Knights of Comfort

“Based on record reviews and interviews the Hospice Agency failed to ensure that the patient’s record included the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes for 1 (Patient #17) of 17 patients’ records reviewed.This failure prevented the Surveyor from evaluating the nursing care provided to the patient and the Agency’s compliance with state and federal regulations which potentially placed patients at risk for poor quality of care. Findings:An entrance conference and interview was conducted with the Administrator/Supervising Nurse/Agency Owner on 8/21/2026 at 12:55pm at an alternate location due to broken water pipes and flood damage that occurred on 8/19/2026 to the Agency’s primary location. The Administrator/Supervising Nurse stated that he was responsible for the majority of the patients’ nursing visits due to the Agency’s small census (census of 6 patients). The Administrator/Supervising Nurse stated that the Alternate Administrator/Alternate Supervising Nurse assisted with patient visits when needed. The Administrator/Supervising Nurse stated that the Administrator/Supervising nurse was responsible for organizing and maintaining patient records and that he received assistance from the Alternate Administrator/Alternate Supervising Nurse when needed. When asked about the Agency’s policy on the time frame for clinicians to complete and turn in documentation following a patient visit, the Administrator/Supervising Nurse stated “We (Agency nurses, Chaplain and Social Worker) aim for the 48 hours, and we are constantly working on that.” When asked about the Agency’s policy on the time frame for filing or uploading documents or clinical notes into the patients’ records, the Administrator/Supervising Nurse stated, “ I have to look at our (the Agency’s) policy.”Record review of the Agency’s 12-month admissions summary list for period 8/22/2025 to 8/22/2026 emailed to the Surveyor on 8/24/2026 by the Administrator/Supervising Nurse revealed that Patient #17 was admitted to hospice on “09/30/2025.” The list contained Patient #17’s admitting diagnosis of “Parkinson’s disease (long term brain disorder that affects movement, balance, and coordination) with dyskinesia (uncontrolled involuntary body movements) with fluctuations.”Record review of the Agency’s 12-month live discharge summary list for period 8/22/2025 to 8/22/2026 emailed to the Surveyor on 8/24/2026 by the Administrator/Supervising Nurse revealed that Patient #17 was discharged on “10/30/2025” for a “Transfer to another hospice (Facility Based).”Record review of Patient #17’s records in the Agency’s EMR A system revealed an “Initial Social Worker Visit” dated 09/30/2025 signed by LMSW C. The visit note contained a time of visit of “09/30/2025 11:50am.” LMSW C documented “LMSW will discuss visit with Chaplain and RNCM (Administrator/Supervising Nurse).” The initial Social Worker visit note contained interventions for the documented care plan problems which included “Deficit related to not having a copy of patient’s MPOA… Deficit related to normal grief process” and “Patient/Family needing assistance with funerial/burial arrangements.” LMSW C documented a visit frequency of once a month and every 7 days as needed.Record review of Patient #17’s records in the Agency’s EMR A system revealed a “Hospice Certification of Terminal Illness” signed by the Hospice Medical Director (MD E) on 10/03/2025. The Hospice Certification of Terminal Illness contained a “Benefit Period Start Date 09/30/2025” and “Benefit Period End date 12/28/2025.” The Hospice Certification of Terminal Illness contained a “Verbal Certification” that read in part “Verbal Certification received from Medical Director (MD E) by (Administrator/Supervising Nurse) on 09/30/2025.” The Verbal Certification was signed by the Administrator/Supervising nurse on “09/30/2025.”Record review of Patient #17 revealed an undated Discharge Summary with no signatures that read in part “Discharge-Transferred to Another Hospice (Facility Based) 10/30/2025 (Routine).”Further record review of Patient #17’s records in the Agency’s EMR A system did not provide evidence of a completed start of care RN comprehensive assessment, initial bereavement assessment, initial spiritual assessment, updated comprehensive assessments, initial plan of care, updated plan of cares, physician orders, missed visit notes, and clinical notes for nursing and chaplain during the period 9/30/2025 to 10/30/2025.An interview was conducted with the Administrator/Supervising Nurse on 8/26/2026 at 2:24pm at the Agency’s alternate location. The Surveyor shared the missing RN comprehensive assessment, initial bereavement assessment, initial spiritual assessment, updated comprehensive assessments, initial plan of care, updated plan of cares, physician orders, missed visit notes, and clinical notes for nursing and chaplain in the Agency’s EMR A system for period 9/30/2025 to 10/30/2025. The Administrator/Supervising nurse stated that the missing visit notes and documents for Patient #17 were on paper or stored electronically in his desktop computer located at the Agency’s primary location and had not been uploaded into the Agency’s EMR A system. The Administrator/Supervising nurse stated that the Agency planned on transitioning to another electronic medical record system after the survey. The Surveyor informed the Administrator/Supervising Nurse that she would need to review all of the patient’s missing documents and visit notes at the Agency’s primary location on 8/28/2026 and that the records needed to be readily available at 9am on 8/28/2026. The Administrator/Supervising Nurse stated that he would have the missing documents and visit notes available on 8/28/2026 when the surveyor arrived at the Agency’s primary location.The Surveyor provided the Administrator/Supervising Nurse a list of requested documents on 8/26/2026 at 4:30pm which included the request for the RN comprehensive assessment, initial bereavement assessment, initial spiritual assessment, updated comprehensive assessments, initial plan of care, updated plan of cares, physician orders, missed visit notes, and clinical notes for nursing and chaplain for Patient #17.Review of the patients’ paper records provided to the Surveyor on 8/28/2026 by the Administrator/Supervising Nurse revealed no paper records for Patient #17.An interview was conducted with the Administrator/Supervising Nurse on 8/28/2026 at 9:12am. When asked about the missing paper records for Patient #17, the Administrator/Supervising Nurse stated that he overlooked Patient #17 on the record request list that was provided by the Surveyor on 8/26/2026. The Administrator/Supervising Nurse stated that Patient #17’s records were on his desktop drive and that he needed time to get the records together.An interview was conducted with the Administrator/Supervising Nurse on 8/28/2026 at 12:22pm. The Administrator/Supervising Nurse stated that after the last survey (8/16/2023) the Agency’s staff started documenting their visits to EMR B software. The Administrator/Supervising Nurse stated that the Agency had a “trial” version of the EMR B software. The Administrator/Supervising Nurse stated that the Agency continued to use the Agency’s EMR A system because the Agency had a signed agreement. The Administrator/Supervising Nurse stated that he uploaded patient files from the EMR B software to the Agency’s EMR A system as an attachment to the patients’ records. The Administrator/Supervising Nurse stated that the uploaded files from EMR B software contained all of the Agency’s staff’s visit notes, orders, plan of cares and IDG notes.An interview was conducted with the Administrator/Supervising Nurse on 8/28/2026 at 5:19pm. The Surveyor followed up on the missing RN comprehensive assessment, initial bereavement assessment, initial spiritual assessment, updated comprehensive assessments, initial plan of care, updated plan of cares, physician orders, missed visit notes, and clinical notes for nursing and chaplain for Patient #17. The Administrator/Supervising Nurse stated that the records were located on a drive on his desktop computer and that he still needed time to retrieve the records. When asked if the Administrator/Supervising Nurse could pull up the records on his desktop computer so the Surveyor could review the records, the Administrator/Supervising Nurse stated, “I can’t compile it for you.” The Administrator/Supervising Nurse stated “I have the records on my” portable touch screen tablet computer. When asked if the Administrator/Supervising Nurse could pull up the patient’s records on his portable touch screen tablet computer, the Administrator/Supervising Nurse stated “I did the (nursing) visits. I have notes and I need to catch up. Catching up on the (nursing visit) notes are difficult.” The Administrator/Supervising Nurse stated that the start of care nurse comprehensive assessment was completed and “I need time to put it (The patient’s records) together.” The Administrator/Supervising Nurse stated that after the patient’s start of care assessment he took “notes” during the nursing visits but had not completed the nurse visit documentation in the Agency’s EMR A system or EMR B software. The Administrator/Supervising Nurse stated that patient had “declined chaplain” services during the admission and that the Administrator/Supervising Nurse had completed the spiritual and bereavement assessment at the time of the start of care RN Comprehensive assessment. The Administrator/Supervising Nurse stated that the Agency had patient records that needed to be uploaded into the Agency’s EMR A system. When asked about the agency’s policy on the time frame to complete documentation after a clinician’s visit with a patient, the Administrator/Supervising Nurse stated, “The truth is after dealing with patients all day I can come home and be exhausted so that’s the reality but as far as policy it’s 48 hours to 72 hours is what we aim for when it comes to efficiency.” The Administrator/Supervising Nurse stated that he took notes during the patients’ visits so he could give the patients and their families his undivided attention. The Administrator/Supervising Nurse stated that due to being the primary nurse that completed the patient admissions and visits “We (the Agency) can’t reasonably expect a 24 hour turn around (with completion of documentation) even though it’s our (the Agency’s) wish and frankly it’s the right way to do so.” When asked why the nursing patient visit documentation had not been completed on Patient #17 after the patient was admitted to hospice on 9/30/2025, the Administrator/Supervising Nurse stated “I understand that one (nursing documentation not being completed) it’s not really an isolated case it’s just that there were multiple” patient visits completed during the same time period (9/30/2025-10/30/2025). The Administrator/Supervising Nurse stated, “Once you dealt with other patients it’s really hard to go back” and document. When asked about the potential patient negative outcome for not completing documentation during the time frame specified by the Agency’s policy, the Administrator/Supervising Nurse stated it could affect the “continuity of care, a (patient’s) transition out to another state and then the Hospice agencies getting a proper handoff especially when they (the patients) transfer.”Review of the Agency’s policy “Timelines” with last review date 01/01/2026 read in part “The Hospice will ensure timely provision of care to meet patient’s needs in compliance with all federal and state laws and regulations. The Hospice will establish staff responsibilities for acceptable timeframes for completion and submission of medical record information including, but not limited to: visit notes and assessments, physician orders, certifications and recertification, transfers and discharges. Procedure Initial nursing assessment visit by the Registered Nurse (RN) will be completed within 48 hours after receipt of the physician’s referral for hospice care, unless the physician, patient, or representative requests otherwise. Initial Plan of Care (POC) will be established prior to the initiation of services and signed prior to billing. The Interdisciplinary Group/Team (IDG/IDT), in consultation with the attending physician, will complete the Comprehensive Health Assessment no later than five calendar days after the start of hospice care, including but not limited to completing the Comprehensive Health Assessment on the same day as the initial RN nursing assessment visit. The Assessment is updated at least every 15 days or as changes occur. The IDG/IDT Plan of Care (POC) will be developed within 15 days of the start of care and updated at least every 15 days. Supplemental verbal orders may be obtained before care is provided and are written within 24 hours of receiving the orders… All medical record information will be incorporated into the patient’s medical record in a timely manner.Review of the Agency’s Policy “Timelines-Addendum” with last review date 04/14/2023 read in part “All clinical and progress notes will be written the day service is rendered and incorporated into the patient’s medical record within 14 working days.””

“Based on record reviews and interviews the Hospice Agency failed to ensure that the patient’s clinical records whether hard copy or in electronic form were made readily available on request by an appropriate authority for 17 (Patients #1, #2, #3, #4,#5, #6, #7, #8, #9,#10, #11, #12, #13, #14, #15, #16, and #17) of 17 hospice patients’ records requested in that: The Agency failed to provide access to the Agency’s electronic medical record system or clinical records stored at another location within eight working hours of the HHSC Surveyor’s request.This failure delayed the Surveyor’s ability to conduct the survey to determine the Agency’s compliance with state and federal regulations which placed patients at risk for poor quality of care. FindingsAn entrance conference and interview was conducted with the Administrator/Supervising Nurse/Agency Owner on 8/21/2026 at 12:55pm at an alternate location due to broken water pipes and flood damage that occurred on 8/19/2026 to the Agency’s primary location. The Surveyor provided her business card to the Administrator/Supervising Nurse with the Surveyor’s email and contact phone number. The Surveyor reviewed the Agency request list with the Administrator/Supervising Nurse. The Administrator/Supervising Nurse stated that the patients’ records were located in the Agency’s EMR A system. The Surveyor requested a surveyor log in to the Agency’s EMR A system to be provided no later than end of day 8/21/2026. The Administrator/Supervising Nurse stated that he would work on getting the surveyor access to the Agency’s EMR A system once he arrived home where he had access to his computer. The Surveyor requested that the login information be emailed to the Surveyor once the Administrator/Supervising Nurse returned home. The Administrator/Supervising Nurse stated that he was working with a building management company to rent an office for the week of 8/24/26 to 8/28/2026 and would notify the surveyor of the address. The Surveyor arranged to meet with the Administrator/Supervising Nurse at 9am on 8/24/2026 at Assisted Living Facility (ALF G) to conduct patient home visits. The Administrator stated that he would notify the patients and families of the scheduled visits by the Surveyor.The Surveyor phoned the Administrator/Supervising Nurse on 8/21/2026 at 4:31pm and left a voice mail message with the Surveyor’s name, contact number and message regarding the follow up on the Surveyor’s login to the Agency’s EMR A system.The Surveyor received a text message from the Administrator/Supervising Nurse on 8/21/2026 at 4:33pm. The message read in part that the Administrator/Supervising Nurse was with a patient due to a fall and “I’ll (Administrator/Supervising Nurse) check the voicemail here in a minute.”The Surveyor sent a text message to the Administrator/Supervising Nurse on 8/21/2026 at 4:34pm that the Surveyor was following up on the access to the Agency’s EMR A system.The Surveyor received a text message from the Administrator/Supervising Nurse on 8/21/2026 at 4:42pm. The message read in part “I got your text and I got your (request) list and I will work on that when I get to my desk…”The Surveyor reviewed her emails and email junk folders on 8/24/2026 at 8:00am. There were no emails from the Agency or the Administrator/Supervising Nurse.The Surveyor phoned the Administrator/Supervising Nurse at 8:15am on 8/24/2026 to follow up on the request for the access to the Agency’s EMR A system. The Administrator/Supervising Nurse stated, “I’m sorry about that (not providing the Surveyor the requested login to the Agency’s EMR A system).” The Administrator/Supervising Nurse stated that he had a personal emergency over the weekend of 8/22/2026 through 8/23/2026 and was unable to send the Surveyor the requested login to the Agency’s EMR A system. The Administrator/Supervising Nurse stated that he was at ALF G during the Surveyor’s call. The Surveyor requested that the Administrator/Supervising Nurse work on the access to the Agency’s EMR A system while waiting for the Surveyor to arrive to conduct the patient home visits.An interview was conducted with the Administrator/Supervising Nurse on 8/24/2026 at 9:28am at ALF G. The Surveyor followed up on the access to the Agency’s EMR A system. The Administrator/Supervising Nurse stated, “I emailed it (login information for the Agency’s EMR A system) to you (the Surveyor).”A home visit and interview was conducted with Patient #1 on 8/24/2026 at 9:32am. The patient had no complaints and was satisfied with the hospice services provided by the Hospice Agency.A home visit and interview was conducted with Patient #2 on 8/24/2026 at 10:12am. The patient had no complaints and was satisfied with the hospice services provided by the Hospice Agency.A home visit and interview was conducted with Patient #3 on 8/24/2026 at 11:27am. The patient had no complaints and was satisfied with the hospice services provided by the Hospice Agency.The Surveyor checked her emails on 8/24/2026 at 1:23pm after completing the home visits and interviews with Patients #1, #2 and #3. There were no emails dated 8/24/2026 from the Administrator/Supervising Nurse with the login information to the Agency’s EMR A system.The Surveyor contacted her Program Manager (PM) on 8/24/2026 at 1:25pm and informed the PM that the Administrator had failed to provide the Surveyor access to the Agency’s EMR A system when requested on 8/21/2026 and on 8/24/2026. The Surveyor informed the PM on the interviews and conversations with the Administrator/Supervising Nurse on 8/21/2024 and 8/24/2026. The Surveyor informed the PM that the Administrator/Supervising Nurse stated that he had emailed the Surveyor the login information during an interview on 8/24/2026 at 9:23am. The PM stated that she would call the Administrator/Supervising Nurse to follow up on the login to the Agency’s EMR A system. The Surveyor provided the PM the name and contact phone number for the Administrator/Supervising Nurse.The PM phoned the Surveyor on 8/24/2026 at 1:40pm. The PM informed the Surveyor that the Administrator/Supervising Nurse had a time frame of end of business day 5:00pm to send the login information for the Agency’s EMR A system. The PM stated that she provided the Administrator/Supervising Nurse her email address and requested that the Administrator/Supervising Nurse include the PM in all email correspondence with the Surveyor. The Surveyor sent the Administrator/Supervising Nurse a follow-up email on the request for the login information for Agency’s EMR A system on 8/24/2026 at 2:12pm and included the PM in the email.The PM sent an email to the Administrator/Supervising Nurse on 8/24/2026 at 4:04pm that the Surveyor’s access to the Agency’s EMR A system was “needed ASAP.” The PM included the Surveyor in the email.The Surveyor sent the Administrator/Supervising Nurse a follow-up email on the request for the login information for the Agency’s EMR A system on 8/24/2026 at 4:33pm. The Surveyor requested that the access to the Agency’s EMR A system be provided no later than “30 minutes” from the time the Surveyor’s email was received.The Surveyor received an email from the Administrator/Supervising Nurse on 8/24/2026 at 5:04pm that read in part that a login for the Surveyor was attempted and an error message was received. The Administrator/Sup “We (the Agency) will have to make a username for you (the Surveyor), Will be sending shortly.”The Surveyor received an email from the Administrator/Supervising Nurse on 8/24/2026 at 5:27pm with a username and password for the Agency’s EMR A system. When the Surveyor attempted to log in to the Agency’s EMR A system, the system did not give the Surveyor the option to enter the password. The Surveyor received a message from the Agency’s EMR A system that a verification email was sent to the email address that the Administrator/Supervising Nurse created.The Surveyor sent the Administrator/Supervising Nurse an email on 8/24/2026 at 5:34pm. The Surveyor notified the Administrator/Supervising Nurse that the Agency’s EMR A system did not give the Surveyor the option to enter the provided password and a verification email was sent to the email address that the Administrator/Supervising Nurse had created.The Surveyor received a phone call from the Administrator/Supervising Nurse on 8/24/2026 at 6:29pm. The Administrator/Supervising Nurse stated that he was having difficulties creating a log-in for the Surveyor’s access to the Agency’s EMR A system and had created alternate emails. The Administrator/Supervising Nurse stated that he would continue to work on the creation of an alternate email address and the Surveyor’s access to the Agency’s EMR A system.The Surveyor received an email from the Administrator/Supervising Nurse on 8/25/2026 at 5:42am with a username and password to the Agency’s EMR A system.The Surveyor logged into the Agency’s EMR A system on 8/25/2026 at 9:31am at the Agency’s alternate location with the Administrator/Supervising Nurse present. The Surveyor only had access to 3 (Patients #1, #3 and #4) of the 6 (Patients #1, #2, #3, #4, #5, and #6) active patient records and 1 death discharge patient (Patient #7) record.An interview was conducted with the Administrator/Supervising Nurse on 8/25/2026 at 9:41am. The Surveyor requested access to the active Patients #2, #5 and #6 records and discharged patients records for the last 3 years (8/21/2023-8/21/2026) which included the discharged Patients #8, #9,#10, #11, #12, #13, #14, #15, #16, and #17. The Administrator/Supervising Nurse stated that he would have to add the additional patients to the Agency’s EMR A system for the Surveyor’s access to the patient records. When asked if the Administrator/Supervising Nurse had brought a laptop computer to add the patients for the Surveyor’s access. The Administrator/Supervising Nurse stated that he did not use a laptop computer because he did not like the “keyboard.” The Administrator/Supervising Nurse stated that he did all his work on a “desktop” computer in his office. The Administrator/Supervising Nurse stated that he had a “private office” 20 minutes away from the Agency’s alternate location.The Administrator/Supervising Nurse left the Alternate Agency location on 8/25/2026 at 10:28am to go to his “private office” for computer access.The Surveyor phoned her Program Manager on 8/25/2026 at 10:46am to inform her of the interview with the Administrator/Supervising Nurse on 8/25/2026 at 9:41am. The Surveyor informed the PM that the Administrator/Supervising Nurse left the Agency’s alternate location to go to his private office for computer access.The Surveyor phoned the Administrator/Supervising Nurse on 8/25/2026 at 11:34am. The Surveyor left a brief voice mail message regarding the Surveyor’s access to the additional active and discharge patients records and requested that the Administrator/Supervising Nurse return the Surveyor’s call.The Surveyor sent the Administrator/Supervising Nurse an email on 8/25/2026 at 12:13pm. The Surveyor informed the Administrator/Supervising Nurse of the attempted phone contact on 8/25/2026 at 11:34am and the follow-up on the requested access to the Agency’s 3 remaining active patients (Patients #2, #5 and #6) and all the discharged patients for the last 3 years. The surveyor requested that access to the patients’ records be provided within 30 minutes form the time of the email. The Surveyor included her Program manager in the email.The Surveyor’s Program Manager conducted a 3- way phone call between the PM, Administrator/Supervising Nurse, and Surveyor on 8/25/2026 at 12:28pm. The Surveyor informed the Administrator/Supervising Nurse that the Surveyor still needed access to the Agency’s 3 remaining active patients (Patients #2, #5 and #6) and all the discharged patients records for the last 3 years which included the discharged Patients #8, #9,#10, #11, #12, #13, #14, #15, #16, and #17. The Administrator/Supervising Nurse stated that he was still working on the Surveyor’s access to the remaining active and discharged patients. The PM asked the Administrator/Supervising Nurse if he could bring a computer to work alongside the Surveyors. The Administrator/Supervising Nurse stated that he would bring his computer. The PM asked where the Administrator/Supervising Nurse’s private office was located and his ETA from his current location. The Administrator/Supervising Nurse stated, “34 minutes.” The PM requested that the Administrator leave his current location with his computer, and the Surveyors would expect the Administrator/Supervising Nurse to arrive to the Agency’s alternate location in 34 minutes.The Administrator/Supervising Nurse phoned the Surveyor on 8/25/2026 at 12:47pm to inquire if the Surveyor had access to the Agency’s 3 remaining active patients (Patients #2, #5 and #6) and all the discharged patients for the last 3 years in the Agency’s EMR A system. The Surveyor informed the Administrator/Supervising Nurse that the Surveyor did not have access to the patients’ records after the Surveyor logged out and back into the Agency’s EMR A system. The Administrator/Supervising Nurse stated that he was on his way to the Alternate Agency location.The Surveyor phoned her Program Manager on 8/25/2026 at 1:14pm. The Surveyor informed the PM that the Administrator/Supervising Nurse had not arrived at the Agency’s alternate location and that the Administrator/Supervising Nurse called at 12:47pm and stated that he was on his way to the Alternate Agency location.The Surveyor received a phone call from her Program Manager on 8/25/2026 at 1:40pm. The PM instructed the Surveyor to terminate the survey due to the Administrator/Supervising Nurse’s failure to provide patient records in a timely manner and the failure to cooperate during the survey. The PM informed the Surveyor to make a list of all Conditions of Participation ( Health, safety, and operational standards set by the Centers for Medicare and Medicaid Services) linked to the Surveyors’ inability to review records and exit the Agency’s alternate location when the Administrator/Supervising Nurse arrived.The Administrator/Supervising Nurse arrived at the Agency’s alternate location on 8/25/2026 at 2:30pm. The Administrator/Supervising Nurse had brought a laptop computer. The Surveyor informed the Administrator/Supervising Nurse that the Surveyor was instructed to terminate the survey due to the Administrator/Supervising Nurse failure to provide access to the Agency’s 3 remaining active patients (Patients #2, #5 and #6) and all the discharged patients for the last 3 years in the Agency’s EMR A system in a timely manner. The Administrator/Supervising Nurse stated “ I’m sorry. I have been a little off. Do what you have to do so I can notify my staff.” The Surveyor informed the Administrator/Supervising Nurse that she would inform her Program manager that the Administrator/Supervising Nurse had arrived and brought his laptop computer.The Surveyor spoke to her Program Manager via phone call on 8/25/2026 at 2:37pm. The Surveyor informed the PM that the Administrator/Supervising Nurse had arrived at the Agency’s alternate location and had brought his laptop computer. The PM informed the Surveyor that the Surveyor could continue the survey if the Administrator/Supervising Nurse continued to provide the requested patient records and access to the Agency’s 3 remaining active patients (Patients #2, #5 and #6) and all the discharged patients for the last 3 years in the Agency’s EMR A system.Interview with the Administrator/Supervising Nurse on 8/25/2026 at 2:41pm. The Surveyor informed the Administrator/Supervising Nurse that the Surveyors would continue the survey on the condition that the Administrator/Supervising Nurse provided the Surveyors the requested records in a timely manner. The Administrator/Supervising Nurse stated that he submitted a request with EMR A for the Surveyors to have “Administrator” access to the patients’ records.An interview was conducted with the Administrator/Supervising Nurse on 8/25/2026 at 4:01pm. The Surveyor informed the Administrator/Supervising Nurse that the Surveyors still did not have access to the Agency’s 3 remaining active patients (Patients #2, #5 and #6) and all the discharged patients for the last 3 years in the Agency’s EMR A system. The Administrator/Supervising Nurse stated that he had not received a response from EMR A. The Administrator/Supervising Nurse stated that he would provide the Administrator’s/Supervising Nurse’s log in information if the Surveyors continued to have issues with access to the patients records upon returning at 9am on 8/26/2026.The Surveyor received an email from the Administrator/Supervising Nurse on 8/26/2026 at 8:51am with the Administrator/Supervising Nurse’s username and password for the Agency’s EMR A system.The Surveyor had access to the Agency’s active and discharge patient records on 8/26/2026 at 9:16am after logging into the Agency’s EMR A system using the Administrator/Supervising Nurses username and password.An interview was conducted with the Administrator/Supervising Nurse on 8/28/2026 at 5:19pm. When asked about the Agency’s policy on the time frame for providing patient records requested by a state Surveyor, the Administrator/Supervising Nurse stated “It’s (providing requested records to a state surveyor is) usually two hours.” When asked about the potential negative patients’ outcomes for not providing the Surveyor the patients’ records with in “2 hours,” the Administrator/Supervising Nurse stated that missing documentation and documents in the patients’ records could affect the patient’s “start of care” and follow up visits by the Agency’s Chaplain and Social Worker if the patient’s records are incomplete. Review of the Agency’s policy “Medical Record Information Release and Removal” with last review date 09/01/2024 read in part “Release to Non-Hospice Entities. The medical record, whether hard copy or in electronic form, will be readily available upon request by an appropriate authority. Appropriate authority includes the State Accrediting agency or other agency who visits the hospice for the purposes of determining compliance with the conditions of participation.””