All for Health Hospice Care, Inc.

“Based on observation, interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (CoP, requirements that healthcare organizations must meet to participate in federal healthcare programs) for Initial & Comprehensive Assessment (an assessment to identify the physical, psychosocial [how a person thinks, feels, and interacts with others], emotional, and spiritual needs related to the terminal illness [a serious, incurable disease that doctors expect will lead to death, often within months] that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process) of patients was met as follows: 1). The HA failed to ensure the comprehensive assessments were accurate, reflected the patient’s current health condition, and identified the patients’ need for hospice care and services for two of 15 sampled patients (Patients 7 and 8).This failure had the potential to result in a decline in the patients’ health condition due to not having proper medical oversight and access to needed specialists, medications, and medical treatments (Refer to L524). 2). The HA failed to ensure the medication profile review (comprehensive assessment of the patient’s medications to evaluate a patient’s medication regimen, assess patient teaching needs, and guides care planning for the patient) for three of 15 sampled patients (Patients 1, 2, and 3) was conducted in accordance with the HA’s own policy and procedures. This failure had the potential to result in ineffective drug therapy and adverse outcomes due to medications not being taken or managed as prescribed by the physician. (Refer to L530). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulation for Initial and Comprehensive Assessment of Patient to ensure the highest quality of care was being provided to patients certified to receive the hospice benefits.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Interdisciplinary Group (IDG, a collaborative team of healthcare professionals responsible for providing holistic care [care for the patient as a whole person] to hospice patients and their families), Care Planning, Coordination of Services was met as follows: The HA failed to ensure the IDG (Interdisciplinary Group, IDG – meeting where the Registered Nurse [RN], Medical Social Worker [MSW], Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) members met to review the Interdisciplinary Group/ Plan of Care (IDG/POC) Review for eleven out of fifteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 6, Patient 9, Patient 10, Patient 12, Patient 13, Patient 14 and Patient 15). This failure had the potential to result in a decline in health of the patients due to not receiving care in accordance with their personal needs due to lack of coordination of care (Refer to 541). 2. The HA failed to review and update the POC to reflect the most current and active medications for two of fifteen sampled patients (Patient 2 and Patient 3). This failure had the potential to cause a decline in the patients’ health related to the lack or delay in delivery of care and services by not providing the patients with the appropriate monitoring and management of their medications (Refer to 552). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure provision of quality care and services to patients certified to receive the hospice benefits.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (CoP, refers to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Medical Director was met as follows: The HA failed to ensure the Medical Director reviewed past medical history and physical’s (H&P), hospital records, diagnostic, and/or laboratory results that indicated the patients met the hospice criteria to be admitted into the hospice patient care program for three of 15 sampled patients (Patient 7, Patient 8, and Patient 12). This failure had the potential to cause a decline in the patients’ health and quality of life due to the possible unmet needs of the patients and/or the family related to patients being enrolled to the HA without proper medical oversight of the implementation of the hospice services (Refer to L667).The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory (written law) mandated compliance with Federal regulation for Medical Director services to ensure quality of patient care was provided to the patients certified to receive hospice services.”

“Based on interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (CoP, requirements that healthcare organizations must meet to participate in federal healthcare programs) for Clinical Records was met as follows: The HA Interdisciplinary Group (IDG, team composed of a Registered Nurse [RN], Medical Social Worker [MSW], spiritual counselor [SC], and physician [MD] who discuss the patient’s plan of care to provide the best individualized care and support to patients and families) failed to ensure the care plans of three of 15 sampled patients (Patients 1, 2, and 3) were accurate, complete, and individualized to reflect the current medications ordered and available for the patients. This failure had the potential to result in Patients 1, 2, and 3 not receiving the necessary treatment and care which could result in patients’ discomfort, worsened condition, and a decline in health (Refer to L672). 2. The HA staff failed to fully complete and sign the POLST (physician orders for life-sustaining treatment) for nine of 15 sampled patients (Patients 1, 2, 4, 7, 8, 9, 12, 14, and 15) to ensure the POLST was a valid physician’s order. This failure had the potential to cause a decline in the patients’ health and quality of life related to not following the patients’ wishes regarding life-sustaining treatment choices (Refer to L678). 3. The HA failed to ensure the IDG Core Members (RN, MD Chaplain, and MSW) signed the IDG notes for 11 of 15 sampled patients (Patients 1, 2, 3, 6, 8, 9, 10, 12, 13, 14, and 15). This failure had the potential to result in patients not receiving continuity of care and services that could result in pain, discomfort, decline of patient condition and decrease in the quality of life (Refer to L679). The cumulative effect of these practices resulted in the systemic failure of the HA to deliver statutorily (written law) mandated compliance with the federal regulations for Clinical Records to ensure accurate and complete documentation of all the care and services provided to these hospice certified patients.”

“Based on interviews and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the comprehensive assessments were accurate, reflected the patient’s current health condition, and identified the patients’ need for hospice care and services for two of 15 sampled patients (Patients 7 and 8). This failure had the potential to result in a decline in the patients’ health due to not receiving the necessary non-hospice care and services related to the limited or denied access to non-hospice specialists, medications, or medical treatments. Findings: a). During a review of Patient 7’s medical record, titled “Personal Information,” the “Personal Information” indicated the start of care (SOC) date of 9/17/2024 with diagnoses including diastolic congestive heart failure (type of heart failure [HF, inability of the heart to pump enough blood to meet the body’s needs] due to the inability of the left lower heart chamber to relax between heartbeats) and essential primary hypertension (abnormally high blood pressure [BP, force of the blood pushing against the artery walls]). During a review of Patient 7’s medical record, titled “Comprehensive Nursing Assessment,” dated 9/17/2024, the “Comprehensive Nursing Assessment” indicated In determining the nature and condition of terminal illness or patient eligibility to receive hospice care and services, Registered Nurse 3 (RN 3) documented Patient 7 met the criteria for New York Heart Association (NYHA) Functional Classification (categorizes the severity of heart failure into four classes based on symptoms and physical limitation) - Class IV level HF (most severe stage of HF with symptoms while at rest and any physical activity causes further discomfort) and Patient 7 required considerable assistance and frequent medical care, was ambulatory with a walker and required moderate assistance and was completely dependent on a caregiver with toileting and feeding. During a review of Patient 7’s medical record, titled “Re-Cert Assessment,” dated 1/9/2026, the “Re-Cert Assessment” indicated “In determining the nature and condition of terminal illness or patient eligibility to receive hospice care and services, the Director of Patient Care Services Designee (DPCSD) documented Patient 7 met the criteria for NYHA Class IV level HF and Patient 7 required considerable assistance and frequent medical care. The record further Patient 7 was ambulatory with a walker and required moderate assistance. Patient 7 was completely dependent on a caregiver with toileting, feeding, and dressing. The assessment further indicated Patient 7 had a normal BP, regular pulse, no edema (swelling due to excess fluid in the body’s tissues), no heart-related pain, and normal skin color, had no shortness of breath (SOB, difficulty catching breath) and cough, and had clear lung sounds and normal respirations and did not have any physician’s order for oxygen therapy (prescribed medical treatment delivering extra oxygen via masks or nasal tubes to patients who cannot get enough through normal breathing). Also the assessment indicated Patient 7 was continent of urine (able to control the urinary bladder) and had clear, yellow urine. -Patient 7 was continent of bowel (able to control bowel movements) and had 2-3 bowel movements per week. During a telephone interview on 3/12/2026 at 12:15 p.m., Patient 7 stated he did not have a terminal illness (incurable medical condition that is expected to result in death, typically within six months). Patient 7 stated he did not have a heart problem or HF. Patient 7 stated he lives by himself and can independently perform activities of daily living (ADLs, fundamental self-care tasks to maintain independence and hygiene). Patient 7 stated he can walk 1,800 steps in the morning and 1,800 steps in the evening daily without getting any SOB or oxygen therapy. Patient 7 stated he has not seen his primary care physician (PCP) or has not been hospitalized because he has been “very healthy” for the last 15 years. During an interview on 3/12/2026 at 1:06 p.m., the Medical Director stated to qualify for hospice care with heart failure as the qualifying diagnosis, the HA must be able to classify the patient as NYHA Class IV Level by reviewing and verifying the cardiologist (medical doctor who specializes in the study and treatment of heart diseases) notes and assessment notes indicating the patient has symptoms, such as pulmonary edema (life-threatening condition characterized by severe shortness of breath [SOB] and impaired oxygen delivery due to the excess fluid buildup in the lung air sacs commonly caused by HF), ascites (characterized by severe swelling and weight gain due to the abnormal fluid buildup in the abdominal cavity sometimes caused by HF), and inability to walk 25 feet or up and down the stairs without having any SOB. During a concurrent interview and record review on 3/12/2026 at 2:42 p.m. with the Acting DPCS, Patient 7’s medical records were reviewed. The Acting DPCS stated Patient 7 was on the 9th recertification period to receive hospice care and services. There was no documented evidence such as History & Physical or hospital records to verify that Patient 7 had a diagnosis of heart failure prior to hospice admission. The Acting DPCS stated based on the Comprehensive Recertification Assessment, dated 1/9/2026, Patient 7 was not eligible for hospice care because there was no documented evidence that Patient 7 had symptoms of NYHA Class IV Level HF. The Acting DPCS stated there was no documented evidence that the HA attempted to obtain medical records from Patient 7’s PCP. The Acting DPCS stated it was important to contact Patient 7’s PCP prior to hospice admission to obtain a complete and accurate assessment of Patient 7 and to keep Patient 7’s PCP well-informed about what was happening to Patient 7. The Acting DPCS further stated it was important to ensure Patient 7 was eligible to receive hospice services prior to admission to the HA to make sure access to needed non-hospice specialists, medications, or curative treatments was available for Patient 7. b). During a review of Patient 8’s medical record, titled “Personal information,” the “Personal Information” indicated a SOC date of 3/18/2025 with diagnoses including chronic atrial fibrillation (sustained, rapid, and irregular heart rhythm lasting longer than seven days) and hyperlipidemia (high levels of fat in the blood). During a review of Patient 8’s medical record, titled “Comprehensive Nursing Assessment,” dated 3/18/2025, the “Comprehensive Nursing Assessment” indicated In determining the nature and condition of terminal illness or patient eligibility to receive hospice care and services, RN 4 documented Patient 8 met the criteria for NYHA Class IV level and Patient 8 required considerable assistance and frequent medical care and was ambulatory (able to walk) with a walker and required maximum assistance. was completely dependent on a caregiver with ambulation, transfer, and bathing. During a review of Patient 8’s medical record, titled “Re-Cert Assessment,” dated 1/11/2026, the “Re-Cert Assessment” indicated in determining the nature and condition of terminal illness or patient eligibility to receive hospice care and services, the DPCSD documented Patient 8 met the criteria for NYHA class IV level and Patient 8 was disabled (unable to care for self) and required special care and assistance, was ambulatory with a walker and required maximum assistance, was completely dependent on a caregiver with ambulation, toileting, dressing, and bathing. During a telephone interview on 3/12/2026 at 10:30 a.m., Patient 8 stated no healthcare provider notified her that she (Patient 8) had a terminal illness. Patient 8 stated she had a history of stroke (medical emergency due to the loss of blood flow to a part of the brain) and atrial fibrillation, but she was not notified about a “heart failure” diagnosis. Patient 8 stated she lived alone in her home. Patient 8 stated she is able to walk around the house and go to the bathroom with a walker and/or a cane. Patient 8 stated she was able to independently perform most ADLs but needed assistance with mopping, vacuuming, and doing the laundry. During an interview on 3/12/2026 at 1:06 p.m., the Medical Director stated having atrial fibrillation diagnosis would not automatically qualify a patient to receive hospice care and services. The Medical Director stated a patient must have a terminal illness with a “prognosis of 6 months or less to live” to qualify for hospice. During a concurrent interview and record review on 3/12/2026 at 2:42 p.m. with the Acting DPCS, Patient 8’s medical records were reviewed. The Acting DPCS stated there was no documented evidence such as History & Physical or hospital records to verify that Patient 8 had a diagnosis of heart failure prior to hospice admission. The Acting DPCS stated it was important to ensure Patient 8 was eligible to receive hospice services prior to admission to the HA to make sure Patient 8 has “access to the care that she needs.” During a review of the HA’s policy and procedures titled “Comprehensive Assessment,” dated 11/2021, the policy and procedure indicated all baseline data and other relevant information must be documented, through interview and observation, in the patient’s clinical record, including at least the following information, as relevant: nature and condition causing admission (including the presence or lack of objective data and subjective complaints), patient’s past and present medical and psychosocial history including pertinent diagnosis and any comorbid (medical conditions that coexist alongside a primary diagnosis) conditions, name and address of the patient’s attending physician, name of the hospital and other agencies or persons involved in the past and present care of the patient, laboratory results, medical, alcohol, and other drug history, past medical and surgical care, including dates of onset (when symptoms first experienced or signs first observed)/exacerbation (when symptoms worsened), the need for referrals and further evaluation by appropriate health professionals, physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patient’s terminal illness, patient’s functional status including, but not limited to, the degree of self-care and the amount and level of assistance needed, complication and risk factors that affect care planning.The policy further indicated that the comprehensive assessment must be updated by the Interdisciplinary Group (IDG, team of healthcare professionals who work together to develop an individualized plan for the patients and support the families) as frequently as the patient’s condition requires but at a minimum every 15 days. If no changes are needed, then that must be documented. If there has been a change in the patient’s condition/status, then the comprehensive assessment must be updated. During a review of the HA’s policy and procedures, titled “Ongoing Assessments,” dated 11/2021, the policy and procedure indicated the nurse must assess each patient on each visit for compliance with treatments and medication regimen and progress toward hospice goals and patient needs and problems. The policy also indicated that ongoing comprehensive assessments must focus on the patient’s response to care, changes in patient condition, changes in patient diagnoses/prognosis, and changes in the patient’s care environment or support systems. The policy further indicated the plan of care—including problems, needs, goals, and outcomes—must be reviewed and updated by the interdisciplinary group members responsible for the case.”

“Based on observation, interviews, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the medication profile review (comprehensive assessment of the patient’s medications to evaluate a patient’s medication regimen, assess patient teaching needs, and guides care planning for the patient) for three of 15 sampled patients (Patients 1, 2, and 3) was conducted in accordance with the HA’s own policy and procedures.This failure had the potential to result in ineffective drug therapy and adverse outcomes due to medications not being taken or managed as prescribed by the physician. Findings:a). During a review of Patient’s 1’s admission record), the admission record indicated a Start of Care (SOC) date of 10/8/2025 with diagnoses including malignant carcinoid tumor of the kidney (slow-growing form of kidney cancer that develops from hormone-producing cells), heart failure (HF, heart disorder which causes the heart to not pump the blood efficiently, and hyponatremia (abnormally low levels of sodium in the blood). During a concurrent observation, interview, and record review on 3/10/2026 at 1:16 p.m., with Register Nurse 2 (RN 2), Patient 1’s medication bottles and ”Current Treatment/Medication/Durable Medical Equipment (DME) List”, dated 1/06/2026 through 4/05/2026 were reviewed. Patient 1’s “Current Treatment/Medication/DME List” indicated the following medications:-Acetaminophen (medication to treat minor to moderate pain) 325 milligram (mg, unit of measurement of weight) tablet, oral, one tablet, every six hours as needed for mild pain, not to exceed 3000 mg of acetaminophen from all sources daily. -Calmoseptine (moisture barrier ointment designed to protect, soothe, and promote healing of skin irritations) one tube, apply topically to affected area (buttocks) once daily as needed for skin care. -Clotrimazole/betamethasone dipropionate (medication that treats inflammatory fungal infections) 1%-0.05%, topical, apply to affected area, for rash. -Omeprazole 40 mg delayed-release capsule, oral, once a day for gastroesophageal reflux disease (GERD, chronic condition where stomach acid frequently flows back into the esophagus, causing persistent heartburn and chest pain).-Pepcid AC (famotidine, medication to treat heartburn) under DME section (no dosage, route, and indications for use)A container of acetaminophen 500mg, 325 tablets was observed on the kitchen table. RN 2 stated according to the “Current Treatment/Medication/DME List” Patient 1 does not have the correct dose of acetaminophen. RN 2 stated that Patient 1 did not have the Calmoseptine, Clotrimazole/betamethasone dipropionate and Omeprazole 40 mg. RN 2 stated Patient 1’s medication list should be updated to reflect the physician orders. During an interview on 3/10/2026 at 1:30 p.m., Patient 1’s Care Giver (PCG 1) stated RNs conduct a home visit every week. PCG1 stated Patient 1 has been taking one tablet of acetaminophen 500 mg as needed for pain management with Patient 1 being responsive to acetaminophen 500 mg (not as ordered by the physician) for two months now. PCG 1 stated two months ago, the HA physician told Patient 1 to only take Pepcid AC for GERD instead of Omeprazole 40 mg.During an interview on 3/10/2026 at 1:50 p.m., Patient 1’s Home Health Aide (HHA) stated Patient 1 “never received” the Calmoseptine, Clotrimazole/betamethasone dipropionate and Omeprazole. During a concurrent interview and record review on 3/11/2026 at 2:15 p.m. with the Director of Patient Care Services Designee (DPCSD), Patient 1’s “Current Treatment/Medication/DME List”, dated 1/06/2026 through 4/05/2026 was reviewed. The DPCSD stated medication reconciliation must be done every home visit. DPCSD stated Patient 1’s missing medication was an oversight on the visiting RN’s part and should have been noted and updated on Patient 1’s medication list. DPCSD stated Patient 1 was at risk of skin tears which can caused discomfort and pain because Patient 1 did not have the topical ointments to apply to rashes as ordered by the physician. The DPSCD stated Patient 1 could “easily” exceed the 3000 mg of acetaminophen per day if taking 500mg tablets instead of the ordered 325 mg tablets. The DPSCD stated Patient 1 has a diagnosis of a kidney tumor and exceeding the acetaminophen levels ordered could damage Patient 1’s kidneys. The DPCSD stated if Patient 1 did not take his Omeprazole 40 mg once a day for GERD, it could cause uncomfortable gastrointestinal pain. b. During a review of Patient 2’s medical record, titled “Personal Information,” the “Personal Information” indicated a start of care (SOC) date of 10/15/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD, long-term lung disease characterized by difficulty breathing due to chronic inflammation that restricts airflow). During a review of Patient 2’s medical record, titled “Plan of Care (POC) Summary,” as of 3/9/2026, the “POC Summary” indicated the following active medication orders for Patient 2: -Order Date: 10/15/2024 – Albuterol (medication to treat COPD by relaxing the airway muscles) 90 micrograms (mcg, unit of measurement of weight)/actuation (single, measured release of the medication from the inhaler) – inhale two puffs orally every six hours as needed for shortness of breath (SOB, difficulty catching breath). -Order Date: 10/15/2024 – Morphine (controlled pain medication, part of the comfort kit [pre-stocked set of emergency medications kept in a hospice patient’s home]) 20 milligrams (mg, unit of measurement of weight)/milliliter (ml, unit of measurement of volume) – Place 0.25 ml under the tongue every 2 hours as needed for moderate to severe pain -Order Date: 10/15/2024 – Levsin (medication to reduce body secretions, part of the comfort kit) 0.125 mg – Place 1 mg under the tongue every 4 hours as needed for excessive secretions -Order Date: 10/15/2024 – ondansetron (medication to prevent throwing up or the urge to throw up, part of the comfort kit) 4 mg – Place 1 tablet under the tongue every 4 hours as needed for nausea or vomiting -Order Date: 8/5/2025 – Ativan (medication to calm the brain and nerves, part of the comfort kit) 2 mg/ml – Place 0.5 ml under the tongue every 2 hours as needed for anxiety (excessive feelings of dread, apprehension, or uneasiness)/agitation (restlessness) -Order Date: 12/5/2025 – DuoNeb (medication to treat COPD by relaxing muscles and opening airways, part of the comfort kit) 0.5 mg solution – 1 vial for oral inhalation via nebulizer (machine that turns the medicine into a mist to be inhaled, often for 15 minutes or less) every 4 hours as needed for SOB or wheezing. -Order Date: 12/5/2025 – Ozempic (medication to treat high blood sugar) 0.25 mg or 0.50 mg/dose pre-filled pen – inject 1 unit subcutaneously (underneath the skin layers and into the fatty tissue) once a week every Monday During a concurrent observation and interview on 3/10/2026 at 12:18 p.m., while on a joint home visit at Patient 2’s living room, with Licensed Vocational Nurse 1 (LVN 1), Patient 2 was noted awake, alert, and ambulatory (able to walk). Patient 2 was observed having SOB, using her accessory muscles (use of muscles in the neck, chest, and abdomen to assist with breathing and signifies the struggle to get enough oxygen), with an oxygen saturation (indicates how well the lungs and circulatory system deliver oxygen to the body with normal values of 88% - 92% for COPD patients) of 58% on room air. LVN 1 administered, with Patient 2’s consent, oxygen therapy to Patient 2 via a nasal cannula (flexible tube with 2 prongs to deliver supplemental oxygen to the patient’s nostrils) after multiple attempts of LVN 1 to educate Patient 2 about the importance of proper oxygenation. Patient 2 stated she lives by herself and self-administers her medications. Patient 2 initially stated she had all the medications she needs and refused to show her medication bottles to LVN 1. Upon further questioning by LVN 1, Patient 2 stated she did not receive the following medications: albuterol, Ozempic, and the comfort kit containing DuoNeb, Morphine, Ativan, Levsin, and ondansetron. Patient 2 stated she has not received her nebulizer. During a concurrent interview and record review on 3/11/2026 at 12:37 p.m. with the DPCSD, tracking records of Patient 2’s delivered medications and Patient 2’s medical record, titled “Plan of Care (POC)/Interdisciplinary Group (IDG) Review,” dated 3/4/2026 were reviewed. The DPCSD stated Patient 2 had a change in health insurance while under hospice care that caused some changes in medication coverage. The DPCSD stated that the medication profile review must be done by the visiting nurse every home visit to evaluate the effectiveness of the medication regimen and verify Patient 2’s compliance with the treatment plan. The DPCSD stated not taking prescribed breathing treatments like albuterol and DuoNeb could lead to ineffective drug therapy and cause a health decline related to decreased oxygenation and could further lead to increased hospitalizations. The DPCSD stated the comfort kit medications were ordered to be used for “emergency purposes” to provide comfort during the end-of-life because Patient 2’s health could potentially “decline quickly.” The DPCSD stated one (1) Albuterol canister was last delivered on 12/6/2026 (to last up to approximately one month if administered consistently as ordered). The DPCSD stated Patient 2’s “POC/IDG Review,” dated 3/4/2026, indicated the goal for Patient 2 to was to “resolve episodes of dyspnea [difficulty breathing] such as having oxygen saturation of not less than 90%, respirations between 12-20 breaths per minute and no use of accessory muscles for breathing after 30 minutes of interventions…” and the intervention to “monitor/assess effectiveness of current medication/treatment” related to albuterol medication order. The DPCSD stated there was no documented evidence regarding the inability of the HA to provide albuterol to Patient 2 as ordered by the physician. Ninety (90) vials of DuoNeb were last delivered on 12/6/2026 (to last up to 15 days if administered consistently as ordered). The DPCSD stated Patient 2’s “POC/IDG Review,” dated 3/4/2026, indicated the goal for Patient 2 to was to “resolve episodes of dyspnea such as having oxygen saturation of not less than 90%, respirations between 12-20 breaths per minute and no use of accessory muscles for breathing after 30 minutes of interventions…” and the intervention to “monitor/assess effectiveness of current medication/treatment” related to DuoNeb medication order. The DPCSD stated there was no documented evidence regarding the inability of the HA to provide DuoNeb to Patient 2 as ordered by the physician. There was no documented evidence of any confirmed delivery of the nebulizer for the DuoNeb administration. The DPCSD stated Patient 2 “did not want the nebulizer last month.” The DPCSD stated there was no documented evidence regarding Patient 2’s refusal to use the nebulizer in 2/2026 and/or education provided by the HA nurse to discuss the importance of the nebulizer). Three pens of Ozempic were last delivered on 11/11/2025 (to last up to 3 months). The DPCSD stated Patient 2’s “POC/IDG Review,” dated 3/4/2026, indicated the goal for Patient 2 of “optimal blood sugar management for patient comfort” and the intervention to “monitor/assess effectiveness of current and new medication/treatment” related to Ozempic medication order. The DPCSD stated Patient 2’s blood sugar level was well-controlled with Metformin (oral medication to treat high blood sugar), but there was no documented evidence regarding the unavailability of Ozempic and any plans to continue, discontinue, or substitute another medication for Ozempic as ordered by the physician. There was no documented evidence of any confirmed delivery of the comfort kit containing Morphine, Ativan, Levsin, and ondansetron. The DPCD stated, “Knowing her (Patient 2), most likely, she did not want these medications (Morphine, Ativan, Levsin, and ondansetron) because she does not need them at this time.” The DPCSD stated there was no documented evidence Patient 2 refused the delivery of Morphine, Ativan, Levsin, and ondansetron. During an interview on 3/12/2026 at 1:06 p.m., the Medical Director stated bronchodilators (medications that relax muscles surrounding airways in the lungs, causing them to widen and open) like albuterol and DuoNeb improve breathing and oxygenation by opening up the airways and decreasing the mucus in COPD patients. The Medical Director stated Ozempic helps with blood sugar control. The Medical Director stated he was not notified regarding Patient 2’s Ozempic being unavailable. The Medical Director stated if Ozempic was not available, other antidiabetic medications could be ordered for better blood sugar control. c. During a review of Patient 3’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 11/26/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (a condition where plaque [fat, cholesterol, calcium] builds up in the heart’s original arteries, narrowing them and restricting blood flow, but without causing chest pain or discomfort). During a review of Patient 3’s medical record, titled “Plan of Care (POC)/Interdisciplinary Group (IDG) Review,” dated 3/4/2026 for certification period #2, the “POC/IDG Review” indicated a physician’s order for frequency visit from the Skilled Nurse (SN) once per week for changes in condition. During an observation while on a joint home visit on 3/10/2026 at 10 a.m. with RN 2, at Patient 3’s residence, Patient 3 was observed in her kitchen, sitting up in a chair, awake, alert, oriented to her name, time, place and events. Patient 2 was observed walking with the assistance of a front-wheeled walker (FWW, assistive device to assist with walking). During a concurrent interview and record review on 3/10/2026 at 10:35 a.m. with RN 2, Patient 3’s medication list and medication bottles were reviewed. Patient 3’s medication list indicated an order for: -Atorvastatin (medication used to treat high cholesterol) 40 mg take one tablet orally once daily at bedtime for hyperlipidemia (high cholesterol) -Norco (narcotic prescribed pain medication) 10 mg-325 mg tablet take one tablet orally every 6 hours as needed for moderate to severe pain Patient 3 stated the dose for atorvastatin on the medication list was not correct and it was supposed to be 80 mg once daily at bedtime. Patient 3 stated a month ago her cardiologist changed the dose order for atorvastatin, and she (Patient 3) had informed the DPCSD about the medication dose change. RN2 stated and confirmed that Patient 3’s medication list indicated an order for atorvastatin 40 mg once daily at bedtime and not 80 mg once daily at bedtime. Patient 3 stated that she did not have her Norco medication, it had been days without it and was waiting for it to be delivered. RN2 stated and confirmed that Patient 3 did not have her medication bottle of Norco and he would notify the patient’s case manager, to find out what happened. During a review of Patient 3’s medication bottles, one of the bottles indicated a medication Bayer low dose 81 mg. Patient 3 stated she takes Bayer (aspirin, medication used to reduce risk of heart attacks and stroke by preventing blood clots) 81 mg once a day in the morning and has been taking it for a long time along with her medication Plavix (prescription medication used to prevent blood clots, blood thinner). RN2 stated and confirmed that Patient 3’s medication list did not include the order for Bayer 81 mg to take once a day and stated he would notify the case manager of the medication to update the medication list. RN2 stated he was not part of Patient 3’s regular care team and would notify the case manager about the medication list discrepancies. During an interview on 3/10/2026 at 11:20 a.m., RN 2 stated that the patient’s medications should be checked during every home visit and if there are any changes with the medications then the nurse should contact the patient’s case manager that same day to inform them of the changes. RN2 stated the case manager is an RN, and they will contact the physician and make any necessary updates on the medication list. During an interview on 3/11/2026 at 1:48 p.m., the DPCSD stated she was made aware by RN2 yesterday, 3/10/2026, of Patient 3’s changes to her medications and stated that the medication list was already updated. The DPCSD also stated Patient 3’s medications Protonix and Norco were ordered STAT (immediately without delay) and were delivered to Patient 3 at 6 p.m... The DPCSD stated it is important that the Skilled Nurse review Patient 3’s medication bottles at every home visit, especially pain medication, to order them with time and prevent the patient from having uncontrolled pain that can cause a change in vital signs, affect her activities of daily living and negatively affect her overall health. The DPCSD stated the purpose of hospice care is to provide the patient with comfort care and pain management.During a review of the undated, HA’s policy and procedures (P&P), titled “Medication Profile/Reconciliation,” the P&P indicated the following:1). Patients receiving medications must have a current, accurate medication profile in the clinical record. Medication profiles must be updated for each change to reflect current medications and new and/or discontinued medications. 2). A medication regimen review must be performed at the time of admission, when updates to the comprehensive assessments are performed, and when care is resumed after a patient has been placed on hold. The review must identify potential adverse effects and drug reactions, ineffective drug therapy, duplicate drug therapy, and noncompliance with drug therapy omissions and unclear information. 3). During subsequent home visits, the medication profile must be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: -to evaluate the use of drugs in the home setting -to teach the purpose of medications, dosages, routes, administration times, side effects, and contraindications -to use as a communication tool for other clinicians involved in care 4. Deviations in taking medications as ordered must be documented in clinical notes, and the physician or other authorized licensed independent practitioner must be notified. An incident report must be filed as necessary. During a review of the facility’s policy and procedure (P&P) titled “Provision of Care and Record Management, Ongoing Assessments”, dated 11/2021, P&P indicated, The nurse will assess each patient on each visit for: Compliance with treatments and medication regimen. Based upon the findings of the assessment, change/verbal orders must be generated and forwarded to the physician (or other authorized independent practitioner) as needed. The physician must be notified to verify any changes in medications, including over-the-counter medications and treatments/interventions that require physician approval. The P&P also indicated the following information must be available in the clinical record as applicable to care and services provided: Current medication profile including: prescription and nonprescription medications, herbal products, and home remedies; dose, frequency, and route of administration; with ongoing updates to the patient’s medication regimen, including new, changed, and discontinued medications, adverse reactions, significant side effects, drug allergies, and contraindications.”

“Based on interviews and record review, the HA failed to ensure the IDG (Interdisciplinary Group, IDG – meeting where the Registered Nurse [RN], Medical Social Worker [MSW], Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) members met to review the Interdisciplinary Group/Plan of Care (IDG/POC) Review for eleven out of fifteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 8, Patient 9, Patient 10, Patient 12, Patient 13, Patient 14 and Patient 15). This failure had the potential to result in a decline in health of the patients related to not receiving care in accordance with their personal needs due to the lack of coordination of care. Findings:a). During a review of Patient’s 1’s medical record, titled “Personal Information (admission record),” the “Personal Information” indicated the Start of Care (SOC) date of 10/8/2025 with diagnoses including malignant carcinoid tumor of the kidney (slow-growing form of kidney cancer that develops from hormone-producing cells), heart failure (HF, heart disorder which causes the heart to not pump the blood efficiently), and hyponatremia (abnormally low levels of sodium in the blood).During an interview on 3/11/2026 at 3:22 p.m., the Director of Patient Care Services Designee (DPCSD) stated that the IDG core members include the chaplain, MSW, MD, Registered Nurse 1 (RN 1), and DPCSD. The DPCSD stated the meetings are held every other Wednesday either in person or via telephone, depending on each member’s availability that day. The DPCSD stated the signatures on the Plan of Care (POC)/Interdisciplinary Group (IDG) Review (IDG notes reviewed and signed by IDG core members who attended the IDG meeting)” are required to be done within a week from the meeting date and serve as a sign-in sheet for the IDG members.During an interview on 3/11/2026 at 3:29 p.m., the DPCSD stated the importance of all IDG core members attending the IDG meetings is to provide input for all aspects of the patient. The DPCSD stated that for example, MSW could provide information on the patients’ (in general) psychosocial (pertaining to the mental, emotional, social, and environmental situation) aspect and chaplain could provide information on the patient’s spiritual aspect of their life and healing. During a concurrent interview and record review on 3/13/2026 at 2:15 p.m. with the DPCSD, Patient 1’s “POC/IDG Review,” dated 2/18/2026, was reviewed. The DPCSD stated Patient 1’s “POC/IDG Review” was missing the Registered Nurse (RN) signature. The DPCSD stated she would follow up within a week to make sure the “POC/IDG Reviews” were completed and signed. The DPCSD stated it was important to have the “POC/IDG Reviews” completed and signed the same day because notes and signatures could be left out which could delay medical, social or spiritual care for the Patients. b. During a review of Patient 2’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 10/15/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD, long-term lung disease characterized by difficulty breathing due to chronic inflammation that restricts airflow). c. During a review of Patient 3’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 11/26/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (a condition where plaque [fat, cholesterol, calcium] builds up in the heart’s original arteries, narrowing them and restricting blood flow, but without causing chest pain or discomfort). During a review of Patient 3’s medical record, titled “POC/IDG Review,” dated 3/4/2026, the POC/IDG Review indicated on the last page, electronic signatures from the DPCSD and the MSW dated 3/4/2026, and missing signatures from the Chaplain and Medical Director (MD). During a concurrent interview and record review on 3/13/2026 at 2:23 p.m. with the DPCSD, Patient 3’s medical record, titled “POC/IDG Review,” dated 3/4/2026, was reviewed. The DPCSD stated and confirmed that Patient 3’s “POC/IDG Review,” dated 3/4/2026, was missing a signature from the Chaplain and the Medical Director. The DPCSD stated that without signatures from the IDG core members on the “POC/IDG Review” their (IDG core members) attendance could not be verified. d. During a review of Patient’s 6’s medical record, titled “Personal Information,” the “Personal Information” indicated Patient 6’s SOC date of 4/4/2024 with diagnoses including Alzheimer’s (brain disorder that negatively affects memory, thinking, and behavior severe enough to interfere with daily tasks), hypothyroidism (condition wherein the thyroid gland is underactive and fails to secrete enough hormones into the bloodstream), and arthritis (inflammation of one or more joints, causing pain, swelling, stiffness, and reduced mobility). During a concurrent interview and record review on 3/13/2026 at 2:15 p.m. with the DPCSD, Patient 4’s “POC/IDG Review,” dated 9/17/2025 and 10/15/2025, were reviewed. The DPCSD stated Patient 4’s “POC/IDG Review,” dated 9/17/2025 and 10/15/2025 were missing the MSW signature. e. During a review of Patient 8’s medical record, titled “Personal information,” the “Personal Information” indicated the SOC date of 3/18/2025 with diagnoses including chronic atrial fibrillation (sustained, rapid, and irregular heart rhythm lasting longer than 7 days) and hyperlipidemia (high levels of fat in the blood). During a concurrent interview and record review on 3/13/2026 at 2:13 p.m. with the DPCSD, Patient 8’s “POC/IDG Review” notes were reviewed. The DPCSD stated Patient 8’s “POC/IDG Review,” dated 3/4/2026, did not have the RN and MSW signatures. The DPCSD stated the signatures confirm the attendance of the IDG core member during the IDG meeting. The DPCSD stated it was important for the RN to attend the meeting because the RN must coordinate the care of Patient 8 and without the RN, there would be no continuity of care and some health-related information could be missed during the meeting. The DPCSD stated it was important for the RN to attend the meeting to discuss any nursing needs of Patient 8. f. During a review of Patient 9’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 5/20/2025 with diagnoses including Alzheimer’s disease and hypertension (abnormally high blood pressure [BP, force of the blood pushing against the artery walls]). During a concurrent interview and record review on 3/13/2026 at 2:13 p.m. with the DPCSD, Patient 9’s “POC/IDG Review” notes were reviewed. The DPCSD stated Patient 9’s “POC/IDG Review,” dated 3/4/2026, did not have the chaplain signature. The DPCSD stated the signatures confirm the attendance of the IDG core member during the IDG meeting. The DPCSD stated it was important for the Chaplain to attend the meeting to discuss any spiritual needs of Patient 9. g. During a review of Patient 10’s medical record, titled “Personal information,” the “Personal Information” indicated the SOC date of 4/30/2024 with the end of care (EOC) date of 11/7/2025 with diagnoses including Alzheimer’s disease.During a review of Patient 10’s medical record, titled “Psychosocial Assessment (comprehensive evaluation of a patient’s mental, emotional, social, and environmental situation),” dated 5/4/2024, the “Psychosocial Assessment” indicated the MSW “will maintain regular contact to monitor the patient’s condition and assist the family with advance care planning.” During a review of Patient 10’s medical record, titled “Visit Note After Death,” dated 11/7/2025, the “Visit Note After Death” indicated the physician Patient 10’s death on 11/7/2025 at 8:05 a.m. after the RN (not identified) reported Patient 10 had no vital signs (objective measurements of basic body functions) and no respirations. During a concurrent interview and record review on 3/13/2026 at 2:13 p.m. with the DPCSD, Patient 10’s “POC/IDG Review” notes were reviewed. The DPCSD stated Patient 10’s “POC/IDG Review,” dated 10/1/2025, 10/15/2025, 10/29/2025, and 11/12/2025, did not have the MSW signatures. The DPCSD stated the signatures confirm the attendance of the IDG core member during the IDG meeting. The DPCSD stated it was important for the MSW to attend the meetings to discuss any psychosocial needs of the patient and/or family. h. During a review of Patient 12’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 11/1/2025, with a primary diagnosis of end-stage HF (most advanced, irreversible stage of HF).During a concurrent interview and record review on 3/13/2026 at 2:25 p.m. with the DPCSD, Patient 12’s “POC/IDG Review,” dated 3/4/2026 was reviewed. The DPCSD stated and confirmed that Patient 12’s “POC/IDG Review,” dated 3/4/2026, was missing the MSW signature. The DPCSD stated without a signature verification, the MSW’s attendance could not be verified. i. During a review of Patient 13’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 7/31/2023, and EOC date of 2/27/2026, and a primary diagnosis of HF.During a concurrent interview and record review on 3/13/2026 at 2:27 p.m. with the DPCSD, Patient 13’s “POC/IDG Review,” dated 1/7/2026, 1/21/2206, 2/4/2026, and 2/18/2026 were reviewed. The DPCSD stated and confirmed that Patient 13’s “POC/IDG Review,” dated 1/7/2026, 1/21/2206, 2/4/2026, and 2/18/2026 were missing the MSW signature. The DPCSD stated she did not recall if the MSW was on vacation at that time, but without her (MSW) signature, the MSW’s participation in the meeting could not be verified. j. During a review of Patient 14’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 11/6/2025 and EOC date of 1/15/2026, and a primary diagnosis of acute diastolic HF (sudden, severe episode where the heart’s left ventricle becomes too stiff to relax and fill properly between beats causing symptoms like shortness of breath, tiredness, and fluid buildup in the lungs). During a concurrent interview and record review on 3/13/2026 at 2:29 p.m. with the DPCSD, Patient 14’s “POC/IDG Review,” dated 12/24/2025, 12/10/2025, 11/26/2025, 11/12/2025, and 11/6/2025 were reviewed. The DPCSD stated and confirmed that Patient 14’s “POC/IDG Review,” dated 12/24/2025, 12/10/2025, 11/26/2025, 11/12/2025, and 11/6/2025 were missing MSW signatures. k. During a review of Patient 15’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 12/29/2025 and EOC date of 3/9/2026 with a primary diagnosis of Alzheimer’s disease.During a concurrent interview and record review on 3/13/2026 at 2:30 p.m. with the DPCSD, Patient 15’s “POC/IDG Review,” dated 3/4/2026, 2/18/2026, 2/4/2026, 1/21/2026, and 1/7/2026 were reviewed. The DPCSD stated and confirmed that Patient 15’s “POC/IDG Review,” dated 3/4/2026, 2/18/2026, 2/4/2026, 1/21/2026, and 1/7/2026 were missing MSW signatures. During a review of the undated HA’s Policy and Procedure (P&P), titled “Interdisciplinary Group (IDG) members Policy,” the P&P indicated that the IDG must include at a minimum the medical director or designee, registered nurse, social worker and pastoral or spiritual counselor. The P&P indicated that IDG meetings must be conducted at least every 15 calendar days or more frequently as the patient condition requires, held in-person or via telecommunication, and attendance and participation must be documented. The P&P also indicated that IDG meeting notes must include the date, participants, summary of discussions, and plan of care changes. The P&P indicated documentation must be maintained in the patient’s medical record.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) failed to review and update the Plan of Care (POC) to reflect the most current and active medications for two of fifteen sampled patients (Patient 2 and Patient 3). This failure had the potential to cause a decline in the patients’ health related to the lack or delay in delivery of care and services by not providing the patients with the appropriate monitoring and management of their medications. Findings:During a review of Patient 2’s medical record, titled “Personal Information,” the “Personal Information” indicated start of care (SOC) date of 10/15/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD, long-term lung disease characterized by difficulty breathing due to chronic inflammation that restricts airflow). During a review of Patient 2’s medical record, titled “POC Summary,” as of 3/9/2026, the “POC Summary” indicated the following active medication orders for Patient 2: Order Date: 10/15/2024 – Albuterol (medication to treat COPD by relaxing the airway muscles) 90 micrograms (mcg, unit of measurement of weight)/actuation (single, measured release of the medication from the inhaler) – inhale 2 puffs orally every 6 hours as needed for shortness of breath (SOB, difficulty catching breath).Order Date: 10/15/2024 – Morphine (controlled pain medication, part of the comfort kit [pre-stocked set of emergency medications kept in a hospice patient’s home]) 20 milligrams (mg, unit of measurement of weight)/milliliter (ml, unit of measurement of volume) – Place 0.25 ml under the tongue every 2 hours as needed for moderate to severe painOrder Date: 10/15/2024 – Levsin (medication to reduce body secretions, part of the comfort kit) 0.125 mg – Place 1 mg under the tongue every 4 hours as needed for excessive secretions Order Date: 10/15/2024 – Ondansetron (medication to prevent throwing up or the urge to throw up, part of the comfort kit) 4 mg – Place 1 tablet under the tongue every 4 hours as needed for nausea or vomitingOrder Date: 8/5/2025 – Ativan (medication to calm the brain and nerves , part of the comfort kit) 2 mg/ml – Place 0.5 ml under the tongue every 2 hours as needed for anxiety (excessive feelings of dread, apprehension, or uneasiness)/agitation (restlessness)Order Date: 12/5/2025 – Duoneb (medication to treat COPD by relaxing muscles and opening airways, part of the comfort kit) 0.5 mg solution – 1 vial for oral inhalation via nebulizer (machine that turns the medicine into a mist to be inhaled, often for 15 minutes or less) every 4 hours as needed for SOB or wheezing.Order Date: 12/5/2025 – Ozempic (medication to treat high blood sugar) 0.25 mg or 0.50 mg/dose pre-filled pen – inject 1 unit subcutaneously (underneath the skin layers and into the fatty tissue) once a week every Monday During a concurrent observation and interview on 3/10/2026 at 12:18 p.m., while on a joint home visit at Patient 2’s living room, with Licensed Vocational Nurse 1 (LVN 1), Patient 2 was noted awake, alert, and ambulatory (able to walk). Patient 2 was observed having SOB, using her accessory muscles (use of muscles in the neck, chest, and abdomen to assist with breathing and signifies the struggle to get enough oxygen), with an oxygen saturation (indicates how well the lungs and circulatory system deliver oxygen to the body with normal values of 88% - 92% for COPD patients) of 58% on room air. LVN 1 administered, with Patient 2’s consent, oxygen therapy to Patient 2 via nasal cannula (flexible tube with 2 prongs to deliver supplemental oxygen to the patient’s nostrils) after multiple attempts of LVN 1 to educate Patient 2 about the importance of proper oxygenation. Patient 2 stated she lives by herself and self-administers her medications. Patient 2 initially stated she had all the medications she needs and refused to show her medication bottles to LVN 1. Upon further questioning by LVN 1, Patient 2 stated she did not receive the following medications: albuterol, Ozempic, and the comfort kit containing Duoneb, Morphine, Ativan, Levsin, and ondansetron. Patient 2 stated she has not received her nebulizer. During a concurrent interview and record review on 3/11/2026 at 12:37 p.m. with the Director of Patient Care Services Designee (DPCSD), tracking records of Patient 2’s delivered medications and Patient 2’s medical record, titled “Plan of Care (POC)/Interdisciplinary Group (IDG) Review,” dated 3/4/2026 were reviewed. The DPCSD stated Patient 2 had a change in health insurance while under hospice care that caused some changes in medication coverage. DPCSD stated medication profile review must be done by the visiting nurse every home visit to evaluate the effectiveness of the medication regimen and verify Patient 2’s compliance with the treatment plan. DPCSD stated not taking prescribed breathing treatments like albuterol and Duoneb could lead to ineffective drug therapy and cause a health decline related to decreased oxygenation and could further lead to increased hospitalizations. DPCSD stated the comfort kit medications were ordered to be used for “emergency purposes” to provide comfort during end-of-life because Patient 2’s health could potentially “decline quickly.” The DPCSD stated the following: One (1) Albuterol canister was last delivered on 12/6/2026 (to last up to approximately 1 month if administered consistently as ordered). DPCSD stated Patient 2’s “POC/IDG Review,” dated 3/4/2026, indicated the goal for Patient 2 to “resolve episodes of dyspnea [difficulty breathing] such as having oxygen saturation of not less than 90%, respirations between 12-20 breaths per minute and no use of accessory muscles for breathing after 30 minutes of interventions…” and the intervention to “monitor/assess effectiveness of current medication/treatment” related to albuterol medication order. DPCSD stated there was no documented evidence regarding the inability of the HA to provide albuterol to Patient 2 as ordered by the physician. -Ninety (90) vials of Duoneb were last delivered on 12/6/2026 (to last up to 15 days if administered consistently as ordered). DPCSD stated Patient 2’s “POC/IDG Review,” dated 3/4/2026, indicated the goal for Patient 2 to “resolve episodes of dyspnea such as having oxygen saturation of not less than 90%, respirations between 12-20 breaths per minute and no use of accessory muscles for breathing after 30 minutes of interventions…” and the intervention to “monitor/assess effectiveness of current medication/treatment” related to Duoneb medication order. DPCSD stated there was no documented evidence regarding the inability of HA to provide Duoneb to Patient 2 as ordered by the physician. -No documented evidence of any confirmed delivery of the nebulizer for the Duoneb administration. DPCSD stated Patient 2 “did not want the nebulizer last month.” DPCSD stated there was no documented evidence regarding Patient 2’s refusal to use the nebulizer in 2/2026 and/or education provided by the HA nurse to discuss the importance of the nebulizer). -Three pens of Ozempic were last delivered on 11/11/2025 (to last up to 3 months). DPCSD stated Patient 2’s “POC/IDG Review,” dated 3/4/2026, indicated the goal for Patient 2 of “optimal blood sugar management for patient comfort” and the intervention to “monitor/assess effectiveness of current and new medication/treatment” related to Ozempic medication order. DPCSD stated Patient 2’s blood sugar level was well-controlled with Metformin (oral medication to treat high blood sugar), but there was no documented evidence regarding the unavailability of Ozempic and any plans to continue, discontinue, or substitute another medication for Ozempic as ordered by the physician. -No documented evidence of any confirmed delivery of the comfort kit containing Morphine, Ativan, Levsin, and ondansetron. DPCD stated, “Knowing her (Patient 2), most likely, she did not want these medications (Morphine, Ativan, Levsin, and ondansetron) because she does not need them at this time.” DPCSD stated there was no documented evidence Patient 2 refused the delivery of Morphine, Ativan, Levsin, and ondansetron. During an interview on 3/12/2026 at 1:06 p.m., the Medical Director stated bronchodilators (medications that relax muscles surrounding airways in the lungs, causing them to widen and open) like albuterol and Duoneb improve breathing and oxygenation by opening up the airways and decreasing the mucus in COPD patients. The Medical Director stated Ozempic helps with blood sugar control. The Medical Director stated he was not notified regarding Patient 2’s Ozempic being unavailable. The Medical Director stated if Ozempic was not available, other antidiabetic medications could be ordered for better blood sugar control. b. During a review of Patient 3’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 11/26/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (a condition where plaque [fat, cholesterol, calcium] builds up in the heart’s original arteries, narrowing them and restricting blood flow, but without causing chest pain or discomfort). During a review of Patient 3’s medical record, titled “Plan of Care (POC)/Interdisciplinary Group (IDG) Review,” dated 3/4/2026 for certification period #2, the POC/IDG Review indicated an order for frequency visit from the Skilled Nurse (SN) once per week for changes in condition. During a joint home visit on 3/10/2026 at 10:15 a.m. with Registered Nurse 2 (RN 2) at Patient 3’s residence, Patient 3 was observed awake, alert, oriented to her name, time, place and events, and walking with the assistance of a front-wheeled walker (FWW, assistive device to assist with walking) taking small, slow steps. Patient 3 was observed able to sit up in a chair, holding onto her FWW for support. During a concurrent interview and record review on 3/10/2026 at 10:35 a.m. with RN 2, Patient 3’s medication list and medication bottles were reviewed. Patient 3’s medication list indicated an order for: Atorvastatin (medication used to treat high cholesterol) 40 milligrams (mg- unit of measurement) take 1 tablet orally once daily at bedtime for hyperlipidemia (high cholesterol) Patient 3 stated the dose for atorvastatin on the medication list was not correct and it was supposed to be 80 mg once daily at bedtime. Patient 3 stated a month ago her cardiologist changed the dose order for atorvastatin, and she (Patient 3) had informed the Director of Patient Care Services (DPCSD) about the medication dose change. RN 2 stated and confirmed that Patient 3’s medication list indicated an order for atorvastatin 40 mg once daily at bedtime and not 80 mg once daily at bedtime. During a review of Patient 3’s medication bottles, one of the bottles indicated a medication Bayer low dose 81 mg. Patient 3 stated she takes Bayer (aspirin, medication used to reduce risk of heart attacks and stroke by preventing blood clots) 81 mg 1 tablet once a day in the morning and has been taking it for a long time along with her medication Plavix (prescription medication used to prevent blood clots, blood thinner). RN 2 stated and confirmed that Patient 3’s medication list did not include the order for Bayer 81 mg to take once a day and stated he would notify the case manager of the medication to update the medication list. RN2 stated he was not part of Patient 3’s regular care team and would notify the case manager about the medication list discrepancies. During a concurrent interview and record review on 3/11/2026 at 2:53 p.m. with the DPCSD, Patient 3’s “POC/IDG Review,” dated 3/4/2026 for certification period #2 was reviewed. Patient 3’s “POC/IDG Review” indicated medication order list that included atorvastatin 40 mg tablet take 1 tablet once daily at bedtime. DPCSD stated there was no documented evidence of Patient 3’s medication Bayer 81 mg to take 1 tablet once daily. The DPCSD stated and confirmed that Patient 3’s “POC/IDG Review” was not updated to reflect patients current atorvastatin dose of 80 mg to take once daily at bedtime and to include the order for patients medication Bayer 81 mg to take once daily. The DPCSD stated the Patient 3’s “POC/IDG Review” should have been updated to reflect the current medications the patient is taking and to avoid the patient’s taking the incorrect medication or dose. During a review of the HA’s policy and procedures (P&P), titled “Interdisciplinary Group (IDG) members Policy,” undated, the P&P indicated that the IDG must include at a minimum the medical director or designee, registered nurse, social worker and pastoral or spiritual counselor. The P&P indicated that IDG meetings must be conducted at least every 15 calendar days or more frequently as patient condition requires, held in-person or via telecommunication, and attendance and participation must be documented. The P&P also indicated that IDG meeting notes must include the dates, participants, summary of discussions, and POC changes. The P&P indicated that documentation must be maintained in the patient’s medical record.”

“Based on interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the Medical Director reviewed the past medical history and physical examination (H&P), hospital records, diagnostic findings, and/or laboratory results demonstrating that patients met the hospice eligibility criteria for admission to the hospice program for three of 15 sampled patients (Patient 7, 8, and 12). This deficient practice had the potential to result in patients being admitted to hospice services without adequate medical oversight to confirm hospice eligibility, which could lead to unmet patient and family needs, inappropriate implementation of hospice services, and a decline in the patient health status ad quality of life. Findings: a). During a review of Patient 7’s medical record, titled “Personal Information,” the “Personal Information” indicated a start of care (SOC) date of 9/17/2024 with diagnoses including diastolic congestive heart failure (type of heart failure [HF, inability of the heart to pump enough blood to meet the body’s needs] due to the inability of the left lower heart chamber to relax between heartbeats) and essential primary hypertension (abnormally high blood pressure [BP, force of the blood pushing against the artery walls]). During a review of Patient 7’s medical record, titled “Comprehensive Nursing Assessment,” dated 9/17/2024, the “Comprehensive Nursing Assessment” indicated the following in determining the nature and condition of terminal illness (incurable, progressive, or irreversible disease expected to end in death within a foreseeable future) or patient eligibility to receive hospice care and services, Registered Nurse 3 (RN 3) documented Patient 7 met the criteria for New York Heart Association (NYHA) Functional Classification (categorizes the severity of heart failure into four classes based on symptoms and physical limitation) - Class IV level HF (most severe stage of HF with symptoms while at rest and any physical activity causes further discomfort) and Patient 7 required considerable assistance and frequent medical care. The assessment indicated Patient 7 was ambulatory with a walker, required moderate assistance, and was completely dependent on a caregiver with toileting and feeding. During a review of Patient 7’s medical record, titled “Re-Cert Assessment,” dated 1/9/2026, the “Re-Cert Assessment” indicated the following in determining the nature and condition of terminal illness or patient eligibility to receive hospice care and services, the Director of Patient Care Services Designee (DPCSD) documented Patient 7 met the criteria for NYHA Class IV level HF. The assessment indicated Patient 7 required considerable assistance, frequent medical care, was ambulatory with a walker and required moderate assistance, and was completely dependent on a caregiver for toileting, feeding, and dressing, had a normal BP, regular pulse, no edema (swelling due to excess fluid in the body’s tissues), no heart-related pain, and normal skin color. The assessment further indicated Patient 7 had no shortness of breath (SOB, difficulty catching breath) or cough, and had clear lung sounds and normal respirations. The assessment also indicated Patient 7 did not have a physician’s order for oxygen therapy (prescribed medical treatment delivering extra oxygen via masks or nasal tubes to patients who cannot get enough through normal breathing), was continent of urine (able to control the urinary bladder) which was clear and yellow, and was continent of bowel (able to control bowel movements) and had two to three bowel movements per week. During a telephone interview on 3/12/2026 at 12:15 p.m., Patient 7 stated he did not have a terminal illness (incurable medical condition that is expected to result in death, typically within 6 months) and did not have a heart problem or HF. Patient 7 stated he lives by himself and can independently perform activities of daily living (ADLs, fundamental self-care tasks to maintain independence and hygiene) and can walk 1,800 steps in the morning and 1,800 steps in the evening daily without SOB or oxygen therapy. Patient 7 stated he has not seen his primary care physician (PCP) and had not been hospitalized because he has been “very healthy” for the last 15 years. During an interview on 3/12/2026 at 1:06 p.m., the Medical Director stated to qualify for hospice care with HF as the qualifying diagnosis, the HA must be able to classify the patient as NYHA Class IV Level by reviewing and verifying the cardiologist (medical doctor who specializes in the study and treatment of heart diseases) notes and assessment notes indicating the patient has symptoms, such as pulmonary edema (life-threatening condition characterized by severe shortness of breath [SOB] and impaired oxygen delivery due to the excess fluid buildup in the lung air sacs commonly caused by HF), ascites (characterized by severe swelling and weight gain due to the abnormal fluid buildup in the abdominal cavity sometimes caused by HF), and inability to walk 25 feet or up and down the stairs without experiencing SOB. During a concurrent interview and record review on 3/12/2026 at 2:42 p.m. with the Acting DPCS, Patient 7’s medical records were reviewed. The Acting DPCS stated the Patient 7 was on the 9th recertification period to receive hospice care and services. There was no documented evidence such as a history & physical examination or hospital records to verify that Patient 7 had a diagnosis of heart failure prior to hospice admission. The Acting DPCS stated based on the Comprehensive Recertification Assessment, dated 1/9/2026, Patient 7 was not eligible for hospice care because there was no documented evidence that Patient 7 had symptoms of NYHA Class IV Level HF. The Acting DPCS stated there was no documented evidence the HA attempted to obtain medical records from Patient 7’s PCP. The Acting DPCS stated it was important to contact Patient 7’s PCP prior to hospice admission to obtain a complete and accurate assessment of Patient 7 and to keep Patient 7’s PCP well-informed about what was happening to Patient 7. The Acting DPCS stated it was important to ensure Patient 7 was eligible to receive hospice services prior to admission to the HA to make sure access to needed non-hospice specialists, medications, or curative treatments was available for Patient 7.b). During a review of Patient 8’s medical record, titled “Personal information,” the “Personal Information” indicated a SOC date of 3/18/2025 with diagnoses including chronic atrial fibrillation (sustained, rapid, and irregular heart rhythm lasting longer than 7 days) and hyperlipidemia (high levels of fat in the blood). During a review of Patient 8’s medical record, titled “Comprehensive Nursing Assessment,” dated 3/18/2025, the “Comprehensive Nursing Assessment” indicated the following in determining the nature and condition of terminal illness or patient eligibility to receive hospice care and services, RN 4 had documented that Patient 8 met the criteria for NYHA Class IV level. The assessment further indicated Patient 8 required considerable assistance and frequent medical care, was ambulatory (able to walk) with a walker and required maximum assistance, was completely dependent on a caregiver with ambulation, transfer, and bathing. During a review of Patient 8’s medical record, titled “Re-Cert Assessment,” dated 1/11/2026, the “Re-Cert Assessment” indicated the following in determining the nature and condition of terminal illness or patient eligibility to receive hospice care and services, the DPCSD documented Patient 8 met the criteria for NYHA class IV level. The assessment indicated Patient 8 was disabled (unable to care for self) and required special care and assistance, was ambulatory with a walker and required maximum assistance, was completely dependent on a caregiver for ambulation, toileting, dressing, and bathing. During a telephone interview on 3/12/2026 at 10:30 a.m., Patient 8 stated no healthcare provider has notified her that she (Patient 8) had a terminal illness. Patient 8 stated she had a history of having a stroke (medical emergency due to the loss of blood flow to a part of the brain) and atrial fibrillation (an irregular heartbeat, or arrhythmia), but she was not notified about a “heart failure” diagnosis. Patient 8 stated she lived alone in her home and is able to walk around the house and go to the bathroom independently with a walker and/or a cane and was able to independently perform most ADLs but needed assistance with mopping, vacuuming, and doing the laundry. During an interview on 3/12/2026 at 1:06 p.m., the Medical Director stated having a diagnosis of atrial fibrillation would not automatically qualify a patient to receive hospice care and services. The Medical Director stated a patient must have a terminal illness with a “prognosis of six months or less to live” to qualify for hospice. During a concurrent interview and record review on 3/12/2026 at 2:42 p.m. with the Acting DPCS, Patient 8’s medical records were reviewed. The Acting DPCS stated there was no documented evidence such as a History & Physical examination or hospital records to verify that Patient 8 had a diagnosis of heart failure prior to hospice admission. The Acting DPCS stated it was important to ensure Patient 8 was eligible to receive hospice services prior to admission to the HA to make sure Patient 8 has “access to the care that she needs.” c. During a review of Patient 12’s clinical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 11/1/2025, with a primary diagnosis of end-stage HF (most advanced, irreversible stage of HF). During a review of Patient 12’s physical chart, Patient 12’s Inquiry document was reviewed. The inquiry indicated Patient 12’s name, date of birth, insurance information and personal needs. During a review of Patient 12’s Electronic Medical Records (EMR), the EMR section, titled “Document/Images” did not indicate documentation of clinical information that included Patient 12’s History and Physical (H&P) examination, laboratory results, imaging results or physician/hospital records. During an interview on 3/11/2026 at 2:55 p.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated that the HA did not upload all patient’s H&P’s onto the EMR but kept hard copies on file. The DPCSD stated that documents like an H&P examination or hospital records help the RNs complete the Local Coverage Determination (LCD, clinical criteria to determine hospice eligibility based on the qualifying terminal illness) and verify if a patient was eligible for hospice care. The DPCSD stated it was important to review a patient’s medical records like the H&P examination, hospital records, and/or labs, so the case manager could determine, even before an admission home visit, if the patient qualified for hospice care or not. During a concurrent interview and record review on 3/11/2026 at 3:10 p.m. with the DPCSD, Patient 12’s EMR and physical chart were reviewed. The DPCSD stated and confirmed that Patient 12’s EMR did not contain documentation of her H&P examination, prior hospital records or labs. The DPCSD stated Patient 12’s physical chart also did not include a copy of any H&P examination or hospital documents. The DPCSD stated Patient 12’s Inquiry is not an acceptable record for an H&P examination because it did not include the patient’s medical information such as diagnosis or medical history. The DPCSD stated when the patient was referred the case manager should have requested to review Patient 12’s past medical records to verify the diagnosis and hospice eligibility. The DPCSD stated that there have been instances where patients had said that they had HF, but when the RNs conducted their admission assessment during the admitting home visit, the RNs noted that the patients did not have HF, were not declining and were healthy. During a review of the undated HA’s policy and procedures (P&P), titled “Certification of Terminal Illness,”the P&P indicated the following: 1. The hospice Medical Director and the patient’s attending physician, if any, must certify the patient’s terminal illness at the time a patient and family/caregiver chooses hospice care. When certifying the patient as terminally ill, the hospice medical director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition of the patient, and current relevant information supporting the diagnosis. 2. At the time of admission to hospice and at the beginning of each new benefit period during a subsequent recertification, the HA Medical Director or the patient’s attending physician must complete a certification narrative that reflects the patient’s individual circumstances based on the review of the patient’s medical records or examination of the patient, if applicable.3. Patients who elect the hospice Medicare or Medicaid benefit must be certified as terminally ill with a prognosis of six (6) months or less life expectancy if the disease runs its normal course by the attending physician and the hospice Medical Director.4. Clinical information and other documentation that supports the medical prognosis must accompany the certification and must be filed in the medical record with the written certification.”

“Based on observation, interviews, and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) Interdisciplinary Group (IDG, team composed of a Registered Nurse [RN], Medical Social Worker [MSW], spiritual counselor [SC], and physician [MD] who discuss the patient’s plan of care to provide the best individualized care and support to patients and families) failed to ensure that the care plans of two of 15 sampled patients (Patients 2 and 3) were accurate, complete, and individualized to reflect the current medications ordered and were available for the patients. This failure had the potential to result in Patients 2 and 3 not receiving the necessary treatment and care services that could result in patients’ discomfort, worsened condition, and decline in health. Findings: a). During a review of Patient 2’s medical record, titled “Personal Information,” the “Personal Information” indicated a start of care (SOC) date of 10/15/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD, long-term lung disease characterized by difficulty breathing due to chronic inflammation that restricts airflow). During a review of Patient 2’s medical record, titled “Plan of Care (POC) Summary,” as of 3/9/2026, the “POC Summary” indicated the following active medication orders for Patient 2: Order Date: 10/15/2024 – Albuterol (medication to treat COPD by relaxing the airway muscles) 90 micrograms (mcg, unit of measurement of weight)/actuation (single, measured release of the medication from the inhaler) – inhale 2 puffs orally every six hours as needed for shortness of breath (SOB, difficulty catching breath).Order Date: 10/15/2024 – Morphine (controlled pain medication, part of the comfort kit [pre-stocked set of emergency medications kept in a hospice patient’s home]) 20 milligrams (mg, unit of measurement of weight)/milliliter (ml, unit of measurement of volume) – Place 0.25 ml under the tongue every 2 hours as needed for moderate to severe painOrder Date: 10/15/2024 – Levsin (medication to reduce body secretions, part of the comfort kit) 0.125 mg – Place 1 mg under the tongue every 4 hours as needed for excessive secretions Order Date: 10/15/2024 – Ondansetron (medication to prevent throwing up or the urge to throw up, part of the comfort kit) 4 mg – Place 1 tablet under the tongue every 4 hours as needed for nausea or vomitingOrder Date: 8/5/2025 – Ativan (medication to calm the brain and nerves, part of the comfort kit) 2 mg/ml – Place 0.5 ml under the tongue every 2 hours as needed for anxiety (excessive feelings of dread, apprehension, or uneasiness)/agitation (restlessness)Order Date: 12/5/2025 – DuoNeb (medication to treat COPD by relaxing muscles and opening airways, part of the comfort kit) 0.5 mg solution – 1 vial for oral inhalation via nebulizer (machine that turns the medicine into a mist to be inhaled, often for 15 minutes or less) every 4 hours as needed for SOB or wheezing.Order Date: 12/5/2025 – Ozempic (medication to treat high blood sugar) 0.25 mg or 0.50 mg/dose pre-filled pen – inject 1 unit subcutaneously (underneath the skin layers and into the fatty tissue) once a week every Monday During a concurrent observation and interview on 3/10/2026 at 12:18 p.m., while on a joint home visit at Patient 2’s living room, with Licensed Vocational Nurse 1 (LVN 1), Patient 2 was noted awake, alert, and ambulatory (able to walk). Patient 2 was observed having SOB, using her accessory muscles (use of muscles in the neck, chest, and abdomen to assist with breathing and signifies the struggle to get enough oxygen), with an oxygen saturation (indicates how well the lungs and circulatory system deliver oxygen to the body with normal values of 88% - 92% for COPD patients) of 58% on room air. LVN 1 administered, with Patient 2’s consent, oxygen therapy to Patient 2 via nasal cannula (flexible tube with 2 prongs to deliver supplemental oxygen to the patient’s nostrils) after multiple attempts of LVN 1 to educate Patient 2 about the importance of proper oxygenation. Patient 2 stated she lives by herself and self-administers her medications. Patient 2 initially stated she had all the medications she needs and refused to show her medication bottles to LVN 1. Upon further questioning by LVN 1, Patient 2 stated she did not receive the following medications: albuterol, Ozempic, and the comfort kit containing DuoNeb, Morphine, Ativan, Levsin, and ondansetron. Patient 2 stated she has not received her nebulizer. During a concurrent interview and record review on 3/11/2026 at 12:37 p.m. with the Director of Patient Care Services Designee (DPCSD), tracking records of Patient 2’s delivered medications and Patient 2’s medical record, titled “Plan of Care (POC)/Interdisciplinary Group (IDG) Review,” dated 3/4/2026 were reviewed. The DPCSD stated Patient 2 had a change in health insurance while under hospice care that caused some changes in medication coverage. The DPCSD stated medication profile reviews must be done by the visiting nurse every home visit to evaluate the effectiveness of the medication regimen and verify Patient 2’s compliance with the treatment plan. The DPCSD stated not taking prescribed breathing treatments like albuterol and DuoNeb could lead to ineffective drug therapy and cause a health decline related to decreased oxygenation and could further lead to increased hospitalizations. The DPCSD stated the comfort kit medications were ordered to be used for “emergency purposes” to provide comfort during end-of-life because Patient 2’s health could potentially “decline quickly.” The DPCSD stated the following: -One (1) Albuterol canister was last delivered on 12/6/2026 (to last up to approximately one month, if administered consistently, as ordered). The DPCSD stated Patient 2’s “POC/IDG Review,” dated 3/4/2026, indicated the goal for Patient 2 to was “resolve episodes of dyspnea [difficulty breathing] such as having oxygen saturation of not less than 90%, respirations between 12-20 breaths per minute and no use of accessory muscles for breathing after 30 minutes of interventions…” and the intervention to “monitor/assess effectiveness of current medication/treatment” related to albuterol medication order. DPCSD stated there was no documented evidence regarding the inability of the HA to provide albuterol to Patient 2 as ordered by the physician. -Ninety (90) vials of DuoNeb were last delivered on 12/6/2026 (to last up to 15 days if administered consistently as ordered). The DPCSD stated Patient 2’s “POC/IDG Review,” dated 3/4/2026, indicated the goal for Patient 2 to “resolve episodes of dyspnea such as having oxygen saturation of not less than 90%, respirations between 12-20 breaths per minute and no use of accessory muscles for breathing after 30 minutes of interventions…” and the intervention to “monitor/assess effectiveness of current medication/treatment” related to DuoNeb medication order. The DPCSD stated there was no documented evidence regarding the inability of the HA to provide DuoNeb to Patient 2 as ordered by the physician. There was no documented evidence of any confirmed delivery of the nebulizer for the DuoNeb administration. The DPCSD stated Patient 2 “did not want the nebulizer last month.” The DPCSD stated there was no documented evidence regarding Patient 2’s refusal to use the nebulizer in 2/2026 and/or education provided by the HA nurse to discuss the importance of the nebulizer). Three pens of Ozempic were last delivered on 11/11/2025 (to last up to 3 months). DPCSD stated Patient 2’s “POC/IDG Review,” dated 3/4/2026, indicated the goal for Patient 2 of “optimal blood sugar management for patient comfort” and the intervention to “monitor/assess effectiveness of current and new medication/treatment” related to Ozempic medication order. DPCSD stated Patient 2’s blood sugar level was well-controlled with Metformin (oral medication to treat high blood sugar), but there was no documented evidence regarding the unavailability of Ozempic and any plans to continue, discontinue, or substitute another medication for Ozempic as ordered by the physician. There was no documented evidence of any confirmed delivery of the comfort kit containing Morphine, Ativan, Levsin, and ondansetron. The DPCD stated, “Knowing her (Patient 2), most likely, she did not want these medications (Morphine, Ativan, Levsin, and ondansetron) because she does not need them at this time.” The DPCSD stated there was no documented evidence Patient 2 refused the delivery of Morphine, Ativan, Levsin, and ondansetron. During an interview on 3/12/2026 at 1:06 p.m., the Medical Director stated bronchodilators (medications that relax muscles surrounding airways in the lungs, causing them to widen and open) like albuterol and DuoNeb improve breathing and oxygenation by opening up the airways and decreasing the mucus in COPD patients. The Medical Director stated Ozempic helps with blood sugar control. The Medical Director stated he was not notified regarding Patient 2’s Ozempic being unavailable. The Medical Director stated if Ozempic was not available, other antidiabetic medications could be ordered for better blood sugar control. b. During a review of Patient 3’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 11/26/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (a condition where plaque [fat, cholesterol, calcium] builds up in the heart’s original arteries, narrowing them and restricting blood flow, but without causing chest pain or discomfort). During a review of Patient 3’s medical record, titled “Plan of Care (POC)/Interdisciplinary Group (IDG) Review,” dated 3/4/2026 for certification period #2, the POC/IDG Review indicated an order for frequency visit from the Skilled Nurse (SN) once per week for changes in condition. During a joint home visit on 3/10/2026 at 10:15 a.m. with Registered Nurse 2 (RN 2) at Patient 3’s residence, Patient 3 was observed awake, alert, oriented to her name, time, place and events, and walking with the assistance of a front-wheeled walker (FWW, assistive device to assist with walking) taking small, slow steps. Patient 3 was observed able to sit up in a chair, holding onto her FWW for support. During a concurrent interview and record review on 3/10/2026 at 10:35 a.m. with RN 2, Patient 3’s medication list and medication bottles were reviewed. Patient 3’s medication list indicated an order for: Atorvastatin (medication used to treat high cholesterol) 40 milligrams (mg- unit of measurement) take 1 tablet orally once daily at bedtime for hyperlipidemia (high cholesterol) Patient 3 stated the dose for atorvastatin on the medication list was not correct and it should have been 80 mg once daily at bedtime. Patient 3 stated a month ago her cardiologist changed the dose order for atorvastatin, and she (Patient 3) had informed the Director of Patient Care Services (DPCSD) about the medication dose change. RN 2 stated and confirmed that Patient 3’s medication list indicated an order for atorvastatin 40 mg once daily at bedtime and not 80 mg once daily at bedtime. During a review of Patient 3’s medication bottles, one of the bottles indicated “Bayer low dose 81 mg.” Patient 3 stated she takes Bayer (aspirin, medication used to reduce risk of heart attacks and stroke by preventing blood clots) 81 mg one tablet once a day in the morning and has been taking it for a long time along with her medication Plavix (prescription medication used to prevent blood clots, blood thinner). RN 2 stated and confirmed that Patient 3’s medication list did not include the order for Bayer 81 mg to take once a day and stated he would notify the case manager of the medication to update the medication list. RN2 stated he was not part of Patient 3’s regular care team and would notify the case manager about the medication list discrepancies. During a concurrent interview and record review on 3/11/2026 at 2:53 p.m. with the DPCSD, Patient 3’s “POC/IDG Review,” dated 3/4/2026 for certification period #2 was reviewed. Patient 3’s “POC/IDG Review” indicated a medication order list that included atorvastatin 40 mg tablet take 1 tablet once daily at bedtime. The DPCSD stated there was no documented evidence of Patient 3’s medication Bayer 81 mg to take 1 tablet once daily. The DPCSD stated and confirmed that Patient 3’s “POC/IDG Review” was not updated to reflect Patient 3’s current atorvastatin dose of 80 mg which was to be taken once daily at bedtime and to include the order for Patient 13’s medication Bayer 81 mg to take once daily. The DPCSD stated that Patient 3’s “POC/IDG Review” should have been updated to reflect the current medications the patient is taking and to avoid the patient taking the incorrect medication or dose. During a review of the HA’s policy and procedures (P&P), titled “Medication Profile/Reconciliation,” undated, the P&P indicated the following: Patients receiving medications must have a current, accurate medication profile in the clinical record. Medication profiles must be updated for each change to reflect current medications and new and/or discontinued medications.Deviations in taking medications as ordered must be documented in clinical notes, and the physician or other authorized licensed independent practitioner must be notified. An incident report must be filed as necessary.”

“Based on interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) staff failed to fully complete and sign the POLST (physician orders for life-sustaining treatment) for eight of 15 sampled patients (Patients 1, 2, 4, 7, 8, 12, 14, and 15) to ensure the POLST was a valid physician’s order. This failure had the potential to cause a decline in the patients’ health and quality of life related to not following the patients’ wishes regarding life-sustaining treatment choices. Findings: a. During a review of Patient’s 1’s medical record, titled “Personal Information,” the “Personal Information” indicated, Patient 1 was admitted on 10/8/2025 with diagnoses including malignant carcinoid tumor of the kidney (slow-growing form of kidney cancer that develops from hormone-producing cells), heart failure (HF, inability of the heart to pump enough blood to meet the body’s needs) and hyponatremia (abnormally low levels of sodium in the blood). During a concurrent interview and record review on 3/12/2026 at 2:43 p.m. with Registered Nurse 1 (RN 1), Patient 1’s Physicians Orders for Life-Susaining Treatment (POLST, a portable medical order form that translates the end-of-life care wishes of seriously ill patients into actionable instructions, such as, to attempt cardiopulmonary resuscitation [CPR, medical procedure involving repeated compression of a patient’s chest, performed in an attempt to restore the blood circulation and breathing of a person]), dated 10/8/2025, was reviewed. The RN 1 stated Patient 1’s POLST was invalid because there was no physician signature. RN 1 stated if CPR was provided to a patient (in general) who has a POLST indicating Do Not Resuscitate (DNR, medical order written by a physician to instruct health care providers not to do CPR if breathing stops or the heart stops beating), it could have an adverse effect on the quality of life of the patient (in general) due to the patient’s wishes not being followed, if Return of Spontaneous Resuscitation (ROSC, the resumption of a sustained, palpable pulse and organized cardiac rhythm in a patient following cardiac arrest and CPR.) was achieved. b. During a review of Patient 2’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 10/15/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD, long-term lung disease characterized by difficulty breathing due to chronic inflammation that restricts airflow). During a concurrent interview and record of Patient 2’s POLST on 3/12/2026 at 2:42 p.m. with RN 1, Patient 2’s POLST, dated 10/15/2024, was reviewed. RN 1 stated Patient 2’s POLST was not signed by the physician. RN 1 stated the POLST would not be considered a valid physician’s order if not filled out completely and signed by the patient (in general) and the physician (in general). RN 1 stated not ensuring a valid POLST could lead to Patient 2’s decreased health and quality of life related to not following Patient 2’s wishes regarding life-sustaining treatment choices. c. During a review of Patient’s 4’s medical record, titled “Personal Information,” the “Personal Information” indicated Patient 4 was admitted on 12/19/2025 with diagnoses including Alzheimer’s disease (disease characterized by a progressive decline in mental abilities) and chronic kidney disease (CKD, serious, long-term condition where kidneys are damaged and cannot effectively filter waste from the blood) During a concurrent interview and record review on 3/12/2026 at 2:43 p.m. with RN 1, Patient 4’s POLST, dated 12/18/2025, was reviewed. RN 1 stated Patient 4’s POLST was invalid because there was no physician signature. d. During a review of Patient 7’s medical record, titled “Personal Information,” the “Personal Information” indicated SOC date of 9/17/2024 with diagnoses including diastolic congestive heart failure (type of HF due to the inability of the left lower heart chamber to relax between heartbeats) and essential primary hypertension (abnormally high blood pressure [BP, force of the blood pushing against the artery walls]). During a concurrent interview and record of Patient 7’s POLST on 3/12/2026 at 2:42 p.m. with RN 1, Patient 7’s POLST, dated 9/17/2024, was reviewed. RN 1 stated Patient 2’s POLST did not indicate a response whether to attempt resuscitation and/or administer artificial nutrition and the printed name of the patient at the bottom of the POLST form. RN 1 stated the POLST would not be considered a valid physician’s order if not filled out completely and signed by the patient (in general) and the physician (in general). RN 1 stated not ensuring a valid POLST could lead to Patient 7’s decreased health and quality of life related to not following Patient 7’s wishes regarding life-sustaining treatment choices. e. During a review of Patient 8’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 3/18/2025 with diagnoses including chronic atrial fibrillation (sustained, rapid, and irregular heart rhythm lasting longer than 7 days) and hyperlipidemia (high levels of fat in the blood). During a concurrent interview and record review on 3/12/2026 at 2:42 p.m. with RN 1, Patient 8’s undated POLST was reviewed. RN 1 stated Patient 8’s POLST did not indicate a response whether to attempt resuscitation and/or administer artificial nutrition, the date when the form was filled out, and the physician signature at the bottom of the POLST form. RN 1 stated the POLST would not be considered a valid physician’s order if not filled out completely and signed by the patient (in general) and the physician (in general). RN 1 stated not ensuring a valid POLST could lead to Patient 8’s decreased health and quality of life related to not following Patient 8’s wishes regarding life-sustaining treatment choices. f. During a review of Patient 12’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 11/1/2025, with a primary diagnosis of end-stage HF. During a concurrent interview and record review on 3/12/2026 at 3:20 p.m. with RN1, Patient 12’s POLST, dated 11/1/2025, was reviewed. RN1 stated and confirmed that Patient 12’s POLST was not complete because it was not signed by the Medical Director (MD). g. During a review of Patient 14’s medical record, titled “Personal Information,” the “Personal Information” indicated a SOC date of 11/6/2025, and End of Care (EOC) date of 1/15/2026, and a primary diagnosis of acute diastolic HF (sudden, severe episode where the heart’s left lower chamber becomes too stiff to relax and fill properly between beats causing symptoms like shortness of breath, tiredness, and fluid buildup in the lungs). During a concurrent interview and record review on 3/12/2026 at 3:22 p.m. with RN1, Patient 14’s POLST, dated 11/6/2025, was reviewed. RN1 stated and confirmed that Patient 14’s POLST was not complete because it was not signed by the MD. RN1 stated that because Patient 14’s POLST was not signed by the MD, if any emergency occurred, Patient 14’s choice to be DNR would not have been honored. h. During a review of Patient 15’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 12/29/2025, and End of Care (EOC) date of 3/9/2026, and a primary diagnosis of Alzheimer’s disease.During an interview on 3/12/2026 at 3:24 p.m. with RN 1, Patient 15’s POLST, dated 12/29/2025, was reviewed. RN1 stated and confirmed that Patient 15’s POLST was not complete because it was not signed by the MD. During a review of the HA’s policy and procedures (P&P), titled “Do Not Resuscitate (DNR)/Do Not Intubate Orders (DNI, medical directive instructing healthcare professionals not to insert a breathing tube if the patient stops breathing),” dated 11/2021, the P&P indicated the following: 1. The purpose was to facilitate a patient’s choice regarding the extent to which emergency medical care must be instituted. 2. A written DNR order signed by the patient’s physician or other authorized independent practitioner must be on file in the patient’s clinical record and admission folder in the patient’s home. If there is no DNR order or valid advance directives and the patient expires in the presence of a CPR-trained staff person, CPR must be initiated according to the American Association’s Basic Life Support (BLS). 3. A DNR/DNI decision must be made by the attending physician in consultation with the patient or other legally responsible person when, in the judgment of the physician, the patient suffers from an incurable medical condition, death is reasonably imminent in all medical probability, and a life-threatening condition exists in which resuscitation would not be expected to render substantial improvement in the ultimate outcome.4. The order must be written only by the attending physician (or other authorized independent practitioner).5. The order must be recertified every 60 days or upon the request of the parties concerned.”

“Based on interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the core members of the Interdisciplinary Group (IDG, team composed of a Registered Nurse [RN], Medical Director [MD], Chaplain, and Medical Social Worker [MSW] who discuss the patients’ plan of care to provide the individualized care to patients and support to patients and families) signed the IDG notes for 11 of 15 sampled patients (Patients 1, 2, 3, 6, 8, 9, 10, 12, 13, 14, and 15). This failure had the potential to cause a decline in the patients’ condition, quality of care, and quality of life related to not receiving continuity of care and services to address any medical, nursing, spiritual, and psychosocial needs of the patient and/or family. Findings:a). During a review of Patient’s 1’s medical record, titled “Personal Information (admission record),” the “Personal Information” indicated a Start of Care (SOC) date of 10/8/2025 with diagnoses including malignant carcinoid tumor of the kidney (slow-growing form of kidney cancer that develops from hormone-producing cells), heart failure (HF, heart disorder which causes the heart to not pump the blood efficiently), and hyponatremia (abnormally low levels of sodium in the blood).During an interview on 3/11/2026 at 3:22 p.m., the Director of Patient Care Services Designee (DPCSD) stated that the IDG core members include the chaplain, MSW, MD, Registered Nurse 1 (RN 1), and DPCSD. The DPCSD stated the meetings are held every other Wednesday either in person or via telephone, depending on each member’s availability that day. The DPCSD stated the signatures on the Plan of Care (POC)/Interdisciplinary Group (IDG) Review (IDG notes reviewed and signed by IDG core members who attended the IDG meeting)” are required to be done within a week from the meeting date and serve as a sign-in sheet for the IDG members.During an interview on 3/11/2026 at 3:29 p.m., the DPCSD stated the importance of all IDG core members attending the IDG meetings is to provide input for all aspects of the patient. The DPCSD stated that for example, MSW could provide information on the patients’ (in general) psychosocial (pertaining to the mental, emotional, social, and environmental situation) aspect and chaplain could provide information on the patient’s spiritual aspect of their life and healing. During a concurrent interview and record review on 3/13/2026 at 2:15 p.m. with the DPCSD, Patient 1’s “POC/IDG Review,” dated 2/18/20, was reviewed. The DPCSD stated Patient 1’s “POC/IDG Review” was missing the Registered Nurse (RN) signature. The DPCSD stated she would follow up within a week to make sure “POC/IDG Reviews” were completed and signed. The DPCSD stated it was important to have the “POC/IDG Reviews” completed and signed the same day because notes and signatures could be left out which could delay medical, social or spiritual care for the Patients. b). During a review of Patient 2’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 10/15/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD, long-term lung disease characterized by difficulty breathing due to chronic inflammation that restricts airflow). During a concurrent interview and record review on 3/13/2026 at 2:13 p.m. with the DPCSD, Patient 2’s “POC/IDG Review” notes were reviewed. The DPCSD stated Patient 2’s “POC/IDG Review,” dated 3/4/2026, did not have the physician and chaplain signatures. The DPCSD stated the signatures confirm the attendance of the IDG core member during the IDG meeting. The DPCSD stated it was important for the physician to attend the meeting because the physician must direct the care of Patient 2 and without the physician, there would be no continuity of care and some health-related information could be missed during the meeting. The DPCSD stated it was important for the Chaplain to attend the meeting to discuss any spiritual needs of Patient 2. c). During a review of Patient 3’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 11/26/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (a condition where plaque [fat, cholesterol, calcium] builds up in the heart’s original arteries, narrowing them and restricting blood flow, but without causing chest pain or discomfort). During a review of Patient 3’s medical record, titled “POC/IDG Review,” dated 3/4/2026, the POC/IDG Review indicated on the last page, electronic signatures for the DPCSD and the MSW dated 3/4/2026, and missing signatures for the Chaplain and Medical Director (MD). During a concurrent interview and record review on 3/13/2026 at 2:23 p.m. with the DPCSD, Patient 3’s medical record, titled “POC/IDG Review,” dated 3/4/2026, was reviewed. The DPCSD stated and confirmed that Patient 3’s “POC/IDG Review,” dated 3/4/2026, was missing a signature from the Chaplain and the Medical Director. The DPCSD stated that without signatures from the IDG core members on the “POC/IDG Review” their (IDG core members) attendance could not be verified. d). During a review of Patient’s 6’s medical record, titled “Personal Information,” the “Personal Information” indicated Patient 6’s SOC date of 4/4/2024 with diagnoses including Alzheimer’s (brain disorder that negatively affects memory, thinking, and behavior severe enough to interfere with daily tasks), hypothyroidism (condition wherein the thyroid gland is underactive and fails to secrete enough hormones into the bloodstream), and arthritis (inflammation of one or more joints, causing pain, swelling, stiffness, and reduced mobility). During a concurrent interview and record review on 3/13/2026 at 2:15 p.m. with the DPCSD, Patient 4’s “POC/IDG Review,” dated 9/17/2025 and 10/15/2025, were reviewed. The DPCSD stated Patient 4’s “POC/IDG Review,” dated 9/17/2025 and 10/15/2025 were missing the signature of the MSW. e). During a review of Patient 8’s medical record, titled “Personal information,” the “Personal Information” indicated the SOC date of 3/18/2025 with diagnoses including chronic atrial fibrillation (sustained, rapid, and irregular heart rhythm lasting longer than 7 days) and hyperlipidemia (high levels of fat in the blood). During a concurrent interview and record review on 3/13/2026 at 2:13 p.m. with the DPCSD, Patient 8’s “POC/IDG Review” notes were reviewed. The DPCSD stated Patient 8’s “POC/IDG Review,” dated 3/4/2026, did not have the RN and MSW signatures. The DPCSD stated the signatures confirm the attendance of the IDG core member during the IDG meeting. The DPCSD stated it was important for the RN to attend the meeting because the RN must coordinate the care of Patient 8 and without the RN, there would be no continuity of care and some health-related information could be missed during the meeting. The DPCSD stated it was important for the RN to attend the meeting to discuss any nursing needs of Patient 8. f). During a review of Patient 9’s medical record, titled “Personal information,” the “Personal Information” indicated the SOC date of 5/20/2025 with diagnoses including Alzheimer’s disease and hypertension (abnormally high blood pressure [BP, force of the blood pushing against the artery walls]). During a concurrent interview and record review on 3/13/2026 at 2:13 p.m. with the DPCSD, Patient 9’s “POC/IDG Review” notes were reviewed. The DPCSD stated Patient 9’s “POC/IDG Review,” dated 3/4/2026, did not have the chaplain signature. The DPCSD stated the signatures confirm the attendance of the IDG core member during the IDG meeting. The DPCSD stated it was important for the Chaplain to attend the meeting to discuss any spiritual needs of Patient 9. g). During a review of Patient 10’s medical record, titled “Personal information,” the “Personal Information” indicated the SOC date of 4/30/2024 with the end of care (EOC) date of 11/7/2025 with diagnoses including Alzheimer’s disease.During a review of Patient 10’s medical record, titled “Psychosocial Assessment (comprehensive evaluation of a patient’s mental, emotional, social, and environmental situation),” dated 5/4/2024, the “Psychosocial Assessment” indicated the MSW “will maintain regular contact to monitor the patient’s condition and assist the family with advance care planning.” h). During a review of Patient 10’s medical record, titled “Visit Note After Death,” dated 11/7/2025, the “Visit Note After Death” indicated the physician noted Patient 10’s death on 11/7/2025 at 8:05 a.m. after the RN (not identified) reported Patient 10 had no vital signs (objective measurements of basic body functions) and no respirations. During a concurrent interview and record review on 3/13/2026 at 2:13 p.m. with the DPCSD, Patient 10’s “POC/IDG Review” notes were reviewed. The DPCSD stated Patient 10’s “POC/IDG Review,” dated 10/1/2025, 10/15/2025, 10/29/2025, and 11/12/2025, did not have the MSW signatures. The DPCSD stated the signatures confirm the attendance of the IDG core member during the IDG meeting. The DPCSD stated it was important for the MSW to attend the meetings to discuss any psychosocial needs of the patient and/or family. i). During a review of Patient 12’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 11/1/2025, with a primary diagnosis of end-stage HF (most advanced, irreversible stage of HF).During a concurrent interview and record review on 3/13/2026 at 2:25 p.m. with the DPCSD, Patient 12’s “POC/IDG Review,” dated 3/4/2026 was reviewed. The DPCSD stated and confirmed that Patient 12’s “POC/IDG Review,” dated 3/4/2026, was missing the MSW signature. The DPCSD stated without a signature verification, the MSW’s attendance could not be verified. j). During a review of Patient 13’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 7/31/2023, and EOC date of 2/27/2026, and a primary diagnosis of HF.During a concurrent interview and record review on 3/13/2026 at 2:27 p.m. with the DPCSD, Patient 13’s “POC/IDG Review,” dated 1/7/2026, 1/21/2206, 2/4/2026, and 2/18/2026 were reviewed. The DPCSD stated and confirmed that Patient 13’s “POC/IDG Review,” dated 1/7/2026, 1/21/2206, 2/4/2026, and 2/18/2026 were missing the MSW signature. The DPCSD stated she did not recall if the MSW was on vacation at that time, but without her (MSW) signature, MSW participation in the meeting could not be verified. k). During a review of Patient 14’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 11/6/2025 and EOC date of 1/15/2026, and a primary diagnosis of acute diastolic HF (sudden, severe episode where the heart’s left ventricle becomes too stiff to relax and fill properly between beats causing symptoms like shortness of breath, tiredness, and fluid buildup in the lungs). During a concurrent interview and record review on 3/13/2026 at 2:29 p.m. with the DPCSD, Patient 14’s “POC/IDG Review,” dated 12/24/2025, 12/10/2025, 11/26/2025, 11/12/2025, and 11/6/2025 were reviewed. The DPCSD stated and confirmed that Patient 14’s “POC/IDG Review,” dated 12/24/2025, 12/10/2025, 11/26/2025, 11/12/2025, and 11/6/2025 were missing MSW signatures. l). During a review of Patient 15’s medical record, titled “Personal Information,” the “Personal Information” indicated the SOC date of 12/29/2025 and EOC date of 3/9/2026 with a primary diagnosis of Alzheimer’s disease.During a concurrent interview and record review on 3/13/2026 at 2:30 p.m. with the DPCSD, Patient 15’s “POC/IDG Review,” dated 3/4/2026, 2/18/2026, 2/4/2026, 1/21/2026, and 1/7/2026 were reviewed. The DPCSD stated and confirmed that Patient 15’s “POC/IDG Review,” dated 3/4/2026, 2/18/2026, 2/4/2026, 1/21/2026, and 1/7/2026 were missing MSW signatures. During a review of the HA’s policy and procedures (P&P), titled “Contents of Clinical Record,” dated 11/2021, the P&P indicated the following: A clinical record must contain sufficient information to describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice IDG members and contract personnel.Documentation must include, but is not limited to: - IDG meetings and individual patient and family/caregiver case conferences Plan of care developed/revised by the IDG based on comprehensive assessments and desired outcomes with time frames -Physician review of medications and plan of care oversight including justification for recertification -Educational needs of patient and family/caregiver -Change in interventions for ineffective drug therapy or other undesired outcomes -Assessment of spiritual care needs -Attitudes and response of the patient and family/caregiver to the plan of care and services provided 3. Each entry must be dated and signed, including title and credentials, by the person providing the care/service. During a review of the HA’s undated policy and procedures (P&P 2), titled “Interdisciplinary Group (IDG) Members Policy,” the policy indicated the HA maintains an IDG responsible for assessing patient needs, developing and updating the POC, and ensuring comprehensive hospice services are provided in accordance with Centers for Medicare and Medicaid Services (CMS), California Department of Public Health (CDPH), and accreditation standards. Attendance and participation must be documented.”

“Upon client record review, 2 of 14 (Patient #3, #14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3:The plan of care indicated SN visits were ordered 1 x week, but there was no evidence of an SN visit during the weeks of 7-14-24 - 7-20-24 and 7-21-24 - 7-27-24. Patient #14: The plan of care dated 11/13/24 indicated SN visits were 1 x week. There was no evidence of an SN visit during the week of 11-10-24 to 11-16-24.”