Aaa Hospice Care & Nursing, Inc.

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live), failed to ensure the Condition of Participation (COP, the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) for Interdisciplinary Group (IDG, a team composed of professionals from different discipline who work together collaboratively to provide comprehensive care for patients), Care Planning, and Coordination of Services for Patients was met as follows: The HA failed to:1. Ensure the Director of Patient Care Services (DPCS) coordinates the services and care for 4 of 10 sampled patients (Patient 1, Patient 2, Patient 3 and Patient 11) as discussed by the interdisciplinary group (IDG). This failure had the potential for Patient 1, Patient 2, Patient 3 and Patient 11 to experience severe pain or distress, agitation, emergency hospitalization and potentially experience an undignified and avoidable traumatic death. (Refer to L-tag 540)2. Ensure the Plan of Care (POC) for 4 of 15 sampled patients (Patient 1, Patient 2, Patient 3, and Patient 11) includes symptom management and other related condition identified during patient’s assessments. This failure had the potential for patients to receive inadequate treatment and monitoring that may lead to severe pain or distress, agitation, emergency hospitalization and potentially experience an undignified and avoidable traumatic death. (Refer to L-tag 545)3. Ensure the Comfort Kit (set of medications intended for symptoms and pain management such as: morphine [treatment for pain], Ativan [medication for agitation and anxiety], Levsin [medication for excessive secretions], albuterol inhaler [medication for shortness of breath and/or wheezing], Zofran (medication for nausea and vomiting), and acetaminophen [medication for mild pain and/or fever]) was ordered and available for three of three sampled patients (Patient 1, Patient 2, and Patient 3) at home, as needed for the management of end of life symptoms, in accordance with the patients’ assessment and Interdisciplinary Group (IDG) discussion /review, and ensure an oxygen concentrator (medical device that delivers oxygen rich air to a person who has difficulty breathing), via nasal canula (a thin flexible tube that wraps around the head and sits on the nose to deliver oxygen), was ordered and available for three of three sampled patients (Patient 1, Patient 2, and Patient 3) at home, as needed for shortness of breath (SOB, difficulty breathing), in accordance with the patients’ assessment and IDG discussion / review. As a result of the noncompliance described above, Patient 1, Patient 2, and Patient 3 were placed at high risk to experience unmanaged pain, severe pain or distress, agitation, emergency hospitalization, exposure to unsafe environments, and potentially experience an undignified and avoidable traumatic death. (Refer to L556)4. Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the ongoing sharing of information with non-hospice healthcare providers furnishing services for two of two sampled Patients (Patient 1 and Patient 11) by:Failing to ensure documentation of communications with the Primary Care Physician (PCP) related to a change in dose for Mounjaro (tirzepatide, an injectable prescription drug used to treat type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing)) in the medical record for Patient 1. Failing to ensure services provided during wound care referral were documented in the medical record for Patient 11.Failing to ensure the results of the wound culture were documented in the medical record for Patient 11.These failures had the potential to place Patient 1 at risk for medication administration errors, increased side effects, uncontrolled blood glucose, and compromised safety, and Patient 11 at risk for inadequate treatment, worsening medical conditions, insufficient symptom management, and avoidable hospitalization.(Refer to L558)The cumulative effect of these systemic practices resulted in the failure of the Hospice Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Comprehensive Assessment of Patients to ensure the quality of care are provided to patients certified to receive hospice benefits.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) for Clinical Records of Patients were met as follows: The HA failed to:To ensure the clinical records of 20 of 20 sampled patients (Patient 1, Patient 2, Patient 3, Patient 12, Patient 13, Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, and Patient 28) reflect the actual date the information was entered in accordance to the facility’s policy and procedure. This failure resulted in actual and potential harm for Patient 1, Patient 2, Patient 3, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, and Patient 28 to have inappropriate and inaccurate medication and treatment orders; unsafe patient care; increased the risk for hospice patients to suffer from unmanaged pain, distress, agitation; and increased the risk for emergency hospitalization and avoidable traumatic and/or undignified death and Patient 12, Patient 13, and Patient 14’s medical record not accurately reflecting the care provided and increased the risk for patient safety and compromised care. (Refer to L-tag 679)(Refer to L-tag 683) The cumulative effect of this systemic practice resulted in the failure of the Hospice Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Clinical Records for the provided services to patients certified to receive hospice benefits. 2. Provide documented evidence the Discharge Summary for five of five sampled Patients (Patient 11, Patient 12, Patient 13, Patient 14, and Patient 29) were sent to the attending physician. These failures had the potential for Patient 11, Patient 12, Patient 13, Patient 14, and Patient 29 to experience discontinuity of care; potentially resulting in delayed treatment, medication errors, and missed opportunities for follow up. (Refer to L683)”

“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-conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people 65 years of age or more and for certain younger people with disabilities]) for Drugs and biologicals, medical supplies and durable medical equipment were met as follows: The HA failed to ensure the physician’s telephone order for the use of oxygen was received, read back, and entered by the Director of Patient Care Services (DPCS) Designee or the Registered Nurse (RN) Designee for three of 10 sampled patients (Patient 2, Patient 3 and Patient 8) in accordance with the HA’s policy and procedure (P&P).This failure had the potential to result in inappropriate and inaccurate ordering of medication and treatment for the hospice patients which can result in an unsafe patient care and increased risk in medical errors and adverse event that can lead to emergency hospitalization and may contribute to an avoidable traumatic death of the hospice patients. (Refer to L690).The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Drugs and biologicals, medical supplies and durable medical equipment are provided to patients certified to receive home health benefits.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to meet the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people 65 years of age or more and for certain younger people with disabilities]) for compliance with Initial and Comprehensive Assessments of the patients as follows: 2. Provide documented evidence the physician order for wound care referral for one of sampled Patients (Patient 11) was completed. This failure had the potential for Patient 11 to experience a delay in diagnosis and treatment; potentially worsening his medical condition and resulting in inadequate pain management and increased risk of infection and avoidable hospitalization. (Refer to L-tag 532).3. Ensure the comprehensive assessment of two of two sampled Patients (Patient 4 and Patient 11) were updated to include changes that have taken place since the initial assessment by:a. Failing to ensure a complete and accurate wound assessment was documented for Patient 4 and Patient 11.b. Failing to ensure an accurate Plan of Care (POC) was implemented for Patient 4 and Patient 11.c. Failing to ensure the Interdisciplinary Group (IDG) Review was conducted to discuss changes, progress, and reassessment for Patient 11. These failures had the potential for Patient 4 and Patient 11 to experience inadequate treatment; potentially worsening medical conditions and resulting in inadequate symptom management. (Refer to L-tag 533).The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Initial and Comprehensive Assessments are provided to patients certified to receive home health benefits. The HA failed to1. Ensure the comprehensive assessment identified and addressed the needs of 3 of 10 sampled patients (Patient 1, Patient 2, and Patient 3). This failure had the potential for Patient 1, Patient 2, and Patient 3 to experience severe pain or distress, agitation, emergency hospitalization and potentially experience an undignified and avoidable traumatic death. (Refer to L-tag 524) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Initial and Comprehensive Assessments are provided to patients certified to receive home health benefits.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to meet the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) compliance with Quality Assessment and Performance Improvement (QAPI, a data driven approach to improve the quality of care and services provided to patients) for the provided services to the patients as follows: The HA failed to:1. Provide evidence that the Performance Improvement Program (PIP, a data driven approach to improve the quality of care and services provided to patients) has measurable improvement related to palliative (a form of medical care focuses on providing comfort and support to patients with serious or life-threatening illness) outcomes and hospice services. (Refer to L-tag 561)2. Provide evidence that the PIP was designed based on patient care assessments and the services HA provides. (Refer to L-tag 563)3. Provide evidence that data was collected to identify opportunities and priorities for improvement and monitor the effectiveness of the PIP. (Refer to L-tag 564)4. Provide documented evidence of the PIP being conducted and the progress achieved. (Refer to L-tag 573)These failures had the potential for patients to receive inconsistent symptom management, safety concerns and poor quality of life.The cumulative effect of these systemic practice resulted in the failure of the Hospice Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Quality Assessment and Performance Improvement for the provided services to patients certified to receive hospice benefits.”

“Based on observation, interview and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to meet the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) for compliance with Federal, State, and local laws and regulations as follows: The Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the hospice agency’s license is active to operate as a Hospice agency issued by the State of California Department of Public Health (CDPH). This failure had the potential risk to result in the provision of a substandard quality of care that could impact the health and safety to all patients certified to receive the hospice benefits. (Refer to L799). This systemic practice resulted in the failure of the Hospice Agency to deliver statutorily mandated (a legal obligation established by a statute or law) Compliance with Federal, State, and local laws and regulations to ensure health and safety, and quality of care are provided to patients certified to receive 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 comprehensive assessment identified and addressed the needs of 3 of 15 sampled patients (Patient 1, Patient 2, and Patient 3). This failure had the potential for Patient 1, Patient 2, and Patient 3 to experience severe pain or distress, agitation, emergency hospitalization and potentially experience an undignified and avoidable traumatic death. Findings: 1. During a review of Patient 1’s “Personal Information,” (page of the medical chart containing a summary of basic patient information) undated, the “Personal Information” indicated the HA admitted Patient 1, a 73-year-old female, on 8/15/2025 with diagnosis that included atherosclerosis heart disease (plaque buildup in the heart’s arteries), shortness of breath (SOB, a subjective sensation of not being able to get enough air, often accompanied by feelings of tightness in the chest, rapid breathing, and wheezing [a high-pitched, whistling sound that occurs when air flows through narrowed airways]), and dependance on supplemental oxygen (a condition requiring the use of a device to deliver extra oxygen). During a review of Patient 1’s “Visit Note LVN,” dated 9/10/2025, the “Visit Note LVN” indicated Patient 1 experienced heavy breathing, diminished lung sounds in bilateral (affecting both sides) lobes, and moderate SOB with exertion. During Patient 1’s home visit with Registered Nurse 3 (RN 3) on 9/10/2025 at 9:32 AM, a medication reconciliation (a process on comparing patient’s current medication against medication ordered by the physician) was conducted. Patient 1’s “Current Treatment/ Medication/ DME List” did not include oxygen for SOB and dependence on supplemental oxygen. During Patient 1’s home visit with Registered Nurse 3 (RN 3) on 9/10/2025 at 9:32 AM, Patient 1’s Caregiver 1 (CG 1) stated the HA did not provide Patient 1 with oxygen for home use. During a concurrent interview and record review on 9/11/2025 at 10:07 AM with the Director of Patient Care Services Designee (DPCS Designee), Patient 1’s “Comprehensive Nursing Assessment,” dated 8/15/2025 was reviewed. The “Comprehensive Nursing Assessment” indicated mild SOB and wheezing on room air. The DPCS Designee stated an order for oxygen should have been entered to treat SOB, wheezing, and diminished lung sounds. The DPCS Designee stated failure to provide oxygen therapy placed Patient 1 at increased risk of respiratory distress (a life-threatening condition that causes severe difficulty breathing) and hospitalization. During an interview on 9/11/2025 at 2:20 PM with the Medical Director (MD), the MD stated that Patient 1 required an order for oxygen based on her clinical symptoms of SOB and diminished lung sounds. 2. During a review of Patient 2’s Comprehensive Nursing Assessment: Primary/Secondary Diagnosis & Comorbidities, dated 8/6/2025, the Comprehensive Nursing Assessment: Primary/Secondary Diagnosis & Comorbidities indicated secondary diagnosis including hypothyroidism (thyroid gland does not produce enough thyroid hormones) and SOB. During a concurrent observation and interview on 9/10/2025 at 1:10 PM with CG 2 at Patient 2’s home, no oxygen tank or supplies were observed. CG 2 stated we have been requesting oxygen since she was admitted on 8/6/2025 but has not received it yet. However, hospice called this morning and said they would deliver it this afternoon (9/10/2025). During a concurrent interview and record review on 9/15/2025 at 11:21 AM with RN 5, Patient 2’s Comprehensive Nursing Assessment: Body System: Head-to-Toe: Respiratory, dated 8/6/2025 was reviewed. The Comprehensive Nursing Assessment: Body System: Head-to-Toe: Respiratory indicated moderate dyspnea (difficulty breathing) with mild and moderate exertion; “Even though SOB is present, does patient decline treatment – No”; diminished lung sounds (decrease in the intensity or volume of breath sounds); and no oxygen therapy. There were no recommendations for oxygen therapy, strategies to reduce SOB, suggestions for patient/family goals to manage SOB, or patient teaching on SOB. RN 5 stated, oxygen therapy should have been ordered on admission for Patient 2 who has a diagnosis of SOB and symptoms of moderate dyspnea. During a concurrent interview and record review on 9/15/2025 at 11:21 AM with RN 5, Patient 2’s “Current Treatment/Medication/DME List” was reviewed. Patient 2’s “Current Treatment/Medication/DME List” indicated no orders for oxygen therapy prior to 9/13/2025. RN 5 stated, oxygen therapy was not, but should have been, ordered on admission for Patient 2. During a concurrent interview and record review on 9/15/2025 at 11:30 AM with RN 5, Patient 2’s Comprehensive Nursing Assessment: Body System: Head-to-Toe, dated 8/6/2025 was reviewed. Patient 2’s Comprehensive Nursing Assessment: Body System: Head-to-Toe indicated no Endocrine section to screen for Patient 2’s needs with a diagnosis of hypothyroidism. RN 5 stated, the Endocrine section of the Comprehensive Nursing Assessment should be completed for patients with a diagnosis of hypothyroidism. 3. During a review of Patient 3’s “Personal Information”, undated, the “Personal Information” indicated the hospice agency admitted Patient 3, an 86-year-old female, on 8/11/2025 with diagnoses including, but not limited to, heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), SOB, and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance (patterns of behaviors, thoughts and moods that are considered unusual for a person’s age and context). During a review of Patient 3’s “Comprehensive Nursing Assessment”, dated 8/11/2025, the “Comprehensive Nursing Assessment” indicated Patient 3 has mild anxiety (a mental condition characterized by excessive worry, fear and nervousness that can interfere with daily life), has SOB with moderate exertion and diminished lung sounds. During Patient 3’s home visit with Medical Social Worker (MSW, a person to provide support to patients and families) on 9/10/2025 at 3:20 PM, a medication reconciliation was conducted. Patient 3’s “Current Treatment/ Medication/ DME List” did not include any treatment or medication for anxiety. During an interview on 9/10/2025 at 3:20 PM, with Patient 3’s care giver (CG 3), CG 3 stated Patient 3 feels short of breath even with small movements. CG 3 stated she requested for Patient 3 to have an oxygen concentrator (medical device that delivers oxygen rich air to a person who has difficulty breathing) from the last nurse visit (9/8/2025) and that the facility will be delivering Patient 3’s oxygen tomorrow (9/11/2025). During a review of Patient 3’s “Physician Order”, dated 9/10/2025, the “Physician Order” indicated Oxygen 5 liters via nasal canula (oxygen was ordered a month after Patient 3 was admitted). During an interview on 9/15/2025 at 10:20 AM with RN 5, RN 5 stated any concerns or change of condition should be addressed as soon as it was assessed by the nurse. RN 5 stated interventions for anxiety can include non-pharmacological techniques and medications. During a review of HA’s policy and procedure (P&P), titled “Initial Assessment”, undated, the P&P indicated the admitting registered nurse will identify and address patient’s and caregiver’s concerns, goals and immediate needs based on their assessments. During a review of the HA’s P&P titled, “Policy and Procedure: Ordering Medications and Supplies,” dated 12/19/2025, the P&P indicated, “The DPCS, case manager, or hospice nurse identifies the need for medications or supplies based on patient assessment, physician plan of care, or IDG [interdisciplinary group] recommendations.” The P&P indicated, “Hospice physician/medical director: reviews, approves, and finalizes all mediation and supply orders” and “all orders, including drafts and finalized version, must be documented in the patient’s clinical record.” During a review of the facility’s policy and procedure titled, “Oxygen Safety in the Home Policy,” undated, indicated, “All oxygen safety education, assessments, and interventions will be documented in the patient’s record” and “Documentation of teaching and patient/caregiver understanding will be placed in the patient’s medical record.” 1”

“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 provide documented evidence the comprehensive assessment included a physician’s order for wound care referral for one of 15 sampled Patients (Patient 11). This failure had the potential for Patient 11’s identified needs will not be met causing a delay in diagnosis and treatment, worsening medical condition, inadequate pain management and increased risk of infection and avoidable hospitalization. Findings: During a review of Patient 11’s “Personal Information,” (page of the medical chart containing a summary of basic patient information) undated, the “Personal Information” indicated the HA admitted Patient 11 on 3/10/2025 with diagnosis that included hypertensive heart disease with heart failure (high blood pressure damaged the heart over time, making it unable to pump blood effectively causing shortness of breath, fatigue, and swelling in the legs), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (elevated cholesterol level). During a review of Patient 11’s “Physician Order,” dated 4/3/2025, the “Physician Order” indicated on 4/3/2025 the Medical Director (MD) indicated an order for wound care evaluation and treatment. During an interview on 9/16/2025 at 11:38 AM with Registered Nurse 5 (RN 5), stated physician orders for referral of evaluation and treatment of wounds should take place within 72 hours of the order being placed. During an interview on 9/17/2025 at 10:40 AM with RN 5 stated Patient 11’s medical record did not include documented evidence to suggest the physician’s order dated 4/3/2025 for referral of wound care services was completed. During a review of the facility’s policy and procedure (P&P) titled, “Policy & Procedure: Referrals and Logs,” undated, the P&P indicated the following: Each referral entry must include the status of the referral and the outcome. The Referral Log must be reviewed weekly by the Administrator/ Director of Nursing and any delays or missed follow-ups must be investigated.”

“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 comprehensive assessment of two of 15 sampled Patients (Patient 4 and Patient 11) were updated to include changes that have taken place since the initial assessment by:Failing to ensure a complete and accurate wound assessment was documented for Patient 4 and Patient 11.Failing to ensure an accurate Plan of Care (POC) was implemented for Patient 4 and Patient 11.Failing to ensure the Interdisciplinary Group (IDG) Review was conducted to discuss changes, progress, and reassessment for Patient 11. These failures had the potential for Patient 4 and Patient 11 to experience inadequate treatment, worsening medical conditions, and resulting in inadequate symptom management. Findings: 1. During a review of Patient 4’s “Personal Information,” (page of the medical chart containing a summary of basic patient information) undated, the “Personal Information” indicated the HA admitted Patient 4, a 85-year-old female, on 4/18/2025 with diagnosis that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), bladder and bowel incontinence (the involuntary loss of urine and stool) and bed confinement status (a person being physically restricted to their bed due to a medical condition, injury, or physical limitation).During a review of Patient 11’s “Personal Information,” undated, the “Personal Information” indicated the HA admitted Patient 11, a 76-year-old male, on 3/9/2025 with diagnosis that included hypertensive heart disease with heart failure (high blood pressure damaged the heart over time, making it unable to pump blood effectively causing shortness of breath, fatigue, and swelling in the legs), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (elevated cholesterol level).a. During a review of Patient 4’s “Comprehensive Nursing Assessment,” dated 4/18/2025, the “Comprehensive Nursing Assessment” indicated Patient 4 did not have any wounds at the time of admission to the HA. During a concurrent interview and record review on 9/17/2025 at 11:08 AM with Registered Nurse 5 (RN 5) Patient 4’s “Visit Note LVN” dated 9/1/2025 was reviewed. The “Visit Note LVN” indicated the presence of a pressure ulcer/injury stage 2 (partial-thickness loss of skin, presenting as a shallow open sore or wound) on the right buttocks that presented red in color, with serosanguinous draining and odor. The “Visit Note LVN” did not indicate wound size, inflammation, and undermining (the destruction of tissue or ulcer extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface) / tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound). RN 5 stated that the incomplete assessment prevented accurate wound staging (a classification system that describes how deep a wound is, used to assess the severity of pressure injuries) and determine the best treatment), proper treatment, and measurement of progression. RN 5 stated Patient 4 was at increased risk of infection, sepsis (a life-threatening blood infection), pain, anxiety, and agitation. b. During a review of Patient 11’s “Visit Note LVN,” dated 3/11/2025, the “Visit Note LVN” indicated Patient 11 had a stage 1 wound (pressure ulcer/ injury stage 1, intact skin with a localized area of redness and/or change in sensation, temperature, or firmness). During an interview on 9/17/2025 at 10:35 AM with RN 5, RN 5 stated there was no documented evidence that a Registered Nurse (RN) completed a wound assessment for Patient 11 after LVN 6 identified the wound on 3/11/2025. RN 5 stated the wound should be assessed by an RN to ensure proper wound staging and treatment, complete assessment of contributing risk factors, to provide patient/ patient care giver education, and ensure optimal patient outcomes. RN 5 stated Patient 11 was at increased risk of skin breakdown and infection. During a review of the facility’s Policy and Procedure (P&P) titled, “Wound Care Policy & Procedure,” undated, the P&P indicated wounds will be evaluated and documented at each visit. The Registered Nurse completes the initial and ongoing wound assessment: assessing wound size, depth, drainage, odor, pain, tissue type, and signs of infection. Wound care documentation in the EMR (electronic medical record) includes wound assessment, treatment, patient response, and teaching provided. 2. a. During a review of Patient 4’s “Visit Note LVN,” dated 9/1/2025, the “Visit Note LVN” indicated the presence of a pressure ulcer/injury stage 2 on the right buttocks.During a review of Patient 4’s “Plan of Care (POC),” dated 9/5/2025, the “POC” indicated, “Patient has alteration of skin integrity: Moisture associated skin damage (MASD) to sacrum.” The “POC” did not indicate additional integumentary/ skin problems. During an interview on 9/16/2025 at 12:30 PM with RN 5, RN 5 stated Moisture Associated Skin Damage (MASD, moisture associated skin damage caused from prolonged exposure to moisture) and pressure injuries were different wound classifications. RN 5 stated that documenting pressure injuries as MASD results in inaccurate classification preventing proper treatment and monitoring.During an interview on 9/17/2025 at 11:22 AM with RN 5, RN 5 stated Patient 4’s POC was inaccurate and did not address Patient 4’s diagnosis of pressure ulcer/injury stage 2 on the right buttocks. RN 5 stated that failure to maintain an accurate POC placed Patient 4 at risk for further skin breakdown, inaccurate treatment, and insufficient education of the patient and caregiver. 2. b. During a review of Patient 11’s “Comprehensive Nursing Assessment (initial assessment),” dated 3/9/2025, the “initial assessment did not indicate the presence of wounds or skin impairment. During a review of Patient 11’s “Visit Note LVN,” dated 3/11/2025, the “Visit Note LVN” indicated the presence of a pressure ulcer/injury stage 1.During a concurrent interview and record review on 9/17/2025 at 11:03 AM with RN 5, Patient 11’s “POC” dated 9/17/2025 was reviewed. The “POC” indicated the POC for integumentary/ skin was created on 3/9/2025. RN 5 stated Patient 11’s POC for integumentary/ skin was not updated on or after 3/11/2025, following the discovery of the pressure ulcer/injury stage 1. RN 5 stated failure to update and maintain an accurate POC placed Patient 11 at risk of receiving inadequate treatment, improper supplies, and compromised quality of care. During a review of the facility’s P&P titled, “The Plan of Care,” undated, the P&P indicated the following:- “The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions.”- “The plan of care will identify the patient’s needs and services to meet those needs”- The written plan of care will contain diagnosis, identification of patient and family/caregiver needs, prognosis (the predicted future course of a disease or condition), DME (durable medical equipment) and medical supplies necessary to meet patient needs, frequency/ amount/ duration and type of services, and placement at the appropriate level of care and referrals as needed. - “Any change in the patient’s condition must result in a change in the plan of care, prior to implementation of the new service.”- “Care provided to the patient will be in accordance with the plan of care.” 3. During a concurrent interview and record review on 9/17/2025 at 10:55 AM with RN 5 Patient 11’s “POC/IDG Review” dated 3/14/2025 was reviewed. The “POC/IDG Review” did not indicate Patient 11’s POC included interventions for the treatment of a pressure ulcer/injury stage 1 on the left foot nor that the IDG (composed of the Medical Director (MD), Registered Nurse 6 (RN 6), Social Worker 1 (SW 1), and Chaplain 2) discussed the wound. RN 5 stated failure to discuss Patient 11’s wound in the IDG Review and update the POC placed Patient 11 at risk for improper treatment, inaccurate monitoring and further harm. During a concurrent interview and record review on 9/17/2025 at 10:55 AM with RN 5 Patient 11’s “POC/IDG Review” dated 3/28/2025 was reviewed. The “POC/IDG Review” did not indicate Patient 11’s POC included interventions for treatment of a pressure ulcer/injury stage 1 on the left foot nor that the interdisciplinary group (composed of MD, RN 6, SW 1, and Chaplain 2) discussed the wound. RN 5 stated failure to discuss Patient 11’s wound in the IDG Review and update the POC placed Patient 11 at risk for improper treatment, inaccurate monitoring and further harm. During a review of the facility’s P&P titled, “Interdisciplinary Group Membership and Responsibilities,” undated, the P&P indicated, “The interdisciplinary group responsibilities include but are not limited to: Participation in the establishment of the plan of care for each patient admitted to the hospice service… Participation in the periodic review and updating of the plan of care for each patient receiving hospice services… Provision and/or supervision and coordination of hospice care and services… Reporting any unusual change in the patient’s physical, mental, spiritual or emotional status to the primary caregiver(s), the attending physician and the interdisciplinary group.” a”

“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 Director of Patient Care Services (DPCS) coordinates the services and care for four of 10 sampled patients (Patient 1, Patient 2, Patient 3 and Patient 11) as discussed by the interdisciplinary group (IDG). This failure had the potential for Patient 1, Patient 2, Patient 3 and Patient 11 to experience severe pain or distress, agitation, emergency hospitalization and potentially experience an undignified and avoidable traumatic death. Findings: 1. During a review of Patient 1’s “Personal Information,” (page of the medical chart containing a summary of basic patient information) undated, the “Personal Information” indicated the HA admitted Patient 1, on 8/15/2025 with diagnosis that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), depression (characterized by persistent feelings of sadness, hopelessness, and loss of interest), shortness of breath (SOB, a subjective sensation of not being able to get enough air, often accompanied by feelings of tightness in the chest, rapid breathing, and wheezing [a high-pitched, whistling sound that occurs when air flows through narrowed airways]), and dependance on supplemental oxygen (a condition requiring the use of a device to deliver extra oxygen). During a review of Patient 1’s “POC (Plan of Care)/ IDG Review,” dated 8/29/2025, the “POC/IDG Review” physician’s plan indicated, “assess, monitor, and control end of life symptoms with medications.” The “POC/IDG Review” did not include provision or use of the Comfort Kit (set of medications intended for symptoms and pain management such as: morphine (treatment for pain), Ativan (treatment for agitation and anxiety), Levsin (treatment for excessive secretions), albuterol inhaler (treatment for shortness of breath (SOB, a subjective sensation of not being able to get enough air, often accompanied by feelings of tightness in the chest, rapid breathing, and wheezing [a high-pitched, whistling sound that occurs when air flows through narrowed airways]) and/or wheezing), Zofran (treatment for nausea and vomiting), and Tylenol (treatment for mild pain and/or fever). During a review of Patient 1’s “POC/IDG Review,” dated 8/29/2025, the “POC/IDG Review” nursing discussion indicated, “mild SOB persists with activity. Lung sounds remain diminished on SN [skilled nurse] assessment.” The “POC/IDG Review” did not include provision or use of oxygen for SOB and dependence on supplemental oxygen. During a review of Patient 1’s “POC/IDG Review,” dated 8/29/2025, the “POC/IDG Review” indicated on 8/15/2025 medication orders for Paxil (treatment for depression) and Mounjaro (treatment for elevated blood sugar) 5 milligrams (mg, unit of measurement) were entered. During joint home visit at Patient 1’s with Registered Nurse 3 (RN 3) on 9/10/2025 at 9:32 AM, a medication reconciliation (a process on comparing patient’s current medication against medication ordered by the physician) was conducted. Patient 1’s “Current Treatment/ Medication/ DME List” did not include the Comfort Kit or oxygen. Patient 1’s Caregiver 1 (CG 1) stated the HA did not provide Patient 1 with the Comfort Kit or oxygen for home use. During Patient 1’s home visit with RN 3 on 9/10/2025 at 9:23 AM, the medication reconciliation was conducted. Patient 1’s “Current Treatment/ Medication/ DME List” included Paxil 30 mg tablet and Mounjaro 5 mg injection. Patient 1 stated she was not taking Paxil and could not recall the last time she had taken the medication. Patient 1 stated the Mounjaro medication dose was 7.5 mg not 5 mg. During a concurrent interview and record review on 9/11/2025 at 10:07 AM with the Director of Patient Care Services Designee (DPCS Designee), Patient 1’s “Comprehensive Nursing Assessment,” dated 8/15/2025 was reviewed. The “Comprehensive Nursing Assessment” indicated mild SOB and wheezing on room air. The DPCS Designee stated an order for oxygen should have been entered to treat SOB, wheezing, and diminished lung sounds. The DPCS Designee stated failure to provide oxygen therapy placed Patient 1 at increased risk of respiratory distress (a life-threatening condition that causes severe difficulty breathing) and hospitalization. During a concurrent interview and record review on 9/11/2025 at 10:07 AM with the DPCS Designee, Patient 1’s “Current Treatment/ Medication/ DME List,” undated was reviewed. The DPSC Designee stated Paxil 30 mg and Mounjaro 5 mg were listed as active medications. The DPCS stated an accurate and up-to-date medication list is essential to ensure patient safety and avoid medication administration errors, duplicate medication therapy, and potential drug-to-drug interactions. During a concurrent interview and record review on 9/11/2025 at 2:20 PM with the Medical Director, the “POC/IDG Review”, dated 8/29/2025 was reviewed. The MD stated the IDG discussion and updated comprehensive assessment review that indicated the treatment plan “Other/ Physician: Assess, monitor, and control end of life symptoms with medications,” included the patient’s use of the Comfort Kit and if the Comfort Kit was not needed it would reflect on the POC/ POC/IDG Review. During an interview on 9/15/2025 at 10:28 AM with RN 5, RN 5 stated IDG meets to review patient events, and additional orders and interventions are implemented based on assessment findings obtained during nursing home visits. 2. During a review of Patient 2’s Comprehensive Nursing Assessment: Primary/Secondary Diagnosis & Comorbidities, dated 8/6/2025, the Comprehensive Nursing Assessment: Primary/Secondary Diagnosis & Comorbidities indicated secondary diagnosis including shortness of breath (SOB, not being able to get enough air to breath). During a review of Patient 2’s “POC/IDG Review Aug 06, 2025 – Cert #1”, dated 8/6/2025, the “POC/IDG (Plan of Care/Interdisciplinary Group) Review Aug 06, 2025 – Cert #1” indicated “Secondary DX (diagnosis):…Anxiety disorder …Shortness of breath”, no comfort kit medications for anxiety or SOB, precautions for oxygen, and “Nursing: Anxiety disorder” with no reference to SOB. During a review of Patient 2’s “POC/IDG Review Aug 15, 2025 – Cert #1”, dated 8/15/2025, the “POC/IDG Review Aug 15, 2025 – Cert #1” indicated “Secondary DX:… Anxiety disorder…Shortness of breath”, no comfort kit medications for anxiety or SOB, precautions for oxygen, and “Nursing: …moderate SOB with mild exertion. Lung sounds remain diminished on SN (skilled nursing) visits” with no reference to anxiety disorder, and no goals/interventions for anxiety or SOB. During a review of Patient 2’s “POC/IDG Review Aug 29, 2025 – Cert #1”, dated 8/29/2025, the “POC/IDG Review Aug 29, 2025 – Cert #1” indicated “Secondary DX… Anxiety disorder…Shortness of breath”, no comfort kit medications for anxiety or SOB, Nursing: “…Patient observed with mild SOB [shortness of breath] during exertion. Lung sounds diminished…Education provided on oxygen use…medications are reconciled and approved” with no reference to anxiety disorder, precautions for oxygen, and no goals/interventions for anxiety or SOB. During a review of Patient 2’s “POC/IDG Review Sep 12, 2025 – Cert #1”, dated 9/12/2025, the “POC/IDG Review Sep 12, 2025 – Cert #1” indicated “Secondary DX…Anxiety disorder….Shortness of breath”, Ativan, ipratropium bromide/Albuterol Sulfate, and morphine (comfort kit medications) for anxiety and SOB, DME (durable medical equipment): oxygen concentrator 5L (stationary) with nasal cannula, Nursing: “…New orders include oxygen at 2 LPM,…Patient continues to experience mild to moderate SOB with exertion; lung sounds remain diminished….”, “Precautions:…oxygen,…”, no goals/interventions for anxiety or SOB, and no required signature by the Chaplain. During a concurrent observation and interview on 9/10/2025 at 1:10 PM with CG 2 at Patient 2’s home, no oxygen tank or supplies, and no comfort kits were observed. CG 2 stated, we have been requesting oxygen since she was admitted on 8/6/2025 but have not received it yet. However, hospice called this morning and said they would deliver it this afternoon [9/10/2025]. CG 2 stated she had no comfort kits. During a record review of the facility’s policy and procedure titled, “Comfort Kit for the Imminently Dying Patient,” undated, indicated, “Comfort Kits is intended to address urgent and distressing symptoms such as pain, agitation, dyspnea (SOB), nausea, secretions, or anxiety, and to prevent unnecessary suffering…” and morphine sulfate or alternative opioid may be ordered for shortness of breath and lorazepam may be ordered for anxiety. During a concurrent interview and record review on 9/15/2025 at 11:21 AM with RN 5, Patient 2’s Comprehensive Nursing Assessment: Body System: Head-to-Toe: Respiratory, dated 8/6/2025 was reviewed. The Comprehensive Nursing Assessment: Body System: Head-to-Toe: Respiratory indicated moderate dyspnea (difficulty breathing) with mild and moderate exertion; “Even though SOB is present, does patient decline treatment – No”; diminished lung sounds (decrease in the intensity or volume of breath sounds); and no oxygen therapy. There were no recommendations for oxygen therapy, strategies to reduce SOB, suggestions for patient/family goals to manage SOB, or patient teaching on SOB. RN 5 stated, oxygen therapy should have been ordered on admission for Patient 2 who has a diagnosis of SOB and symptoms of moderate dyspnea. During a concurrent interview and record review on 9/15/2025 at 11:21 AM with RN 5, Patient 2’s “Current Treatment/Medication/DME List” was reviewed. Patient 2’s “Current Treatment/Medication/DME List” indicated no orders for oxygen therapy prior to 9/13/2025. RN 5 stated, oxygen therapy was not, but should have been, ordered on admission for Patient 2. During a review of the facility’s policy and procedure titled, “Oxygen Safety in the Home Policy,” undated, indicated, “All oxygen safety education, assessments, and interventions will be documented in the patient’s record” and “Documentation of teaching and patient/caregiver understanding will be placed in the patient’s medical record.” 3. During a review of Patient 3’s “Personal Information”, undated, the “Personal Information” indicated the hospice agency admitted Patient 3, on 8/11/2025 with diagnoses including, but not limited to, heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), shortness of breath, and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance (patterns of behaviors, thoughts and moods that are considered unusual for a person’s age and context). During Patient 3’s home visit with Medical Social Worker (MSW, a person to provide support to patients and families) on 9/10/2025 at 3:20 PM, a medication reconciliation (a process on comparing patient’s current medication against medication ordered by the physician) was conducted. Patient 3’s “Current Treatment/ Medication/ DME List” did not include the “Comfort Kit”: morphine sulfate, Zofran, Levsin, acetaminophen, Ativan, and bisacodyl. During an interview on 9/10/2025 at 3:20 PM, with Patient 3’s care giver (CG 3), CG 3 stated Patient 3 feels short of breath even with small movements. CG 3 stated she requested for Patient 3 to have an oxygen concentrator (medical device that delivers oxygen rich air to a person who has difficulty breathing) from the last nurse visit (9/8/2025) and that the facility will be delivering Patient 3’s oxygen tomorrow (9/11/2025). During a review of Patient 3’s “POC/IDG Review”, dated 8/29/2025, the “POC/IDG Review” Physician’s assessment review indicated “Assess, monitor, and control end of life symptoms with medications.”. The IDG review indicated Patient 13 remains with moderate shortness of breath on exertion and lung sounds diminished. The plan of care discussed during the IDG review did not include concerns regarding Patient 13’s SOB. During a concurrent interview and record review on 9/11/2025 at 2:20 PM with the MD. the “POC/IDG Review”, dated 8/29/2025 was reviewed. The MD stated the “POC/ IDG Review” that indicated “Other/ Physician: Assess, monitor, and control end of life symptoms with medications,” this treatment plan included the patient’s use of Comfort Kit medications and if the Comfort Kit was not needed it would reflect on the POC/ IDG Review. During an interview on 9/15/2025 at 10:20 AM with RN 5, RN 5 stated the DPCS was the one attending the IDG meeting and reports on the hospice patients’ nursing care and needs. RN 5 stated the visiting nurses would report nursing updates, patient condition and patient needs/concerns to the DPCS, and the DPCS will collaborate with the MD for any treatments and services to provide on the patient based on nurse’s report during the IDG meeting. RN 5 stated the DPCS will coordinate the updates and changes regarding patient care and treatments to the healthcare team for implementation. During an interview on 9/15/2025 at 10:20 AM with RN 5, RN 5 stated any concerns or change of condition should be addressed as soon as it was assessed by the nurse. RN 5 stated these interventions should be reflected on Patient 3’s Plan of care and should be discussed in the IDG meeting. RN 5 stated when the physician indicated Comfort Kits on his notes, the nurse should place an order of Comfort Kit for the patient. 4. During a review of Patient 11’s “Personal Information,” the “Personal Information” indicated the HA admitted Patient 11, on 3/10/2025 with diagnosis that included hypertensive heart disease with heart failure (high blood pressure damaged the heart over time, making it unable to pump blood effectively causing shortness of breath, fatigue, and swelling in the legs), type 2 diabetes mellitus, and hyperlipidemia (elevated cholesterol level). During a review of Patient 11’s “Visit Note LVN,” dated 3/11/2025, the “Visit Note LVN” indicated, “wounds: stage 1” (pressure ulcer/injury stage 1 (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness). During a review of Patient 11’s “Physician Order,” dated 4/3/2025, the “Physician Order” indicated the Medical Director (MD) entered an order for wound care evaluation and treatment on 4/3/2025. During a review of Patient 11’s “POC/IDG Review,” dated 4/11/2025, the “POC/IDG Review” did not indicate the creation and implementation of a plan of care for skin/ integumentary. The “POC/IDG Review” nursing discussion did not include a review of the referral for wound care evaluation and treatment entered on 4/3/2025. During a concurrent interview on 9/17/2025 at 10:55 AM with Registered Nurse 5 (RN 5), Patient 11’s “POC/IDG Review,” dated 3/14/2025 and 3/28/2025 were reviewed. RN 5 stated that Patient 11’s wound was identified on 3/11/2025 and IDG discussions held on 3/14/2025 and 3/28/2025 did not include a review of Patient 11’s wound. RN 5 stated failure to discuss wound care placed Patient 11 at increased risk of inadequate treatment and monitoring of wound progression. During a review of Patient 11’s “Discharge Summary,” dated 5/6/2025, the “Discharge Summary” indicated Patient 11 was discharged from the HA due to hospitalization. During a review of HA’s P&P, titled “Interdisciplinary Group Membership and Responsibilities”, undated, the P&P indicated the IDG responsibilities include establishment, reviewing and updating of plan of care and “taking proactive approach in developing/revising the plan of care by planning ahead for anticipated patient changes and needs.” ... “provision and/or supervision and coordination of hospice care and services” During a review of “Clinical Director’s Job Description”, undated, the “Clinical Director’s Job Description” indicated essential job functions include “Coordinate and oversee all direct and indirect patient services provided by clinical organization personnel.” ... “If the DPCS is also acting as the clinical manager, the clinical manager’s oversight must also include coordinating patient care, assuring the development, implementation and updates in the individualized POC.””

“Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Plan of Care (POC) for 4 of 15 sampled patients (Patient 1, Patient 2, Patient 3, and Patient 11) includes symptom management and other related condition identified during patient’s assessments. This failure had the potential for patients to receive inadequate treatment and monitoring that may lead to severe pain or distress, agitation, emergency hospitalization and potentially experience an undignified and avoidable traumatic death. Findings: 1. During a review of Patient 1’s “Personal Information,” (page of the medical chart containing a summary of basic patient information) undated, the “Personal Information” indicated the HA admitted Patient 1, on 8/15/2025 with diagnosis that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), depression (characterized by persistent feelings of sadness, hopelessness, and loss of interest), shortness of breath (SOB, a subjective sensation of not being able to get enough air, often accompanied by feelings of tightness in the chest, rapid breathing, and wheezing [a high-pitched, whistling sound that occurs when air flows through narrowed airways]), and dependance on supplemental oxygen (a condition requiring the use of a device to deliver extra oxygen). During a review of Patient 1’s “Comprehensive Nursing Assessment,” dated 3/9/2025, the “Comprehensive Nursing Assessment” indicated Patient 1 had mild SOB with exertion, diminished lung sounds, type 2 diabetes mellitus, and depression. During a review of four of Patient 1’s “Visit Note LVN,” dated 9/10/2025, 9/3/2025, 8/27/2025, and 8/20/2025, the “Visit Note LVN” indicated heavy breathing, mild to moderate SOB, and diminished lung sounds. During Patient 1’s home visit with Registered Nurse 3 (RN 3) on 9/10/2025 at 9:32 AM, a medication reconciliation (a process on comparing patient’s current medication against medication ordered by the physician) was conducted. Patient 1’s “Current Treatment/ Medication/ DME List” did not include the Comfort Kit or oxygen. Patient 1’s Caregiver 1 (CG 1) stated the HA did not provide Patient 1 with the Comfort Kit or oxygen for home use. During Patient 1’s home visit with RN 3 on 9/10/2025 at 9:23 AM, the medication reconciliation was conducted. Patient 1’s “Current Treatment/ Medication/ DME List” included Paxil (treatment for depression) 30 mg tablet and Mounjaro (treatment for elevated blood sugar) 5 mg injection. Patient 1 stated she was not taking Paxil and could not recall the last time she had taken the medication. Patient 1 stated the Mounjaro medication dose was 7.5 mg and not 5 mg. During a concurrent interview and record review on 9/11/2025 at 10:07 AM with the Director of Patient Care Services Designee (DPCS Designee), Patient 1’s “Comprehensive Nursing Assessment,” dated 8/15/2025 was reviewed. The “Comprehensive Nursing Assessment” indicated mild SOB and wheezing on room air. The DPCS Designee stated an order for oxygen should have been entered to treat SOB, wheezing, and diminished lung sounds. The DPCS Designee stated failure to provide oxygen therapy placed Patient 1 at increased risk of respiratory distress (a life-threatening condition that causes severe difficulty breathing) and hospitalization. During an interview on 9/11/2025 at 2:40 PM with the MD, MD stated, a patient with a diagnosis of “dependence on supplemental oxygen” requires oxygen, and there should be an order for oxygen. During a review of Patient 1’s “Plan of Care,” dated 9/12/2025, the “POC” did not indicate the creation or implementation of a POC for respiratory, SOB, or dependence on supplemental oxygen. The endocrine POC indicated Mounjaro 5 mg and not 7.5 mg. The neurological/ mental POC indicated Paxil was an active medication order. During an interview on 9/15/2025 at 10:28 AM with RN 5, RN 5 stated the HA must create and implement a POC for each patient assessment finding. 2. During a record review of Patient 2’s “Personal Information”, undated, “Personal Information” indicated the Hospice agency admitted Patient 2, on 8/6/2025 with diagnoses that included hypothyroid (low levels of thyroid hormone that is necessary to sustain life), shortness of breath (difficulty breathing), and anxiety (excessive worry). During a review of three of Patient 2’s POC/IDG, dated 8/6/2025, 8/15/2025, and 8/29/2025, Patient 2’s POC/IDG indicated no medications for comfort measures for anxiety or nausea were ordered. During an interview on 9/10/2025 at 1:00 PM with CG 2, CG 2 stated, she had no comfort kits. During a concurrent interview and record review on 9/11/2025 at 11:20 AM with MD, Patient 2’s “POC/IDG Review”, dated 8/6/2025 was reviewed. Patient 2’s “POC/IDG (Plan of Care/Interdisciplinary Group) Review” indicated “Patient will be provided with comfort measures…”. The MD stated comfort measures include medications for anxiety and nausea. During a concurrent interview and record review on 9/15/2025 at 11:21 AM with RN 5, Patient 2’s Plan of Care (POC), dated 9/15/2025 was reviewed. The POC indicated secondary diagnosis of hypothyroidism and shortness of breath with no interventions or goals for these diagnoses. RN 5 stated, there should be an endocrine section for hypothyroidism on the POC, and the cardiovascular section of the POC should include a POC for SOB. During a review of Hospice Agency’s (HA) Policy and Procedure (P&P), titled, “The Plan of Care”, undated, the P&P indicated, “This plan [of care] will focus on identified problems, goals, and interventions” and “The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments…” During a review of Patient 6’s “Comprehensive Nursing Assessment,” dated 7/11/2025, the “Comprehensive Nursing Assessment,” indicated Patient 6’s secondary diagnosis of Dependence on supplemental oxygen. During an interview on 9/11/2025 at 10:06 AM with the DPCS Designee, DPCS Designee stated, a patient with a diagnosis of “dependence on supplemental oxygen” needs to have oxygen, and not having oxygen can be life-threatening. During an interview on 9/11/2025 at 2:40 PM with the MD, MD stated, a patient with a diagnosis of “dependence on supplemental oxygen” requires oxygen, and there should be an order for oxygen. During a concurrent interview and record review on 9/15/2025 at 11:21 AM with RN 5, Patient 6’s “Current Treatment/Medication/DME List” dated 9/15/2025 was reviewed. The “Current Treatment/Medication/DME List” indicated, no orders for oxygen since patient was ordered since Patient 6 was admitted on 7/11/2025. RN 5 stated, oxygen should have been delivered on the day the patient was assessed, and if the patient does not have oxygen, they could die. 3. During a review of Patient 3’s “Personal Information”, the “Personal Information” indicated the hospice agency admitted Patient 3, on 8/11/2025 with diagnoses including, but not limited to, heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), shortness of breath, and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance (patterns of behaviors, thoughts and moods that are considered unusual for a person’s age and context). During a review of Patient 3’s “Comprehensive Nursing Assessment”, dated 8/11/2025, the “Comprehensive Nursing Assessment” indicated Patient 3 has mild anxiety, has shortness of breath with moderate exertion and diminished lung sounds. During Patient 3’s home visit with Medical Social Worker (MSW, a person to provide support to patients and families) on 9/10/2025 at 3:20 PM, a medication reconciliation (a process on comparing patient’s current medication against medication ordered by the physician) was conducted. Patient 3’s “Current Treatment/ Medication/ DME List” did not include the “Comfort Kit”: morphine sulfate, Zofran, Levsin, acetaminophen, Ativan, and bisacodyl. Patient 3’s “Current Treatment/ Medication/ DME List” did not include any treatment or medication for anxiety. During an interview on 9/10/2025 at 3:20 PM, with Patient 3’s care giver (CG 3), CG 3 stated Patient 3 feels short of breath even with small movements. CG 3 stated she requested for Patient 3 to have an oxygen concentrator (medical device that delivers oxygen rich air to a person who has difficulty breathing) from the last nurse visit (9/8/2025) and that the facility will be delivering Patient 3’s oxygen tomorrow (9/11/2025). During a review of Patient 3’s “Physician Order”, dated 9/10/2025, the “Physician Order” indicated Oxygen 5 liters via nasal canula (oxygen was ordered a month after Patient 3 was admitted). During a review of Patient 3’s “Visit Note”, dated 8/14/2025, 8/21/2025, 8/24/2025, 8/252025, 8/31/2025, 9/7/2025, 9/8/2025 and 9/10/2025, the “Visit Note” indicated Patient 3 has mild anxiety, shortness of breath with exertion, and diminished lung sounds. During a concurrent interview and record review on 9/11/2025 at 10:10 AM with the Director of Patient Care Services Designee (DPCS Designee), Patient 3’s “Plan of Care”, dated 9/11/2025 was reviewed. The PDCS Designee stated Patient 3 does not include a plan of care related to shortness of breath. The DPCS Designee stated plan of care should reflect concerns regarding patient such as shortness of breath. The DPCS Designee stated having oxygen concentrator at patient’s home is one of the interventions for shortness of breath. During an interview on 9/15/2025 at 10:20 AM with RN 5, RN 5 stated any concerns or change of condition should be addressed as soon as it was assessed by the nurse. RN 5 stated these interventions should be reflected on Patient 3’s Plan of Care. RN 5 stated Patient 3 should have a plan of care regarding shortness of breath and anxiety. RN 5 stated these concerns may not be addressed if they are not included in patient’s plan of care and may result in delay of care. 4. During a review of Patient 11’s “Personal Information,” the “Personal Information” indicated the HA admitted Patient 11, on 3/10/2025 with diagnosis that included hypertensive heart disease with heart failure (high blood pressure damaged the heart over time, making it unable to pump blood effectively causing shortness of breath, fatigue, and swelling in the legs), type 2 diabetes mellitus, and hyperlipidemia (elevated cholesterol level). During a review of Patient 11’s “Physician Order,” dated 4/3/2025, the “Physician Order” indicated the Medical Director (MD) entered an order for wound care evaluation and treatment on 4/3/2025. During a review of Patient 11’s “POC/IDG Review,” dated 4/11/2025, the “POC/IDG Review” did not indicate the creation and implementation of a plan of care for skin/ integumentary. The “POC/IDG Review” nursing discussion did not include a review of the referral for wound care evaluation and treatment entered on 4/3/2025. During a concurrent interview on 9/17/2025 at 10:55 AM with Registered Nurse 5 (RN 5), Patient 11’s “POC/IDG Review,” dated 3/14/2025 and 3/28/2025 were reviewed. RN 5 stated failure to create, update, and implement a POC for skin/ integumentary placed Patient 11 at increased risk of inadequate treatment and monitoring of wound progression. During a review of Patient 11’s “Discharge Summary,” dated 5/6/2025, the “Discharge Summary” indicated Patient 11 was discharged from the HA due to hospitalization. During a review of HA’s P&P, titled “The Plan of Care”, undated. The P&P indicated “the plan of care will be based on the initial, comprehensive and ongoing assessments performed by the members of the interdisciplinary group” … this plan will focus on identified problems, goals and interventions.” … “The plan of care will identify the patient’s needs and services to meet those needs, including management of pain, discomfort and symptom relief.””

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to:1. Ensure the Comfort Kit (set of medications intended for symptoms and pain management such as: morphine [treatment for pain], Ativan [medication for agitation and anxiety], Levsin [medication for excessive secretions], albuterol inhaler [medication for shortness of breath and/or wheezing], Zofran (medication for nausea and vomiting), and acetaminophen [medication for mild pain and/or fever]) was ordered and available for three of three sampled patients (Patient 1, Patient 2, and Patient 3) at home, as needed for the management of end of life symptoms, in accordance with the patients’ assessment and Interdisciplinary Group (IDG) discussion /review. 2. Ensure an oxygen concentrator (medical device that delivers rich air to a person who has difficulty breathing), via nasal canula (a thin flexible tube that wraps around the head and sits on the nose to deliver oxygen), was ordered and available for three of three sampled patients (Patient 1, Patient 2, and Patient 3) at home, as needed for shortness of breath (SOB, ), in accordance with the patients’ assessment and IDG discussion / review. As a result of the noncompliance described above, Patient 1, Patient 2, and Patient 3 to experience unmanaged pain, severe pain or distress, agitation, emergency hospitalization, exposure to unsafe environments, and potentially experience an undignified and avoidable traumatic death. On 9/16/2025, at 9:57 AM, the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient), in the presence of the agency’s Chief Financial Officer (CFO) and Registered Nurse Case Manager (RN 5), related to the hospice agency failure to demonstrate a process and provide documented evidence that the facility ensure the care and services provided for Patient 1, Patient 2, and Patient 3 are based on assessments of the patient and family needs, by failing to ensure the Comfort Kit were ordered, available, and ready for use, and to ensure an oxygen concentrator ready to use, at home, as needed for shortness of breath (SOB). On 9/17/2025, at 3:30 PM, the survey team completed the survey tasks and conducted an exit conference in the presence of the agency’s CFO, with the Director of Patient Care Services (DPCS) Designee and RN 5 via telephone with the IJ situations not removed. On 9/23/2025 at 12:51 PM, the agency provided an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The IJ removal plan was accepted. Findings:A. During a review of Patient 1’s “Personal Information,” (containing a summary of basic patient information), the “Personal Information” indicated the hospice agency admitted Patient 1 on 8/15/2025 with diagnosis that included atherosclerosis heart disease (plaque buildup in the heart’s arteries), SOB, and dependance on supplemental oxygen (a condition requiring the use of a device to deliver extra oxygen).During a joint home visit observation on 9/10/2025 at 9:23 AM, with Registered Nurse 3 (RN 3) at Patient 1’s home, Patient 1 was lying on the couch and stated she felt nauseous and had a pain level of nine (out of 10, on the 0-10 pain scale, 0 indicating the absence of pain and 10 representing the worst pain imaginable) in her stomach and lower back. During an observation and interview on 9/10/2025 at 9:23 AM, with Patient 1’s Caregiver 1 (CG 1), CG1 stated Patient 1 did not have in-home oxygen provided by the HA available for use.During an interview and record review on 9/10/2025 at 9:23 AM, of Patient 1’s “Current Treatment/ Medication/ DME List,” undated was reviewed. The “Current Treatment/ Medication/ DME List”, did not include the Comfort Kit: morphine sulfate, Zofran, Levsin, acetaminophen, Ativan, bisacodyl, ipratropium. CG 1 stated Patient 1 did not have the Comfort Kit. During a review of Patient 1’s “Comprehensive Nursing Assessment,” dated 8/15/2025, the “Comprehensive Nursing Assessment” indicated Patient 1 was assessed with moderate shortness of breath with moderate exertion, diminished breath sounds bilaterally, wheezing, “chest wall asymmetry noted; unequal rise”, and “O2 [oxygen] PRN [as needed] per protocol.” During a review of Patient 1’s “Visit Note,” dated 9/10/2025, 9/3/2025, 8/29/2025, 8/27/2025, and 8/20/205, the Visit Notes indicated Patient 1 experienced heavy breathing and mild to moderate abnormal lung sounds. During a review of Patient 1’s “Physician Orders” on 9/11/2025 at 9 AM, the orders did not include oxygen nor Comfort Kit. During a review of Patient 1’s “POC/IDG Review,” dated 8/29/2025, the IDG Review indicated “Nursing: Mild SOB persists with activity. Lung sounds remain diminished on SN [skilled nurse] assessments.” The IDG Review indicated “Other/ Physician: Assess, monitor, and control end of life symptoms with medications. [...] Provide symptoms management, pain control and comfort measures.” During an interview on 9/11/2025 at 10:07 AM., with the Director of Patient Care Services Designee (DPCS Designee), the DPCS Designee stated the Comfort Kit should be ordered upon admission for all patients. The DPCS Designee stated the Comfort Kit should be readily available in the patient’s home to use during emergencies. During an interview on 9/11/2025 at 10:07 AM., with the DPCS Designee, the DPCS Designee stated Patient 1 required oxygen because of her diagnosis of dependence on supplemental oxygen. The DPCS designee stated Patient 1’s admitting nurse should have reported Patient 1’s symptoms of SOB and diminished lung sound to the DPCS and the Medical Director (MD). The DPCS Designee stated failure to provide oxygen, if needed, could potentially result in Patient 1 experiencing respiratory distress (a severe medical condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide, or both) and other life-threatening emergencies. During an interview on 9/11/2025 at 2:20 PM., with the MD, the MD stated nurses should report SOB and diminished lung sounds so that he [MD] could order appropriate treatment. The MD stated the “POC/ IDG Review” that indicated “Other/ Physician: Assess, monitor, and control end of life symptoms with medications,” the MD stated this treatment plan included the patient’s use of Comfort Kit medications and if the Comfort Kit was not needed it would reflect on the POC/ IDG Review. B. During a review of Patient 2’s “Personal Information”, undated, the “Personal Information” indicated the hospice agency admitted Patient 2, on 8/6/2025, with diagnoses including, but not limited to, atherosclerosis heart disease, anxiety disorder (excessive and persistent worry, fear, and unease), and shortness of breath. During a joint home visit observation and interview on 9/10/2025 at 1 PM, with RN 4, at Patient 2’s home, Patient 2 did not have an oxygen tank at home to use if needed. During a review of Patient 2’s “Current Treatment/ Medication/ DME List”, dated 9/9/2025, the “Current Treatment/ Medication/ DME List” indicated the following Comfort Kit medications were not ordered: morphine sulfate, Zofran, Levsin, acetaminophen, Ativan, bisacodyl, ipratropium, and oxygen.During concurrent observation and interview on 9/9/2025 at 1:20 PM with Patient 2’s Care Giver (CG 2) in Patient 2’s home, no Comfort Kit medications were observed on the table with Patient 2’s medications. CG2 stated, the medications on the table are all her [Patient 2’s] medications. We have not received a Comfort Kit.During an interview on 9/10/2025 at 1:10 PM, with CG 2, CG 2 stated Patient 2 has had shortness of breath since she was admitted to hospice and that she [CG 2] was told the oxygen would be delivered today (9/10/2025). During a review of Patient 2’s “Comprehensive Nursing Assessment” dated 8/6/2025, the “Comprehensive Nursing Assessment” indicated Patient 2’s assessment included diminished lung sounds. During a review of Patient 2’s “Visit Notes”, dated 8/19/2025, 8/20/2025, 8/26/2025, 9/2/2025, and 9/3/2025, the “Visit Notes” indicated Patient 2 had mild to moderate SOB on exertion and mild abnormal to diminished lung sounds on bilateral lobes. During a review of Patient 2’s “POC/IDG Review,” dated 8/15/2025 and 8/29/2025, the “POC/IDG Review” indicated “Nursing: Continues to be observed with moderate SOB with mild exertion. Lung sounds remain diminished on SN [skilled nurse] visits.” The IDG Review indicated “Other/ Physician: Assess, monitor, and control end of life symptoms with medications. [...] Provide symptoms management, pain control and comfort measures.” During a review of Patient 2’s “Physician Orders,” dated 9/10/2025, indicated Oxygen 5L via nasal canula (oxygen was ordered a month after Patient 2 was admitted). The order did not include “Comfort Kit.” During an interview on 9/11/2025 at 10:07 AM., with the DPCS Designee, the DPCS Designee stated the Comfort Kit should be ordered upon admission for all patients and should be available for patients to use in case of emergencies. During an interview on 9/11/2025 at 2:20 PM., with the MD, the MD stated nurses should report SOB and diminished lung sounds so that he [MD] could order appropriate treatment. The MD stated the “POC/ IDG Review” that indicated “Other/ Physician: Assess, monitor, and control end of life symptoms with medications,” the MD stated this treatment plan included the patient’s use of Comfort Kit medications and if the Comfort Kit was not needed it would reflect on the POC/ IDG Review. C. During a review of Patient 3’s “Personal Information”, undated, the “Personal Information” indicated the hospice agency admitted Patient 3, on 8/11/2025, with diagnoses including, but not limited to, heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), shortness of breath, and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance (patterns of behaviors, thoughts and moods that are considered unusual for a person’s age and context). During a joint home visit on Patient 3’s home visit with Medical Social Worker (MSW, a person to provide support to patients and families) on 9/10/2025 at 3:20 PM, a medication reconciliation (a process on comparing patient’s current medication against medication ordered by the physician) was conducted. Patient 3’s “Current Treatment/ Medication/ DME List” did not include the “Comfort Kit”: morphine sulfate, Zofran, Levsin, acetaminophen, Ativan, and bisacodyl. Patient 3 did not have the “Comfort Kit”. During an interview on 9/10/2025 at 3:20 PM, with Patient 3’s care giver (CG 3), CG 3 stated Patient 3 feels short of breath even with small movements. CG 3 stated she requested for Patient 3 to have an oxygen concentrator (medical device that delivers rich air to a person who has difficulty breathing) from the last nurse visit (9/8/2025) and that the facility will be delivering Patient 3’s oxygen tomorrow (9/11/2025). During a review of Patient 3’s “Comprehensive Nursing Assessment”, dated 8/11/2025, the “Comprehensive Nursing Assessment” indicated Patient 3 has mild anxiety, has shortness of breath with moderate exertion and diminished lung sounds. During a review of Patient 3’s “Visit Note”, dated 8/14/2025, 8/21/2025, 8/24/2025, 8/252025, 8/31/2025, 9/7/2025, 9/8/2025 and 9/10/2025, the “Visit Note” indicated Patient 3 has mild anxiety, shortness of breath with exertion, and diminished lung sounds. During a review of Patient 3’s “Physician Order”, dated 9/10/2025, the “Physician Order” indicated Oxygen 5 liters via nasal canula (oxygen was ordered a month after Patient 3 was admitted). The order did not include “Comfort Kit”. During a review of Patient 3’s “POC/IDG Review”, dated 8/29/2025, the “POC/IDG Review” under IDG Discussion/Updated Comprehensive Assessment Review of Physician indicated plan to assess and control end-of-life symptoms with medications. During a concurrent interview and record review on 9/11/2025 at 2:20 PM with the MD. the “POC/IDG Review”, dated 8/29/2025 was reviewed. The MD stated the “POC/ IDG Review” that indicated “Other/ Physician: Assess, monitor, and control end of life symptoms with medications,” this treatment plan included the patient’s use of Comfort Kit medications and if the Comfort Kit was not needed it would reflect on the POC/ IDG Review. During an interview on 9/15/2025 at 10:20 AM with RN 5, RN 5 stated the DPCS was the one attending the IDG meeting and reports on the hospice patients’ nursing care and needs. RN 5 stated the visiting nurses would report nursing updates, patient condition and patient needs/concerns to the DPCS, and the DPCS will collaborate with the MD for any treatments and services to provide on the patient based on nurse’s report during the IDG meeting. RN 5 stated the DPCS will coordinate the updates and changes regarding patient care and treatments to the healthcare team for implementation. During an interview on 9/15/2025 at 10:20 AM with RN 5, RN 5 stated any concerns or change of condition should be addressed as soon as it was assessed by the nurse. RN 5 stated interventions for anxiety can include non-pharmacological techniques and medications. RN 5 stated these interventions should be reflected on Patient 3’s Plan of care and should be discussed in the IDG meeting. RN 5 stated when the physician indicated Comfort Kits on his notes, the nurse should place an order of Comfort Kit for the patient. During a review of the facility’s policies and procedures (P&P) titled, “Comfort Kit for the Imminently Dying Patient,” undated, the P&P indicated, “It is the policy of AAA Hospice Care Inc to provide timely symptom management for patients who are imminently dying by ensuring access to a pre-approved Comfort Kit…The Comfort Kit is intended to address urgent and distressing symptoms such as pain, agitation, dyspnea, nausea, secretions, or anxiety, and to prevent unnecessary suffering or emergency room transfers at the end of life. The Comfort Kit will be dispensed, stored, and administered in compliance with federal, state, and local regulations, as well as hospice standards of practice.” During a review of the facility’s P&P titled, “The Plan of Care,” undated, the P&P indicated the following: - “The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care…” - “The Case Manager (or admitting registered nurse) will then notify the attending physician and a core member of the interdisciplinary group of the initial assessment findings, the identification of patient needs and the recommended services to meet those needs. The plan of care will be reviewed prior to care being delivered.” - “Orders for the start of care will be verbally received by the Case Manager (or hospice registered nurse) from the attending physician (or other authorized independent practitioner) and documented on the plan of care/physician order form.” - “The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief..””

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the ongoing sharing of information with non-hospice healthcare providers furnishing services for two of two sampled Patients (Patient 1 and Patient 11) by: Failing to ensure documentation of communications with the Primary Care Physician (PCP) related to a change in dose for Mounjaro (tirzepatide, an injectable prescription drug used to treat type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing)) in the medical record for Patient 1. Failing to ensure services provided during wound care referral were documented in the medical record for Patient 11.Failing to ensure the results of the wound culture were documented in the medical record for Patient 11. These failures had the potential to place Patient 1 at risk for medication administration errors, increased side effects, uncontrolled blood glucose, and compromised safety, and Patient 11 at risk for inadequate treatment, worsening medical conditions, insufficient symptom management, and avoidable hospitalization. Findings: During a review of Patient 1’s “Personal Information,” (page of the medical chart containing a summary of basic patient information) undated, the “Personal Information” indicated the HA admitted Patient 1, a 73-year-old female, on 8/15/2025 with diagnosis that included atherosclerosis heart disease (plaque buildup in the heart’s arteries), shortness of breath (SOB, a subjective sensation of not being able to get enough air, often accompanied by feelings of tightness in the chest, rapid breathing, and wheezing [a high-pitched, whistling sound that occurs when air flows through narrowed airways]), and dependance on supplemental oxygen (a condition requiring the use of a device to deliver extra oxygen). During a review of Patient 11’s “Personal Information,” undated, the “Personal Information” indicated the HA admitted Patient 11 on 3/9/2025 with diagnosis that included hypertensive heart disease with heart failure (high blood pressure damaged the heart over time, making it unable to pump blood effectively causing shortness of breath, fatigue, and swelling in the legs), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (elevated cholesterol level). 1. During a review of Patient 1’s “Current Treatment/ Medication/ DME List,” undated, the “Current Treatment/ Medication/ DME List” indicated Mounjaro 5 milligrams (mg, unit of measurement) subcutaneous injection once a week for type 2 diabetes mellitus.During a home visit observation on 9/10/2025 at 9:32 AM, Patient 1’s medications included Mounjaro 7.5 mg/ 0.5 milliliters (mL, unit of measurement) injection pen. During an interview on 9/11/2025 at 2:20 PM, with the Medical Director (MD), the MD stated he does not collaborate with other physicians to develop HA patient’s treatment plans. During a concurrent interview and record review on 9/17/2025 at 11:29 AM, with Registered Nurse 5 (RN 5), Patient 1’s “Patient Consent for Primary Care Physician (consent form),” dated 8/15/2025 was reviewed. The consent form indicated Patient 1 elected to continue care with her PCP. RN 5 stated that when a patient elects to continue care with their PCP, the HA must fax the consent form to the Patient’s PCP and request continued communication including medical visits, updates, and changes in treatment or medication. During an interview on 9/17/2025 at 11:37 AM with RN 5 stated there was no documented evidence in Patient 1’s medical record to indicate the consent form was faxed to Patient 1’s PCP. RN 5 stated there was no documented evidence in Patient 1’s medical record to indicate the HA communicated with Patient 1’s PCP regarding a change in dose for Mounjaro from 5 mg to 7.5 mg. RN 5 stated failure to maintain communication with the PCP placed Patient 1 at risk of medication administration errors, drug-to-drug interactions, and increased side effects including constipation, nausea, vomiting, headache, and fatigue. During a review of the facility’s policy and procedure (P&P) titled, “Policy & Procedure: Ordering Medications and Supplies,” dated 12/19/2024, the P&P indicated the following:· “All orders, including drafts and finalized versions, must be documented in the patient’s clinical record.”· “The DPCS [Director of Patient Care Services] is responsible for ensuring that orders are accurate, clinically appropriate, and compliant with regulations.”· DPCS coordinates with physicians, ensures documentation and oversees the process. During a review of the facility’s P&P titled, “Interdisciplinary Group Membership and Responsibilities,” undated, the P&P indicated, “The interdisciplinary group [IDG] will collaborate with the patient’s attending physician to develop an individualized written plan of care. The P&P indicated the IDG is responsible for the provision and/or supervision and coordination of hospice care and services. 2. During a review of Patient 11’s “Physician Order,” dated 4/3/2025, the “Physician Order” indicated on 4/3/2025 the Medical Director (MD) entered an order for wound care evaluation and treatment. During a concurrent interview and record review on 9/16/2025 at 10:55 AM with RN 5, Patient 11’s electronic medical record (EMR) was reviewed. The EMR did not contain documentation of wound care services furnished by the HA’s wound care service provider. RN 5 stated notes from the wound care specialist should be uploaded into the EMR and stated Patient 11’s EMR did not contain documentation of wound care referral visits. RN 5 stated the HA is required to obtain records from healthcare providers furnishing services to the HA’s patients. During a concurrent interview and record review on 9/16/2025 at 11:38 AM with RN 5, Patient 11’s electronic medical record (EMR) was reviewed. The EMR did not contain documentation of refusal of wound care services. RN 5 stated Patient 11’s EMR did not contain documented evidence to indicate he refused care with the HA’s wound care service provider. During an interview on 9/17/2025 at 10:40 AM with RN 5, RN 5 stated Patient 11’s medical record did not include documented evidence to suggest the physician’s order dated 4/3/2025 for referral of wound care services was completed. RN 5 stated she would contact the HA’s wound care service provider and request documentation of any visits.During a review of Patient 11’s “Progress Note Details (progress note)” dated 3/10/2025, the “progress note” indicated the initial home visit for wound care referral was attempted on 3/10/2025. The HA was unable to provide documentation of wound care referral for evaluation and treatment dated on or after 4/3/2025, when the physician order was entered. During a review of the facility’s P&P titled, “Policy: Submission of Notes,” dated 1/8/2025, the P&P indicated, “All notes must be submitted to the agency office no later than 72 hours from the date of the visit […] The medical records department will review, process, and file the submitted notes into the patient’s medical record.”During a review of the facility’s P&P titled, “Policy & Procedure: Referrals and Logs,” undated, the P&P indicated the following:· Each referral entry must include the status of the referral and the outcome. · The Referral Log must be reviewed weekly by the Administrator/ Director of Nursing and any delays or missed follow-ups must be investigated. 3. During a review of Patient 11’s “Current Treatment/ Medication/ DME List,” undated, the “Current Treatment/ Medication/ DME List” indicated on 4/21/2025 a laboratory order for wound culture was entered. During a review of Patient 11’s EMR, the EMR did not contain documentation of wound culture collection or results. During an interview on 9/16/2025 at 12:40 PM with RN 5, RN 5 stated she would attempt to obtain Patient 11’s wound culture results from the HA’s laboratory service provider. During an interview on 9/17/2025 at 1:40 PM with RN 5, RN 5 stated the HA had not obtained wound care culture results from the laboratory service provider. RN 5 stated Patient 11’s medical record did not indicate the HA received and reviewed the wound culture results. RN 5 stated failure to communicate with the laboratory service provider placed Patient 11 at risk of delayed or inappropriate treatment and increased complications. During a review of the facility’s P&P titled, “Policy: Submission of Notes,” dated 1/8/2025, the P&P indicated, “All notes must be submitted to the agency office no later than 72 hours from the date of the visit […] The medical records department will review, process, and file the submitted notes into the patient’s medical record.”During a review of the facility’s P&P titled, “Policy & Procedure: Referrals and Logs,” undated, the P&P indicated the following:· Each referral entry must include the status of the referral and the outcome. · The Referral Log must be reviewed weekly by the Administrator/ Director of Nursing and any delays or missed follow-ups must be investigated.”

“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 provide evidence that the Performance Improvement Program (PIP, a data driven approach to improve the quality of care and services provided to patients) has measurable improvement related to palliative (a form of medical care focuses on providing comfort and support to patients with serious or life-threatening illness) outcomes and hospice services. This failure had the potential for patients to receive inconsistent symptom management, safety concerns and poor quality of life. Findings:During a concurrent interview and record review on 9/17/2025 at 2:15 PM with Registered Nurse Case Manager (RN 5), HA’s “Performance Improvement Plans / Projects for 2025-2026”, undated was reviewed. RN 5 stated the PIP risk focus is on hand washing, medication management and personal care for patients with dementia (a progressive state of decline in mental abilities). RN 5 stated the PIP is led by the Director of Patient Care Services (DPCS) and acts as the Quality Assurance Nurse.During an interview on 9/17/2025 at 2:40 PM with RN 5, RN 5 stated she usually attends the PIP meeting, but she is not familiar with the current PIP in place. RN 5 stated there were no available staff to answer questions regarding the PIP for 2025.During a concurrent interview and review on 9/17/2025 at 2:40 PM with RN 5. The HA’s “Performance Improvement Project (PIP) for 2025”, dated 3/21/2025 was reviewed. The PIP indicated for the first quarter (January 2025 – March 2025) of the quality assessment and performance project focuses on hand washing, bathing and personal care for patients with dementia. RN5 was unable to provide evidence that the PIP improved the palliative outcome, or the services HA provides.During a concurrent interview and review on 9/17/2025 at 2:45 PM with RN 5. The HA’s “Performance Improvement Project (PIP) for 2025”, dated 6/20/2025 was reviewed. The PIP indicated for the second quarter (April 2025 – June 2025) of the quality assessment and performance project focuses on developing a plan and conducting emergency preparedness evacuation drills for hospice patients. R RN5 was unable to provide evidence that the PIP improved the palliative outcome, or the services HA provides.During a review of HA’s policy and procedures (P&P) titled “Reducing Risk of Infection: Hand Hygiene, HA Service Performance Improvement Project”, undated. The P&P indicated “The program involves all hospice services, focus on indicators related to improved palliative outcomes and takes action to improve hospice performances” … “the PIP sustains an improvement in the quality of care by measuring previous review assessment” … “the hospice documents the measurable progress achieved on PIP in quarterly QAPI report. The evaluation process demonstrates effectiveness by assessing the established standards are met and palliative outcomes improved.””

“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 provide evidence that the Performance Improvement Plans (PIP, a data driven approach to improve the quality of care and services provided to patients) was designed based on patient care assessments and the services HA provides. This failure had the potential for patients to receive inconsistent symptom management, safety concerns and poor quality of life. Findings:During a concurrent interview and record review on 9/17/2025 at 2:15 PM with Registered Nurse Case Manager (RN 5), the HA’s “Performance Improvement Plans / Projects for 2025-2026”, undated was reviewed. RN 5 stated the PIP risk focus is on hand washing, medication management and personal care for patients with dementia (a progressive state of decline in mental abilities). RN 5 stated the PIP is led by the Director of Patient Care Services (DPCS) and acts as the Quality Assurance Nurse. RN 5 stated the risk focus should be based on gathered data evidence related to patient care and services provided. RN 5 stated medication management was included as a risk focus due to medication errors from the previous year (2024). RN 5 was unable to provide documented evidence why handwashing and personal care for dementia patients are the current risk focus for PIP related to the services the HA provides.During a review of facility’s “Medication Error” log, dated 2024-2025. The “Medication Error” log indicated there were no medication error from January 2024 to August 2025.During a review of HA’s “Performance Improvement Project (PIP) for 2024”, dated 12/18/2024. The PIP indicated 50 percent (%) of the patients admitted to the HA were diagnosed with heart disease (conditions affecting the heart or blood vessels), 18 % were diagnosed with autoimmune disease (conditions that the body mistakenly attacks its own healthy tissue and organ) and 12 % were diagnosed with respiratory disease (illness that affects the lungs and airways).During an interview on 9/17/2025 at 2:40 PM with RN 5, RN 5 stated she usually attends the PIP meeting, but she is not familiar with the current PIP in place and the reason why it was selected as the current focus for this year. RN 5 stated there were no available staff to answer questions regarding the PIP for 2025.During a review of HA’s policy and procedures (P&P) titled “Reducing Risk of Infection: Hand Hygiene, HA Service Performance Improvement Project”, undated. The P&P indicated “The hospice agency maintains an effective, ongoing hospice-wide data-driven quality assessment and performance improvement program” … “the program involves all hospice services, focus on indicators related to improved palliative outcomes and takes action to improve hospice performances.””

“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 provide evidence that data were collected to identify opportunities and priorities of improvement and monitor the effectiveness of the Performance Improvement Program (PIP, a data driven approach to improve the quality of care and services provided to patients). This failure had the potential for patients to receive inconsistent symptom management, safety concerns and poor quality of life. Findings:During a concurrent interview and record review on 9/17/2025 at 2:15 PM with Registered Nurse Case Manager (RN 5), HA’s “Performance Improvement Plans / Projects for 2025-2026”, undated was reviewed. RN 5 stated the PIP risk focus is on handwashing, medication management and personal care for patients with dementia (a progressive state of decline in mental abilities). RN 5 stated the PIP is led by the Director of Patient Care Services (DPCS) and acts as the Quality Assurance Nurse. RN 5 stated the risk focus should be based on gathered data evidence related to patient care and services provided. RN 5 was unable to provide documented evidence why handwashing and personal care for dementia patients are the current risk focus for PIP related to the services the HA provides.During a review of facility’s “Medication Error” log, dated 2024-2025. The “Medication Error” log indicated there were no medication error from January 2024 to August 2025.During an interview on 9/17/2025 at 2:40 PM with RN 5, RN 5 stated she usually attends the PIP meeting, but she is not familiar with the current PIP in place and the reason why it was selected as the current focus for this year. RN 5 stated there were no available staff to answer questions regarding the PIP for 2025.During a concurrent interview and review on 9/17/2025 at 2:45 PM with RN 5. The HA’s “Performance Improvement Project (PIP) for 2025”, dated 3/21/2025 was reviewed. The PIP indicated for the first quarter (January 2025 – March 2025) of the quality assessment and performance project focuses on handwashing and personal care for patients with dementia. The PIP indicated that the project resulted in staff demonstrating improved adherence to hand hygiene and more consistent dementia appropriate care. RN 5 was unable to provide data collected evidence that the staff demonstrated improved adherence to hand hygiene and more consistent dementia appropriate care and how the program improved the hospice services provided to patients.During a review of HA’s “Performance Improvement Project (PIP) for 2024”, dated 12/18/2024. The PIP indicated 50 percent (%) of the patients admitted to the HA were diagnosed of heart disease, 18 % were diagnosed with autoimmune disease and 12 % were diagnosed with respiratory disease.During a concurrent interview and review on 9/17/2025 at 2:45 PM with the Chief Financial Officer (CFO). The HA’s “Performance Improvement Project (PIP) for 2025”, dated 6/20/2025 was reviewed. The PIP indicated for the second quarter (April 2025 – June 2025) of the quality assessment and performance project focuses on developing a plan and conducting emergency preparedness evacuation drills for hospice patients. The PIP indicated the project resulted in “Staff demonstrated improved response times, stronger knowledge on of evacuation protocols, and greater confidence in executing preparedness procedures”. The CFO stated the project was selected due to the recent incident in the Loas Angeles county fire early this year. The CFO was unable to provide data collected evidence that demonstrated staff’s improvement with response time and stronger knowledge on evacuation protocol and how the program improved the hospice services provided to patients.During a review of HA’s policy and procedures (P&P) titled “Reducing Risk of Infection: Hand Hygiene, HA Service Performance Improvement Project”, undated. The P&P indicated the following:1. “The hospice agency maintains an effective, ongoing hospice-wide data-driven quality assessment and performance improvement program”2. “The program involves all hospice services, focus on indicators related to improved palliative outcomes and takes action to improve hospice performances.”3. “The hospice documents the measurable progress achieved on PIP in the quarterly report.”4. “The evaluation process demonstrates effectiveness by assessing the established standards are met and palliative outcomes are improved.””

“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 provide documented evidence of the Performance Improvement Program’s (PIP, a data driven approach to improve the quality of care and services provided to patients) being conducted and the progress achieved. This failure had the potential for patients to receive inconsistent symptom management, safety concerns and poor quality of life. Findings:During a record review the HA’s “Performance Improvement Plans / Projects for 2025-2026”, undated was reviewed. The PIP indicated that the risk focus is on hand washing and medication management. The PIP indicated the “Hand Hygiene Audit tool” and “Chart Review and Medication Management Audit Tool” will be used in conducting the PIP.During a concurrent interview and review on 9/17/2025 at 2:45 PM with RN 5. The HA’s “Performance Improvement Project (PIP) for 2025”, dated 3/21/2025 was reviewed. The PIP indicated for the first quarter (January 2025 – March 2025) of the quality assessment and performance project focuses on handwashing and personal care for patients with dementia (a progressive state of decline in mental abilities). The PIP indicated that the project resulted in staff demonstrating improved adherence to hand hygiene and more consistent dementia appropriate care. RN 5 was unable to provide evidence that the staff demonstrated improved adherence to hand hygiene and more consistent dementia appropriate care and how the program improved the hospice services provided to patients. RN 5 was unable to provide evidence that “Hand Hygiene Audit tool” were used for this quarter.During a concurrent interview and review on 9/17/2025 at 2:45 PM with the Chief Financial Officer (CFO). The HA’s “Performance Improvement Project (PIP) for 2025”, dated 6/20/2025 was reviewed. The PIP indicated for the second quarter (April 2025 – June 2025) of the quality assessment and performance project focuses on developing a plan and conducting emergency preparedness evacuation drills for hospice patients. The PIP indicated the project resulted in “Staff demonstrated improved response times, stronger knowledge on of evacuation protocols, and greater confidence in executing preparedness procedures”. The CFO was unable to provide evidence that the staff demonstrated improvement with response time and stronger knowledge of evacuation protocol and how the program improved the hospice services provided to patients.During a review of HA’s policy and procedures (P&P) titled “Reducing Risk of Infection: Hand Hygiene, HA Service Performance Improvement Project”, undated. The P&P indicated the following:1. “The hospice agency maintains an effective, ongoing hospice-wide data-driven quality assessment and performance improvement program”2. “The program involves all hospice services, focus on indicators related to improved palliative outcomes and takes action to improve hospice performances.”3. “The hospice documents the measurable progress achieved on PIP in the quarterly report.”4. “The evaluation process demonstrates effectiveness by assessing the established standards are met and palliative outcomes are improved.””

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed:1. To ensure the physician’s orders of oxygen and Comfort Kit (set of medications intended for symptoms and pain management such as: Morphine (treatment for pain), Ativan (treatment for agitation and anxiety), Levsin (treatment for excessive secretions), albuterol inhaler (treatment for shortness of breath and/or wheezing), Zofran (treatment for nausea and vomiting), and Tylenol (treatment for mild pain and/or fever)) for 17 of 17 sampled patients (Patient 1, Patient 2, Patient 3, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, and Patient 28) were accurately entered to reflect the actual date of physician’s order of the oxygen and Comfort Kit, and in accordance to the facility’s policy and procedure. 2. To ensure Licensed Vocational Nurse 3 (LVN 3) did not back date and entered the discharged summary notes and plan of care for the three of five sampled discharged patients’ (Patient 12, Patient 13, and Patient 14) medical records.These failures resulted in actual and potential harm for:1. Patient 1, Patient 2, Patient 3, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, and Patient 28 to have inappropriate and inaccurate medication and treatment orders; unsafe patient care; increased the risk for hospice patients to suffer from unmanaged pain, distress, agitation; and increased the risk for emergency hospitalization and avoidable traumatic and/or undignified death.2. Patient 12, Patient 13, and Patient 14’s medical record not accurately reflecting the care provided and increased the risk for patient safety and compromised care. On 9/12/2025, at 4:38 PM., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient), in the presence of the agency’s Chief Financial Officer (CFO) present in person and Director of Patient Care Services Designee (DPCSD) via telephone, related to failing to demonstrate a process and provide documented evidence that the agency ensured the physician’s orders for oxygen and Comfort Kit were accurately entered to reflect the actual date of physician’s order of the oxygen and Comfort Kit orders for 17 of 17 sampled patients (Patient 1, Patient 2, Patient 3, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, and Patient 28). On 9/16/2025, at 6:52 PM, the Department called an IJ addendum, the IJ addendum was with the CFO and Registered Nurse Case Manager 5 (RN 5) present in person for failing to demonstrate a process and provide documented evidence that the facility ensured LVN 3 entered the actual date the discharge summary and plan of care was created for three of five sampled discharged patient’s (Patient 12, Patient 13, and Patient 14) medical records. On 9/17/2025, at 3:30 PM, the survey team completed the survey tasks and conducted an exit conference while onsite in the presence of the CFO, and DPCS Designee and RN 5 via telephone with the IJ situations not removed. On 9/17/2025 at 3:42 PM, the HA was unable to submit an acceptable IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The IJ removal plan was not accepted. Findings:During a review of Patient 1’s “Personal Information,” (containing a summary of basic patient information) undated, the “Personal Information” indicated the hospice agency (HA) admitted Patient 1, on 8/15/2025 with diagnosis that included atherosclerosis heart disease (plaque buildup in the heart’s arteries), shortness of breath (SOB), and dependance on supplemental oxygen (a condition requiring the use of a device to deliver extra oxygen).During a review of Patient 2’s “Personal Information”, the “Personal Information” indicated Patient 2, admitted on 8/6/2025, with diagnoses including, but not limited to, atherosclerosis heart disease, anxiety disorder (excessive and persistent worry, fear, and unease), and shortness of breath.During a review of Patient 3’s “Personal Information”, the “Personal Information” indicated Patient 3, was admitted on 8/11/2025 with diagnoses including, but not limited to, heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), shortness of breath, and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance (patterns of behaviors, thoughts and moods that are considered unusual for a person’s age and context). During a review of Patient 12’s “Personal Information,” the “Personal Information” indicated Patient 12, was admitted on 7/17/2025, with diagnoses including hypertensive heart disease with heart failure (high blood pressure damaged the heart over time, making it unable to pump blood effectively), acute respiratory failure with hypoxia (a sudden condition where the lungs cannot get enough oxygen into the blood for the body’s organs to function), and chronic kidney disease (a condition where the kidneys are damaged and cannot filter waste and extra fluid from the blood effectively, leading to a buildup of toxins in the body) . Patient 12’s end of care date was 8/17/2025 due to hospitalization.During review of Patient 13’s “Personal Information”, undated, the “Personal Information” indicated Patient 13, admitted on 3/12/2025 with diagnoses including, but not limited to, dementia (a group of brain disorders that cause a gradual decline in cognitive abilities, including memory, thinking, language, and problem-solving), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and shortness of breath. Patient 13 expired and was discharged from hospice on 4/16/2025. During a review of Patient 14’s “Personal Information”, the “Personal Information” indicated Patient 14, was admitted on 3/8/2025, with diagnoses including, but not limited to, malignant neoplasm of cervix uteri, unspecified (cervical cancer that develops in the lower part of the uterus), shortness of breath, and dependence on supplemental oxygen.During a review of Patient 15’s “Personal Information”, the “Personal Information” indicated Patient 15, was admitted on 4/4/2025, with diagnoses including, but not limited to, atherosclerosis heart disease, and essential hypertension (high blood pressure).During a review of Patient 16’s “Personal Information”, the “Personal Information” indicated Patient 16, was admitted on 4/19/2025, with diagnoses including, but not limited to, atherosclerosis heart disease, and essential hypertension.During a review of Patient 17’s “Personal Information”, the “Personal Information” indicated Patient 17 was admitted on 4/24/2025, with diagnoses including, but not limited to, atherosclerosis heart disease, constipation (common digestive condition characterized by infrequent or difficult bowel movements), and weakness (generalized weakness with no precise underlying cause).During a review of Patient 18’s “Personal Information”, the “Personal Information” indicated Patient 18, admitted on 5/6/2025, with diagnoses including, but not limited to, atherosclerosis heart disease, shortness of breath, and essential hypertension.During a review of Patient 19’s “Personal Information”, the “Personal Information” indicated Patient 19, was admitted on 5/7/2025, with diagnoses including, but not limited to, atherosclerosis heart disease, shortness of breath, and essential hypertension.During a review of Patient 20’s “Personal Information,” the “Personal Information” indicated Patient 20 was admitted on 5/24/2025 with diagnoses including heart failure and shortness of breath.During a review of Patient 21’s “Personal Information,” the “Personal Information” indicated the hospice agency admitted Patient 21 on 6/3/2025 with diagnoses including heart failure and anxiety disorder.During a review of Patient 22’s “Personal Information,” the “Personal Information” indicated Patient 22, was admitted on 6/5/2025 with diagnoses including heart disease, shortness of breath, and dependance on supplemental oxygen.During a review of Patient 23’s “Personal Information,” the “Personal Information” indicated Patient 23 was admitted on 6/13/2025 with diagnoses including atherosclerosis heart disease and anxiety disorder.During a review of Patient 24’s “Personal Information,” the “Personal Information” indicated Patient 24, was admitted on 6/13/2025 with diagnoses including chronic systolic heart failure (a long-term condition where the heart’s main pumping chamber is too weak to squeeze forcefully enough to pump sufficient blood to the body) and dementia.During review of Patient 25’s “Personal Information”, the “Personal Information” indicated the hospice agency admitted Patient 25, on 6/23/2025 with diagnoses including, but not limited to, heart failure, diabetes mellitus and respiratory failure (a condition where the lungs are unable to exchange oxygen and carbon dioxide adequately) with hypoxia (a condition where there is an inadequate supply of oxygen to the body).During review of Patient 26’s “Personal Information”, the “Personal Information” indicated the hospice agency admitted Patient 26, on 6/23/2025 with diagnoses including, but not limited to, heart failure, anxiety and hypertension.During review of Patient 27’s “Personal Information”, the “Personal Information” indicated the hospice agency admitted Patient 27, on 7/7/2025 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), essential hypertension, and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).During review of Patient 28’s “Personal Information”, the “Personal Information” indicated the hospice agency admitted Patient 28, on 3/25/2025 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and shortness of breath.1. During a concurrent interview and record review on 9/10/2025 at 9:23 AM, Patient 1’s “Current Treatment/ Medication/ DME List,” undated, was reviewed along side Caregiver 1 (CG1- Patient 1’s care giver). The “Current Treatment/ Medication/ DME List” for Patient 1 did not include the Comfort Kit: morphine sulfate, Zofran, Levsin, acetaminophen, Ativan, bisacodyl, ipratropium. Patient 1’s Caregiver 1 (CG 1) stated that Patient 1 did not have the Comfort Kit. During a review of Patient 1’s “Visit Note LVN,” dated 9/10/2025, the “Visit Note LVN” indicated Patient 1 had heavy breathing and mild abnormal lung sounds. During a review of Patient 1’s “Current Treatment/ Medication/ DME List,” undated, the “Current Treatment/ Medication/ DME List” indicated the following medication were ordered on 8/15/2025: “Comfort Pack: morphine sulfate 100 milligram (mg, unit of measurement) /5 milliliter (mL, unit of measurement) solution 0.25, Zofran 4 mg tablet, Levsin 0.125 mg sublingual tablet (to place under the tongue and let dissolve in mouth), acetaminophen 650 mg rectal suppository (medication inserted into the rectum), Ativan 2 mg tablet, bisacodyl 10 mg rectal suppository, and ipratropium bromide/ albuterol sulfate 0.5 mg 3 mL solution.” During an interview on 9/11/2025 at 1:20 PM., with the Chief Financial Officer (CFO), the CFO stated the agency was starting to do corrections on the medication orders. The CFO stated the Director of Patient Care Services (DPCS), DPCS Designee and LVN 3 entered “Comfort Kit” and oxygen orders on 9/11/2025 for several patients and back dated the order using the patients’ respective start of care (SOC) date. A review of Patient 2’s Visit Note, authored by Licensed Vocational Nurse 1 (LVN 1), dated 9/8/2025, indicated “Pt [Patient 2] was anxious and angry.” During joint home visit on 9/10/2025 at 1:10 PM, at Patient 2’s home, with Registered Nurse 4 (RN 4), a medication reconciliation was conducted. Patient 2’s “Current Treatment/ Medication/ DME List,” did not include the following medications in the Comfort Kits: morphine sulfate, Zofran, Levsin, acetaminophen, Ativan, and bisacodyl. Patient 2’s Caregiver (CG 2) stated Patient 2 did not have a Comfort Kit. During a review of Patient 2’s Current Treatment/Medication/DME List, dated 9/11/2025, the Current Treatment/Medication/DME List indicated the following medications were ordered on 8/6/2025: Acetaminophen 650 mg rectal suppository; Ativan 2 mg tablet; Bisacodyl 10 mg Rectal suppository; Levsin SL 0.125 Sublingual tablet; Morphine Sulfate 100mg/5mL solution 0.25; Zofran 4 mg tablet. During an interview on 9/11/2025 at 1:20 PM., with the Chief Financial Officer (CFO), the CFO stated the agency was starting to do corrections on the medication orders. The CFO stated the Director of Patient Care Services (DPCS), DPCS Designee and LVN 3 entered “Comfort Kit” and oxygen orders on 9/11/2025 back dated the order using the patients’ respective start of care (SOC) date. During a joint home visit observation on 9/10/2025 at 3:20 PM, a medication reconciliation (a process on comparing patient’s current medication against medication ordered by the physician) was conducted with Medical Social Worker (MSW). Patient 3’s “Current Treatment/ Medication/ DME List” did not include the “Comfort Kit”: morphine sulfate, Zofran, Levsin, acetaminophen, Ativan, and bisacodyl. Patient 3 did not have the “Comfort Kit”. During an interview on 9/10/2025 at 3:20 PM, with Patient 3’s Caregiver 3 (CG 3), CG 3 stated Patient 3 feels short of breath even with small movements. CG 3 stated she requested for Patient 3 to have an oxygen concentrator (medical device that delivers rich air to a person who has difficulty breathing) from the last nurse visit (9/8/2025) and that the facility will be delivering Patient 3’s oxygen tomorrow (9/11/2025). During a review of Patient 3’s “Visit Note”, dated 9/8/2025, the “Visit Note” indicated Patient 3 has “moderate shortness of breath”, has “heavy breathing” (increased effort in inhaling and exhaling air), and “moderate abnormal lung sounds”. During a review on 9/11/2025 at 10:30 AM, Patient 3’s “Physician Order” was reviewed, the following medications were ordered on 8/11/2025: Acetaminophen 650 mg rectal suppository; Ativan 2 mg tablet; Bisacodyl 10 mg Rectal suppository; Levsin SL 0.125 Sublingual tablet; Morphine Sulfate 100mg/5mL solution 0.25; Zofran 4 mg tablet. The Physician Order indicated “Oxygen Concentrator” were ordered on 9/10/2025.During a review on 9/11/2025 at 1:15 PM, Patient 3’s “Physician Order”, dated 8/11/2025, the “Physician Order” indicated, “Oxygen 5L with nasal cannula” (a thin flexible tube that wraps around the head and sits on the nose to deliver oxygen). During an interview on 9/11/2025 at 1:18 PM with the Chief Financial Officer (CFO), the CFO stated the facility was starting to do corrections on the medication orders. The CFO stated the DPCS, DPCS Designee and LVN 3 entered “Comfort Kit” and oxygen orders today on several patients and back dated the order from patients’ respective start of care. The CFO was heard talking on the phone and stated, “Stop what you are doing, do not touch anything anymore.” The CFO stated he was on the phone with the DPCS Designee. During a concurrent interview and record review on 9/11/2025 at 3:05 PM with LVN 3. Patient 3’s “Physician Order”, dated 9/10/2025, was reviewed. LVN 3 stated she made an error of entering the order and putting 8/11/2025 (Patient 3’s SOC). LVN 3 stated she should not back date the order and enter the date the order was put in. 1.D. During an interview on 9/11/2025 at 1:18 PM., with the Chief Financial Officer (CFO), the CFO stated the agency was starting to do corrections on the medication orders. The CFO stated the DPCS, DPCS Designee and LVN 3 entered “Comfort Kit” and oxygen orders today on several patients and back dated the order from patients’ respective start of care. The CFO was heard talking on the phone and stated, “Stop what you are doing, do not touch anything anymore.” The CFO stated he was on the phone with the DPCS Designee. During an interview on 9/11/2025 at 1:20 PM with the CFO, the CFO provided the list of patients (Patient 1, Patient 2, Patient 3, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, Patient 20, Patient 21. Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, and Patient 28) that the DPCS, DPCS Designee and LVN 3 entered the “Comfort Kit” and back dated from the patients’ start of care. 2.During a concurrent interview and record review on 9/16/2025 at 12:02 PM., with RN 5 and) Representative 2 (HMR 2), the electronic medical record audit trail log for Patient 12 was reviewed. HMR 2 stated that based on Patient 12’s audit trail log, LVN 3 accessed Patient 12’s record and updated Patient 12’s Plan of Care (POC) on 9/11/2025 (one month after Patient 12 was discharged). HMR 2 stated Patient 12’s audit trail log indicated the following Focus Areas of Patient 12’s POC were closed (resolved) and backdated to reflect 8/18/2025: cardiovascular, gastro-intestinal, genitourinary, musculoskeletal, neurological/ mental, nutrition, pain, and respiratory. HMR 2 stated the actual date of the POC edit was 9/11/2025.During an interview with LVN 3 on 9/16/2025 at 1:22 PM, LVN 3 stated she does not conduct patient visits. LVN 3 stated she accessed Patient 12’s POC one month after Patient 12 was discharged discharge to ensure the medical chart was “done correctly” and if it “needed to be fixed”. , LVN 3 stated closed Patient 12’s POC to ensure completeness of the record. LVN 3 stated she backdated the closure of POC to 8/18/25 to “make it look right”.During a review of Patient 13’s “Discharge Summary”, dated 4/16/2025, the “Discharge Summary” did not include a signature of who completed the discharge summary narrative. During a concurrent interview and record review on 9/16/2025 at 11:28 AM, with Representative 1 (HMR 1) and RN 5, Patient 13’s electronic medical record audit trail log was reviewed. HMR 1 stated that based on Patient 13’s electronic medical record audit trail log, LVN 3 access Patient 13’s “Discharge Summary” and entered the discharge summary narrative on 9/9/2025 (five months after Patient 13 was discharged from hospice). During an interview on 9/16/2025 at 1:22 PM, with LVN 3, LVN 3 stated she is an LVN Case manager and part of her responsibility was to write discharge summary narrative for the discharge patients. LVN 3 stated she did not visit patients and the narrative for discharge summary she entered was based on the report given to her by the visiting nurse. LVN 3 stated the discharge summary narrative should be done within 7 days, but she usually completes the discharge summary within 24 hours. LVN 3 stated she accessed the record of Patient 13 to make sure everything is done correctly LVN 3 stated when she entered Patient 13’s discharge summary, and she back dated (use the date the patient was discharge) to reflect 4/16/25 “to make it look right.” During a concurrent interview and record review on 9/16/2025 at 11:28 AM, with HMR 1 and RN 5, Patient 14’s audit trail log was reviewed. HMR 1 stated based on the audit trail log, LVN 3 access Patient 14’s “Discharge Summary” and entered the discharge summary narrative on 9/9/2025 (five months after Patient 14 was discharged from hospice on 4/5/2025). During an interview on 9/16/2025 at 1:22 PM, with LVN 3, LVN 3 stated she is an LVN Case manager and part of her responsibility was to write discharge summary narrative for the discharge patients. LVN 3 stated she does not visit patients and the narrative for discharge summary she entered was based on the report given to her by the visiting nurse. LVN 3 stated the discharge summary narrative should be done within 7 days, but she usually completes the discharge summary within 24 hours. LVN 3 stated she accessed the record of Patient 14 to make sure everything is done correctly. LVN 3 stated when she entered Patient 14’s discharge summary, and she back dated (use the date the patient was discharge) to reflect 4/5/25 “to make it look right.” During a review of the facility’s policy and procedure (P&P) titled, “Discharge From Hospice Program,” undated, the P&P indicated, “The Case Manager will ensure that necessary paperwork is completed at the time of discharge…When a patient is discharged, transferred, or referred to another organization, relevant information will include…summary of the care provided and progress toward achieving goals, including both positive and adverse patient responses to treatment or services…Documentation will be filed in the clinical record. Information will be documented on a discharge/transfer form, which is to be completed within 72 hours…” During a review of the facility’s policy and procedure titled, “Late Entry Policy,” undated, the P&P indicated the following: - “All entries in the patient record must be made at the time care or services are provided.” - “If an entry is not made on the date and time services were rendered, a late entry is permissible under the following conditions: The information is accurate, factual, and relevant to the case and services provided. The late entry is clearly identified as such. The entry includes the actual date and time the service was provided and the date and time of the late documentation.”- “Late entries must never be used to falsify records, alter prior documentation, or cover up errors.””

“Based on interview and record review the Hospice Agency failed to provide documented evidence the Discharge Summary for five of five sampled Patients (Patient 11, Patient 12, Patient 13, Patient 14, and Patient 29) were sent to the attending physician. These failures had the potential for Patient 11, Patient 12, Patient 13, Patient 14, and Patient 29 to experience discontinuity of care; potentially resulting in delayed treatment, medication errors, and missed opportunities for follow up. Findings: During a review of Patient 11’s “Personal Information,” undated, the “Personal Information” indicated the HA admitted Patient 11, a 76-year-old male, on 3/10/2025 with diagnosis that included hypertensive heart disease with heart failure (high blood pressure damaged the heart over time, making it unable to pump blood effectively causing shortness of breath, fatigue, and swelling in the legs), type 2 diabetes mellitus, and hyperlipidemia (elevated cholesterol level). Patient 11’s end of care (EOC) date was 5/6/2025 due to hospitalization. During a review of Patient 12’s “Personal Information,” undated, the “Personal Information” indicated the hospice agency admitted Patient 12, a 76-year-old male, on 7/17/2025 with diagnoses including hypertensive heart disease with heart failure (high blood pressure damaged the heart over time, making it unable to pump blood effectively causing shortness of breath, fatigue, and swelling in the legs), acute respiratory failure with hypoxia (a sudden condition where the lungs cannot get enough oxygen into the blood for the body’s organs to function), and chronic kidney disease (a condition where the kidneys are damaged and cannot filter waste and extra fluid from the blood effectively, leading to a buildup of toxins in the body) . Patient 12’s EOC date was 8/17/2025 due to hospitalization. During a review of Patient 13’s Comprehensive Nursing Assessment: Primary/Secondary Diagnosis & Comorbidities, dated 3/28/2025, the Comprehensive Nursing Assessment: Primary/Secondary Diagnosis & Comorbidities indicated Alzheimer`s disease (a disease characterized by a progressive decline in mental abilities), Type 2 diabetes mellitus without complications (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN-high blood pressure) During a review of Patient 14’s Comprehensive Nursing Assessment: Primary/Secondary Diagnosis & Comorbidities, dated 4/6/2025, the Comprehensive Nursing Assessment: Primary/Secondary Diagnosis & Comorbidities indicated anxiety disorder (excessive worrying and fear), shortness of breath (SOB, difficulty breathing), and insomnia (trouble falling asleep or staying asleep). During a review of Patient 29’s “Personal Information,” undated, the “Personal Information” indicated the hospice agency admitted Patient 29, a 71-year-old female, on 7/2/2025 with diagnoses including multiple sclerosis (a disease that affects the central nervous system), HTN, and SOB. Patient 29’s EOC date was 7/25/2025 due to transfer to a different Hospice Agency. During a review of Patient 11, Patient 12, Patient 13, Patient 14, and Patient 29’s “Discharge Summary,” undated, Patient 11, Patient 12, Patient 13, Patient 14, and Patient 29’s “Discharge Summary” indicated the discharge summaries were not specifically sent to the attending physician. During an interview on 9/17/2025 at 11:45 AM with the Director of Patient Care Services Designee (DPCS Designee), the DPCS Designee stated the discharge summary is not sent to the attending physician when the patient is discharged, and HospiceMD (patient care charting monitoring and management system used by the facility) does not document the route or when any documents were sent. During an interview with the DPCS Designee, on 9/17/2025 at 12:07 PM, the DPCS Designee stated failure to send the Discharge Summary to the attending physician placed Patient 11, Patient 12, Patient 13, Patient 14, and Patient 29 at risk of delayed treatment and aspects of the Patient’s medical history may not be conveyed to the receiving physician. During a review of the facility’s policy and procedure titled, “Discharge From Hospice Program,” undated, indicated “A copy of the discharge summary will be sent to the attending physician.” f”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the physician’s telephone order for the use of oxygen was received, read back, and entered by the Director of Patient Care Services (DPCS) Designee or the Registered Nurse (RN) Designee for three of 10 sampled patients (Patient 2, Patient 3 and Patient 8) in accordance with the HA’s policy and procedure (P&P). This failure had the potential to result in inappropriate and inaccurate ordering of medication and treatment for the hospice patients which can result in an unsafe patient care and increased risk in medical errors and adverse event that can lead to emergency hospitalization and may contribute to an avoidable traumatic death of the hospice patients. On 9/12/2025, at 12:02 PM, the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient), in the presence of the agency’s Chief Financial Officer (CFO) and Director of Patient Care Services Designee (DPCSD) via telephone, for failure to ensure the physician’s telephone order for the use of oxygen was received, read back, and entered by a licensed nurse. On 9/17/2025 at 3:08 PM, the survey team lifted the IJ in the presence of the CFO and Office Administrator (OADM, a non-licensed staff) after implementation of an acceptable IJ Removal Plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) was verified. Findings:1. During a record review of Patient 2’s “Personal Information”, the “Personal Information” indicated the hospice agency (HA) admitted Patient 2, on 8/6/2025 with diagnoses included atherosclerotic heart disease (hardening of the arteries), shortness of breath (SOB, difficulty breathing), and anxiety (excessive worry).During a review of Patient 2’s “Visit Note”, authored by Licensed Vocational Nurse 1 (LVN 1), dated 9/8/2025, the “Visit Note” indicated Patient 2 had mild shortness of breath, mild abnormal lung sounds, and oxygen saturation of 91% on room air. During a review of Patient 2’s “Physician Order,” dated 9/10/2025, the “Physician’s Order” indicated “Oxygen Concentrator five liter ([5L, unit of measurement], Stationary [oxygen concentrators are designed for home use, providing a consistent and reliable supply of oxygen therapy]) with nasal cannula (a medical device consisting of a thin, flexible tube with two prongs that sit in a patient’s nostrils to deliver supplemental oxygen)” the order indicated “phone order/read back order by Office Administrator (OADM), non-licensed staff)].” During concurrent interview and record review, on 9/11/2025 at 10:07 AM, with the DPCS Designee, Patient 2’s “Physician Order,” dated 9/10/2025 was reviewed. The “Physician’s Order” indicated, “Oxygen 5L (Stationary) via nasal cannula” was entered and “phone order/read back order by OADM.” The DPCS Designee stated the OADM was not licensed staff and was not qualified to receive and enter medications or treatment orders. During a concurrent interview and record review, on 9/11/2025 at 11:39 AM, with the OADM, Patient 2’s order Physician Order,” dated 9/10/2025 was reviewed. The “Physician’s Order” indicated, “Oxygen 5L (Stationary) via nasal cannula” was entered and “phone order/read back order by OADM.” The OADM stated, “I entered the order for Oxygen 5L with nasal canula for Patient 2….” During an interview on 9/11/2025 at 3:28 p.m. with the OADM, the OADM stated, the DPCS Designee instructed her on 9/10/2025 to enter a physician’s order for Patient 2’s oxygen. 2. During a review of Patient 3’s “Personal Information”, the “Personal Information” indicated the HA admitted Patient 3 on 8/11/2025, with diagnoses included heart failure (a heart disorder which causes the heart to not pump the blood efficiently), shortness of breath, and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance (patterns of behaviors, thoughts and moods that are considered unusual for a person’s age and context). During an interview on 9/10/2025 at 3:20 PM, with Patient 3’s caregiver (CG 3), CG 3 stated Patient 3 feels short of breath even with small movements. CG 3 stated she requested for Patient 3 to have an oxygen concentrator (medical device that delivers oxygen rich air to a person who has difficulty breathing) during the last nurse visit (9/8/2025) and the HA will be delivering Patient 3’s oxygen tomorrow (9/11/2025). During a concurrent interview and record review on 9/11/2025 at 11:39 AM, with the OADM, Patient 3’s order indicated on 9/10/2025, Oxygen Concentrator 5 L (Stationary) with nasal cannula was entered and “phone order/read back order by OADM” The OADM stated, “I entered the order of Oxygen 5 L with nasal canula for Patient 3.” During a record review on 9/11/2025 at 1:50 p.m., Patient 3’s Physician order, dated 9/10/2025, indicated the order “Oxygen 5 L via nasal cannula,” entered by Licensed Vocational Nurse 3 (LVN 3). During an interview on 9/11/2025 at 3:28 p.m. with the OADM, the OADM stated the DPCS Designee gave her (OADM) instructions on 9/10/2025 to enter a physician’s order for Patient 3’s oxygen. During an interview on 9/12/2025 on 9:54 a.m., with LVN 3, LVN 3 stated the Patient 3’s daughter called her (LVN3) a couple days ago (9/10/2025) informing LVN 3 that Patient 3 needed oxygen. LVN 3 stated that Patient 3 has a diagnosis of heart failure and when a patient is diagnosed with heart failure, oxygen should be ordered and available. LVN 3 stated she (LVN3) took it upon herself to order the oxygen for Patient 3. LVN 3 stated she notified the DPCS but did not notify Patient 3’s physician. LVN 3 stated she notified everyone (DPCS and Medical Director) after she entered the order. 3. During a review of Patient 8’s “Personal Information”, the “Personal Information” indicated the HA admitted Patient 8, on 7/10/2025 with diagnoses that included Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), SOB, and dependence on supplemental oxygen. During a review of Patient 8’s “Physician Order”, dated 7/18/2025, the “Physician Order” indicated “order, note 2 L” the order indicated “phone order/ read back order by [OADM].” During an interview on 9/11/2025 at 11:10 with DPCS Designee, the DPCS Designee stated supplies such as oxygen concentrators were entered by OADM. The DPCS Designee stated having “2 L”, “5 L” or “with nasal cannula” are treatment orders. The DPCS Designee stated treatment orders should be entered by the licensed nurse (in general).During a concurrent interview and record review, on 9/12/2025 at 10:30 a.m., with the DPCS Designee, the facility’s Policy and Procedure (P&P), titled “Ordering Medication and Supplies”, dated 12/19/2024, was reviewed. the P&P indicated the following: - “the Director of Patient Care Services (DPCS) or designee may initiate written orders for medications and supplies based on the individualized plan care and patient assessment.” - “The DPCS (or designee RN [Registered Nurse]) may draft written/ verbal orders for medications and supplies.” - “DPSC: Drafts orders, coordinates with physicians, ensures documentation, and oversees the process.” The P&P indicated “Hospice Nurse/ Case Manager: Monitors patient needs, communicates with DPCS, and implements finalized orders.” - “The DPSC is responsible for ensuring that orders are accurate, clinically appropriate, and compliant with regulations.” The DPCS designee stated based on the P&P, the DPCS and RN designee may initiate orders for medication and supplies. The DPCS Designee stated based on the P&P, the DPCS and RN designee may draft written/verbal orders for medication and supplies. 1. During a record review of Patient 2’s “Personal Information”, undated, “Personal Information” indicated the Hospice agency admitted Patient 2, 89-year-old female, on 8/6/2025 with diagnoses that included Atherosclerotic heart disease (hardening of the arteries), shortness of breath (SOB, difficulty breathing), and anxiety (excessive worry).During a review of Patient 2’s “Visit Note”, authored by Licensed Vocational Nurse 1 (LVN 1), dated 9/8/2025, the “Visit Note” indicated Patient 2 had mild shortness of breath, mild abnormal lung sounds, and oxygen saturation of 91% on room air. During a review of Patient 2’s “Physician Order,” dated 9/10/2025, the “Physician’s Order” indicated “Oxygen Concentrator 5L (Stationary) with nasal cannula” the order indicated “phone order/read back order by OADM (Office Administrator, non-licensed staff)].” A concurrent interview and record review, on 9/11/2025 at 10:07 AM, with the DPCS Designee, Patient 2’s “Physician Order,” dated 9/10/2025 was reviewed. The “Physician’s Order” indicated, “Oxygen 5L (Stationary) via nasal cannula” was entered and “phone order/read back order by OADM.” The DPCS Designee stated the OADM was not licensed staff and was not qualified to receive and enter medications or treatment orders. A concurrent interview and record review, on 9/11/2025 at 11:39 AM, with the OADM, Patient 2’s order Physician Order,” dated 9/10/2025 was reviewed. The “Physician’s Order” indicated, “Oxygen 5L (Stationary) via nasal cannula” was entered and “phone order/read back order by OADM.” The OADM stated, “I entered the order for Oxygen 5L with nasal canula for Patient 2….” During an interview on 9/11/2025 at 3:28 p.m. with the OADM, the OADM stated, the DPCS Designee instructed her on 9/10/2025 to enter a physician’s order for Patient 2’s oxygen. 2. During a review of Patient 3’s “Personal Information”, undated, the “Personal Information” indicated the Hospice agency admitted Patient 3 on 8/11/2025, an 86 year old female, with diagnoses that included heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), shortness of breath, and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance (patterns of behaviors, thoughts and moods that are considered unusual for a person’s age and context). During an interview on 9/10/2025 at 3:20 PM, with Patient 3’s caregiver (CG 3), CG 3 stated Patient 3 feels short of breath even with small movements. CG 3 stated she requested for Patient 3 to have an oxygen concentrator (medical device that delivers oxygen rich air to a person who has difficulty breathing) from the last nurse visit (9/8/2025) and the HA will be delivering Patient 3’s oxygen tomorrow (9/11/2025). During a concurrent interview and record review on 9/11/2025 at 11:39 AM, with the OADM, Patient 3’s order indicated on 9/10/2025, Oxygen Concentrator 5 L (Stationary) with nasal cannula was entered and “phone order/read back order by OADM” The OADM stated, “I entered the order of Oxygen 5 L with nasal canula for Patient 3.” During a review on 9/11/2025 at 1:50 p.m., Patient 3’s Physician order, dated 9/10/2025, indicated the order “Oxygen 5 L via nasal cannula,” entered by LVN 3. During an interview on 9/11/2025 at 3:28 p.m. with the OADM, the OADM stated the DPCS Designee gave her instructions on 9/10/2025 to enter a physician’s order for Patient 3’s oxygen. During an interview on 9/12/2025 on 9:54 a.m., with LVN 3, LVN 3 stated the daughter called her a couple days ago (9/10/2025) that Patient 3 needs oxygen sometime. LVN 3 stated Patient 3 has a diagnosis of heart failure and when a patient was diagnosed with heart failure, oxygen should be ordered and available for them. LVN 3 stated she took it upon herself to order the oxygen for Patient 3. LVN 3 stated she notified the DPCS but did not notify the physician. LVN 3 stated she notified everyone (DPCS and Medical Director) after she entered the order. 3. During a review of Patient 8’s “Personal Information”, undated, the “Personal Information” indicated the HA admitted Patient 8, 82 year-old female, on 7/10/2025 with diagnoses that included Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), SOB, and dependence on supplemental oxygen. During a record review of Patient 8’s “Physician Order”, dated 7/18/2025, the “Physician Order” indicated “order, note: 2 L” the order indicated “phone order/ read back order by [OADM].” During an interview on 9/11/2025 at 11:10 with DPCS Designee, the DPCS Designee stated supplies such as oxygen concentrators were entered by OADM. The DPCS Designee stated having “2 L”, “5 L” or “with nasal cannula” are treatment orders. The DPCS Designee stated treatment orders should be entered by licensed nurse.During a concurrent interview and record review, on 9/12/2025 at 10:30 a.m., with the DPCS Designee, the facility’s Policy and Procedure (P&P), titled “Ordering Medication and Supplies”, dated 12/19/2024, was reviewed. the P&P indicated the following: - “the Director of Patient Care Services (DPCS) or designee may initiate written orders for medications and supplies based on the individualized plan care and patient assessment.” - “The DPCS (or designee RN [Registered Nurse]) may draft written/ verbal orders for medications and supplies.” - “DPSC: Drafts orders, coordinates with physicians, ensures documentation, and oversees the process.” The P&P indicated “Hospice Nurse/ Case Manager: Monitors patient needs, communicates with DPCS, and implements finalized orders.” - “The DPSC is responsible for ensuring that orders are accurate, clinically appropriate, and compliant with regulations.” The DPCS designee stated based on the P&P, the DPCS and RN designee may initiate orders for medication and supplies. The DPCS Designee stated based on the P&P, the DPCS and RN designee may draft written/verbal orders for medication and supplies.”

“Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the hospice agency’s license is active to operate as a Hospice agency issued by the State of California Department of Public Health (CDPH). This failure had the potential risk to result in the provision of a substandard quality of care that could impact the health and safety to all patients certified to receive the hospice benefits. Findings: During a concurrent observation and interview on 9/9/2025 at 11:20 AM, with the Chief Financial Officer (CFO), the State license issued by CDPH expired on 7/15/2025. The CFO stated he recently issued a check to pay the renewal application. During a review of a letter sent by CDPH to HA, dated 9/4/2025, the letter indicated CDPH has not received payment for the license renewal and the HA has a total unpaid amount of $5,560.50. During a concurrent interview and record review on 9/9/2025 at 11:40 AM, with the CFO, the facility’s check transaction register was reviewed. The check register indicated the facility issued check number 1888 to CDPH for license renewal on 7/29/2025 with the total amount of $5,055.00. The CFO stated the facility’s account did not reflect the check numbered 1888 has been charged. The CFO stated no documentation or proof of evidence the check number 1888 was mailed to CDPH for license renewal. During a concurrent interview and record review on 9/9/2025 at 2 PM with the CFO, the HA mail with shipping label addressed to CDPH, dated 9/9/2025 with expected delivery date of 9/10/2025. The CFO stated a new check was issued to pay the remaining balance to renew the license of the HA. During an interview on 9/10/2025 at 1:30 PM, with the CFO stated the mail was delivered. The CFO stated he spoke with someone from CDPH and was informed that the license renewal process may take 10 business days. During a concurrent interview and record review on 9/17/2025 at 11:46 AM, with the CFO, a copy of check number 1962, dated 9/8/2025 was reviewed. The check indicated the amount of $6,100.00 addressed to CDPH for license renewal 550006540 was received on 9/16/2025. During a concurrent interview and record review on 9/17/2025 at 11:46 AM, with the CFO, the facility’s policy and procedure (P&P) regarding HA licensing and renewal was requested. The CFO was unable to provide a P&P related to license renewal.”