Bless Care Hospice Inc.

“Upon patient record review, 6 of 14 (Patient #1, 2, 3, 5, 7, 11) did not contain evidence that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review included, but was not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: Order date 09/11/24; Triamcinolone Acetonide 0.5% ointment ordered as “apply to affected area” but did not contain a frequency for use or the area to be applied to. Order date 05/09/24; Erythromycin 0.5% ophthalmic ointment ordered as “apply to Eyes Two times a Day for Eye Infection” but did not contain an end date and per daughter during home visit patient no longer has eye infection. Patient#2: Per Cardiovascular Intervention/Goals; patient had intervention that contained “PATIENT WILL USE OX AN NEEDED WHEN SOB” but oxygen was not included on the medication record. Patient #3: Order date 01/24/25; Biofreeze ordered as “applied to affected area three times daily as needed” but did not instruct on an area to be applied to. Oxygen was noted on the DME list but was not on medication record. Patient #5: Order date 10/28/25; Clobetasol Propionate 0.05% cream ordered as “apply to affected areas times daily” but did not contain a frequency or the area to be applied to. Order date 11/24/25; Claritin Hives Relief 10mg ER tab ordered as “Taekwondo tablet daily as needed.” Order date 12/24/25; Clobetasol Propionate 0.05% ordered as “applied to affected area three times a week” but did not instruct on area to be applied to. Also, duplicate drug therapy. Sarna Topical Lotion ordered as “apply to affected areas two times daily as needed” but did not instruct on area to be applied to. Order date 01/05/26; Hydrocortisone 2.5% cream ordered as “apply to affected area two times daily as needed” but did not instruct on area to be applied to. Triamcinolone Acetonide 0.1% cream ordered as “apply to affected area two times daily as needed” but did not instruct on area to be applied to. Patient #7: Order date 12/24/25; A&D original topical ointment 15.5% ordered as “apply a thin later to the affected area as needed” but did not instruct on area to be applied to. Calmoseptine topical ointment 0.44% ordered as “apply a thin layer of Calmoseptine ointment (approximately 1-2 gr) to affected area topically every shift and as needed for skin protection, unless irritation or allergy occurs” but did not instruct on area and patient was living at home with family. Senna 8.6mg Tab ordered as “take 1-2 tab(s) by mouth PO” but did not contain a frequency. Patient #11: Order date 08/26/24; hydrocortisone 1% maximum strength cream ordered as “APPLY to Affected area twice a week” but did not instruct on area to be applied to. Order date 10/08/24; Atropin Care 1% Ophthalmic Solution ordered as “3 drops every 6 hours a needed for excessive secretions” but was listed for “Ophthalmic” route not oral.”

“Upon patient record review, 1 of 14 (Patient #10) did not contain evidence that the Registered Nurse was designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #10: RN admission assessment on 01/07/26 provided assessment of right calf venous ulcer and all necessary wound orders were written at this time. This same RN visited on 01/09/26 and per her visit note she documented “skin warm and dry; no breakdown noted. Interventions completed: Full head-to-toe assessment”. There was no indication that this wound was evaluated per wound care orders. There was further evidence that wound was still present during the LVN visit on 01/16/26. Per her visit note she did evaluate and dress wound, per the orders, and continued education with patient and caregiver. There was no evidence of continuous assessment of the wound by the RN.”

“Upon patient record review, 7 of 14 (Patient #1, 2, 3, 5, 7, 10, 11) did not contain evidence that the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: POC order date 09/11/24; Triamcinolone Acetonide 0.5% ointment ordered as “apply to affected area” but did not contain a frequency for use or the area to be applied to. POC order date 05/09/24; Erythromycin 0.5% ophthalmic ointment ordered as “apply to Eyes Two times a Day for Eye Infection” but did not contain an end date and per daughter during home visit patient no longer has eye infection. Patient#2: Per Cardiovascular Intervention/Goals; patient had intervention that contained “PATIENT WILL USE OX AN NEEDED WHEN SOB” but oxygen was not included POC Patient #3: POC order date 01/24/25; Biofreeze ordered as “applied to affected area three times daily as needed” but did not instruct on an area to be applied to. Oxygen was noted on the DME list but was not on POC. Patient #5: POC order date 10/28/25; Clobetasol Propionate 0.05% cream ordered as “apply to affected areas times daily” but did not contain a frequency or the area to be applied to. POC order date 11/24/25; Claritin Hives Relief 10mg ER tab ordered as “Taekwondo tablet daily as needed.” POC order date 12/24/25; Clobetasol Propionate 0.05% ordered as “applied to affected area three times a week” but did not instruct on area to be applied to. Also, duplicate drug therapy. Sarna Topical Lotion ordered as “apply to affected areas two times daily as needed” but did not instruct on area to be applied to. POC order date 01/05/26; Hydrocortisone 2.5% cream ordered as “apply to affected area two times daily as needed” but did not instruct on area to be applied to. Triamcinolone Acetonide 0.1% cream ordered as “apply to affected area two times daily as needed” but did not instruct on area to be applied to. Patient #7: POC order date 12/24/25; A&D original topical ointment 15.5% ordered as “apply a thin later to the affected area as needed” but did no instruct on area to be applied to. Calmoseptine topical ointment 0.44% ordered as “apply a thin layer of Calmoseptine ointment (approximately 1-2 gr) to affected area topically every shift and as needed for skin protection, unless irritation or allergy occurs” but did not instruct on area and patient was living at home with family. Senna 8.6mg Tab ordered as “take 1-2 tab(s) by mouth PO” but did not contain a frequency. Patient #10: The initial POC indicated the need for daily wound care to right calf venous ulcer but the SN visits were only ordered 1x/weekly. Order did not indicate who would assume wound care on days that the SN would not visit the home. Patient #11: POC order date 08/26/24; hydrocortisone 1% maximum strength cream ordered as “APPLY to Affected area twice a week” but did not instruct on area to be applied to. POC order date 10/08/24; Atropin Care 1% Ophthalmic Solution ordered as “3 drops every 6 hours a needed for excessive secretions” but was listed for “Ophthalmic” route not oral.”

“Upon client record review, 6 of 14 (Patient #3, 5, 7, 8, 9,10) did not contain evidence that the plan of care included IDG’s documentation of the patient’s or families level of understanding, involvement and agreement with the plan of care. Patient #3: Initial POC/IDG and all updated indicated SN 1/weekly; weeks of 03/02/25, 03/30/25, 04/13/25, 05/11/25, 05/25/25, 06/08/25 all noted two visits. Week of 04/27/25 noted three visits. Week of 12/12/25 there were no visits noted. Patient #5: Updated POC/IDG starting 04/29/25 indicated SN visits at 1x/weekly; weeks of 09/21/25, 10/05/25, 10/19/25, 11/02/25, 11/16/25, 11/30/25 and 01/11/26 all noted two visits. Patient #7: Initial POC/IDG and all updated indicated SN visit 1x/weekly; week of 08/24/25 no visits were noted. Weeks of 10/12/25 and 10/26/25 all noted two visits. Patient #8: Initial POC/IDG and all updated indicated SN visit 1x/weekly; week of 11/16/25 noted two visits. Patient #9: Initial POC/IDG and all updated indicated SN visit 1x/weekly; weeks of 10/19/25, 12/07/25 and 12/21/25 there were no visits noted. Week of 10/26/25 noted two visits. Patient #10: RN admission assessment on 01/07/26 provided assessment of right calf venous ulcer and all necessary wound orders were written at this time. This same RN visited on 01/09/26 and per her visit note she documented “skin warm and dry; no breakdown noted. Interventions completed: Full head-to-toe assessment”. There was no indication that this wound was evaluated or addressed per wound care orders.”

“Upon patient record review, 3 of 14 (Patient #3, 6, 8) did not contain evidence that the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #3: Social Work recertification assessment on 06/21/25 states “The social worker plans to provide ongoing counseling and monitor the psychological and social well-being of the patient through monthly follow-up visits”. There were no further visits made. The current orders do not meet the patient needs. Patient #6: Social Work initial assessment on 05/02/25 states “MSW plans to continue providing monthly visits to offer ongoing psychosocial support to both the patient and his family, ensuring that emotional and practical needs are met as patients condition evolves. SW will follow up 1x month”. Recertification assessment dated 07/31/25 states “Follow-up visits will continue on a monthly basis to provide counseling interventions and assess the psycho-social status of the PT”. There were no further visits made. Spiritual Care initial assessment dated 05/05/25 states “Chaplain remains accessible and will provide ongoing spiritual and emotional support to this Patient every month”. Recertification assessment dated 07/31/25 states “Chaplain remains available and will continue to provide monthly follow-up support”. Recertification assessment dated 10/30/25 states “Chaplain remains available and will continue to follow up monthly”. There were no further visits made. The current orders do not meet the patient needs. Patient #8: Social Work initial assessment dated 08/29/25 states “MSW will continue to make follow up visits to resume the counseling interventions and to monitor the patient psychosocial status”. There were no further visits made. The current orders do not meet the patient needs.”

“Upon patient record review 4 of 14 (Patient #5, 6, 7, 8) did not contain evidence documentation that a hospice aide provided services that were: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #5: Aide initial POC/IDG and all updated indicated 2x/weekly visits; week of 12/14/25 there were three visits noted. Patient #6: Aide initial POC/IDG and all updated indicated 1x/weekly visits; the last visit was noted on 12/25/25 and there were no orders to discontinue. Patient #7: Aide initial POC/IDG and all updated indicated 1x/weekly visits; week of 08/24/25 there were no visits noted. Weeks of 10/12/25 and 10/26/25 there were two visits noted. Patient #8: Aide initial POC/IDG indicated 2x/weekly visits; week of 10/26/25 there were no visits noted. Week of 01/11/26 there was only one visit noted.”

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the Administrator/Director of Patient Care Services (Admin/DPCS), DPCS designee (DPCSD), Registered Nurse (RN) Case Manager, and Masters in Social Work (MSW) completed orientation to the Hospice Agency upon hire for five of eight sampled patients (Patient 15, Patient 16, Patient 17, Patient 18, Patient 19). The deficient practice had the potential to result in patients receiving improper care. During a review of Patient 15s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 10/31/2024, with a terminal diagnosis of chronic combined systolic and diastolic heart failure (a condition where the hearts ventricles are unable to pump and fill with enough blood). During a review of Patient 16s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 10/21/2024, with a terminal diagnosis of heart disease unspecified, (a disorder characterized by the inability of the heart to pump blood at an adequate volume). During a review of Patient 17s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 10/29/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, (a group of lung diseases that block airway and make it difficult to breathe). During a review of Patient 18’s Personal Information Sheet indicated; Patient 18 was admitted to the hospice agency on 9/4/2024, with a terminal diagnosis of Atherosclerotic heart disease of native coronary artery without angina pectoris ( a condition where plaque builds up in the walls of the coronary arteries ( a network of blood vessels that supply the heart with oxygen and nutrients)which can reduce or block blood flow to the heart). During a review of Patient 19s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 10/5/2024, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). During a review of HAs Policy and Procedure titled, “;Orientation”, revised November 2023, the Policy and Procedure indicated, “;all staff will be required to attend an initial orientation program upon employment. Staff orientation promotes safe and effective job performance the goal of orientation will be to address and instruct new staff regarding Blessed care hospices mission, goals, organization wide and relevant setting or program specific policies and procedures, benefits, the performance appraisal process, competency testing, as well as individual responsibilities and relationships to other staff.” The policy and procedure further indicated, “;7. An orientation checklist (see personnel orientation checklist) will be completed for each new staff. New staff will sign and date when their orientation has been completed. The preceptor/assigned supervisor will sign and date when the new staff have completed all required activities.” During a review of ADMIN/DPCSS employee file, the employment application was undated. The orientation checklist was not signed by a preceptor, and has no date on the form. The employee file did not have the personnel orientation checklist that included all the competency validations, or performance evaluations. During an interview on 12/03/2024 at 1:15pm with the ADMIN/DPCS, the ADMIN/DPCS stated, “;I am not sure why its not in my employee file. All employee files has to have completed applications with dates and signatures, orientation and the competency evaluation completed and signed by the preceptor that performed the evaluation. The ADMIN/DPCS stated that its important because all hospice staff need to show that they were competent to perform the skills needed.” During a review of DPCSDS employee file, the employment application indicated DPCSD was hired on 08/01/2023. The orientation checklist dated 08/01/2023 was not signed by a preceptor. The employee file did not have the personnel orientation checklist which lists all the competency validations, or performance evaluations. During an interview on 12/03/2024 at 1:25 pm with ADMIN/DPCS, ADMIN/DPCS stated, “;I was not here at that time. I started working here since August of 2024. This should have been completed by the DPCS before me. All employee files need to have orientation and competency evaluation completed and signed by the preceptor who is doing the evaluation. This is important because all hospice staff need to show they are competent to perform the skills needed.” During a review of RN case managers employee file, the employment application indicated RN case manager was hired on 08/01/2023. The orientation checklist dated 08/01/2023 was not signed by a preceptor. The employee file also did not have the personnel orientation checklist which lists all the competency validations, or performance evaluations. During an interview on 12/03/2024 at 1:35 pm with ADMIN/DPCS, ADMIN/DPCS stated, “;Again, I was not here at that time. I started working here since August of 2024. This should have been completed by the DPCS before me. All employee files need to have orientation and competency evaluation completed and signed by the preceptor who is doing the evaluation. This is important because all hospice staff need to show they are competent to perform the skills needed.” During a review of MSWs employee file, the employment application indicated MSW was hired on 08/01/2023. The orientation checklist dated 08/01/2023 was not signed by a preceptor. The employee file also did not have the personnel orientation checklist which lists all the competency validations, or performance evaluations. During an interview on 12/03/2024 at 1:45 pm with ADMIN/DPCS, ADMIN/DPCS stated, “;Again, I was not here at that time. I started working here since August of 2024. This should have been completed by the DPCS before me. All employee files need to have orientation and competency evaluation completed and signed by the preceptor who is doing the evaluation. This is important because all hospice staff need to show they are competent to perform the skills needed.””

“Based on interview and record review, the Hospice Agency (HA) failed to ensure performance evaluations were conducted for the Administrator/Director of Patient Care Services (Admin/DPCS), DPCS designee (DPCSD), RN (registered nurse) case manager, and MSW (Masters in Social Work) for five of eight sampled patients (Patient 15, Patient 16, Patient 17, Patient 18, Patient 19). The deficient practice had the potential to result in patients not receiving quality of care. Findings: During a review of Patient 15s Personal Information Sheet, the personal information sheet indicated Patient 15’s start of care (SOC) date was 10/31/2024, with a terminal diagnosis of chronic combined systolic and diastolic heart failure (a condition where the hearts ventricles are unable to pump and fill with enough blood). During a review of Patient 16s Personal Information Sheet, the personal information sheet indicated Patient 16’s start of care (SOC) date was 10/21/2024, with a terminal diagnosis of heart disease unspecified, (a disorder characterized by the inability of the heart to pump blood at an adequate volume). During a review of Patient 17s Personal Information Sheet, the personal information sheet indicated Patient 17’s start of care (SOC) date was 10/29/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, (a group of lung diseases that block airway and make it difficult to breathe). During a review of Patient 18’s Personal Information Sheet, the personal information sheet indicated, Patient 18’s start of care (SOC) date was 9/4/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris ( a condition where plaque builds up in the walls of the coronary arteries ( a network of blood vessels that supply the heart with oxygen and nutrients)which can reduce or block blood flow to the heart). During a review of Patient 19s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 10/5/2024, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). During a review of HAs Policy and Procedure titled, “;Performance Evaluations”, dated November 2023, the Policy and Procedure indicated, “;all staff will be evaluated at periodic intervals based on their job descriptions: 1. During the probationary period 2. At the end of the first three months of employment 3. Annually, based on personnel’s annual evaluation date...” During a review of ADMIN/DPCSS employee file, the employment application was undated. The orientation checklist was not signed by a preceptor, undated. The employee file also did not have the personnel orientation checklist which lists all the competency validations, or performance evaluations. During an interview on 12/03/2024 at 1:15pm with ADMIN/DPCS, ADMIN/DPCS stated, “;I am not sure why its not in my employee file. I did do one. All employee files need to have complete applications with dates and signatures, orientation and competency evaluation completed and signed by the preceptor who is doing the evaluation. This is important because all hospice staff need to show they are competent to perform the skills needed.” During a review of DPCSDS employee file, the employment application indicated DPCSD was hired on 08/01/2023. The orientation checklist dated 08/01/2023 was not signed by a preceptor. The employee file did not have the personnel orientation checklist which lists all the competency validations, or performance evaluations. During an interview on 12/03/2024 at 1:25 p.m., with the ADMIN/DPCS, the ADMIN/DPCS stated, “;I was not here at that time. I started working here since August of 2024. This should have been completed by the DPCS before me. All employee files need to have orientation and competency evaluation completed and signed by the preceptor who is doing the evaluation. This is important because all hospice staff need to show they are competent to perform the skills needed.” During a review of RN case managers employee file, the employment application indicated RN case manager was hired on 08/01/2023. The orientation checklist dated 08/01/2023 was not signed by a preceptor. The employee file also did not have the personnel orientation checklist which lists all the competency validations, or performance evaluations. During an interview on 12/03/2024 at 1:35 p.m., with the ADMIN/DPCS, the ADMIN/DPCS stated, “;Again, I was not here at that time. I started working here since August of 2024. This should have been completed by the DPCS before me. All employee files need to have orientation and competency evaluation completed and signed by the preceptor who is doing the evaluation. This is important because all hospice staff need to show they are competent to perform the skills needed.” During a review of MSWs employee file, the employment application indicated MSW was hired on 08/01/2023. The orientation checklist dated 08/01/2023 was not signed by a preceptor. The employee file also did not have the personnel orientation checklist which lists all the competency validations, or performance evaluations. During an interview on 12/03/2024 at 1:45 p.m., with the ADMIN/DPCS, the ADMIN/DPCS stated, “;Again, I was not here at that time. I started working here since August of 2024. This should have been completed by the DPCS before me. All employee files need to have orientation and competency evaluation completed and signed by the preceptor who is doing the evaluation. This is important because all hospice staff need to show they are competent to perform the skills needed.””

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Conditions of Participation (the terms healthcare organizations must meet to participate in federally funded healthcare programs) regarding Patients Rights was met as follows: 1. The HA failed to inform two of 14 sampled patients (Patient 4 and Patient 8) about the services the HA provided and the limitations on those services. (Refer to L519) The cumulative effect of these systemic practice resulted in the failure of the hospice to deliver statutorily mandated Federal compliance for Patients Rights to ensure the patient rights are not violated and receive the highest quality of hospice care certified to receive the benefits.”

“Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of the Patient were met as follows: Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of the Patient was met as follows: 1. The hospice agency staff failed to conduct and document an accurate comprehensive assessment that reflected the patient’s current health status and identify patients’ need for hospice care and services related to hospice eligibility and management of terminal illness for six of 14 sampled patients (Patient 4, Patient 7, Patient 8, Patient 9, Patient 10, and Patient 11). (Refer to L524) 2. The hospice agency failed to maintain an accurate, current medication profile for one of 14 sampled patients (Patient 8). (Refer to L530) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits. qqqqq”

“Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation regarding IDG, Care Planning, Coordination Of Services was met as follows: The hospice agency (HA, agency providing care to terminally ill patients who has 6 months or less to live) failed to ensure patient care plan was developed and completed that included problems, interventions, and goals, for one of 14 sampled patients (Patient 5) (Refer to L545). The visiting nurse failed to notify the physician regarding a newly identified existing open wound for one out of 14 sampled patients (Patient 5). (Refer to L555). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulation for IDG, Care Planning, Coordination Of Services to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits. 1. The hospice agency failed to ensure home visit was conducted in accordance with the plan of care for one of 14 sampled patients (Patient 8). (Refer to L543).”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [is a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Medical Director was met as evidenced by: 1. The hospice agency failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice care and services for one of 14 sampled patients (Patient 8). (Refer to L667) 2. The hospice agency failed to ensure the Medical Director and/or physician designee conducted a review and verified the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for four of 14 sampled patients (Patient 4, Patient 9, Patient 10, and Patient 11). (Refer to L668) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutory (written rules or law) mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care was provided to the patients certified to receive hospice services.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to inform two of 14 sampled patients (Patient 4 and Patient 8) about the services the HA provided and the limitations of these services. This deficient practice resulted for Patient 4 and Patient 8 not to be informed about the purpose of the hospice care services and had the potential to affect the patients’ care. Findings: During a review of Patient 8s admission record indicated a start of care (SOC) date of 4/2/2024 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), unspecified. During a review of Patient 8’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 4/17/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week plus 1 prn (or pro re nata, which means as needed) visits, the spiritual counselor (SC) and social worker (MSW) to visit monthly and 1 prn visit, and the hospice aide to visit 2 times a week. During a joint home visit, on 5/15/2024 at 11:05 a.m. with the licensed vocational nurse (LVN 2) at Patient 8s residence, Patient 8 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device. During an interview, Patient 8 stated no doctors or nurses told her that she had terminal illness and had 6 months or less to live, what hospice service was, and that nobody explained to her that what she signed up for was for hospice care and service. During an interview on 5/16/2024 at 1:20 p.m., with the Director of Patient Care Services (DPCSD), the DPCSD stated during an initial visit by the registered nurse to the patient and before the patient signed the consent for hospice care and service, agency nurses should have explained to the patient and to the patients family the kind of service they provide and the limitations of these services. During a review of the agencys policy and procedure titled, “;Rights/Responsibilities”, revised April 2021, indicated each patient will be an active, informed participant in his/her plan of care. The patient will be informed during the initial assessment visit, in advance of furnishing care, of the hospice philosophy and program of care, the organizations mission and care and services provided directly or through contractual arrangements, and the goals of hospice, the interventions that support those goals and the identification of the staff providing service. a. During a review of Patient 4s admission record indicated a start of care (SOC) date of 10/13/2023, with a terminal diagnosis of hypertensive heart disease (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation). During a review of Patient 1’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 5/14/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification. On 5/15/2024, at 12 p.m., a home visit was conducted at Patient 4’s residence with LVN 1 (license vocational nurse). Patient 4 was walking in steady gait (walking with balance) without using an assistive device (any kind of tool or device that can help simplify caregiving or make the environment safer). During an interview on 5/15/2024, at 12:20 p.m., with Patient 1, Patient 4 stated he did not have an idea what hospice services was about. Patient 4 stated the HA would send a nurse (unidentified) to come visit her every week to take his vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient’s essential body functions). Patient 4 also stated he was not sick and that he was not dying in the next six months. Findings: a. During a review of Patient 4s admission record indicated a start of care (SOC) date of 10/13/2023, with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). During a review of Patient 4’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 5/14/2024, the POC/IDG indicated the frequency of visits of Licensed Vocational Nurse (LVN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification. During a home visit observation, and interview, on 5/15/2024, at 12 p.m., at Patient 4’s residence with LVN 1, Patient 4 was walking in steady gait (walking with balance) without using an assistive device (any kind of tool or device that can help simplify caregiving or make the environment safer). Patient 4 stated he did not have an idea what hospice services was about. Patient 4 stated the HA would send a nurse (unidentified) to come visit her every week to take his vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient’s essential body functions). Patient 4 also stated he was not sick and that he was not dying in the next six months. b. During a review of Patient 8s admission record indicated a start of care (SOC) date of 4/2/2024 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), unspecified. During a review of Patient 8’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 4/17/2024, indicated the frequency of visits of Licensed Vocational Nurse (LVN) to one visit per week plus one prn (as needed) visits, the spiritual counselor (SC) and social worker (MSW) to visit monthly and 1 prn visit, and the hospice aide to visit two times a week. During a joint home visit observation, and interview, on 5/15/2024, at 11:05 a.m. with LVN 2 at Patient 8s residence, Patient 8 was awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device. Patient 8 stated no doctors or nurses told her that she had terminal illness and had six months or less to live, what hospice service was, and that nobody explained to her that what she signed up for was for hospice care and service. During an interview on 5/16/2024, at 1:20 p.m., with the Director of Patient Care Services (DPCSD), the DPCSD stated during an initial visit by the Registered Nurse to the patient (in general) and before the patient signed the consent for hospice care and service, the agency nurses needed to explain to the patient and to the patients family the kind of service they provided and the limitations of these services. During a review of the agencys policy and procedure titled, “;Rights/Responsibilities”, revised April 2021, indicated each patient will be an active, informed participant in his/her plan of care. The patient will be informed during the initial assessment visit, in advance of furnishing care, of the hospice philosophy and program of care, the organizations mission and care and services provided directly or through contractual arrangements, and the goals of hospice, the interventions that support those goals and the identification of the staff providing service.”

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure an accurate comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness [irreversible or incurable disease] that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process) to reflect the patient’s current health status and need for hospice care and services was conducted for five of 14 sampled patients (Patient 4, Patient 8, Patient 9, Patient 10, and Patient 11). This deficient practice resulted in the hospice agencys claimed reimbursement (pay) for patients who did not meet the need for hospice care and services and had the potential to affect the quality of life for the affected patients. Findings: c. During a review of Patient 8s admission record indicated a start of care (SOC) date of 4/2/2024 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), unspecified. During a review of Patient 8’s Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process), dated 4/2/2024, indicated Patient 8 was awake, alert, oriented x 3 (to time, place, and person), had normal respirations (breathing), had mild dyspnea (shortness of breath) with mild exertion, was dependent on cane or walker for ambulation, and needed moderate assistance with bathing. dressing, feeding, toileting, transferring, and ambulation. During a review of Patient 8’s Physicians Certification for Hospice Benefit (or CTI, Physician’s certification of the patient being terminally ill to have Medicare hospice benefit), for the 1st benefit period from 4/2/2024 to 6/30/2024, indicated the hospice Medical Director (Physician 1) certified that Patient 8 has a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documented evidence the hospice’s Medical Director communicated with the patients primary physician to certify Patient 8 had a life expectancy of six months or less if the terminal illness runs its normal course. The “;Physician Narrative” section of the CTI indicated Patient 8 with progressive decline in physical/functional/cognitive decline, had increased SOB (shortness of breath) with exertion, ambulates with stand-by assist, and met LCD guidelines (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits) for hospice eligibility. During a review of Patient 8s LCD Hospice Eligibility Determination form for Pulmonary Disease, dated 4/2/2024, indicated Patient 8 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 should be met. It was marked “yes” in section 1 that Patient 8 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways), resulting in decreased functional capacity. It was marked “;yes” in section 2 that Patient 8 had hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) due to her O2 sat (oxygen saturation, the amount of oxygen you have circulating in your blood. Normal range will be around 95–100%) less than or equal to 88% determined either by arterial blood gases (a test that measures the oxygen and carbon dioxide levels in your blood) or O2 sat monitors. During a review of Patient 8’s clinical record indicated there was no documented evidence Patient 8 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, or had O2 saturation of 88% or less prior to hospice admission. During a joint home visit, on 5/15/2024 at 11:05 a.m. with the licensed vocational nurse (LVN 2) at Patient 8s residence, Patient 8 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device. Patient 8 was observed not using oxygen supplement, had normal breathing and no SOB. During an interview, Patient 8 stated no doctors or nurses told her that she had terminal illness and had 6 months or less to live, what hospice service was, and that nobody explained to her that what she signed up for was for hospice care and service. Patient 8 stated she was independent, used bronchodilator medication to help relieve her symptoms, seldom used oxygen supplement, and does not have terminal illness. During a joint interview on 5/16/2024 at 1:20 p.m., with the Administrator (ADM/RN) and the Director of Patient Care Services (DPCSD), the DPCSD stated they were not able to find documented evidence Patient 8 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, or had O2 saturation of 88% or less prior to hospice admission. d. During a review of Patient 9s admission record indicated a start of care date of 12/31/2023 with a terminal diagnosis of COPD, unspecified. During a review of Patient 9’s Comprehensive Recertification (Re-Cert) Assessment, dated 3/25/2024, indicated Patient 9 was awake, alert, oriented x 3, had labored respirations, had mild dyspnea with mild exertion, had regular pulse rate (heart rate), and needed moderate assistance with feeding, toileting and ambulation, and maximum assistance with transfer, dressing and bathing. During a review of Patient 9’s Physicians Certification for Hospice Benefit for the 2nd benefit period from 3/30/2024 to 6/27/2024, indicated the hospice Medical Director recertified that Patient 9 has a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documented evidence the hospice’s Medical Director communicated with the patients primary physician to certify Patient 9 had a life expectancy of six months or less if the terminal illness runs its normal course. The “;Physician Narrative” section of the CTI indicated Patient 9 with progressive decline in physical/functional/cognitive decline, had increased SOB with exertion, ambulates occasionally with use of cane or walker with stand-by assist, and met LCD guidelines for hospice eligibility. During a review of Patient 9s LCD Hospice Eligibility Determination form for Pulmonary Disease, dated 3/25/2024, indicated Patient 9 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 should be met. It was marked “yes” in section 1 that Patient 9 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. It was marked “;yes” in section 2 that Patient 9 had hypoxia due to her O2 sat less than or equal to 88% determined either by arterial blood gases or O2 sat monitors. During a review of Patient 9’s clinical record indicated there was no documented evidence Patient 8 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, or had O2 saturation of 88% or less prior to hospice admission. During a telephone interview on 5/15/2024 at 1:41 p.m. with Patient 9, Patient 9 stated she was doing fine, does not have shortness of breath when at rest, and takes bronchodilator medication to help her breath better. During a joint interview on 5/16/2024 at 1:20 p.m., with the Administrator (ADM/RN) and the Director of Patient Care Services (DPCSD), the DPCSD stated they were not able to find documented evidence Patient 9 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, or had O2 saturation of 88% or less prior to hospice admission. e. During a review of Patient 10s admission record indicated a SOC date of 12/17/2023 with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure (a condition when your heart doesn’t pump enough blood for your body’s needs). During a review of Patient 10’s Re-Cert Assessment, dated 3/13/2024, indicated Patient 10 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related pain, regular pulse rate, had normal respirations, mild dyspnea with medium exertion, and required moderate assistance with ambulation, toileting, transfer, dressing, and bathing. The Re-Cert Assessment also indicated Patient 10 was on NYHA IV (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest) stage of heart failure and met LCD guidelines for hospice eligibility. During a review of Patient 10s CTI, dated 3/16/2024, indicated the hospice Medical Director recertified that Patient 10 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice’s Medical Director communicated with the patients primary physician to certify Patient 10 had a life expectancy of six months or less if the terminal illness runs its normal course. The “;Certifying Physician Narrative” section indicated Patient 10 with progressive decline in physical/functional/cognitive decline, and based on RNs assessment, patient qualified for hospice. The narrative section did not indicate any documented and supporting evidence from the Medical Director that included laboratory test results, imaging data, and patients history and physical prior to hospice admission to support Patient 10s terminal illness diagnosis. During a review of Patient 10s LCD Hospice Eligibility Determination form for Heart Disease, dated 3/13/2024, indicated Patient 10 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked “yes” in section 1 that Patient 10 had declined surgical procedures. Section 2 was marked “yes” that Patient 10s heart disease met the criteria for NYHA Class IV level. During a review of Patient 10’s clinical record indicated there was no documented evidence Patient 10 had declined surgical procedures. There was also no documented evidence Patient 10 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest, or had an ejection fraction of less than 20. During an interview, on 5/16/2024 at 11:00 a.m. with the Administrator/Registered Nurse (ADM/RN), ADM/RN stated she conducted the recert assessment of Patient 10. ADM/RN stated Patient 10 was awake, alert, oriented x 3 (to person, place, and time), ambulatory, blood pressure controlled with medications, not confined to bed or chair, and was not aware if Patient 10 had declined surgical procedure. During a joint interview on 5/16/2024 at 1:20 p.m., with the Administrator (ADM/RN) and the Director of Patient Care Services (DPCSD), the DPCSD stated they were not able to find documented evidence Patient 10 had declined surgical procedures, was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest, or had an ejection fraction of less than 20. f. During a review of Patient 11s admission record indicated a SOC date of 11/21/2023 with a terminal diagnosis of hypertensive heart disease without heart failure. During a review of Patient 11’s Re-Cert Assessment, dated 2/13/2024, indicated Patient 11 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related pain, regular pulse rate, had normal respirations, had no dyspnea, and required moderate assistance with ambulation, transfer and dressing, and maximum assistance with toileting and bathing. The Re-Cert Assessment also indicated Patient 11 was on NYHA IV stage of heart failure and met LCD guidelines for hospice eligibility. During a review of Patient 11s CTI, for the 2nd benefit period from 2/19/2024 to 5/18/2024, indicated the hospice Medical Director recertified that Patient 11 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice’s Medical Director communicated with the patients primary physician to certify Patient 11 had a life expectancy of six months or less if the terminal illness runs its normal course. The “;Certifying Physician Narrative” section indicated Patient 11 with progressive decline in physical/functional/cognitive decline, and based on RNs assessment, patient qualified for hospice. The narrative section did not indicate any documented and supporting evidence from the Medical Director that included laboratory test results, imaging data, and patients history and physical prior to hospice admission to support Patient 11s terminal illness diagnosis. During a review of Patient 11s LCD Hospice Eligibility Determination form for Heart Disease, dated 2/13/2024, indicated Patient 11 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked “yes” in section 1 that Patient 11 had declined surgical procedures and was optimally treated for heart disease with diuretics (medicines that help you move extra fluid and salt out of your body) and vasodilators (medicines that treat high blood pressure). Section 2 was marked “yes” that Patient 11s heart disease met the criteria for NYHA Class IV level. During a review of Patient 11’s clinical record indicated there was no documented evidence Patient 11 had declined surgical procedures or was optimally treated for heart disease with diuretics and vasodilators, or was confined to bed or chair, or any physical activity brings on discomfort and symptom at rest, or had an ejection fraction of less than 20. During a telephone interview on 5/15/2024 at 2:01 p.m. with Patient 11, Patient 11 stated she was doing fine, her blood pressure controlled with medications, was independent of her ADLs (or activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating), was not confined to bed or chair, and has not declined any surgical procedures. During a joint interview on 5/16/2024 at 1:20 p.m., with the Administrator (ADM/RN) and the Director of Patient Care Services (DPCSD), the DPCSD stated they were not able to find documented evidence Patient 11 had declined surgical procedures, was optimally treated for heart disease with diuretics and vasodilators, and was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest, or had an ejection fraction of less than 20. During a review of the agencys policy and procedure titled “Admission Criteria and Process”, revised November 2020, indicated Bless Care Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Bless Care Hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician, if any. During a review of the agencys policy and procedure titled “;Certification of Terminal Illness”, revised November 2020, indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, and the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. a. During a review of Patient 4s admission record indicated a start of care (SOC) date of 10/13/2023, with a terminal diagnosis of hypertensive heart disease (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation). During a review of Patient 4’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 5/14/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification. During a review of Patient 4’s Recertification (Re-Cert) Assessment, dated 4/10/2024, indicated Patient 4 was awake, alert, oriented x 3 (person, place, time), had cardiac-related pain, normal respirations, moderate dyspnea (difficult or labored breathing) with mild exertion, and requires maximum assistance with ambulation, toileting, and transfer. The Re-Cert Assessment also indicated Patient 4 was on NYHA IV (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest) stage of heart failure and met LCD guidelines for hospice eligibility. During a review of Patient 9s CTI, dated 4/10/2024, the Physician 1 indicated Patient 4 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice’s Medical Director communicated with the patients primary physician to certify Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. During a review of Patient 4s LCD Hospice Eligibility Determination form for Heart Disease, dated 4/9/2024, indicated Patient 4 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked “yes” in section 1 that Patient 4 has been ruled out as a candidate or has declined surgical procedures. Section 2 was marked “yes” that Patient 4s heart disease met the criteria for NYHA Class IV level. During a review of Patient 4’s clinical record indicated there was no documented evidence Patient 4 had been ruled out as a candidate or had declined surgical procedures. There was also no documented evidence Patient 4 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest, or had an ejection fraction of less than 20. On 5/15/2024, at 12 p.m., a home visit was conducted at Patient 4’s residence with LVN 1 (license vocational nurse). Patient 4 was walking in steady gait (walking with balance) without using an assistive device (any kind of tool or device that can help simplify caregiving or make the environment safer). Patient 4 has no shortness of breath and did not complain of any chest pain. During an interview on 5/15/2024, at 12:20 p.m., with Patient 1, Patient 4 stated he did not have an idea what hospice services was about. Patient 4 stated the HA would send a nurse (unidentified) to come visit her every week to take his vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient’s essential body functions). Patient 4 also stated he was not sick and that he was not dying in the next six months.”

“Based on observation, interview and record review, the hospice agency (HA) failed to maintain an accurate and current medication profile for one of 14 sampled patients (Patient 8). This failure has the potential in placing the patient at risk for medication errors and adverse drug reactions. Findings: A review of Patient 8s admission record indicated a start of care (SOC) date of 4/2/2024 with a terminal diagnosis (irreversible or incurable disease) of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), unspecified. A review of Patient 8’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 4/17/2024, indicated the frequency of visits of Licensed Vocational Nurse (LVN) to one visit per week plus 1 prn (as needed) visits to administer and monitor the effectiveness of medication, and to instruct the patient caregiver (PCG) regarding prescribed medication and side effects (are unwanted undesirable effects). During a joint home visit conducted on 5/15/2024 at 11:05 a.m. with the LVN 2 at Patient 8s residence, Patient 8 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without an assistive device (tool used to assist in walking). A review of Patient 8s current medication, on 5/15/2024 at 11:22 a.m., with LVN 2, a bottle of atorvastatin calcium (medication used to lower bad cholesterol [a waxy substance found in your blood] levels) 40 milligram (mg, a unit of measurement) 1 tablet oral daily could not be found. However, the patients current medication profile provided by the HA indicated Patient 8 had been taking atorvastatin calcium 40 mg. During an interview with Patient 8, Patient 8 stated she had stopped taking atorvastatin calcium 40 mg for more than a month after the physician had ordered to stop taking it. During an interview on 5/16/2024 at 1:20 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated nursing staff must review patients current medication on every visit and update the medication profile in the patients clinical record. A review of the hospice agencys undated policy and procedure (P&P) titled, “;Medication Profile”, indicated patients receiving medications administered by the organization should have a current, accurate medication profile in the clinical record. The P&P indicated medication profiles should be updated for each change to reflect current medications and new and/or discontinued medications.”

“Based on interview and record review, the hospice agency failed to ensure home visit was conducted in accordance with the plan of care (POC) for one of 14 sampled patients (Patient 8). This failure had the potential to negatively affect the patients’ physical comfort, psychosocial well-being, and not receiving the needed and necessary services timely. Findings: During a review of Patient 8s admission record indicated a start of care (SOC) date of 4/2/2024 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), unspecified. During a review of Patient 8’s Plan of Care (POC) Summary form indicated an order, dated 4/2/2024, for the licensed vocational nurse (Lvn) to visit once a week for assessments, clinical care, and support for ongoing evaluation of the patient`s condition. During a review of Patient 8s history of skilled nursing visit for the month of April 2024, indicated there was no Lvn visit conducted for the week starting from 4/7/2024 (Sunday) to 4/13/2024 (Saturday). During a concurrent interview and record review, on 5/16/2024 at 1:20 p.m., with the Director of Patient Care Services (DPCSD), the DPCSD acknowledged the findings and stated patient care visit should be provided to patients in accordance with the plan of care. During a review of the agency’s policy and procedure titled, “The Plan of Care”, revised November 2020, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions.”

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has 6 months or less to live) failed to ensure patient care plan was developed and completed that included problems, interventions, and goals, for one of 14 sampled patients (Patient 5). This deficient practice had the potential to affect the necessary care and services needed to maintain the highest practicable physical, mental, and psychosocial well-being of Patient 5 receiving hospice care services. A review of Patient 5’s demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated he was admitted to the hospice agency on 10/2/2023, with a terminal diagnosis of chronic congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). A review of Patient 5s POC (Plan of Care)/IDG (interdisciplinary group) Review, indicated an order dated 5/1/2024, for routine level of care (routine visits from a home provided by licensed medical professionals under the direct supervision of a physician) by a LVN (license vocational nurse) once a week, Social Worker (MSW) to evaluate and assess for needs within 5 days of admission, and the Spiritual Care Coordinator (SC) for spiritual assessment within 5 days of admission to identify spiritual needs. A review of Patient 5’s Physician’s order dated 4/18/2024, indicated to administer Seroquel (psychotropic medication [any drug that affects mental function, behavior, and mood]) 25 mg (milligrams, a unit of measurement) one tablet daily in the evening and one tab in the morning as needed. On 5/16/2024, at 1 p.m., during an interview with the Director of Patient Care Services (DPCS), when she was asked if the Seroquel medication dosages were safe to give to Patient 5, she stated yes, that it was safe to help control Patient 5s disease process. A further review of Patient 5s clinical record did not indicate a Plan of Care (POC) was developed and/or completed for psychotropic medication management (Seroquel) for Patient 5. On 5/16/2024, at 1:20 p.m., during an interview with the DPCS, she stated that there was no plan of care developed for psychotropic medication management for Patient 5. A review of the agency’s undated policy and procedure titled, “Plan of Care”, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.”

“Based on interview and record review, the visiting nurse failed to notify the physician regarding a newly identified existing open wound for one out of 14 sampled patients (Patient 5). This deficient practice placed the patient’s open wound at risk for infection if not treated promptly. A review of Patient 5’s demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated he was admitted to the hospice agency on 10/2/2023, with a terminal diagnosis of chronic congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). A review of Patient 5s POC (Plan of Care)/IDG (interdisciplinary group) Review, indicated an order dated 5/1/2024, for routine level of care (routine visits from a home provided by licensed medical professionals under the direct supervision of a physician) by a LVN (license vocational nurse) once a week, Social Worker (MSW) to evaluate and assess for needs within 5 days of admission, and the Spiritual Care Coordinator (SC) for spiritual assessment within 5 days of admission to identify spiritual needs. A review of Patient 5’s Visit Note RN (registered nurse) dated 4/5/2024, indicated the visiting nurse identified a newly open wound at left leg. The visiting nurse provided wound treatment by applying Triamcinolone 0.1 percent topical cream on open wound at left leg. However, there was no documented evidence the physician was notified about the patient’s skin condition. A further review of Patient 5’s clinical record indicated no documented evidence of a communication note indicating the visiting nurse notified the physician regarding the new existing wound at patient’s left leg. On 5/16/2024, at 12 p.m., during an interview with the DPCS (director of patient care services), she stated the visiting nurse should have notified the physician for any change of condition during their patient care visits. A review of agency’s undated policy “Change of Condition,” indicated the clinician is responsible for any specific treatment would notify the attending physician of significant changes in the patient’s condition.”

“Based on observation, interview and record review, the hospice agency failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for one out of 14 sampled patients (Patient 8). This deficient practice resulted in patients being admitted for hospice care with no documented evidence of patients written clinical information was being reviewed and evaluated by the Medical Director and/or physician designee to support their diagnoses of terminal illness. Findings: A review of Patient 8s admission record indicated a start of care (SOC) date of 4/2/2024 with a terminal diagnosis of unspecified chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 8’s Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process), dated 4/2/2024, indicated Patient 8 was awake, alert, oriented x 3 (to time, place, and person), had normal respirations (breathing), had mild dyspnea (shortness of breath) with mild exertion, was dependent on cane or walker for ambulation, and needed moderate assistance with bathing. dressing, feeding, toileting, transferring, and ambulation. A review of Patient 8’s Physicians Certification for Hospice Benefit (or CTI, Physician’s certification of the patient being terminally ill to have Medicare hospice benefit), for the 1st benefit period from 4/2/2024 to 6/30/2024, indicated the hospice Medical Director (Physician 1) certified that Patient 8 has a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documented evidence the hospice’s Medical Director communicated with the patients primary physician to certify Patient 8 had a life expectancy of six months or less if the terminal illness runs its normal course. The “;Physician Narrative” section of the CTI indicated Patient 8 with progressive physical/functional/cognitive decline, had increased SOB (shortness of breath) with exertion, ambulates with stand-by assist, and met LCD guidelines (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits) for hospice eligibility. A review of Patient 8s LCD Hospice Eligibility Determination form for Pulmonary Disease, dated 4/2/2024, indicated Patient 8 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 should be met. It was marked “yes” in section 1 that Patient 8 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways), resulting in decreased functional capacity. It was marked “;yes” in section 2 that Patient 8 had hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) due to her O2 sat (oxygen saturation, the amount of oxygen circulating in person’s blood. Normal range will be around 95 – 100 % [percent]) less than or equal to 88% determined either by arterial blood gases (a test that measures the oxygen and carbon dioxide levels in the blood) or O2 sat monitors. During a review of Patient 8’s clinical record indicated there was no documented evidence Patient 8 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, or had O2 saturation of 88% or less prior to hospice admission. During a joint home visit, on 5/15/2024 at 11:05 a.m. with the licensed vocational nurse (LVN 2) at Patient 8s residence, Patient 8 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device. Patient 8 was observed not using oxygen supplement, had normal breathing and no SOB (shortness of breath). During an interview, Patient 8 stated no doctors or nurses told her that she had terminal illness and had six months or less to live, what hospice service was, and that nobody explained to her that what she signed up for was for hospice care and service. Patient 8 stated she was independent, used bronchodilator medication to help relieve her symptoms, seldom used oxygen supplement, and does not have terminal illness. During a joint interview on 5/16/2024 at 1:20 p.m., with the Administrator (ADM/RN [Registered Nurse]) and the Director of Patient Care Services Designee (DPCSD), the DPCSD stated they were not able to find documented evidence that Patient 8 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, or had O2 saturation of 88% or less prior to hospice admission. During a telephone interview on 5/16/2024 at 2:05 p.m. with the Medical Director (Physician 1), Physician 1 stated he was not the attending physician, and became the attending physician for Patient 8 only upon admission to the hospice agency. Physician 1 stated he determined the patients were eligible for hospice services by reviewing patient’s past medical records/history and the assessment report by the registered nurse upon their initial visit to the patients and certified patients for hospice care using LCD guidelines. Physician 1 stated there should be a primary physician referral before the agency admit a patient. A review of the agencys policy and procedure titled “;Physician Services-Medical Director”, revised November 2020, indicated hospice Medical Director will have overall responsibility for the medical component of the hospice program. The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care. A review of the agencys policy and procedure titled “;Certification of Terminal Illness”, revised November 2020, indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, and the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification.”

“Based on interview and record review, the hospice agency (HA) failed to ensure the medical director and/or physician designee conducted a review and verified the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for four of 14 sampled patients (Patient 4, Patient 9, Patient 10, and Patient 11). This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. Findings: a. During a review of Patient 9s admission record indicated a start of care (SOC) date of 12/31/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), unspecified. During a review of Patient 9’s Comprehensive Recertification (Re-Cert) Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process) , dated 3/25/2024, indicated Patient 9 was awake, alert, oriented x 3 (to person, place, and time), had labored respirations, had mild dyspnea (shortness of breath) with mild exertion, had regular pulse rate (heart rate), and needed moderate assistance with feeding, toileting and ambulation, and maximum assistance with transfer, dressing and bathing. During a review of Patient 9’s Physicians Certification for Hospice Benefit (or CTI, Physician’s certification of the patient being terminally ill to have Medicare hospice benefit), for the 2nd benefit period from 3/30/2024 to 6/27/2024, indicated the hospice Medical Director recertified that Patient 9 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documented evidence the hospice’s Medical Director communicated with the patients primary physician to certify Patient 9 had a life expectancy of six months or less if the terminal illness runs its normal course. The “;Physician Narrative” section of the CTI indicated Patient 9 with progressive decline in physical/functional/cognitive decline, had increased SOB with exertion, ambulates occasionally with use of cane or walker with stand-by assist, and met LCD guidelines (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits) for hospice eligibility. During a review of Patient 9s LCD Hospice Eligibility Determination form for Pulmonary Disease, dated 3/25/2024, indicated Patient 9 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 should be met. It was marked “yes” in section 1 that Patient 9 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways), resulting in decreased functional capacity. It was marked “;yes” in section 2 that Patient 9 had hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) due to her O2 sat (oxygen saturation, the amount of oxygen you have circulating in your blood. Normal range will be around 95–100%) less than or equal to 88% determined either by arterial blood gases (a test that measures the oxygen and carbon dioxide levels in your blood) or O2 sat monitors. During a review of Patient 9’s clinical record indicated there was no documented evidence Patient 9 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, or had O2 saturation of 88% or less prior to hospice admission. During a telephone interview on 5/15/2024 at 1:41 p.m. with Patient 9, Patient 9 stated she was doing fine, does not have shortness of breath when at rest, and takes bronchodilator medication to help her breath better. During a joint interview on 5/16/2024 at 1:20 p.m., with the Administrator (ADM/RN) and the Director of Patient Care Services (DPCSD), the DPCSD stated they were not able to find documented evidence Patient 9 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, or had O2 saturation of 88% or less prior to hospice admission. b. During a review of Patient 10s admission record indicated a SOC date of 12/17/2023 with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure (a condition when your heart doesn’t pump enough blood for your body’s needs). During a review of Patient 10’s Re-Cert Assessment, dated 3/13/2024, indicated Patient 10 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related pain, regular pulse rate, had normal respirations, mild dyspnea with medium exertion, and required moderate assistance with ambulation, toileting, transfer, dressing, and bathing. The Re-Cert Assessment also indicated Patient 10 was on NYHA IV (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest) stage of heart failure and met LCD guidelines for hospice eligibility. During a review of Patient 10s CTI, dated 3/16/2024, indicated the hospice Medical Director recertified that Patient 10 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice’s Medical Director communicated with the patients primary physician to certify Patient 10 had a life expectancy of six months or less if the terminal illness runs its normal course. The “;Certifying Physician Narrative” section indicated Patient 10 with progressive decline in physical/functional/cognitive decline, and based on RNs assessment, patient qualified for hospice. The narrative section did not indicate any documented and supporting evidence from the Medical Director that included laboratory test results, imaging data, and patients history and physical prior to hospice admission to support Patient 10s terminal illness diagnosis. During a review of Patient 10s LCD Hospice Eligibility Determination form for Heart Disease, dated 3/13/2024, indicated Patient 10 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked “yes” in section 1 that Patient 10 had declined surgical procedures. Section 2 was marked “yes” that Patient 10s heart disease met the criteria for NYHA Class IV level. During a review of Patient 10’s clinical record indicated there was no documented evidence Patient 10 had declined surgical procedures. There was also no documented evidence Patient 10 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest, or had an ejection fraction of less than 20. During an interview, on 5/16/2024 at 11:00 a.m. with the Administrator/Registered Nurse (ADM/RN), ADM/RN stated she conducted the recert assessment of Patient 10. ADM/RN stated Patient 10 was awake, alert, oriented x 3 (to person, place, and time), ambulatory, blood pressure controlled with medications, not confined to bed or chair, and was not aware if Patient 10 had declined surgical procedure. During a joint interview on 5/16/2024 at 1:20 p.m., with the Administrator (ADM/RN) and the Director of Patient Care Services (DPCSD), the DPCSD stated they were not able to find documented evidence Patient 10 had declined surgical procedures, was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest, or had an ejection fraction of less than 20. c. During a review of Patient 11s admission record indicated a SOC date of 11/21/2023 with a terminal diagnosis of hypertensive heart disease without heart failure. During a review of Patient 11’s Re-Cert Assessment, dated 2/13/2024, indicated Patient 11 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related pain, regular pulse rate, had normal respirations, had no dyspnea, and required moderate assistance with ambulation, transfer and dressing, and maximum assistance with toileting and bathing. The Re-Cert Assessment also indicated Patient 11 was on NYHA IV stage of heart failure and met LCD guidelines for hospice eligibility. During a review of Patient 11s CTI, for the 2nd benefit period from 2/19/2024 to 5/18/2024, indicated the hospice Medical Director recertified that Patient 11 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice’s Medical Director communicated with the patients primary physician to certify Patient 11 had a life expectancy of six months or less if the terminal illness runs its normal course. The “;Certifying Physician Narrative” section indicated Patient 11 with progressive decline in physical/functional/cognitive decline, and based on RNs assessment, patient qualified for hospice. The narrative section did not indicate any documented and supporting evidence from the Medical Director that included laboratory test results, imaging data, and patients history and physical prior to hospice admission to support Patient 11s terminal illness diagnosis. During a review of Patient 11s LCD Hospice Eligibility Determination form for Heart Disease, dated 2/13/2024, indicated Patient 11 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked “yes” in section 1 that Patient 11 had declined surgical procedures and was optimally treated for heart disease with diuretics (medicines that help you move extra fluid and salt out of your body) and vasodilators (medicines that treat high blood pressure). Section 2 was marked “yes” that Patient 11s heart disease met the criteria for NYHA Class IV level. During a review of Patient 11’s clinical record indicated there was no documented evidence Patient 11 had declined surgical procedures or was optimally treated for heart disease with diuretics and vasodilators, or was confined to bed or chair, or any physical activity brings on discomfort and symptom at rest or had an ejection fraction of less than 20. During a telephone interview on 5/15/2024 at 2:01 p.m. with Patient 11, Patient 11 stated she was doing fine, her blood pressure controlled with medications, was independent of her ADLs (or activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating), was not confined to bed or chair, and has not declined any surgical procedures. During a joint interview on 5/16/2024 at 1:20 p.m., with the Administrator (ADM/RN) and the Director of Patient Care Services (DPCSD), the DPCSD stated they were not able to find documented evidence Patient 11 had declined surgical procedures, was optimally treated for heart disease with diuretics and vasodilators, and was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest, or had an ejection fraction of less than 20. During a telephone interview on 5/16/2024 at 2:05 p.m. with the Medical Director (Physician 1), Physician 1 stated he was not the attending physician, and became the attending physician for Patient 9, Patient 10, and Patient 11 only upon admission to the hospice agency. Physician 1 stated he determined the patients were eligible for hospice services by reviewing patient’s past medical records/history, and the assessment report by the registered nurse upon their initial visit to the patients and certify patients for hospice care using LCD guidelines. Physician 1 stated there should be a primary physician referral before the agency admit a patient. During a review of the agencys policy and procedure titled “;Physician Services-Medical Director”, revised November 2020, indicated hospice Medical Director will have overall responsibility for the medical component of the hospice program. The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care. During a review of the agencys policy and procedure titled “;Certification of Terminal Illness”, revised November 2020, indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, and the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. During a review of Patient 4s admission record indicated a start of care (SOC) date of 10/13/2023, with a terminal diagnosis of hypertensive heart disease (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation). During a review of Patient 4’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 5/14/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification. During a review of Patient 4’s Recertification (Re-Cert) Assessment, dated 4/10/2024, indicated Patient 4 was awake, alert, oriented x 3 (person, place, time), had cardiac-related pain, normal respirations, moderate dyspnea (difficult or labored breathing) with mild exertion, and requires maximum assistance with ambulation, toileting, and transfer. The Re-Cert Assessment also indicated Patient 4 was on NYHA IV (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest) stage of heart failure and met LCD guidelines for hospice eligibility. During a review of Patient 9s CTI, dated 4/10/2024, the Physician 1 indicated Patient 4 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice’s Medical Director communicated with the patients primary physician to certify Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. During a review of Patient 4s LCD Hospice Eligibility Determination form for Heart Disease, dated 4/9/2024, indicated Patient 4 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked “yes” in section 1 that Patient 4 has been ruled out as a candidate or has declined surgical procedures. Section 2 was marked “yes” that Patient 4s heart disease met the criteria for NYHA Class IV level. During a review of Patient 4’s clinical record indicated there was no documented evidence Patient 4 had been ruled out as a candidate or had declined surgical procedures. There was also no documented evidence Patient 4 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest, or had an ejection fraction of less than 20. On 5/15/2024, at 12 p.m., a home visit was conducted at Patient 4’s residence with LVN 1 (license vocational nurse). Patient 4 was walking in steady gait (walking with balance) without using an assistive device (any kind of tool or device that can help simplify caregiving or make the environment safer). Patient 4 has no shortness of breath and did not complain of any chest pain. During an interview on 5/15/2024, at 12:20 p.m., with Patient 1, Patient 4 stated he did not have an idea what hospice services was about. Patient 4 stated the HA would send a nurse (unidentified) to come visit her every week to take his vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient’s essential body functions). Patient 4 also stated he was not sick and that he was not dying in the next six months.”

“Based on interview and record review, the hospice agency failed to ensure skilled nurse clinical visit notes were completed and documented timely for one of 14 sampled patients (Patient 11). This failure had the potential to result in inability to evaluate the care provided to the patient and will compromise patient care. Findings: A review of Patient 11s admission record indicated an SOC date of 11/21/2023 with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure (a condition when person’s heart doesn’t pump enough blood for the body’s needs). A review of Patient 11s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form, dated 2/21/2024, indicated the frequency of visits for the licensed vocational nurse (LVN) to one visit per two weeks and one prn (pro re nata, which means “;as needed”) visits for assessments, clinical care and support for ongoing evaluation of the patients condition, and for the hospice registered nurse (RN) to one visit per 2 weeks and one prn for a supervisory visit. During a review of Patient 11s History of Visit Notes, on 5/15/2024 at 3:40 p.m., the record indicated the last visit notes submitted by the hospice RN was on 4/23/2024, and the LVN was on 4/18/2024. During a concurrent interview and record review, on 5/16/2024 at 1:20 p.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated the agencys policy for submission of skilled nurse (SN) visit notes was to submit within 5 (five) days after the service was rendered. The DPCSD acknowledged the SN visit notes for Patient 11 was not submitted in a timely manner. A review of the agency’s policy and procedure titled, “Entries into the Clinical Record”, revised April 2021, indicated hospice personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical record will be made on the day care is provided to the patient. All documentation will be turned in to the office at the end of the workday.”