Revolutionary Hospice

“Based upon review of hospice policy/procedure and documentation and based on interview with the Administrator (Admin-Employee #3) and the Alternate Administrator (Alt Admin-Employee #9), the hospice failed to maintain documentation which provided evidence a Hazard Vulnerability Analysis (HVA) review had been conducted at least every 2 years. (None in the calendar years of 2024 nor 2025) Findings include: On March 4, 2026 at approximately 2:55 PM, review of the “Emergency Preparedness Program Policy”, for which the last review was documented as being conducted on 01/05/2026, and attachments revealed the following: Purpose...To establish and maintain an emergency preparedness program. The hospice maintains an all-hazards emergency preparedness plan to ensure continuity of care during emergencies. Emergency Hospice Care During a Severe Snow Storm...Please keep this page visible during the storm. On March 6, 2026 at approximately 1:10 PM, review of the undated “Emergency Preparedness Program Summary” revealed the following: Program Overview...Revolutionary Hospice maintains an Emergency Preparedness Program designated to ensure the safety of patients, staff and caregivers during emergency situations. The program follows an all-hazard approach and addresses natural disasters, emerging infectious diseases, technological disruptions and other community emergencies that could impact patient care. On March 6, 2026 at approximately 1:18 PM, review of the undated “Emergency Preparedness Policy” revealed the following: Relationship to Hazard Vulnerability Analysis....Fire events occurring in the hospice administrative office or in patient homes are identified as potential hazards within the agency’s Hazard Vulnerability Analysis (HVA). There was no documentation on the “Emergency Preparedness Program Policy” (01/05/2026), the undated “Emergency Preparedness Program Summary” nor the undated “Emergency Preparedness Policy” which provided evidence a review of the hospice HVA was conducted at a minimum of every 2 years as there was no documentation an HVA review had been conducted in 2024 nor 2025. During interview conducted on March 6, 2026 at approximately 3:40 PM, the Admin and Alt Admin did not report questions nor concerns regarding the above referenced emergency preparedness program HVA review findings.”

“Based upon review of hospice policy/procedure and documentation and based on interview with the Administrator (Admin-Employee #3) and the Alternate Administrator (Alt Admin-Employee #9), the hospice failed to maintain documentation which provided evidence a transfer agreement had been established with at least one (1) of one (1) hospice to allow for patient transfer when limitation or cessation of hospice services occurs during an emergency event. Findings include: On March 4, 2026 at approximately 2:55 PM, review of the “Emergency Preparedness Program Policy”, for which the last review was documented as being conducted on 01/05/2026, revealed the following: Purpose...To establish and maintain an emergency preparedness program. The hospice maintains an all-hazards emergency preparedness plan to ensure continuity of care during emergencies. On March 6, 2026 at approximately 1:10 PM, review of the undated “Emergency Preparedness Program Summary” revealed the following: Program Overview...Revolutionary Hospice maintains an Emergency Preparedness Program designated to ensure the safety of patients, staff and caregivers during emergency situations. There was no documentation on the “Emergency Preparedness Program Policy” (01/05/2026) nor the undated “Emergency Preparedness Program Summary” which provided evidence a transfer agreement had been established with one (1) of one (1) hospice to allow for patient transfer when limitation or cessation of hospice services occurs during an emergency event. During interview conducted on March 6, 2026 at approximately 3:40 PM, the Admin and Alt Admin did not present questions nor concerns regarding the above referenced emergency preparedness program transfer agreement findings.”

“Based upon review of hospice policy/procedure. documentation and clinical records and based on interview with the Administrator (Admin-Employee #3) and the Alternate Administrator (Alt Admin-Employee #9), the hospice failed to maintain documentation which provided evidence the contact information for four (4) of four (4) emergency management officials had been included in the hospice emergency preparedness program. (Federal Emergency Management Agency (FEMA), State-Pennsylvania Emergency Management Agency (PEMA), County Emergency Management Agencies (EMA) and the Licensing Agency: Pennsylvania Department of Health (PA DOH)/Division of Home Health) Findings include: On March 4, 2026 at approximately 2:55 PM, review of the “Emergency Preparedness Program Policy”, for which the last review was documented as being conducted on 01/05/2026, and attachments revealed the following: Purpose...To establish and maintain an emergency preparedness program. The hospice maintains an all-hazards emergency preparedness plan to ensure continuity of care during emergencies. Emergency Hospice Care During a Severe Snow Storm...Please keep this page visible during the storm...Important Phone Numbers... -Revolutionary Hospice 24/7 On -Call Nurse...Beck-up number...Medical Equipment Company... On March 6, 2026 at approximately 1:10 PM, review of the undated “Emergency Preparedness Program Summary” revealed the following: Program Overview...Revolutionary Hospice maintains an Emergency Preparedness Program designated to ensure the safety of patients, staff and caregivers during emergency situations... Communication Systems...Revolutionary Hospice maintains procedures to communicate with...emergency management agencies during emergency situations. Emergency contact lists are maintained and reviewed regularly. Patient #1: Between March 2, 2026 at approximately 2:04 PM and March 5, 2026 at approximately 7:43 AM, review of the clinical record revealed the patient resides in Wayne County. Patient #2: Between March 2, 2026 at approximately 3:04 PM and March 5, 2026 at approximately 1:24 PM, review of the clinical record revealed the patient resides in Monroe County. Patient #3: Between March 2, 2026 at approximately 3:35 PM and March 6, 2026 at approximately 7:00 AM, review of the clinical record revealed the patient resides in Luzerne County. Patient #4: Between March 4, 2026 at approximately 7:00 AM and March 6, 2026 at approximately 7:15 AM, review of the clinical record revealed the patient resides in Pike County. There was no documentation on the “Emergency Preparedness Program Policy” (01/05/2026) nor the undated “Emergency Preparedness Program Summary” which provided evidence the emergency preparedness program included the contact information for FEMA, PEMA, PA DOH/Division of Home Health (717-783-1379) nor the above referenced County EMA in which the above identified patients reside. During interview conducted on March 6, 2026 at approximately 3:40 PM, the Admin and Alt Admin did not report questions nor concerns regarding the above referenced emergency preparedness official contact information findings.”

“Based upon review of hospice policy/procedure and documentation and based on interview with the Administrator (Admin-Employee #3) and the Alternate Administrator (Alt Admin-Employee #9), the hospice failed to maintain documentation of the primary and alternate methods of communication to be utilized when communicating with two (2) of two (2) groups during an emergency. (Hospice staff and Emergency Preparedness Officials) Findings include: On March 4, 2026 at approximately 2:55 PM, review of the “Emergency Preparedness Program Policy”, for which the last review was documented as being conducted on 01/05/2026, and attachments revealed the following: Purpose...To establish and maintain an emergency preparedness program. The hospice maintains an all-hazards emergency preparedness plan to ensure continuity of care during emergencies. Emergency Hospice Care During a Severe Snow Storm...Please keep this page visible during the storm...Important Phone Numbers... -Revolutionary Hospice 24/7 On -Call Nurse...Beck-up number...Medical Equipment Company... On March 6, 2026 at approximately 1:10 PM, review of the undated “Emergency Preparedness Program Summary” revealed the following: Program Overview...Revolutionary Hospice maintains an Emergency Preparedness Program designated to ensure the safety of patients, staff and caregivers during emergency situations... Communication Systems...Revolutionary Hospice maintains procedures to communicate with...emergency management agencies during emergency situations. Emergency contact lists are maintained and reviewed regularly. There was no documentation on the “Emergency Preparedness Program Policy” (01/05/2026) nor the undated “Emergency Preparedness Program Summary” which provided evidence the emergency preparedness program included the primary and alternate means of communication to utilized to communicate with hospice staff and emergency preparedness officials during an emergency. During interview conducted on March 6, 2026 at approximately 3:40 PM, the Admin and Alt Admin did not report questions nor concerns regarding the above referenced findings related to the emergency preparedness program primary and alternate means of communication.”

“Based upon review of hospice policy/procedure and documentation and based on interview with the Administrator (Admin-Employee #3) and the Alternate Administrator (Alt Admin-Employee #9), the hospice failed to maintain documentation which provided evidence testing of the emergency preparedness program included a community based, facility based or natural/man-made emergency exercise/event for one (1) of two (2) years between January 2023 and January 2026. (2024) Findings include: On March 4, 2026 at approximately 2:55 PM, review of the “Emergency Preparedness Program Policy”, for which the last review was documented as being conducted on 01/05/2026, and attachments revealed the following: Training and Testing...At least one annual drill is completed and documented. On March 6, 2026 at approximately 1:10 PM, review of the undated “Emergency Preparedness Program Summary” revealed the following: Training and Exercises...Revolutionary Hospice conducts an emergency preparedness exercise each year during January. Exercises may be conducted as a tabletop discussion or may be satisfied through response to an actual emergency event. On March 6, 2026 at approximately 1:19 PM, review of the “Revolutionary Hospice Emergency Preparedness Exercise Log” revealed the following exercises or events were documented as being conducted: -01/22/2023: Tabletop Exercise: Severe Weather/Storm -01/08/2024: Tabletop Exercise: Patient Home Fire -01/13/2025: Tabletop Exercise: Emerging Infectious Outbreak -01/26/2026: Actual Emergency Event: Winter Snow Event There was no documentation on the “Emergency Preparedness Program Policy” (01/05/2026), the undated “Emergency Preparedness Program Summary” nor the “Revolutionary Hospice Emergency Preparedness Exercise Log” which provided evidence testing of the emergency preparedness program included a community based, facility based or natural/man-made emergency exercise/event in January 2024. During interview conducted on March 6, 2026 at approximately 3:40 PM, the Admin and Alt Admin did not report questions nor concerns regarding the above referenced findings related to testing of the emergency preparedness program.”

“Based upon review of hospice documentation and clinical records and based on interview with the Administrator (Admin-Employee #3) and the Alternate Administrator (Alt Admin-Employee #9), the hospice failed to ensure documentation was maintained in the clinical record which provided evidence two (2) of fourteen (14) patients were provided the option to select an attending physician. (Patients #3 and #12) Findings include: On March 2, 2026 at approximately 12:16 PM, review of the hospice 2025 licensure renewal application revealed the physician identified as the hospice Medical Director is Employee #10 as documented under the “Personnel” section on the “Licensure Application-Written Survey”. On March 2, 2026 at approximately 11:56 AM, review of the hospice patient admission folder/packet revealed the following: Page 2: Attending Physician...Employee #10 Page 7: Medical Director...Oversees the medical plan of care and the hospice team... Patient’s Physician...Continues to participate in developing the individual plan of care for the patient. Oversees medical regimen during the entire course of treatment. Page 2 of the patient admission folder/packet failed to identity Employee #10 as the hospice Medical Director. Patient #3: Between March 2, 2026 at approximately 3:35 PM and March 6, 2026 at approximately 7:00 AM, review of the clinical record revealed the hospice benefit election date was 01/09/2026 as documented on the “Hospice Election Statement” form. Review of the initial “Care Plan/Physician Order” and the “Physician Certification/Recertification” of terminal illness for the initial certification period of 01/09 through 03/09/2026 revealed that sole physician identified on the forms was the hospice Medical Director (Employee #10). There was no documentation in the clinical record which provided evidence the patient was provided an option with selecting an attending physician. Patient #12 (Bereavement Record): On March 6, 2026 at approximately 8:17 AM, review of the clinical record revealed the hospice benefit election date was 04/29/2025 as documented on the “Hospice Election Statement” form. Review of the initial “Care Plan/Physician Order” and the “Physician Certification/Recertification” of terminal illness for the initial certification period of 04/29 through 07/25/2025 revealed that sole physician identified on the forms was the hospice Medical Director (Employee #10). There was no documentation in the clinical record which provided evidence the patient was provided an option with selecting an attending physician. During interview conducted on March 6, 2026 at approximately 3:40 PM, the Admin and Alt Admin did not report questions nor concerns regarding the above referenced findings related to the patient rights to select an attending physician.”

“Based on review of agency policy/procedure, clinical records, personnel files and tuberculosis (TB) screening guidance from the Centers for Disease Control (CDC), and based on interview with the Administrator (Admin-Employee #3) and the Alternate Administrator (Alt Admin-Employee #9), the hospice failed to ensure documentation was maintained in the personnel file which provided evidence initial TB screening was completed in accordance with CDC recommendations for five (5) of six (6) hospice staff members whose date of hire was after May 30, 2023 and who were employed by the hospice for more than 21 days. (Employees #1, #3, #4, #5 and #8) Findings include: On March 6, 2026 at approximately 3:03 PM, review of hospice policy C-2-041.3, with the heading “Quality of Services and Products” revealed the following: “TB Screening”...3. Where required by state and/or local regulations, a two (2)-step Mantoux tuberculin skin test will be given to all personnel upon hire, if no TST (TB skin test) has been performed within 12 months of the hire date... On March 6, 2026 at approximately 3:16 PM, review of the initial TB screening guidance from the CDC ( https://www.cdc.gov/tb-healthcare-settings/hcp/screening-testing/index.html ) for prospective staff without a past history of a positive TB test revealed the following All health care personnel should be screened for TB upon hire (preplacement). The TB screening process for health care personnel includes: -A baseline individual TB risk assessment; -TB symptom evaluation; and -A TB test (TB blood test or a TB skin test (2-Step))... Patient #1: Between March 2, 2026 at approximately 2:04 PM and March 5, 2026 at approximately 7:43 AM, review of the clinical record revealed the following staff provided hospice services in February and/or March 2026: -Skilled Nursing: Employees #1 and #4 -Social Work: Employee #5 -Spiritual Counseling (Chaplain): Employee #8 Patient #2: Between March 2, 2026 at approximately 3:04 PM and March 5, 2026 at approximately 1:24 PM, review of the clinical record revealed the following staff provided hospice services in March 2026: -Home Health Aide: Employee #2 On March 6, 2026 between the approximate times of 10:35 AM and 5:22 PM, review of personnel file documentation revealed the following: Employee #1: The date of hire of the licensed practical nurse was 09/02/2025. There was no documentation in the personnel file which provided evidence the second step TB skin test had been completed. Employee #3: The date of hire of the Administrator was 06/19/2025. There was no documentation in the personnel file which provided evidence that a baseline individual TB risk assessment nor a TB symptom evaluation had been completed. Employee #4: The start date of the nurse practitioner (NP) was 02/02/2026. TB screening documentation revealed a chest x-ray was performed on 05/28/2025 but there was no documentation on the chest-xray result form which provided evidence the NP had a past history of a positive TB test. There was no documentation in the personnel file which provided evidence a two-step TB skin test or single blood test, TB baseline individual TB risk assessment nor TB symptom evaluation form had been completed. Employee #5: The start date of the social worker/bereavement counselor was 02/02/2026. There was no documentation in the personnel file which provided evidence the second step TB skin test had been completed. Employee #8: The start date of the spiritual counselor/chaplain was 01/08/2026. There was no documentation in the personnel file which provided evidence a two-step TB skin test or single blood test, TB baseline individual TB risk assessment nor TB symptom evaluation form had been completed. During interview conducted on March 6, 2026 at approximately 3:40 PM, the Admin and Alt Admin confirmed documentation related to the above referenced TB screening findings for the above identified personnel was not available for review on 03/06/2026.”

“Based upon review of hospice policy/procedure and clinical records and based on interview with the Administrator (Admin-Employee #3) and the Alternate Administrator (Alt Admin-Employee #9), the hospice failed to ensure documentation was maintained in the clinical record which provided evidence and organized bereavement program was implemented for four (4) of fourteen (14) hospice patients. (Patients #3, #5, #9 and #11) Findings include: On March 6, 2026 at approximately 12:51 PM, review of the “Bereavement Policy and Procedure” revealed the following: Purpose: To provide bereavement support services to families and caregivers for up to thirteen (13) months following the death of a hospice patient. Bereavement services are offered based on assessed need and family preference. Patient #3: Between March 2, 2026 at approximately 3:35 PM and March 6, 2026 at approximately 7:00 AM, review of the clinical record revealed the patient had refused social work and spiritual counseling services as documented on the start of care (SOC) skilled nursing (SN) “Service Note” dated 01/09/2026. There was no documentation in the clinical record which provided evidence the RN assessed the bereavement risk during the SN visits conducted on 01/09, 01/12, 01/20, 02/04, 02/27 nor 03/02/2026. Patient #5 (Live Discharge): Between March 5, 2026 at approximately 3:19 PM and March 6, 2026 at approximately 12:38 PM, review of the clinical record revealed the SOC date was 01/16/2026 as documented on the “Care Plan/Physician Order” form for the hospice certification period of 01/16 through 03/16/2026. Review of “Service Note” documentation revealed SN services were provided on 01/16 and 01/22/2026. There was no documentation in the clinical record which provided evidence the bereavement risk as assessed by the RN during the SOC visit performed on 01/16/2026. Patient #9 (Bereavement Record): On March 5, 2026 at approximately 4:51 PM, review of the clinical record revealed the SOC date was 06/13/2025 as documented on the “Care Plan/Physician Order” form for the initial certification period of 06/13 through 09/10/2025. Review of “Discharge Summary” documentation revealed the patient expired on 06/16/2026. Review of “Bereavement” assessment documentation revealed the bereavement risk as assessed on 03/02/2026 which was more than 261 days after the patient’s death. Patient #11 (Bereavement Record): On March 6, 2026 at approximately 7:58 AM, review of the clinical record revealed the SOC date was 08/13/2025 as documented on the “Care Plan/Physician Order” form for the initial certification period of 08/13 through 11/10/2025. Review of “Discharge Summary” documentation revealed the patient expired on 08/24/2025. Review of the initial bereavement assessment dated 08/13/2025 revealed the bereavement risk as identified as low. There was no documentation in the clinical record which provided evidence bereavement services had been offered nor provided after 09/18/2025. During interview conducted on March 6, 2026 at approximately 3:40 PM, the Admin and Alt Admin did not report questions nor concerns regarding the above referenced bereavement program findings for the above referenced patients.”

“Based upon review of hospice policy/procedure and clinical records, based on interviews with a patient’s spouse, the Administrator (Admin-Employee #3) and the Alternate Administrator (Alt Admin-Employee #9), the hospice failed to ensure documentation was maintained in the clinical record which provided evidence home health/hospice aide (HHA) services were provided in accordance with orders included on the hospice plan of care for four (4) of four (4) active patients. (Patients #1, #2, #3 and #4) Findings include: On March 10, 2026 at approximately 4:21 PM, review of the “Aide Services Policy”, which was forwarded by the Admin via email on 03/10/2026, revealed the following under “Documentation”: Hospice aides document each patient visit in the clinical record including...Services provided... On March 10, 2026 at approximately 4:28 PM, review of the “Plan of Care (POC) Policy”, which was forwarded by the Admin via email on 03/10/2026, revealed the following under “Documentation”: Clinicians will document care provided in accordance with the POC, noting any variations or adjustments made based on patient condition. Patient #1: Between March 2, 2026 at approximately 2:04 PM and March 5, 2026 at approximately 7:43 AM, review of the clinical record revealed HHA duties are to include the following as documented on the “Care Plan/Physician Order” form for the initial certification period of 02/17 through 05/17/2026: Assist with ambulation (walking), dressing, bathing and light meal preparation each visit. Review of the HHA electronic “Service Note” dated 02/21/2026 revealed the tasks performed by the HHA were not documented on the service note. There was no documentation in the clinical record which provided evidence the aforementioned duties were provided by the HHA on 02/21/2026. Patient #2: Between March 2, 2026 at approximately 3:04 PM and March 5, 2026 at approximately 1:24 PM, review of the clinical record revealed HHA orders include, but are not limited to, the following as documented on the “Care Plan/Physician Order” form for the initial certification period of 02/17 through 05/17/2026: Visit Frequency: Effective 02/17/2026, one (1) time a week for one (1) week, followed by two (2) times a week for 12 weeks effective 02/22/2026. Duties: Assist with ambulation (walking), dressing, bathing and light meal preparation each visit.During an interview conducted during the home visit on 03/05/2026 at 9:55 AM, the patient’s spouse reported an issue occurred with HHA visit scheduling which resulted in a missed aide visit. Review of “Service Note” documentation revealed one (1) of two (2) HHA visits were provided during the week beginning 02/26/2026. Review of the HHA electronic “Service Note” dated 02/24/2026 revealed the duties performed by the home health aide were not documented on the service note. There was no documentation in the clinical record which provided evidence HHA services were provided per the ordered visit frequency during the week beginning 02/22/2026 nor was documentation present which provided evidence the aforementioned duties were provided by the HHA on 02/21/2026. Patient #3: Between March 2, 2026 at approximately 3:35 PM and March 6, 2026 at approximately 7:00 AM, review of the clinical record revealed the start of care dated was 01/09/2026 and that HHA orders include the following as documented on the “Care Plan/Physician Order” form for the hospice certification period of 01/09 through 03/09/2026: Visit Frequency effective 01/11/2026: Three (3) times a week for 12 weeks. Review of missed visit documentation revealed one (1) HHA visit was refused on 01/12/2026 but there was no documentation in the clinical record which provided evidence the remaining two (2) HHA visits were provided during the week beginning 01/11/2026 nor was documentation present which provided evidence three (3) HHA visits had been provided during the weeks beginning 01/18, 01/25, 02/01, 02/08 nor 02/15/2026. Review of “Service Note” documentation revealed one (1) of three (3) HHA visits were completed during the week beginning 02/22/2026. There was no documentation in the clinical record which provided evidence HHA services were provided per the ordered visit frequency during the above referenced weeks beginning 01/12/2026 through 02/22/2026. Patient #4: Between March 4, 2026 at approximately 7:00 AM and March 6, 2026 at approximately 7:15 AM, review of the clinical record revealed HHA duties are to include, but not limited to, the following as documented on the “Care Plan/Physician Order” form for the initial certification period of 12/10/2025 through 03/09/2026: Assist with ambulation (walking), dressing, bathing and light meal preparation each visit. Review of the HHA electronic “Service Note”(s) dated 12/15/2025, 01/05, 01/14, 01/21, 02/02, 02/09, 02/16, 02/22 and 02/26/2026 revealed the duties performed by the HHA were not documented on the service notes. There was no documentation in the clinical record which provided evidence the aforementioned duties were provided by the HHA on the above referenced dates. During interview conducted on March 6, 2026 at approximately 3:40 PM, the Admin and Alt Admin reported that the HHA duties did not capture on the HHA service notes for the above referenced patients and that the software provider has been notified of the issue. The Admin and Alt Admi did not report questions nor concerns regarding the above referenced HHA visit frequency findings for the above identified patients.”

“Based upon review of hospice policy/procedure, clinical records and the Code of Federal Regulations and based on interview with the Administrator (Admin-Employee #3) and the Alternate Administrator (Alt Admin-Employee #9), the hospice failed to ensure documentation was maintained in the clinical record which provided evidence the certification of terminal illness was entered medical (clinical) record in accordance with the requirements under the Code of Federal Regulations for 12 of 14 hospice patients. (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 and #12) Findings include: On March 6, 2026 at approximately 3:37 PM, review of the “Certification of Terminal Illness (CTI) Policy and Workflow” revealed the following under “Timing Consideration”: When practitioners are not immediately available to sign printed or electronic documentation, the hospice may temporarily maintain the documentation pending signature. The practitioner will review and sign the certification within a timeframe that reasonably accommodates practitioner availability while ensuring the medical record reflects practitioner involvement in confirming hospice eligibility. On March 6, 2026 at approximately 3:07 PM, review of the Code of Federal Regulations revealed the following under § 418.22 Certification of terminal illness: (d) Maintenance of records. Hospice staff must— (1) Make an appropriate entry in the patient’s medical record as soon as they receive an oral certification; and (2) File written certifications in the medical record. Patient #1: Between March 2, 2026 at approximately 2:04 PM and March 5, 2026 at approximately 7:43 AM, review of the clinical record revealed the start of care (SOC) date was 02/17/2026 as documented on the “Care Plan/Physician Order” form for the initial certification period of 02/17 through 05/17/2026. Review of the “Physician Certification/Recertification” of terminal illness order revealed a RN electronically signed the oral certification order on 03/02/2026 which was 13 days after the SOC date. Patient #2: Between March 2, 2026 at approximately 3:04 PM and March 5, 2026 at approximately 1:24 PM, review of the clinical record revealed the SOC date was 02/17/2026 as documented on the “Care Plan/Physician Order” form for the initial certification period of 02/17 through 05/17/2026. Review of the “Physician Certification/Recertification” of terminal illness order revealed a RN electronically signed the oral certification order on 03/02/2026 which was 13 days after the SOC date. Patient #3: Between March 2, 2026 at approximately 3:35 PM and March 6, 2026 at approximately 7:00 AM, review of the clinical record revealed the SOC date was 01/09/2026 as documented on the “Care Plan/Physician Order” form for the hospice certification period of 01/09 through 03/09/2026. Review of the “Physician Certification/Recertification” of terminal illness order revealed the RN electronically signed the oral certification order on 02/16/2026 which was 38 days after the SOC date. Patient #4: Between March 4, 2026 at approximately 7:00 AM and March 6, 2026 at approximately 7:15 AM, review of the clinical record revealed the SOC date was12/10/2025 as documented on the “Care Plan/Physician Order” form for the initial certification period of 12/10/2025 through 03/09/2026.. Review of the “Physician Certification/Recertification” of terminal illness order revealed the RN electronically signed the oral certification order on 01/20/2026 which was 41 days after the SOC date. Patient #5 (Live Discharge): Between March 5, 2026 at approximately 3:19 PM and March 6, 2026 at approximately 12:38 PM, review of the clinical record revealed the SOC date was 01/16/2026 as documented on the “Care Plan/Physician Order” form for the hospice certification period of 01/16 through 03/16/2026. Review of hospice “Discharge Summary” documentation revealed the hospice discharge date was 01/23/2026. Review of the “Physician Certification/Recertification” of terminal illness order revealed the RN electronically signed the oral certification order on 02/16/2026 which was 31 days after the SOC date and after the patient transfer/discharge date. Patient #6 (Live Discharge): Between March 5, 2026 at approximately 3:40 PM and March 6, 2026 at approximately 12:41 PM, review of the clinical record revealed the SOC date was 09/02/2025 as documented on the “Care Plan/Physician Order” form for the initial certification period of 09/02 through 11/30/2025. Review of “Discharge Summary” documentation revealed the discharge date was 09/07/2025. Review of the “Physician Certification/Recertification” of terminal illness order revealed the RN electronically signed the oral certification order on 09/10/2025 which was 8 days after the SOC date and after the hospice discharge date. Patient #7 (Live Discharge): Between March 5, 2026 at approximately 3:59 PM and March 6, 2026 at approximately 12:45 PM, review of the clinical record revealed the hospice recertification period began on 06/29/2025 as documented on the “Care Plan/Physician Order” form for the recertification period of 06/29 through 08/27/2025. Review of “Discharge Summary” documentation revealed the discharge date was 07/21/2025. Review of the “Physician Certification/Recertification” of terminal illness order revealed the RN electronically signed the oral certification order on 07/03/2025 which was 4 days after the initiation of the recertification period. Patient #8 (Live Discharge): Between March 5, 2026 at approximately 4:25 PM and March 6, 2026 at approximately 12:47 PM, review of the clinical record revealed the hospice recertification period began on 11/22/2025 as documented on the “Care Plan/Physician Order” form for the recertification period of 11/22/2025 through 01/20/2026. Review of “Discharge Summary” documentation revealed the discharge date was 12/08/2025. Review of the “Physician Certification/Recertification” of terminal illness order revealed the RN electronically signed the oral certification order on 12/21/2025 which was 29 days after the initiation of the recertification period and after the hospice discharge date. Patient #9 (Bereavement Record): On March 5, 2026 at approximately 4:51 PM, review of the clinical record revealed the SOC date was 06/13/2025 as documented on the “Care Plan/Physician Order” form for the initial certification period of 06/13 through 09/10/2025. Review of “Discharge Summary” documentation revealed the patient expired on 06/16/2025. Review of the “Physician Certification/Recertification” of terminal illness order revealed the RN electronically signed the oral certification order on 06/20/2025 which was 7 days after the SOC and after the patient had expired. Patient #10 (Bereavement Record): Between March 5, 2026 at approximately 4:59 PM and March 6, 2026 at approximately 2:46 PM, review of the clinical record revealed the recertification period began on 10/31/2025 as documented on the “Care Plan/Physician Order” form for the recertification period of 10/31 through 12/29/2025. Review of “Discharge Summary” documentation revealed the patient expired on 11/02//2025. Review of the “Physician Certification/Recertification” of terminal illness order revealed the RN electronically signed the oral certification order on 11/17/2025 which was 17 days after the initiation of the recertification period and after the patient had expired. Patient #11 (Bereavement Record): On March 6, 2026 at approximately 7:58 AM, review of the clinical record revealed the SOC date was 08/13/2025 as documented on the “Care Plan/Physician Order” form for the initial certification period of 08/13 through 11/10/2025.Review of “Discharge Summary” documentation revealed the patient expired on 08/24/2025. Review of the “Physician Certification/Recertification” of terminal illness order revealed the RN electronically signed the oral certification order on 09/05/2025 which was 23 days after the SOC and after the patient had expired. Patient #12 (Bereavement Record): On March 6, 2026 at approximately 8:17 AM, review of the clinical record revealed the SOC date was 04/29/2025 as documented on the “Care Plan/Physician Order” form for the initial certification period of 04/29 through 07/27/2025..Review of “Discharge Summary” documentation revealed the patient expired on 05/05/2025. Review of the “Physician Certification/Recertification” of terminal illness order revealed the RN electronically signed the oral certification order on 05/07/2025 which was 8 days after the SOC and after the patient had expired. During interview conducted on March 6, 2026 at approximately 3:40 PM, the Admin and Alt Admin did not report questions nor concerns regarding the above referenced CTI findings identified for the above referenced patients.”

“Based upon review of hospice policy/procedures and documentation and based on interview with the Administrator (Admin-Employee #3) and the Alternate Administrator (Alt Admin-Employee #9), the hospice failed to ensure a written agreement was established with one (1) of three (3) entities identified as inpatient providers. (Inpatient Provider #1) Findings include: On March 6, 2026 at approximately 12:32 PM, review of hospice “Policy: Hospice Specific Education for Contracted Inpatient and Respite Providers” revealed the following: Purpose: To ensure contracted inpatient and respite providers receive hospice specific information necessary to coordinate care in accordance with Medicare Conditions of Participation... On March 6, 2026 at approximately 11:30 AM, review of the hospice contract list revealed contracts had been established with inpatient providers #2 and #3. On March 6, 2026 at approximately 12:33 PM, review of 2025 hospice inpatient details revealed inpatient provider #1 provided inpatient services in 2025. There was no documentation which provided evidence the hospice had established a written agreement for inpatient services with inpatient provider #1. During interview conducted on March 6, 2026 between the approximate times of 03:20 PM and 03:35 PM, the Admin reported a written agreement may have been established with inpatient provider #1 but the Admin failed to provide a copy of the agreement. During interview conducted on March 6, 2026 at approximately 3:40 PM, the Admin reported and Alt Admin did not report questions nor concerns regarding the above referenced inpatient contract findings.”