Ajoy Healthcare

“Based on review of policies and procedures, clinical record reviews, home observation, and staff interviews, it was determined the governing body failed to organize, manage, or administer its resources to provide hospice care and services necessary for the palliation and management of the terminal illness and related conditions. Specifically, the hospice failed to educate P3 and the caregiver of medication administration, conduct a medication reconciliation on a home visit for P3, notify Medical Director (MD) of medication outcomes and change of condition of P3, dispose of expired medications prescribed to P3, and provide documentation. Findings included: Review of the undated policy titled “Governing Body,” reveals the following:“7. Hospice scope of services are approved by Governing Body.” Review of the undated policy titled “Medication Administration,” reveals the following:“5. Staff will check all patient medicines to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies and contraindicated medication and report any problems to the physician.9. Prior to administration of any medication by any route, the nurse will verify: Medication has not expired 10. The patient and family will be educated about potential adverse reactions and other concerns.” During a patient home visit on 04/14/2026 at 10:00 AM, with the Director of Nursing (DON), an observation revealed patient P3 sitting in recliner asking” Did you bring my medication? I have been without pain medication for 15 hours. I cannot do anything with you (surveyor) until I get my Codeine (opioid) used for mild to moderate pain. I was told it would be here this morning and I haven’t received it.” Observed a small amount of liquid in a bottle labeled Codeine on a bedside table near P3. Codeine was not listed on the medications for P3.The DON confirmed that P3 did not have an order for Codeine. DON stated ” I did not get a chance to put in an order; I don’t have time.” DON stated she placed an order for P3 for Codeine on 04/10/2026. DON reported the Codeine was delivered on 04/11/2026, and P3 signed for the medication. On 04/14/2026, observed DON make a call to order Codeine for P3. Interview conducted with DON on 04/14/2026 during home visit, DON acknowledged not reconciling P3’s medications during home visits. Observed Emergency kit (a prescribed set of medications kept in a patient’s home in the event of an emergency) in refrigerator containing Haloperidol (Haldol) an antipsychotic medication with an expiration date of 12/25, and Bactrim DS (antibiotic) used for infection, with expiration date of 6/10/2025. Interview with DON during patient home visit on 04/14/2026, confirmed P3 had expired medications in the refrigerator. The DON failed to provide education during home visit on 04/10/2026 for P3’s medications. On 04/14/2026 at 1:05 PM, during an in-office interview, The Director of Nursing (DON) confirmed P3 originally was ordered Codeine on 10/15/2025. DON confirmed she called the Medical Director (MD) on 4/10/2026 for a refill of Codeine and again on 04/14/2026 for P3. DON confirmed that clinical record of P3 failed to reveal evidence of physician’s order for codeine. DON confirmed P3’s medication profile had not been updated to include an order for Codeine. On 04/14/2026 at 1:30 PM during an office interview the Executive Director (ED) revealed “I was not aware the DON was not putting in medication orders for P3.” The ED confirmed P3’s medication profile had not been updated to include an order for Codeine. On 04/14/2026 at 1:45 PM, during a phone interview, the Medical Director (MD) confirmed he was aware P3 was ordered Codeine originally on 10/15/2025. The MD revealed he received a call from the DON requesting a refill for Codeine on Friday 04/10/2026 for P3. The MD confirmed he received another call on Tuesday 04/14/2026 for another refill for codeine for P3. The MD stated, “I was not aware the DON was not adding the ordered medication into the patient’s chart.””

“Based on policies and procedures, clinical record reviews, and patient and staff interviews, it was determined that the agency failed to provide an updated plan of care and failed to coordinate services ordered or needed related to the terminal illness by failing to document interdisciplinary group (IDG) meetings for three patients (P) (P2, P3, and P4) of fourteen sampled patients. Review of the undated policy titled “INTERDISCIPLINARY GROUP (IDG) Care Planning Process, reveals the following:Procedure:4 A Registered Nurse that is a member of the IDG is designated to provide coordination of care and to ensure continuous assessment of each patient’s and family’s needs and implementation of the IDG plan of care.6. All care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any) , the patient or representative and the primary caregiver in accordance with the patient’s needs.8. An individualized written plan of care is developed for each patient. the plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments. The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions including Measurable outcomes anticipated from implementing and coordination the plan of care. 9. The IDG (in collaboration with the patient’s attending physician, if any) reviews, revises and documents the individualized plan as frequently as he patient’s condition requires, but no less than every 15 calendar days.The revised plan of care includes information from the patient’s updated comprehensive assessment and notes the patient’s progress toward outcomes and goals specified in the plan of care, advance directive, effectiveness of pain and symptom management, and spiritual and psychosocial needs. 1. Review of Registered Nurse (RN) “WS RN Admission Visit (V2)” note for P2 dated 03/06/2025, Director of Nursing (DON) noted on the Nursing Summary Notes section, that due to Benign Prostate Hyperplasia (BPH) i(enlarged prostate), patient has a permanent indwelling urinary catheter draining amber colored urine. DON documents under the Catheter section Catheter Type Foley - 16 Fr .Review of IDG Comprehensive Assessment Details note dated 03/17/2026 for P2 revealed that P2 has stage 1 wound on right sole of foot, and heels are soft but not mushy. P2 also has a stage 1 wound on left sole of foot and three multiple spots on buttocks, right hip. These wounds are pea-size and skin are barely open. Review of document titled “Physician/Provider orders dated 03/04/2026 for P2 revealed an order; Foley to assist with bladder emptying due to stone and enlarged prostate. The order also revealed as follows: Pt also has a wound on upper right arm, caused by burn, and a wound on his lateral right ankle. IDG meeting notes dated 03/04/2026 and 03/17/2026, and Physician orders dated 03/04/2026 for P2 failed to reveal orders for Foley catheter management, wound care management, goals and interventions and care coordination for wound management and Foley catheter management. 2.Review of document titled “WS RN Admission Visit (V2)” note dated 03/16/2026, for P4, DON documents in the Nursing Summary Notes, the following: left hip pressure ulcer, Right lateral foot stage 1, left proximal ankle and lateral ball of foot stage 1, right proximal elbow stage 1. , 10cmx10cm Pressure ulcer is dry, jagged edges, covered with hardening scab, no drainage.Review of IDG Comprehensive Assessment Details dated 03/16/26 and Physician order dated 03/16/2026, for P4 failed to reveal orders for Foley catheter management, wound care management, goals and interventions and care coordination for wound care and Foley catheter management.Review of the visit note dated 03/21/2026, for P4, the Director of Nursing (DON) documents as follows: “As supplies had arrived to pt’s house I visited to insert the indwelling catheter. This procedure was a success and patient displayed little to no pain. I taught brother how to care for foley, empty drainage bag. I opened the dressing and the hip wound looked completely different. Last week it was closed with eschar, pink edges. Today it was completely open with green slough, yellow craggy edges. I changed the wound care routine”. Clinical record for P4 failed to reveal orders for foley catheter insertion, wound care routine that was provided to P4, and care coordination for wound care and Foley catheter management.Review of IDG Meeting notes dated 03/16/2026, 03/31/2026, for P4 failed to reveal physician orders for foley catheter care and orders for wound care.During an interview on 4/14/26 approximately at 2:10 PM, with Director of Nursing (DON) revealed that the IDG meeting notes do not reveal orders for foley and wound care and care coordination for wound care and Foley catheter management. For P2 and P4. On 04/14/2026 at approximately 2:00 PM, during an office interview, Director of Nursing (DON) confirmed P2 and P3 did not have orders for foley catheter and wound care management. Refer to citation L0547 for findings related to Patient (P) P3’s orders.”

“Based on review of policies and procedures, clinical record reviews, and staff interviews, it was determined the agency failed to provide a skilled nurse within one hour of notification for symptom management crisis. Additionally the agency failed to maintain an on-call log for all calls received after normal business hours. Findings included: Review of the undated policy titled “After hours, accessibility on call Policy,” reveals the following: “5. All calls are documented on an on-call form. These forms are on the file in the Director’s office.6. If visit is made, a nursing visit report is completed.7. The On-call patient information book contains: a. Copy of current patients’ plan of care b. Current medication profile for all active patients d. Copy of initial referral form e. Current orders8. An on-call RN is available and may be contacted 24 hours/7 days/week. The nurse will respond at a minimum with all calls answered within 15 minutes and visits made within 1 hour on site/patient’s address.9. On-Call onsite visits are required within 1 hour for symptoms management crisis situations.” Review of untitled document dated 01/01/2025-12/31/2025 revealed the following:1. On 10/22/2025, 11/21/2025, 11/29/2025, and 12/19/2025 after-hours calls were received regarding P1. 2. On 11/21/2025, 11/29/2025, and 12/19/2025 after-hours calls were received regarding P3. 3.On 09/08/2025, 10/22/2025, 10/29/2025, 10/28/2025, 11/14/2025, 11/21/2025,12/10/2025, and 12/17/2025, after-hours call were received regarding P5. On 04/15/2026 at 3:00 PM, during an office interview, the Executive Director confirms the untitled document dated 01/01/2025-12/31/2025 is the on-call documentation. ED states” That’s all the documentation I have for on call”. A review of the agency’s on-call schedule reveals Director of Nursing (DON) is identified as the on-call nurse, every day for the year, for the northern region (North). Registered Nurse (RN) (RN AA) is identified as the backup nurse for the northern region when DON is not available. RN AA is identified as the on-call nurse, every day of the year, for southern region (South) and the DON is the backup nurse when RN AA is not available. During an interview on 04/14/2026 at 9:45 AM RN AA confirmed she does not work as an on-call nurse during afterhours or during the weekend. On 04/14/2026 at 1:05 PM, during an in-office interview, the DON stated, “it takes more than an hour to get to the patients on the southside.” The DON stated, “when a call is received from a patient on the southside, the Administrator will go to the patient’s house to be a warm body until I am able to make it to the house.” Review of records failed to reveal on-call documentation for P1, P2, and P3.”

“Based on review of policy titled “Patient Bill of Rights,” review of records, observation, and staff interview, it was determined the agency failed to provide effective pain management and symptom control related to terminal illness for one patient (P) (P3) of four active patients sampled. Findings included: Review of undated policy titled ”Patient Bill of Rights,” failed to include requirements for patient education, pain and symptom management, and interventions to address the patients’ condition. Review of document for P3 received from pharmacy titled “Medication,” reveals written and fill date 3/25/26 Codeine-guaifenesin (Opioid), used for mild to moderate pain, had an initial frequency and dosage as follows “200 milliliter (ml)-take 5 milliliter by mouth every six hours may take 5ml-10ml every 6 hours as needed. Review of document for P3 received from pharmacy titled “Medication,” reveals the frequency and dosage for Codeine-guaifenesin was increased on 04/04/2026 as follows “300 milliliter-take 10ml by mouth every four hours take 5-10ml (1-2 teaspoons) as needed every 4 hours.” During a patient home visit on 04/14/2026 at 10:00AM, with the Director of Nursing (DON), observation P3 sitting in recliner asking ”Did you bring my medication? I have been without pain medication for 15 hours. I cannot do anything with you (surveyor) until I get my Codeine. I was told it would be here this morning and I haven’t received it. The DON confirmed [LO1] P3 had received 300 ml (milliliters) of Codeine on 04/11/2026 and had consumed the Codeine by 04/13/2026. On 4/14/2026 at 1:45 PM, during a phone interview, the Medical Director (MD) confirmed he was aware P3 was ordered Codeine. MD confirmed he was not aware the Codeine was not effectively managing P3’s pain. MD stated,” If I had known the Codeine was not effectively managing his (P3) pain I would have made changes to his (P3) pain medication. I was not made aware the patient was taking the Codeine more frequently than it was ordered.””

“Based on record review, observation, and staff interviews, it was determined the agency failed to reconcile medications for one patient (P) (P3) of three observed patients. Findings included: During a patient (P3) home visit on 04/14/2026 at 10:00 AM, with the Director of Nursing (DON), observed P3 sitting in recliner asking DON about his pain medication, Codeine. DON confirmed P3 did not have an order for Codeine. DON stated ”I did not get a chance to put in an order; I don’t have time.” DON confirmed she placed an order for P3 for Codeine on 04/10/2026. Medication profile for P3 failed to reveal Codeine (opioid) used for mild to moderate pain. Emergency kit was observed in refrigerator containing Haloperidol (Haldol) an antipsychotic medication with an expiration date of 12/2025, and Bactrim DS (antibiotic) used for infection, with expiration date of 06/10/2025. On 04/14/2026, during the home visit at 10:00 AM observed DON make a call to order Codeine for P3. DON failed to reconcile medication for P3 during home visit. DON acknowledged not reconciling P3’s medications during home visits and confirmed that P3 had expired medications in the refrigerator. Additionally the DON confirmed P3 originally was ordered Codeine on 10/15/2025. DON confirmed she called the Medical Director (MD) on 04/10/2026 for a refill of Codeine and again on 04/14/2026 for P3. DON confirmed that clinical record of P3 failed to reveal physician’s order for codeine. DON confirmed P3’s medication profile had not been updated to include an order for Codeine.”

“Based on review of the policy titled “Bereavement Services,” record reviews and staff interview, it was determined that the agency failed to provide a completed initial bereavement risk assessment and an ongoing bereavement assessment focusing on spiritual and physical needs for two patients (P) (P8, P13) of 14 sampled patient charts reviewed. Findings included: Review of the undated policy titled “Bereavement Services,” reveals the following:“2. An initial Bereavement Risk Assessment will be performed as part of the ComprehensiveAssessment.1. Unless Bereavement Services have been refused, a Bereavement Counselor, Chaplain or Social Worker will call designated bereaved to continue bereavement supportive or counseling services.” 1. Review of chart for P8 failed to include a completed initial or ongoing bereavement assessment.2. Review of chart for P13 failed to include a completed initial or ongoing bereavement assessment. On 04/15/2026 at 10:00 AM, during an office interview, the Executive Director (ED) confirmed P8 and P13 did not have a completed initial or ongoing bereavement assessment.”

“Based on policies and procedures, record reviews, facility documents, and patient and staff interviews, it was determined the agency failed to provide an updated comprehensive assessment by the agency Interdisciplinary Group (IDG) and failed to provide updated plan of care with patient’s progress toward desired outcomes, as well as a reassessment of the patient’s response to care/treatment for 14 patients (P) (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) of 14 sampled patients reviewed. Findings included: Review of the undated policy titled “ IDG Care Planning Process,” reveals the following:“Procedure:6. All care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any) , the patient or representative and the primary caregiver in accordance with the patient’s needs.8. An individualized written plan of care is developed for each patient. the plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments. . The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions including• Measurable outcomes anticipated from implementing and coordination the plan of care.9. The IDG (in collaboration with the patient’s attending physician, if any) reviews, revises and documents the individualized plan as frequently as the patient’s condition requires, but no less than every 15 calendar days.• The revised plan of care includes information from the patient’s updated comprehensive assessment and notes the patient’s progress toward outcomes and goals specified in the plan of care, advance directive, effectiveness of pain and symptom management, and spiritual and psychosocial needs.” Review of records for P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14 failed to ensure the plan of care was updated and individualized for all services necessary for the palliation and management of the terminal illness and related conditions with measurable outcomes. Review of Interdisciplinary Group (IDG) Meeting notes for P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14, failed to reveal updated comprehensive assessments, and updated plan of care. On 04/14/2026 at 1:00 PM, an interview was conducted with the Director of Nursing (DON) and the Executive Director (ED) who confirmed that the plan of care and the IDG meeting notes were not updated for patient’s current assessment.”

“Based on review of policies and procedures, clinical record review, surveyor observation, and staff interviews, it was determined that the agency failed to provide education and training regarding medications. to one patient (P) (P3) of three observed patients. Findings included: Review of undated policy titled “Medication Administration,” reveals the following:“10. The patient and family will be educated about potential adverse reactions and other concerns.” Clinical chart failed to reveal education being provided to patient and family. During a patient home visit on 04/14/2026 at 10:00 AM, with the Director of Nursing (DON), an observation revealed (P3) sitting in recliner asking” Did you bring my medication? I have been without pain medication for 15 hours. I cannot do anything with you (surveyor) until I get my Codeine (opioid) used for mild to moderate pain. I was told it would be here this morning and I haven’t received it.” Observed a small amount of liquid in a bottle labeled Codeine on a bedside table near P3. DON confirmed Codeine had been delivered on 04/11/2026. DON failed to provide education regarding medication during home visit on 04/14/2026”

“Based on policy titled “IDG Care Planning Process,” clinical record reviews, and staff interview, it was determined that the agency failed to develop an individualized written plan of care to include all services necessary for the palliation and management of the terminal illness and related conditions for 14 patients (P) (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14 ) of 14 sampled patients reviewed. Findings included: Review of the undated policy titled “ (IDG) Care Planning Process,” reveals the following:“Procedure:6. All care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any) , the patient or representative and the primary caregiver in accordance with the patient’s needs.8. An individualized written plan of care is developed for each patient. the plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments. . The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions including• Measurable outcomes anticipated from implementing and coordination the plan of care.9. The IDG (in collaboration with the patient’s attending physician, if any) reviews, revises and documents the individualized plan as frequently as he patient’s condition requires, but no less than every 15 calendar days.• The revised plan of care includes information from the patient’s updated comprehensive assessment and notes the patient’s progress toward outcomes and goals specified in the plan of care, advance directive, effectiveness of pain and symptom management, and spiritual and psychosocial needs.” Review of clinical record for P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14 failed to reveal individualized plan of care that includes all services necessary for the palliation and management of the terminal illness and related conditions, including the measurable outcomes anticipated from implementing and coordinating the plan of care. During an interview on 04/14/2026 approximately at 2:00 PM, the Executive Director (ED) confirmed that the clinical record failed to reveal patient specific plan of care for patients P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14.”

“Based on review of policy titled “Medication Administration,” clinical record review, pharmacy records, staff interviews, and observation, it was determined that the agency failed to manage pain and symptoms. Specifically, the facility failed to evaluate the effectiveness of the plan of care to address one patient (P) (P3) of three observed patients. Findings included: Review of the undated policy titled “Medication Administration,” reveals the following:“5. Staff will check all patient medicines to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies and contraindicated medication and report any problems to the physician. 6.Patients will be assessed and reassessed on an ongoing basis for medication effectiveness.” Clinical record review failed to reveal documentation of effectiveness of pain medication for P3. Review of document from pharmacy for P3 titled “Medication,” revealed Codeine-guaifenesin (opioid) used for mild to moderate pain, was filled on 03/09/2026, 03/14/2026, 03/18/2026, 03/25/2026, 04/04/2026, 04/10/2026, and 04/14/2026. During a patient home visit on 4/14/2026 at 10:00 AM, with the Director of Nursing (DON), observed P2 sitting in recliner asking” Did you bring my medication? I have been without pain medication for 15 hours. I cannot do anything with you (surveyor) until I get my Codeine I was told it would be here this morning and I haven’t received it.” DON reported the Codeine was delivered on 04/11/2026. Observed a small amount of liquid in a bottle labeled Codeine, dated 04/10/2026 on a bedside table near P3. On 04/14/2026 at 1:45 PM, during a phone interview, the Medical Director (MD) confirmed he was aware P3 was originally ordered Codeine-guaifenesin on 10/15/2025. The MD denied being made aware of patient requiring more than the ordered dose and taking the Codeine more frequently than prescribed.”

“Based on facility documents, clinical record reviews, and staff interviews, it was determined that the agency failed to include all services necessary for the palliation and management of the terminal illness and related conditions, and a detailed statement of the scope and frequency of services necessary to meet the patient’s needs. The agency failed to update the plan of care to include the need for additional nursing visits to meet the specific pain management needs for one patient (P) (P3) of 14 sampled patients. Findings included: Review of document for P3 received from pharmacy titled “Medication,” reveals written and fill date 3/25/26 Codeine-guaifenesin (Opioid), used for mild to moderate pain, had an initial frequency and dosage as follows “200 milliliter (ml)-take 5 milliliter by mouth every six hours may take 5ml-10ml every 6 hours as needed. Review of document for P3 received from pharmacy titled “Medication,” reveals the frequency and dosage for Codeine-guaifenesin was increased on 04/04/2026 as follows “300 milliliter-take 10ml by mouth every four hours take 5-10ml (1-2 teaspoons) as needed every 4 hours.” During a patient home visit on 04/14/2026 at 10:00 AM, with the Director of Nursing (DON), observed patient P3 sitting in recliner asking” Did you bring my medication? I have been without pain medication for 15 hours. I cannot do anything with you (surveyor) until I get my Codeine (opioid) used for mild to moderate pain. I was told it would be here this morning and I haven’t received it. The DON confirmed [LO1] P3 had received 300 ml (milliliters) of Codeine on 04/11/2026 and had consumed the Codeine by 04/13/2026. The DON revealed that no follow up visit was made on 04/14/2026 for P3 after observing changes in patient condition. DON confirmed that there had been no changes made in the nurse visit frequency. Review of document titled ” IDG (Interdisciplinary Group) Comprehensive Assessment Details,” dated 03/31/2026 failed to reveal a frequency order for skilled nurse visits for P3. During an office interview conducted on 04/15/2026 at 10:15 AM the Executive Director (ED) revealed that no follow up visit was made on 04/14/2026 for P3 after observing changes in patient condition. ED confirmed that there had been no changes made in the nurse visit frequency. During an office interview conducted on 04/14/2026 at 2:00 PM, the Director of Nursing (DON) confirmed P3 was receiving skilled nursing visits one day a week. On 4/14/2026 at 1:45 PM, during a phone interview, the Medical Director (MD) confirmed he was aware P3 was ordered Codeine. MD confirmed he was not aware the Codeine was not effectively managing P3’s pain. MD stated,” If I had known the Codeine was not effectively managing his (P3) pain I would have made changes to his (P3) pain medication. I was not made aware the patient was taking the Codeine more frequently than it was ordered.” MD confirmed P3’s change in condition warranted an increase in frequency of skilled nurse visits.”

“Based on record reviews, policy and procedure, and staff interview, it was determined that the agency failed to ensure that the care and services are provided in accordance with the plan of care for one patient (P) (P4) of 14 sampled patients. Findings included: Review of the undated policy titled “INTERDISCIPLINARY GROUP (IDG) Care Planning Process,” reveals the following:“Procedure:6. All care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any) , the patient or representative and the primary caregiver in accordance with the patient’s needs.8. An individualized written plan of care is developed for each patient. the plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments. . The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions including• Measurable outcomes anticipated from implementing and coordination the plan of care.9. The IDG (in collaboration with the patient’s attending physician, if any) reviews, revises and documents the individualized plan as frequently as he patient’s condition requires, but no less than every 15 calendar days.• The revised plan of care includes information from the patient’s updated comprehensive assessment and notes the patient’s progress toward outcomes and goals specified in the plan of care, advance directive, effectiveness of pain and symptom management, and spiritual and psychosocial needs.” Review of document titled “WS RN Admission Visit (V2)” note dated 03/16/2026, for P4, DON documents in the Nursing Summary Notes, the following left hip pressure ulcer, right lateral foot stage 1, left proximal ankle and lateral ball of foot stage 1, right proximal elbow stage 1. 10cmx10cm Pressure ulcer is dry, jagged edges, covered with hardening scab, no drainage. Review of the visit note dated 03/21/2026, the Director of Nursing (DON) documents as follows: “As supplies had arrived to pt’s house I visited to insert the indwelling catheter. This procedure was a success and patient displayed little to no pain. I taught brother how to care for foley, empty drainage bag. I opened the dressing and the hip wound looked completely different. Last week it was closed with eschar, pink edges. Today it was completely open with green slough, yellow craggy edges. I changed the wound care routine.” Review of IDG Meeting notes dated 03/16/2026, 03/31/2026, for P4 failed to reveal physician orders for foley catheter insertion and orders for wound care. Review of clinical record for P4 failed to reveal orders for foley catheter insertion and wound care routine that was provided to P4. DON provided Foley care and wound care to P4 without physician’s orders. During an interview on 04/14/2026 approximately at 2:10 PM, with Director of Nursing (DON) confirmed that the IDG meeting notes and document titled “Physician order/Provider order,” failed to reveal orders for foley and wound care management for P4.”

“Based on review of policies and procedures, record reviews and staff interviews it was determined the agency failed to ensure the ongoing sharing of information between all disciplines providing care and services for three patients (P) (P2, P3, P4) of four active patients charts reviewed. Findings included: Review of undated policy titled “IDG Care Planning Process” revealed the following:1. The IDG works together to meet the physical, medical, psychosocial, emotional and spiritual needs of the Hospice patients and families facing terminal illness and bereavement.2. A registered nurse that is a member of the IDG is designated to provide coordination of care to ensure continuous assessment of each patient’s and family’s needs and implementation of the IDG plan of care.3. All care and services furnished to patients and their families follow an individualized written plan of care established by the IDG in collaboration with the attending physician, the patient or representative and the primary caregiver in accordance with the patient’s needs. Refer to citation L536 for findings related to IDG coordination of care (sharing of information) for P2 and P4.Refer to citation L547 for findings related to IDG coordination of care (sharing of information) for P3.”

“Based on review of agency’s policies and procedures, record reviews, and staff interviews it was determined the hospice governing body and Administrator failed to assume responsibility for the management of the hospice and hospice services.Specifically, the hospice governing body failed to:1. Ensure the Interdisciplinary Group (IDG) requirements were met for reviewing, revising, and documenting patients individualized plan of care (POC) for three patients (P) (P2, P3, P4) of fourteen sampled patients charts reviewed.2. Ensure the Plan of Care was updated for three patients (P) (P2, P3, P4) of fourteen sampled patients charts reviewed.3. Provide bereavement services for two patients (P) (P8, P13) of 14 sampled patient charts reviewed.4. Complete a discharge summary which includes plan of care (POC) with all physician orders to assist with continuity of care. Findings included: Refer to citation L554 for finding related to Interdisciplinary Group (IDG) requirements for coordination of services.Refer to citation L536 for findings related to updated Plan of Care.Refer to citation L531 for findings related to bereavement services.Refer to citation L683 for findings related to discharge summary.”

“Based on staff interview and an onsite visit to the agency branch, it was determined that the agency failed to ensure that the branch was an active part of the hospice agency and failed to ensure that the branch and its services were managed and supervised by the parent agency. Findings included: During an entrance meeting on 04/13/2026 at 2:00 PM, the Executive Director (ED) confirmed that the agency has a branch in another location. ED confirmed that P4 is serviced by that branch and the branch is open. On 04/14/2026 at 9:45 AM during a home visit for P4 with Registered Nurse (RN) AA confirmed that the branch is always locked, no one goes to the that office, RN AA confirmed that RN AA manages P4 from the parent office. On 04/14/2026 at 10:30 AM, survey visited the branch. Upon arrival the branch (office building) was closed. The office building did not display agency’s name, agency’s contact information and the hours of operations. During an office interview on 04/14/2026 at 1:00 PM, the ED confirmed that the office was closed. ED revealed that the Director of Nursing (DON) manages the branch as needed and RN AA manages the office as well.”

“Based on policy titled “Medication Administration,” home observation, record reviews and staff interview, it was determined that the agency failed to ensure that each patient’s record included the initial plan of care, updated plans of care, and updated comprehensive assessments for three patients (P) (P2, P3, and P4) of 4 sampled patients reviewed. 1. Review of Registered Nurse (RN) “WS RN Admission Visit (V2)” note for P2 dated 03/06/2025, Director of Nursing (DON) noted on the Nursing Summary Notes section, that due to Benign Prostate Hyperplasia (BPH) (enlarged prostate), patient has a permanent indwelling urinary catheter draining amber colored urine. Review of IDG Comprehensive Assessment Details note dated 03/17/2026 for P2 revealed that P2 has stage 1 wound on right sole of foot, and heels are soft but not mushy. P2 also has a stage 1 wound on left sole of foot and three multiple spots on buttocks, right hip. These wounds are pea-size and skin are barely open. .Review of Interdisciplinary Group (IDG) Meeting notes dated 03/04/2026 and 03/17/2026, for P2, failed to reveal updated comprehensive assessments, updated plan of care to include orders for foley catheter care, wound care, wound measurements and care coordination for wound care management.2.Review of document titled “WS RN Admission Visit (V2)” note dated 03/16/2026, for P4, DON documents in the Nursing Summary Notes, the following: left hip pressure ulcer, right lateral foot stage 1, left proximal ankle and lateral ball of foot stage 1, right proximal elbow stage 1. 10cmx10cm Pressure ulcer is dry, jagged edges, covered with hardening scab, no drainage.Review of the visit note dated 03/21/2026, the Director of Nursing (DON) documents as follows: “As supplies had arrived to pt’s house I visited to insert the indwelling catheter. This procedure was a success and patient displayed little to no pain. I taught brother how to care for foley, empty drainage bag. I opened the dressing and the hip wound looked completely different. Last week it was closed with eschar, pink edges. Today it was completely open with green slough, yellow craggy edges. I changed the wound care routine”. Review of IDG Meeting notes dated 03/16/2026, 03/31/26 for P4, failed to reveal updated comprehensive assessments, updated plan of care to include orders for foley catheter care, wound care, wound measurements and care coordination for wound care management.During an office interview conducted on 4/14/26 at 2:00 PM with Executive Director revealed that the agency failed to include an updated plan of care to include orders for foley catheter care, wound care, wound measurements and care coordination for wound care management. for P2 and P4.3. Review of policy titled “Medication Administration”, not dated, reveals the following:10. The patient and family will be educated about potential adverse reactions and other concerns.Review of Interdisciplinary Group (IDG) Meeting notes dated 03/31/2026, for P3, failed to reveal updated comprehensive assessments, and updated plan of care to include orders for Codeine (Opioid) used to treat mild to moderate pain and education regarding medication for pain management.During a patient home visit on 04/14/2026 at approximately 10:00AM, with the Director of Nursing (DON), DON confirmed that clinical record of P3 failed to reveal evidence of physician order for Codeine. DON confirmed P3’s medication profile and plan of care had not been updated to include an order for Codeine.During an office interview conducted on 04/14/2026 at 2:00 PM with the Executive Director (ED) revealed that the agency failed to include an updated plan of care to include orders for Codeine and education regarding pain medications.Refer to Citation L0547 for further findings regarding P3.”

“Based on clinical record reviews, policies and procedures, and staff interviews, it was determined that the agency failed to include wound care orders in the plan of care for two patients (P) (P2, P4) of two sampled patients. Findings included: Review of the undated policy titled “ (IDG) Care Planning Process,” reveals the following:“Procedure:6. All care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any) , the patient or representative and the primary caregiver in accordance with the patient’s needs.8. An individualized written plan of care is developed for each patient. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments. The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions including• Measurable outcomes anticipated from implementing and coordinating the plan of care.9. The IDG (in collaboration with the patient’s attending physician, if any) reviews, revises and documents the individualized plan as frequently as he patient’s condition requires, but no less than every 15 calendar days.• The revised plan of care includes information from the patient’s updated comprehensive assessment and notes the patient’s progress toward outcomes and goals specified in the plan of care, advance directive, effectiveness of pain and symptom management, and spiritual and psychosocial needs.” Review of IDG Comprehensive Assessment Details note dated 03/17/2026 for P2 revealed that P2 has stage 1 wound on right sole of foot, and heels are soft but not mushy. P2 also has a stage 1 wound on left sole of foot and three multiple spots on buttocks, right hip. These wounds are pea-size and skin are barely open. Review of document titled “Physician/Provider orders dated 03/04/2026 for P2 revealed as follows: Pt also has a wound on upper right arm, caused by burn, and a wound on his lateral right ankle. IDG meeting notes dated 03/04/2026 and 03/17/2026, and Physician orders dated 03/04/2026 for P2 failed to reveal complete order for wound care management, goals and interventions and care coordination for wound management. 2. Review of document titled “WS RN Admission Visit (V2)” note dated 03/16/2026, for P4, Director of Nursing (DON) documents in the Nursing Summary Notes, the following: left hip pressure ulcer, Right lateral foot stage 1, left proximal ankle and lateral ball of foot stage 1, right proximal elbow stage 1. , 10cmx10cm Pressure ulcer is dry, jagged edges, covered with hardening scab, no drainage. Review of the visit note dated 03/21/2026, the Director of Nursing (DON) documents as follows: “ I opened the dressing and the hip wound looked completely different. Last week it was closed with eschar, pink edges. Today it was completely open with green slough, yellow craggy edges. I changed the wound care routine.” Clinical record for P4 failed to reveal orders for wound care that was provided to P4. Review of IDG Meeting notes dated 03/16/2026, and 03/31/2026, for P4 failed to reveal physician orders for wound care. During an interview on 04/14/2026 at 2:10 PM, with Director of Nursing (DON) revealed that the IDG meeting notes do not reveal orders for wound care management for P2 and P4.”

“Based on record reviews and staff interviews, it was determined the agency failed to ensure the patient’s record contained physician orders for foley catheter (a thin, flexible tube that is inserted through the urethra into the bladder to drain urine) care and wound care, with signature and date for authentication for one patient (P) (P4) of four active patients (P2, P3, P4, and P5) charts reviewed. 1.Review of the visit note dated 03/21/2026 , the Director of Nursing (DON) documents as follows: “As supplies had arrived to pt’s house I visited to insert the indwelling catheter. This procedure was a success and patient displayed little to no pain. I taught brother how to care for foley, empty drainage bag. I opened the dressing and the hip wound looked completely different. Last week it was closed with eschar, pink edges. Today it was completely open with green slough, yellow craggy edges. I changed the wound care routine”. Clinical record for P4 failed to reveal the supplies were used to insert the foley Catheter; the size of the catheter, the name and the amount of solution used to inflate the balloon and failed to reveal the supplies were used to provide wound care and the step-by-step procedure to complete the wound treatment for P4.Review of IDG Meeting notes dated 03/16/2026, 03/31/2026, for P4 failed to reveal physician orders for foley catheter care and orders for wound care.During an interview on 4/14/26 approximately at 2:10 PM, with Director of Nursing (DON), DON confirmed that 16 Fr catheter was used to insert the foley and 15 CC of Normal saline was used to inflate the balloon. DON revealed that the IDG meeting notes do not reveal orders for foley and wound care management for P2 and P4. Surveyor requested an agency policy regarding physician order requirements. No policy was available during the survey or upon exit.”

“Based on policy titled “Discharge Summary,” record reviews and staff interview, it was determined that the agency failed to forward a discharge summary and patient clinical records to medical doctors or facilities receiving transferred patients from the hospice for five patients (P) (P1, P6, P7, P9, and P12) of five discharged patients charts reviewed. Findings included: Review of the undated policy titled “Discharge Summary,” reveals the following:“Procedure:1. If the care of a patient is transferred to another Medicare/Medicaid-certified facility, hospice will forward to the receiving facility, a copy of:The hospice discharge summary.The patient’s record, if requested.” 1. Review of records reveals P1’s chart failed to include documentation of discharge summary and patient’s records forwarded to receiving facility for continuation of care. 2. Review of records reveals P6’s chart failed to include documentation of discharge summary and patient’s records forwarded to receiving facility for continuation of care. 3. Review of records reveals P7’s chart failed to include documentation of discharge summary and patient’s records forwarded to receiving facility for continuation of care. 4. Review of records reveals P9’s chart failed to include documentation of discharge summary and patient’s records forwarded to receiving facility for continuation of care. 5. Review of records reveals P12’s chart failed to include documentation of discharge summary and patient’s records forwarded to receiving facility for continuation of care. On 04/15/2026 at 3:00 PM, during an office interview, the Executive Director (ED) confirmed documents, discharge summary and patient’s records, were not forwarded to receiving facility for continuation of care during the discharge process for P1, P6, P7, P9, and P12.”

“Based on review of policy titled “Discharge Summary,” record reviews and staff interview, it was determined the agency failed to complete a discharge summary, to assist with continuity of care for 10 patients (P) (P1, P6, P7, P8, P9, P10, P11, P12, P13, P14) of 10 sampled discharged patients charts reviewed. Findings included: Review of undated policy titled “Discharge Summary,” reveals the following:“A discharge Summary will be completed for patients as required by law and regulations.3. The hospice discharge summary will include:A summary of the patient’s stay including treatments, symptoms, and pain management.The patient’s current plan of care.The patient’s latest physician orders.Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician of receiving facility.” 1. Review of records reveals P1’s chart failed to include a discharge summary.2. Review of records reveals P6’s chart failed to include a discharge summary.3. Review of records reveals P7’s chart failed to include a discharge summary.4. Review of records reveals P8’s chart failed to include a discharge summary.5. Review of records reveals P9’s chart failed to include a discharge summary.6. Review of records reveals P10’s chart failed to include a discharge summary.7. Review of records reveals P11’s chart failed to include a discharge summary.8. Review of records reveals P12’s chart failed to include a discharge summary.9. Review of records reveals P13’s chart failed to include a discharge summary.10. Review of records reveals P14’s chart failed to include a discharge summary. On 04/15/2026 at 3:00 PM, during an office interview, the Executive Director (ED) confirmed that P1, P6, P7, P8, P9, P10, P11, P12, P13, P14’s clinical chart did not contain a discharge summary.”

“Based on record reviews, staff interviews, it was determined that the agency failed to ensure that patients records have signed orders for the medications that are ordered via pharmacy for one patient (P) (P3) of 14 sampled patients. Findings included: Review of document titled “Medication” for P3 from pharmacy revealed the following under Current medication:1. order date 04/14/2026 -Codeine-guaifenesin (helps to reduce cough and chest congestion) 100 mg-10mg/5 ml liquid- 300 milliliter- take 10 milliliters by mouth every four hours take 5-10 ml (1-2 teaspoons) as needed every 4 hours. The medication was sent by the pharmacy to the P3’s residence on 04/14/2026. Review of Document titled “Physician/provider orders for P3 failed to reveal the frequency for Codeine- guaifenesin. Review of clinical record failed to reveal signed order for this medication for P3. 2. Order date 04/14/2026 -Morphine (opioid pain-relieving medication used to treat acute pr severe pain) concentrate 100 mg/5 ml (20mg/ml) solution- 30 milliliters- Take 0.5 milliliter by mouth every 4 hours as needed for pain for shortness of breath. Review of Document titled “Physician/provider orders for P3 failed to reveal the exact amount and the frequency of Morphine to be taken by P3. “Physician/provider orders for P3 failed to reveal the frequency for Morphine Sulfate. Review of clinical record failed to reveal signed order for this medication for P3. 3. Order date 04/10/2026 - Codeine-guaifenesin 100 mg-10mg/5 ml liquid- 300 milliliter- take 10 milliliters by mouth every four hours take 5-10 ml (1-2 teaspoons) as needed every 4 hours. Review of Document titled “Physician/provider orders for P3 failed to reveal signed order for Codeine- guaifenesin that was ordered by the medical director and delivered to P3. Past Medications included the following dates:1.Order date - 04/04/2026 - Codeine-guaifenesin 100 mg-10mg/5 ml liquid- 300 milliliters- take 10 milliliters by mouth every four hours take 5-10 ml (1-2 teaspoons) as needed every 4 hours.Review of Document titled “Physician/provider orders for P3 failed to reveal signed order for Codeine- guaifenesin that was ordered by the medical Director and delivered to P3. 2.Order date 03/25/2026 -Codeine-guaifenesin 100 mg-10mg/5 ml liquid- 200 milliliter- take 5 milliliters by mouth every six hours, may take 5 ml- 10 ml every 6 hours as needed for anxiety and shortness of breath. Review of Document titled “Physician/provider orders for P3 failed to reveal signed order for Codeine- guaifenesin that was ordered by the medical Director and delivered to P3. 3. Order date 03/18/2026- Codeine-guaifenesin 100 mg-10mg/5 ml liquid- 200 milliliter- take 5 milliliters by mouth every six hours, may take 5 ml- 10 ml every 6 hours as needed for anxiety and shortness of breath. Review of Document titled “Physician/provider orders for P3 failed to reveal signed order for Codeine- guaifenesin that was ordered by the medical Director and delivered to P3. 4. Order date 03/14/2026- Codeine-guaifenesin 100 mg-10mg/5 ml liquid- 200 milliliter- take 5 milliliters by mouth every six hours, may take 5 ml- 10 ml every 6 hours as needed for anxiety and shortness of breath. Review of Document titled “Physician/provider orders for P3 failed to reveal signed order for Codeine- guaifenesin that was ordered by the medical Director and delivered to P3. 5.Order date - 03/09/2026 - Codeine-guaifenesin 100 mg-10mg/5 ml liquid- 200 milliliters- take 5 milliliters by mouth every six hours, may take 5 ml- 10 ml every 6 hours as needed for anxiety and shortness of breath.Review of Document titled “Physician/provider orders for P3 failed to reveal signed order for Codeine- guaifenesin that was ordered by the medical Director and delivered to P3. 6. Order date- 10/15/2025 codeine-guaifenesin 100 mg-10mg/5 ml liquid- 200 milliliter- take 5 milliliters by mouth every six hours, may take 5 ml- 10 ml every 6 hours as needed for anxiety and shortness of breath.Review of Document titled “Physician/provider orders for P3 failed to reveal signed order for Codeine- guaifenesin that was ordered by the medical Director and delivered to P3. 7. Order date- 05/16/2025 - Morphine concentrate 100 mg/5 ml(20mg/ml) solution- 30 milliliters- Take 0.5 milliliters by mouth every 4 hours as needed for pain for shortness of breath.Review of Document titled “Physician/provider orders for P3 failed to reveal signed order for Morphine concentrate 100 mg/5 ml(20mg/ml) solution- 30 milliliters- Take 0.5 milliliter by mouth every 4 hours as needed for pain for shortness of breath. 8. Order date - 12/10/2025 - Morphine concentrate 100 mg/5 ml(20mg/ml) solution- 30 milliliters- Take 0.5 milliliter by mouth every 4 hours as needed for pain for shortness of breath.Review of Document titled “Physician/provider orders for P3 failed to reveal signed order for Morphine concentrate 100 mg/5 ml(20mg/ml) solution- 30 milliliters- Take 0.5 milliliter by mouth every 4 hours as needed for pain for shortness of breath. Clinical record for P3 failed to reveal signed orders for medications that was provided to P3 by the pharmacy. On 04/14/2026 at 1:05 PM, during an in-office interview, The Director of Nursing (DON) confirmed that P3 originally was ordered Codeine on 10/15/2025. DON confirmed she called the Medical Director (MD) on 4/10/2026 for a refill of Codeine and again on 04/13/2026 for P3. DON confirmed that clinical record of P3 failed to reveal physician’s order for codeine. DON confirmed P3’s medication profile had not been updated to include an order for Codeine and Morphine. The DON stated that P3 did not have an order for Codeine,” I did not get a chance to put in an order; I don’t have time.” DON confirmed she placed an order for P3 for Codeine on 04/10/2026. DON reported the Codeine was delivered on 04/11/2026, and P3 signed for the medication. On 04/14/2026 at 1:30 PM during an office interview the Executive Director (ED) revealed, “I was not aware the DON was not putting in medication orders for P3.” The ED confirmed P3’s medication profile had not been updated to include an order for Codeine. On 04/14/2026 at 1:45 PM, during a phone interview, the Medical Director (MD) confirmed he was aware P3 was ordered Codeine originally on 10/15/2025. The MD revealed he received a call from the DON requesting a refill for Codeine on Friday 4/10/2026 for P3. The MD confirmed he received another call on Monday 4/13/2026 for another refill for codeine for P3. The MD stated, “I was not aware the DON was not adding the ordered medications into the patient’s chart.””