Merit Hospice of Atlanta, LLC

“Based on clinical record reviews, policies and procedures patient and staff interviews, it was determined 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, P4 and P14) of 14 sampled patients. Findings include: Review of records for P14 with a start of care (SOC) 6/4/2025 revealed patient has a diagnosis of Type 2 diabetes Mellitus (DM) requiring medication to control patient’s blood sugar (BS). Records revealed Skilled Nurse (SN) RNAA documented in initial assessment P14 has a history of type 2 DM. Review of records revealed P14 plan of care (POC) does not contain an order for insulin.On 3/24/2026 at 10:00 AM, during a home visit, surveyor observed P14 home medications and found P14 was taking insulin for Type 2 diabetes Mellitus (DM). During the home visit P14 confirmed taking insulin for her DM.On 3/24/2026 at 10:10 AM, during a home visit, surveyor questioned RNBB about the insulin observed in the patient’s home. RNBB confirmed the insulin was not on P14’s medication profile from the agency. RNBB added that the hospice agency does not manage P14’s DM.On 3/24/2026 at 3:20 PM, during a phone interview, P14 confirmed a diagnosis of DM with insulin dependency. P14 revealed she was administering her insulin with dosage per her discretion. P14 stated” I don’t have a doctor’s order for the insulin dosage I just regulate the dosage myself”. P14 confirmed she does not discuss her DM medication with the hospice nurse. P14 stated “the nurse never asked me about my insulin”. P14 confirmed receiving medication from “my pharmacy” and not through the hospice provided pharmacy.On 3/24/2026 at 3:45 PM, during a phone interview, RNAA confirmed P14 was an insulin dependent diabetic and that there was not an order for insulin.On 3/24/2026 at 3:56 PM, during an office interview, Director of Nursing (DON) confirmed P14 did not have an order for insulin. DON stated, “we do not order this patient (P14) medications”. On 3/26/2026 at 10:00 AM, during a phone interview MD confirmed he knew P14 was an insulin dependent diabetic. MD admitted he did not order insulin for P14 and did not monitor P14’s blood sugar (BS). The agency’s Medical Director (MD) admitted he did not coordinate care nor had he documented coordination of care with the patient’s physician who manages the insulin for P14.Review of interdisciplinary group (IDG) notes dated 2/20/2026 and 3/6/2026 reveals discussion of P14 with diagnosis of type 2 diabetes mellitus without discussion of any medications management for P14, specifically insulin. Review of the policy titled “Plan of Care” undated states the following:All Merit Hospice of Atlanta, LLC Interdisciplinary group (IDG) members involved in the patient’s care will contribute to the written plan of care, in coordination with the patient’s attending physician, the patient/patient representative and the primary care giver.The analysis of data obtained during assessments shall facilitate the ongoing identification and prioritization of patient problems, needs, goals and care, treatment and services.Review of the policy titled “Interdisciplinary Group (IDG) Coordination of Care” undated states the following:The group communicates changes via telephone, one -on -one meetings, case conferences, and home visits. Hospice staff include documentation of all communications in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation includes, the date and time of the communication, individual involved with communication, information discussed and the outcome of the communication.Review of the policy titled “ Wound Care Policy & Procedure” undated states the following:Initial wound assessment includes:location of the woundSize (length, width, depth)Stage (if pressure injury)Tissue typeDrainagePeriowund conditionPain level2. Ongoing Assessment Performed at each skilled nursing visitDocument:Changes in wound size or appearanceSigns of infectionPatient comfort/pain levelEffectiveness of treatmentnotify physician of suspected infection10. IDG InvolvementWound status reviewed during IDG meetingsAdjust care plan as needed11.Physican /NP responsibilitiesProvide wound care ordersApprove changes in treatmentEvaluate need for antibiotics or other interventions.1.Review of RN Initial Assessment for P2 dated 02/19/2025 revealed that P2 has wound and signs of infection due to cellulitis/osteomyelitis, including redness, warmth, and drainage. The RN noted on the assessment that the caregiver appeared overwhelmed and was provided with education on wound care.Review of nursing visit note for P2 dated 2/19/26, revealed that patient’s right leg is abnormal, edematous with open area with scant amount of drainage noted, area cleansed with normal saline, Neosporin applied according to patient. The RN noted that the care giver appeared overwhelmed and was provided education on wound care.Review of nursing visit note for P2 dated 2/26/26, revealed that Left leg open area noted due to poor circulation, treatment continue per hospital to prevent infection. Edema abnormal. The RN noted that the care giver appeared overwhelmed and was provided education on wound care.Review of nursing visit note for P2 dated 3/5/26, revealed Left leg open area noted due to poor circulation, treatment continue per hospital to prevent infection. Edema abnormal. The RN noted that care giver appeared overwhelmed and was provided education on wound care.Review of nursing visit note for P2 dated 3/12/26, revealed Left leg open area noted due to poor circulation, treatment continued per hospital to prevent infection. Edema abnormal. The RN noted that care giver appeared overwhelmed and was provided education on wound care.Review of document tilted Face to face (F2F) for P2 dated 7/21/25 revealed Nurse Practitioner (NP) documented that P2 is non-ambulatory, has more than a dozen wounds between her left leg and right stump. P2 has a stasis ulcer on her left leg, red. edematous and painful. P2 has just completed second course of antibiotics. P2 uses antibacterial ointment to treat the ulcers. P2 was ordered Mupirocin for wound care. Review of F2F dated 11/24/25, for P2, the NP documented that P2 has just been discharged from hospital, where P2 was treated for the infection in her left leg. P2 has poor circulation, and stasis ulcers on that leg. The ulcers have not responded well to conservative treatments. P2 has been hospitalized many times for infections on left leg, the right stump has ulcers too. Review of F2F dated 1/20/26 for P2, the NP documented that P2 has just been discharged from hospital again, for infection in P2’s left leg. The stasis ulcers on P2’s left leg are multiple and bigger in size. Left leg is swollen with very faint pedal pulses, and bluish color. The ulcers have not responded well to conservative treatments. P2 has been hospitalized many times for infections on her left leg, the right stump has ulcers too.Review of hospital record titled ’’IP after visit summary”, it is documented that P2 was admitted to the hospital from 2/5/26 to 2/15/26 with primary diagnosis of Bacterial Skin Infection, ulcer of left foot with necrosis of bone and chronic skin ulcer.Review of IDG Meeting notes dated 02/21/25 for P2, failed to reveal orders for wound care, wound measurements and care coordination wound care management.Review of IDG Meeting notes dated 03/6/26 for P2, failed to reveal orders for wound care, wound measurements and care coordination wound care management.Review of Plan of Care dated 2/19/25 for P2, failed to reveal orders for wound care management and care coordination for wound management.Review of Plan of care dated 2/14/26 for P2 failed to reveal orders for wound care management and care coordination for wound management.2.Review of Registered Nurse (RN) Initial Assessment note dated 11/19/25 for P4, revealed that P4 has fragile skin integrity; blanchable erythema noted over sacrum and heels.Review of RN skilled visit note dated 1/15/26 for P4, RN documented wound treatment is being done to the open area on the sacrum.Review of RN skilled visit note dated 2/12/26 for P4, RN documented wound treatment is being done to the open area on the sacrum.Review of RN skilled visit note dated 2/26/26 for P4, RN documented wound treatment is being done to the open area on the sacrum.Review of RN skilled visit note dated 3/12/26, for P4, RN documents wound treatment is being done to the open area on the sacrum. Review of IDG Meeting note dated 11/28/2025 for P4, failed to reveal evidence of care coordination for P4’s sacral wound management.Review of IDG Meeting note dated 1/9/2026 for P4, failed to reveal evidence of care coordination for P4’s sacral wound management On 3/24/2026 at 3:20 PM, during a phone interview, RNAA confirmed that P2 has multiple wounds on left leg and goes to hospital once a week for wound care treatment. RNAA confirmed that the hospice agency does not provide wound care to P2. RNAA confirmed that P4 did have sacral wound and it is healed now.On 3/24/26 at 3:45 pm, during a phone interview, NP confirmed that P2 has multiple wounds on left leg and goes to hospital frequently for wound infections. NP stated that P2’s wound care is provided by the hospital once or twice a week and the hospice agency also provides wound care at home for P2.On 3/25/26 at 2:00 PM, during a phone interview, P2 stated that a hospital manages P2’s wounds on left leg. P2 stated that she goes to the hospital once a week for wound care.Review of clinical record of P2 and P4 failed to reveal any care coordination notes for wound care management.On 3/26/26 at 10:00 AM, a phone interview was conducted with the Medical Director (MD), who stated that there is no coordination for P2 and P4 wound care management. MD also stated that the IDG meeting notes do not reveal evidence that wound care management for P2 and P4 was discussed.3.Review of records for P14 with a start of care (SOC) 6/4/2025 revealed patient has a diagnosis of Type 2 diabetes Mellitus (DM) requiring medication to control patient’s blood sugar (BS). Records revealed Skilled Nurse (SN) RNAA documented in initial assessment P14 has a history of type 2 DM. Review of records revealed P14 plan of care (POC) does not contain an order for insulin.On 3/24/2026 at 10:00 AM, during a home visit, surveyor observed P14 home medications and found P14 was taking insulin for Type 2 diabetes Mellitus (DM). During the home visit P14 confirmed taking insulin for her DM.On 3/24/2026 at 10:10 AM, during a home visit, surveyor questioned RNBB about the insulin observed in the patient’s home. RNBB confirmed the insulin was not on P14’s medication profile from the agency. RNBB added that the hospice agency does not manage P14’s DM.On 3/24/2026 at 3:20 PM, during a phone interview, P14 confirmed a diagnosis of DM with insulin dependency. P14 revealed she was administering her insulin with dosage per her discretion. P14 stated” I don’t have a doctor’s order for the insulin dosage I just regulate the dosage myself”. P14 confirmed she does not discuss her DM medication with the hospice nurse. P14 stated “the nurse never asked me about my insulin”. P14 confirmed receiving medication from “my pharmacy” and not through the hospice provided pharmacy.On 3/24/2026 at 3:45 PM, during a phone interview, RNAA confirmed P14 was an insulin dependent diabetic and that there was not an order for insulin.On 3/24/2026 at 3:56 PM, during an office interview, Director of Nursing (DON) confirmed P14 did not have an order for insulin. DON stated, “we do not order this patient (P14) medications”.On 3/26/2026 at 10:00 AM, during a phone interview MD confirmed he knew P14 was an insulin dependent diabetic. MD admitted he did not order insulin for P14 and did not monitor P14’s blood sugar (BS). The agency’s Medical Director (MD) admitted he did not coordinate care nor had he documented coordination of care with the patient’s physician who manages the insulin for P14.Review of interdisciplinary group (IDG) notes dated 2/20/2026 and 3/6/2026 reveals discussion of P14 with diagnosis of type 2 diabetes mellitus without discussion of any medications management for P14, specifically insulin. Cross reference to L0533 relating to failure to provide updated plan of careCross reference to L0545 relating to content of plan of care”

“Based on agency policies, clinical record reviews, and staff interviews it was determined the agency failed to comply with the following:1. Providing Chaplain/Counseling services to eight patients (P) (P1, P2, P3, P4, P5, P6, P7, and P14) of nine active sampled patients. 2. Providing an ongoing bereavement assessment focusing on spiritual and physical needs impacting patients and family’s ability to cope with death and dying for 14 patients (P) (P1,P2,P3,P4,P5,P6,P7,P8,P9,P10,P11,P12,P13,P14) of 14 sampled patient charts reviewed.3. Ensuring the hospice Social Worker (SW) is qualified by law to perform SW duties for hospice patients. Findings included: 1. Review of undated policy titled “PLAN OF CARE,” revealed the following: “The plan of care shall include all services necessary for the palliation and management of the terminal illness and related conditions, including the following:-Interventions to manage pain and symptoms.-A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.-Measurable outcomes anticipated from implementing and coordinating the plan of care.” Review of initial plan of care dated 11/21/2024 revealed that Chaplain/Counseling services were not ordered for P1.Review of initial plan of care dated 02/19/2025 revealed that Chaplain/Counseling services were not ordered for P2.Review of initial plan of care dated 08/09/2025 revealed that Chaplain/Counseling services were not ordered for P3.Review of initial plan of care dated 11/19/2025 revealed that Chaplain/Counseling services were not ordered for P4.Review of initial plan of care dated 09/07/2025 revealed that Chaplain/Counseling services were not ordered for P5. Review of initial plan of care dated 06/04/2025 revealed that Chaplain/Counseling services were not ordered for P6. Review of initial plan of care dated 07/17/2025 revealed that Chaplain/Counseling services were not ordered for P7. Review of initial plan of care dated 06/04/2025 revealed that Chaplain/Counseling services were not ordered for P14. Review of records revealed P1, P2, P3, P4, P5, P6, P7, and P14 had no documentation of declining Chaplain services. On 03/24/2026 at 4:10 PM, during an office interview, Director of Nursing (DON) acknowledged Chaplain/ Counseling services were not ordered for P1, P2, P3, P4, P5, P6, P7, and P14. DON states “most of our patients decline chaplain services.” On 03/24/2026 at 3:20 PM, during a phone interview, P14 stated “I have never been offered Chaplain services. I would like to see a Chaplain if the hospice has one available.” On 3/24/2026 at 3:40 PM, during a phone interview, family of P3 stated “we have never been offered Chaplain services.” 2. Review of P1 clinical chart revealed patient did not have a signed completed initial or ongoing bereavement assessment. Review of P2 clinical chart revealed patient failed to include a signed completed initial or ongoing bereavement assessment.Review of P3 clinical chart revealed patient failed to include a signed completed initial or ongoing bereavement assessment.Review of P4 clinical chart revealed patient failed to include a signed completed initial or ongoing bereavement assessment.Review of P5 clinical chart revealed patient failed to include a signed completed initial or ongoing bereavement assessment.Review of P6 clinical chart revealed patient failed to include a signed completed initial or ongoing bereavement assessment.Review of P7 clinical chart revealed patient failed to include a signed completed initial or ongoing bereavement assessment.Review of P8 clinical chart revealed patient failed to include a signed completed initial or ongoing bereavement assessment.Review of P9 clinical chart revealed patient failed to include a signed completed initial or ongoing bereavement assessment.Review of P10 clinical chart revealed patient failed to include a signed completed initial or ongoing bereavement assessment.Review of P11 clinical chart revealed patient failed to include a signed completed initial or ongoing bereavement assessment.Review of P12 clinical chart revealed patient failed to include a signed completed initial or ongoing bereavement assessment.Review of P13 clinical chart revealed patient failed to include a signed completed initial or ongoing bereavement assessment.Review of P14 clinical chart revealed patient failed to include a signed completed initial or ongoing bereavement assessment. On 03/24/2026 at 12:00 PM during an office interview the director of nursing (DON) confirmed P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14 did not have a signed completed initial or ongoing bereavement assessment. Surveyors requested an agency policy regarding bereavement but did not receive a policy from the agency. 3. A review of the human resource (HR) files revealed the MSW did not hold a current professional license in social work. A review of the agency document titled “[Name], LLC Job Description: Social Worker,” which was signed by the Master Social Work (MSW) and the supervisor reveals: Qualifications: 2. Currently licensed by the state of Georgia to practice social work. On 03/26/2026 at 11:42 AM, during a phone interview, the MSW acknowledged that she did not have a professional social work license. She further explained that she had taken the exam, however, she had not passed. On 03/26/2026 at 11:45 AM, during an in-office interview, the director of nursing confirmed the MSW did not have a professional social work license.”

“Based on review of agency policies, record review, and staff interview, it was determined that the agency failed to provide documentation of mock disaster drills or tabletop exercises, which has the potential to cause serious harm, injury, impairment, or death. Findings include: Review of the undated policy titled “EMERGENCY MANAGEMENT PROGRAM,” revealed the following:“Hazard Vulnerability Analysis (HVA)For each emergency/disaster identified in the hospice’s HVA, the following shall be defined:Mitigation activities that are designed to reduce the risk of and potential damage due to an emergency/disaster.Preparedness activities that organize and mobilize essential resources.” Review of the undated policy titled “EMERGENCY OPERATIONS PLAN-EXERCISES AND IMPROVEMENT PLANS,” revealed the following:“POLICYImplementation of the response phase of the Emergency Operations Plan shall be conducted at least annually, either in response to an emergency even or in a planned exercise.PROCEDURE[Name] Inc. has the responsibility to develop the scenario and disseminate the necessary information to the employees. The time and other details concerning the emergency shall be controlled by the state regulation.The emergency response exercise shall be realistic and based on potential emergencies identified in the hazards of Hospice.” Review of the agency’s binder titled “Emergency Preparedness” revealed the agency failed to provide documentation indicating that the agency had conducted a mock disaster drill or a tabletop exercise. During an in-office interview on 03/24/2026 at 1:10 PM, the Director of Nursing confirmed that he did not have documentation of the agency conducting a mock disaster drill or tabletop exercises by stating, “I don’t have it.””

“Based on review of policy titled “INTERDISCIPLINARY GROUP (IDG) COORDINATION OF CARE,” record review and staff interview, it was determined the hospice failed to ensure that the interdisciplinary group (IDG) included all required disciplines to participate when establishing and reviewing the plan of care (POC). Findings include: Review of review of policy titled, “INTERDISCIPLINARY GROUP (IDG) COORDINATION OF CARE,” reveals the following:“PROCEDUREThe interdisciplinary group consists of physicians, registered nurses, social workers, hospice aides, clergy, counselors, volunteer, and therapists.When patients require more than one service, the group is responsible for cooperative care planning to assure goals, actions that the interrelationship of services are not duplicated.The group conducts assessments and develops and updates the plan of care. The group reviews effectiveness of the plan of care at least every 15 calendar days.” Review of the IDG meeting sign in sheet failed to reveal that a chaplain or social worker attended the IDG meetings as evidenced by their missing signatures from the IDG meeting sign in sheet for the following dates: 02/01/2025, 11/28/2025, 01/09/2026, and 03/06/2026. On 03/26/2026 at 10:00 AM, during a phone interview, the Medical Director (MD) confirmed that the Director of Nursing (DON) and the MD are usually the only IDG members present for the IDG meetings.”

“Based on record reviews and staff interviews it was determined the agency failed to provide a completed initial bereavement risk assessment and an ongoing bereavement assessment focusing on spiritual and physical needs with staff signature and date for 14 patients (P) P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14) of 14 sampled patients reviewed. Findings included:1. Review of P1 clinical chart failed to include a signed completed initial or ongoing bereavement assessment. 2. Review of P2 clinical chart failed to include a signed completed initial or ongoing bereavement assessment.3. Review of P3 clinical chart failed to include a signed completed initial or ongoing bereavement assessment.4. Review of P4 clinical chart failed to include a signed completed initial or ongoing bereavement assessment.5. Review of P5 clinical chart failed to include a signed completed initial or ongoing bereavement assessment.6. Review of P6 clinical chart failed to include a signed completed initial or ongoing bereavement assessment.7. Review of P7 clinical chart failed to include a signed completed initial or ongoing bereavement assessment.8. Review of P8 clinical chart failed to include a signed completed initial or ongoing bereavement assessment.9. Review of P9 clinical chart failed to include a signed completed initial or ongoing bereavement assessment.10. Review of P10 clinical chart failed to include a signed completed initial or ongoing bereavement assessment.11. Review of P11 clinical chart failed to include a signed completed initial or ongoing bereavement assessment.12. Review of P12 clinical chart failed to include a signed completed initial or ongoing bereavement assessment.13. Review of P13 clinical chart failed to include a signed completed initial or ongoing bereavement assessment.14. Review of P14 clinical chart failed to include a signed completed initial or ongoing bereavement assessment. On 03/24/2026 at 12:00 PM during an office interview the director of nursing (DON) confirmed P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14 did not have a signed completed initial or ongoing bereavement assessment. Surveyors requested an agency policy regarding bereavement. No policy was available during the survey or upon exit.”

“Based on clinical record reviews, policies and procedures review, patient and staff interviews, it was determined the agency failed to provide an updated comprehensive assessment 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 three patients (P) (P2, P4, and P14) of 14 sampled patients reviewed.Findings included: Review of records for P14 with a start of care (SOC) 6/4/2025 revealed patient has a diagnosis of Type 2 diabetes Mellitus (DM) requiring medication to control patient’s blood sugar (BS). Records revealed Skilled Nurse (SN) RNAA documented in initial assessment P14 has a history of type 2 DM. Review of records revealed P14 plan of care (POC) does not contain an order for insulin.On 3/24/2026 at 10:00 AM, during a home visit, surveyor observed P14 home medications and found P14 was taking insulin for Type 2 diabetes Mellitus (DM). During the home visit P14 confirmed taking insulin for her DM.On 3/24/2026 at 10:10 AM, during a home visit, surveyor questioned RNBB about the insulin observed in the patient’s home. RNBB confirmed the insulin was not on P14’s medication profile from the agency. RNBB added that the hospice agency does not manage P14’s DM.On 3/24/2026 at 3:20 PM, during a phone interview, P14 confirmed a diagnosis of DM with insulin dependency. P14 revealed she was administering her insulin with dosage per her discretion. P14 stated” I don’t have a doctor’s order for the insulin dosage I just regulate the dosage myself”. P14 confirmed she does not discuss her DM medication with the hospice nurse. P14 stated “the nurse never asked me about my insulin”. On 3/24/2026 at 3:45 PM, during a phone interview, RNAA confirmed P14 was an insulin dependent diabetic and that there was not an order for insulin.On 3/24/2026 at 3:56 PM, during an office interview, Director of Nursing (DON) confirmed P14 did not have an order for insulin. DON stated, “we do not order this patient (P14) medications”. On 3/26/2026 at 10:00 AM, during a phone interview MD confirmed he knew P14 was an insulin dependent diabetic. MD admitted he did not order insulin for P14 and did not monitor P14’s blood sugar (BS). The agency’s Medical Director (MD) admitted he did not coordinate care nor had he documented coordination of care with the patient’s physician who manages the insulin for P14.Review of interdisciplinary group (IDG) notes dated 2/20/2026 and 3/6/2026 reveals discussion of P14 with diagnosis of type 2 diabetes mellitus without discussion of any medications management for P14, specifically insulin. Review of the policy titled “ Plan of Care” undated states the following:All Merit Hospice of Atlanta, LLC Interdisciplinary group (IDG) members involved in the patient’s care will contribute to the written plan of care, in coordination with the patient’s attending physician, the patient/patient representative and the primary care giver.The analysis of data obtained during assessments shall facilitate the ongoing identification and prioritization of patient problems, needs, goals and care, treatment and services.Review of the policy titled “Interdisciplinary Group (IDG) Coordination of Care” undated, states the following:The group communicates changes via telephone, one -on -one meetings, case conferences, and home visits. Hospice staff include documentation of all communications in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation includes, the date and time of the communication, individual involved with communication, information discussed and the outcome of the communication.Review of policy titled “Wound Care Policy and Procedure” undated says the following:10. IDG InvolvementWound status reviewed during IDG meetingsAdjust care plan as needed11.Physican /NP responsibilitiesProvide wound care ordersApprove changes in treatmentEvaluate need for antibiotics or other interventions. 1.Review of nursing visit note for P2 dated 2/19/26, revealed that patient’s right leg is abnormal, edematous (swelling) with open area with scant amount of drainage noted, area cleansed with normal saline, Neosporin applied according to patient. The RN noted that the care giver appeared overwhelmed and was provided education on wound care.Review of nursing visit note for P2 dated 2/26/26, revealed that Left leg open area noted due to poor circulation, treatment continue per hospital to prevent infection. Edema abnormal. The RN noted that the care giver appeared overwhelmed and was provided education on wound care.Review of nursing visit note for P2 dated 3/5/26, revealed Left leg open area noted due to poor circulation, treatment continue per hospital to prevent infection. Edema abnormal. The RN noted that care giver appeared overwhelmed and was provided education on wound care.Review of nursing visit note for P2 dated 3/12/26, revealed Left leg open area noted due to poor circulation, treatment continued per hospital to prevent infection. Edema abnormal. The RN noted that care giver appeared overwhelmed and was provided education on wound care.Review of document tilted Face to face (F2F) for P2 dated 7/21/25 revealed Nurse Practitioner (NP) documented that P2 is non-ambulatory, has more than a dozen wounds between her left leg and right stump. P2 has a stasis ulcer on her left leg, red. edematous and painful. P2 has just completed second course of antibiotics. P2 uses antibacterial ointment to treat the ulcers. P2 was ordered Mupirocin for wound care. Review of F2F dated 11/24/25, for P2, the NP documented that P2 has just been discharged from hospital, where P2 was treated for the infection in her left leg. P2 has poor circulation, and stasis ulcers on that leg. The ulcers have not responded well to conservative treatments. P2 has been hospitalized many times for infections on left leg, the right stump has ulcers too. Review of F2F dated 1/20/26 for P2, the NP documented that P2 has just been discharged from hospital again, for infection in P2’s left leg. The stasis ulcers on P2’s left leg are multiple and bigger in size. Left leg is swollen with very faint pedal pulses, and bluish color. The ulcers have not responded well to conservative treatments. P2 has been hospitalized many times for infections on her left leg, the right stump has ulcers too.Review of hospital record titled ’’IP after visit summary”, it is documented that P2 was admitted to the hospital from 2/5/26 to 2/15/26 with primary diagnosis of Bacterial Skin Infection, ulcer of left foot with necrosis of bone and chronic skin ulcer.Review of IDG Meeting notes dated 02/21/25 for P2, failed to reveal updated comprehensive assessments, updated plan of care to include orders for wound care, wound measurements and care coordination for wound care management.Review of IDG Meeting notes dated 03/6/26 for P2, failed to reveal updated comprehensive assessments, updated plan of care to include orders for wound care, wound measurements and care coordination for wound care management.2. Review of Registered Nurse (RN) Initial Assessment note dated 11/19/25 for P4, revealed that P4 has fragile skin integrity; blanchable erythema noted over sacrum and heels.Review of RN skilled visit note dated 1/15/26 for P4, RN documented wound treatment is being done to the open area on the sacrum.Review of RN skilled visit note dated 2/12/26 for P4, RN documented wound treatment is being done to the open area on the sacrum.Review of RN skilled visit note dated 2/26/26 for P4, RN documented wound treatment is being done to the open area on the sacrum.Review of RN skilled visit note dated 3/12/26, for P4, RN documents wound treatment is being done to the open area on the sacrum. Review of IDG Meeting note dated 11/28/2025 for P4, failed to reveal updated comprehensive assessments, updated plan of care to include orders for wound care, wound measurements and care coordination for wound care management.Review of IDG Meeting note dated 1/9/2026 for P4, failed to reveal updated comprehensive assessments, updated plan of care to include orders for wound care, wound measurements and care coordination for wound care management.On 3/24/2026 at 3:20 PM, during a phone interview, RNAA confirmed that P2 has multiple wounds on left leg and goes to hospital once a week for wound care treatment. RNAA confirmed that the hospice agency does not provide wound care to P2.RNAA confirmed that P4 did have sacral wound, but it is healed now.On 3/24/26 at 3:45 pm, during a phone interview, NP confirmed that P2 has multiple wounds on left leg and goes to hospital frequently for wound infections. NP stated that P2’s wound care is provided by the hospital once or twice a week and the hospice agency also provides wound care at home for P2.On 3/25/26 at 2:00 PM, during a phone interview, P2 stated that a hospital manages P2’s wounds on left leg. P2 stated that she goes to the hospital once a week for wound care.On 3/26/26 at 10:00 AM, a phone interview was conducted with the Medical Director (MD), who stated that there is no coordination for P2 and P4 wound care management. MD also stated that the IDG meeting notes do not reveal evidence of updated plan of care and updated comprehensive assessment and that wound care management for P2 and P4 was discussed.3.”

“Based on clinical record reviews, policies and procedure review, patient and staff interviews, 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 three patients (P) (P2, P4, and P14) of 14 sampled patients reviewed. Findings included: 3. Review of records for P14 with a start of care (SOC) 6/4/2025 revealed patient has a diagnosis of Type 2 diabetes Mellitus (DM) requiring medication to control patient’s blood sugar (BS). Records revealed Skilled Nurse (SN) RNAA documented in initial assessment P14 has a history of type 2 DM. Review of records revealed P14 plan of care (POC) does not contain an order for insulin.On 3/24/2026 at 10:00 AM, during a home visit, surveyor observed P14 home medications and found P14 was taking insulin for Type 2 diabetes Mellitus (DM). During the home visit P14 confirmed taking insulin for her DM.On 3/24/2026 at 10:10 AM, during a home visit, surveyor questioned RNBB about the insulin observed in the patient’s home. RNBB confirmed the insulin was not on P14’s medication profile from the agency. RNBB added that the hospice agency does not manage P14’s DM.On 3/24/2026 at 3:20 PM, during a phone interview, P14 confirmed a diagnosis of DM with insulin dependency. P14 revealed she was administering her insulin with dosage per her discretion. P14 stated” I don’t have a doctor’s order for the insulin dosage I just regulate the dosage myself”. P14 confirmed she does not discuss her DM medication with the hospice nurse. P14 stated “the nurse never asked me about my insulin”. On 3/24/2026 at 3:45 PM, during a phone interview, RNAA confirmed P14 was an insulin dependent diabetic and that there was not an order for insulin.On 3/24/2026 at 3:56 PM, during an office interview, Director of Nursing (DON) confirmed P14 did not have an order for insulin. DON stated, “we do not order this patient (P14) medications”. On 3/26/2026 at 10:00 AM, during a phone interview MD confirmed he knew P14 was an insulin dependent diabetic. MD admitted he did not order insulin for P14 and did not monitor P14’s blood sugar (BS). The agency’s Medical Director (MD) admitted he did not coordinate care nor had he documented coordination of care with the patient’s physician who manages the insulin for P14.Review of interdisciplinary group (IDG) notes dated 2/20/2026 and 3/6/2026 reveals discussion of P14 with diagnosis of type 2 diabetes mellitus without discussion of any medications management for P14, specifically insulin. Review of the policy titled “Plan of Care” undated states the following:All Merit Hospice of Atlanta, LLC Interdisciplinary group (IDG) members involved in the patient’s care will contribute to the written plan of care, in coordination with the patient’s attending physician, the patient/patient representative and the primary care giver.The analysis of data obtained during assessments shall facilitate the ongoing identification and prioritization of patient problems, needs, goals and care, treatment and services.Review of the policy titled “Interdisciplinary Group (IDG) Coordination of Care” undated states the following:The group communicates changes via telephone, one -on -one meetings, case conferences, and home visits. Hospice staff include documentation of all communications in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation includes, the date and time of the communication, individual involved with communication, information discussed and the outcome of the communication.Review of the policy titled “ Wound Care Policy & Procedure” undated states the following:Initial wound assessment includes:location of the woundSize (length, width, depth)Stage (if pressure injury)Tissue typeDrainagePeriowund conditionPain level2. Ongoing Assessment Performed at each skilled nursing visitDocument:Changes in wound size or appearanceSigns of infectionPatient comfort/pain levelEffectiveness of treatmentnotify physician of suspected infection10. IDG InvolvementWound status reviewed during IDG meetingsAdjust care plan as needed11.Physican /NP responsibilitiesProvide wound care ordersApprove changes in treatmentEvaluate need for antibiotics or other interventions. 1.Review of RN Initial Assessment for P2 dated 02/19/2025 revealed that P2 has wound and signs of infection due to cellulitis (skin infection)/osteomyelitis (bone infection), including redness, warmth, and drainage. The RN noted on the assessment that the caregiver appeared overwhelmed and was provided with education on wound care.Review of nursing visit note for P2 dated 2/19/26, revealed that patient’s right leg is abnormal, edematous (swelling) with open area with scant amount of drainage noted, area cleansed with normal saline, Neosporin applied according to patient. The RN noted that the care giver appeared overwhelmed and was provided education on wound care.Review of nursing visit note for P2 dated 2/26/26, revealed that Left leg open area noted due to poor circulation, treatment continue per hospital to prevent infection. Edema abnormal. The RN noted that the care giver appeared overwhelmed and was provided education on wound care.Review of nursing visit note for P2 dated 3/5/26, revealed Left leg open area noted due to poor circulation, treatment continue per hospital to prevent infection. Edema abnormal. The RN noted that care giver appeared overwhelmed and was provided education on wound care.Review of nursing visit note for P2 dated 3/12/26, revealed Left leg open area noted due to poor circulation, treatment continued per hospital to prevent infection. Edema abnormal. The RN noted that care giver appeared overwhelmed and was provided education on wound care.Review of Plan of Care, Benefit Period: 02/19/2025 - 05/19/2025 for P2, failed to reveal orders for wound care management, goals and interventionsand care coordination for wound management.Review of Plan of Care, Benefit Period: 05/20/2025 - 08/17/2025 for P2, failed to reveal orders for wound care management, goals and interventions and care coordination for wound management.Review of Plan of Care, Benefit Period: Benefit Period: 08/18/2025 - 10/16/2025 for P2, failed to reveal orders for wound care management, goals and interventions and care coordination for wound management.Review of Plan of Care, Benefit Period: Benefit Period: 12/16/2025 - 02/13/2026 for P2, failed to reveal orders for wound care management, goals and interventions and care coordination for wound management.Review of Plan of care Benefit Period: 02/14/2026 - 04/14/2026 for P2 failed to reveal orders for wound care management, goals and interventions and care coordination for wound management.2 Review of Registered Nurse (RN) Initial Assessment note dated 11/19/25 for P4, revealed that P4 has fragile skin integrity; blanchable erythema noted over sacrum and heels.Review of RN skilled visit note dated 1/15/26 for P4, RN documented wound treatment is being done to the open area on the sacrum.Review of RN skilled visit note dated 2/12/26 for P4, RN documented wound treatment is being done to the open area on the sacrum.Review of RN skilled visit note dated 2/26/26 for P4, RN documented wound treatment is being done to the open area on the sacrum.Review of RN skilled visit note dated 3/12/26, for P4, RN documents wound treatment is being done to the open area on the sacrum. Review of Plan of Care, Benefit Period: Benefit Period: 11/19/2025 - 02/16/2026 for P4, failed to reveal orders for wound care management, goals and interventions and care coordination for wound management.On 3/24/2026 at 3:20 PM, during a phone interview, RNAA confirmed that P2 has multiple wounds on left leg and goes to hospital once a week for wound care treatment. RNAA confirmed that the hospice agency does not provide wound care to P2. RNAA confirmed that P4 did have sacral wound and it is healed now.On 3/24/26 at 3:45 pm, during a phone interview, NP confirmed that P2 has multiple wounds on left leg and goes to hospital frequently for wound infections. NP stated that P2’s wound care is provided by the hospital once or twice a week and the hospice agency also provides wound care at home for P2.On 3/25/26 at 2:00 PM, during a phone interview, P2 stated that a hospital manages P2’s wounds on left leg. P2 stated that she goes to the hospital once a week for wound care.3.”

“Based on clinical record reviews, policies and procedure, staff and patient 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 wound care needs for one patient (P) (P2) of 14 sampled patients. Findings included: Review of the undated policy titled “PLAN OF CARE,” REFERENCE #9102, states the following:“1. All [Name] Interdisciplinary group (IDG) members involved in the patient’s care will contribute to the written plan of care, in coordination with the patient’s attending physician, the patient/patient representative and the primary care giver.2. The analysis of data obtained during assessments shall facilitate the ongoing identification and prioritization of patient problems, needs, goals and care, treatment and services.” Review of the undated policy titled “INTERDISCIPLINARY GROUP (IDG) COORDINATION OF CARE,” REFERENCE #9104, states the following:“The group communicates changes via telephone, one -on -one meetings, case conferences, and home visits. Hospice staff include documentation of all communications in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation includes the date and time of the communication, individual involved with communication, information discussed and the outcome of the communication.” Review of the undated policy titled “ WOUND CARE POLICY & PROCEDURE,” REFERENCE #9143, states the following:“Initial wound assessment includes:• location of the wound• Size(length, width, depth)• Stage (if pressure injury)• Tissue type• Drainage• Periwound condition• Pain level2. Ongoing Assessment• Performed at each skilled nursing visitDocument:• Changes in wound size or appearance• Signs of infection• Patient comfort/pain level• Effectiveness of treatment• notify physician of suspected infection10. IDG Involvement• Wound status reviewed during IDG meetings• Adjust care plan as needed11.Physican /NP responsibilities• Provide wound care orders• Approve changes in treatment• Evaluate need for antibiotics or other interventions.” Review of Face to Face (F2F) dated 11/24/2025, for P2, the Nurse Practitioner (NP) documented that P2 has just been discharged from hospital, where P2 was treated for the infection in her left leg. P2 has poor circulation, and stasis ulcers on that leg. The ulcers have not responded well to conservative treatments. P2 has been hospitalized many times for infections on left leg, the right stump has ulcers too. Review of F2F dated 1/20/2026 for P2, the NP documented that P2 has just been discharged from hospital again, for infection in P2’s left leg. The stasis ulcers on P2’s left leg are multiple and bigger in size. Left leg is swollen with very faint pedal pulses, and bluish color. The ulcers have not responded well to conservative treatments. P2 has been hospitalized many times for infections on her left leg, the right stump has ulcers too. Review of hospital record titled ’’IP after visit summary,” documentation revealed that P2 was admitted to the hospital from 02/05/2026 to 02/15/2026 with primary diagnosis of Bacterial Skin Infection, ulcer of left foot with necrosis of bone and chronic skin ulcer. Clinical record for P2 failed to reveal any documentation of P2’s frequent hospitalization for wound infections. Review of initial plan of care dated 02/19/2025 revealed that nurse visit frequency is once a week, and there were no changes made in nursing visit frequency to assess and manage the wound more frequently for wound infection since the initial plan of care was created on 02/19/2025. On 03/24/2026 at 3:20 PM, during a phone interview, Registered Nurse (RN) AA confirmed that P2 has multiple wounds on left leg and goes to hospital once a week for wound care treatment. RN AA confirmed that P2 was hospitalized in February for wound infection. On 03/24/2026 at 3:45 PM during a phone interview, NP confirmed that P2 has multiple wounds on left leg and goes to hospital frequently for wound infections. NP stated that P2’s wound care is provided by the hospital once or twice a week and the hospice agency also provides wound care at home for P2. On 03/25/2026 at 2:00 PM, during a phone interview, P2 stated that P2 was hospitalized for wound infection in February of 2026. P2 stated that hospital manages P2’s wounds on left leg. P2 stated that she goes to the hospital once a week for wound care. P2 stated that P2 has chronic wound infections on left leg and goes to the hospital for treatment for infections. On 03/26/2026 at 10:00 AM, a phone interview was conducted with the MD who stated that he wasn’t aware that P2 was hospitalized for wound infections and being treated for wound at the hospital.”

“Based on clinical record reviews, policies and procedure review, patient and staff interviews, it was determined that the agency failed to develop 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 for three patients (P) (P2, P4, and P14) of fourteen patients.Findings include: Review of records for P14 with a start of care (SOC) 6/4/2025 revealed patient has a diagnosis of Type 2 diabetes Mellitus (DM) requiring medication to control patient’s blood sugar (BS). Records revealed Skilled Nurse (SN) RNAA documented in initial assessment P14 has a history of type 2 DM. Review of records revealed P14 plan of care (POC) does not contain an order for insulin.On 3/24/2026 at 10:00 AM, during a home visit, surveyor observed P14 home medications and found P14 was taking insulin for Type 2 diabetes Mellitus (DM). During the home visit P14 confirmed taking insulin for her DM.On 3/24/2026 at 10:10 AM, during a home visit, surveyor questioned RNBB about the insulin observed in the patient’s home. RNBB confirmed the insulin was not on P14’s medication profile from the agency. RNBB added that the hospice agency does not manage P14’s DM.On 3/24/2026 at 3:20 PM, during a phone interview, P14 confirmed a diagnosis of DM with insulin dependency. P14 revealed she was administering her insulin with dosage per her discretion. P14 stated” I don’t have a doctor’s order for the insulin dosage I just regulate the dosage myself”. P14 confirmed she does not discuss her DM medication with the hospice nurse. P14 stated “the nurse never asked me about my insulin”. On 3/24/2026 at 3:45 PM, during a phone interview, RNAA confirmed P14 was an insulin dependent diabetic and that there was not an order for insulin.On 3/24/2026 at 3:56 PM, during an office interview, Director of Nursing (DON) confirmed P14 did not have an order for insulin. DON stated, “we do not order this patient (P14) medications”. On 3/26/2026 at 10:00 AM, during a phone interview MD confirmed he knew P14 was an insulin dependent diabetic. MD admitted he did not order insulin for P14 and did not monitor P14’s blood sugar (BS). The agency’s Medical Director (MD) admitted he did not coordinate care nor had he documented coordination of care with the patient’s physician who manages the insulin for P14.Review of interdisciplinary group (IDG) notes dated 2/20/2026 and 3/6/2026 reveals discussion of P14 with diagnosis of type 2 diabetes mellitus without discussion of any medications management for P14, specifically insulin. Review of the policy titled “Plan of Care” undated states the following:All Merit Hospice of Atlanta, LLC Interdisciplinary group (IDG) members involved in the patient’s care will contribute to the written plan of care, in coordination with the patient’s attending physician, the patient/patient representative and the primary care giver.The analysis of data obtained during assessments shall facilitate the ongoing identification and prioritization of patient problems, needs, goals and care, treatment and services.Review of the policy titled “Interdisciplinary Group (IDG) Coordination of Care”, undated states the following:The group communicates changes via telephone, one -on -one meetings, case conferences, and home visits. Hospice staff include documentation of all communications in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation includes, the date and time of the communication, individual involved with communication, information discussed and the outcome of the communication.1.Review of RN Initial Assessment for P2 dated 02/19/2025 revealed that P2 has wound and signs of infection due to cellulitis/osteomyelitis, including redness, warmth, and drainage. The RN noted on the assessment that the caregiver appeared overwhelmed and was provided with education on wound care.Review of nursing visit note for P2 dated 2/19/26, revealed that patient’s right leg is abnormal, edematous with open area with scant amount of drainage noted, area cleansed with normal saline, Neosporin applied according to patient. The RN noted that the care giver appeared overwhelmed and was provided education on wound care.Review of nursing visit note for P2 dated 2/26/26, revealed that Left leg open area noted due to poor circulation, treatment continue per hospital to prevent infection. Edema abnormal. The RN noted that the care giver appeared overwhelmed and was provided education on wound care.Review of nursing visit note for P2 dated 3/5/26, revealed Left leg open area noted due to poor circulation, treatment continue per hospital to prevent infection. Edema abnormal. The RN noted that care giver appeared overwhelmed and was provided education on wound care.Review of nursing visit note for P2 dated 3/12/26, revealed Left leg open area noted due to poor circulation, treatment continued per hospital to prevent infection. Edema abnormal. The RN noted that care giver appeared overwhelmed and was provided education on wound care.Review of hospital record titled ’’IP after visit summary”, it is documented that P2 was admitted to the hospital from 2/5/26 to 2/15/26 with primary diagnosis of Bacterial Skin Infection, ulcer of left foot with necrosis of bone and chronic skin ulcer.Review of IDG Meeting notes dated 02/21/25 for P2, failed to reveal orders for wound care, wound measurements, and care coordination, wound care management, including measurable outcomes and goals for the wounds for P2.Review of IDG Meeting notes dated 03/6/26 for P2, failed to reveal orders for wound care, wound measurements, care coordination, and all treatment plan necessary for wound management including the measurable outcomes and goals for the wounds for P2.Review of Plan of Care dated 2/19/25 for P2, failed to reveal orders for wound care management and care coordination for wound management, including the measurable outcomes and goals for the wounds for P2.Review of Plan of care dated 2/14/26 for P2 failed to reveal orders for wound care management and care coordination for wound management, including the measurable outcomes and goals for the wounds for P2.2.Review of Registered Nurse (RN) Initial Assessment note dated 11/19/25 for P4, revealed that P4 has fragile skin integrity; blanchable erythema noted over sacrum and heels.Review of RN skilled visit note dated 1/15/26 for P4, RN documented wound treatment is being done to the open area on the sacrum.Review of RN skilled visit note dated 2/12/26 for P4, RN documented wound treatment is being done to the open area on the sacrum.Review of RN skilled visit note dated 2/26/26 for P4, RN documented wound treatment is being done to the open area on the sacrum.Review of RN skilled visit note dated 3/12/26, for P4, RN documents wound treatment is being done to the open area on the sacrum. Review of IDG Meeting note dated 11/28/2025 for P4, failed to reveal evidence of care coordination for P4’s sacral wound management, including the measurable outcomes and goals for the wounds for P2.Review of IDG Meeting note dated 1/9/2025 for P4, failed to reveal evidence of care coordination for P4’s sacral wound management, including the measurable outcomes and goals for the wounds for P2. Review of Plan of care dated 11/19/25 for P4 failed to reveal orders for wound care and care coordination for wound management, including the measurable outcomes and goals for the wounds for P4.Review of Plan of care dated 2/17/26 for P4 failed to reveal orders for wound care and care coordination for wound management, including the measurable outcomes and goals for the wounds for P4.On 3/26/26 at 10:00 AM, a phone interview was conducted with the Medical Director (MD), who stated that there is no wound care orders on the plan of care for P2 and P4, no coordination of care for wound management for P2 and P4. MD also stated that the IDG meeting notes do not reveal evidence that wound care management for P2 and P4 was discussed.3. Review of records for P14 with a start of care (SOC) 6/4/2025 revealed patient has a diagnosis of Type 2 diabetes Mellitus (DM) requiring medication to control patient’s blood sugar (BS). Records revealed Skilled Nurse (SN) RNAA documented in initial assessment P14 has a history of type 2 DM. Review of records revealed P14 plan of care (POC) does not contain an order for insulin.On 3/24/2026 at 10:00 AM, during a home visit, surveyor observed P14 home medications and found P14 was taking insulin for Type 2 diabetes Mellitus (DM). During the home visit P14 confirmed taking insulin for her DM.On 3/24/2026 at 10:10 AM, during a home visit, surveyor questioned RNBB about the insulin observed in the patient’s home. RNBB confirmed the insulin was not on P14’s medication profile from the agency. RNBB added that the hospice agency does not manage P14’s DM.On 3/24/2026 at 3:20 PM, during a phone interview, P14 confirmed a diagnosis of DM with insulin dependency. P14 revealed she was administering her insulin with dosage per her discretion. P14 stated” I don’t have a doctor’s order for the insulin dosage I just regulate the dosage myself”. P14 confirmed she does not discuss her DM medication with the hospice nurse. P14 stated “the nurse never asked me about my insulin”. On 3/24/2026 at 3:45 PM, during a phone interview, RNAA confirmed P14 was an insulin dependent diabetic and that there was not an order for insulin.On 3/24/2026 at 3:56 PM, during an office interview, Director of Nursing (DON) confirmed P14 did not have an order for insulin. DON stated, “we do not order this patient (P14) medications”. On 3/26/2026 at 10:00 AM, during a phone interview MD confirmed he knew P14 was an insulin dependent diabetic. MD admitted he did not order insulin for P14 and did not monitor P14’s blood sugar (BS). The agency’s Medical Director (MD) admitted he did not coordinate care nor had he documented coordination of care with the patient’s physician who manages the insulin for P14.Review of interdisciplinary group (IDG) notes dated 2/20/2026 and 3/6/2026 reveals discussion of P14 with diagnosis of type 2 diabetes mellitus without discussion of any medications management for P14, specifically insulin.”

“Based on clinical record reviews, policies and procedures, patient and staff interviews, it was determined that the agency failed to ensure the ongoing sharing of information between all disciplines providing care and services in all settings, provided directly or under arrangement for three patients (P) (P2, P4, and P14) of 14 sampled patients. Findings included: Review of the policy titled “Plan of Care” states undated the following:All Merit Hospice of Atlanta, LLC Interdisciplinary group (IDG) members involved in the patient’s care will contribute to the written plan of care, in coordination with the patient’s attending physician, the patient/patient representative and the primary care giver.The analysis of data obtained during assessments shall facilitate the ongoing identification and prioritization of patient problems, needs, goals and care, treatment and services.Review of the policy titled “Interdisciplinary Group (IDG) Coordination of Care” undated states the following:The group communicates changes via telephone, one -on -one meetings, case conferences, and home visits. Hospice staff include documentation of all communications in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation includes, the date and time of the communication, individual involved with communication, information discussed and the outcome of the communication.Review of the policy titled “ Wound Care Policy & Procedure” undated states the following:Initial wound assessment includes:location of the woundSize(length, width, depth)Stage (if pressure injury)Tissue typeDrainagePeriowund conditionPain level2. Ongoing Assessment Performed at each skilled nursing visitDocument:Changes in wound size or appearanceSigns of infectionPatient comfort/pain levelEffectiveness of treatmentnotify physician of suspected infection10. IDG InvolvementWound status reviewed during IDG meetingsAdjust care plan as needed11.Physican /NP responsibilitiesProvide wound care ordersApprove changes in treatmentEvaluate need for antibiotics or other interventions.1.Review of document tilted Face to face (F2F) for P2 dated 7/21/25 revealed Nurse Practitioner (NP) documented that P2 is non-ambulatory, has more than a dozen wounds between her left leg and right stump. P2 has a stasis ulcer on her left leg, red. edematous and painful. P2 has just completed second course of antibiotics. P2 uses antibacterial ointment to treat the ulcers. P2 was ordered Mupirocin for wound care. Review of F2F dated 11/24/25, for P2, the NP documented that P2 has just been discharged from hospital, where P2 was treated for the infection in her left leg. P2 has poor circulation, and stasis ulcers on that leg. The ulcers have not responded well to conservative treatments. P2 has been hospitalized many times for infections on left leg, the right stump has ulcers too. Review of F2F dated 1/20/26 for P2, the NP documented that P2 has just been discharged from hospital again, for infection in P2’s left leg. The stasis ulcers on P2’s left leg are multiple and bigger in size. Left leg is swollen with very faint pedal pulses, and bluish color. The ulcers have not responded well to conservative treatments. P2 has been hospitalized many times for infections on her left leg, the right stump has ulcers too.Review of hospital record titled ’’IP after visit summary”, it is documented that P2 was admitted to the hospital from 2/5/26 to 2/15/26 with primary diagnosis of Bacterial Skin Infection, ulcer of left foot with necrosis of bone and chronic skin ulcer.Review of IDG Meeting notes dated 02/21/25 for P2, failed to reveal evidence of care coordination for wound care management, failed to reveal evidence of the ongoing sharing of information between all disciplines providing care and services for P2.Review of IDG Meeting notes dated 03/6/26 for P2, failed to reveal evidence of care coordination for wound care management, failed to reveal evidence of the ongoing sharing of information between all disciplines providing care and services for P2.2.Review of Registered Nurse (RN) Initial Assessment note dated 11/19/25 for P4, revealed that P4 has fragile skin integrity; blanchable erythema noted over sacrum and heels.Review of RN skilled visit note dated 1/15/26 for P4, RN documented wound treatment is being done to the open area on the sacrum.Review of RN skilled visit note dated 2/12/26 for P4, RN documented wound treatment is being done to the open area on the sacrum.Review of RN skilled visit note dated 2/26/26 for P4, RN documented wound treatment is being done to the open area on the sacrum.Review of RN skilled visit note dated 3/12/26, for P4, RN documents wound treatment is being done to the open area on the sacrum. Review of IDG Meeting note dated 11/28/2025 for P4, failed to reveal evidence of care coordination for wound care management, failed to reveal evidence of the ongoing sharing of information between all disciplines providing care and services for P2.Review of IDG Meeting note dated 1/9/2026 for P4, failed to reveal evidence of care coordination for wound care management, failed to reveal evidence of the ongoing sharing of information between all disciplines providing care and services for P2.3. Review of records for P14 with a start of care (SOC) 6/4/2025 revealed patient has a diagnosis of Type 2 diabetes Mellitus (DM) requiring medication to control patient’s blood sugar (BS). Records revealed Skilled Nurse (SN) RNAA documented in initial assessment P14 has a history of type 2 DM. Review of records revealed P14 plan of care (POC) does not contain an order for insulin.On 3/24/2026 at 10:00 AM, during a home visit, surveyor observed P14 home medications and found P14 was taking insulin for Type 2 diabetes Mellitus (DM). During the home visit P14 confirmed taking insulin for her DM.On 3/24/2026 at 10:10 AM, during a home visit, surveyor questioned RNBB about the insulin observed in the patient’s home. RNBB confirmed the insulin was not on P14’s medication profile from the agency. RNBB added that the hospice agency does not manage P14’s DM.On 3/24/2026 at 3:20 PM, during a phone interview, P14 confirmed a diagnosis of DM with insulin dependency. P14 revealed she was administering her insulin with dosage per her discretion. P14 stated” I don’t have a doctor’s order for the insulin dosage I just regulate the dosage myself”. P14 confirmed she does not discuss her DM medication with the hospice nurse. P14 stated “the nurse never asked me about my insulin”. P14 confirmed receiving medication from “my pharmacy” and not through the hospice provided pharmacy.On 3/24/2026 at 3:45 PM, during a phone interview, RNAA confirmed P14 was an insulin dependent diabetic and that there was not an order for insulin.On 3/24/2026 at 3:56 PM, during an office interview, Director of Nursing (DON) confirmed P14 did not have an order for insulin. DON stated, “we do not order this patient (P14) medications”.On 3/26/2026 at 10:00 AM, during a phone interview MD confirmed he knew P14 was an insulin dependent diabetic. MD admitted he did not order insulin for P14 and did not monitor P14’s blood sugar (BS). The agency’s Medical Director (MD) admitted he did not coordinate care nor had he documented coordination of care with the patient’s physician who manages the insulin for P14.Review of interdisciplinary group (IDG) notes dated 2/20/2026 and 3/6/2026 reveals discussion of P14 with diagnosis of type 2 diabetes mellitus without discussion of any medications management for P14, specifically insulin.”

“Based on review of policy titled “ORGANIZATIONAL PERFORMANCE IMPROVEMENT PLAN,” record reviews, and staff interview, it was determined the agency failed to maintain a Quality Improvement Plan (QAPI) program with indicators that are measured, analyzed and tracked for improvement and quality of care. Findings included: Review of agency’s undated policy titled “ORGANIZATIONAL PERFORMANCE IMPROVEMENT PLAN,” revealed the following:“ [Name] Services’ performance improvement plan is designed to monitor, evaluate and improve the quality, appropriateness and outcomes of care, treatment and services by:• Planning, designing, measuring, assessing, improving new or revised processes of patient care and service• Identifying opportunities through continuous assessment of systems and processes of care through a collaborative, interdisciplinary focus• Implementing solutions and actions which will bring about the desired change, to• Facilitate a positive patient outcome, while• Maintaining a safe environment for staff, patients and visitorsPOLICY:The administration of [Name] is committed to and supports a planned, systematic organization wide performance improvement plan that encompasses well-designed processes and performance measurement, analysis and improvement.The performance improvement activities are planned in a collaborative, interdisciplinary manner throughout the organization. Review of document titled “Performance Improvement Monitoring and Evaluation Plan,” dated 01/24/2025, 04/24/2025, 07/25/2025 and 10/172025 revealed performance improvement plan (PIP) failed to contain data collection, audits, or relevant data collection from identified quality indicators for improving hospice services. On 03/23/2026 at 1:15 PM, during an office interview, the Director of Nursing (DON) acknowledged the Quality Improvement Plan (QAPI) program did not contain Performance Improvement Projects (PIP) with indicators that are measured, analyzed and tracked for improvement and quality of care. Furthermore, when surveyor requested the PIP documentation for the last four quarters the DON stated, “No PIPS, I do not have it.””

“Based on clinical record reviews, policies and procedures patient and staff interviews, it was determined that the agency failed to provide nursing services that ensures that the nursing needs of the patients are met as identified in the patient’s initial assessment, comprehensive assessment, and updated assessments for three patients (P) (P2, P4, and P14) of 14 patients reviewed. Findings included: Review of the policy titled “Plan of Care” undated states the following:All Merit Hospice of Atlanta, LLC Interdisciplinary group (IDG) members involved in the patient’s care will contribute to the written plan of care, in coordination with the patient’s attending physician, the patient/patient representative and the primary care giver.The analysis of data obtained during assessments shall facilitate the ongoing identification and prioritization of patient problems, needs, goals and care, treatment and services.Review of the policy titled “Interdisciplinary Group (IDG) Coordination of Care” undated states the following:The group communicates changes via telephone, one -on -one meetings, case conferences, and home visits. Hospice staff include documentation of all communications in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation includes, the date and time of the communication, individual involved with communication, information discussed and the outcome of the communication.Review of the policy titled “ Wound Care Policy & Procedure” undated states the following:Initial wound assessment includes:location of the woundSize(length, width, depth)Stage (if pressure injury)Tissue typeDrainagePeriowund conditionPain level2. Ongoing Assessment Performed at each skilled nursing visitDocument:Changes in wound size or appearanceSigns of infectionPatient comfort/pain levelEffectiveness of treatmentnotify physician of suspected infection10. IDG InvolvementWound status reviewed during IDG meetingsAdjust care plan as needed11.Physican /NP responsibilitiesProvide wound care ordersApprove changes in treatmentEvaluate need for antibiotics or other interventions. 1.Review of nursing visit note for P2 dated 2/19/26, revealed that patient’s right leg is abnormal, edematous with open area with scant amount of drainage noted, area cleansed with normal saline, Neosporin applied according to patient. The RN noted that the care giver appeared overwhelmed and was provided education on wound care.Review of nursing visit note for P2 dated 2/26/26, revealed that Left leg open area noted due to poor circulation, treatment continue per hospital to prevent infection. Edema abnormal. The RN noted that the care giver appeared overwhelmed and was provided education on wound care.Review of nursing visit note for P2 dated 3/5/26, revealed Left leg open area noted due to poor circulation, treatment continue per hospital to prevent infection. Edema abnormal. The RN noted that care giver appeared overwhelmed and was provided education on wound care.Review of nursing visit note for P2 dated 3/12/26, revealed Left leg open area noted due to poor circulation, treatment continued per hospital to prevent infection. Edema abnormal. The RN noted that care giver appeared overwhelmed and was provided education on wound care.Review of Plan of Care dated 2/19/25 for P2, failed to reveal orders for wound care management, wound measurements, goals and interventions and care coordination for wound management.Review of Plan of care dated 2/14/26 for P2 failed to reveal orders for wound care management, goals and interventions, wound measurements and care coordination for wound management.Review of hospital record titled ’’IP after visit summary”, it is documented that P2 was admitted to the hospital from 2/5/26 to 2/15/26 with primary diagnosis of Bacterial Skin Infection, ulcer of left foot with necrosis of bone and chronic skin ulcer.On 3/24/2026 at 3:20 PM, during a phone interview, RNAA confirmed that P2 has multiple wounds on left leg and goes to hospital once a week for wound care treatment. RNAA confirmed that the hospice agency does not provide wound care to P2.On 3/24/26 at 3:45 pm, during a phone interview, NP confirmed that P2 has multiple wounds on left leg and goes to hospital frequently for wound infections. NP stated that P2’s wound care is provided by the hospital once or twice a week and the hospice agency also provides wound care at home for P2.On 3/25/26 at 2:00 PM, during a phone interview, P2 stated that a hospital manages P2’s wounds on left leg. P2 stated that she goes to the hospital once a week for wound care. Review of records for P14 with a start of care (SOC) 6/4/2025 revealed patient has a diagnosis of Type 2 diabetes Mellitus (DM) requiring medication to control patient’s blood sugar (BS). Records revealed Skilled Nurse (SN) RNAA documented in initial assessment P14 has a history of type 2 DM. Review of records revealed P14 plan of care (POC) does not contain an order for insulin.Review of records revealed P14 POC did not contain evidence that nursing staff was assessing or managing P14’s DM for all certification periods since SOC on 6/4/2025.On 3/24/2026 at 10:00 AM, during a home visit, surveyor observed P14 home medications and found P14 was taking insulin for Type 2 diabetes Mellitus (DM). During the home visit P14 confirmed taking insulin for her DM.On 3/24/2026 at 10:10 AM, during a home visit, surveyor questioned RNBB about the insulin observed in the patient’s home. RNBB confirmed the insulin was not on P14’s medication profile from the agency. RNBB added that the hospice agency does not manage P14’s DM.On 3/24/2026 at 3:20 PM, during a phone interview, P14 confirmed a diagnosis of DM with insulin dependency. P14 revealed she was administering her insulin with dosage per her discretion. P14 stated” I don’t have a doctor’s order for the insulin dosage I just regulate the dosage myself”. P14 confirmed she does not discuss her DM medication with the hospice nurse. P14 stated “the nurse never asked me about my insulin”. P14 confirmed receiving medication from “my pharmacy” and not through the hospice provided pharmacy.On 3/24/2026 at 3:45 PM, during a phone interview, RNAA confirmed P14 was an insulin dependent diabetic and that there was not an order for insulin.”

“Based on review of policies and procedures, record reviews, staff , patient and family interviews, it was determined the agency failed to provide patient care that optimized comfort to meet the needs and goals for bereavement for 14 patients (P) (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14) of 14 sampled patient charts reviewed. The hospice agency failed to provide patient care that optimized comfort to meet the needs and goals for treatment and medication management for three patients (P) (P2, P4, P14) of nine active patients charts reviewed. Findings included: Refer to citation L531 for findings related to bereavement.Refer to citation L533 for findings related to treatment and medication management.”

“Based on review of agency policies, record reviews, and staff interviews it was determined the hospice governing body and Administrator failed to assume responsibility for the management of the hospice, hospice services, and quality assessment and performance improvement program.Specifically, the hospice governing body failed to:1. Provide a qualified Social Worker for hospice patients and their family.2. Ensure the Emergency Preparedness program conducted a documented annual full-scale exercise or actual event.3. Provide Chaplain/Counseling services for eight patients (P) (P1, P2, P3, P4, P5, P6, P7, and P14) of nine active sampled patients.4. Ensure the Interdisciplinary Group (IDG) requirements were met with attendance of all members of the IDG.5. Ensure the Quality Assurance Program measured, analyzed and tracked identified indicators for improvement and quality of care.6. 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 for three patients (P) (P2, P4, and P14) of fourteen patients.7. Provide bereavement services for 14 patients (P) (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14) of 14 sampled patient charts reviewed.8. Coordinate services ordered or needed related to the terminal illness by failing to document interdisciplinary group (IDG) meetings for three patients (P) (P2, P4 and P14) of fourteen sampled patients.9. Develop and maintain a system of communication and integration, in accordance with the hospice’s own policies and procedures.10. Nursing needs of the patients are met as identified in the patient’s initial assessment, comprehensive assessment, and updated assessments for three patients (P) (P2, P4, and P14) of fourteen patients.11. Forward discharge summary and clinical records at the time when patient (P) P2 was hospitalized for further wound care treatment.Findings included: 1. Review of the human resource (HR) files revealed that the agency Master of Social Work (MSW) failed to reveal a current professional license in social work. A review of the agency document titled “ [Name] Job Description: Social Worker,” which was signed by the MSW and the supervisor reveals: Qualifications:2. Currently licensed by the state of Georgia to practice social work. On 03/26/2026 at 11:42 AM, during a phone interview, the MSW acknowledged that she did not have a professional social work license. She further explained that she had taken the exam, however, she had not passed. On 03/26/2026 at 11:45 AM, during an in-office interview, the director of nursing (DON) confirmed the MSW did not have a professional social work license.2. Review of undated policy titled “PLAN OF CARE,” revealed the following: “The plan of care shall include all services necessary for the palliation and management of the terminal illness and related conditions, including the following:- Interventions to manage pain and symptoms.- A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.-Measurable outcomes anticipated from implementing and coordinating the plan of care.” Review of initial plan of care dated 11/21/2024 revealed that Chaplain/Counseling services were not ordered for P1. Review of initial plan of care dated 2/19/2025 revealed that Chaplain/Counseling services were not ordered for P2. Review of initial plan of care dated 8/9/2025 revealed that Chaplain/Counseling services were not ordered for P3. Review of initial plan of care dated 11/19/2025 revealed that Chaplain/Counseling services were not ordered for P4. Review of initial plan of care dated 9/7/2025 revealed that Chaplain/Counseling services were not ordered for P5. Review of initial plan of care dated 6/4/2025 revealed that Chaplain/Counseling services were not ordered for P6. Review of initial plan of care dated 7/17/2025 revealed that Chaplain/Counseling services were not ordered for P7. Review of initial plan of care dated 6/4/2025 revealed that Chaplain/Counseling services were not ordered for P14. Review of records revealed P1, P2, P3, P4, P5, P6, P7, and P14 failed to reveal documentation of declining Chaplain services. On 03/24/2026 at 3:20 PM, during a phone interview P14 stated, “I have never been offered Chaplain services. I would like to see a Chaplain if the hospice has one available.” On 03/24/2026 at 3:40 PM, during a phone interview, family of P3 stated, “we have never been offered Chaplain services.” On 03/24/2026 at 4:10 PM, during an office interview, Director of Nursing (DON) acknowledged Chaplain/ Counseling services were not ordered for P1, P2, P3, P4, P5, P6, P7, and P14. DON states “most of our patients decline chaplain services”. Cross reference to E0039 relating to EP testing requirementsRefer to citation L0523 for findings related to interdisciplinary Group.Refer to citation L0562 for findings related to Quality Assurance program.Refer to citation L0533, L0536, L0678 for findings related to updated plan of care.Refer to citation L0545 for findings related to individualized plan of care.Refer to citation L0547, L0548 for findings related to necessary services provided including scope of frequency.Refer to citation L0557 for findings related to sharing of information.Refer to citation L0591 for findings related to meeting the patients.Refer to citation L0650 for findings related to Bereavement.Refer to citation L0682 for findings related to discharge summary.”

“Based on review Medical Director (MD) job description and contract, record reviews and staff interviews it was determined the MD failed to assume overall responsibility for the medical component of the hospice patient care program. for 14 patients (P) (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) of 14 sampled patients. Findings included: Review of the document titled “ [Name] of Atlanta, LLC Job Description: Medical Director,” reveals:Job Summary:The medical directorship is a position of active participation and clinical leadership. The medical director is the primary physician representative and leader of the interdisciplinary team, to include but not limited to RN, SW, Chaplain, CAN. Oversight services in the hospice is generally considered to be the responsibility of the medical director.Job Responsibilities:2. Provide medical expertise with respect to planning and establishing goals and policies to improve medical management.3. Provides guidance to the Agency’s staff regarding developing and maintaining appropriate policies and standards of the medical activities of the organization in delivering care and services to the patients and their family units.B. Clinical Duties2. Develops, amends, recommends, and implements appropriate clinical practices and medical care policies that help ensure that each patient’s medical regime is incorporated appropriately into the plan of care. 5. Acts as medical resource to the IDT. Monitor clinical performance in interdisciplinary meetings.C. Admission and Certification:4. Establishes patient plan of care. The plan must be established by the medical director and the IDT prior to providing care.D. Assurance of quality care. Adequacy and completeness of records:3. Reviews recommendations and reports of drug regimen review and quality assurance activities and take appropriate and timely action as needed to implement recommendations. Review of the document titled “ [Name]: Medical Director Contract,” reveals:3. Duties of the Medical Director A. The Medical Director shall perform such services and functions as are customary of a Medical Director of a Homecare Hospice agency comparable in size and scope of services to that of MHA (Merit Hospice Atlanta, Inc), and to perform such services in accordance with all applicable requirements of federal, state, and local and or MHA laws, rules, regulations, which shall include but not be limited to full compliance with Title 42, Section 405.1122 of the Code of Federal Regulations and any applicable state regulations. Such services shall include but not be limited to:• The Medical Director shall serve as the head of the Interdisciplinary Team Meeting (IDT).• Serve in the supervising role of the care services provided by MHA• Serve as resource of medical information to provide guidance in care services provided by MHA.”

“Based on review of policy titled “MEDICATION MANAGEMENT – PATIENT INFORMATION, ” review of records, staff interviews and patient interviews it was determined the agency failed to document updated medication regimen, symptom management and treatments for two patients (P) (P4, P14) of nine sampled patients. Findings included: Review of undated policy titled “MEDICATION MANAGEMENT – PATIENT INFORMATION,” revealed the following:“PROCEDURE:During the initial assessment visit, the Registered Nurse shall generate a list of the patient’s current medications, including prescription and over the counter (OTC) medications and herbal remedies. The information is documented in the initial assessment and in the Patient Medication Information/Reconciliation Form, and includes at least the following information:• Name of the medication/herbal remedy• Date the medication was initially prescribed for the patient• Date the OTC and/or herbal remedy was initiated• When a medication order expires• How many refills on a current order of medications• Whether the current dosage is new or changed• Classification of the medication or herbal remedy• Dosage, route and frequency of administration of the medication and/or herbal remedy• Verification shall be documented in the patient’s medical record.The Patient Medication Information/Reconciliation Form is completed in its entirety, including dosage, frequency and administration routes, according to Hospice policy.The list of current medications is incorporated into the plan of care.The patient’s medications are reviewed and assessed during each skilled visit. Any changes to the medications or changes in the patient’s response to the medications are conveyed to the ordering physician.” 1. Review of records for P14 with a start of care (SOC) 06/04/2025 revealed patient has a diagnosis of Type 2 diabetes Mellitus (DM-a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) requiring medication to control patient’s blood sugar (BS). Records revealed that Registered Nurse (RN) AA documented in initial assessment that P14 has a history of type 2 DM. Review of records revealed P14 plan of care does not contain an order for insulin. On 03/24/2026 at 10:00 AM, during a home visit, surveyor observed P14 home medications and found P14 was taking insulin for Type 2 diabetes Mellitus (DM). During the home visit P14 confirmed taking insulin for her DM. On 03/24/2026 at 10:10 AM, during a home visit, RN BB confirmed the insulin was not on P14’s medication profile from the agency. RN BB added that the hospice agency does not manage P14’s DM. Review of interdisciplinary group (IDG) notes dated 02/20/2026 and 03/06/2026 reveals discussion of P14 with diagnosis of type 2 diabetes mellitus without discussion of any medications management for P14, specifically insulin. 2. Review of RN Initial Assessment note dated 11/19/2025 for P4, revealed that P4 has fragile skin integrity; blanchable erythema noted over sacrum and heels. Review of RN skilled visit note dated 01/15/2026 for P4, RN documented wound treatment is being done to the open area on the sacrum. Review of RN skilled visit note dated 02/12/2026 for P4, RN documented wound treatment is being done to the open area on the sacrum. Review of RN skilled visit note dated 02/26/2026 for P4, RN documented wound treatment is being done to the open area on the sacrum. Review of RN skilled visit note dated 03/12/2026, for P4, RN documents wound treatment is being done to the open area on the sacrum. Review of Plan of Care, Benefit Period: 11/19/2025 - 02/16/2026 for P4, failed to reveal orders for wound care management, goals and interventions and care coordination for wound management. On 03/24/2026 at 3:20 PM, during a phone interview, P14 confirmed a diagnosis of DM with insulin dependency. P14 revealed she was administering her insulin with dosage per her discretion. P14 stated” I don’t have a doctor’s order for the insulin dosage I just regulate the dosage myself”. P14 confirmed she does not discuss her DM medication with the hospice nurse. P14 stated “the nurse never asked me about my insulin.” P14 confirmed receiving medication from “my pharmacy” and not through the hospice provided pharmacy. On 03/24/2026 at 3:45 PM, during a phone interview, RN AA confirmed P14 was an insulin dependent diabetic and that there was not an order for insulin. On 03/24/2026 at 3:56 PM, during an office interview, Director of Nursing (DON) confirmed P14 did not have an order for insulin. DON stated, “we do not order this patient (P14) medications”. On 03/26/2026 at 10:00 AM, during a phone interview Medical Director (MD) confirmed he knew P14 was an insulin dependent diabetic. The MD admitted he did not order insulin for P14 and did not monitor P14’s blood sugar (BS). The MD admitted he did not coordinate care nor had he documented coordination of care with the patient’s physician who manages the insulin for P14.Cross reference to citation L0536 and L0545 related to findings for P4.”

“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 14 sampled patients. Findings included: Review of the undated policy titled “PLAN OF CARE,” states the following:“1. [Name] Interdisciplinary group (IDG) members involved in the patient’s care will contribute to the written plan of care, in coordination with the patient’s attending physician, the patient/patient representative and the primary care giver.2. The analysis of data obtained during assessments shall facilitate the ongoing identification and prioritization of patient problems, needs, goals and care, treatment and services.Review of the policy titled “ Wound Care Policy & Procedure” undated states the following:10. IDG Involvement• Wound status reviewed during IDG meetings• Adjust care plan as needed11.Physican /NP responsibilities• Provide wound care orders• Approve changes in treatment• Evaluate need for antibiotics or other interventions.’ 1. Review of RN Initial Assessment for P2 dated 02/19/2025 revealed that P2 has wound and signs of infection due to cellulitis/osteomyelitis, including redness, warmth, and drainage. The RN noted on the assessment that the caregiver appeared overwhelmed and was provided with education on wound care. Review of nursing visit note for P2 dated 02/19/2026, revealed that patient’s right leg is abnormal, edematous with open area with scant amount of drainage noted, area cleansed with normal saline, Neosporin applied according to patient. The RN noted that the care giver appeared overwhelmed and was provided education on wound care. Review of nursing visit note for P2 dated 02/26/2026, revealed that Left leg open area noted due to poor circulation, treatment continue per hospital to prevent infection. Edema abnormal. The RN noted that the care giver appeared overwhelmed and was provided education on wound care. Review of nursing visit note for P2 dated 03/05/2026, revealed Left leg open area noted due to poor circulation, treatment continue per hospital to prevent infection. Edema abnormal. The RN noted that care giver appeared overwhelmed and was provided education on wound care.Review of nursing visit note for P2 dated 03/12/2026, revealed Left leg open area noted due to poor circulation, treatment continued per hospital to prevent infection. Edema abnormal. The RN noted that care giver appeared overwhelmed and was provided education on wound care. Review of document tilted Face to face (F2F) for P2 dated 07/21/2025 revealed Nurse Practitioner (NP) documented that P2 is non-ambulatory, has more than a dozen wounds between her left leg and right stump. P2 has a stasis ulcer on her left leg, red. edematous and painful. P2 has just completed second course of antibiotics. P2 uses antibacterial ointment to treat the ulcers. P2 was ordered Mupirocin for wound care. Review of Plan of Care dated 02/19/2025 for P2, failed to reveal orders for wound care management and care coordination for wound management. Review of Plan of care dated 02/14/2026 for P2 failed to reveal orders for wound care management and care coordination for wound management. 2.Review of Registered Nurse (RN) Initial Assessment note dated 11/19/2025 for P4, revealed that P4 has fragile skin integrity; blanchable erythema noted over sacrum and heels. Review of RN skilled visit note dated 01/15/2026 for P4, RN documented wound treatment is being done to the open area on the sacrum. Review of RN skilled visit note dated 02/12/2026 for P4, RN documented wound treatment is being done to the open area on the sacrum. Review of RN skilled visit note dated 02/26/2026 for P4, RN documented wound treatment is being done to the open area on the sacrum. Review of RN skilled visit note dated 03/12/2026, for P4, RN documents wound treatment is being done to the open area on the sacrum. Review of Plan of Care dated 11/19/2025 for P4, failed to reveal orders for wound care and care coordination for wound management. Review of Plan of Care dated 02/17/2026 for P4, failed to reveal orders for wound care and care coordination for wound management. On0 03/24/2026 at 3:20 PM, during a phone interview, RN AA confirmed that P2 has multiple wounds on left leg and goes to hospital once a week for wound care treatment. RNAA confirmed that the hospice agency does not provide wound care to P2. On 03/24/2026 at 3:45 PM, during a phone interview, NP confirmed that P2 has multiple wounds on left leg and goes to hospital frequently for wound infections. NP stated that P2’s wound care is provided by the hospital once or twice a week and the hospice agency also provides wound care at home for P2. On 03/25/2026 at 2:00 PM, during a phone interview, P2 stated that a hospital manages P2’s wounds on left leg. P2 stated that she goes to the hospital once a week for wound care. On 03/26/2026 at 10:00 AM, a phone interview was conducted with the Medical Director (MD), who stated that there is no coordination for P2 and P4 wound care management. The MD also stated that the IDG meeting notes do not reveal evidence that wound care management for P2 and P4 was discussed. The MD stated that the plan of care do not have wound care orders for P2 and P4”

“Based on clinical record review and staff interview it was determined that the agency failed to ensure the Plan of Care (POC) were completed with appropriate authenticated signatures and dates for nine patients (P) of nine active patients sampled (P1, P2, P3, P4, P5, P6, P7, P13, and P14). Specifically, the medical director (MD) signed multiple POC on the same dates.Findings included: Review of the clinical record for P1 for the hospice certification benefit period of 03/16/2026-05/14/2026 revealed:• The MD signed eight POC on 03/25/2026.• The MD signed two POC on 03/23/2026. Review of the clinical record for P2 for the hospice certification benefit period of 02/14/2026-04/14/2026 revealed:• The MD signed six POC on 03/25/2026.• The MD signed three POC on 03/24/2026. Review of the clinical records for P3 for the certification benefit period of 02/05/2026-04/05/2026 revealed:• The MD signed three POC on 03/25/2026.• The MD signed three POC on 03/23/2026. Review of the clinical records for P4 for the certification benefit period of 02/17/2026-05/17/2026 revealed:• The MD signed one POC on 03/25/2026.• The MD signed two POC on 03/24/2026. Review of the clinical records for P5 for the certification benefit period of 03/06/2026-05/04/2026 revealed:• The MD signed four POC on 03/25/2026. Review of the clinical records for P6 for the certification benefit period of 03/31/2026-05/29/2026 revealed:• The MD signed four POC on 03/25/2026. Review of the clinical records for P7 for the certification benefit period of 03/14/2026-05/12/2026 revealed:• The MD signed four POC on 03/25/2026• The MD signed two POC on 03/23/2026 Review of the clinical records for P13 for the certification benefit period of 03/15/2026-06/12/2026 revealed:• The MD signed two POC on 03/25/2026. On 03/26/2026 at 10:00 AM, during a phone interview, the MD acknowledged that he was not timely signing documents. He further explained that he “went into the office on Monday (03/23/2026) to sign documents.” The MD also revealed that he signs “the documents in the folder” the director of nursing (DON) provides him with.”

“Based on record reviews, policy titled “TRANSFER OF PATIENT INFORMATION,” and staff and patient interviews, it was determined that the agency failed to forward discharge summary and clinical records when one patient (P) (P2) was hospitalized for further wound care treatment. Findings included: Review of undated policy titled “TRANSFER OF PATIENT INFORMATION,” states the following:“All patients transferred from Hospice shall have a transfer summary completed and filed in the clinical record.Procedure:• The physician shall be notified of any transfers or patients from Hospice to another organization, i.e., hospital.• The transferring physician shall verbally call the receiving organization with a preliminary report on the patient.• Within 48 hours of transfer, the transferring physician shall complete a transfer summary which includes.• The reason for transfer• A summary of the care, treatment and services provided and the progress toward achieving goals.• Any instructions and /or referrals provided to the patient• The existence of any advance directive known to Hospice.• Completed transfer summaries shall be given to a clinical records clerk who shall send a copy to the receiving organization with in72 hours of transfer and file the original clinical record.” 1. Review of F2F dated 11/24/2025, for P2, the Nurse Practitioner (NP) documented that P2 has just been discharged from hospital, where P2 was treated for the infection in her left leg. P2 has poor circulation, and stasis ulcers on that leg. The ulcers have not responded well to conservative treatments. P2 has been hospitalized many times for infections on left leg, the right stump has ulcers too. Review of F2F dated 01/20/2026 for P2, the NP documented that P2 has just been discharged from hospital again, for infection in P2’s left leg. The stasis ulcers on P2’s left leg are multiple and bigger in size. Left leg is swollen with very faint pedal pulses, and bluish color. The ulcers have not responded well to conservative treatments. P2 has been hospitalized many times for infections on her left leg, the right stump has ulcers too. Review of hospital record titled ’’IP after visit summary”, it is documented that P2 was admitted to the hospital from 02/05/2026 to 02/15/2026 with primary diagnosis of Bacterial Skin Infection (occurs when bacteria enters the body through cuts or openings), ulcer (sore on skin that fails to heal properly) of left foot with necrosis (death of cells in body tissues) of bone and chronic skin ulcer. Review of IDG Meeting notes dated 02/21/2025 for P2, failed to reveal care coordination for P2’s hospitalization and for transfer /discharge for P2. Review of IDG Meeting notes dated 03/06/2026 for P2, failed to reveal care coordination for P2’s hospitalization and for transfer/discharge for P2. Review of clinical record of P2 failed to reveal any care coordination notes for P2’s hospitalizations, any transfer notes and discharge summaries for P2. On 03/25/2026 at 2:00 PM, during a phone interview, P2 stated that a hospital manages P2’s wounds on left leg. P2 stated that she goes to the hospital once a week for wound care. P2 stated that she was admitted in the hospital from 2/8/26 - 2/15/26 for left leg wound treatment. P2 stated that she notified the hospice nurse of the hospitalization in the month of February. P2 stated that every time she goes to the hospital, she notifies the hospice nurse. P2 stated that she was not notified of any discharge from hospice at the time P2 was admitted to the hospital. P2 stated that P2 did not receive any forms for discharge or transfer. On 03/24/2026 at 3:20 PM, during a phone interview, RN AA confirmed that P2 has multiple wounds on left leg and goes to hospital once a week for wound care treatment. RN AA confirmed that P2 has been hospitalized many times for wound infections. RN AA confirmed that the hospice agency does not provide wound care to P2. On 03/24/2026 at 3:45 PM during a phone interview, NP confirmed that P2 has multiple wounds on left leg and goes to hospital frequently for wound infections. NP stated that P2’s wound care is provided by the hospital once or twice a week and the hospice agency also provides wound care at home for P2. On 03/26/2026 at 10:00 AM, a phone interview was conducted with the Medical Director (MD), who stated that he was not aware of P2’s hospitalization. MD also stated that the IDG meeting notes do not reveal evidence that hospitalization and wound care management for P2 was discussed. .”