Next Level Hospice Care

“Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing and supervising the care and services provided for one of four sampled patients (Patient 10). This failure had the potential of not addressing the care needs for these patients. Findings: Review of the hospice’s P&P titled Interdisciplinary Group Coordination of Care revised 11/2021 showed the type and scope of services provided by the interdisciplinary group will be based upon the comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals and interventions. The interdisciplinary group will maintain responsibility for the provision and coordination of care, regardless of the setting where care is provided to its patients.Review of Patient 10’s clinical record was initiated on 6/3/26. The clinical record showed the SOC was 9/26/25. The patient was certified for hospice services during the certification periods from 9/26/25 to 11/24/25, 11/25/25 to 1/23/26, 1/24/26 to 3/24/26, 3/25/26 to 5/23/26, and 5/24/26 to 7/22/26.On 6/4/26 at 1100 hours, a home visit was conducted with RN 1 to the board and care facility where Patient 10 resided.Review of the patient’s Current Medication List showed morphine sulfate (opioid analgesic) 15 mg one tab orally every four hours as needed for acute respiratory distress. However, the bubble pack containing the medications had an expiration date of 4/2026 and had not been disposed.An interview and concurrent medication profile review was conducted with RN 1. RN 1 confirmed the expired medication had not been disposed.On 6/5/26 at 1130 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and acknowledged the findings.The IDG failed to maintain the responsibility for the supervision of care and services as the RN did not coordinate with the board and care facility regarding the expired medication.”

“Based on observation, interview, and record review, the hospice failed to ensure the initial and comprehensive assessments were completed, reviewed, and revised to address and meet the patients’ care needs as evidenced by: 1.The hospice failed to ensure the initial assessment was completed by a hospice registered nurse. Cross reference to L522.2.The hospice failed to ensure the comprehensive assessments were completed no later than five calendar days after the election of hospice care. Cross reference to L523.3.The hospice failed to ensure the comprehensive assessments included the assessment for the imminence of death. Cross reference to L528.4.The hospice failed to ensure the medication profiles were reviewed to include the patients’ current medications. Cross reference to L530.5. The hospice failed to ensure the comprehensive assessments included the initial bereavement assessments to address the needs of the patient’s family and other individuals/PCG focusing on the social, religious, and cultural factors which may impact their ability to cope with patient’s death. Cross reference to L531.6.The hospice failed to ensure the updated comprehensive assessments included the changes that had occurred since the initial assessment, information on the patient’s progress, and reassessment of the patient’s responses. Cross reference to L533. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the initial and comprehensive assessments to meet the patients’ care needs.”

“Based on interview and record review, the hospice failed to ensure the IDG, care planning, and coordination of services were provided to meet the patients’ care needs as evidenced by: 1. The hospice failed to ensure the care and services were provided in accordance with the POC. Cross reference to L543.2. The hospice failed to ensure the individualized care plans were developed. Cross reference to L545.3. The hospice failed to ensure the initial and revised POCs included the indication for the PRN discipline visits. Cross reference to L547.4. The hospice failed to ensure the POCs included measurable outcomes. Cross reference to L548.5. The hospice failed to ensure the IDG had reviewed/revised the patients’ POCs no less frequently than every 15 calendar days. Cross reference to L552.6. The hospice failed to ensure the revised POCs included the patients’ progress toward goals specified in the POCs. Cross reference to L553.7. The hospice failed to ensure the IDG maintained the responsibility for directing and supervising the care and services. Cross reference to L554.The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the interdisciplinary team, care planning and coordination of services to meet the patients’ care needs.”

“Based on interview and record review, the hospice failed to ensure volunteer services were provided to meet the patients’ care needs as evidenced by: 1. The hospice failed to ensure a volunteer was used in day-to-day administrative role and/or direct patient care roles. Cross reference to L644.2. The hospice failed to ensure there were ongoing efforts for recruiting and retaining volunteers. Cross reference to L645.3. The hospice failed to ensure the cost saving was achieved using volunteers. Cross reference to L646.4. The hospice failed to ensure the volunteers provided at a minimum, equals to 5% of the total patient care hours of all paid hospice employees and contracted staff. Cross reference to L647. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the volunteer services to meet the patients’ care needs.”

“Based on interview and record review, the hospice failed to ensure the Medical Director performed roles and responsibilities of a Medical Director as evidenced by: 1. The hospice failed to ensure the Medical Director or physician designee completed the certifications of terminal illness. Cross reference to L667.2. The hospice failed to ensure the Medical Director or physician designee reviewed the patients’ clinical information to certify the patients for hospice services as per the hospice’s P&P. Cross reference to L668.These systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance of the Medical Director to identify the patients’ care needs.”

“Based on interview and record review, the hospice failed to ensure the initial assessment was completed by a hospice registered nurse for one of six sampled patients (Patient 4). This failure had the potential for not addressing the care needs for this patient. Review of the hospice’s P&P titled Initial Assessment (undated) showed an initial assessment will be performed by a registered nurse within 48 hours after election of hospice care. If the comprehensive assessment is completed during the admission visit, the initial assessment will be included as a part of the comprehensive assessment. Review of Patient 4’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 11/16/24. The patient was certified for hospice services during the certification periods from 11/16/24 to 2/13/25, 2/14/25 to 4/14/25, 4/15/25 to 6/13/25, 6/14/25 to 8/12/25, 8/13/25 to 10/11/25, 10/12/25 to 12/10/25, and 12/11/25 to 2/8/26. Review of the Comprehensive Nursing Assessment dated 11/16/24, showed an LVN had completed the initial assessment instead of an RN as per the hospice’s P&P. On 2/12/26 at 0942 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS stated initial comprehensive assessment should be performed by a registered nurse. The CEO/DPCS was informed and verified the finding.”

“Based on interview and record review, the hospice failed to ensure the comprehensive assessments were completed no later than five calendar days after the election of hospice care for two of six sampled patients (Patients 3 and 5). This failure had the potential for not addressing the care needs for these patients. Review of the hospice’s P&P titled Comprehensive Assessment revised 11/2021, showed a comprehensive assessment will be performed by the hospice IDG no later than 5 calendar days after the election of hospice care in consultation with attending physician. 1. Review of Patient 3’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 9/13/25. The patient was certified for hospice services during the certification periods from 9/13/25 to 12/11/25 and 12/12/25 to 3/11/25. The Informed Consent and Treatment Authorization dated 9/13/25, showed the family member authorized for hospice services.The initial comprehensive nursing assessment was completed on 9/13/25.However, the initial comprehensive spiritual and psychosocial assessments for the patient were not completed.On 2/12/26 at 0930 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings. 2. Review of Patient 5’s clinical record was initiated on 2/10/26. The clinical record showed the SOC was 8/15/25. The patient was certified for hospice services during the certification periods from 8/15/25 to 10/13/25, 10/14/25 to 12/12/25, and 12/13/25 to 2/10/25.The Informed Consent and Treatment Authorization dated 8/15/25, showed the family member authorized for hospice services.The initial comprehensive nursing assessment was completed on 8/15/25.However, the initial comprehensive spiritual and psychosocial assessments for the patient were not completed.On 2/12/26 at 1019 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.”

“Based on interview and record review, the hospice failed to ensure the comprehensive assessments included the imminence of death for six of six sampled patients (Patients 1, 2, 3, 4, 5 and 6). This failure had the potential risk of not appropriately addressing the patients’ needs. Review of the hospice’s P&P titled Comprehensive Assessment revised 11/2021, showed during the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s clinical record including imminence of death. 1. Review of Patient 1’s clinical record was initiated on 2/3/26. The clinical record showed the SOC was 2/6/25. The patient was certified for hospice services during the certification periods from 2/6/25 to 5/6/25, 5/7/25 to 8/4/25, 8/5/25 to 10/3/25, 10/4/25 to 12/2/25, 12/3/25 to 1/31/26, and 2/1/26 to 4/1/26.Review of the initial comprehensive nursing assessment dated 2/6/25, showed RN 2 had assessed the patient’s communication and body system (head-to-toe).However, the initial comprehensive assessment did not include the imminence of death for Patient 1.On 2/12/26 at 0833 hours, an interview and concurrent clinical record review was conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the finding. 2. Review of Patient 2’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 12/3/24. The patient was certified for hospice services during the certification periods from 12/3/24 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, 9/29/25 to 11/27/25, 11/28/25 to 1/26/26, and 1/27/26 to 3/27/26.Review of the initial comprehensive nursing assessment dated 12/3/24, showed RN 1 had assessed the patient’s communication and body system (head-to-toe).However, the initial comprehensive assessment did not include the imminence of death for Patient 2.On 2/12/26 at 0900 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the finding. 3. Review of Patient 3’s clinical record was initiated on 2/4/26. The clinical record showed SOC was 9/13/25. The patient was certified for hospice services during the certification periods from 9/13/25 to 12/11/25 and 12/12/25 to 3/11/25.Review of the initial comprehensive nursing assessment dated 9/13/25, showed the CEO/DPCS had assessed the patient’s communication and body system (head-to-toe).However, the initial comprehensive assessment did not include the imminence of death for Patient 3.On 2/12/26 at 0930 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the finding. 4. Review of Patient 4’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 11/16/24. The patient was certified for hospice services during the certification periods from 11/16/24 to 2/13/25, 2/14/25 to 4/14/25, 4/15/25 to 6/13/25, 6/14/25 to 8/12/25, 8/13/25 to 10/11/25, 10/12/25 to 12/10/25, and 12/11/25 to 2/8/26.Review of the initial comprehensive nursing assessment dated 11/16/24, showed the CEO/DPCS had assessed the patient’s communication and body system (head-to-toe).However, the initial comprehensive assessment did not include the imminence of death for Patient 4.On 2/12/26 at 0942 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings. 5. Review of Patient 5’s clinical record was initiated on 2/10/26. The clinical record showed the SOC was 8/15/25. The patient was certified for hospice services during the certification periods from 8/15/25 to 10/13/25, 10/14/25 to 12/12/25, and 12/13/25 to 2/10/25.Review of the initial comprehensive nursing assessment dated 8/15/25, showed the CEO/DPCS had assessed the patient’s communication and body system (head-to-toe).However, the initial comprehensive assessment did not include the imminence of death for Patient 5.On 2/12/26 at 1019 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the finding. 6. Review of Patient 6’s clinical record was initiated on 2/11/26. The clinical record showed SOC was 2/27/25. The patient was certified for hospice services during the certification periods from 2/27/25 to 5/27/25, 5/28/25 to 8/25/25, 8/26/25 to 10/24/25, 10/25/25 to 12/23/25, and 12/24/25 to 2/21/26.Review of the initial comprehensive nursing assessment dated 2/27/25, showed RN 2 had assessed the patient’s communication and body system (head-to-toe).However, the initial comprehensive assessment did not include the imminence of death for Patient 6.On 2/12/26 at 1038 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the finding.”

“Based on observation, interview, and record review, the hospice failed to ensure the medication profile was reviewed to include all current medications for one of six sampled patients (Patient 2). This failure had the potential for the patient not receiving the appropriate care and necessary services that could negatively affect the patient’s well-being. The hospice’s P&P titled Medication Profile revised 2021 showed the patient receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect the current medications and new medications.Review of Patient 2’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 12/3/24. The patient was certified for hospice services during the certification periods from 12/3/24 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, 9/29/25 to 11/27/25, 11/28/25 to 1/26/26, and 1/27/26 to 3/27/26.On 2/6/26 at 1145 hour, a home visit was conducted with LVN 1 to the assisted living facility where Patient 2 resided. The following medications were included in the patient’s medication administration record at the assisted living facility:-clindamycin (antibiotic) (no dosage documented) one capsule three times a day for seven days started on 2/1/26.-sulfamethoxazole (antibiotic) (no dosage documented) one tablet two times a day for seven days started on 2/1/26.-hyoscyamine (antispasmodic) 0.125 mg, dissolve one tablet under the tongue every four hours as needed.-acetaminophen (analgesic) 650 mg one suppository rectally every four hours as needed for temperature more than 100 degrees Fahrenheit-albuterol Solution (bronchodilator) 2.5 mg/3 ml solution inhale one vial via nebulizer every four hours as needed.-bisacodyl (laxative) 10 mg suppository insert one suppository rectally once a day as needed.-lorazepam (antianxiety) 1 mg one tablet every two hours as needed.-morphine sulfate (opioid analgesic) 15 mg take orally every two hours as needed. One half tablet for mild to moderate pain and one tablet for severe pain.-ondansetron (antiemetic) 4 mg one tablet on the tongue every 8 hours as needed.However, review of the current medication profile for Patient 2 did not include the above medications.An interview and concurrent medication profile review was conducted with LVN 1. LVN 1 was informed and confirmed the patient’s medication profile was not updated.On 2/12/26 at 0900 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the comprehensive assessments included the initial bereavement assessments to address the needs of the patients’ family and other individuals/PCG focusing on the social, religious, and cultural factors which may impact their ability to cope with patients’ death for two of six sampled patients (Patients 3 and 5). This failure had the potential of not addressing the bereavement needs for these patients’ family/PCG. Review of the hospice’s P&P titled Bereavement Services revised 11/2021, showed a bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care.1.Review of Patient 3’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 9/13/25. The patient was certified for hospice services during the certification periods from 9/13/25 to 12/11/25 and 12/12/25 to 3/11/25.The Informed Consent and Treatment Authorization dated 9/13/25, showed the family member authorized for hospice services.However, there was no documented evidence a bereavement risk assessment was completed by the hospice at the time of admission.On 2/12/26 at 0930 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the finding. 2. Review of Patient 5’s clinical record was initiated on 2/10/26. The clinical record showed the SOC was 8/15/25. The patient was certified for hospice services during the certification period from 8/15/25 to 10/13/25, 10/14/25 to 12/12/25, and 12/13/25 to 2/10/25.The Informed Consent and Treatment Authorization dated 8/15/25, showed the family member authorized for hospice services.However, there was no documented evidence a bereavement risk assessment was completed by the hospice at the time of admission.On 2/12/26 at 1019 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the finding.”

“Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments included the changes that occurred since the initial assessments, information on the patients’ progress, and reassessment of the patients’ responses for six of six sampled patients (Patients 1, 2, 3, 4, 5 and 6). This failure had the potential of not addressing the care needs for these patients.Findings: Review of the hospice’s P&P titled Plan of Care revised 11/2021, showed the plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every 15 days. The plan of care must be initiated at the start of care.1. Review of Patient 1’s clinical record was initiated on 2/3/26. The clinical record showed the SOC was 2/6/25. The patient was certified for hospice services during the certification periods from 2/6/25 to 5/6/25, 5/7/25 to 8/4/25, 8/5/25 to 10/3/25, 10/4/25 to 12/2/25, 12/3/25 to 1/31/26, and 2/1/26 to 4/1/26.Review of LVN 1’s Skin Impairment Assessment dated 2/27/25, showed Patient 1 had an ulcer on the left lower extremity. Wound care was provided as ordered: cleansed with wound cleanser, patted dry, applied triple antibiotic ointment to wound bed and covered with 4x4 border gauze.Review of the POC/IDG Review dated 3/4/25, showed a new order for wound treatment for the left leg. However, there was no documented evidence the IDG discussed the patient’s wound on the left leg.Review of the Medication List showed to administer melatonin (supplement) 5 mg daily at bedtime started on 4/10/25.Review of the POC/IDG Review dated 4/15/25, showed a new order for melatonin. However, there was no documented evidence the IDG had discussed the patient’s inability to sleep.Review of the Comprehensive Nursing Assessment dated 2/6/25, Re-Cert Assessment dated 4/26, 8/2 and 9/27/25 and Updated Assessment dated 11/22/25, showed there was no need for a volunteer.However, there was no documented evidence of the IDG had reviewed/discussed the reason why there was no need for a volunteer.Review of the Re-Cert Assessment dated 4/26, 8/2, and 9/27/25 and Updated Assessment dated 11/22/25, showed an RN performed comprehensive assessment.However, the update assessments were incomplete as the section for imminently dying was left blank. On 2/12/26 at 0833 hours, an interview and concurrent clinical record review was conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings. 2. Review of Patient 2’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 12/3/24. The patient was certified for hospice services during the certification periods from 12/3/24 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, 9/29/25 to 11/27/25, 11/28/25 to 1/26/26, and 1/27/26 to 3/27/26.Review of the Comprehensive Nursing Assessment dated 12/3/24, Re-Cert Assessment dated 3/3, 5/24, 7/20, and 11/23/25 and Updated Assessment dated 9/28/25, showed there was no need for a volunteer.However, there was no documented evidence of the IDG had reviewed/discussed the reason why there was no need for a volunteer.Review of the Re-Cert Assessment dated 3/3, 5/24, 7/20, and 11/23/25 and Updated Assessment dated 9/28/25, showed an RN performed comprehensive assessment.However, the update assessments were incomplete as the section for imminently dying was left blank. Review of the POC/IDG Review dated 3/18, 4/29, 5/13, 5/27, 6/24, 7/8, 7/22, 8/5, and 8/19/25, showed IDG discussions for spiritual and psychosocial.However, there was no documented evidence there were IDG discussions for nursing.Review of RN 1’s Re-Cert Assessment dated 11/23/25, showed the patient continues to show gradual and measurable decline, current changes were not significant enough to meet hospice eligibility criteria. The patient would be closely monitored with possible discharge next month should decline remain minimal.However, the POC/IDG Review dated 11/25/25, showed no documented evidence the IDG had discussed the possibility of discharge from hospice.Review of LVN 1’s Visit Note dated 1/31/26, showed patient had a wound on the lower left back and an initial wound care was performed: cleansed with wound cleanser, patted dry, applied triple antibiotic ointment, and covered with sterile bandage; and new medications were ordered: clindamycin (antibiotic) 150 mg one capsule three times a day for seven days, Bactrim DS (antibiotic) one tablet two times a day for seven days. Dermatology consult was also ordered.However, there was no documented evidence the IDG had discussed the patient’s new wound and medications.On 2/12/26 at 0900 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS stated the IDG should discuss the patient’s condition. The CEO/DPCS acknowledged and verified the findings3. Review of Patient 3’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 9/13/25. The patient was certified for hospice services during the certification periods from 9/13/25 to 12/11/25 and 12/12/25 to 3/11/25.Review of the POC/IDG Review dated 12/23/25, showed recent order for buspirone hydrochloride (antianxiety) 15 mg one tablet two times a day for anxiety and risperidone (antipsychotic) 2 mg one tablet two times a day for restlessness.However, there was no documented evidence the IDG discussed the patient’s anxiety and restlessness.Review of the POC/IDG Review dated 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25, and 1/6/26 showed IDG discussions for nursing.However, there was no documented evidence there were IDG discussions for spiritual and psychosocial.Review of the Comprehensive Nursing Assessment dated 9/13/25 and Re-Cert Assessment dated 12/7/25, showed there was no need for SC and volunteer.However, there was no documented evidence the IDG had reviewed/discussed the reason why there was no need for SC and volunteer.Review of the Comprehensive Nursing Assessment dated 9/13/25, showed there was no need for MSW.However, there was no documented evidence the IDG had reviewed/discussed the reason why there was no need for an MSW.Review of the Re-Cert Assessment dated 12/7/25, showed an RN performed comprehensive assessment.However, the update assessments were incomplete as the section for imminently dying was left blank. On 2/12/26 at 0930 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.4. Review of Patient 4’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 11/16/24. The patient was certified for hospice services during the certification periods from 11/16/24 to 2/13/25, 2/14/25 to 4/14/25, 4/15/25 to 6/13/25, 6/14/25 to 8/12/25, 8/13/25 to 10/11/25, 10/12/25 to 12/10/25, and 12/11/25 to 2/8/26.Review of the Comprehensive Nursing Assessment dated 11/16/24, showed the patient had an episode of severe diarrhea for the past three to four days and was prescribed Flagyl (antibiotic) 500 mg three times a day for seven days.Review of the POC/IDG Review dated 12/23/24, showed the IDG discussed about nursing. However, there was no documented evidence the IDG discussed patient’s severe diarrhea and the prescribed medication Flagyl.Review of the Communication/Progress Log dated 1/22/26, showed a report from LVN 2 that Patient 4 needed a refill of the oxygen tank used when patient goes on dialysis. Documentation also showed there were crackles on the patient’s left side lung and blood pressure was elevated to 148/84 mm/hg.Review of the POC/IDG Review dated 2/3/26, showed a new DME order dated 1/22/26 for an oxygen E tank. However, there was no documented evidence the IDG discussed the crackles on the patient’s left side lung and elevated blood pressure of 148/84 mm/hg.Review of the Communication/Progress Log dated 1/27/26, showed a communication note that Patient 4’s PCG reported the patient was experiencing intermittent delusions and periods of confusion. In addition, there was a report of severe, “exploding” headache; and morphine was administered at 0700 hours to manage distress.However, the Hospice POC/IDG Review dated 2/3/26, showed no documented evidence the IDG had discussed the patient’s reported intermittent delusions, periods of confusion, and severe “exploding” headache.Review of the Comprehensive Nursing Assessment dated 11/16/24, Recert Assessment dated 2/13, 4/15, 8/12, 10/7, and 12/4/25 and Update Assessment dated 6/12/25, showed there was no need for a volunteer.However, there was no documented evidence of the IDG had reviewed/discussed the reason why there was no need for a volunteer.Review of the Recert Assessment dated 2/13, 4/15, 8/12, 10/7, and 12/4/25 and Update Assessment dated 6/12/25, showed an RN performed comprehensive assessment.However, the update assessments were incomplete as the section for imminently dying was left blank. On 2/12/26 at 0942 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.5. Review of Patient 5’s clinical record was initiated on 2/10/26. The clinical record showed the SOC was 8/15/25. The patient was certified for hospice services during the certification periods from 8/15/25 to 10/13/25, 10/14/25 to 12/12/25, and 12/13/25 to 2/10/25.Review of RN 3’s Skin Assessment dated 10/1/25, showed there was redness on the upper posterior knee measuring 2.5 cm (length) x 2 cm (width); and treated with wound cleanser, pat dry, triple antibiotic, collagen powder, and covered with dressing.Further review of the Skin Assessment dated 10/1/25, showed a wound on the sacral area measuring 3 cm (length) x 3 cm (length). The area was cleansed with wound spray, dried, treated with triple antibiotic, collagen powder, and covered with a 4x4 silicone foam dressing.However, the Hospice POC/IDG Review dated 10/14/25, showed no documented evidence the IDG had discussed the patient’s redness located at the upper posterior knee and wound on the sacral area.Review of LVN 2’s Skin Assessment dated 12/19/25, showed the worsening condition for the wounds located at:-sacral/coccyx: several open wounds with a mixture of pink/red tissue. The surrounding skin was dark red to purple and appeared inflamed. The moisture on the skin folds had caused mild maceration (skin softening and breakdown). There was a small open lesion on the lower right side with exposed red tissue and the general area measured 7 cm (length) x 7 cm (width).-spine area: large dark-purple discoloration and the general area measured 6 cm (length) x 4 cm (width).However, the Hospice POC/IDG Review dated 12/23/25, showed no documented evidence the IDG had discussed the patient’s worsening condition of the wound located at the sacral/coccyx and discoloration located at the spine.Review of the Comprehensive Nursing Assessment dated 8/15/25, Recert Assessment dated 10/1/25 and 12/1/25, showed there was no need for an SC. However, there was no documented evidence of the IDG had reviewed/discussed the reason why there was no need for an SC.Review of the Comprehensive Nursing Assessment dated 8/15/25, Recert Assessment dated 10/1/25 and 12/1/25, showed there was no need for a volunteer.However, there was no documented evidence of the IDG had reviewed/discussed the reason why there was no need for a volunteer.Review of the Recert Assessment dated 10/1/25 and 12/1/25, showed an RN performed comprehensive assessment.However, the update assessments were incomplete as the section for imminently dying was left blank. On 2/12/26 at 1019 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.6. Review of Patient 6’s clinical record was initiated on 2/11/26. The clinical record showed SOC was 2/27/25. The patient was certified for hospice services during the certification periods from 2/27/25 to 5/27/25, 5/28/25 to 8/25/25, 8/26/25 to 10/24/25, 10/25/25 to 12/23/25, and 12/24/25 to 2/21/26.Review of the initial Comprehensive Nursing Assessment dated 2/27/25, showed the patient was noted with some scattered pustules (blister-like skin lesions) to the bilateral lower extremities. The bilateral groin area appeared with redness.However, the IDG/POC Review dated 3/4/25, showed no documented evidence the IDG had discussed the patient’s scattered pustules to the bilateral lower extremities and redness on the bilateral groin area. Review of the Communication/Progress Log dated 12/5/25, showed patient reported symptoms of pain when voiding. A new order was received from the physician for Levaquin (antibiotic) 500 mg once daily for five days.However, the IDG/POC Review dated 12/9/25, showed no documented evidence the IDG had discussed the patient’s reported pain when voiding and Levaquin was not included in the recent orders.Review of the Comprehensive Nursing Assessment dated 2/27/25, Recert Assessment dated 5/24, 8/30, 10/11/25 and Updated Assessment dated 12/6/25, showed there was no need for a volunteer.However, there was no documented evidence of the IDG had reviewed/discussed the reason why there was no need for a volunteer.Review of the Recert Assessment dated 5/24, 8/30, 10/11/25 and Updated Assessment dated 12/6/25, showed an RN performed comprehensive assessment.However, the update assessments were incomplete as the section for imminently dying was left blank. On 2/12/26 at 1038 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.”

“Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POCs for six of six sampled patients (Patients 1, 2, 3, 4, 5 and 6). This failure had the potential for not providing appropriate, consistent, and quality care to the patients. Review of the hospice’s P&P titled the Plan of Care revised 11/2021, showed the written plan of care will contain, but not limited to, the following:A. DiagnosisB. Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, and counseling.C. Reduction in risk factorsD. Functional limitationsE. Mental StatusF. Safety measures to protect against abuse, injury, infection, or communicable disease, as appropriateG. Nutritional requirementsH. PrognosisI. DME and medical supplies necessary to meet patient needsJ. Frequency of servicesK. Placement of the appropriate level of care and referrals as needed for counseling, additional disciplines, volunteers, and adjunctive servicesL. Individualized interventions to assist with end-of-life careM. Patient and family/caregiver educational needs and assessment of their ability to learn and understand teaching.N. Statement of treatment goalsO. Interdisciplinary group assessment of needsP. Pain and symptom management interventionsQ. Drugs and treatments (including allergies)R. Physician-directed instruction to patient and family/caregiverS. Physician (or other authorized licensed independent practitioner) ordersT. Measurable outcomes anticipated from implementing and coordinating the plan of care.U. Patient or representative’s level of understanding, involvement and agreement with the plan of care1. Review of Patient 1’s clinical record was initiated on 2/3/26. The clinical record showed the SOC was 2/6/25. The patient was certified for hospice services during the certification periods from 2/6/25 to 5/6/25, 5/7/25 to 8/4/25, 8/5/25 to 10/3/25, 10/4/25 to 12/2/25, 12/3/25 to 1/31/26, and 2/1/26 to 4/1/26.Review of Patient 1’s POC/IDG Review dated 2/18/25, showed a recent order dated 2/6/25, for SN visits one time per week plus three PRN visits; MSW visits one time monthly plus one PRN visit; and SC visits one time monthly plus one PRN visit.Record of Patient 1’s History of Nursing Assessments showed the RN conducted the recertification visits on 4/26, 8/2 and 9/27/25 and Updated Assessment on 11/22/25.Review of the Spiritual Assessment dated 2/6/25, showed the SC conducted a telehealth spiritual care visit for the patient. However, there was no documented evidence a physician had ordered a telehealth visit for the patient.Further review of the clinical record failed to show documented evidence of SC and MSW visits as ordered.On 2/12/26 at 0833 hours, an interview and concurrent clinical record review was conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.2. Review of Patient 2’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 12/3/24. The patient was certified for hospice services during the certification periods from 12/3/24 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, 9/29/25 to 11/27/25, 11/28/25 to 1/26/26, and 1/27/26 to 3/27/26.Review of the Spiritual Assessment dated 12/6/24, showed the SC conducted a telehealth visit for the patient. However, there was no documented evidence a physician had ordered a telehealth visit for the patient.Review of the POC/IDG Review dated 9/16/25 and 11/25/25, showed MSW visits one per month plus one PRN visits.Further review of the clinical record failed to show documented evidence of MSW visits as ordered.However, the record of Patient 2’s History of Psychosocial Assessment failed to show any documentation of the MSW visits for the months of 9/2025, 10/2025, 11/2025 and 12/2025.On 2/12/26 at 0900 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and acknowledged the findings.3. Review of Patient 3’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 9/13/25. The patient was certified for hospice services during the certification periods from 9/13/25 to 12/11/25 and 12/12/25 to 3/11/25.The POC/IDG Review dated 9/16/25, showed RN visits one per two weeks plus one PRN visit.Further review of the clinical record failed to show documented evidence the RN had visited the patient on Week 3 (9/21/25 to 9/27/25) as ordered in the POC.The POC/IDG Review dated 9/16/25, showed the MSW visits one time then, PRN.Further review of the clinical record failed to show documented evidence the MSW had visited the patient as ordered in the POC.On 2/12/26 at 0930 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings. 4. Review of Patient 4’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 11/16/24. The patient was certified for hospice services during the certification periods from 11/16/24 to 2/13/25, 2/14/25 to 4/14/25, 4/15/25 to 6/13/25, 6/14/25 to 8/12/25, 8/13/25 to 10/11/25, 10/12/25 to 12/10/25, and 12/11/25 to 2/8/26.Review of Patient 4’s POC/IDG Review dated 11/26/24, showed MSW visits on admission, recert, and PRN as per patient/family request; and SC on admission, recert, and PRN visit as per patient/family request.Record of Patient 4’s History of Nursing Assessments showed the RN provided the recertification visits dated 2/13, 4/15, 6/12, 8/12, 10/7and 12/4/25.However, there was no documented evidence of MSW visits during the recertification on 2/13, 4/15, 6/12, 8/12, 10/7 and 12/4/25; and SC visits on 6/12, 8/12 and 10/7/25.Review of the Spiritual Assessment dated 2/13/25 and 4/14/25, showed the SC conducted a telehealth spiritual care visits; however, there was no documented evidence a physician had ordered telehealth visits for the patient.Review of Patient 4’s POC/IDG Review dated 10/14/25, showed LVN visits one per week plus three PRN visits to manage shortness of breath, nausea/vomiting, anxiety and pain.Review of the clinical record failed to show documented evidence the LVN had conducted visits during Week 3 (10/26/25 to 11/1/25), Week 4 (11/2/25 to 11/8/25), Week 5 (11/9/25 to 11/15/25), Week 6 (11/16/25 to 11/22/25), Week 8 (11/30/25 to 12/6/25) and Week 9 (12/7/25 to 12/13/25).Further review of the clinical record failed to show documented evidence the physician was informed of the missed visits and there was no attempt to reschedule the visits for the above weeks. On 2/12/26 at 0942 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.5. Review of Patient 5’s clinical record was initiated on 2/10/26. The clinical record showed the SOC was 8/15/25. The patient was certified for hospice services during the certification periods from 8/15/25 to 10/13/25, 10/14/25 to 12/12/25, and 12/13/25 to 2/10/25.The POC/IDG Review dated 10/14/25, showed a plan of care intervention for Integumentary/Skin dated 8/15/25, for the following:-coccyx wound: cleansed with a sterile cotton tip applicator, treated with triple antibiotic, and covered with a 6 x 6 silicone foam dressing and a sacrum silicone dressing.-bilateral posterior knee wounds: cleansed with wound cleanser, patted dry, and treated with triple antibiotic ointment. Dressed with 2 x 2 alginate dressing and a 4 x 4 island dressing, and covered with a 5 x 9 abdominal pad, secured with tape. Review of RN 3’s Skin Assessment dated 10/15/25, showed a wound care treatment for the following:-coccyx wound: the area was gently cleansed, dried, treated with triple antibiotic and collagen powder, and covered with a sacral silicone foam dressing.-skin at the back of both legs: areas were cleaned with wound spray, dried, and treated with medihoney ointment and collagen powder, covered with a 4 x 4 island dressing, wrapped with an abdominal pad and secured with tape.However, there was no documented evidence the physician had ordered the above wound treatments for Patient 5’s coccyx and bilateral posterior knee wounds.The POC/IDG Review dated 12/23/25, 1/6/26 and 1/20/26, showed SN visits one per week plus three PRN visits for skilled nursing crisis intervention.Review of the clinical record showed the SN had visited the patient on Week 2 (12/14/25 to 12/20/25), Week 3 (12/21/25 to 12/27/25), Week 4 (12/28/25 to 1/3/26), Week 5 (1/4/26 to 1/10/26) and Week 6 (1/11/26 to 1/17/26).However, there was no documented evidence SN had visited the patient on Week 7 (1/18/26 to 1/24/26) as ordered in the POC.The POC/IDG Review dated 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25, 1/6 and 1/20/26, showed MSW visit at recert, one PRN visit for psychosocial/emotional support and assistance with outside resources.Review of the clinical record showed no documented evidence the MSW had visited the patient as ordered in the POC.The POC/IDG Review dated 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25, 1/6 and 1/20/26, showed an HA visits two per week.However, there was no documented evidence the HA had visited the patient for the weeks from 11/23/25 to 11/29/25, 12/28/25 to 1/3/26, 1/4/26 to 1/10/26, 1/11/26 to 1/17/26, and 2/1/26 to 2/7/26 as ordered in the POC.On 2/12/26 at 1019 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.6. Review of Patient 6’s clinical record was initiated on 2/11/26. The clinical record showed the SOC was 2/27/25. The patient was certified for hospice services during the certification periods from 2/27/25 to 5/27/25, 5/28/25 to 8/25/25, 8/26/25 to 10/24/25, 10/25/25 to 12/23/25, and 12/24/25 to 2/21/26.Review of the Spiritual Assessment dated 3/2/25, showed the SC conducted a telehealth spiritual care visit for the patient; however, there was no documented evidence the physician had ordered a telehealth visit for the patient.Review of Patient 6’s POC/Review dated 3/4/25, showed MSW visits one time monthly for psychosocial/emotional support and assistance with outside resources plus one PRN visit for miscellaneous needs; and SC one time monthly for spiritual and bereavement support plus one PRN visit for spiritual crisis/intervention.Further review of the clinical record failed to show documented evidence the MSW conducted monthly visits and SC conducted monthly visits as ordered.The POC/IDG Review dated 12/23/25 and 1/6/26, showed LVN visits one per week plus two PRN visits to manage shortness of breath, nausea/vomiting, anxiety and pain.Review of the LVN Visit Notes failed to show documented evidence the LVN conducted a visit during Week 7 (2/1/26 to 2/7/26) as ordered.On 2/12/26 at 1038 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.”

“Based on interview and record review, the hospice failed to ensure individualized care plans were developed for six of six sampled patients (Patients 1, 2, 3, 4, 5 and 6). This failure had the potential to cause inconsistent delivery of care which could result in the decline or lack of improvement of the patients’ health conditions. Review of the hospice’s P&P titled the Plan of Care revised 11/2021 showed the written plan of care will contain, but not limited to, the following:A. DiagnosisB. Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, and counseling.C. Reduction in risk factorsD. Functional limitationsE. Mental StatusF. Safety measures to protect against abuse, injury, infection, or communicable disease, as appropriateG. Nutritional requirementsH. PrognosisI. DME and medical supplies necessary to meet patient needsJ. Frequency of servicesK. Placement of the appropriate level of care and referrals as needed for counseling, additional disciplines, volunteers, and adjunctive servicesL. Individualized interventions to assist with end-of-life careM. Patient and family/caregiver educational needs and assessment of their ability to learn and understand teaching.N. Statement of treatment goalsO. Interdisciplinary group assessment of needsP. Pain and symptom management interventionsQ. Drugs and treatments (including allergies)R. Physician-directed instruction to patient and family/caregiverS. Physician (or other authorized licensed independent practitioner) ordersT. Measurable outcomes anticipated from implementing and coordinating the plan of care.U. Patient or representative’s level of understanding, involvement and agreement with the plan of care1. Review of Patient 1’s clinical record was initiated on 2/3/26. The clinical record showed the SOC was 2/6/25. The patient was certified for hospice services during the certification periods from 2/6/25 to 5/6/25, 5/7/25 to 8/4/25, 8/5/25 to 10/3/25, 10/4/25 to 12/2/25, 12/3/25 to 1/31/26, and 2/1/26 to 4/1/26.Review of the Comprehensive Nursing Assessment dated 2/6/25, showed the patient was assessed as anxious and agitated; had +2 pitting edema; and had poor appetiteThe POC/IDG Review dated 2/18/25. showed a new order for Ativan (antianxiety) 1 mg tablet every six hours as needed, risperidone (antipsychotic) 1 mg one tablet two times a day and Seroquel (antipsychotic) 25 mg one tablet two times a day. It showed the IDG had discussed patient’s diagnosis of unspecified protein-calorie malnutrition and +2 pitting edema.However, there was no documentation the IDG had developed an individualized POC to address Patient 1’s anxiety, agitation, +2 pitting edema, and poor appetite.Review of the POC/IDG Review dated 3/4/25, showed a new wound care treatment order on 3/1/25, for the left leg wound: to cleanse with normal saline, pat dry, and apply gauze and dry dressing daily and as needed if soiled or dislodged. However, there was no documentation the IDG had developed an individualized POC to address Patient 1’s wound.Review of the POC/IDG Review dated 4/15/25, showed a new order for melatonin (supplement) 5 mg one tablet daily at bedtime. However, there was no documentation the IDG had developed an individualized POC to address Patient 1’s inability to sleep. On 2/12/26 at 0833 hours, an interview and concurrent clinical record review was conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.2. Review of Patient 2’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 12/3/24. The patient was certified for hospice services during the certification periods from 12/3/24 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, 9/29/25 to 11/27/25, 11/28/25 to 1/26/26, and 1/27/26 to 3/27/26.Review of LVN 1’s Visit Note dated 1/31/26, showed the patient had a wound on the lower left back and an initial wound care was performed: cleansed with wound cleanser, patted dry, applied triple antibiotic ointment and covered with sterile bandage. Documentation showed new medications were ordered: clindamycin (antibiotic) 150 mg one capsule three times a day for seven days and Bactrim DS (antibiotic) one tablet two times a day for seven days; and dermatology consult was ordered.However, there was no documented evidence the IDG had developed an individualized POC to address Patient 2’s wound.On 2/12/26 at 0900 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and acknowledged the findings.3. Review of Patient 3’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 9/13/25. The patient was certified for hospice services during the certification periods from 9/13/25 to 12/11/25 and 12/12/25 to 3/11/25.Review of the POC/IDG Review dated 12/23/25, showed an order for buspirone hydrochloride (antianxiety) 15 mg 1 tablet two times a day for anxiety and risperidone (antipsychotic) 2 mg one tablet two times a day for restlessness.However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s anxiety and restlessness.On 2/12/26 at 0930 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings. 4. Review of Patient 4’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 11/16/24. The patient was certified for hospice services during the certification periods from 11/16/24 to 2/13/25, 2/14/25 to 4/14/25, 4/15/25 to 6/13/25, 6/14/25 to 8/12/25, 8/13/25 to 10/11/25, 10/12/25 to 12/10/25, and 12/11/25 to 2/8/26.Review of LVN 3’s Comprehensive Nursing Assessment dated 11/16/24, showed the following:-The patient was on hemodialysis every Mondays, Wednesdays, and Fridays; and was on fluid restriction of 1000 ml per day.-The patient had an episode of severe diarrhea for the past three to four days and nausea/vomiting. The physician prescribed Flagyl (antibiotic) 500 mg three times a day for seven days.-The patient was diabetic.-The patient reported a lack of appetite and had a weight loss of about 20 to 30 pounds.However, there was no documented evidence the IDG had developed an individualized POC to address the patient’s identified care issues. On 2/12/26 at 0942 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.5. Review of Patient 5’s clinical record was initiated on 2/10/26. The clinical record showed the SOC was 8/15/25. The patient was certified for hospice services during the certification periods from 8/15/25 to 10/13/25, 10/14/25 to 12/12/25, and 12/13/25 to 2/10/25.Review of LVN 2’s Skin Assessment dated 10/24/25, showed multiple wounds noted on the left hand (base of thumb, ldorsum, and spine area).The Hospice’s POC/IDG Review dated 10/28/25, showed IDG had discussed the multiple wounds; however, there was no documented evidence an individualized POC was developed to address the patient’s wounds.On 2/12/26 at 1019 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.6. Review of Patient 6’s clinical record was initiated on 2/11/26. The clinical record showed the SOC was 2/27/25. The patient was certified for hospice services during the certification periods from 2/27/25 to 5/27/25, 5/28/25 to 8/25/25, 8/26/25 to 10/24/25, 10/25/25 to 12/23/25, and 12/24/25 to 2/21/26.Review of the initial Comprehensive Nursing Assessment dated 2/27/25, showed the patient had some scattered pustules (blister-like skin lesions) to the bilateral lower extremities; and redness on the bilateral groin area.However, the IDG/POC Review dated 3/4/25, failed to show documented evidence the IDG had developed an individualized POC to address Patient 6’s scattered pustules to the bilateral lower extremities and redness on the bilateral groin area.Review of the Communication/Progress Log dated 12/5/25, showed the patient reported symptoms of pain when voiding; and the physician ordered Levaquin (antibiotic) 500 mg once daily for five days.However, the IDG/POC Review dated 12/9/25, failed to show documented evidence the IDG had developed an individualized POC to address Patient 6’s reported pain when voiding and the antibiotic medication Levaquin.On 2/12/26 at 1038 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.”

“Based on interview and record review, the hospice failed to ensure the initial and revised POCs included the indication for the PRN discipline visits for two of six sampled patients (Patients 2 and 3). This failure had the potential of not providing necessary services for these patients.Findings: 1. Review of Patient 2’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 12/3/24. The patient was certified for hospice services during the certification periods from 12/3/24 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, 9/29/25 to 11/27/25, 11/28/25 to 1/26/26, and 1/27/26 to 3/27/26.The POC/IDG Review dated 12/24/24, 1/7, 1/21/, 2/4, 2/18, 3/4, 3/18, 4/1, 4/15, 4/29, 5/13, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25 and 1/6/26, showed LVN visits one per week plus three PRN visits; MSW visits one per month plus one PRN visit; and RN visits one per two weeks plus one PRN visit.However, there was no documented evidence showing the indication for the PRN visits.On 2/12/26 at 0900 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and acknowledged the findings.2. Review of Patient 3’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 9/13/25. The patient was certified for hospice services during the certification periods from 9/13/25 to 12/11/25 and 12/12/25 to 3/11/25.The POC/IDG Review dated 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25 and 1/6/26, showed the LVN visits one per two weeks plus two PRN visits; MSW one time and then, PRN; and RN visits one per two weeks and one PRN visit.However, there was no documented evidence showing the indication for the PRN visits.On 2/12/26 at 0930 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.”

“Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for six of six sampled patients (Patients 1, 2, 3, 4, 5 and 6). This failure had the potential risk of not evaluating the POC and providing appropriate care and services to these patients. Review of the clinical records for Patients 1, 2, 3, 4, 5 and 6 showed no documented evidence the POCs included measurable outcomes. For example:1. Review of Patient 1’s clinical record was initiated on 2/3/26. The clinical record showed the SOC was 2/6/25. The patient was certified for hospice services during the certification periods from 2/6/25 to 5/6/25, 5/7/25 to 8/4/25, 8/5/25 to 10/3/25, 10/4/25 to 12/2/25, 12/3/25 to 1/31/26, and 2/1/26 to 4/1/26.The POC/IDG Review dated 3/4, 3/18, 4/1, 4/15, 4/29, 5/13, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25, and 1/20/26 showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example, Patient 1 had a care plan addressing edema to bilateral lower extremities. Documentation showed one of the goals was to prevent discomfort due to increasing edema. There was no documented evidence as to what was the acceptable comfort for the patient.On 2/12/26 at 0833 hours, an interview and concurrent clinical record review was conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.2. Review of Patient 2’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 12/3/24. The patient was certified for hospice services during the certification periods from 12/3/24 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, 9/29/25 to 11/27/25, 11/28/25 to 1/26/26 and 1/27/26 to 3/27/26.The POC/IDG Review dated 12/10, 12/24/24, 1/7, 1/21/, 2/4, 2/18, 3/4, 3/18, 4/1, 4/15, 4/29, 5/13, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25 and 1/6/26 showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example, Patient 2 had a care plan addressing weakness. Documentation showed one of the goals was to increase strength/energy for functional activities. There was no documented evidence as to what increased strength/energy was for the patient.On 2/12/26 at 0900 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and acknowledged the findings.3. Review of Patient 3’s clinical record was initiated on 2/4/26. The clinical record showed SOC was 9/13/25. The patient was certified for hospice services during the certification periods from 9/13/25 to 12/11/25 and 12/12/25 to 3/11/25. The POC/IDG Review dated 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25, and 1/6/26, showed patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example, Patient 3 had a care plan addressing altered cardiac status. Documentation showed one of the goals was to prevent discomfort due to increasing edema. There was no documented evidence as to what was acceptable comfort for the patient.On 2/12/26 at 0930 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.4.Review of Patient 4’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 11/16/24. The patient was certified for hospice services during the certification periods from 11/16/24 to 2/13/25, 2/14/25 to 4/14/25, 4/15/25 to 6/13/25, 6/14/25 to 8/12/25, 8/13/25 to 10/11/25, 10/12/25 to 12/10/25, and 12/11/25 to 2/8/26.The POC/IDG Review dated 11/26, 12/23/24, 1/7, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25, and 1/6/26, showed patient’s identified problems with established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example, Patient 4 had a care plan addressing altered cardiac status related to two plus bilateral lower extremities edema. Documentation showed one of the goals was to prevent discomfort due to increasing edema. There was no documented evidence as to what was acceptable comfort for the patient.On 2/12/26 at 0942 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.5. Review of Patient 5’s clinical record was initiated on 2/10/26. The clinical record showed the SOC was 8/15/25. The patient was certified for hospice services during the certification periods from 8/15/25 to 10/13/25, 10/14/25 to 12/12/25, and 12/13/25 to 2/10/25.The POC/IDG Review dated 8/19, 9/2, 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25, 1/6, and 1/20/26, showed patient’s identified problems with established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example, Patient 5 had a care plan addressing alteration in comfort symptoms related to generalized body pain. Documentation showed one of the goals was for pain will remain in comfortable level during care. There was no documented evidence as to what comfortable level was for the patient.On 2/12/26 at 1019 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.6. Review of Patient 6’s clinical record was initiated on 2/11/26. The clinical record showed the SOC was 2/27/25. The patient was certified for hospice services during the certification periods from 2/27/25 to 5/27/25, 5/28/25 to 8/25/25, 8/26/25 to 10/24/25, 10/25/25 to 12/23/25, and 12/24/25 to 2/21/26.The POC/IDG Review dated 3/4, 3/18, 10/28, 11/11, 11/25, 12/9, 12/23/25, and 1/6/26, showed the patient’s identified problems with established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example, Patient 6 had a care plan addressing potential for increasing pain with disease process. Documentation showed one of the goals was pain will remain at a comfortable level during care. There was no documented evidence as to what the comfortable level for pain was for this patient.On 2/12/26 at 1038 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.”

“Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patients’ POCs no less frequently than every 15 calendar days for six of six sampled patients (Patients 1, 2, 3, 4, 5 and 6). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. The hospice’s P&P titled Interdisciplinary Group Membership and Responsibilities revised 11/2021, showed the hospice interdisciplinary team/group members will include, at a minimum:A. PhysicianB. Registered NurseC. Social WorkerD. Pastoral or other counselorThe hospice’s P&P titled Interdisciplinary Group Meeting revised 11/2021, showed the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor.1.Review of Patient 1’s clinical record was initiated on 2/3/26. The clinical record showed the SOC was 2/6/25. The patient was certified for hospice services during the certification periods from 2/6/25 to 5/6/25, 5/7/25 to 8/4/25, 8/5/25 to 10/3/25, 10/4/25 to 12/2/25, 12/3/25 to 1/31/26, and 2/1/26 to 4/1/26.Review of the POC/IDG Review dated 3/4, 3/18, 4/1, 4/15, 4/29, 5/13, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25 and 1/20/26, showed the patient’s identified care plan problem included potential for altered cardiac status, risk for constipation, agitation, anger, anxiety, potential for increasing pain, and dyspnea with activity. The identified problems were opened on 2/6/25.There was no documented evidence the identified care plan problems were updated to provide appropriate care for the patient.Review of the clinical record showed the POC/IDG Review was conducted on 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25 and 1/20/26. However, there was no documented evidence a POC/IDG Review was conducted after 12/23/25 and 1/20/26.In addition, review of the POC/IDG Review dated 1/20/26, showed the members of the IDG included the Medical Director, RN, MSW and SC. However, the IDG members were incomplete as the section of the Medical Director and SC were left blank.On 2/12/26 at 0833 hours, an interview and concurrent clinical record review was conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.2. Review of Patient 2’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 12/3/24. The patient was certified for hospice services during the certification periods from 12/3/24 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, 9/29/25 to 11/27/25, 11/28/25 to 1/26/26, and 1/27/26 to 3/27/26.Review of the POC/IDG Review dated 3/18, 4/1, 4/15, 4/29, 5/13, 5/27, 6/10, 6/24, 7/8, 7/22, 8/5, 8/19, 9/2, 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9 and 12/23/25, showed the patient’s identified care plan problem opened on the following dates:-12/3/24, weakness and altered neurological status-12/5/24, grieving family, patient not having mortuary plan yet and lack coping skillsHowever, there was no documented evidence the identified care plan problems were updated to provide appropriate care for the patient.Review of the clinical record showed the POC/IDG review was conducted on 3/4, 3/18, 4/1, 4/15, 4/29, 5/13, 5/27, 6/10, 6/24, 7/8, 7/22, 8/5, 8/19, 9/2, 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25 and 1/6/26. However, there was no documented evidence of a POC/IDG Review was conducted after 1/6/26.On 2/12/26 at 0900 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and acknowledged the findings.3. Review of Patient 3’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 9/13/25. The patient was certified for hospice services during the certification periods from 9/13/25 to 12/11/25 and 12/12/25 to 3/11/25.The POC/IDG Review dated 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25 and 1/6/26, showed the patient’s identified care plan problem included altered cardiac status related to syncope (fainting or passing out), altered mobility related to stroke, altered neurological status related to confusion, altered nutritional status related to difficulty swallowing. The identified problems were opened on 9/13/25.There was no documented evidence the identified care plan problems were updated to provide appropriate care for the patient.Review of the clinical record showed the POC/IDG review was conducted on 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25 and 1/6/26. However, there was no documented evidence of a POC/IDG review was conducted after 1/6/26.In addition, review of the POC/IDG Review dated 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25 and 1/6/26, showed the members of the IDG included the Medical Director, RN, MSW and SC. However, the IDG members were incomplete as the section of the MSW and SC were left blank.On 2/12/26 at 0930 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.4. Review of Patient 4’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 11/16/24. The patient was certified for hospice services during the certification periods from 11/16/24 to 2/13/25, 2/14/25 to 4/14/25, 4/15/25 to 6/13/25, 6/14/25 to 8/12/25, 8/13/25 to 10/11/25, 10/12/25 to 12/10/25, and 12/11/25 to 2/8/26.Review of the POC/IDG Review dated 11/26, 12/23/24, 1/7, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25, 1/6, 1/20, and 2/3/26, showed the patient’s identified care problem included the following:-Altered respiratory status related to dyspnea (difficulty breathing). The identified problem was opened by RN 3 on 11/16/24.-Grieving family, patient does not have a mortuary and lacks coping skills. The identified problems were opened by the MSW on 11/19/24.-Spiritual distress. The identified problem was opened by the SC on 11/20/24.There was no documented evidence the identified care plan problems were updated to provide appropriate care for the patient.Review of the POC/IDG Review dated 1/20/26, showed the members of the IDG included the Medical Director, RN, MSW and SC. However, the IDG members were incomplete as the section of the Medical Director was left blank.Review of the POC/IDG Review dated 2/3/26, showed the members of the IDG included the Medical Director, RN, MSW and SC. However, the IDG members were incomplete as the section of the Medical Director and RN were left blank.On 2/12/26 at 0942 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.5. Review of Patient 5’s clinical record was initiated on 2/10/26. The clinical record showed the SOC was 8/15/25. The patient was certified for hospice services during the certification periods from 8/15/25 to 10/13/25, 10/14/25 to 12/12/25 and 12/13/25 to 2/10/25.Review of RN 3’s Skin Assessment dated 8/15/25, showed patient have existing wounds in the coccyx area, right back knee, and left back knee.Review of RN 3’s Skin Assessment dated 10/1/25, showed patient have redness on the upper posterior knee.Review of RN 3’s Skin Assessment dated 10/15/25, showed patient have skin tears in the left hand inner side and wound on the tail bone.The POC/Review dated 10/14 and 10/28/25, showed IDG conducted the meetings. However, the care plan for skin/integumentary was not updated. Documentation showed the care plan still had an open date of 8/15/25.Review of the POC/IDG Review dated 8/19, 9/2, 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25, 1/6, and 1/20/26 showed the members of the IDG included the Medical Director, RN, MSW and SC. However, the IDG members were incomplete as the section of the MSW and SC were left blank. Furthermore, there was no documented evidence the spiritual and psychosocial were discussed during the abovementioned IDG/POC Review dates. Review of the POC/IDG Review dated 8/19, 9/2, 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25, 1/6, and 1/20/26, showed the members of the IDG included the Medical Director, RN, MSW and SC. However, the members of the IDG were left blank.On 2/12/26 at 1019 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.6. Review of Patient 6’s clinical record was initiated on 2/11/26. The clinical record showed the SOC was 2/27/25. The patient was certified for hospice services during the certification periods from 2/27/25 to 5/27/25, 5/28/25 to 8/25/25, 8/26/25 to 10/24/25, 10/25/25 to 12/23/25, and 12/24/25 to 2/21/26.Review of the POC/IDG Review dated 10/28, 11/11, 11/25, 12/9 and 12/23/25, showed the patient’s identified care plan problem opened on the following dates:-2/27/25, potential for altered cardiac status related to hypertension, Diabetes, incontinent, drug allergy, depression, potential for increasing pain with disease process, dyspnea with activity, insomnia-3/2/25, spiritual distress-3/3/25, grieving PCG, not having a mortuary plan yet, lacks coping skill-6/16/25, wounds to BLE-7/29/25, Bed-bound/Chair-bed transfer-8/30/25, pain requiring increasing dosage of analgesics related to chronic back pain with muscle spasmHowever, there was no documented evidence the identified care plan problems were updated to provide appropriate care for the patient.Review of the clinical record showed the POC/IDG review was conducted on 10/28, 11/11, 11/25, 12/9, 12/23/25, and 1/6/26. However, there was no documented evidence a POC/IDG review conducted after 1/6/26.On 2/12/26 at 1038 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.”

“Based on interview and record review, the hospice failed to ensure the revised POCs included the patient’s progress toward goals specified in the POCs for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6). This failure had the potential of not identifying the care needs and providing necessary care and services to meet the care needs for these patients. Review of the hospice’s P&P titled Interdisciplinary Group Membership and Responsibilities revised 11/2021, showed the interdisciplinary team/group will collaborate with the patient’s attending physician to develop a patient-directed plan of care. The interdisciplinary group will participate in the establishment of the plan of care for each patient admitted to the hospice service.1. Review of Patient 1’s clinical record was initiated on 2/3/26. The clinical record showed the SOC was 2/6/25. The patient was certified for hospice services during the certification periods from 2/6/25 to 5/6/25, 5/7/25 to 8/4/25, 8/5/25 to 10/3/25, 10/4/25 to 12/2/25, 12/3/25 to 1/31/26, and 2/1/26 to 4/1/26.Review of the POC/IDG Review dated 5/13/25, showed the patient’s identified care problems included a target date. The identified care problems were edema to bilateral lower extremities, risk for constipation, agitation, potential for increasing pain, lack of coping skills, dyspnea with activity and spiritual distress. The identified problems showed a target date of 4/29/25.However, there was no documentation showing the patient’s progress towards the outcome and goals specified in the plan of care. Review of the POC/IDG Review dated 10/14, 10/28, 11/11, 11/25, and 12/9/25, showed patient’s identified care problems included a target date. The identified care problems were edema to bilateral lower extremities, risk for constipation and spiritual distress. The identified problems showed a target date of 7/22/25.However, there was no documentation showing the patient’s progress towards the outcome and goals specified in the plan of care.On 2/12/26 at 0833 hours, an interview and concurrent clinical record review was conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.2. Review of Patient 2’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 12/3/24. The patient was certified for hospice services during the certification periods from 12/3/24 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, 9/29/25 to 11/27/25, 11/28/25 to 1/26/26, and 1/27/26 to 3/27/26.Review of the POC/IDG Review dated 3/18, 4/1, 4/15, 4/29, 5/13, 5/27, 6/10, 6/24, 7/8, 7/22, 8/5, 8/19, 9/2, 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9 and 12/23/25, showed the patient’s identified care plan problem were opened on the following dates and showed a target date of 3/4/25.-12/3/24, weakness and altered neurological status-12/5/24, grieving family, patient not having mortuary plan yet and lack coping skillsHowever, there was no documentation showing the patient’s progress toward outcome and goals specified in the plan of care.On 2/12/26 at 0900 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.3. Review of Patient 3’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 9/13/25. The patient was certified for hospice services during the certification periods from 9/13/25 to 12/11/25 and 12/12/25 to 3/11/25.The POC/IDG Review dated 9/30/25 showed the patient’s identified care plan problems opened on 9/16/25:-Altered cardiac status related to syncope (fainting or passing out) with goal of patient’s edema to right will decrease within the next two weeks.-Altered neurological status related to confusion with goal of patient’s episode of confusion will be minimal within the next two weeks.However, there was no documented evidence the POC included the patient’s progress towards the goal for the care plan problem identified.The POC/IDG Review dated 11/25/25, showed the patient’s identified care plan problems opened on 9/16/25:-Altered mobility related to stroke with goal of patient will be able to transfer from bed to wheelchair within the next two months.-Altered nutritional status related to difficulty swallowing with goal of patient able to tolerate puree diet as ordered within the next two months.However, there was no documented evidence the POC included the patient’s progress towards the goal for the care plan problem identified.On 2/12/26 at 0930 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.4. Review of Patient 4’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 11/16/24. The patient was certified for hospice services during the certification periods from 11/16/24 to 2/13/25, 2/14/25 to 4/14/25, 4/15/25 to 6/13/25, 6/14/25 to 8/12/25, 8/13/25 to 10/11/25, 10/12/25 to 12/10/25, and 12/11/25 to 2/8/26.Review of the POC/IDG Review dated 12/23/24 showed patient’s identified care problems included a target date. The identified care problems were grieving family, altered cardiac status related to two plus bilateral lower extremities pitting edema, nausea and vomiting, altered neurological status related to restlessness, hallucination, anxiety, alteration in comfort symptoms related to abdominal pain, does not have a mortuary, lacks coping skills, alteration in respiratory status, dyspnea (difficulty breathing) and spiritual distress. The identified problems showed a target date of 12/10/24.However, there was no documentation showing the patient’s progress towards the outcome and goals specified in the plan of care.Review of the POC/IDG Review dated 10/14, 10/28, 11/11, 11/25, 12/9, and 12/23/25, showed patient’s identified care problems included a target date. The identified care problems were grieving family, altered cardiac status related to two plus bilateral lower extremities pitting edema, increase risk related to falls, nausea and vomiting, does not have a mortuary, and spiritual distress. The identified problems showed a target date of 9/30/25.However, there was no documentation showing the patient’s progress towards the outcome and goals specified in the plan of care. On 2/12/26 at 0942 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.5. Review of Patient 5’s clinical record was initiated on 2/10/26. The clinical record showed the SOC was 8/15/25. The patient was certified for hospice services during the certification periods from 8/15/25 to 10/13/25, 10/14/25 to 12/12/25, and 12/13/25 to 2/10/25.Review of the POC/IDG Review dated 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25, 1/6, and 1/20/26 showed the patient’s identified problems included a target date. For example, deficit in self-care, increased fall risk and alteration in comfort related to generalized pain. The identified problems showed a target date of 9/2/25.However, there was no documentation showing the patient’s progress towards the outcome and goals specified in the plan of care. Review of the POC/IDG Review dated 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25, 1/6, and 1/20/26 showed the patient’s identified problems included a target date. The identified problem included skin integrity related to bilateral posterior knee and coccyx (small triangular bone at the base of the spinal column) wounds. The identified problems showed a target date of 9/16/25.However, there was no documentation showing the patient’s progress towards the outcome and goals specified in the plan of care.On 2/12/26 at 1019 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.6. Review of Patient 6’s clinical record was initiated on 2/11/26. The clinical record showed the SOC was 2/27/25. The patient was certified for hospice services during the certification periods from 2/27/25 to 5/27/25, 5/28/25 to 8/25/25, 8/26/25 to 10/24/25, 10/25/25 to 12/23/25, and 12/24/25 to 2/21/26.Review of the POC/IDG Review dated 10/28, 11/11, 11/25, 12/9, and 12/23/25, showed the patient’s identified problems included a target date. The identified problems were grieving PCG, potential for altered cardiac status related to hypertension, diabetes, incontinent, drug allergy, depression, potential for increasing pain with disease process, does not have a mortuary plan, lacks coping skill, dyspnea with activity, insomnia and spiritual distress. The identified problems showed a target date of 4/29/25.However, there was no documentation showing the patient’s progress toward outcome and goals specified in the plan of care.On 2/12/26 at 1038 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.”

“Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing and supervising the care and services provided for five of six sampled patients (Patients 1, 3, 4, 5 and 6). This failure had the potential of not addressing the care needs for these patients.Findings: Review of the hospice’s P&P titled Interdisciplinary Group Membership and Responsibilities revised 11/2021, showed the interdisciplinary group will among others: participate in the establishment of the plan of care for each patient admitted to the hospice service, participate in the periodic review and updating of the plan of care for each patient receiving hospice services and provide or supervise hospice care and services.Review of the hospice’s P&P titled Interdisciplinary Group Coordination of Care revised 11/2021, showed the type and scope of services provided by the interdisciplinary group will be based upon the comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and intervention. All interdisciplinary group shall direct, coordinate and supervise the hospice services.1.Review of Patient 1’s clinical record was initiated on 2/3/26. The clinical record showed the SOC was 2/6/25. The patient was certified for hospice services during the certification periods from 2/6/25 to 5/6/25, 5/7/25 to 8/4/25, 8/5/25 to 10/3/25, 10/4/25 to 12/2/25, 12/3/25 to 1/31/26, and 2/1/26 to 4/1/26.Review of the Spiritual Assessment dated 2/6/25, showed the SC would continue to visit for recertification and as needed.Review of the POC/IDG Review dated 2/18/25, showed a new order for SC visits one time monthly for spiritual and bereavement support.However, there was no documented evidence the SC had conducted the visit as ordered and no documented evidence it was coordinated with the IDG.On 2/12/26 at 0833 hours, an interview and concurrent clinical record review was conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.2. Review of Patient 3’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 9/13/25. The patient was certified for hospice services during the certification periods from 9/13/25 to 12/11/25 and 12/12/25 to 3/11/25.Review of the Re-Cert Assessment dated 12/7/25, showed RN 1 checked Social Work in the referral section.However, there was no documented evidence the MSW visited the patient and no documented evidence it was coordinated with the IDG.On 2/12/26 at 0930 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.3. Review of Patient 4’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 11/16/24. The patient was certified for hospice services during the certification periods from 11/16/24 to 2/13/25, 2/14/25 to 4/14/25, 4/15/25 to 6/13/25, 6/14/25 to 8/12/25, 8/13/25 to 10/11/25, 10/12/25 to 12/10/25, and 12/11/25 to 2/8/26.Review of the Psychosocial Assessment dated 11/19/24, showed the MSW would continue to assess the patient and family’s situation with each recertification visit, provide support once a month, and as needed.Review of the POC/IDG Review dated 11/26/24, showed MSW visits on admission, recert, and PRN visit per patient/family request.However, there was no documented evidence the MSW had conducted the visit and no documented evidence it was coordinated with the IDG.On 2/12/26 at 0942 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.4. Review of Patient 5’s clinical record was initiated on 2/10/26. The clinical record showed the SOC was 8/15/25. The patient was certified for hospice services during the certification periods from 8/15/25 to 10/13/25, 10/14/25 to 12/12/25, and 12/13/25 to 2/10/25.Review of the Comprehensive Nursing Assessment dated 8/15/25, showed RN 3 checked Social Work in the referral section. However, there was no documented evidence the MSW had a visit and no documented evidence it was coordinated with the IDG.Review of LVN 2’s Skin Assessment dated 12/19/25, showed there was worsening condition for the wounds located at:-sacral/coccyx had several open wounds with a mixture of pink/red tissue. The surrounding skin is dark red to purple and appeared inflamed. Moisture in the skin folds had caused mild maceration (skin softening and breakdown). There was a small open lesion on the lower right side with exposed red tissue and general area measured 7 cm (length) x 7 cm (length).-spine had large dark-purple discoloration and the general area measured 6 cm (length) x 4 cm (length).However, there was no documented evidence the worsening condition of the wounds were coordinated with the IDG. On 2/12/26 at 1019 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.5. Review of Patient 6’s clinical record was initiated on 2/11/26. The clinical record showed the SOC was 2/27/25. The patient was certified for hospice services during the certification periods from 2/27/25 to 5/27/25, 5/28/25 to 8/25/25, 8/26/25 to 10/24/25, 10/25/25 to 12/23/25 and 12/24/25 to 2/21/26.Review of the Psychosocial Assessment dated 3/3/25, showed the MSW would continue to monitor the patient and family situation during recertification visits or as needed, providing psychosocial support and assistance at least once a month and on as needed basis.Review of the POC/IDG Review dated 3/4/25, showed MSW visits one time monthly for psychosocial/emotional support and assistance with outside resources plus one PRN visit for miscellaneous needs.However, there was no documented evidence the MSW had a monthly visit and no documented evidence it was coordinated with the IDG.Review of the Spiritual Assessment 3/2/25, showed the SC would continue to visit for recertification and as needed.Review of the POC/IDG Review dated 3/4/25, showed SC visit one time monthly for spiritual and bereavement support plus one PRN visit for spiritual crisis/intervention. However, there was no documented evidence the SC had a monthly visit and no documented evidence it was coordinated with the IDG.On 2/12/26 at 1038 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.”

“Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for six of six sampled patients (Patients 1, 2, 3, 4, 5 and 6). This failure had the potential for not providing appropriate, consistent, and quality care to the patients. Review of the hospice’s P&P titled the Plan of Care revised 11/2021, showed the written plan of care will contain, but not limited to, the following:A. DiagnosisB. Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, and counseling.C. Reduction in risk factorsD. Functional limitationsE. Mental StatusF. Safety measures to protect against abuse, injury, infection, or communicable disease, as appropriateG. Nutritional requirementsH. PrognosisI. DME and medical supplies necessary to meet patient needsJ. Frequency of servicesK. Placement of the appropriate level of care and referrals as needed for counseling, additional disciplines, volunteers, and adjunctive servicesL. Individualized interventions to assist with end-of-life careM. Patient and family/caregiver educational needs and assessment of their ability to learn and understand teaching.N. Statement of treatment goalsO. Interdisciplinary group assessment of needsP. Pain and symptom management interventionsQ. Drugs and treatments (including allergies)R. Physician-directed instruction to patient and family/caregiverS. Physician (or other authorized licensed independent practitioner) ordersT. Measurable outcomes anticipated from implementing and coordinating the plan of care.U. Patient or representative’s level of understanding, involvement and agreement with the plan of care1. Review of Patient 1’s clinical record was initiated on 2/3/26. The clinical record showed the SOC was 2/6/25. The patient was certified for hospice services during the certification periods from 2/6/25 to 5/6/25, 5/7/25 to 8/4/25, 8/5/25 to 10/3/25, 10/4/25 to 12/2/25, 12/3/25 to 1/31/26, and 2/1/26 to 4/1/26.Review of Patient 1’s POC/IDG Review dated 2/18/25, showed a recent order dated 2/6/25, for SN visits one time per week plus three PRN visits; MSW visits one time monthly plus one PRN visit; and SC visits one time monthly plus one PRN visit.Record of Patient 1’s History of Nursing Assessments showed the RN conducted the recertification visits on 4/26, 8/2 and 9/27/25 and Updated Assessment on 11/22/25.Review of the Spiritual Assessment dated 2/6/25, showed the SC conducted a telehealth spiritual care visit for the patient. However, there was no documented evidence a physician had ordered a telehealth visit for the patient.Further review of the clinical record failed to show documented evidence of SC and MSW visits as ordered.On 2/12/26 at 0833 hours, an interview and concurrent clinical record review was conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.2. Review of Patient 2’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 12/3/24. The patient was certified for hospice services during the certification periods from 12/3/24 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, 9/29/25 to 11/27/25, 11/28/25 to 1/26/26, and 1/27/26 to 3/27/26.Review of the Spiritual Assessment dated 12/6/24, showed the SC conducted a telehealth visit for the patient. However, there was no documented evidence a physician had ordered a telehealth visit for the patient.Review of the POC/IDG Review dated 9/16/25 and 11/25/25, showed MSW visits one per month plus one PRN visits.Further review of the clinical record failed to show documented evidence of MSW visits as ordered.However, the record of Patient 2’s History of Psychosocial Assessment failed to show any documentation of the MSW visits for the months of 9/2025, 10/2025, 11/2025 and 12/2025.On 2/12/26 at 0900 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and acknowledged the findings.3. Review of Patient 3’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 9/13/25. The patient was certified for hospice services during the certification periods from 9/13/25 to 12/11/25 and 12/12/25 to 3/11/25.The POC/IDG Review dated 9/16/25, showed RN visits one per two weeks plus one PRN visit.Further review of the clinical record failed to show documented evidence the RN had visited the patient on Week 3 (9/21/25 to 9/27/25) as ordered in the POC.The POC/IDG Review dated 9/16/25, showed the MSW visits one time then, PRN.Further review of the clinical record failed to show documented evidence the MSW had visited the patient as ordered in the POC.On 2/12/26 at 0930 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings. 4. Review of Patient 4’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 11/16/24. The patient was certified for hospice services during the certification periods from 11/16/24 to 2/13/25, 2/14/25 to 4/14/25, 4/15/25 to 6/13/25, 6/14/25 to 8/12/25, 8/13/25 to 10/11/25, 10/12/25 to 12/10/25 and 12/11/25 to 2/8/26.Review of Patient 4’s POC/IDG Review dated 11/26/24, showed MSW visits on admission, recert, and PRN as per patient/family request; and SC on admission, recert, and PRN visit as per patient/family request.Record of Patient 4’s History of Nursing Assessments showed the RN provided the recertification visits dated 2/13, 4/15, 6/12, 8/12, 10/7and 12/4/25.However, there was no documented evidence of MSW visits during the recertification on 2/13, 4/15, 6/12, 8/12, 10/7 and 12/4/25; and SC visits on 6/12, 8/12 and 10/7/25.Review of the Spiritual Assessment dated 2/13/25 and 4/14/25, the SC conducted a telehealth spiritual care visits; however, there was no documented evidence a physician had ordered telehealth visits for the patient.Review of Patient 4’s POC/IDG Review dated 10/14/25, showed LVN visits one per week plus three PRN visits to manage shortness of breath, nausea/vomiting, anxiety and pain.Review of the clinical record failed to show documented evidence the LVN had conducted visits during Week 3 (10/26/25 to 11/1/25), Week 4 (11/2/25 to 11/8/25), Week 5 (11/9/25 to 11/15/25), Week 6 (11/16/25 to 11/22/25), Week 8 (11/30/25 to 12/6/25) and Week 9 (12/7/25 to 12/13/25).Further review of the clinical record failed to show documented evidence the physician was informed of the missed visits and there was no attempt to reschedule the visits for the above weeks. On 2/12/26 at 0942 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.5. Review of Patient 5’s clinical record was initiated on 2/10/26. The clinical record showed the SOC was 8/15/25. The patient was certified for hospice services during the certification periods from 8/15/25 to 10/13/25, 10/14/25 to 12/12/25, and 12/13/25 to 2/10/25.The POC/IDG Review dated 10/14/25, showed a plan of care intervention for Integumentary/Skin dated 8/15/25, for the following:-Coccyx wound: cleansed with a sterile cotton tip applicator, treated with triple antibiotic, and covered with a 6 x 6 silicone foam dressing and a sacrum silicone dressing.-Bilateral posterior knee wounds: cleansed with wound cleanser, patted dry, and treated with triple antibiotic ointment. Dressed with 2 x 2 alginate dressing and a 4 x 4 island dressing, and covered with a 5 x 9 abdominal pad, secured with tape. Review of RN 3’s Skin Assessment dated 10/15/25, showed a wound care treatment for the following:-Coccyx wound: the area was gently cleansed, dried, treated with triple antibiotic and collagen powder, and covered with a sacral silicone foam dressing.-Skin at the back of both legs: areas were cleaned with wound spray, dried, and treated with medihoney ointment and collagen powder, covered with a 4 x 4 island dressing, wrapped with an abdominal pad and secured with tape.However, there was no documented evidence the physician had ordered the above wound treatments for Patient 5’s coccyx and bilateral posterior knee wounds.The POC/IDG Review dated 12/23/25, 1/6/26 and 1/20/26, showed SN visits one per week plus three PRN visits for skilled nursing crisis intervention.Review of the clinical record showed the SN had visited the patient on Week 2 (12/14/25 to 12/20/25), Week 3 (12/21/25 to 12/27/25), Week 4 (12/28/25 to 1/3/26), Week 5 (1/4/26 to 1/10/26) and Week 6 (1/11/26 to 1/17/26).However, there was no documented evidence SN had visited the patient on Week 7 (1/18/26 to 1/24/26) as ordered in the POC.The POC/IDG Review dated 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25, 1/6 and 1/20/26, showed MSW visit at recert, one PRN visit for psychosocial/emotional support and assistance with outside resources.Review of the clinical record showed no documented evidence the MSW had visited the patient as ordered in the POC.The POC/IDG Review dated 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25, 1/6 and 1/20/26, showed an HA visits two per week.However, there was no documented evidence the HA had visited the patient for the weeks from 11/23/25 to 11/29/25, 12/28/25 to 1/3/26, 1/4/26 to 1/10/26, 1/11/26 to 1/17/26, and 2/1/26 to 2/7/26 as ordered in the POC.On 2/12/26 at 1019 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.6. Review of Patient 6’s clinical record was initiated on 2/11/26. The clinical record showed the SOC was 2/27/25. The patient was certified for hospice services during the certification periods from 2/27/25 to 5/27/25, 5/28/25 to 8/25/25, 8/26/25 to 10/24/25, 10/25/25 to 12/23/25, and 12/24/25 to 2/21/26.Review of the Spiritual Assessment dated 3/2/25, showed the SC conducted a telehealth spiritual care visit for the patient; however, there was no documented evidence the physician had ordered a telehealth visit for the patient.Review of Patient 6’s POC/Review dated 3/4/25, showed MSW visits one time monthly for psychosocial/emotional support and assistance with outside resources plus one PRN visit for miscellaneous needs; and SC one time monthly for spiritual and bereavement support plus one PRN visit for spiritual crisis/intervention.Further review of the clinical record failed to show documented evidence the MSW conducted monthly visits; and the SC conducted monthly visits as ordered.The POC/IDG Review dated 12/23/25 and 1/6/26, showed LVN visits one per week plus two PRN visits to manage shortness of breath, nausea/vomiting, anxiety and pain.Review of the LVN Visit Notes failed to show documented evidence the LVN conducted a visit during Week 7 (2/1/26 to 2/7/26) as ordered.On 2/12/26 at 1038 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS acknowledged and verified the findings.”

“Based on interview and record review, the hospice failed to ensure a volunteer was used in day-to-day administrative role and/or direct patient care roles. This failure had the potential for creating an operational strain on the hospice.Findings: Review of the hospice’s volunteer program was initiated on 2/10/26. The Volunteer Time Sheet showed the volunteer provided administrative work on 5/21/24, 6/15/24 and 7/23/24. Further review of the Volunteer Time Sheet showed the Office Manager had provided non-direct patient care on 11/22/23, 4/24/24, 1/10/25, 3/15/25, 5/2/25, 7/15/25, 9/17/25 and 11/4/25 instead of a volunteer. However, the volunteer binder showed the hospice did not have any volunteer and/or Volunteer Coordinator. On 2/10/26 at 1451 hours, an interview and concurrent hospice document review was conducted with the Administrator. The Administrator was informed and confirmed the hospice did not have any volunteer and/or Volunteer Coordinator. On 2/11/26 at 1024 hours, an interview was conducted with the CEO/DPCS and COO. The COO verified the Office Manager who had performed the non-direct care was an employee and not a volunteer. The CEO/DPCS and COO both acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure there was an ongoing efforts for recruiting and retaining volunteers. This failure had the potential for not providing adequate volunteer services.Findings: Review of the hospice’s P&P titled Volunteer Services revised 11/2021, showed the Volunteer Coordinator will document ongoing efforts to recruit, train and retain volunteers of all ages and ethnic backgrounds. Review of the hospice’s volunteer program was initiated on 2/10/26. There was no documented evidence of ongoing efforts to recruit and retain volunteers for the years 2023, 2024 and 2025. On 2/10/26 at 1451 hours, an interview and concurrent hospice document review was conducted with the Administrator. The Administrator was informed and confirmed the hospice did not have any volunteer and/or Volunteer Coordinator. On 2/11/26 at 1024 hours, an interview was conducted with the CEO/DPCS and COO. The CEO/DPCS and COO were informed and both acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the cost saving was achieved using volunteers. This failure had the potential of not providing adequate volunteer services.Findings: Review of the hospice’s P&P titled Volunteer Services revised 11/2021, showed the Volunteer Coordinator will track the use of volunteers and the cost savings achieved. Review of the hospice’s volunteer program was initiated on 2/10/26. The Volunteer Time Sheet showed the Office Manager provided non-direct patient care on 11/22/23, 4/24/24, 1/10/25, 3/15/25, 5/2/25, 7/15/25, 9/17/25 and 11/4/25. However, the Office Manager was an employee and not a volunteer. Cross reference to L644. Further review of the hospice’s volunteer program failed to show documented evidence of cost savings achieved using volunteers for the year 2023, 2024 and 2025. On 2/10/26 at 1451 hours, an interview and concurrent hospice document review was conducted with the Administrator. The Administrator was informed and stated the hospice did not have a cost saving report utilizing volunteers. On 2/11/26 at 1024 hours, an interview was conducted with the CEO/DPCS and COO. The CEO/DPCS and COO were informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the volunteers provided at a minimum, equal to 5% of the total patient care hours of all paid hospice employees and contracted staff. This failure had the potential of not providing adequate volunteer services.Findings: Review of the hospice’s P&P titled Volunteer Services revised 11/2021, showed the Volunteer Coordinator will track the use of volunteers, cost savings achieved, and the hours of volunteer services exceed 5% of the total day-to-day administrative or direct patient care hours of paid and contracted hospice personnel. Review of the hospice’s volunteer program was initiated on 2/10/26. The hospice’s documents failed to show documented evidence the volunteers provided day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff for the years 2024 and 2025. On 2/10/26 at 1451 hours, an interview and concurrent hospice document review was conducted with the Administrator. The Administrator stated the hospice did not have a cost saving report utilizing volunteers. On 2/11/26 at 1024 hours, an interview was conducted with the CEO/DPCS and COO. The CEO/DPCS and COO were informed and acknowledged findings.”

“Based on interview and record review, the hospice’s GB and Administrator failed to be responsible for the day-to-day operations of the organization and maintain the administrative responsibility as evidenced by:-Failure to ensure the Administrator directed the hospice services, resulting in non-compliance with the COPs under 418.54 (Initial & Comprehensive Assessment); 418.56 (Interdisciplinary Group, Care Planning, and Coordination of Services); 418:78 (Volunteers); and 418.100 (Organization and Administration of Services).-Failure to ensure the Medical Director’s written agreement included the specific rights, roles and responsibilities as per the standards.-Failure of the Governing Body to review and address specific hospice operations, services and QAPI program.-Failure to ensure provided services were within the hospice’s geographical area.-Failure to ensure the RN provided timely supervision to the HAs.-Failure to ensure that the hospice had a referral for evaluation prior to admission of hospice patients.-Failure to ensure the patients’ clinical records were complete and accurate.-Failure to ensure member of the IDG signed the IDG meeting attendance form.-Failure to ensure the discharge summary was completed.These failures had the potential for poor health outcomes for the patients receiving hospice services. Review of the hospice’s P&P titled Governing Body revised 11/2021, showed the Governing Body will assume legal authority and responsibility for the operation of the hospice. The Governing Body will routinely review all fiscal affairs and the financial position of the hospice. The Governing Body will routinely evaluate to what extent the hospice has met the needs of the community for hospice care, has provided adequate and appropriate care to patients. The Governing Body will review the QAPI plan and update it to reflect any changes in strategic priorities and in response to any changes in the internal and external environment. 1.The hospice failed to ensure the COPs under 418.54 (Initial & Comprehensive Assessment); 418.56 (Interdisciplinary Group, Care Planning, and Coordination of Services); 418:78 (Volunteers), 418.100 (Organization and Administration of Services), and 418.102 (Medical Director) were met. Cross references to L520, L536, L641, L648, and L664. 2. According to the Standards of Quality Hospice Care 2005 Section 6.2 B (1) (2): 1.When program services are not provided directly by employees there shall be a written agreement defining the nature and scope of services provided. 2. The agreement shall address, but not be limited to: a. Services to be provided. b. Rights and responsibilities of the program or individual providing services and of the contracting organization in the implementation, coordination, supervision and evaluation of the care or services. c. Roles and responsibilities of the program and the contracted individual or organization in the following: (1) Patient/family admission process. (2) Patient/family assessment. (3) Development, review, revision and management of the plan of care. (4) Interdisciplinary team conferences. (5) Scheduling visits or hours. (6) Discharge planning. (7) Bereavement follow-up. d. Submission of documentation of services provided. e. Responsibility of the contracted individual or organization to adhere to applicable policies, including personnel qualifications. F. Procedure for charges and reimbursement. g. Term of the agreement and the conditions for its renewal or termination. h. Education requirements. a. Review of the Professional Services Agreement between the hospice and Medical Director Designee was initiated on 2/10/26 at 1630 hours.The agreement failed to include the roles and responsibilities of the program and the contracted individual in the discharge planning and bereavement follow-up. b. Review of the Professional Services Agreement between the hospice and Medical Director was initiated on 2/11/26 at 1024 hours, with the CEO/DPCS and COO.The agreement failed to include the roles and responsibilities of the program and the contracted individual in the discharge planning and bereavement follow-up. On 2/11/26 at 1024 hours and interview and concurrent hospice document review were conducted with the CEO/DPCS and COO. The CEO/DPCS and COO were informed and acknowledged the findings. 3. Review of the Board/Leadership Annual QAPI Report showed the following:-For 2023, the focus area was wound management. Documentation showed the Governing body and senior leadership received quarterly wound QAPI summaries with trend data, staging distribution, and compliance metrics. However, the section to document the person who reviewed the report, title, and date reviewed were left blank.-For 2025, the focus area was comfortable dying measure. The Board determination showed reviewed findings on consistent completion of pain screening and reassessment process aligned with hospice standards. However, the section to document the person who reviewed the report, title, and date reviewed were left blank. Review of the Governing Body meeting minutes showed the hospice’s Board of Directors met and discussed the following:-On 7/1/23, passed a corporate resolution for transferring of assets and stocks.-On 2/26/24, passed a board resolution for transfer of office address.-On 8/9/24, considered and acted upon the appointment of an Assistant Administrator.-On 4/25/25, appointed a new Medical Director.However, there was no documented evidence the focus areas on the QAPI reports were discussed and reviewed by the Governing Body. On 2/10/26 at 1546 hours, an interview and concurrent document review was conducted with the Administrator. The Administrator stated the Governing Body would meet whenever there were changes in the hospice. On 2/11/26 at 1024 hours, an interview was conducted with the CEO/DPCS and COO. The CEO/DPCS stated the QAPI was not reviewed and included in the topics to be discussed during the Governing Body meetings. 4. Review of the hospice’s P&P titled Admission Criteria and Process revised 11/2021, showed the following:-Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patient must reside within the geographical area that the hospice serves.-The initial home visit will be made within 24 hours or within the time frame requested by the referral source and according to organization policy, or as ordered by the physician (or other authorized independent practitioner). The purpose of the initial visit will review appropriate forms by patient and family/caregiver once agreement for the hospice program has been decided. Review of the Hospice Request for Certification in the Medicare Program (CMS-417) showed the hospice’s geographical service area includes Los Angeles County, Orange County, Riverside, San Bernardino County, Santa Barbara County and Ventura County. Review of the hospice’s active census as of 2/3/26, showed a total patient count of 25. However, nine out of the 25 patients’ place of service were located the Imperial County which was not included in the hospice’s geographical service area. On 2/3/26 at 1521 hours, an interview and concurrent hospice document review was conducted with the Administrator. The Administrator confirmed Imperial County was not included in the approved hospice’s geographical service areas. On 2/11/26 at 1024 hours, an interview was conducted with the CEO/DPCS and COO. The COO confirmed Imperial County was not among the approved hospice’s geographical service areas. 5. Review of the hospice’s P&P titled Responsibilities/Supervision of Clinical Services revised 11/2021, showed supervision of clinical care and services will be available 24 hours a day, seven days a week. The Clinical Director will ensure supervision is maintained within hospice. Hospice aide supervisory visits will be conducted on-site at least every 14 days by a hospice registered nurse. Review of Patient 5’s clinical record was initiated on 2/10/26. The clinical record showed the SOC was 8/15/25. The patient was certified for hospice services during the certification periods from 8/15/25 to 10/13/25, 10/14/25 to 12/12/25 and 12/13/25 to 2/10/25.Review of the POC/IDG Review dated 12/9/25, showed HA visits two per week.Review of the clinical record during the certification period from 12/13/25 to 2/10/25, showed the HA conducted visits for the week 1/18/26 to 1/24/26 and 1/25/26 to 1/31/26. However, there was no documented evidence the RN conducted HA supervision for these weeks. 6. Review of the hospice’s P&P titled Intake Process revised 11/2021, showed referrals may be accepted from Doctor of Medicine, discharge planners from inpatient and/or outpatient services, social services agencies, individual patients or their family/caregivers, clinical and/or insurance company representative and other home health care organizations. a. Review of Patient 1’s clinical record was initiated on 2/3/26. The clinical record showed the SOC was 2/6/25. The patient was certified for hospice services during the certification periods from 2/6/25 to 5/6/25, 5/7/25 to 8/4/25, 8/5/25 to 10/3/25, 10/4/25 to 12/2/25, 12/3/25 to 1/31/26 and 2/1/26 to 4/1/26.However, there was no documented evidence a referral for evaluation came from the patient’s attending physician prior to explanation of hospice benefit and admission to hospice. On 2/12/26 at 0833 hours, an interview and concurrent clinical record review was conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the finding. b. Review of Patient 2’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 12/3/24. The patient was certified for hospice services during the certification periods from 12/3/24 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, 9/29/25 to 11/27/25, 11/28/25 to 1/26/26 and 1/27/26 to 3/27/26. However, there was no documented evidence a referral for evaluation came from the patient’s attending physician prior to explanation of hospice benefit and admission to hospice. On 2/10/26 at 1352 hours, a telephone interview was conducted with Patient 2’s authorized representative. Patient 2’s authorized representative stated the patient was placed on hospice and Patient 2’ authorized representative was asked to sign the consent. However, nobody explained why Patient 2 was placed on hospice. On 2/12/26 at 0900 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the finding. c. Review of Patient 3’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 9/13/25. The patient was certified for hospice services during the certification periods from 9/13/25 to 12/11/25 and 12/12/25 to 3/11/25. However, there was no documented evidence a referral for evaluation came from the patient’s attending physician prior to explanation of hospice benefit and admission to hospice. On 2/10/26 at 1430 hours, a telephone interview was conducted with Patient 3’s authorized representative. Patient 3’ authorized representative stated the hospice did not explain the benefit of hospice and the consent form was sent thru electronic mail for signature. On 2/12/26 at 0930 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the finding. d. Review of Patient 4’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 11/16/24. The patient was certified for hospice services during the certification periods from 11/16/24 to 2/13/25, 2/14/25 to 4/14/25, 4/15/25 to 6/13/25, 6/14/25 to 8/12/25, 8/13/25 to 10/11/25, 10/12/25 to 12/10/25 and 12/11/25 to 2/8/26. However, there was no documented evidence a referral for evaluation came from the patient’s attending physician prior to explanation of hospice benefit and admission to hospice. On 2/12/26 at 0942 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the finding. e. Review of Patient 5’s clinical record was initiated on 2/10/26. The clinical record showed the SOC was 8/15/25. The patient was certified for hospice services during the certification periods from 8/15/25 to 10/13/25, 10/14/25 to 12/12/25 and 12/13/25 to 2/10/25. However, there was no documented evidence a referral for evaluation came from the patient’s attending physician prior to explanation of hospice benefit and admission to hospice. On 2/12/26 at 1019 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the finding.f. Review of Patient 6’s clinical record was initiated on 2/11/26. The clinical record showed the SOC was 2/27/25. The patient was certified for hospice services during the certification periods from 2/27/25 to 5/27/25, 5/28/25 to 8/25/25, 8/26/25 to 10/24/25, 10/25/25 to 12/23/25 and 12/24/25 to 2/21/26. However, there was no documented evidence a referral for evaluation came from the patient’s attending physician prior to explanation of hospice benefit and admission to hospice. On 2/12/26 at 1038 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the finding. On 2/11/26 at 1024 hours, an interview was conducted with the CEO/DPCS and COO. The CEO/DPCS stated the hospice did not have a referral from the attending physician or hospital to evaluate patient. 7. Review of the hospice’s P&P titled Contents of the Clinical Record revised 11/2021, showed a clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe patient problems/needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contact personnel.a. Review of Patient 1’s clinical record was initiated on 2/3/26. The clinical record showed the SOC was 2/6/25. The patient was certified for hospice services during the certification periods from 2/6/25 to 5/6/25, 5/7/25 to 8/4/25, 8/5/25 to 10/3/25, 10/4/25 to 12/2/25, 12/3/25 to 1/31/26, and 2/1/26 to 4/1/26.1. Review of the Comprehensive Nursing Assessment dated 2/6/25, showed inconsistent assessment on the following:- The ADL Assessment showed 0/6 (meaning totally dependent on others for all basic self-care task); however, the ADL assessment on the narrative section showed 2/6 (meaning requiring assistance from another person to perform basic self-care task).- The KPS (assessment tool for functional impairment) score was 60; however, KPS score on the narrative section was 50.Review of the Re-Cert Assessment dated 8/2/25 and 9/27/25 and Update Assessment dated 11/22/25, showed the patient/PCG needed teaching on oxygen. However, there was no physician’s order for oxygen.2. Review of the Election of Medicare Hospice Benefit showed RN 2’s signature; however, the date was left blank.Review of Information and Consent for Treatment showed Patient 1 and RN 2’s signatures; however, the dates were left blank.Review of the Consent for Choice of Primary Care Physician showed it was signed and dated by Patient 1; however, the was no documentation on Patient 1’s choice whether to continue with Primary Care with current Physician or would prefer the hospice’s Medical Director to attend to primary care needs and comfort management or would prefer the hospice’s Medical Director to intercede only for the terminal illness treatment needs and pain management. In addition, RN 2 had signed the abovementioned form, however, the date and time were left blank.Review of the Consent for Medical Photography was signed and dated by the patient; however, there was no documentation on Patient 1’s choice whether the patient consented to allow medical photographs or did not provide consent to allow recording or saving of medical photographs. In addition, RN 2 had signed the abovementioned form; however, the date was left blank.Review of the Durable Medical Equipment Agreement was signed by both Patient 1 and RN 2; however, the date was left blank.On 2/12/26 at 0833 hours, an interview and concurrent clinical record review was conducted with the CEO/DPCS. The CEO/DPCS verified the findings.b. Review of Patient 2’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 12/3/24. The patient was certified for hospice services during the certification periods from 12/3/24 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, 9/29/25 to 11/27/25, 11/28/25 to 1/26/26, and 1/27/26 to 3/27/26.Review of the Informed Consent and Treatment Authorization was signed by Patient 2’s authorized representative; however, the Medicare/Medi-Cal Hospice Benefit Election effective date was left blank.Review of the Release of Information and Consent for Treatment was signed and dated by Patient 2’s authorized representative; however, the signature of the witness, date, and explanation were left blank.Review of the Consent for Choice of Primary Care Physician showed it was signed by Patient 2’s authorized representative; however, the date and time Patient 2’s authorized representative signed the document, witness name, signature, and date and time were left blank. In addition, the was no documentation on Patient 1’s choice whether to continue with Primary Care with current Physician or would prefer the hospice’s Medical Director to attend to primary care needs and comfort management or would prefer the hospice’s Medical Director to intercede only for the terminal illness treatment needs and pain management.Review of the Consent for Medical Photography was signed and dated by the patient; however, there was no documentation on Patient 2’s choice whether the patient consented to allow medical photographs or did not provide consent to allow recording or saving of medical photographs. In addition, the witness/staff’s signature and date were left blank.Review of the Durable Medical Equipment Agreement was signed by Patient 2’s authorized representative, however, the date, admitting nurse’s signature, and date were left blank.On 2/10/26 at 1352 hours, a telephone interview was conducted with Patient 2’s authorized representative. Patient 2’s authorized representative stated the patient was placed on hospice and was asked to sign the consent; however, nobody explained why Patient 2 was placed on hospice.On 2/12/26 at 0900 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.c. Review of Patient 3’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 9/13/25. The patient was certified for hospice services during the certification periods from 9/13/25 to 12/11/25 and 12/12/25 to 3/11/25.1. Review of the Comprehensive Nursing Assessment dated 9/13/25, showed Patient 3 was unable to ambulate; however, the Visit Note LVN dated 9/13/25, showed the patient occasionally brief ambulated with moderate assistance.Review of the Visit Notes LVN showed inconsistent information on the following dates:- Dated 9/13/25, the Signs and Symptoms Screening for Nutrition showed the patient consumed 26% to 50% of meals; however, the narrative section showed 51% to 75% of meals.- Dated 9/20/25, the Signs and Symptoms Screening for Cardiovascular showed the patient had +2 edema (moderate swelling); however, the narrative section showed +1 (mild swelling).- Dated 10/26/25, the Signs and Symptoms Screening for Musculoskeletal showed the patient had weakness/stiffness, unable to stand, non-ambulatory and required maximum assistance; however, the narrative section showed the patient was able to ambulate short distances occasionally within moderate assistance. 2. Review of the Consent for Choice of Primary Care Physician showed it was signed by Patient 3’s authorized representative; however, the was no documentation on Patient 3’s choice whether to continue with Primary Care with current Physician or would prefer the hospice’s Medical Director to attend to primary care needs and comfort management or would prefer the hospice’s Medical Director to intercede only for the terminal illness treatment needs and pain management.On 2/12/26 at 0930 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.d. Review of Patient 4’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 11/16/24. The patient was certified for hospice services during the certification periods from 11/16/24 to 2/13/25, 2/14/25 to 4/14/25, 4/15/25 to 6/13/25, 6/14/25 to 8/12/25, 8/13/25 to 10/11/25, 10/12/25 to 12/10/25, and 12/11/25 to 2/8/26.1. Review of the Comprehensive Nursing Assessment dated 11/16/24, showed the patient was on 3 LPM continuous oxygen with oxygen saturation of 100%; however, the narrative section showed the patient occasionally used oxygen and the patient’s oxygen saturation was 94% on room air.Review of the Comprehensive Nursing Assessment dated 11/16/24, Re-Cert Assessment dated 2/13/25 and 4/15/25, and Updated Assessment dated 6/12/25, showed the same information for vital signs: temperature of 98.4°F, pulse of 76 bpm, blood pressure of 123/93 mmhg and respirations of 18.Review of the POC/IDG Review dated 10/28/25, 11/11/25, 11/25/25, 12/9/25, 12/23/25 and 1/6/26, showed the same information for Spiritual and Psychosocial status on the IDG Discussion/Updated Comprehensive Assessment Review every meeting.Review of the POC/IDG Review dated 12/9/25 and 12/23/25, showed the same information for Nursing, Spiritual and Psychosocial status on the IDG Discussion/Updated Comprehensive Assessment Review every meeting.Review of the POC/IDG Review dated 1/20/26 and 2/3/26, showed the same information for Nursing, Spiritual and Psychosocial status on the IDG Discussion/Updated Comprehensive Assessment Review every meeting.2. Review of the Patient Consent for Choice of Primary Care Physician dated 11/16/24, showed the patient wished to continue primary care with current physician; however, the physician’s name and date were left blank.On 2/12/26 at 0942 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.e. Review of Patient 5’s clinical record was initiated on 2/10/26. The clinical record showed the SOC was 8/15/25. The patient was certified for hospice services during the certification periods from 8/15/25 to 10/13/25, 10/14/25 to 12/12/25, and 12/13/25 to 2/10/25.1. Review of the Re-Cert Assessment dated 10/1/25, showed the left back of the knee wound measured 3 cm (length) x 2.5 cm (width); however, per Skin Assessment dated 10/1/25, left back knee wound measured 3 cm x 3 cm.Review of the Re-Cert Assessment dated 10/1/25 and 12/1/25, showed the same vital signs: temperature of 98°F, pulse of 80 bpm, blood pressure of 130/92 mmhg and respiration of 21.Review of the POC/IDG Review dated 9/2/25 and 9/16/25, showed the same information for Nursing on the IDG Discussion/Updated Comprehensive Assessment Review every meeting.Review of the POC/IDG Review dated 11/11/25, 11/25/25 and 12/9/25, showed the same information for the Nursing on the IDG Discussion/Updated Comprehensive Assessment Review every meeting.Review of the POC/IDG Review dated 1/6/26 and 1/20/26, showed the same information for Nursing on the IDG Discussion/Updated Comprehensive Assessment Review every meeting.Review of the Visit Note LVN dated 11/7/25, showed the following inconsistencies:- Respiration was 17; however, the narrative section showed respirations was 22 every minute.-Assessment of Sleep/Rest showed about eight hours of sleep; however, the narrative section showed the patient slept approximately nine hours at night.Review of the Visit Note LVN dated 11/21/25 and 11/29/25, showed the same vital signs on both dates.2. Review of the Durable Medical Equipment Agreement was signed and dated by the admitting nurse, however, the patient’s date of birth, address, contracted provider for the DME, Patient 5’s authorized representative’s signature and date were all left blank.On 2/12/26 at 1019 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.f. Review of Patient 6’s clinical record was initiated on 2/11/26. The clinical record showed the SOC was 2/27/25. The patient was certified for hospice services during the certification periods from 2/27/25 to 5/27/25, 5/28/25 to 8/25/25, 8/26/25 to 10/24/25, 10/25/25 to 12/23/25, and 12/24/25 to 2/21/26.1. Review of the Visit Note LVN dated 10/28/25 and 11/6/25, showed the narrative had the same information for both visits except for the last bowel movement reported date.Review of the Informed Consent and Treatment Authorization was signed and dated by the patient; however, the Medicare/Medi-Cal Hospice Benefit Election effective date, staff’s signature, and date were left blank.Review of the Release of Information and Consent for Treatment was signed and dated by the patient; however, the witness signature and date were left blank.Review of the Consent for Choice of Primary Care Physician failed to show the patient’s choice whether to continue with Primary Care with current Physician or prefer the hospice’s Medical Director to attend to primary care needs and comfort management or would prefer the hospice’s Medical Director to intercede only for the terminal illness treatment needs and pain management. In addition, the patient’s signature, witness name/signature, date and time were all left blank.Review of the Consent for Medical Photography was signed and dated by the patient; however, there was no documentation on the patient’s choice whether to allow medical photographs or did not provide consent to allow recording or saving of medical photographs. In addition, the witness/staff’s signature and date were left blank.2. Review of the Durable Medical Equipment Agreement was signed by the patient; however, the date, signature of the admitting nurse, and date were left blank.On 2/12/26 at 1038 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.8. Review of the hospice’s P&P titled Interdisciplinary Group Membership and Responsibilities revised 11/2021, showed the hospice interdisciplinary team/group members will include, at a minimum: a Physician, Registered Nurse, Social Worker and Pastoral or other counselor.Review of the hospice’s P&P titled Interdisciplinary Group Meeting revised 11/2021, showed members of the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor.a. Review of Patient 1’s clinical record was initiated on 2/3/26. The clinical record showed the SOC was 2/6/25. The patient was certified for hospice services during the certification periods from 2/6/25 to 5/6/25, 5/7/25 to 8/4/25, 8/5/25 to 10/3/25, 10/4/25 to 12/2/25, 12/3/25 to 1/31/26, and 2/1/26 to 4/1/26.The POC/IDG Review dated 1/20/26, showed the POC was discussed during the IDG meeting. The RN and MSW electronically signed the attendance form. However, the section for the Medical Director and SC’s electronic signatures were left blank. On 2/12/26 at 0833 hours, an interview and concurrent clinical record review was conducted with the CEO/DPCS. The CEO/DPCS verified the finding.b. Review of Patient 3’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 9/13/25. The patient was certified for hospice services during the certification periods from 9/13/25 to 12/11/25 and 12/12/25 to 3/11/25.The POC/IDG Review dated 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9 and 12/23/25, showed the POC were discussed during these IDT meetings. The Medical Director and RN electronically signed the attendance form. However, the section for the MSW and SC’s electronic signatures were left blank.On 2/12/26 at 0930 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.c. Review of Patient 4’s clinical record was initiated on 2/5/26. The clinical record showed SOC was 11/16/24. The patient was certified for hospice services during the certification period from 11/16/24 to 2/13/25, 2/14/25 to 4/14/25, 4/15/25 to 6/13/25, 6/14/25 to 8/12/25, 8/13/25 to 10/11/25, 10/12/25 to 12/10/25, and 12/11/25 to 2/8/26.The POC/IDG Review dated 1/20/26, showed the POC was discussed in the IDG meeting. The RN, MSW and SC electronically signed the attendance. However, the section for the Medical Director’s electronic signature was left blank.The POC/IDG Review dated 2/3/26, showed the POC was discussed in the IDG meeting. The MSW and SC electronically signed the attendance. However, the section for the Medical Director and RN’s electronic signatures were left blank. On 2/12/26 at 0942 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.d. Review of Patient 5’s clinical record was initiated on 2/10/26. The clinical record showed the SOC was 8/15/25. The patient was certified for hospice services during the certification periods from 8/15/25 to 10/13/25, 10/14/25 to 12/12/25, and 12/13/25 to 2/10/25.The POC/IDG Review dated 8/19, 9/2, 9/16, 9/30, 10/14, 10/28, 11/11, 11/25, 12/9, 12/23/25 and 1/6/26, showed the POC were discussed during these IDG meetings. The Medical Director and RN electronically signed the attendance. However, the section for the MSW and SC’s electronic signatures were left blank.The POC/IDG Review dated 1/20/26, showed the POC was discussed during the IDG meeting. However, the Medical Director, RN, MSW and SC’s electronic signature were left blank. On 2/12/26 at 1019 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.9. Review of the hospice’s P&P titled Discharge from Hospice Program revised 11/2021, showed the hospice Case Manager will ensure that the necessary paperwork is completed at the time of discharge. This will include completion of a discharge summary. Review of Patient 4’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 11/16/24. The patient was certified for hospice services during the certification periods from 11/16/24 to 2/13/25, 2/14/25 to 4/14/25, 4/15/25 to 6/13/25, 6/14/25 to 8/12/25, 8/13/25 to 10/11/25, 10/12/25 to 12/10/25, and 12/11/25 to 2/8/26.Patient 4 was initially admitted to hospice on 10/10/24. The patient was certified for hospice services during the certification period from 10/10/24 to 1/7/25. The patient was discharged on 11/12/24.The Discharge Summary showed the EOC was 11/12/24 and reason for discharge was hospitalized. However, there was no documented evidence a discharge summary was completed.On 2/12/26 at 0942 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the finding.”

“Based on interview and record review, the hospice failed to ensure the Medical Director or physician designee completed the certifications of terminal Illness for five of six patients (Patients 1, 2, 3, 4 and 6). This failure had the potential of not identifying the patients’ care needs.Findings: Review of the hospice’s P&P titled Certification of Terminal Illness revised 11/2021, showed at a time a patient and family/caregiver chooses hospice care, the hospice Medical Director, physician member of the interdisciplinary team and/or the patient’s attending physician, if any will certify the patient’s terminal illness.Patients who elect the hospice’s Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six months or less life expectancy if the disease runs its normal course, by the attending physician, physician member of the interdisciplinary team and/or the hospice Medical Director. Hospice services will be provided in two 90-day periods and an unlimited number of 60-day periods if the patient is recertified at the beginning of each benefit period.The Hospice Medical Director, physician member of the interdisciplinary team and/or the patient’s attending physician will complete a certification narrative that reflects the patient’s individual circumstances based on his/her review of patient’s medical record or, if applicable, examination of the patient. (The hospice’s Medical Director, physician member of the interdisciplinary team and/or the patient’s attending physician will sign the certification of illness and authorization for hospice services forms). 1.Review of Patient 1’s clinical record was initiated at 2/3/26. The clinical record showed the SOC was 2/6/25. The patient was certified for hospice services during the certification periods from 2/6/25 to 5/6/25, 5/7/25 to 8/4/25, 8/5/25 to 10/3/25, 10/4/25 to 12/2/25, 12/3/25 to 1/31/26 and 2/1/26 to 4/1/26. The Physician’s Certification for Hospice Benefit for the next 60-day period effective 2/1/26 to 4/1/26, did not include certifying physician’s narrative and signature. On 2/12/26 at 0833 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings. 2.Review of Patient 2’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 12/3/24. The patient was certified for hospice services during the certification periods from 12/3/24 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, 9/29/25 to 11/27/25, 11/28/25 to 1/26/26 and 1/27/26 to 3/27/26. a. The Physician’s Certification for Hospice Benefit for Statement for the first 90-day period effective 12/3/24 to 3/2/25, showed the referring physician’s attestation that this patient had a life expectancy of six months or less, if the terminal illness runs its normal course and certifying physician’s narrative; however, it did not include the physician’s signatures. b. The Physician’s Certification for Hospice Benefit for the second 90-day period effective 3/3/25 to 5/31/25, showed the certifying physician’s narrative. However, it did not include the physician’s signature. c. The Physician’s Certification for Hospice Benefit for the next 60-day period effective 1/27/26 to 3/27/26, did not include the certifying physician’s narrative and signature. On 2/12/26 at 0900 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings. 3. Review of Patient 3’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 9/13/25. The patient was certified for hospice services during the certification periods from 9/13/25 to 12/11/25 and 12/12/25 to 3/11/25. The Physician’s Certification for Hospice Benefit for the next 60-day period effective 12/12/25 to 3/11/26, did not include the certifying physician’s narrative and signature. On 2/12/26 at 0930 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings. 4. Review of Patient 4’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 11/16/24. The patient was certified for hospice services during the certification periods from 11/16/24 to 2/13/25, 2/14/25 to 4/14/25, 4/15/25 to 6/13/25, 6/14/25 to 8/12/25, 8/13/25 to 10/11/25, 10/12/25 to 12/10/25 and 12/11/25 to 2/8/26. The Physician’s Certification for Hospice Benefit for the next 60-day period effective 12/11/25 to 2/8/26, did not include the certifying physician’s narrative and signature. On 2/12/26 at 0942 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings. 5. Review of Patient 6’s clinical record was initiated on 2/11/26. The clinical record showed the SOC was 2/27/25. The patient was certified for hospice services during the certification periods from 2/27/25 to 5/27/25, 5/28/25 to 8/25/25, 8/26/25 to 10/24/25, 10/25/25 to 12/23/25 and 12/24/25 to 2/21/26. a. The Physician’s Certification for Hospice Benefit for Statement for the first 90-day period effective 2/27/25 to 5/27/25, showed the referring physician’s attestation that this patient had a life expectancy of six months or less, if the terminal illness runs its normal course and the certifying physician’s narrative; however, it did not include the physician’s signature. b. The Physician’s Certification for Hospice Benefit for the second 90-day period effective 5/28/25 to 8/25/25, did not include the certifying physician’s narrative and signature. c. The Physician’s Certification for Hospice Benefit for the next 60-day period effective 12/24/25 to 2/21/26, did not include the certifying physician’s narrative and signature. On 2/12/26 at 1038 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.”

“Based on interview and record review, the hospice failed to ensure the Medical Director or physician designee reviewed five of six sampled patients (Patients 1, 2, 4, 5, and 6’s) clinical information to certify the patients for hospice services as per the hospice’s P&P. This failure had the potential for not identifying the patients’ care needs.Findings: Review of the hospice’s P&P titled Face-To-Face Encounter revised 11/2021, a face-to-face encounter will be performed for patients entering the third and all subsequent benefit periods. The hospice director or a hospice employed nurse practitioner will perform face-to-face encounter within 30 days prior to the hospice recertification for the third and all subsequent benefit periods. The physician/NP who performs the face-to-face encounter will attest in writing that he/she had the face-to-face encounter including the date of the visit. The NP must also attest that the clinical findings were provided to the certifying physician. The face-to-face attestation must be signed and dated by the individual who performed the visit. 1.Review of Patient 1’s clinical record was initiated at 2/3/26. The clinical record showed the SOC was 2/6/25. The patient was certified for hospice services during the certification periods from 2/6/25 to 5/6/25, 5/7/25 to 8/4/25, 8/5/25 to 10/3/25, 10/4/25 to 12/2/25, 12/3/25 to 1/31/26 and 2/1/26 to 4/1/26. Review of the Physician’s Certification for Hospice Benefit for the certification periods from 10/4/25 to 12/2/25, 12/3/25 to 1/31/26 and 2/1/26 to 4/1/26, showed the certifications were based on face-to-face encounters. However, there was no documented evidence face-to-face encounters were performed by the physician or nurse practitioner within 30 days prior to the fourth, fifth and sixth benefit periods. On 2/12/26 at 0833 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings. 2.Review of Patient 2’s clinical record was initiated on 2/4/26. The clinical record showed the SOC was 12/3/24. The patient was certified for hospice services during the certification periods from 12/3/24 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, 9/29/25 to 11/27/25, 11/28/25 to 1/26/26 and 1/27/26 to 3/27/26. Review of the Physician’s Certification for Hospice Benefit for the certification periods from 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, 9/29/25 to 11/27/25, 11/28/25 to 1/26/26 and 1/27/26 to 3/27/26, showed the certifications were based on face-to-face encounters.However, there was no documented evidence face-to-face encounters were performed by the physician or nurse practitioner within 30 days prior to the third, fourth, fifth, sixth and seventh benefit periods. On 2/12/26 at 0900 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings. 3.Review of Patient 4’s clinical record was initiated on 2/5/26. The clinical record showed the SOC was 11/16/24. The patient was certified for hospice services during the certification periods from 11/16/24 to 2/13/25, 2/14/25 to 4/14/25, 4/15/25 to 6/13/25, 6/14/25 to 8/12/25, 8/13/25 to 10/11/25, 10/12/25 to 12/10/25 and 12/11/25 to 2/8/26. Review of the Physician’s Certification for Hospice Benefit for the certification periods from 2/14/25 to 4/14/25, 4/15/25 to 6/13/25, 6/14/25 to 8/12/25, 8/13/25 to 10/11/25, 10/12/25 to 12/10/25 and 12/11/25 to 2/8/26, showed the certifications were based on face-to-face encounters. However, there was no documented evidence face-to-face encounters were performed by the physician or nurse practitioner within 30 days prior to the third, fourth, fifth, sixth, seventh and eighth benefit periods. On 2/12/26 at 0942 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings. 4.Review of Patient 5’s clinical record was initiated on 2/10/26. The clinical record showed the SOC was 8/15/25. The patient was certified for hospice services during the certification periods from 8/15/25 to 10/13/25, 10/14/25 to 12/12/25 and 12/13/25 to 2/10/25.Review of the Physician’s Certification for Hospice Benefit for the certification periods from 8/15/25 to 10/13/25, 10/14/25 to 12/12/25 and 12/13/25 to 2/10/25, showed the certifications were based on face-to-face encounters. However, there was no documented evidence face-to-face encounters were performed by the physician or nurse practitioner within 30 days prior to the 17th, 18th and 19th benefit periods. On 2/12/26 at 1019 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings. 5. Review of Patient 6’s clinical record was initiated on 2/11/26. The clinical record showed SOC was 2/27/25. The patient was certified for hospice services during the certification periods from 2/27/25 to 5/27/25, 5/28/25 to 8/25/25, 8/26/25 to 10/24/25, 10/25/25 to 12/23/25 and 12/24/25 to 2/21/26. Review of the Physician’s Certification for Hospice Benefit for the certification periods from 8/26/25 to 10/24/25, 10/25/25 to 12/23/25 and 12/24/25 to 2/21/26, showed the certifications were based on face-to-face encounters. However, there was no documented evidence face-to-face encounters were performed by the physician or nurse practitioner within 30 days prior to the third, fourth and fifth benefit periods.On 2/12/26 at 1038 hours, an interview and concurrent clinical record review were conducted with the CEO/DPCS. The CEO/DPCS was informed and verified the findings.On 2/11/26 at 1446 hours, an interview was conducted with the previous Medical Director. The previous Medical Director stated he had not had face-to-face encounter with hospices’ patients.”