effectiveness of treatment regimen, response to treatment, effectiveness of interdisciplinary services, need for assessment by Wound Care Specialist, patient/caregiver participation and identification of obstacles/risk factors interfering with wound healing. The nurse will notify the physician for any change in the patient’s condition or lack of progress. At each visit, the patient’s skin will be assessed. At each dressing change the wound will be assessed and documentation will include a description of the wound bed, drainage, signs and symptoms of infection, healing and peri wound skin condition. At least every week, the wound assessment and documentation will include measurement of length, width, depth, and undermining and tunneling if present.Review of Patient 7’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/2/25. The patient was certified for hospice services during the certification period from 5/31/25 to 8/28/25.Review of the current treatment and medication list showed a physician treatment order dated 4/28/25, to apply silver sulfadiazine (a cream used to prevent and treat wound infections in patients with second-and third degree burns) 1 % topical cream topically to patient’s facial burn 3x a day.The POC/IDG Review dated 6/11, 6/25, and 7/9/25, did not show POC for skin issues such as the patient’s facial burn.Review of SN notes dated 5/31, 6/8, 6/20, 6/27, and 7/6/25 failed to show documented evidence the patient’s facial burns were assessed to include information such as a description of the wound bed, drainage, signs and symptoms of infection, healing and peri wound skin condition, or the measurement length, width, depth, and undermining and tunneling of the wound as per the hospice’s P&P.On 7/24/25 at 1139 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS stated at every SN visit, the SN should assess the patient’s wound and document the description of the wound, look for any signs and symptoms of infection, and the measurement of the wound. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of the hospice’s P&P revised March 2013 showed the RN shall do supervisory visit for the LVN every month.Review of Patient 4’s clinical record was initiated on 7/16/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25.Review of the Visit Notes dated 5/29, 6/12, 6/27, and 7/5/25, showed the LVN conducted a home visit for the patient. Review of the Visit Note-RN dated 7/1/25, showed under the Supervisory Note section, LVN questions regarding supervisory assessment were left blank.*However, there was no documented evidence the RN completed a supervisory visit for a LVN as per the hospice’s P&P.On 7/24/25 at 1459 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding. According to Standards of Quality Hospice Care, 2005 Section (B) Contractual Services, when program services are not provided directly by employees there shall be a written agreement defining the nature and scope of services provided. The agreement shall address, but not be limited to: rights and responsibilities of the program and the contracted individual or organization in the implementation, coordination, supervision and evaluation of care services and the roles and responsibilities in the patient/family admission process, development, review, revision and management of the plan of care, interdisciplinary team conferences, scheduling of visit hours and bereavement follow-up. The agreement shall also address the submission of documentation of services provided and the procedure for charge and reimbursement. - Review of the written agreement between the hospice and Contractor 1 providing pharmacy services was initiated on 7/24/25. The written agreement was effective 2/5/25. However, the written agreement with Contractor 1 did not include the rights and responsibilities related to supervision of services. - Review of the written agreement between the hospice and Contractor 2 providing DME services was initiated on 7/24/25. The written agreement was effective 2/1/25. However, the written agreement with Contractor 2 did not include the rights and responsibilities related to supervision of services. - Review of the written agreement between the hospice and Contractor 3 providing PT, OT, ST services was initiated on 7/24/25. The written agreement was effective 6/10/25. However, the written agreement with Contractor 3 did not include the rights and responsibilities related to coordination of services.In addition, the written agreement did not include the roles and responsibilities related to patient/family admission process, review and management of the plan of care, interdisciplinary team conferences and scheduling of visit hours.Further review of the written agreement did not include the submission of documentation of services provided. - Review of the written agreement between the hospice and Contractor 4 as a Medical Director was initiated on 7/24/25. The written agreement was effective 1/6/25. However, the written agreement with Contractor 4 did not include the roles and responsibilities related to interdisciplinary team conferences and bereavement follow-up.In addition, the written agreement with the Contractor 4 did not include the procedure for charges and reimbursement. Further, review of the written agreement with Contractor 4 showed the section for the compensation was left blank.Moreover, the section of Notice showed the hospice name was Love Light Hospice instead of Carebest hospice. On 7/24/25 an interview and concurrent document review was conducted with the Consultant. The Consultant was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the patients’ clinical records were complete, accurate and submitted timely for 14 of 15 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, and 15). This failure had the potential risk of the patients receiving substandard care and disrupting the continuity of care due to incomplete, inaccurate and untimely submitted documentation. Findings: #. Review of Patient 2’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/22/25. The patient was certified for hospice services during the certification period from 5/22/25 to 8/1/25.The POC/IDG Review dated 5/22, 5/28, 6/11, 6/25 and 7/9/25, showed the frequency of visit for the SC was cited as one visit per month.Review of the clinical record showed the SC had performed telephone visits on 5/26 and 6/9/25. Review of the SC’s telephone visits on 5/26 and 6/9/25, on the section of narrative showed “the Chaplain observed and followed all COVID-19 precautions.”* However, the SC performed a telephone visit instead of in- person visit which was inaccurate for the SC to observe the COVID 19 precautions. On 7/24/25 at 1056 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS stated it was inaccurate documentation. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 4’s clinical record was initiated on 7/16/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25.The POC/IDG Review dated 5/28, 6/11, 6/25, and 7/9/25, showed the frequency of visit for the SC was cited as one visit per month.Review of the clinical record showed the SC had performed telephone visits on 5/24 and 6/9/25. Review of the SC’s telephone visits on 5/24 and 6/9/25, on the section of narrative showed “the Chaplain observed and followed all COVID-19 precautions.”* However, the SC performed a telephone visit instead of in- person visit which was inaccurate for the SC to observe the COVID 19 precautions. On 7/24/25 at 0956 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS stated it was inaccurate documentation. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 5’s clinical record was initiated on was initiated on 7/17/25. The clinical record showed the SOC was on 5/13/25. The patient was certified for hospice services during the certification period from 5/13/25 to 8/10/25.The POC/IDG Review dated 5/28, 6/11, 6/25 and 7/9/25 showed the frequency of visit for the SC was cited as one visit per month.Review of the clinical record showed the SC had performed telephone visits on 5/17, 6/9, and 7/16/25. Review of the SC’s telephone visits on 5/17, 6/9 and 7/16/25, on the section of narrative showed “the Chaplain observed and followed all COVID-19 precautions.”* However, the SC performed a telephone visit instead of in- person visit which was inaccurate for the SC to observe the COVID 19 precautions. On 7/24/25 at 1117 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS stated it was inaccurate documentation. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 7’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/2/25. The patient was certified for hospice services during the certification period from 5/31/25 to 8/28/25.The POC/IDG Review dated 6/11, 6/25 and 7/9/25 showed the frequency of visit for the SC was cited as one visit per month.Review of the clinical record showed the SC had performed telephone visits on 5/28 and 6/9/25. Review of the SC’s telephone visits on 5/28 and 6/9/25, on the section of narrative showed “the Chaplain observed and followed all COVID-19 precautions.”* However, the SC performed a telephone visit instead of in- person visit which was inaccurate for the SC to observe the COVID 19 precautions. On 7/24/25 at 1127 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS stated it was inaccurate documentation. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 11’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and revoked hospice services on 5/20/25.The Physician Orders for Life-Sustaining Treatment (POLST) prepared on 3/6/25, showed the patient elected for attempted resuscitation/ cardiopulmonary resuscitation (CPR) and full treatment in situation of a health emergency.*However, review of the Physician’s Certification for Hospice Benefit dated 3/6/25, showed the physician’s narrative notes, the patient was Do Not Resuscitate (DNR) in situation of a health emergencyOn 7/24/25 at 1526 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS stated the documentation was inaccurate. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 15’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/22/24. The patient was certified for hospice services during the certification period from 3/22/24 to 6/19/24. The patient expired on 4/13/24.a. The POC/IDG Review dated 3/23/24, showed under the other orders section included the following:-MSW service: initial evaluation and PRN thereafter-RN x 1 every 14 days for supervisory visit-SC service: initial evaluation and PRN thereafter-SN x1 per week + 2 prn for symptom management and changes in condition* However, under the frequency of visit section, showed the following frequency visits:-MSW: 1 per month-SC: 1 per month-SN: 2 per week + 3 prn visitOn 7/24/25 at 1355 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS stated the frequency visits were inconsistent and should match the orders. The Administrator Designee/ DPCS was informed and acknowledged the finding.b. The Visit Note- RN dated 4/9 and 4/12/24, showed under the genitourinary section, RN documented “never” for the question of urinary problem. In addition, RN documented “yes” for the question of incontinence. *However, under the narrative notes showed was provided Foley catheter care, which incontinence cannot be rated, and the patient has urinary problem because of the use of a urinary catheter.On 7/24/25 at 1459 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS stated the documentation was inaccurate. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 1’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/23/25. The patient was certified for hospice services during the certification period from 4/5/25 to 7/3/25 and 7/4/25 to 10/1/25. The patient was transferred from another hospice on 5/23/25.The POC/IDG Review for the certification period from 7/4/25 to 10/1/25 dated 5/23/25 showed the frequency of visit. The SC visit cited as one per month.Review of the clinical record showed the BC/SC had performed a telephone visits on 5/27 and 7/16/25.Further review of the BC/SC telephone visits on 5/27 and 7/16/25, on the section of narrative showed “the Chaplain observed and followed all COVID-19 precautions”.However, the BC/SC performed a telephone visit instead of in- person visit which was inaccurate for the BC/SC to observed the COVID 19 precautions. On 7/24/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. #. Review of Patient 10’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 1/6/25. The patient was certified for hospice services during the certification period from 5/25/25 to 7/23/25. The POC/IDG Review dated 5/28, 6/11, 6/25 and 7/9/25 showed the frequency of visit. The SC visit cited as one per month.Review of the clinical record showed the BC/SC had performed a telephone visits on 5/28, 6/6 and 7/15/25. Further review of the BC/SC telephone visits on 5/28, 6/6 and 7/15/25, on the section of narrative showed “the Chaplain observed and followed all COVID-19 precautions”.However, the BC/SC performed a telephone visit instead of in- person visit which was inaccurate for the BC/SC to observed the COVID 19 precautions. On 7/24/25 at 1008 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. #. Review of Patient 6’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/9/25. The patient was certified for hospice services during the certification periods from 3/9/25 to 6/6/25 and 6/7/25 to 9/4/25.a. The POC/IDG Review dated 5/28, 6/11, 6/25 and 7/9/25 showed the frequency of visit. The SC visit cited as one per month.Review of the clinical record showed the BC/SC had performed a telephone visits on 5/28, 6/9 and 7/15/25. Further review of the BC/ SC telephone visits on 5/28, 6/9 and 7/15/25, on the section of narrative showed “the Chaplain observed and followed all COVID-19 precautions”.However, the SC performed a telephone visit instead of in- person visit which was inaccurate for the BC/SC to observed the COVID 19 precautions. b. The POC/IDG Review dated 3/19 and 4/2/25 showed the frequency of visit. The RN visit cited as one every two weeks.Review of the RN 1 notes dated 3/23/25 on the section on narrative, showed the patient was assessed to have mild edema (plus one) in the lower extremities. Further review of the cardiovascular assessment on the comments section showed the patient had mild edema (plus one) in the lower extremities. However, on the section of cardiovascular comments showed the RN 1 documented the edema (pitting) as 11 to 20 seconds (plus two) in the lower extremities which was inconsistent. On 7/24/25 at 1146 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. #. Review of Patient 14’s closed clinical record was initiated on 7/22/25. The clinical record showed the SOC was on 4/17/25. The patient was certified for hospice services during the certification period from 4/17/25 to 6/15/25. The patient was discharged and transferred to another hospice on 5/20/25.a. Review of the Psychosocial Assessment dated 4/25/25, showed the MSW 2/BC performed the initial assessment. The assessment showed the MSW 2/BC had electronically signed the visit note. However, review of the visit note showed handwritten signature of the MSW 3/SC which was inconsistent as the MSW 2/BC conducted the visit. b. Review of the Comprehensive Nursing Assessment dated 4/17/24 at 1500 hours, showed the RN 4 documented the patient to performed self catheterization three times daily. Review of the Telephone Order dated 4/17/2024 at 2030 hours, showed the treatment orders. The treatment orders included the following: irrigate foley with normal saline as needed or per agency protocol and use soap and water cleanse the drain port and and replace the stopper on the leg bag or clamp the port of the large bag.However, there was no documented evidenced of the patient was assessed to have a foley catheter which was inconsistent with a self catheterization. Further review of the Telephone Order dated 4/17/2024 at 2030 hours showed the treatment orders included straight catheter.However, review of the Initial Interdisciplinary Plan of Care dated 4/18/24 on the section of Functional Limitation showed a check marked on the box next to foley catheter and may insert foley catheter per routine order protocol which was inconsistent with straight catheter order. On 7/24/25 at 0942 hours, an interview and concurrent closed clinical record review was conducted with the Consultant. The Consultant was asked as to who conducted the visit. The Consultant reviewed the closed clinical records and replied, the visit was conducted by the MSW 2/BC, the MSW 3/SC should have not signed the form. The Consultant was also asked if the patient had a foley or straight catheter. The Consultant replied, needed to verify with the Administrator/Volunteer Coordinator/Owner. The Administrator/Volunteer Coordinator/Owner verified the patient had a straight catheter. The Consultant informed and acknowledged the findings. #. Review of Patient 3’s clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25. The POC/IDG Review for the certification period from 5/20/25 to 8/17/25 dated 5/20/25 showed the frequency of visit. The SC visit cited as one per month.Review of the clinical record showed the BC/SC had performed a telephone visits on 5/24, 6/9 and 7/16/25. Further review of the BC/SC telephone visits on 5/24, 6/9 and 7/16/25 on the section of narrative showed “the Chaplain observed and followed all COVID-19 precautions”.However, the BC/SC performed a telephone visit instead of in- person visit which was inaccurate for the BC/SC to observed the COVID 19 precautions. On 7/24/25 at 0920 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. Review of the hospice’s P&P titled Content of Clinical Record revised 4/2020 showed the clinical record contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel.Review of the Timely Submission of Patient Documentation revised 7/2016 showed the telephone or verbal physician’s orders must be submitted to Hospice office for processing within three business days after receipt. Itineraries, with all visit reports attached, must be submitted the next scheduled work day, not exceeding seven business days. #. Review of Patient 8’s clinical record review was initiated on 7/17/24. The clinical record showed the SOC was 2/7/25. The patient was certified for hospice services during the certification periods from 2/7/25 to 5/7/25 and 5/8/25 to 8/5/25.a.Review of the Physician’s Order dated 2/7/25, showed an order for A&D ointment (cream that prevents rash) applied to dry skin daily as needed.*However, review of the Physician’s order dated 5/13/25, showed an order for A&D ointment to be applied intramuscularly which was inaccurate. b.The communication log dated 2/28/25, showed documentation that the patient had complaint of chronic back pain, radiating to the legs for weeks affecting sleep and elemental tasks. Documentation showed the physician was informed and ordered the following:-Cymbalta (medication to treat depression) 30 mg by mouth daily.-Ibuprofen (medication to relieve pain) 600 mg every eight hours as needed with food.-Heating pack daily for comfort.-Famotidine (medication used to reduce acid in the stomach) 40 mg by mouth daily.The POC/IDG review dated 3/5/25, showed the above medications, however, the nursing IDG discussion/updated comprehensive assessment review documented medications were reviewed, no new orders.c.Review of the Physician’s order dated 5/9/25, showed an order for Ketorolac Tromethamine 60 mg/2 ml solution for injection intramuscular for sciatica pain one time then repeat in two weeks. Give Omeprazole (medication used to reduced amount of acid in the stomach) 40 mg daily for three days upon administering ketorolac. *However, LVN 2 note dated 5/24/25 documented LVN 2 administered Ketorolac Tromethamine (medication to managed moderately severe acute pain) 60 mg/2 ml IM on the gluteus muscle (muscle located in the buttocks) for chronic pain which was not consistent. Furthermore, there was no documented evidence regarding Omeprazole 40 mg to be taken daily after the administration of ketorolac.On 7/24/25 at 0953 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. #.Review of Patient 9’s clinical record review was initiated on 7/17/25. The clinical record showed the SOC was 2/4/25. The patient was certified for hospice services during the certification period from 2/4/25 to 5/4/25 and 5/5/25 to 8/2/25.a.Review of the POC/IDG dated 5/14/25, showed the LVN visit frequency was one per week.*On 7/24/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the Administer. The Administrator stated RN 5 had a visit on 7/8/25. However, RN 5 completed the SN visit notes on 7/22/25. Furthermore, the Administrator stated the notes should be completed seven days from date of visit. b.The Recert Assessment dated 4/29/25 showed in the narrative that patient was on oxygen therapy as needed and has been using oxygen frequently due to constant shortness of breath.*However, further review of the POC showed no documented evidence the patient was on oxygen therapy. c.The POC/IDG review dated 3/19/25 showed the IDG discussion regarding a 67 year old female admitted to hospice.*However, the patient to be discussed was a 77 year old male patient admitted to hospice which was inconsistent.d.The POC/IDG review dated 4/16/25 showed the IDG discussion that the patient was on Alprazolam and Escitalopram.*However, further review of the POC showed no documented evidence the POC included Alprazolam (medication used to treat anxiety) and Escitalopram (medication used to treat depression and anxiety) in the medications.e.The POC/IDG review dated 5/14/25 showed the IDG discussion that Tylenol (over the counter medication for relieving mild to moderate pain) was available as needed for pain.*However, further review of the POC showed no documented evidence the POC included Tylenol for pain. f.The RN 5 visit note dated 4/15/25 showed in the narrative that patient was on Ensure for nutritional supplement.*However, further review of the POC showed no documented evidence the POC included Ensure for nutritional supplement.On 7/24/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. Review of Patient 13’s closed clinical record was initiated on 7/18/25. The closed clinical record showed the SOC was 6/30/24. The patient was certified for hospice services during the certification period from 6/30/24 to 8/28/24.a.The visit progress note dated 7/1/24 showed the MSW 3 contacted patient’s family to schedule an initial chaplain assessment. Per patient’s daughter, there was no need for chaplain services at this time.*However, The POC/IDG review dated 7/3/24 showed an IDG discussion that patient was unresponsive but daughter would like her mother to continue to receive spiritual counselling care.b.Review of the RN 6 visit note dated 6/30/25 under the narrative section, showed the following:-Patient has shortness of breath upon ambulation and exertion, some wheezing noted.-Patient has occasional constipation and diarrhea*However, review of the signs and symptoms screening showed:-For respiratory, none for the abnormal lung sound.-For gastro-intestinal digestive showed, none for constipation and never for diarrhea.c.Review of the RN 7 visit note dated 7/12/25 under the narrative section, showed the following:-Patient began to appear a bit agitated after turning and repositioning.-The daughter stated the patient has not had a BM in over two weeks.*However, review of the signs and symptoms screening showed:-For neurological/mental/sensory showed none for anxiety and agitation.-For gastro-intestinal digestive showed none for constipation.On 7/24/25 at 1124 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the clinical records were authenticated and dated timely in accordance with the hospice’s P&P for eight of 15 sampled patients (Patients 1, 3, 4, 6, 8, 10, 11, and12 ). This failure had the potential risk of substandard care provided to these patients as their clinical information were not completed timely.Findings: #. Review of Patient 8’s clinical record review was initiated on 7/17/24. The clinical record showed the SOC was 2/7/25. The patient was certified for hospice services during the certification periods from 2/7/25 to 5/7/25 and 5/8/25 to 8/5/25.*The initial psychosocial assessment dated 2/7/25, showed no documented evidence of RN 2’s electronic signature.*The initial spiritual assessment dated 2/7/25, showed no documented evidence of RN 2’s electronic signature.*The initial bereavement assessment dated 2/7/25, showed no documented evidence of RN 2’s electronic signature.*The POC/IDG review dated 6/25/25, showed no documented evidence of the RN’s electronic signature.*The POC/IDG review dated 2/10/25, 2/19/25, 3/5/25, 4/2/25, 4/16/25 and 5/14/25 showed no documented evidence of the SC’s electronic signature.On 7/24/25 at 0953 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. #. Review of Patient 1’s clinical record was initiated on 7/15/25. The clinical record showed the SOC was on 5/23/25. The patient was certified for hospice services during the certification period from 4/5/25 to 7/3/25 and 7/4/25 to 10/1/25. The patient was transferred from another hospice on 5/23/25.The POC/IDG Meeting Review dated 5/23, 5/28, 6/11, 6/26 and 7/9/25 showed the IDG meeting was conducted. The IDG included Medical Director and the Administrator Designee/DPCS had electronically signed the POC/IDG Meeting Review. However, the section for the MSW and Chaplain signature was left blank. On 7/24/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was asked as to the core members of the IDG meeting. The Consultant replied, the members were the Medical Director, DPCS , MSW and the Spiritual Counselor. The Consultant was also asked if they needed to sign the IDG meeting. The Consultant reviewed the clinical records and replied, yes, they should. The Consultant was informed and acknowledged the findings. #. Review of Patient 10’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 1/6/25. The patient was certified for hospice services during the certification period from 5/25/25 to 7/23/25. The POC/IDG Meeting Review dated 5/14/25 showed the IDG meeting was conducted. The IDG included Medical Director, the Administrator Designee/DPCS, the MSW and the Chaplain. The IDG meeting was electronically signed by the MD, the Administrator Designee/DPCS and the MSW. However, the SC failed to electronically signed the meeting as the section for the Chaplain signature was left blank. On 7/24/25 at 1008 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. #. Review of Patient 6’s clinical record was initiated on 7/17/25. The clinical record showed the SOC was on 3/9/25. The patient was certified for hospice services during the certification periods from 3/9/25 to 6/6/25 and 6/7/25 to 9/4/25.a. The POC/IDG Review dated 3/9, 3/19, 4/2, 4/30 and 5/14/25 showed the IDG was conducted. The IDG included the MD, the Administrator Designee/DPCS, the MSW and the Chaplain. The IDG meeting was electronically signed by the MD, the Administrator Designee/DPCS and the MSW. However, the SC failed to electronically signed the meeting as the section for the Chaplain signature was left blank. In addition review of the POC/IDG Review dated 4/16/25, showed the IDG was conducted. The IDG included the MD, the Administrator Designee/DPCS, the MSW and the Chaplain. The IDG meeting was electronically signed by the MD and the MSW. However, the Administrator Designee/DPCS and the SC failed to electronically signed the meeting as the section for the RN and SC signature was left blank. b. Review of the Bereavement Assessment dated 3/17/25, showed the Administrator Designee/DPCS performed bereavement assessment.However, the Administrator Designee/DPCS failed to electronically signed and dated the visit assessment. On 7/24/25 at 1008 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. #. Review of Patient 12’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and transferred to another hospice on 4/30/25.The POC/IDG Review dated 3/6, 3/19, 4/2, 4/16 and 4/30/25 showed the IDG was conducted. The IDG included the MD, the Administrator Designee/DPCS, the MSW and the Chaplain. The IDG meeting was electronically signed by the MD, the Administrator Designee/DPCS and the MSW. However, the MSW and the Chaplain failed to electronically signed the meeting as the section for the MSW and the Chaplain signature was left blank.On 7/24/25 at 1102 hours, an interview and concurrent closed clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the findings. Review of the hospice’s P&P titled Timely Submission of Patient Documentation revised 7/2016 showed itineraries, with all visit reports attached, must be submitted the next scheduled workday, not exceeding seven business days. All patients visit reports from contract personnel must be submitted within seven business days from the date of the visit e.g. PT, SLP, etc.Review of the hospice’s P&P titled Contents of Clinical Record revised April 2020 showed A clinical record will be maintained for each patient receiving care. Each entry will be dated and signed, including the title and credentials, by the person providing the care/services.#. Review of Patient 4’s clinical record was initiated on 7/16/25. The clinical record showed the SOC was on 5/20/25. The patient was certified for hospice services during the certification period from 5/20/25 to 8/17/25.a. The History of Visit Notes showed a home visit dated 7/5/25, conducted by an LVN. *However, the visit note had a status of an “X.”On 7/16/25 at 1604 hours, an interview and concurrent clinical record review was conducted with the Consultant. The Consultant was asked what the “X” meant in the visit note status. The Consultant replied that the LVN had not submitted their visit notes yet. The Consultant further stated the LVN should have turned in their visit notes within five days of the visit date. The Consultant was informed and acknowledged the finding.b. On 7/16/25 at 0951 hours, a joint home visit was conducted with LVN 1 to the patient’s residency. LVN 1 was observed performing a head-to-toe physical assessment to the patient and reviewed the patient’s medication profile.* However, on 7/23/25 at 0908 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS verified LVN 1 had not submitted his visit note for 7/16/25 home visit and stated home visit notes should be submitted within seven days of the home visit. The Administrator Designee/ DPCS verified LVN 1 should had submitted his notes prior to his next visit on 7/23/25 as per the hospice’s P&P. The Administrator Designee/ DPCS was informed and acknowledged the finding. #. Review of Patient 11’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and revoked hospice services on 5/20/25.a. Review of the initial comprehensive spiritual assessment dated 3/6/25, showed a SN assessed the patient for spiritual support. *However, there was no documented evidence of a signature, date, title or credential of the personnel completing the assessment as per the hospice’s P&P.On 7/24/25 at 1516 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding.b. Review of the initial comprehensive psychosocial assessment dated 3/6/25, showed under the narrative section, a SN assessed the patient for psychological needs. *However, there was no documented evidence of a signature, date, title or credential of the personnel completing the assessment as per the hospice’s P&P.On 7/24/25 at 1520 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/ DPCS. The Administrator Designee/ DPCS was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure a copy of the discharge summary was forwarded to the physician for two of 15 sampled patients (Patient 11 and 14). This failure had the potential of not communicating the post-discharge care needs of these patients to the physician. Findings: Review of the hospice P&P titled Revocation of Hospice Benefit revised April 2020 showed the Case Manager will notify the attending physician and interdisciplinary group about the revocation and reason. A discharge summary will be sent to the attending physician.Review of Patient 11’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and revoked hospice services on 5/20/25.Review of the closed clinical record showed a discharge summary was completed on 5/20/25. However, there was no documented evidence the discharge summary was sent to the physician as per the hospice’s P&P.On 7/24/25 at 1522 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS was informed and acknowledged the finding. #. Review of Patient 14’s closed clinical record was initiated on 7/22/25. The clinical record showed the SOC was on 4/17/25. The patient was certified for hospice services during the certification period from 4/17/25 to 6/15/25. The patient was discharged and transferred to another hospice on 5/20/25.Review of the closed clinical record showed a discharge summary was completed on 5/20/25. However, there was no documented evidence the discharge summary was sent to the physician as per the hospice’s P&P.On 7/24/25 at 0942 hours, an interview and concurrent closed clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the finding. Review of the hospice’s P&P titled Discharge Summary revised April 2020 showed a copy of the discharge summary will be provided to the patient’s attending physician. If requested, the patient’s clinical records will be provided.Review of the hospice P&P titled Revocation of Hospice Benefit revised April 2020 showed the Case Manager will notify the attending physician and interdisciplinary group about the revocation and reason. A discharge summary will be sent to the attending physician.1. Review of Patient 11’s closed clinical record was initiated on 7/18/25. The clinical record showed the SOC was on 3/6/25. The patient was certified for hospice services during the certification period from 3/6/25 to 6/3/25. The patient was discharged and revoked hospice services on 5/20/25.Review of the closed clinical record showed a discharge summary was completed on 5/20/25. However, there was no documented evidence the discharge summary was sent to the physician as per the hospice’s P&P.On 7/24/25 at 1522 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee/DPCS. The Administrator Designee/DPCS was informed and acknowledged the finding. 2. Review of Patient 14’s closed clinical record was initiated on 7/22/25. The clinical record showed the SOC was on 4/17/25. The patient was certified for hospice services during the certification period from 4/17/25 to 6/15/25. The patient was discharged and transferred to another hospice on 5/20/25.Review of the closed clinical record showed a discharge summary was completed on 5/20/25. However, there was no documented evidence the discharge summary was sent to the physician as per the hospice’s P&P. On 7/24/25 at 0942 hours, an interview and concurrent closed clinical record review was conducted with the Consultant. The Consultant was informed and acknowledged the finding.”