Mountain Valley Hospice & Palliative Care

“Based on clinical record review, the hospice failed to ensure an initial assessment was conducted to accurately gather essential information necessary to begin the plan of care and provide the immediate necessary care and services in one out of sixteen records reviewed (Patient # 1). Failure to accurately gather essential information has the potential to result in unmet patient needs and inhibits the hospice’s ability to develop an accurate comprehensive plan of care. Finding:Patient # 1 (start of care 09/10/2025) has diagnoses of Chronic Diastolic (Congestive) Heart Failure and Acute and Chronic Respiratory Failure with Hypoxia. The record contains an initial comprehensive assessment conducted on 09/10/2025 that states the patient is on a low sodium diet in one section of the assessment and is on a regular premium protein diet on another section of the assessment. The assessment needs clarification as to which diet the patient is currently on. The finding was confirmed on 10/24/2025 at 08:45 AM with the Director of Operations and House Clinical Manager; no additional evidence was provided.”

“Based on clinical record review, the hospice failed to ensure in sixteen of sixteen clinical records reviewed (Patient # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16) a complete and comprehensive physician Plan of Care (POC) was developed to meet the needs of the patient. Failure to develop a complete and comprehensive POC has the potential to result in unmet patient needs and negative patient outcomes. Findings:The agency’s policy and procedure entitled “Pain & Symptom Management” (dated 04/04/2025) states “(7) Dyspnea is also assessed upon Admission and with each Comprehensive visit. A dyspnea scale of 0-10 is utilized to guide symptom relief interventions”.Patient # 1 (start of care 09/10/2025) has diagnoses of Chronic Diastolic (Congestive) Heart Failure and Acute and Chronic Respiratory Failure with Hypoxia. The record contains a physician’s POC for certification period 09/10/2025 through 12/08/2025 that contains orders for: - Morphine 20 milligrams (mg) /milliliter (ml) oral concentrate; Administer 0.25-1 milliliter(s) oral every 2 hours as needed for dyspnea (Comments: Morphine- Take 5-20 milligrams of morphine concentrate (20 mg/ml) by mouth every 2 hours (hrs.) as needed for pain/dyspnea. 5 mg = 0.25 ml; 10 mg = 0.5 ml; 15 mg = 0.75; 20 mg=1 ml. Maximum daily dosage (MDD) 12 mls **HIGH RISK MEDICATION**. The order lacks a pain or dyspnea scale to guide symptom relief interventions.The POC includes the following additional (standing) orders lacking a pain and /or dyspnea scale: - Morphine (100 mg/5 ml) 5-20 mg by mouth every 2 hours as needed for pain or dyspnea 12 mg (0.25 ml=5 mg) (0.5 ml=10 mg) (0.75 ml=15 ml) (1 ml=20-mg) MDD 12 ml; - Oxyfast (100 mg/5 ml) by mouth every 2 hours as needed for pain or dyspnea 12 mls. (0.25 ml=5 mg) (0.5 ml=10 mg) (0.75 ml=15 ml) (1 ml=20-mg) MDD 12 ml; - Take 650 mg of Acetaminophen oral every 4-6 hrs as needed for pain/fever. MDD 3,000 mg; Insert 650 mg of Acetaminophen (650 mg suppository) rectally every 4-6 hrs as needed for pain/fever MDD 3,000 mg Take 20 mls of Acetaminophen (160mg/5 ml) oral every 4-6 hrs as needed for pain or fever MDD 3,000 mg and - Take 200-400 mg of Ibuprofen oral every 4-6 hours as needed for pain or fever MDD 2,400 mg. Patient # 2 (start of care 10/10/2025) has diagnoses of Atherosclerotic Native Arteries of Extremities with Intermittent Claudication, bilateral legs and Hypertensive heart disease with heart failure. The record contains a physician’s POC for certification period 10/10/2025 through 12/08/2025 that contains orders for Polyethylene glycol 3350 oral powder for reconstitution; Administer 17 grams (gms) orally once a day for constipation. The order is incomplete as it is lacking reconstitution instructions of how much and type of fluid to reconstitute the medication in. Also, the POC includes the following additional (standing) orders lacking a pain and /or dyspnea scale: - Morphine (100 mg/5 ml) 5-20 mg by mouth every 2 hours as needed for pain or dyspnea 12 mg (0.25 ml=5 mg) (0.5 ml=10 mg) (0.75 ml=15 ml) (1 ml=20-mg) MDD 12 ml. The order requires clarification as to whether the patient is to take 0.75 ml = 15 ml or mg and lacks a pain or dyspnea scale to guide symptom relief interventions. - Oxyfast (100 mg/5 ml) by mouth every 2 hours as needed for pain or dyspnea 12 mls. (0.25 ml=5 mg) (0.5 ml=10 mg) (0.75 ml=15 ml) (1 ml=20-mg) MDD 12 ml. The order lacks a pain or dyspnea scale to guide symptom relief interventions. - Take 650 mg of Acetaminophen oral every 4-6 hrs as needed for pain/fever. MDD 3,000 mg; - Insert 650 mg of Acetaminophen (650 mg suppository) rectally every 4-6 hrs as needed for pain/fever MDD 3,000 mg, take 20 mls of Acetaminophen (160 mg/5 ml) oral every 4-6 hrs as needed for pain or fever MDD 3,000 mg. The orders lack a pain scale to guide symptom relief interventions. - Take 200-400 mg of Ibuprofen oral every 4-6 hours as needed for pain or fever MDD 2,400 mg. The order lacks a pain scale to guide symptom relief interventions.Patient # 3 (start of care 09/22/2025) has diagnoses of Alzheimer’s Disease and Hypertensive heart and Chronic Kidney Disease with Heart Failure and Stage 1-4/Unspecified Chronic Kidney. The record contains a physician’s POC for certification period 09/22/2025 through 12/20/2025 that contains orders lacking a pain and /or dyspnea scale: - Morphine (20 mg/ml) Administer 5-20 mg oral every 2 hours as needed for pain, dyspnea (Comments: 0.25 ml=5 mg, 0.5 ml=10 mg, 0.75 ml=15 mg, 1 ml=20 mg MDD 12 mos) - Oxycodone 5 mg oral tablet; Take 1 tab(s) oral every 8 hours as needed for pain (Comments: MDD for as needed (PRN) 3 tabs).Also, this morphine order requires clarification as to what the maximum daily dosage is.Additionally, the POC includes the following additional (standing) orders lacking a pain scale to guide symptom relief interventions: - Take 650 mg Acetaminophen oral every 4-6 hrs. as needed for pain or fever. MDD 3,000 mg; Insert 650 mg of Acetaminophen (650 mg suppository) rectally every 4-6 hrs as needed for pain or fever MDD 3,000; - Take 20 ml of Acetaminophen (160 mg/5 ml) oral every 4-6 hrs as needed for pain or fever MDD 3,000mg and - Take 200-400 mg Ibuprofen oral every 4-6 hrs. as needed for pain or fever MDD 2,400 mg. Further, the POC contains an order for Morphine (100 mg/5 ml) 5-20 mg by mouth every 2 hours as needed for pain, dyspnea 12 mls (0.25 ml=5 mg), (05.ml=10 mg), (0.75 ml=15 ml), (1 ml=20-mg) MDD 12 ml that needs clarification as to whether the dosage for 0.75 ml = 15 ml or mg and is lacking a pain/dyspnea scale.Patient # 4 (start of care 10/15/2025) has diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney /End Stage Renal Disease (ESRD) and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The record contains a Physician’s POC for certification period 10/15/2025 through 01/12/2026 that contains an order that lacks a pain or dyspnea scale to guide symptom relief interventions: - Morphine (20 mg/ml) oral concentrate Administer 0.25-1 milliliter(s) oral every 2 hours as needed for pain/breathing (Comments: Take 5-20 mg of morphine concentrate (100 mg/5 ml) by mouth every 2 hrs as needed for pain/dyspnea. 5 mg=0.25ml, 10 mg=0.5 ml, 15 mg=0.75 ml, 20 mg=1 ml MDD 12 mls). **HIGH RISK MEDICATION**. Also, the POC includes the following additional (standing) orders lacking a pain or dyspnea scale to guide symptom relief interventions. - Oxyfast (100 mg/5 ml) by mouth every 2 hours as needed for pain or dyspnea 12 mls. (0.25 ml=5 mg) (0.5 ml=10 mg) (0.75 ml=15 ml) (1 ml=20-mg) MDD 12 ml. The order lacks a pain or dyspnea scale to guide symptom relief interventions. - Take 650 mg Acetaminophen oral every 4-6 hrs. as needed for pain or fever. MDD 3,000 mg; Insert 650 mg of Acetaminophen (650 mg suppository) rectally every 4-6 hrs as needed for pain or fever MDD 3,000; Take 20 ml of Acetaminophen (160mg/5 ml) oral every 4-6 hrs as needed for pain or fever MDD 3,000mg. The orders lack a pain scale to guide symptom relief interventions and - Take 200-400 mg of Ibuprofen oral every 4-6 hours as needed for pain or fever MDD 2,400 mg. The order lacks a pain scale to guide symptom relief interventions.Additionally the POC contains an additional order for Morphine (100 mg/5 ml) 5-20 mg by mouth every 2 hours as needed for pain or dyspnea 12 mls (0.25 ml=5 mg) (0.5 ml=10 mg) (0.75 ml=15 ml) (1 ml=20-mg) MDD 12 ml that requires clarification as to whether the dosage for 0.75 ml = 15 ml or mg and is lacking a pain and dyspnea scale.Patient # 5 (start of care 10/13/2025) has diagnoses of Malignant Neoplasm of Fundus of Stomach and Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct. The record contains a Physician’s POC for certification period 10/13/2025 through 01/10/2026 that contains orders for: - Morphine (20 mg/ml) oral concentrate; Administer 0.25-1 milliliter(s) oral every 2 hours as needed for pain/breathing (Comments: Take 5-20 milligrams of morphine concentrate (20 mg/ml) by mouth every 2 hrs as needed for pain/dyspnea. 5 mg=0.25ml, 10 mg=0.5 ml, 15 mg=0.75 ml, 20 mg=1 ml MDD 12 mls). **HIGH RISK MEDICATION**. The order lacks a pain and/or dyspnea scale to guide symptom relief interventions and - Cyanocobalamin 1000 micrograms/ml injectable solution; Infection 1000 microgram(s) injectable once a week. The order is incomplete as it is lacking what type of injection to deliver the medication: intravenous, intramuscular, subcutaneous or intradermal.Patient # 6 (start of care 08/26/2025) has diagnoses of Parkinson’s Disease with Dyskinesia and Dementia. The record contains a Physician’s POC for certification period 08/26/2025 through 11/23/2025,that contains orders for: - Take 5-20 mg of morphine concentrate (100 mg /5 ml) by mouth every 2 hrs as needed for pain/dyspnea. 5 mg=.25 mls; 10 mg = 0.5 ml; 15 mg= 0.75 ml; 20 mg=1 ml. (MDD 12 mls) Dosage Form: solution. The order lacks a pain or dyspnea scale to guide symptom relief interventions.Also, the POC includes the following additional (standing) orders lacking a pain or dyspnea scale to guide symptom relief interventions. - Take 650 mg of Acetaminophen (2-325 mg tablets) oral every 4-6 hrs as needed for pain or fever. MDD 3,000 mg Medication Indication: Elevated Temperature, Pain; - Insert 650 mg of acetaminophen (650 mg suppository) rectally every 4-6 hrs as needed for pain or fever MDD 3,000 Medication Indication: Elevated Temperature, Pain; - Take 20 mls of Acetaminophen (160 mg/5 ml) oral every 4-6 hrs as needed for pain or fever. MDD 3,000 Medication Indication: Elevated Temperature, Pain and - Take 200-400 mg of Ibuprofen oral every 4-6 hrs as needed for pain or fever MDD 2,400 mg Medication Indication: Elevated Temperature, Pain. Additionally, the POC is lacking documentation of the patient’s activity level, functional limitations, mental status and psychosocial/cognitive status. Further, the following physician’s order on 08/29/2025 lacks a pain or dyspnea scale to guide symptom relief interventions: - Morphine 20 mg/ml oral concentrate; Administer 5-20 milligrams oral every 2 hours as needed for pain/dyspnea (Comments: 0.25 ml = 5 ml; 0.5 ml =10 mg, 0.75 ml = 15 mg, 1 ml = 20 mg. MDD 12 mls).Patient # 7 (start of care 10/03/2025) has diagnoses of Malignant Neoplasm of Prostate and Secondary Malignant Neoplasm of Bone. The record contains a Physician’s POC for certification period 10/03/2025 through 12/31/2025 that contains an order for Polyethylene glycol 3350 oral powder for reconstitution; Administer 17 grams (gms) orally once a day as needed for constipation (Comments: MDD 17 gms **HIGH RISK MEDICCATION**). The order is incomplete as it is lacking reconstitution instructions of how much and what type of fluid to reconstitute the medication in.Patient # 8 (start of care 05/28/2025) has diagnoses of Secondary Malignant Neoplasm of Retroperitoneum and Peritoneum and Pleural Effusion. The record contains a Physician’s POC for certification period 08/26/2025 through 11/23/2025 that contains the following orders that lacks a pain and/or dyspnea scale: - Take 650 mg of acetaminophen (325 mg tablet) by mouth 2 x day as needed for discomfort: MDD 4 tabs Dosage Form: tablet. Medication Indication: Pain; - Take 5-20 milligrams of morphine concentrate (100 mg /5 ml) by mouth every 2 hrs as needed for pain/dyspnea. 5 mg = 0.25 mls; 10 mg = 0.5 ml; 15 mg = .75 ml; 20 mg=1 ml. (MDD 12 ml) Dosage Form: Concentrate. Medication Indication: Dyspnea, Pain;Also, the POC includes the following additional (standing) orders lacking a pain or dyspnea scale to guide symptom relief interventions: - Take 650 mg of Acetaminophen (2-325 mg tablets) oral every 4-6 hrs as needed for pain or fever. MDD 3,000 mg Medication Indication: Elevated Temperature, Pain; - Insert 650 mg of Acetaminophen (650 mg suppository) rectally every 4-6 hrs as needed for pain or fever MDD 3,000 Medication Indication: Elevated Temperature, Pain; - Take 20 mls of Acetaminophen (160 mg/5 ml) oral every 4-6 hrs as needed for pain or fever. MDD 3,000 Medication Indication: Elevated Temperature, Pain and -Take 200-400 mg of Ibuprofen oral every 4-6 hrs as needed for pain or fever MDD 2,400 mg Medication Indication: Elevated Temperature, Pain. Additionally, the POC is lacking documentation of the patient’s activity level, functional limitations, mental status and psychosocial/cognitive status.Patient # 9 (start of care 10/02/2025) has diagnoses of Myelodysplastic Syndrome and Aplastic Anemia. The record contains a Physician’s POC for certification period 10/02/2025 through 12/30/2025 that contains the following orders that lacks a pain and/or dyspnea scale: - Oxycodone 20 mg/ml oral concentrate; Administer 5-20 milligrams orally every 2 hours as needed for pain, dyspnea (Comments: 0.25 ml=5 mg, 0.5 ml=10 mg, 0.75 ml=15 gm, 1 ml=20-mg) MDD 12 ml and - Tylenol 500 mg Take 2 tab (s) oral every 8 hours as needed for pain, fever. (Comments: MDD 3,000 mg). Also, the POC includes the following additional (standing) orders lacking a pain or dyspnea scale to guide symptom relief interventions: - Take 650 mg of Acetaminophen oral every 4-6 hrs as needed for pain/fever MDD 3,000 mg; - Insert 650 mg of Acetaminophen (650 mg suppository) rectally every 4-6 hrs as needed for pain/fever MDD 3,000 mg, take 20 mls of Acetaminophen (160 mg/5 ml) oral every 4-6 hrs as needed for pain or fever MDD 3,000 mg and - Take 200-400 mg of Ibuprofen oral every 4-6 hours as needed for pain or fever MDD 2,400 mg.Additionally, the POC contains an additional order for Morphine (100 mg/5 ml) 5-20 mg by mouth every 2 hours as needed for pain or dyspnea 12mls (0.25 ml=5 mg) (0.5 ml=10 mg) (0.75 ml=15 ml) (1 ml=20-mg) MDD 12 ml for pain or dyspnea 12 mls. (0.25 ml=5 mg) (0.5 ml=10 mg) (0.75 ml=15 ml) (1 ml=20-mg) MDD 12 ml that needs clarification as to whether the dosage for 0.75 ml = 15 ml or mg and requires a pain/dyspnea scale.Patient # 10 (start of care 09/25/2025) has diagnoses of Senile Degeneration of Brain and Dementia. The record contains a Physician’s POC for certification period 09/25/2025 through 12/23/2025, that contains the following order that is lacking a dyspnea scale: - Morphine 20 mg/ml oral concentrate; Administer 0 .25-1 milliliter oral every 2 hours as needed for severe pain (Comments: Take 5 - 20 mg of morphine concentrate (20 mg/ml) by mouth every 2 hours (hrs) as needed for pain/dyspnea 5 mg = 0.25 ml, 10 mg = 0.5 ml, 15 mg = 0.75 ml, 20 mg = 1 ml. MDD 12 mls). Also, the POC includes the following additional (standing) orders that lack a pain or dyspnea scale to guide symptom relief intervention: - Take 650 mg of Acetaminophen oral every 4-6 hrs as needed for pain/fever. MDD 3,000 mg; - Insert 650 mg of Acetaminophen (650 mg suppository) rectally every 4-6 hrs as needed for pain/fever MDD 3,000 mg; - Take 20 mls of Acetaminophen (160 mg/5 ml) oral every 4-6 hrs as needed for pain or fever MDD 3,000 mg and - Take 200-400 mg of Ibuprofen oral every 4-6 hours as needed for pain or fever MDD 2,400 mg. The orders lack a pain scale to guide symptom relief intervention.Additionally, the POC contains the following additional orders that need clarification as to whether the dosage for 0.75 ml = 15 ml or mg and lack a pain/dyspnea scale. - Morphine (100mg/5 ml) 5-20 mg by mouth every 2 hours as needed for pain or dyspnea 12 mls (0.25 ml=5 mg) (0.5 ml=10 mg) (0.75 ml=15 ml) (1 ml=20-mg) MDD 12 ml; - Take Oxyfast (100 mg/5 ml) by mouth every 2 hours as needed for pain or dyspnea 12 mls. (0.25 ml=5 mg) (0.5 ml=10 mg) (0.75 ml=15 ml) (1 ml=20-mg) MDD 12 ml;Patient # 11 (start of care 04/11/2025) has diagnoses of Degenerative Disease of Nervous System and Alzheimer’s Disease. The record contains a Physician’s POC for certification period 10/08/2025 through 12/06/202 that contains the following order lacking a pain and dyspnea scale to guide symptom relief interventions. - Morphine 20 mg/ml oral concentrate; Administer 5- -20 mg milligrams oral every 2 hours as needed for pain/dyspnea. (Comments: 0.25 ml - 5 mg, 0.5 ml = 10 mg, 0.75 ml = 15 mg, 1 ml = 20 mg MDD 12 mls. Also, the POC contains the following additional orders that lack a pain scale to guide symptom relief intervention: - Take 650 mg of Acetaminophen oral every 4-6 hrs as needed for pain/fever. MDD 3,000 mg; - Insert 650 mg of Acetaminophen (650 mg suppository) rectally every 4-6 hrs as needed for pain/fever MDD 3,000 mg; - Take 20 mls of Acetaminophen (160 mg/5 ml) oral every 4-6 hrs as needed for pain or fever MDD 3,000 mg and - Take 200-400 mg of Ibuprofen oral every 4-6 hours as needed for pain or fever MDD 2,400 mg. Patient # 12 (start of care 07/01/2025) has diagnoses of Parkinson’s Disease without Dyskinesia and Abnormal Weight Loss. The record contains a Physician’s POC for certification period 07/01/2025 through 09/28/2025 that contains the following order lacking a pain and/or dyspnea scale to guide symptom relief interventions: - Take 5-20 mg of morphine concentrate (100 mg/5 ml) by mouth every 2 hrs as needed for pain/dyspnea. 5 mg = .25 ml, 10 mg = 0.5 ml, 15 mg = 0.75 ml, 20 mg - 1 ml. (MDD 12 mls) Dosage Form: solution.Also, the POC contains the following additional orders that lack a pain scale to guide symptom relief intervention: - Take 650 mg of Acetaminophen (2-525 mg tablets) oral every 4-6 hrs as needed for pain/fever. MDD 3,000 mg; - Insert 650 mg of Acetaminophen (650 mg suppository) rectally every 4-6 hrs as needed for pain/fever MDD 3,000 mg Medication Indication: Elevated Temperature, Pain; - Take 20 mls of Acetaminophen (160 mg/5 ml) oral every 4-6 hrs as needed for pain or fever MDD 3,000 mg and - Take 200-400 mg of Ibuprofen oral every 4-6 hours as needed for pain or fever MDD 2,400 mg Medication Indication: Elevated Temperature, Pain. Additionally, the POC is lacking documentation of the patient’s activity level, functional and mental status.Further, the record contains a Physician’s POC for certification period 09/29/2025 through 12/27/2025 that contains the following orders lacking a pain and/or dyspnea scale to guide symptom relief interventions: - Acetaminophen 650 mg oral tablet, extended release; Take 1-2 tab (s) orally 2 times a day as needed for pain and - Morphine 20 mg/ml oral concentrate; Administer 0 .25-1 milliliter(s) oral every 2 hours as needed for pain. (Comments: Take 5-20 mg of morphine concentrate (100 mg/5 ml) by mouth every 2 hrs as needed for pain/dyspnea. 5 mg = .25 mls, 10 mg = 0.5 ml; 15 mg = 0.75 ml, 20 mg = 1 ml. (MDD 12 mls). Furthermore, the POC lacks the following durable medical equipment (DME) located on the 09/19/2025 nursing assessment: Bathroom/toilet equipment Bedside commode, handheld shower, shower bench, Bed/transfer equipment, grab bars/safety rails, shower chair and bedside table.Patient # 13 (start of care 09/11/2025) has diagnoses of Hemorrhage of Anus and Rectum and Alzheimer Disease. The record contains a physicians POC for certification period 09/11/2025 through 12/09/2025 that contains the following order lacking a pain and/or dyspnea scale to guide symptom relief interventions: - Morphine 20 mg/ml oral concentrate: Administer 5-20 milligrams oral every 2 hours as needed for pain, dyspnea. (Comments: 0.25 ml = 5 mg, 0.5 ml - 10 mg, 0.75 ml - 15 mg and 1 ml = 20 mg MDD 12 mls).Also, the POC contains the following additional orders that lack a pain and/or dyspnea scale to guide symptom relief intervention: - Take 650 mg of Acetaminophen oral every 4-6 hrs as needed for pain/fever. MDD 3,000 mg; - Insert 650 mg of Acetaminophen (650 mg suppository) rectally every 4-6 hrs as needed for pain/fever MDD 3,000 mg Medication Indication: Elevated Temperature, Pain; - Take 20 mls of Acetaminophen (160mg/5 ml) oral every 4-6 hrs as needed for pain or fever MDD 3,000 mg and - Take 200-400 mg of Ibuprofen oral every 4-6 hours as needed for pain or fever MDD 2,400 mg Medication Indication: Elevated Temperature, Pain. Additionally, the POC contains the following additional orders that need clarification as to whether the dosage for 0.75 ml = 15 ml or mg and lack a pain/dyspnea scale. - Morphine (100mg/5 ml) 5-20 mg by mouth every 2 hours as needed for pain or dyspnea 12 mls (0.25 ml=5 mg) (0.5 ml=10 mg) (0.75 ml=15 ml) (1 ml=20-mg) MDD 12 ml; - Take Oxyfast (100 mg/5 ml) by mouth every 2 hours as needed for pain or dyspnea 12 mls. (0.25 ml=5 mg) (0.5 ml=10 mg) (0.75 ml=15 ml) (1 ml=20-mg) MDD 12 ml;Patient # 14 (start of care 10/22/2025) has diagnoses of Alzheimer’s Disease and Dementia. The record contains a physicians POC for certification period 10/22/2025 through 01/19/2026 that contains the following orders lacking a pain and/or dyspnea scale to guide symptom relief interventions: - Morphine 20 mg/ ml oral concentrate; Administer 5-20 mg milligrams oral every 2 hours as needed for pain/dyspnea. (Comments: 0.25 ml = 5 mg, 0.5 ml - 10 mg, 0.75 ml - 15 mg and 1 ml = 20 mg MDD 12 mls).Also, the POC contains the following additional orders that lack a pain and/or dyspnea scale to guide symptom relief intervention: - Take 650 mg of Acetaminophen oral every 4-6 hrs as needed for pain/fever. MDD 3,000 mg; - Insert 650 mg of Acetaminophen (650 mg suppository) rectally every 4-6 hrs as needed for pain/fever MDD 3,000 mg Medication Indication: Elevated Temperature, Pain; - Take 20 mls of Acetaminophen (160mg/5 ml) oral every 4-6 hrs as needed for pain or fever MDD 3,000 mg and - Take 200-400 mg of Ibuprofen oral every 4-6 hours as needed for pain or fever MDD 2,400 mg Medication Indication: Elevated Temperature, Pain. Additionally, the POC contains the following additional orders that need clarification as to whether the dosage for 0.75 ml = 15 ml or mg and lack a pain/dyspnea scale: - Morphine (100mg/5 ml) 5-20 mg by mouth every 2 hours as needed for pain or dyspnea 12 mls (0.25 ml=5 mg) (0.5 ml=10 mg) (0.75 ml=15 ml) (1 ml=20-mg) MDD 12 ml; - Take Oxyfast (100 mg/5 ml) by mouth every 2 hours as needed for pain or dyspnea 12 mls. (0.25 ml=5 mg) (0.5 ml=10 mg) (0.75 ml=15 ml) (1 ml=20-mg) MDD 12 ml;Patient # 15 (start of care 12/18/2024 discharged 01/09/2025) has diagnoses of Malignant Melanoma of Left Lower Limb including Hip and Secondary Malignant Neoplasm of Unspecified Lung. The record contains a physician’s POC for certification period 12/18/2024 through 03/17/2025 that contains the following orders lacking a pain and/or dyspnea scale to guide symptom relief interventions: - Take 5-20 mg of morphine concentrate 20 mg/ml by mouth every 2 hrs as needed for pain or dyspnea 12 ml 0.25 ml = 5 mg, 0.5 ml = 10 mg, 0.75 ml = 15 mg and 1 ml = 20 mg MDD 12 ml. Dosage Form: solution and - Give 50 mg of tramadol (50 mg tablet) by mouth every 6 hrs as needed for pain. MDD 4 tabs Dosage Form: tablet.Also, the POC contains the following additional orders that lack a pain and/or dyspnea scale to guide symptom relief intervention: - Take 650 mg of Acetaminophen (2-325 mg tablets) oral every 4-6 hrs as needed for pain/fever. MDD 3,000 mg Medication indication: Elevated temperature, pain; - Insert 650 mg of Acetaminophen (650 mg suppository) rectally every 4-6 hrs as needed for pain/fever MDD 3,000 mg Medication Indication: Elevated Temperature, Pain; - Take 20 mls of Acetaminophen (160mg/5 ml) oral every 4-6 hrs as needed for pain or fever MDD 3,000 mg Medication Indication: Elevated Temperature, Pain and - Take 200-400 mg of Ibuprofen oral every 4-6 hours as needed for pain or fever MDD 2,400 mg Medication Indication: Elevated Temperature, Pain. Also, the POC is lacking documentation of the patient’s psychosocial status, activity level, functional and mental status.Patient # 16 (start of care 02/20/2025, discharge date of 10/13/2025) has diagnoses Of Cerebral Atherosclerosis and Vascular Dementia, moderate, with agitation. The record contains a physician’s POC for certification period 06/02/2025 through 08/30/2025 that contains the following additional orders lacking a pain and/or dyspnea scale to guide symptom relief interventions: - Take 650 mg of Acetaminophen (2-32 mg tablets) oral every 4-6 hrs as needed for pain/fever. MDD 3,000 mg Medication indication: Elevated temperature, pain; - Insert 650 mg of Acetaminophen (650 mg suppository) rectally every 4-6 hrs as needed for pain/fever MDD 3,000 mg Medication Indication: Elevated Temperature, Pain; - Take 20 mls of Acetaminophen (160 mg/5 ml) oral every 4-6 hrs as needed for pain or fever MDD 3,000 mg Medication Indication: Elevated Temperature, Pain and - Take 200-400 mg of Ibuprofen oral every 4-6 hours as needed for pain or fever MDD 2,400 mg Medication Indication: Elevated Temperature, Pain. Also, the POC is lacking documentation of the patient’s psychosocial status, activity level, functional and mental status.Additionally, the POC for certification period 08/31/2025 through 11/28/2025 contains the following orders lacking a pain and/or dyspnea scale to guide symptom relief interventions: - Take 650 mg of Acetaminophen (2-325 mg tablets) oral every 4-6 hrs as needed for pain/fever. MDD 3,000 mg Medication indication: Elevated temperature, pain; - Insert 650 mg of Acetaminophen (650 mg suppository) rectally every 4-6 hrs as needed for pain/fever MDD 3,000 mg Medication Indication: Elevated Temperature, Pain; - Take 20 mls of Acetaminophen (160 mg/5 ml) oral every 4-6 hrs as needed for pain or fever MDD 3,000 mg Medication Indication: Elevated Temperature, Pain and - Take 200-400 mg of Ibuprofen oral every 4-6 hours as needed for pain or fever MDD 2,400 mg Medication Indication: Elevated Temperature, Pain. Further, the POC is lacking bleeding precautions related to the use of aspirin.Furthermore, the POC is lacking documentation of the patient’s psychosocial status, activity level, functional and mental status.The findings were confirmed on 10/24/2025 at 08:45 AM and 11:00 AM with the Director of Operations and House Clinical Manager; no additional evidence was provided.”

“Based on staff interview and an observational home visit to a inpatient facility, the hospice failed to ensure orientation was provided to the inpatient facility staff furnishing care to Hospice patients regarding the Hospice philosophy, Hospice policies and procedures regarding methods of comfort, pain control, symptom management, principles about death and dying, individual response to death, patient rights, appropriate forms and record keeping requirements. Failure to ensure inpatient facility staff have received orientation, regarding the Hospice philosophy, Hospice policies and procedure regarding methods of comfort, pain control, symptom management, principles about death and dying, individual responses to death, patient rights, appropriate forms and record keeping requirements has the potential to result in the provision of inappropriate care, unmet patient and family needs and negative patient outcomes. Finding:The Director of Operations was interviewed on 10/20/2025. A request was made for documentation of orientation of Skilled Nursing Facility (SNF) staff providing care to Hospice patients to the Hospice philosophy, Hospice policies and procedures, appropriate forms and record keeping requirements. On 10/21/2025, the Director of Operations stated the human resources department at the SNF does not have any documentation of orientation of their staff to the Hospice requirements.On 10/22/2025, during a home visit at the SNF, the Hospice registered nurse case manager verified with the SNF education department there was not any documentation of the education of the SNF personnel to the Hospice philosophy, Hospice policies and procedures, appropriate forms and record keeping requirements. The Hospice is lacking any documented evidence of SNF staff orientation.The finding was confirmed on 10/22/2025 at 2:00 PM with the Director of Operations; no additional evidence was provided.”

“Based on observations and staff interview during a Life Safety Code Standard Survey, on 10/21/2025, required fire resistance-rated construction was not maintained in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 Edition Chapter 19.1.3.3 requires that sections of health care facilities classified as other occupancies shall be separated from the health care occupancy by not less than two (2)-hour fire resistance-rated construction in accordance with Chapter 8. Chapter 8 also requires that penetrations and miscellaneous openings to be sealed with materials equal to the fire resistance rating of the wall assembly. Specifically, the permitted facility was not separated from the non-permitted administrative space with a 2-hour fire resistance-rated construction due to penetrations not being properly sealed. This is evidenced as follows:During observations on 10/21/2025 at 12:30PM, an approximately 4-inch by 6-inch penetration in the fire barrier were found above the double fire doors in the main hallway to the resident rooms. During an interview on 10/21/2025 at 2:30 PM, Facilities Director #1 stated that they were unaware and will be sure it is patched and fire protected within next few days. New York Codes Rules and Regulations Title 10 §10NYCRR 415.29(a)(2), 711.2(a) 2012 NFPA 101: 19.1.3.3, 8.3”

“Based on observations, record review and interviews conducted during a Life Safety Code Standard Survey, on 10/21/2025, the facility did maintain automatic sprinkler components or inspections in accordance with 2012 National Fire Protection Association (NFPA) 101.This is evidenced by: 1) During record review on 10/212025 between 12:00pm and 2:00pm it was identified that the dry sprinkler heads have not been replaced within the past ten (10) years as is required in accordance with National Fire Protection Association (NFPA) 25.2) During record review on 10/212025 between 12:00pm and 2:00pm it was identified that the Quick Response(QR) sprinkler heads have not been replaced within the past twenty (20) years as is required in accordance with National Fire Protection Association (NFPA) 25.3) During record review on 10/212025 between 12:00pm and 2:00pm it was identified that the sprinkler system components were last inspected on 04/16/2024 which is not within the past one (1) year as is required in accordance with National Fire Protection Association (NFPA) 25.4) During record review on 10/212025 between 12:00pm and 2:00pm it was identified that, based on provided documents, the backflow preventors were last inspected on 11/14/2023 which is not within the past one (1) year as is required in accordance with National Fire Protection Association (NFPA) 25.During interview with Administrator #1 on 10/21/2025 at 2:30 pm it was stated that sprinkler company is scheduled for 2nd week this November but will try and push it to earlier. They will discuss with them the changing of the heads and will also be looking into other vendorsNew York Codes Rules and Regulations Title 10 §10NYCRR 415.29(a)(2), 711.2(a) 2012 NFPA 101: 9.752011 NFPA 25: 5.4.1.3,5.4.14,13.7.12010 NFPA 14: 6.4.5.12010 NFPA 13: 8.3.3, 21.4.2”