Acg Hospice III

“It is required that the patient’s pain be assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes: a history of pain and its treatment, both pharmacological and non-pharmacological; use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status; characteristics of the pain, including: location, frequency, and intensity; how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping); and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review, document review and interview. 2 of 19 (11%) clinical records reviewed revealed that the agency did not ensure that patients with pain and being treated with opioids for ongoing pain issues received a pain assessment as part of the updated comprehensive assessment update at least every 14 days. The hospice’s policy “Ongoing Comprehensive Assessment Policy No. 1-016” (board approval date 12/2025) read in part, “...The scope and intensity of ongoing hospice patient assessments will be determined by the patient’s prognosis, diagnoses, condition...During each home visit the Registered Nurse...will evaluate the patient according to the care plan problems identified during the initial assessment and thereafter the comprehensive assessment...The nurse will assess each patient on each visit for pain, including the origin, location, duration, severity and relief measures....” The agency’s policy “Pain Assessment Policy No. 1-019” (board approval date 12/2025) read in part, “...on an ongoing basis, the patient will be asked a general screening question regarding current or recent pain...When the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained...Pain intensity...Pain location, Pain quality...Pain onset...The patient’s pain goal, including pain intensity and goals related to function, activities, and quality of life...If the patient is unable to communicate pain using the rating scale, is cognitively impaired...the clinician will assess behavioral factors that signal pain or discomfort and include this information in the assessment...Pain assessments will be part of the comprehensive assessment....” CLINICAL RECORD 1: The patient resides in a nursing facility and elected the hospice benefit on 02/06/2026 with a terminal diagnosis of hemiplegia following cerebral infarction and comorbid conditions, including fibromyalgia, rheumatoid arthritis, and chronic pain. During the admission visit on 02/06/2026, the Registered Nurse (RN) documented that the patient was alert and oriented to person, place, and time. The patient reported mild, intermittent, daily pain involving her bilateral lower extremities and generalized body pain. She described the pain as aching, burning, dull, shooting, sore, stabbing, and throbbing. The RN documented that the pain was exacerbated by activity and movement and negatively affected the patient’s functional status, mobility, emotional well-being, and ability to enjoy activities. During a nursing follow-up visit on 02/11/2026, no pain assessment was completed or documented. The only reference to pain noted was that the patient stated her current pain level was within her “tolerated limits,” without further assessment, quantification, or evaluation of the effectiveness of the pain regimen. During the nursing visit on 02/13/2026, the nurse documented that the patient “reports generalized pain all over due to neuropathy” and indicated that PRN (as needed) pain medications helped relieve the pain; however, no formal pain assessment was completed or documented. Subsequent nursing visits on 02/17/2026, 02/20/2026, and 02/24/2026 lacked documented pain assessments, only noting that the patient denied pain while the nurse was present. On 02/20/2026, the nurse noted the presence of generalized pain but did not assess, quantify, or evaluate the patient’s pain or response to treatment. On 02/26/2026, the nurse documented that the patient requested that her PRN (as needed) Norco (hydrocodone-acetaminophen) be changed to a scheduled medication because she had to request it every 6 hours and sometimes waited up to an hour for administration by the nursing facility staff. A new order was received to schedule the medication. No pain assessment was documented at that visit to support the change in pain management. During nursing visits on 03/02/2026 and 03/06/2026, no pain assessments were completed. On 03/06/2026, the nurse documented that the patient reported her pain was controlled with the newly scheduled pain regimen, however, no objective or subjective pain assessment was documented to validate pain control. At the nursing visit on 03/10/2026, there was no documentation indicating pain or discomfort, and no pain assessment was completed. The patient’s medication regimen for pain management included: Pregabalin 75 mg twice daily for fibromyalgia, Prednisone 5 mg daily for rheumatoid arthritis, and Hydrocodone/Acetaminophen 5 mg/325 mg every 6 hours scheduled for pain. Despite ongoing management of the patient’s chronic and ongoing pain with medication adjustments, pain assessments were inconsistently completed with no comprehensive pain assessment, including location, intensity, quality, frequency, duration, impact on the patient’s quality of life, or pain goal, documented since admission to hospice care. CLINICAL RECORD 4: The patient resides in a nursing facility and elected the hospice benefit on 02/27/2026 with a terminal diagnosis of malignant neoplasm of the skin, with secondary malignancies involving the brain, liver, and thyroid. During the RN admission assessment on 02/27/2026, the patient reported abdominal and back pain that was described as aching, occurred intermittently on a daily basis, and was exacerbated by activity and movement. The patient rated his pain as 4/10 and stated that it negatively impacted his appetite, concentration, emotional status, sleep, functional status, and mobility. On 03/02/2026 at 5:40 PM, the hospice triage service documented a triage call initiated by the patient’s daughter-in-law. She reported that the patient did not ask for PRN pain medications and instead would remain in bed “all day and night without asking for pain medications.” She stated that the patient told his family he was experiencing severe abdominal pain that day. The caller requested that the patient’s PRN pain medications be changed to scheduled dosing and indicated that it was acceptable if changes were made the following day, as her concern was preventing the patient from “lying in pain all night again.” On 03/03/2026 at 8:52 AM, a care coordination note completed by the Licensed Practical Nurse (LPN) documented that the patient was sitting on his hospital bed and was alert and oriented. The LPN noted wheezing, with breathing treatments being administered by the facility staff, and documented that the patient’s abdomen was distended and hard. The patient’s pain was neither assessed nor addressed during this visit. Later that same morning, at 11:26 AM, the RN documented that the patient was not uncomfortable and was receiving opioid narcotic pain medication. The RN noted that the patient requested his pain medications be changed from PRN to scheduled dosing. An order was obtained from the physician for Morphine Sulfate Concentrate (20 mg/mL), 0.5 mL four times daily, in addition to the already-ordered every-4-hours PRN dose. No pain assessment was documented to support or evaluate this medication change. The patient’s medication profile included: Lorazepam 1 mg every 4 hours PRN for anxiety/restlessness (order dated 03/01/2026). Morphine Sulfate Concentrate (20 mg/mL) 0.5 mL every 4 hours PRN for pain (order dated 03/01/2026), and Morphine Sulfate Concentrate (20 mg/mL) 0.5 mL scheduled four times daily (order dated 03/03/2026). On 03/05/2026, during an LPN visit, the LPN documented that the patient was not uncomfortable. In the assessment section titled “indicate any comfort meds used and number of PRNs in the last 24 hours,” only Morphine and Ativan were listed, without indicating dosages, frequency, or number of administrations. No pain assessment was completed, and the narrative portion of the note did not address the patient’s pain. No pain assessments were documented during subsequent visits on 03/09/2026 or 03/18/2026 by the LPN, nor during the RN visit on 03/11/2026, just a brief mention that the patient was not complaining of pain at the time of the visits. A review of the clinical record revealed that no updated comprehensive pain assessment, including location, intensity, quality, frequency, duration, impact on the patient’s quality of life, or pain goal, was documented since admission to hospice care. After a joint clinical record review and an interview with the Director of Operations (ADS-1 location)/Alternate Clinical Director (Personnel Record 4) on 03/18/2026, she confirmed that no comprehensive pain assessments had been completed since admission, but noted that pain was addressed only briefly, as “no pain during the visit” in the nurse’s notes. During an interview with the Manager of Compliance and Accreditation on 03/18/2026, she stated that during nursing follow-up visits, nurses should conduct a comprehensive pain assessment for patients whose pain is actively managed while in hospice care.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care and ensure continuous assessment of each patient’s and family’s needs and the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that the patient’s wound was assessed and monitored for progress since admission. The agency’s policy, “Ongoing Comprehensive Assessment Policy No. 1-016” (board approval date 12/2025) read in part, “...The scope and intensity of ongoing hospice patient assessments will be determined by the patient’s prognosis, diagnoses, condition...During each home visit, the Registered Nurse...will evaluate the patient according to the case plan problems identified during the initial assessment and thereafter...The nurse will assess each patient... on each visit for... skin integrity....” CLINICAL RECORD 4: The patient resides at a nursing facility and elected the hospice benefit on 02/27/2026 with the terminal diagnosis of malignant neoplasm of the skin. During the Registered Nurse’s (RN) admission visit on 02/27/2026, the RN documented the presence of a 3.5 cm x 3.5 cm wound on the plantar surface of the patient’s right foot, with a small amount of serosanguinous drainage. The initial hospice plan of care for the benefit period 02/27/2026 through 05/27/2026 included an order for the facility nursing staff to perform wound care every other day and as needed for soiled or dislodged dressing, utilizing clean technique, cleansing with normal saline, and covering the wound with a foam dressing. At the time of record review, nineteen (19) days had elapsed since admission, and no subsequent documentation of the wound’s status, measurements, appearance, drainage, or healing progress was present in the clinical record. A review of nursing documentation during this period revealed inconsistent and conflicting entries regarding skin integrity, with no evidence of ongoing wound assessment or monitoring. On 03/03/2026, during an RN visit, the RN documented that the patient had no altered skin integrity, despite the previously identified wound. On 03/05/2026, during an LPN (Licensed Practical Nurse) visit, the LPN documented no altered skin integrity. On 03/09/2026, during an LPN visit, the LPN documented altered skin integrity, but the wound was neither addressed nor assessed. On 03/11/2026, during an RN visit, the RN documented that the patient did not have a skin condition, and on 03/18/2026, during an LPN visit, the LPN again documented no altered skin integrity. Despite a documented wound at admission and an active wound care order in the plan of care, the record lacked ongoing assessment, monitoring, and evaluation of the wound, including documentation of wound characteristics, treatment response, or healing progress. After a joint clinical record review and an interview with the Director of Operations (ADS-1 location)/Alternate Clinical Director (Personnel Record 4) on 03/18/2026, she confirmed that no wound assessment had been documented in the clinical record since the admission visit, and noted the facility was providing the wound care and that she was unaware of any policy that specified the frequency for which wound assessments should be documented.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and document review. 5 of 19 (26%) clinical records reviewed revealed that the agency did not ensure that the patient’s plans of care (POC) included goals that were individualized and measurable. The hospice’s policy “Initial Assessment Policy No. 1-014) (board approval 12/2025) read in part that the “...Admitting Registered Nurse uses an assessment scale/rating tool to assess for problems and to establish a baseline status of each symptom rated...Admitting Nurse will determine the patient’s and caregiver’s primary concern, goals.” The agency’s policy “Contents of the Medical Record Policy No. 6-041” (board approval 12/2025) read in part. “...The medical record will...describe the patient’s problems and needs...Documentation will include...Plan of care developed/revised by the IDT/IDG based on comprehensive assessments and desired outcomes with time frames.” CLINICAL RECORD 1: The patient resides in a nursing facility and elected the hospice benefit on 02/06/2026 with the terminal diagnosis of hemiplegia following cerebral infarction and comorbid conditions including fibromyalgia, rheumatoid arthritis, and chronic pain. During the Registered Nurse (RN) admission visit on 02/06/2026, the RN documented that the patient was alert and oriented to person, place, and time. The patient reported mild bilateral lower extremity and generalized pain that occurred intermittently on a daily basis. She described the pain as aching, burning, dull, shooting, sore, stabbing, and throbbing. The RN further documented that the pain was exacerbated by activity and movement and negatively impacted the patient’s functional status, mobility, emotional status, and ability to enjoy activities. During the Interdisciplinary Group (IDG) meeting on 02/12/2026, the RN documented that the patient’s pain level remained mild. However, the only documented goal for the subsequent two-week period was prevention of patient falls, with no pain-specific goals, monitoring parameters, or measurable outcomes identified, despite the patient’s reported ongoing pain and its impact on quality of life. At the RN visit on 03/12/2026, the RN documented increased pain reported by the patient. As a result, the patient’s PRN (as-needed) pain medication was changed to scheduled dosing in an effort to better manage pain. The goal documented for the following two weeks was for the patient’s pain to be managed per the patient’s verbal report. The patient’s medication regimen at that time included: Pregabalin 75 mg twice daily for fibromyalgia, Prednisone 5 mg daily for rheumatoid arthritis, and Hydrocodone/Acetaminophen 5 mg/325 mg every 6 hours scheduled for pain A review of the patient’s POC for the benefit period dated 02/06/2026 through 05/06/2026 identified pain and the need for pain-related teaching as active problems. However, the documented goals were non-specific and not measurable, including statements that the patient would: verbalize satisfaction with the level of pain management, demonstrate understanding of pain management measures, and report changes in pain to hospice. The POC did not include measurable goals, time-limited outcomes, specific interventions, or objective criteria to evaluate the effectiveness of pain management or patient teaching. Additionally, goals were not clearly individualized to reflect the patient’s reported functional limitations, quality-of-life concerns, or changes in pain that required escalation of treatment. CLINICAL RECORD 4: The patient resides in a nursing facility and elected the hospice benefit on 02/27/2026 with a terminal diagnosis of malignant neoplasm of the skin, with secondary malignancies involving the brain, liver, and thyroid. During the RN admission assessment on 02/27/2026, the patient reported abdominal and back pain described as aching, occurring intermittently on a daily basis, and exacerbated by activity and movement. The patient rated his pain at 4/10 and stated that the pain negatively impacted his appetite, concentration, emotional status, sleep, functional status, and mobility. On 03/02/2026 at 5:40 PM, hospice triage documented a call from the patient’s daughter-in-law, who reported that the patient did not request PRN pain medication and instead would remain in bed “all day and night without asking for pain medications.” She further reported that the patient told family members he was experiencing severe abdominal pain and requested that pain medications be changed from PRN to scheduled dosing. On 03/03/2026, the patient’s pain regimen was revised to include scheduled Morphine Sulfate Concentrate, reflecting an escalation in pain management needs. Despite this change in condition and treatment, a review of the patient’s interdisciplinary documentation demonstrated a lack of clearly defined, measurable, and patient-specific pain management goals. CLINICAL RECORD 5: The patient resides in a nursing facility and elected the hospice benefit on 08/08/2025 with a terminal diagnosis of malignant neoplasm of the colon, with secondary malignant neoplasms of the liver and intrahepatic bile duct. During the RN admission visit on 08/08/2025, the patient did not report pain, and no patient-specific pain goal was documented at admission. On 01/20/2026, the RN documented that the patient was alert and oriented to person, place, and time and was experiencing increased pain requiring stronger doses of analgesia, indicating disease progression. On 02/26/2026, the RN documented that the patient complained of generalized pain rated at 2/10. Subsequently, during a nursing visit on 03/03/2026, the nurse documented receipt of a new hydrocodone order to manage the patient’s pain. At admission, the patient’s medication regimen included Acetaminophen 325 mg, two tablets nightly for pain and every four hours as needed. On 03/03/2026, an order was added for Hydrocodone/Acetaminophen 5 mg/325 mg every six hours PRN for pain, reflecting a change in pain management needs. During the IDG meeting on 03/13/2026, the RN documented that the goal for the next two weeks was for the patient to have “less pain”. This goal was non-specific and not measurable, lacking defined criteria for evaluation, such as a target pain score, functional outcome, or timeframe for reassessment. A review of the patient’s hospice POCs for the benefit periods dated 11/06/2025 through 02/03/2026 and 02/04/2026 through 04/04/2026 identified ongoing problems of pain/altered comfort and the need for skilled teaching regarding pain control measures, dated 08/08/2025 and 08/11/2025 with documented goals included that the patient and/or caregiver would: verbalize satisfaction with the level of pain management, demonstrate an understanding of pain management measures, and verbalize the need to report changes in pain to hospice. The goals were broad, subjective, and not measurable, and did not identify a patient-specific pain goal, such as an acceptable pain level, impact on function, or a quality-of-life indicator. CLINICAL RECORD 6: The patient resides at home and elected the hospice benefit on 05/07/2025 with a terminal diagnosis of unspecified heart failure and a comorbid condition of chronic pain. During the RN admission visit on 05/07/2025, the RN documented that the patient was alert and oriented to person, place, and time. The patient reported mild generalized and bilateral lower extremity pain, described as sore and aching, occurring daily but not constantly, with a reported pain score of 3/10. The patient stated her pain goal was 0/10 and reported that pain negatively impacted her appetite, mobility, functional status, and ability to enjoy activities. On 03/05/2026, the Licensed Practical Nurse (LPN) documented that the patient’s son reported difficulty swallowing, which affected the patient’s ability to swallow her pain medication. The son further reported that approximately three days prior, the patient’s pain level had increased, and a dose of morphine had been administered, after which the patient complained of nausea and feeling like she was “jumping out of the bed.” The LPN contacted the hospice physician and left a message with assessment findings. A new order was initiated for a Fentanyl 25 mcg/hour transdermal patch for pain management. During the RN visit on 03/13/2026, the RN documented that the Fentanyl transdermal patch was keeping the patient comfortable, with no reported negative side effects. The patient’s medication regimen included Hydrocodone/Acetaminophen 5 mg/325 mg twice daily as needed for pain and Fentanyl 25 mcg/hour transdermal patch for pain management. Also, during the RN admission visit on 05/07/2025, the RN documented that the patient experienced dyspnea with exertion and at rest, with a dyspnea score of 2/10, and the worst dyspnea in the prior 24 hours was rated at 6/10, with a stated dyspnea goal of 0/10. The patient required 3 liters per minute of supplemental oxygen at that time. On 02/17/2026, the RN documented a dyspnea score of 5/10, with a stated goal of 0/10. On 02/25/2026, the patient’s oxygen saturation was recorded as 92% on 3 liters per minute via nasal cannula. The POC for the benefit period dated 05/07/2025 through 08/04/2025 included durable medical equipment: a 5-liter oxygen concentrator. During IDG meetings on 01/22/2026, 02/04/2026, and 03/04/2026, nursing staff documented that the patient’s pain was controlled and that symptom management goals for the subsequent two-week periods were to “continue POC.” No measurable goals, reassessment timelines, or objective outcome criteria were documented during these IDG reviews. A review of the hospice POCs for the benefit periods dated 01/02/2026 through 03/02/2026 and 03/03/2026 through 05/01/2026 identified the problem of pain, with the goal of the patient and/or caregiver verbalizing satisfaction with pain management. An additional problem of altered cardiopulmonary status was identified, with the goal of achieving a reduction or relief of cardiopulmonary symptoms. These goals were not patient-specific, measurable, or time-oriented, and lacked defined pain or dyspnea targets (numeric or descriptive), functional or quality of life indicators, timeframes for reassessment, or objective criteria to evaluate the effectiveness of interventions or medication changes. CLINICAL RECORD 17: The patient resided in a nursing facility and elected the hospice benefit on 05/07/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). During the RN admission visit on 05/07/2025, the patient was documented to be alert and oriented to person, place, time, and situation. The RN observed dyspnea with minimal exertion, evidenced by the patient becoming short of breath (SOB) after speaking two to three sentences during the assessment. The patient rated his SOB/dyspnea at 3/10, with a stated goal of 0/10. During the IDG meeting on 05/08/2025, nursing staff documented that symptom management would focus on the patient’s dyspnea; however, the documented goal for the next two weeks was “no falls,” rather than a dyspnea-specific, patient-centered, or measurable outcome. The patient’s medication regimen included: Ipratropium 0.5 mg/Albuterol 3 mg per 3 mL via nebulizer every 4 hours PRN for shortness of breath, Albuterol Sulfate 2.5 mg/3 mL (0.083%) nebulizer solution scheduled twice daily for shortness of breath, Albuterol Sulfate HFA 90 mcg/actuation inhaler, two puffs every 4 hours PRN for shortness of breath, and Oxygen at 1–3 liters per minute via nasal cannula for shortness of breath. On 11/07/2025, the Licensed Practical Nurse (LPN) documented wheezing in the upper left and right lung lobes with diminished breath sounds throughout on auscultation and requested that the patient receive his as-needed breathing treatment during the visit. During the IDG meeting on 11/20/2025, the nurse noted that the patient wore his CPAP (Continuous Positive Airway Pressure) whenever sleeping and intermittently while awake, and that over the previous two weeks, the patient had experienced increased dyspnea, manifested by increased work of breathing, drowsiness, and fatigue. The documented goal for the next two weeks was to have decreased episodes of dyspnea; there were no defined measurable criteria or reassessment parameters included in the goal. During the RN visit on 12/09/2025, the patient was documented to be lying in bed with his CPAP in place, with dyspnea noted during conversation, and the patient again rated his dyspnea at 3/10. On 01/27/2026, the LPN documented that the patient was tachypneic, with a respiratory rate of 28 breaths per minute and an oxygen saturation of 90% on room air. The patient again rated his dyspnea at 3/10, with a stated goal of 3/10. The LPN observed visible distress, and the patient reported feeling as though he was “drowning.” The patient also complained of a headache, and the facility nurse administered PRN Clonidine for a blood pressure of 177/84 and headache. A breathing treatment was administered, and supplemental oxygen was applied at 1 liter per minute via nasal cannula, resulting in improved oxygen saturation to 95–97%, decreased distress, and the patient stating he felt better. During the IDG meeting on 01/29/2026, nursing staff documented focused symptom management for headache, anxiety, and shortness of breath, with the goal for the next two weeks being decreased anxiety and headaches, without measurable dyspnea-specific goals. On 01/30/2026, the RN documented a respiratory rate of 20 breaths per minute, an oxygen saturation of 92% on room air, and the patient rated his dyspnea at 5/10, with a stated goal of 2/10. The RN noted the use of accessory muscles during breathing. The facility physician ordered laboratory testing and a chest X-ray and placed an order for daily nursing visits. During the RN visit on 01/31/2026, the RN documented that the physician reviewed the laboratory results and determined the patient was in kidney failure. After discussion with the patient and his sister, a decision was made to pursue comfort-focused care only. Daily nursing visits continued until the patient’s death on 02/07/2026. A review of the hospice POCs for the benefit periods dated 11/03/2025 through 01/01/2026 and 01/02/2026 through 02/27/2026 identified problems, including the need to assess the effectiveness of cardiopulmonary interventions, address pain/altered comfort, and provide skilled teaching on oxygen therapy. However, the associated goals were not patient-specific, measurable, or time-limited and included generalized statements that the patient and/or caregivers would understand indications, proper use, liter flow, and safety of oxygen, exhibit a reduction of cardiopulmonary symptoms, and verbalize understanding of measures to manage acute cardiac or respiratory symptoms and to contact hospice as needed. These goals lacked defined dyspnea targets, functional or quality-of-life indicators, timeframes for reassessment, and objective criteria to evaluate the effectiveness of interventions or the escalation of care, despite documented fluctuations and progression of respiratory symptoms. During an interview and review of the documented POC goals with the Manager of Compliance and Accreditation on 03/18/2026, she agreed that the goals were neither objective nor patient-specific.”

“It is required that each patient’s individualized written plan of care includes all drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and document review. 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that the patient’s oxygen treatment with prescribed liter flow, method of delivery and whether continuous or PRN (as needed) was included on the plan of care (POC). The “Administration of Oxygen (B-100)” policy/clinical procedure provided by the Manager of Compliance and Accreditation included, in part, the procedure for oxygen as follows: “...Obtain orders from the primary care physician for type of oxygen therapy, administration device, and liter flow rate.” CLINICAL RECORD 6: The patient resides at home and elected the hospice benefit on 05/07/2025 with a terminal diagnosis of unspecified heart failure. During the Registered Nurse (RN) admission visit on 05/07/2025, the RN documented dyspnea at rest and with exertion, with a dyspnea score of 2/10; the worst dyspnea in the prior 24 hours was rated 6/10; and with a stated goal of 0. The RN documented that the patient was requiring 3 liters per minute of supplemental oxygen at that time. On 02/17/2026, during the RN recertification visit, the RN documented ongoing dyspnea with exertion, with a dyspnea score of 5/10 and a stated goal of 0, noting the patient was oxygen-dependent; however, no oxygen saturation, oxygen liter flow, or indication of room air versus supplemental oxygen was documented during that visit. On 02/25/2026, the RN documented the patient’s oxygen saturation as 92% while receiving 3 liters per minute of oxygen via nasal cannula. The initial POC for the benefit period dated 05/07/2025 through 08/04/2025 included a 5-liter oxygen concentrator as durable medical equipment and referenced oxygen safety precautions. Despite repeated clinical documentation identifying ongoing dyspnea, oxygen-dependence, and measured oxygen saturation while on supplemental oxygen, however, a review of the patient’s subsequent POCs for the benefit periods dated 01/02/2026 through 03/02/2026 and 03/03/2026 through 05/01/2026 revealed that oxygen was not listed in the medication profile, and no physician order specifying oxygen use or oxygen flow rate was included.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan. A revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and document review. 2 of 19 (11%) clinical records reviewed revealed that the agency did not ensure the patients’ plans of care were updated to reflect new problems, interventions, and/or goals based on updated assessment data. The agency’s policy, “Ongoing Comprehensive Assessment Policy No. 1-016” (board approval date 12/2025), included in part, “...Based on the assessments, the plan of care - including problems, needs, goals, and outcomes - will be reviewed and updated by the interdisciplinary group members responsible for the case.” CLINICAL RECORD 5: The patient resides in a nursing facility elected the hospice benefit on 08/08/2025 with the terminal diagnosis of malignant neoplasm of the colon with secondary malignant neoplasm of the liver and intrahepatic bile duct. During the admission visit by the Registered Nurse (RN) on 08/08/2025, the patient did not complain of any nausea. During an on-call nurse visit on 01/29/2026, the nurse noted that the facility staff called to report the patient had loose dark, tarry stools, pallor, and hypotension. On exam, the patient’s abdomen was slightly distended, and the facility staff reported that the patient had complained of nausea during the morning. The patient stated he was “not feeling great,” but vital signs were at baseline. There was a physician’s order documented on 01/29/2026 for Promethazine 25mg every 8 hours as needed for nausea/vomiting. During the Interdisciplinary Group Meeting (IDG) on 02/27/2026, the RN documented that the goal for the next 2 weeks was to have a decrease in nausea/vomiting episodes. A review of the POCs for the benefit periods dated 11/06/2025 to 02/03/2026 and 02/04/2026 to 04/04/2026 evidenced a problem for altered nutrition and hydration with the goals for the patient to be in control of what, how much, and when to eat, to understand dietary modifications to improve nutrition and hydration as tolerated and verbalize an understanding of the effects of the terminal illness on the patient’s nutrition and hydration status. There was no update to the patient’s POCs to reflect the new symptom of nausea requiring the addition of a new medication for management. Altered gastrointestinal status with the potential for constipation was identified in the plan of care, with goals for the patient and/or caregiver to verbalize appropriate dietary and fluid intake as tolerated, verbalize that constipation is controlled, and verbalize understanding of the medications to use to prevent constipation. The patient’s loose, tarry stools were not addressed with newly added interventions or goals for care. CLINICAL RECORD 6: The patient resides at home and elected the hospice benefit on 05/07/2025 with the terminal diagnosis of unspecified heart failure and comorbid conditions, including myasthenia gravis and chronic pain. On 03/05/2026, during a nursing visit, the Licensed Practical Nurse (LPN) documented that the patient’s son reported the patient was having difficulty swallowing, which was affecting her ability to take her pain medication. This report indicated the development of dysphagia, placing the patient at an increased risk for aspiration. On 03/10/2026, because of the patient’s difficulty swallowing oral pain medication, the patient’s pain management regimen was modified, and she was transitioned to a Fentanyl 25 mcg/hour transdermal patch. A review of the patient’s hospice plans of care for the benefit periods dated 01/02/2026 through 03/02/2026 and 03/03/2026 through 05/01/2026 identified an ongoing problem of altered nutrition. However, despite reports of swallowing difficulty and a medication change necessitated by dysphagia, no updated interventions, monitoring parameters, or safety measures were added to the plans of care to address the patient’s developing swallowing impairment. There was no documentation of interventions such as aspiration precautions, dietary modifications, positioning strategies, monitoring for signs of aspiration, or caregiver education related to dysphagia management.”