Myrtue Medical Center Hospice

“Based on clinical record review, hospice policy review, hospice admission packet review, patient interview, family interview and staff interview, the hospice failed to:1) Ensure hospice staff inform and distribute written information to the patient concerning its policies on advance directives, including a description of applicable State law. (see L0503)2) Ensure patients receive information about the services covered under the hospice benefit. (see L0518) Findings include: The cumulative effects of this systemic practice resulted in the failure to ensure the organizational framework of the hospice, promoted and supported the coordination of safe and effective delivery of care according to patient’s rights and responsibilities.”

“Based on hospice staff interviews, clinical record reviews and agency policy reviews, the hospice failed to: 1)Ensure the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments and clinical notes are included in the patient’s medical record (L0672), 2) Ensure all entries in the clinical record are appropriately authenticated in accordance with hospice policy and currently accepted standards of practice (L0679) and 3) Ensure all revoked or discharged patients have a discharge summary completed and forwarded to the patient’s attending physician (L0683). The cumulative effects of these systemic practices resulted in the failure of the agency to ensure the accuracy and integrity of clinical records and increased the risk that hospice staff provided services without current and/or accurate information for its patients.”

“Based on review of the emergency preparedness plan and policies and staff interview, the hospice failed to ensure the policy contained verbiage to inform State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. Failure to include this verbiage in the emergency preparedness policy placed hospice patients at risk should an emergency situation arise. Findings include: During an interview on 3/10/26 at 3:45 PM, Staff I, Public Health Nurse, confirmed information regarding evacuation was missing from emergency preparedness policy and would be added at next revision of the policy. The above findings were reviewed with the Administrator/Clinical Manager.”

“Based on review of emergency preparedness training rosters, review of the emergency preparedness plan and policies and staff interview, the hospice failed to ensure training in emergency preparedness for all staff, including individuals providing services under arrangement (contracted staff) and volunteers, consistent with their expected roles for the calendar years of 2024 and 2025. The agency currently employed a total of 9 directly hired staff, utilized a total of 1 contracted staff (Music Therapist) and had a total of 18 volunteers to provide services to patients. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: During an interview on 3/10/26 at 11:30 AM, the Administrator/Clinical Manager, reported Staff E, Music Therapist, did not receive emergency preparedness training. During an interview on 3/10/26 at 2:15 PM, Staff I, Public Health Nurse, reported nursing staff are involved in annual drills and this is their annual education of emergency preparedness policy. Staff C, Registered Nurse, was not included in drills completed in 2024 and 2025. Staff I had no additional educational information for Staff C. During an interview on 3/10/26 at 4:00 PM, the Administrator/Clinical Manager, reported the social worker provided volunteer training and had retired. The Administrator/Clinical Manager and Volunteer Coordinator have looked through files for documentation of emergency preparedness training for Staff F, Volunteer and Staff G, Volunteer, but were unable to locate any documentation. The above findings were reviewed with the Administrator/Clinical Manager.”

“Based on hospice staff Interview, hospice clinical record reviews, and hospice policу review, the hospice failed to ensure the the documentation and correct Identification, in a prominent part of the patient’s record, any advance directives executed by the patient or patient’s representative for 5 of 14 sampled patients (Patients #3, #4, #7, #8, and #13) with a record review. Failure to ensure the hospice documented and correctly identified any executed advance directives in a prominent part of the record placed patients at risk for their advance directives not being correctly carried out. Findings include: 5. Patient # 4 had a hospice admission date of 12/10/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 12/10/25 to 3/9/26, identified the patient had a primary diagnosis of chronic obstructive pulmonary disease and conflicting advanced directive information including the patient did not want resuscition, dated 10/25/25 and also identified the patient a full code, dated 2/21/25. b. The admission consent forms, signed by the patient on 12/10/25 identified the patient does not want CPR. The hospice agency failed to include accurate advance directive information on the patient’s plan of care at the time of admission to hospice services. The above findings were reviewed with the Administrator/Clinical Manager. 2. Patient # 3 had a hospice admission date of 1/26/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/26/26 to 4/25/26, identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and identified no active advance directives exist for the patient. b. The admission consent forms, signed by the patient’s authorized representative on 1/26/26 identified the patient does not want cardiopulmonary resuscitation (CPR). The hospice agency failed to include accurate advance directive information on the patient’s plan of care at the time of admission to hospice services. 3. Patient #8 had a hospice admission date of 1/22/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/22/26 to 4/21/26, identified the patient had a primary diagnosis of sepsis and identified no active advance directives exist for the patient. b. The admission consent forms, signed by the patient’s authorized representative on 1/22/26 identified the patient does not want CPR. The hospice agency failed to include accurate advance directive information on the patient’s plan of care at the time of admission to hospice services. 4. Patient #13 had a hospice admission date of 6/13/25, a death date of 9/19/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 6/13/25 to 9/10/25, identified the patient had a primary diagnosis of panlobular emphysema and identified patient’s advance directive as a full code (wants resuscitative measures). b. The admission consent forms, signed by the patient on 6/13/25 identified the patient as a DNR (do not attempt resuscitation). The hospice agency failed to include accurate advance directive information on the patient’s plan of care at the time of admission to hospice services. According to the hospice policy titled Advance Directives Procedure, last revised November 2008, the agency recognizes that all persons have the fundamental right to make decisions about their own medical treatment, including the right to accept or refuse medical treatment. The individual has the right to revoke or change an advance directive at any time and will need to notify the agency of any changes. In an interview on 3/17/26 at 3:47 PM, the Administrator reported the process used for the advanced directive form used at admission. When the patient/patient representative chooses resuscitate or do not resuscitate (DNR) this form content is then entered into the Plan of Care (POC). The nurses may not be doing this or the nurses may not be updating the POC to reflect patient’s advanced directive. 1. Patient #7 had a hospice admission date of 2/12/26 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a.The Plan of Care (POC), dated 2/12/26 to 5/12/26, identified the patient had a primary diagnosis of hepatic encephalopathy and identified no active advance directives exist for the patient. b. The admission consent forms, signed by the patient’s authorized representative on 1/26/26 identified the patient does not want cardiopulmonary resuscitation (CPR). Review of the clinical record included conflicting code status information in a situation the patient had no pulse and was not breathing.”

“Based on staff interview, clinical record reviews, and policy review, the hospice failed to ensure patients received information about the services covered under the hospice benefit for 14 of 14 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14). Failure of the hospice to ensure the patient received information about the services covered under the hospice benefit increased the risk that patients did not receive appropriate services to meet assessed needs. Findings include: Review of patient’s #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14 clinical record revealed a Medicare Hospice Election Statement form completed at the time of admission to hospice services. The clinical record failed to contain notification of a right to request patient notification of hospice non-covered items, services and drugs. The hospice failed to notify the patients of their rights to receive notification of services not covered by the hospice benefit. The above findings were reviewed with the Administrator/Clinical Manager According to the agency document titled Patient Notification of Hospice Non-Covered Items, Services, and Drugs, dated July 2023, the purpose of this addendum is to notify the requesting Medicare beneficiary (or representative), in writing, of those conditions, items, services, and drugs not covered by the hospice because the hospice has determined they are unrelated to your terminal illness and related conditions. If you request this notification on the effective date of the hospice election (that is, on the start date of hospice care), the hospice must provide you this form within 5 days. If you request this form at any point after the start date of hospice care, the hospice must provide you this form within 3 days. In an interview on 3/11/26 at 8:27 AM, the Administrator reported the nursing staff are verbally notifying patient and family of the Medicare benefit election addendum that explains what the hospice did not cover for medications, services and treatment; but nothing is documented in the patient chart. A form was created in the past, but not used.”

“Based on staff interview, clinical record reviews, and agency policy review, the hospice failed to ensure the hospice registered nurse completed a comprehensive assessment which included wound measurements for 3 of 4 sampled patients (#1, #10, and #12) with wounds. Failure to complete wound assessments increased the risk that patients’ needs would not be identified and/or addressed appropriately. Findings include: According to the agency policy titled Wound Assessment, last revised December 2023, clients will receive comprehensive assessment and ongoing treatment of wounds in compliance with physician orders and evidence based practice in order to provide continuity in wound care, assess outcomes, and provide documentation of actions implemented by departmental staff. A thorough wound assessment should consist of objective criteria and measurements that promote accurate, consistent comparisons to determine the extent of the wound and the effectiveness of wound healing. Comprehensive wound assessment is necessary during every dressing change and includes data on wound type, location, drainage, color, size and shape, presence of tunneling, condition of the wound edges, and condition of the surrounding tissue. In an interview on 3/10/26 at 10:27 AM, the Administrator reported that full wound assessments are performed weekly or with any changes and include length, width, depth, description, if there is drainage, and skin color around the wound. 1.Patient #1 had a start of care date of 10/16/25 and received hospice services in a nursing home. a.The Plan of Care (POC), dated 1/14/26 to 4/13/26, included a primary diagnosis of Alzheimer’s disease and orders for skilled nursing. b.Skilled nurse visit note on 2/17/26 by Staff C, Registered Nurse (RN), identified a skin tear to the patient’s right lower forearm skin tear with no assessment of the wound performed. c.Skilled nurse visit note on 2/24/26, by Staff C, identified a wound assessment of the patient’s left heel stage 2 pressure ulcer with length measuring 2 cm (centimeters) and 1.3 cm in width. The wound measurement did not include the wound’s depth. The hospice failed to accurately assess the patient’s wounds. 2. Patient #12 had a hospice admission date of 3/31/25, a discharge date of 9/26/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 3/31/25 to 6/28/25 and 6/29/25 to 9/26/25 identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and included orders for skilled nurse to assess integrity of skin. b. The skilled nurse initial assessment, dated 3/31/25, completed by Staff B, RN identified the patient had an open, unstageable pressure ulcer to the left gluteal fold and described the wound bed as pink/red with no drainage or odor. The wound measures 0.6 cm length by 0.4 cm width by 0 depth. The measurements lacked an accurate depth measurement for the open wound. c. The skilled nurse visit note, dated 9/8/25, completed by Staff B, RN, identified a new wound to the left gluteal fold with a small amount of serous drainage and described the wound bed as pink/red. The wound measures 1 cm length by 0.7 cm width by 0 depth. The measurements lacked an accurate depth measurement for the open wound. The clinical record lacked accurate wound measurements including length, width and depth. 3. Patient #10 had a hospice admission date of 12/19/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 12/19/25 to 3/18/26, identified the patient had a primary diagnosis of dementia and included orders for skilled nurse to assess integrity of skin. b. The skilled nurse note, dated 1/5/26, completed by Staff C, RN identified the patient had a small abrasion to the back of the right leg due to the wheelchair pedal. The wound lacked assessment of wound bed and surrounding skin and measured 0.5 length by 0.5 width with no depth measured. c. The skilled nurse visit note, dated 2/26/26, completed by Staff A, Administrator/Clinical Manager, identified the patient had a dressing to the inner part of the left lower leg. The documentation failed to include an assessment of the skin integrity of the left lower leg. The clinical record lacked accurate wound assessment or measurements including length, width and depth. The above findings reviewed with the Administrator/Clinical Manager According to the agency policy titled Wound Assessment, last revised December 2023, clients will receive comprehensive assessment and ongoing treatment of wounds in compliance with physician orders and evidence based practice in order to provide continuity in wound care, assess outcomes and provide documentation of actions implemented by departmental staff. A thorough wound assessment should consist of objective criteria and measurements that promote accurate, consistent comparisons to determine the extent of the wound and the effectiveness of wound healing. Comprehensive wound assessment is necessary during every dressing change and includes data on wound type, location, drainage, color, size and shape, presence of tunneling, condition of the wound edges and condition of the surrounding tissue. In an interview on 3/10/26 at 10:27 AM, the Administrator reported that full wound assessments are performed weekly or with any changes. The assessment includes length, width, depth, description, if there is drainage, and skin color around the wound. 1.Patient #1 had a start of care date of 10/16/25 and received hospice services in a nursing home. a.The Plan of Care (POC), dated 1/14/26 to 4/13/26, included a primary diagnosis of Alzheimer’s disease and orders for skilled nursing. b.Skilled nurse visit note on 2/17/26 by Staff C, Registered Nurse (RN), identified a skin tear to the patient’s right lower forearm skin tear with no assessment of the wound performed. c.Skilled nurse visit note on 2/24/26, by Staff C, identified a wound assessment of the patient’s left heel stage 2 pressure ulcer with length measuring 2 cm (centimeters) and 1.3 cm in width. The wound measurement did not include the wound’s depth. The hospice failed to accurately assess the patient’s wounds. 2. Patient #12 had a hospice admission date of 3/31/25, a discharge date of 9/26/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 3/31/25 to 6/28/25 and 6/29/25 to 9/26/25 identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and included orders for skilled nurse to assess integrity of skin. b. The skilled nurse initial assessment, dated 3/31/25, completed by Staff B, RN identified the patient had an open, unstageable pressure ulcer to the left gluteal fold and described the wound bed as pink/red with no drainage or odor. The wound measures 0.6 cm length by 0.4 cm width by 0 depth. The measurements lacked an accurate depth measurement for the open wound. c. The skilled nurse visit note, dated 9/8/25, completed by Staff B, RN, identified a new wound to the left gluteal fold with a small amount of serous drainage and described the wound bed as pink/red. The wound measures 1 cm length by 0.7 cm width by 0 depth. The measurements lacked an accurate depth measurement for the open wound. The clinical record lacked accurate wound measurements including length, width and depth. 3. Patient #10 had a hospice admission date of 12/19/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 12/19/25 to 3/18/26, identified the patient had a primary diagnosis of dementia and included orders for skilled nurse to assess integrity of skin. b. The skilled nurse note, dated 1/5/26, completed by Staff C, RN identified the patient had a small abrasion to the back of the right leg due to the wheelchair pedal. The woundmeasured 0.5 length by 0.5 width with no depth measured. lacked assessment of wound bed and surrounding skin and measured 0.5 length by 0.5 width with no depth measured. c. The skilled nurse visit note, dated 2/26/26, completed by Staff A, Administrator/Clinical Manager, identified the patient had a dressing to the inner part of the left lower leg. The documentation failed to include an assessment of the skin integrity of the left lower leg. The clinical record lacked accurate wound assessment or measurements including length, width and depth. The above findings reviewed with the Administrator/Clinical Manager”

“Based on clinical record reviews, hospice policy review and staff interview, the hospice failed to ensure hospice staff used routine and standing orders that were Individualized and specific to the needs of the patients for 14 of 14 patients sampled (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) with a record review. Failure to establish the use of individualized routine and standing orders rather than generalized, non-specific standing orders, placed patients for potential risk of receiving or not receiving medications, treatments, and services that did not adequately meet the needs of hospice patients. Findings include: According to the agency policy titled Interdisciplinary Team (IDT) Guidelines, last revised September 2020, the primary responsibility of the IDT is to provide and supervise care and services delivered in the patient’s home or on an inpatient or respite basis. The role of IDT includes participation in establishment of an interdisciplinary, individualized plan of care for each patient/family. In an interview on 3/10/26 at 10:27 AM, the Administrator reported that on admission, standing orders are created and sent to the physician. If the patient starts a medication listed on standing orders, it is then added to the patient’s medication list. Nurses should be able to remove a standing order that does not apply, such as ostomy, so that the order should not be present on the Plan of Care (POC). The routine standing orders signed off by a physician contained the following patient non-specific orders for Patients #1 through #14, on the patients’ POC. a.Incisional/wound cares as appropriate as needed. The standing order failed to include wound care specific to the needs of the patients. Every patient had the same non-specific order regardless whether or not the patient had a wound and/or incision. b.Calmoseptine topical ointment as needed. The standing order failed to specify what the topical ointment should be used to treat. c.Silvadene 3% topical cream to affected area 1-2 times power day and as needed. The standing order failed to specify what the topical cream should be used to treat. d.Suction as needed. The standing order failed to specify under what circumstances suctioning would be needed. e.Oxygen at 2 liters per minute and may increase as needed. The standing order failed to include a route for delivery of the oxygen, failed to specify under what circumstances the patient would increase the oxygen rate per minute and at what rate the patient could or should increase the oxygen rate per minute to above the 2 liters per minute. f.Placement of external/indwelling or suprapublic urinary catheter straight catheterization as needed. If indwelling, change the catheter every 4 weeks and as needed. May irrigate catheter as needed with sterile water/saline 100 mL (milliliters) as needed. The standing order failed to specify under what circumstances a catheter would need to be placed and failed to specify a catheter size or type specific to the individual needs of the patient and under what circumstances irrigation of the catheter would be needed. g.Ostomy care and maintenance (includes gastrostomy) as indicated. None of the patients sampled (Patients #1 through #14 had an ostomy of any type. h. The standing orders included the following medications: 1)Colace 100 mg 1-2 twice daily as needed. The order lacked a route and failed to specify the reason why the as needed medication should be taken. 2)Milk of Magnesia 30-60 cc (cubic centimeter) as needed. The order lacked a frequency and route and failed to specify the reason why the as needed medication should be taken. 3)Senokot or Senokot S 1-2 tablets by mouth daily and as needed. The order falled to specify the reason why the as needed medication should be taken. 4)Miralax 17 gm(grams) by mouth daily or daily as needed. The order failed to specify the reason why the as needed medication should be taken. 5)Lactulose 10 gm/15 mL 15-30 mL by mouth as needed. The order failed to specify a frequency and the reason why the as needed medication should be taken. 6)Dulcolax 10 mg rectal suppository daily as needed. The order lacked a route and failed to specify the reason why the as needed medication should be taken. 7)Fleets enema as needed. The order failed to specify a frequency and the reason why the as needed medication should be taken. The above medications are used to treat/prevent constipation. The standing orders failed to identify how the nurse and/or patient would know in what order the medications should be implemented or if they should all be implemented at once. 8)Lasix 20 mg 1-2 tablets by mouth daily and as needed. The order failed to specify the reason why the as needed medication should be taken. 9)Maalox 30 mL daily as needed. The order lacked a route and failed to specify the reason why the as needed medication should be taken. 10)Zofran 4-8 mg by mouth every 4-6 hours as needed. The order failed to specify the reason why the as needed medication should be taken. 11)Simethicone 80 mg by mouth twice per day as needed. The order failed to specify the reason why the as needed medication should be taken. 12)Benadryl cream 1 application to the affected area 2-3 times per day as needed. The standing order failed to specify what the topical cream should be used to treat. 13)Scopolamine transdermal patch 1 mg every 72 hours. The order failed to specify the reason why the as needed medication should be taken. 14)Mucinex 600 mg by mouth twice per day as needed. The order failed to specify the reason why the as needed medication should be taken. 15)Miracle mouthwash/swish and swallow mouthwash equal parts Benadryl, lidocaine, viscus, Mylanta 10 mL by mouth twice per day and as needed. The order failed to specify the reason why the as needed medication should be taken. 16)Ocean spray 1 spray each nostril as needed. The order failed to specify the reason why the as needed medication should be used. 17)Albuterol 2.5 mg/3 mL nebulized every 4 hours as needed. The order failed to specify the reason why the as needed medication should be used. The above findings were reviewed with the Administrator/Clinical Manager.”

“Based on staff interviews, clinical record reviews and agency policy review, the hospice failed to ensure the hospice plan of care included complete orders for all necessary medications and treatments to meet the needs of the patients for 4 of 14 sampled patients (Patients #2, #10, #8 and #12). Failure to ensure the plan of care included complete orders for medications and treatments placed the patients at risk to receive inappropriate treatment of symptoms and/or not meet the needs of the patients. Findings include: 3. Patient #2 had a hospice admission date of 2/26/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 2/26/26 to 5/26/26, identified the patient had a primary diagnosis of senile degeneration and included physician orders for skilled nurse visits, medications and treatments. b. The POC included standing orders for placement of an external/indwelling or suprapubic urinary catheter or straight catheterization as needed. c. During an observation home visit on 3/10/26 at 9:30 AM with Staff D, RN the surveyor observed the skilled nurse change the patinets existing suprapubic catheter. The hospice failed to include complete physician orders for the patients specific urinary catheter to meet the patients needs. 4. Patient #10 had a hospice admission date of 12/19/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 12/19/25 to 3/18/26, identified the patient had a primary diagnosis of dementia and included physician orders for skilled nurse visits, medications and treatments. b. The skilled nurse visit note, dated 2/26/26, completed by Staff D, RN, identified the patient had a dressing to the inner part of the left lower leg. c. Review of the clinical record lacked orders for the dressing to the patient’s inner left lower leg. The hospice failed to include complete physician orders for necessary treatment on the patient’s plan of care. The above findings were reviewed with the Administrator/Clinical Manager. According to the agency policy titled Plan of Care, last revised July 2017, the Plan of Care (POC) is established by the Interdisciplinary Group (IDG) in collaboration with the patient’s attending physician, the patient and the primary caregiver. The POC includes patient diagnosis, a complete assessment of patient and family needs including medical, nursing psychosocial and spiritual status and frequency of services, treatments and medications. The POC is reviewed and updated at least every two weeks. During an interview on 3/10/26 at 10:27 AM, the Administrator stated the agency does use standing orders for some medications and treatment; however, the orders are individualized prior to being put on the POC. 1.Patient #8 had a hospice admission date of 1/22/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/22/26 to 4/21/26, identified the patient had a primary diagnosis of sepsis and included physician orders for skilled nurse visits, medications and treatments. b. The IDG update to the POC, dated 1/29/26, identified the patient had a foley catheter but lacked complete orders with French size and balloon volume. c. The skilled nurse visit note, dated 2/12/26, completed by Staff B, Registered Nurse (RN), identified she covered a reddened area to the patient’s buttocks with a foam wound dressing for protection. d. The IDG update to the POC, dated 2/26/26, lacked orders for the foam wound dressing. The hospice failed to include complete physician orders for necessary treatment on the patient’s plan of care. 2. Patient #12 had a hospice admission date of 3/31/25, a discharge date of 9/26/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 3/31/25 to 6/28/25 identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and included orders for skilled nurse visits, medication and treatments. b. The skilled nurse initial comprehensive assessment, dated 3/31/25, completed by Staff B, RN identified the patient had an open, unstageable pressure ulcer to the left gluteal fold and noted it covered with a foam wound dressing. c. The plan of care lacked wound care orders. The hospice failed to include physician orders for necessary treatment on the patient’s plan of care.”

“Based on home observation visits, staff interview, clinical record reviews and agency policy reviews, the hospice failed to ensure the Plans of Care (POC) for 2 of 3 sampled patients with home observation visits (Patient #2 and #3) identified all medical equipment and supplies necessary to meet identified patient needs. Failure to include all needed items of medical equipment and supplies the patient used on the POC placed the patients at risk of unanticipated decline or injury and of needs not met. Findings include: According to the hospice policy titled Interdisciplinary Group (IDG) Guidelines, last revised September 2020, the role of the IDG includes reviewing the plan of care for hospice patients at least every two weeks, conduct ongoing assessments of patient and family needs, present patient/family assessments at the IDG meeting and document care plan revisions on the IDG patient review record. In an interview on 3/10/26 at 10:27 AM, the Administrator reported supplies and equipment are part of the comprehensive assessment and are assessed by talking with the patient, family members/caregivers and reviewing physician notes. 1.Patient #3 had a hospice admission date of 1/26/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 1/26/26 to 4/25/26, identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and used the following medical equipment and supplies: grab bars, hand held shower, lift chair, raised toilet seat, wheeled walker and shower chair and motion alarm. b. The IDG meeting note, dated 2/12/26, identified additional medical equipment and supplies needed by the patient: incontinence products, hospital bed, side rails and motion alarm. c. During a home observation visit on 3/12/26 at 2:00 PM, with Staff B, Registered Nurse (RN), the surveyor observed the RN to use patient’s pill cutter to cut a medication prior to putting the medication in the medication planner. The pill cutter has been utilized since the start of care. The hospice failed to include all medical equipment and supplies utilized by the patient. 2. Patient #2 had a hospice admission date of 2/26/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 2/26/26 to 5/26/26, identified the patient had a primary diagnosis of senile degeneration and failed to identify any medical equipment or supplies used by the patient. c. During a home observation visit on 3/10/26 at 9:30 AM, with Staff D, RN, the surveyor observed the patient utilized the following medical equipment and supplies: lift chair, suprapubic catheter and supplies, incontinence supplies. The hospice failed to include all medical equipment and supplies utilized by the patient. The above findings reviewed with the Administrator/Clinical Manager”

“Based on review of a written hospice agreement for services under arrangement and staff interview, the hospice failed to ensure the hospice provided orientation on the hospice’s philosophy for 1 of 1 sampled contracted staff (Staff E). The hospice reported working with a total of 1 contracted individual at the time of the survey. Failure to provide orientation on hospice’s philosophy increased the potential for provision of services in a manner contradictory to the hospice’s philosophy. Findings include: A contract, dated 11/2/22, identified the hospice contracted for music therapy services. During an interview on 3/11/26 at 8:50 AM, the Administrator/Clinical Manager reported the hospice verbally provided Staff E, Music Therapist, with education on hospice philosophy but does not have any documentation in writing that this occurred. The above findings were reviewed with the Administrator/Clinical Manager.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure clinical records contained pertinent, up-to-date and complete information in a timely manner for 8 of 14 sampled patients (Patients #2, #3, #4, #5, #6, #8, #9 and #10). Failure to maintain accurate clinical records with current patient information increased the risk that hospice staff provided services without up-to-date information related to the patient’s condition and decreased the ability of hospice staff to communicate effectively in order to coordinate patient care. Findings include: According to the hospice policy titled Clinical Record/Medical Record Retention, last revised April 2011, required documentation for each service or care provided shall be completed on the day the service is rendered if possible and computer generated assessments, visit notes, and plans of treatment shall be locked by the nurse author upon completion. In an interview on 3/10/26 at 10:27 AM, the Administrator stated admission visits are expected to be completed in the electronic record within 5 days of the visit and routine visits are to be completed within 48 hours. 1.Patient #3 had a hospice admission date of 1/26/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 1/26/26 to 4/25/26, identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and included physician orders for skilled nurse to visit the patient 2-3 times per week. b. The Interdisciplinary Group (IDG) meeting note, dated 2/26/26, identified the skilled nurse visits the patient 2-3 times per week. c. At the time of the clinical record review on 3/9/26, the clinical record lacked documentation of completed skilled nurse visits the week of 3/1/2026. The agency failed to ensure the patients clinical record included all clinical notes. 2. Patient #5 had a hospice admission date of 1/20/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/20/26 to 4/19/26, identified the patient had a primary diagnosis of amyotrophic neurodegenerative disease and included physician orders for skilled nurse to visit the patient 1-2 times per week. b. The IDG meeting note, dated 2/19/26, identified the skilled nurse visits the patient 1-2 times per week. c. The IDG meeting note, dated 3/5/26, identified no missed visits. d. At the time of the clinical record review on 3/10/26, the clinical record lacked documentation of completed skilled nurse visits the week of 3/1/2026. The agency failed to ensure the patients clinical record included all clinical notes. 3. Patient #8 had a hospice admission date of 1/22/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/22/26 to 4/21/26, identified the patient had a primary diagnosis of sepsis and included physician orders for skilled nurse to visit the patient 2-3 times per week. b. The IDG meeting note, dated 2/26/26, identified the skilled nurse visits the patient 2-3 times per week. c. At the time of the clinical record review on 3/10/26, the clinical record lacked documentation of completed skilled nurse visits the week of 3/1/2026. The agency failed to ensure the patients clinical record included all clinical notes. 4.Patient #6 had a hospice admission date of 2/16/26 and received hospice services while residing in a private home. Clinical record review revealed: a. The POC, dated 2/16/26 to 4/16/26, identified the patient had a diagnosis of acute and chronic respiratory failure with hypoxia and included orders for skilled nurse to visit the patient 2-3 times per week. b. At the time of the clinical record review on 3/10/26, the clinical record lacked documentation of completed skilled nurse visits the week of 2/15/2026 and 2/22/26. The agency failed to ensure the patients clinical record included all clinical notes. 4.Patient #6 had a hospice admission date of 2/16/26 and received hospice services while residing in a private home. Clinical record review revealed: a. The POC, dated 2/16/26 to 4/16/26, identified the patient had a diagnosis of acute and chronic respiratory failure with hypoxia and included orders for skilled nurse to visit the patient 2-3 times per week. b. At the time of the clinical record review on 3/10/26, the clinical record lacked documentation of completed skilled nurse visits the week of 2/15/2026 and 2/22/26. The agency failed to ensure the patients clinical record included all clinical notes. According to the hospice policy titled Clinical Record/Medical Record Retention, last revised April 2011, required documentation for each service or care provided shall be completed on the day the service is rendered if possible and computer generated assessments, visit notes, and plans of treatment shall be locked by the nurse author upon completion. In an interview on 3/10/26 at 10:27 AM, the Administrator stated admission visits are expected to be completed in the electronic record within 5 days of the visit and routine visits are to be completed within 48 hours. 1.Patient #3 had a hospice admission date of 1/26/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 1/26/26 to 4/25/26, identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and included physician orders for skilled nurse to visit the patient 2-3 times per week. b. The Interdisciplinary Group (IDG) meeting note, dated 2/26/26, identified the skilled nurse visits the patient 2-3 times per week. c. At the time of the clinical record review on 3/9/26, the clinical record lacked documentation of completed skilled nurse visits the week of 3/1/2026. The agency failed to ensure the patients clinical record included all clinical notes. 2. Patient #5 had a hospice admission date of 1/20/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/20/26 to 4/19/26, identified the patient had a primary diagnosis of amyotrophic neurodegenerative disease and included physician orders for skilled nurse to visit the patient 1-2 times per week. b. The IDG meeting note, dated 2/19/26, identified the skilled nurse visits the patient 1-2 times per week. c. The IDG meeting note, dated 3/5/26, identified no missed visits. d. At the time of the clinical record review on 3/10/26, the clinical record lacked documentation of completed skilled nurse visits the week of 3/1/2026. The agency failed to ensure the patients clinical record included all clinical notes. 3. Patient #8 had a hospice admission date of 1/22/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/22/26 to 4/21/26, identified the patient had a primary diagnosis of sepsis and included physician orders for skilled nurse to visit the patient 2-3 times per week. b. The IDG meeting note, dated 2/26/26, identified the skilled nurse visits the patient 2-3 times per week. c. At the time of the clinical record review on 3/10/26, the clinical record lacked documentation of completed skilled nurse visits the week of 3/1/2026. The agency failed to ensure the patients clinical record included all clinical notes. 4. Patient #6 had a hospice admission date of 2/16/26 and received hospice services while residing in a private home. Clinical record review revealed: a. The POC, dated 2/16/26 to 4/16/26, identified the patient had a diagnosis of acute and chronic respiratory failure with hypoxia and included orders for skilled nurse to visit the patient 2-3 times per week. b. At the time of the clinical record review on 3/10/26, the clinical record lacked documentation of completed skilled nurse visits the week of 2/15/2026 and 2/22/26. The agency failed to ensure the patients clinical record included all clinical notes. he agency failed to ensure the patients clinical record included all clinical notes. 5. Patient #2 had a hospice admission date of 2/26/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 2/26/26 to 5/26/26, identified the patient had a primary diagnosis of senile degeneration and included physician orders for skilled nurse to visit the patient 1-2 times per week. b. At the time of the clinical record review on 3/9/26, the clinical record lacked documentation of completed skilled nurse visits the week of 3/1/2026 to 3/7/26. The agency failed to ensure the patients clinical record included all clinical notes. 6. Patient #4 had a hospice admission date of 12/10/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 12/10/25 to 3/9/26, identified the patient had a primary diagnosis of chronic obstructive lung disease and included physician orders for skilled nurse to visit the patient 2-3 times per week. b. At the time of the clinical record review on 3/10/26, the clinical record lacked documentation of completed skilled nurse visits the week of 2/15/2026 to 2/21/26, 2/22/26 to 2/28/26 and 3/1/26 to 3/7/26. c. The IDG note, dated 2/26/26, failed to identify missed skilled nurse visits. The agency failed to ensure the patients clinical record included all clinical notes. 7. Patient #9 had a hospice admission date of 10/23/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 1/21/26 to 4/20/26, identified the patient had a primary diagnosis of pulmonary fibrosis and included physician orders for skilled nurse to visit the patient 1-2 times per week. b. At the time of the clinical record review on 3/10/26, the clinical record lacked documentation of completed skilled nurse visits the week of 3/1/26 to 3/7/26. The agency failed to ensure the patients clinical record included all clinical notes. c. The IDG note, dated 2/26/26, failed to identify missed skilled nurse visits. The agency failed to ensure the patients clinical record included all clinical notes. 8. Patient #10 had a hospice admission date of 12/19/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 12/19/25 to 3/18/26, identified the patient had a primary diagnosis of dementia and included physician orders for skilled nurse to visit the patient 1-2 times per week. b. At the time of the clinical record review on 3/11/26, the clinical record lacked documentation of completed skilled nurse visits the week of 3/1/26 to 3/7/26. c. The IDG note, dated 2/26/26, failed to identify missed skilled nurse visits. The agency failed to ensure the patients clinical record included all clinical notes. The above findings were reviewed with the Administrator/Clinical Manager”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure all documentation was completed timely in accordance with accepted standards of practice and agency standards for 12 of 14 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #12 and #13). Failure to ensure all documentation was completed, dated and signed in a timely manner decreased the ability of hospice staff to communicate and coordinate patient care effectively and to provide safe, effective hospice services to its patients. Findings include: 4. Patient #3 had a hospice admission date of 1/26/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/26/26 to 4/25/26, identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and included orders for skilled nurse, hospice aide and social work services. b. Skilled nurse visit note, dated 2/9/26, signed completed 2/24/26 by Staff C, RN, 15 days after the visit and 13 days late per agency expectation. c. Skilled nurse visit note, dated 2/12/26, signed completed 3/4/26 by Staff B, RN, 20 days after the visit and 18 days late per agency expectation. d. Skilled nurse visit note, dated 2/19/26, signed completed 3/4/26 by Staff B, RN, 13 days after the visit and 11 days late per agency expectation. e. Skilled nurse visit note, dated 2/24/26, signed completed 3/4/26 by Staff B, RN, 8 days after the visit and 6 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 5. Patient #5 had a hospice admission date of 1/20/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/20/26 to 4/19/26, identified the patient had a primary diagnosis of amyotrophic neurodegenerative disease and included orders for skilled nurse and social work services. b. Skilled nurse visit note, dated 2/10/26, signed completed 3/5/26 by Staff B, RN, 23 days after the visit and 21 days late per agency expectation. c. Skilled nurse visit note, dated 2/24/26, signed completed 3/5/26 by Staff B, RN, 9 days after the visit and 7 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 6. Patient #8 had a hospice admission date of 1/22/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/22/26 to 4/21/26, identified the patient had a primary diagnosis of sepsis and included orders for skilled nurse, hospice aide and social work services. b. Skilled nurse visit note, dated 1/23/26, signed completed 2/9/26 by Staff B, RN, 17 days after the visit and 15 days late per agency expectation. c. Skilled nurse visit note, dated 1/26/26, signed completed 2/9/26 by Staff B, RN, 14 days after the visit and 12 days late per agency expectation. d. Skilled nurse visit note, dated 2/12/26, signed completed 3/3/26 by Staff B, RN, 19 days after the visit and 17 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 7. Patient #12 had a hospice admission date of 3/31/25, a discharge date of 9/26/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 6/29/25 to 9/26/25, identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and included orders for skilled nurse, hospice aide, social work and music therapy services. b. Skilled nurse visit note, dated 8/12/25, signed completed 8/25/25 by Staff C, RN, 13 days after the visit and 11 days late per agency expectation. c. Skilled nurse visit note, dated 8/22/25, signed completed 8/29/25 by Staff B, RN, 7 days after the visit and 5 days late per agency expectation. d. Skilled nurse visit note, dated 8/25/25, signed completed 9/4/25 by Staff B, RN, 10 days after the visit and 8 days late per agency expectation. e. Skilled nurse visit note, dated 9/11/25, signed completed 9/25/25 by Staff B, RN, 14 days after the visit and 12 days late per agency expectation. f. Skilled nurse visit note, dated 9/17/25, signed completed 9/25/25 by Staff B, RN, 8 days after the visit and 6 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 8. Patient #13 had a hospice admission date of 6/13/25, a discharge date of 9/19/25 and received hospice services in a nursing home. Clinical record review revealed: a. The POC, dated 6/13/25 to 9/10/25, identified the patient had a diagnosis of panlobular emphysema and included orders for skilled nurse, hospice aide and social work services. b. Skilled nurse visit note, dated 8/22/25, signed completed 9/3/25 by Staff D, RN, 12 days after the visit and 10 days late per agency expectation. c. Skilled nurse visit note, dated 9/3/25, signed completed 9/19/25 by Staff D, RN, 16 days after the visit and 14 days late per agency expectation. d. Skilled nurse visit note, dated 9/5/25, signed completed 9/18/25 by Staff D, RN, 13 days after the visit and 11 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. According to the hospice policy titled Clinical Record/Medical Record Retention, last revised April 2011, required documentation for each service or care provided shall be completed on the day the service is rendered if possible and computer generated assessments, visit notes, and plans of treatment shall be locked by the nurse author upon completion. In an interview on 3/10/26 at 10:27 AM, the Administrator reported that the expectation for admission visits to be completed in the electronic record is 5 days and daily visits are to be completed within 48 hours. 1.Patient #1 had a hospice admission date of 10/16/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plans of Care (POC), dated 10/16/25 to 1/13/26 and 1/14/26 to 4/13/26, identified the patient had a diagnosis of Alzheimer’s disease and included orders for skilled nursing. b. Skilled nurse visit note, dated 1/5/26, was signed completed on 1/16/26 by Staff C, Registered Nurse (RN), 11 days after the visit and 9 days late per agency expectation. c. Skilled nurse visit note, dated 1/20/26, was signed completed on 1/27/26 by Staff C, 7 days after the visit and 5 days late per agency expectation. d. Skilled nurse visit note, dated 1/27/26, was signed completed on 2/9/26 by Staff C, 14 days after the visit and 12 days late per agency expectation. e. Skilled nurse visit note, dated 2/3/26, was signed completed on 2/16/26 by Staff C, 13 days after the visit and 11 days late per agency expectation. f. Skilled nurse visit note, dated 2/10/26, was signed completed on 3/1/26 by Staff C, 20 days after the visit and 18 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 2.Patient #6 had a hospice admission date of 2/16/26 and received hospice services while residing in a private home. Clinical record review revealed: a. The POC, dated 2/16/26 to 4/16/26, identified the patient had a diagnosis of acute and chronic respiratory failure with hypoxia and included orders for skilled nursing. b. Skilled nurse visit note, dated 3/2/26 and completed 3/13/26 by Staff B, 18 days after the visit and 18 days late per agency policy. The agency failed to ensure timely completion of routine visit documentation. 3.Patient #7 had a hospice admission date of 2/12/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 2/12/26 to 4/12/26, identified the patient had a diagnosis of hepatic encephalopathy and included orders for skilled nursing. b. Skilled nurse visit note, dated 2/12/26, signed completed 3/17/26 by Staff D, Registered Nurse (RN), 27 days after the visit and 27 days late per agency policy. c. Skilled nurse visit note, dated 2/25/26, signed completed 3/17/26 by Staff D, 21 days after the visit and 21 days late per agency policy. The agency failed to ensure timely completion of routine visit documentation. 9. Patient #2 had a hospice admission date of 2/26/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 2/26/26 to 5/26/26, identified the patient had a primary diagnosis of senile degeneration and included orders for skilled nurse, hospice aide and social work services. b. Skilled nurse comprehensive assessment visit note at start of care, dated 2/9/26, signed completed 3/9/26 by Staff D, RN, 11 days after the visit and 6 days late per agency expectation. The agency failed to ensure timely completion of start of care visit documentation. 10. Patient #4 had a hospice admission date of 12/10/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 12/10/25 to 3/9/26, identified the patient had a primary diagnosis of chronic pulmonary disease and included orders for skilled nurse, hospice aide and social work services. b. Skilled nurse visit note, dated 1/26/26, signed completed 2/4/26 by Staff D, RN, 9 days after the visit and 7 days late per agency expectation. c. Skilled nurse visit note, dated 2/3/26, signed completed 3/5/26 by Staff D, RN, 30 days after the visit and 28 days late per agency expectation. d. Skilled nurse visit note, dated 2/11/26, signed completed 3/5/26 by Staff D, RN, 12 days after the visit and 20 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 11. Patient #9 had a hospice admission date of 10/23/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 1/21/26 to 4/20/26, identified the patient had a primary diagnosis of pulmonary fibrosis and included orders for skilled nurse, chaplain and social work services. b. Skilled nurse visit note, dated 2/3/26, signed completed 2/16/26 by Staff C, RN, 13 days after the visit and 11 days late per agency expectation. c. Skilled nurse visit note, dated 2/10/26, signed completed 3/4/26 by Staff C, RN, 22 days after the visit and 20 days late per agency expectation. d. Skilled nurse visit note, dated 2/17/26, signed completed 3/10/26 by Staff C, RN, 21 days after the visit and 19 days late per agency expectation. e. Skilled nurse visit note, dated 2/24/26, by Staff C, RN, not signed completed. The agency failed to ensure timely completion of routine visit documentation. 12. Patient #11 had a hospice admission date of 12/19/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 12/19/25 to 3/18/26, identified the patient had a primary diagnosis of dementia and included orders for skilled nurse, chaplain and social work services. b. Skilled nurse visit note, dated 2/17/26, signed completed 3/10/26 by Staff C, RN, 21 days after the visit and 9 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. The above findings reviewed with the Administrator/Clinical Manager. According to the hospice policy titled Clinical Record/Medical Record Retention, last revised April 2011, required documentation for each service or care provided shall be completed on the day the service is rendered if possible and computer generated assessments, visit notes, and plans of treatment shall be locked by the nurse author upon completion. In an interview on 3/10/26 at 10:27 AM, the Administrator clarified that the expectation for admission visits to be completed in the electronic record is 5 days and daily visits are to be completed within 48 hours. 1.Patient #1 had a hospice admission date of 10/16/25 and received hospice services while residing in a nursing home. Clinical record review revealed:a. The Plans of Care (POC), dated 10/16/25 to 1/13/26 and 1/14/26 to 4/13/26, identified the patient had a diagnosis of Alzheimer’s disease and included orders for skilled nursing.b. Skilled nurse visit note, dated 1/5/26, was signed completed on 1/16/26 by Staff C, Registered Nurse (RN), 11 days after the visit and 9 days late per agency expectation.c. Skilled nurse visit note, dated 1/20/26, was signed completed on 1/27/26 by Staff C, 7 days after the visit and 5 days late per agency expectation.d. Skilled nurse visit note, dated 1/27/26, was signed completed on 2/9/26 by Staff C, 14 days after the visit and 12 days late per agency expectation. e. Skilled nurse visit note, dated 2/3/26, was signed completed on 2/16/26 by Staff C, 13 days after the visit and 11 days late per agency expectation. f. Skilled nurse visit note, dated 2/10/26, was signed completed on 3/1/26 by Staff C, 20 days after the visit and 18 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 2.Patient #6 had a hospice admission date of 2/16/26 and received hospice services while residing in a private home. Clinical record review revealed:a. The POC, dated 2/16/26 to 4/16/26, identified the patient had a diagnosis of acute and chronic respiratory failure with hypoxia and included orders for skilled nursing. b. Skilled nurse visit note, dated 3/2/26 and completed 3/13/26 by Staff B, 18 days after the visit and 16 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 3.Patient #7 had a hospice admission date of 2/12/26 and received hospice services while residing in a nursing home. Clinical record review revealed:a. The POC, dated 2/12/26 to 4/12/26, identified the patient had a diagnosis of hepatic encephalopathy and included orders for skilled nursing.b. Skilled nurse visit note, dated 2/12/26, signed completed 3/17/26 by Staff D, Registered Nurse (RN), 27 days after the visit and 25 days late per agency expectation. c. Skilled nurse visit note, dated 2/25/26, signed completed 3/17/26 by Staff D, 21 days after the visit and 19 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 4. Patient #3 had a hospice admission date of 1/26/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/26/26 to 4/25/26, identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and included orders for skilled nurse, hospice aide and social work services. b. Skilled nurse visit note, dated 2/9/26, signed completed 2/24/26 by Staff C, RN, 15 days after the visit and 13 days late per agency expectation. c. Skilled nurse visit note, dated 2/12/26, signed completed 3/4/26 by Staff B, RN, 20 days after the visit and 18 days late per agency expectation. d. Skilled nurse visit note, dated 2/19/26, signed completed 3/4/26 by Staff B, RN, 13 days after the visit and 11 days late per agency expectation. e. Skilled nurse visit note, dated 2/24/26, signed completed 3/4/26 by Staff B, RN, 8 days after the visit and 6 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 5. Patient #5 had a hospice admission date of 1/20/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/20/26 to 4/19/26, identified the patient had a primary diagnosis of amyotrophic neurodegenerative disease and included orders for skilled nurse and social work services. b. Skilled nurse visit note, dated 2/10/26, signed completed 3/5/26 by Staff B, RN, 23 days after the visit and 21 days late per agency expectation. c. Skilled nurse visit note, dated 2/24/26, signed completed 3/5/26 by Staff B, RN, 9 days after the visit and 7 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 6. Patient #8 had a hospice admission date of 1/22/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/22/26 to 4/21/26, identified the patient had a primary diagnosis of sepsis and included orders for skilled nurse, hospice aide and social work services. b. Skilled nurse visit note, dated 1/23/26, signed completed 2/9/26 by Staff B, RN, 17 days after the visit and 15 days late per agency expectation. c. Skilled nurse visit note, dated 1/26/26, signed completed 2/9/26 by Staff B, RN, 14 days after the visit and 12 days late per agency expectation. d. Skilled nurse visit note, dated 2/12/26, signed completed 3/3/26 by Staff B, RN, 19 days after the visit and 17 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 7. Patient #12 had a hospice admission date of 3/31/25, a discharge date of 9/26/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 6/29/25 to 9/26/25, identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and included orders for skilled nurse, hospice aide, social work and music therapy services. b. Skilled nurse visit note, dated 8/12/25, signed completed 8/25/25 by Staff C, RN, 13 days after the visit and 11 days late per agency expectation. c. Skilled nurse visit note, dated 8/22/25, signed completed 8/29/25 by Staff B, RN, 7 days after the visit and 5 days late per agency expectation. d. Skilled nurse visit note, dated 8/25/25, signed completed 9/4/25 by Staff B, RN, 10 days after the visit and 8 days late per agency expectation. e. Skilled nurse visit note, dated 9/11/25, signed completed 9/25/25 by Staff B, RN, 14 days after the visit and 12 days late per agency expectation. f. Skilled nurse visit note, dated 9/17/25, signed completed 9/25/25 by Staff B, RN, 8 days after the visit and 6 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 8. Patient #13 had a hospice admission date of 6/13/25, a discharge date of 9/19/25 and received hospice services in a nursing home. Clinical record review revealed: a. The POC, dated 6/13/25 to 9/10/25, identified the patient had a diagnosis of panlobular emphysema and included orders for skilled nurse, hospice aide and social work services. b. Skilled nurse visit note, dated 8/22/25, signed completed 9/3/25 by Staff D, RN, 12 days after the visit and 10 days late per agency expectation. c. Skilled nurse visit note, dated 9/3/25, signed completed 9/19/25 by Staff D, RN, 16 days after the visit and 14 days late per agency expectation. d. Skilled nurse visit note, dated 9/5/25, signed completed 9/18/25 by Staff D, RN, 13 days after the visit and 11 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 9. Patient #2 had a hospice admission date of 2/26/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 2/26/26 to 5/26/26, identified the patient had a primary diagnosis of senile degeneration and included orders for skilled nurse, hospice aide and social work services. b. Skilled nurse comprehensive assessment visit note at start of care, dated 2/9/26, signed completed 3/9/26 by Staff D, RN, 11 days after the visit and 9 days late per agency expectation. The agency failed to ensure timely completion of start of care visit documentation. 10. Patient #4 had a hospice admission date of 12/10/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 12/10/25 to 3/9/26, identified the patient had a primary diagnosis of chronic pulmonary disease and included orders for skilled nurse, hospice aide and social work services. b. Skilled nurse visit note, dated 1/26/26, signed completed 2/4/26 by Staff D, RN, 9 days after the visit and 7 days late per agency expectation. c. Skilled nurse visit note, dated 2/3/26, signed completed 3/5/26 by Staff D, RN, 30 days after the visit and 28 days late per agency expectation. d. Skilled nurse visit note, dated 2/11/26, signed completed 3/5/26 by Staff D, RN, 12 days after the visit and 10 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 11. Patient #9 had a hospice admission date of 10/23/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 1/21/26 to 4/20/26, identified the patient had a primary diagnosis of pulmonary fibrosis and included orders for skilled nurse, chaplain and social work services. b. Skilled nurse visit note, dated 2/3/26, signed completed 2/16/26 by Staff C, RN, 13 days after the visit and 11 days late per agency expectation. c. Skilled nurse visit note, dated 2/10/26, signed completed 3/4/26 by Staff C, RN, 22 days after the visit and 20 days late per agency expectation. d. Skilled nurse visit note, dated 2/17/26, signed completed 3/10/26 by Staff C, RN, 21 days after the visit and 19 days late per agency expectation. e. Skilled nurse visit note, dated 2/24/26, by Staff C, RN, not signed completed as of date of clinical record review on 3/12/26, 16 days after the visit and 14 days late per agency expectation.The agency failed to ensure timely completion of routine visit documentation. 12. Patient #11 had a hospice admission date of 12/19/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 12/19/25 to 3/18/26, identified the patient had a primary diagnosis of dementia and included orders for skilled nurse, chaplain and social work services. b. Skilled nurse visit note, dated 2/17/26, signed completed 3/10/26 by Staff C, RN, 21 days after the visit and 19 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. The above findings reviewed with the Administrator/Clinical Manager.”

“Based on hospice staff interview, clinical record reviews, and agency policy review the hospice failed to ensure the hospice staff sent a copy of the patient’s discharge summary to the attending physician for 2 of 2 sampled, live discharged patients (Patients #11 and #12). Failure to ensure the hospice staff included the attending physician in the process of discharge placed the patients at risk for not receiving ongoing medical care and services to meet the needs of the patient. Findings include: 2. Patient #12 had a hospice admission date of 3/31/25, a discharge date of 9/26/25 (no longer terminally ill) and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 6/29/25 to 9/26/25, identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis. The POC included orders for skilled nursing services. b. Clinical record review lacked documentation the discharge summary was forwarded to the patient’s attending physician. The above findings were reviewed with the Administrator/Clinical Manager. According to the hospice policy, titled Discharge for Reasons Other than Death, dated November 2008, when the patient is discharged from hospice, the hospice provides a copy of the clinical record (if requested) and the hospice discharge summary to the patient’s attending physician. 1. Patient #11 had a start of care date of 4/25/25, a discharge date of 5/22/25 (revoked hospice services) and received hospice services while residing in a nursing home. a. The Plan of Care (POC), dated 4/25/25 to 7/23/25, identified the patient had a primary diagnosis of congestive heart failure and included orders for skilled nursing services. b. The discharge summary, dated 5/22/25, included a summary of hospice services and a list of the patient’s current medications. c. Clinical record review lacked documentation of the discharge summary forwarded to the patient’s attending physician. During an interview on 3/17/26 at 3:47 PM, the Administrator reported they could not find in the clinical record that the discharge summary was faxed to the patient’s attending physician. The hospice failed to forward a copy of the discharge summary to the patient’s attending physician.”

“Based on clinical record review and agency policy review, the hospice failed to maintain documentation in the patient clinical records as evidence patients received a copy of the hospice policy concerning the disposal of controlled medications and hospice staff discussed this policy with the patient/caregiver for 2 of 2 sampled patients who received routine home care while living in a private residence and received orders for controlled medications after the start of care (Patients #4 and #8). Failure to ensure patients and/or caregivers received adequate education on the use and disposal of controlled substances increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for whom the medication was prescribed. Findings include: 2. Patient #4 had a hospice admission date of 12/10/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 12/10/25 to 3/9/26, included physician orders for medications, but no controlled medications. The POC identified the patient had a primary diagnosis of chronic obstructive pulmonary disease. b. A physician’s order, dated 12/29/25, revealed a new order for Hydrocodone (controlled medication) 5 mg/Acetaminophen 325 mg every 4 hours as needed for pain or air hunger. c. The skilled nurse visit note, dated 12/30/25, lacked documentation of education for the disposal of controlled medications. The clinical record lacked documentation hospice staff reviewed the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medication. The above findings reviewed with the Administrator/Clinical Manager. According to the agency policy titled Labeling, Disposing and Storing of Drugs and Biologicals, last revised July 2018, when controlled substances are first ordered the Interdisciplinary Group (IDG) provides a copy of the hospice’s written policies and procedures on the management of and disposal of controlled drugs to the patient or patient representative and family, the IDG discusses the hospice’s policies and procedures for managing the safe use and disposal of controlled drugs with the patient or patient representative and family and the IDG documents in the patient’s clinical record the written policies and procedures related to disposal of controlled substances were provided and discussed. 1.Patient #8 had a hospice admission date of 1/22/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 1/22/26 to 4/21/26, included physician orders for medications, but no controlled medications. The POC identified the patient had a primary diagnosis of sepsis. b. A skilled nurse visit note, dated 1/29/26, completed by Staff B, Registered Nurse (RN), identified the patient’s primary physician ordered Lorazepam (controlled medication) as needed and the RN educated the patient on how to take the medication and potential side effects of the medication. The clinical record lacked documentation hospice staff reviewed the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medication.”