Better Care Matters

“Based on record review and interview, the hospice failed to ensure that all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of Patient property by anyone furnishing services on behalf of the hospice, are reported immediately by hospice employees and contracted staff to the hospice administrator for 1 of 14 patients whose records were reviewed (Patient #12). These failures have the potential to place all Patients at risk for substandard quality of care, and further risk of abuse, neglect and exploitation. FindingsRecord review of Intake #1070743 during pre-survey preparation on 03/16/2026 revealed that COMP alleged that patient was to only receive provider services but during the patient’s enrolment; the patient was signed up to hospice services without the patient’s consent. COMP also alleged that the hospice never delivered patient’s diabetic medications throughout patient’s enrollment with the hospice but instead added several other medications not related to patient’s actual diagnosis. Record review of document entitled, “Health Issues- Current Health Issues” from [HSY#1], received and reviewed on 03/18/2026 reads in part, “Mixed hyperlipidemia (also known as familial combined hyperlipidemia (where there is high levels of cholesterol and triglycerides in the blood) (started on 08/19/2020), Type 1 diabetes with eye complications (started on 02/19/2020), Long term (current) use of insulin (started on 02/19/2020), and presence of insulin pump (external) (internal) (started on 02/19/2020)…”Second record review of the Complaint Log on 03/20/2026 revealed that intake #1070743 was not documented in the Complaint Log. During an interview with Patient #12 on 03/18/2026 at 10:54AM. SR inquired from Patient #12, can you tell me why did you call in the complaint? Patient #12 stated, “I called the complaint in multiple times into the hospice first; one time around thanksgiving, around the ending of December 2025. When I would call the complaints into the hospice; they were weird about it and the hospice kept telling me to hush hush and they told me to keep quiet about it and that they would resolve my issues eventually. Three weeks after my third attempt in January went by, and I still had not heard anything. So, I finally called in the complaint into the state because I didn’t know what else I was supposed to do. I was supposed to be just getting HHA services but somehow hospice was tacked on. I don’t know when that happened, but what I do know is when the hospice started. The RN in my case; RN A never could get my medicines right. RN A kept adding medications to the docket that I have never used before in my entire life. For instance, RN A was adding B12 medications (cyanocobalamin (is a synthetic form of B12 used to treat and prevent deficiency, which can cause pernicious anemia (autoimmune disorder where the body cannot absorb enough vitamin B12 leading to low red blood cell counts, severe fatigue, neurological issues, etc), nerve damage and fatigue); anyone that knows anything about B12 medications is that stuff is filled with nothing but sugar, and I am and always will be a diabetic. Honestly, the second I got it (hospice), I never got the right services from them since September of 2025. Then to top it off the RN stopped coming.” During an interview with Patient #12 on 03/18/2026 at 10:58AM. SR inquired from Patient #12, when did you notice the Hospice service was tacked on? Patient #12 stated, “Oh let’s see here oh whenever I went to the [ER (emergency room)] for an emergency and they said that they couldn’t really keep me because I was getting hospice services, and the ER didn’t want the hospice benefit to be cancelled out. So, I left.” SR inquired further, what was the emergent situation? Patient #12 stated, “My blood sugar ended up getting very high, it was over 500 and that’s why I went to the ER. Because I never seem to get any of my insulins (a vital hormone produced by the pancreas that allows cells to absorb glucose from the blood for energy, thereby lowering the blood sugar levels in the body) from the hospice, I had spare insulins from my own stock, but I never got my insulins from the hospice. I ended up having to call my PCP for help, and he was the one that prescribed me my insulins due to the urgency.”During an interview with Patient #12 on 03/18/2026 at 11:08AM. SR inquired from Patient #12, when you called in the complaint into the hospice initially; who did you speak with? Patient #12 stated, “My very first complaint was made initially to the ADM-A and the DON. After the many times of speaking to the hospice leadership; I realized shortly after they weren’t going to do anything. So, I up the chain of the command all the way to the Owner of the hospice and they (the hospice) still didn’t do anything. So, that’s when I finally decided to call the State with my complaint as I mentioned before.” During an interview with the ADM and the DON on 03/20/2026 at 7:17PM. ADM looked perplexed and stated, “But we are.” SR inquired from the DON, why are you not reporting the complaints and/or incidents; when you have firsthand accounts of the complaints and/or incidents? DON stated, “I don’t have firsthand accounts; I get all of my reports from my nurses, I then relay that information to the proper channels, and then we report it accordingly.” ADM looked perplexed and stated, “But we are.” During an interview with the DON on 03/20/2026 at 7:18PM. SR inquired from the DON, who is responsible for reporting complaints and incidents into the state and/or HHSC? DON stated, “who is responsible that would be [MSW]. SR inquired further, are you not the DON? DON stated, “I am, however, [MSW] is responsible because it is within her job description. SR asked further, [MSW] job description is that of a MSW, how is the MSW responsible and not the DON? DON stated, “[MSW] is responsible because she is the one that has APS (Texas Adult Protective Services) background.” Record review of the hospice’s administrative policy manual entitled, “Patient’s Rights and Responsibilities” last reviewed on 10/01/2021 pages 1 to 4 reads in part, “Purpose: To ensure the Patient, their representative (if any), and the Hospice staff acknowledge, protect, observe,and implement the Patient’s rights and responsibilities… C. To voice grievances regarding treatment or care that is (or fails to be) furnished and the lack of respect for property by anyone who is furnishing services on behalf of the Hospice; and D. To not be subjected to discrimination or reprisal for exercising his or her rights…” Record review of the hospice’s administrative policy manual entitled, “Abuse, Neglect and Exploitation” last reviewed on 09/01/2024 pages 1 to 4 reads in part, “… Policy: I. Patients have the right to be free from mistreatment, neglect or verbal, mental, sexual and physicalabuse, including injuries of unknown sources and misappropriation of property. II. II. The Hospice must ensure that alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of Patient property by anyone furnishing services on behalf of the Hospice, are reported immediately by Hospice employees and contracted staff to the Hospice Administrator and other appropriate authorities in accordance with state laws… B. “Immediately” means as soon as possible, but not to exceed 24 hours after discovery of the incident, in the absence of a shorter state time frame requirement…” Record review of the hospice’s administrative policy manual entitled, “Resolution of Patient Conflicts, Grievances or Complaints” last reviewed on 12/01/2025 pages 1 to 3 reads in part, “Purpose: To establish a procedure and ensure the rights of Patients, their representatives (if any) and their caregivers and/or families to file a report of a grievance or complaint and to make recommendations for resolutions of conflicts without fear of retaliation, coercion, discrimination, reprisal, or unreasonable interruption of care. Policy: The Hospice will investigate complaints made by a Patient, the Patient’s representative (if any), and the Patient’s caregivers and family. A. A healthcare provider of the Patient may also file a complaint regarding the treatment or care that is being provided. II. The Hospice will not hamper, compel, discriminate, treat differently, or retaliate against a Patient or family for exercising the Patient’s rights… III. The Hospice will inform the Patient, their representative (if any) and/or caregiver, in writing, at the time of the initial assessment to notify the Administrator or designee at the Hospice regarding any conflicts, grievances or complaints and the time frames for initiation of an investigation. IV. The Hospice will follow state guidelines for documentation of the receipt of the complaint/grievance and initiation of a complaint investigation… VI. The appropriate Clinical Manager or designated Supervisor will be notified of the complaint… VII. Documentation will include, but not be limited to, the name, address and phone number of the person filing the complaint, the nature of the complaint, and the remedy/relief the person is seeking. VIII. The Hospice will complete the investigation and documentation of the resolution per state guidelines upon receipt of the complaint…””

“Based on observation, record review and interview, the hospice failed to ensure that the patient has a right to the following: Be involved in developing his or her hospice plan of care for 8 of 14 Patients (Patients #1, #2, #3, #5, #6, #9, #12, and #14) whose records were reviewed, in that; 1. Patients were not informed of the hospice services in a timely manner and/or not at all. 2. Patients were not notified of being discharged from the hospice services. 3. Patients were not aware of their diagnoses being changed. These failures have the potential to place all Patients at risk for substandard quality of care, and not having their actual medical needs addressed. Findings include Not Informed of Hospice Services, and/or Not Aware of Medical Diagnoses Being Changed Patient #1 Observation SR arrived at Patient #14’s home on 03/19/2026 at 11:30AM. Before a home visit could be conducted with Patient #1 inside the home of Patient #14 on 03/19/2026; SR observed at 11:31AM. Patient #1 was driving in a white vehicle into Patient #14’s driveway; Patient #1 waved hello to SR and walked into Patient #14’s home with ease (with no usage of any medical adaptive equipment for ambulation limitation such as a cane, walker, etcetera). SR went into Patient #14’s home to conduct consented home visit with Patient #1 at 11:40AM with hospice Chaplain. Record Review Record review of Patient #1’s active CR revealed a SOC of 06/10/2025 with a past certification period of 08/09/2025 to 10/07/2025 with primary diagnosis of BXX with two secondary diagnoses of depression (persistent and severe sadness), unspecified and anxiety disorder (persistent, excessive fear or worry), unspecified. Further review of Patient #1’s CR revealed current certification period of 02/05/2026 to 04/05/2026 with primary diagnosis of Chronic hepatic failure without coma (is a long-term liver condition characterized by impaired liver function without the presence of hepatic encephalopathy (a reversible decline in brain function due to severe liver disease (often cirrhosis), where the liver cannot filter toxins, specifically ammonia, from the blood) or coma) with two secondary diagnoses of depression, unspecified and anxiety disorder, unspecified. In Patient #1’s current certification period, there was no mention of the primary diagnosis of BXX becoming a secondary and/or if the diagnosis became latent and/or resolved on what date the resolution was found. Record review of document entitled, “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” dated 06/10/2025 reads in part, “… Primary Terminal Diagnosis: BXX…” Record review of document entitled, “Referral Order” dated 06/10/2025 written by MD A reads in part, “… referring diagnosis code: BXX… Evaluate and admit to hospice level of care if the Patient qualifies. If Patient does not qualify, please refer to a lower level of care…” Record review of document entitled, “Physician Certification / Recertification” dated 08/09/2025 and written by MD C reads in part, “… was admitted to hospice level of care on 6/10/2025 with a terminal diagnosis of BXX. Comorbidities are: F32.A: Depression, unspecified, and F41.9: Anxiety disorder, unspecified. They have a life expectancy of less than 6 months provided their terminal illness progresses at a regular rate…” Record review of document entitled, “Care Plan/Physician Order” dated 08/09/2025 written by DON and approved by MD A for the certification period of 8/9/2025 to 10/7/2025 reads in part, “… BXX: Principal Diagnosis: BXX (this disorder attacks and destroys CD4 cells (T- helper cells), reducing the body’s ability to fight infection), date: 06/10/2025… Functional Ability: Ambulation Limitations… Activity Level: Up as Tolerated, Walker Required… Advanced Directives: DNR… Orders for Disciplines and Treatments: SN: 0WK1 (0 times a week for 1 week), 1WK9 (1 times a week for 9 weeks), PRN (as needed) 3 - Weekly and PRN for emergencies, requests, recerts, and decline. MSW: 1M2 (1 times every 2 months), PRN3 - Monthly and PRN for emergencies, requests, and decline. CHAP: 1M2 (1 times every 2 months) - Monthly and PRN for emergencies, requests, and decline… Clinician Attestation: I certify that this medical record entry for Physician’s orders accurately reflects the most recent assessment of the Patient’s condition as well as a verbal conversation with the physician to provide these services. I understand that signing this document electronically is the legal equivalent of having placed my handwritten signature on this document. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission or concealment of material fact may be subject me to administrative, civil or criminal liability…” Patient #2 Record review of Patient #2’s discharged CR revealed a SOC of 07/25/2025 with a certification period of 07/25/2025 to 10/22/2025 with a primary diagnosis of Heart failure, unspecified (a chronic, progressive condition where the heart muscle cannot pump enough blood to meet the body’s needs, often resulting from coronary artery disease, high blood pressure, or damage. It causes fatigue, shortness of breath, and fluid retention (swelling)). Further record review revealed that there was no documentation in the entirety of Patient’s CR as to what stage of heart failure Patient #2 was in. Record review of document entitled, “Referral Order” dated 07/25/2025 written by MD C reads in part, “… referring diagnosis code: Heart failure, unspecified… Evaluate and admit to hospice level of care if the Patient qualifies. If Patient does not qualify, please refer to a lower level of care…” Record review of document entitled, “Care Plan/Physician Order” dated 07/29/2025 written by DON and approved by MD C for the certification period of 07/25/2025 to 10/22/2025 reads in part, “… Principal Diagnosis: Heart failure, unspecified… Prognosis: Terminal: 6 Month Prognosis… Activity Level: Up as Tolerated… Advanced Directives: DNR… Orders for Disciplines and Treatments: SN: 2WK1 (2 times a week for 1 week), 1WK13 (1 times a week for 13 weeks), PRN 3 - Weekly and PRN for emergencies, requests, recerts, and decline. MSW: 0WK1 (0 times a week for 1 week), 1WK1 (1 times a week for 1 week), 1M3 (1 times every 3 months), PRN3 - Monthly and PRN for emergencies, requests, and decline. HHA: 0WK1 (0 times a week for 1 week), 3WK12 (3 times a week for 12 weeks), 2WK1 (2 times a week for 1 week)- 3 X a week. CHAP: 0WK1 (0 times a week for 1 week), 1WK1 (1 times a week for 1 week), 1M3 (1 times every 3 months) PRN3- Monthly and PRN for emergencies, requests, and decline… Clinician Attestation: I certify that this medical record entry for Physician’s orders accurately reflects the most recent assessment of the Patient’s condition as well as a verbal conversation with the physician to provide these services. I understand that signing this document electronically is the legal equivalent of having placed my handwritten signature on this document. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission or concealment of material fact may be subject me to administrative, civil or criminal liability…” Record review of document entitled, “Physician Certification / Recertification” dated 08/09/2025 written by DON and approved by MD C reads in part, “… was admitted to hospice level of care on 07/25/2025 with a terminal diagnosis of I50.9 Heart failure, unspecified. Comorbidities are: I10 Essential (primary) hypertension (high blood pressure), J45.909 Unspecified asthma (a chronic respiratory condition characterized by inflammation, swelling, and narrowing of the airways, often causing wheezing, chest tightness, coughing, and breathing difficulties), uncomplicated (used when a patient has asthma without specified type (e.g., allergic, intrinsic) or complications (e.g., exacerbation (sudden worsening of a condition), status asthmaticus (life-threatening, severe asthma exacerbation unresponsive to standard treatments like bronchodilators, characterized by extreme wheezing, labored breathing, and potential respiratory failure)), M19.90 Unspecified osteoarthritis (is a degenerative joint disease, often called “wear-and-tear” arthritis, caused by the breakdown of protective cartilage, leading to pain, stiffness, and reduced mobility) unspecified site, E03.9 Hypothyroidism (when the thyroid gland does not produce enough thyroid hormone), unspecified. They have a life expectancy of less than 6 months provided their terminal illness progresses at a regular rate…” Patient #5 Record review of Patient #5’s active CR revealed a SOC of 01/23/2024 with a certification period of 01/12/2026 to 03/12/2026 with a primary diagnosis of Heart failure, unspecified. Further record review revealed that there was no documentation in the entirety of Patient’s CR as to what stage of heart failure Patient #5 was in. Record review of document entitled, “Referral Order” dated 01/23/2024 written by MD C reads in part, “… referring diagnosis code: Alzheimer’s disease (is a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia), unspecified… Evaluate and admit to hospice level of care if the Patient qualifies. If Patient does not qualify, please refer to a lower level of care…” Record review of document entitled, “Care Plan/Physician Order” dated 03/04/2026 written by RN C and approved by MD A for the certification period of 03/13/2026 to 05/11/2026 reads in part, “… Principal Diagnosis: Heart failure, unspecified… Prognosis: Terminal: 6 Month Prognosis… Advanced Directives: Full Code… Orders for Disciplines and Treatments: SN: 0WK1 (0 times a week for 1 week), 1WK9 (1 times a week for 9 weeks), PRN 3 - Weekly and PRN for emergencies, requests, recerts, and decline. MSW: 1M2 (1 times every 2 months), PRN3 - Monthly and PRN for emergencies, requests, and decline. HHA: 1WK1 (1 times a week for 1 week), 5WK8 (5 times a week for 8 weeks), 1WK1 (2 times a week for 1 week)- Weekly X 5 (weekly times 5). CHAP: 1M2 (1 times every 2 months) PRN3- Monthly and PRN for emergencies, requests, and decline… Clinician Attestation: I certify that this medical record entry for Physician’s orders accurately reflects the most recent assessment of the Patient’s condition as well as a verbal conversation with the physician to provide these services. I understand that signing this document electronically is the legal equivalent of having placed my handwritten signature on this document. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission or concealment of material fact may be subject me to administrative, civil or criminal liability…” Record review of document entitled, “Physician Certification / Recertification” dated 02/01/2026 and approved by MD C reads in part, “… admitted to hospice level of care on 01/23/2024 w/a terminal diagnosis of I50.9 heart failure, unspecified… They have a life expectancy of less than 6 months provided their terminal illness progresses at a regular rate…” Patient #6 Record review of Patient #6’s active CR revealed a SOC of 07/06/2023 with a certification period of 02/20/2026 to 04/20/2026 with a primary diagnosis of Chronic obstructive pulmonary disease (COPD (ongoing lung disease caused by damage to the lungs), unspecified. Further record review revealed that there was no documentation in the entirety of Patient’s CR as to what stage of COPD Patient #6 was in. Record review of document entitled, “Referral Order” dated 07/06/2023 written by MD B reads in part, “… referring diagnosis code: Heart failure, unspecified … Evaluate and admit to hospice level of care if the Patient qualifies. If Patient does not qualify, please refer to a lower level of care…” Record review of document entitled, “Medical Records” from [HSY #1] dated 08/21/2024 reads in part, “… Has CKD: Yes, Has COPD: No. Has CHF (Congestive Heart Failure): Yes…” Further review of the medical records documented that one of Patient #6’s diagnoses was HFrEF w/ ICD (30-35% 2021 (Heart Failure with reduced ejection fraction (a type of systolic heart failure where the left ventricle’s pumping capability is weakened, resulting in a ejection fraction (EF) of less than 40%. This condition prevents the heart from pumping enough blood, often causing fatigue and shortness of breath). COPD was not listed as part of the diagnoses. Record review of document entitled, “Care Plan/Physician Order” dated 03/02/2026 written by RN C and approved by MD B for the certification period of 02/20/2026 to 04/20/2026 reads in part, “… Principal Diagnosis: Chronic obstructive pulmonary disease, unspecified… Prognosis: Terminal: 6 Month Prognosis… Advanced Directives: DNR… Orders for Disciplines and Treatments: SN: 0WK1 (0 times a week for 1 week), 1WK9 (1 times a week for 9 weeks), PRN 3 - Weekly and PRN for emergencies, requests, recerts, and decline. MSW: 1M2 (1 times every 2 months), PRN3 - Monthly and PRN for emergencies, requests, and decline. CHAP: 1M2 (1 times every 2 months) PRN3- Monthly and PRN for emergencies, requests, and decline… Clinician Attestation: I certify that this medical record entry for Physician’s orders accurately reflects the most recent assessment of the Patient’s condition as well as a verbal conversation with the physician to provide these services. I understand that signing this document electronically is the legal equivalent of having placed my handwritten signature on this document. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission or concealment of material fact may be subject me to administrative, civil or criminal liability…” Record review of document entitled, “Physician Certification / Recertification” dated 03/02/2026 and approved by MD B reads in part, “… admitted to hospice level of care on 07/06/2023 with a terminal diagnosis of J44.9 chronic obstructive pulmonary disease.… His life expectancy is less than 6 months provided their terminal illness progresses at a regular rate…” Patient #9 Observation SR arrived at Patient #9’s home on 03/18/2026 at 2:20PM. SR and MSW into the Patient’s home at 2:35PM for consented home visit. SR introduced self to Patient #9 and Patient #9’s Family member (FM); SR stated purpose of the visit. Patient #9 stated to SR at 2:36PM, “All the chairs are used up; let me get you a chair from outside, so you can sit.” SR observed Patient #9 walk from the living room area to the porch and grabbed an extra wooden chair for SR to sit on. SR observed that while Patient #9 was holding onto the wooden chair that SR was able to assess that Patient’s gait (person’s manner of walking) was steady with no ambulation limitations that required the usage of a (medical adaptive equipment for ambulation limitation such as cane, etcetera). Record Review Record review of Patient #9’s active CR revealed a SOC of 04/19/2024 with a certification period of 02/08/2026 to 04/08/2026 with a primary diagnosis of Heart failure, unspecified. Further record review revealed that there was no documentation in the entirety of Patient’s CR as to what stage of heart failure Patient #9 was in. Record review of document entitled, “Referral Order” dated 04/19/2024 written by MD C reads in part, “… referring diagnosis code: Heart failure, unspecified… Evaluate and admit to hospice level of care if the Patient qualifies. If Patient does not qualify, please refer to a lower level of care…” Record review of document entitled, “Care Plan/Physician Order” dated 02/01/2026 written by DON and approved by MD A for the certification period of 02/08/2026 to 04/08/2026 reads in part, “… Principal Diagnosis: Heart failure, unspecified. Other Pertinent Diagnosis: Essential (primary) hypertension … Prognosis: Terminal: 6 Month Prognosis… Activities Permitted: Cane Required, Up as Tolerated… Advanced Directives: Full Code… Orders for Disciplines and Treatments: SN: 1WK9 (1 times a week for 9 weeks), PRN3 - Weekly and PRN for emergencies, requests, recerts, and decline. MSW: 1M2 (1 times every 2 months), PRN3 - Monthly and PRN for emergencies, requests, and decline. CHAP: 1M2 (1 times every 2 months) PRN3- Monthly and PRN for emergencies, requests, and decline… Clinician Attestation: I certify that this medical record entry for Physician’s orders accurately reflects the most recent assessment of the Patient’s condition as well as a verbal conversation with the physician to provide these services. I understand that signing this document electronically is the legal equivalent of having placed my handwritten signature on this document. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission or concealment of material fact may be subject me to administrative, civil or criminal liability…” Record review of document entitled, “Physician Certification / Recertification” dated 03/02/2026 and written by MD A reads in part, “… was admitted to hospice level of care on 04/19/2024 with a terminal diagnosis of I50.9 heart failure, unspecified. Comorbidities are: I10 essential (primary) hypertension. He has a life expectancy of less than 6months provided his terminal illness progresses at a regular rate…” Patient #12 Record review of Patient #12’s discharged CR revealed a SOC of 10/07/2025 with a certification period of 01/05/2026 to 04/04/2026 with a primary diagnosis of chronic kidney disease (CKD), Unspecified. Further record review revealed that there was no documentation in the entirety of Patient’s CR as to what stage of CKD Patient #12 was in. Even further record review revealed that there was no documentation of a referral order for Patient #12 from a hospice MD and/or Patient #12’s PCP (Primary Care Physician) regarding the reason for hospice. Record review of document entitled, “Hospice RN Admission- HOPE” dated 10/07/2025 written by RN D reads in part, “… Diagnosis code: A. CKD, unspecified… Principal Diagnosis: None of the above, Co-morbidities and Co-existing Conditions: I1510. Renal Disease (or kidney disease, refers to conditions that impair kidney function, ranging from mild chronic kidney disease to end-stage renal failure requiring dialysis or transplantation), I2900. Diabetes Mellitus (DM (is a chronic condition that occurs when the body cannot make use of glucose (blood sugar). There are three main types: Type 1 (immune system destroys insulin-producing cells in the pancreas, leading to little to no insulin production and high glucose levels), Type 2 (a chronic condition that the body resists insulin or fails to produce enough, causing high glucose levels) and gestational diabetes (condition that occurs in pregnancy)), I2910. Neuropathy (breakdown and/or damage of the nerves), I8005. Other Medical Condition… Prognosis: Terminal: 6 Month Prognosis… History and Trajectory of disease (Why hospice, why now?): Patient has extensive history of CKD, DM1, Diabetic Retinopathy (damage to the eyes because of diabetes), PTSD (is a mental disorder caused by an extremely stressful and/or terrifying event either being a part of the event and/or not), and Neuropathy. Pt has Dyspnea (shortness of breath) on exertion (physical or mental strain or effort). O2 sats are 94% on RA (room air). Pt (Patient) is fall risk due to being legally blind…” Record review of document entitled, “Care Plan/Physician Order” dated 12/11/2025 written by written by RN C and approved by MD A for the certification period of 01/05/2026 to 04/04/2026reads in part, “… Principal Diagnosis: chronic kidney disease, unspecified. Other Pertinent Diagnosis: Type 1 diabetes mellitus with unspecified diabetic retinopathy and macular edema (swelling in the macula (center of the retina)), post-traumatic stress disorder, unspecified, legal blindness, as defined in USA, and polyneuropathy (breakdown of the peripheral nerves that impacts multiples sites of the body), unspecified… Functional Limitations… Legally Blind… Activities Permitted: Up as Tolerated… Prognosis: Terminal: 6 Month Prognosis… Activities Permitted: Cane Required, Up as Tolerated… Advanced Directives: Full Code… Orders for Disciplines and Treatments: SN: 1WK13 (1 times a week for 13 weeks), PRN3 - Weekly and PRN for emergencies, requests, recerts, and decline. MSW: 1M3 (1 times every 3 months), PRN3 - Monthly and PRN for emergencies, requests, and decline… Clinician Attestation: I certify that this medical record entry for Physician’s orders accurately reflects the most recent assessment of the Patient’s condition as well as a verbal conversation with the physician to provide these services. I understand that signing this document electronically is the legal equivalent of having placed my handwritten signature on this document. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission or concealment of material fact may be subject me to administrative, civil or criminal liability…” Record review of document entitled, “Physician Certification / Recertification” dated 02/01/2026 and written by MD A reads in part, “[Patient #12]… was admitted to hospice level of care on 10/07/2025 with a terminal diagnosis of N18.9 chronic kidney disease, unspecified. Comorbidities are: E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema, F43.10 Post-traumatic stress disorder, unspecified, H54.8 Legal blindness, as defined in USA, and G62.9 Polyneuropathy, unspecified. He has a life expectancy of less than 6 months provided his terminal illness progresses at a regular rate. [Other Patient #1] is being admitted to hospice level of care due to the following reasons: At the time of hisassessment his V/S (vital signs) were Temp (temperature):97.5 Pulse:73 Resp (respirations):18 O2Sat (oxygen saturation):94% on room air... BP (blood pressure):132/54 sitting. WT (weight):179.4lbs (pounds)… Pt reported a pain rating of 2/10… Pt L (left) and R (right) vision corrected with eyeglasses. Pt is legally blind in L and R eyes… Neuro (neurology) - Pt reported an anxiety rating of 0/10. PT is A&OX4 (alert and oriented times 4). PT is forgetful, anxious and depressed at times. Pt reported a tiredness rating of 3/10 and a drowsiness rating of 1/10. Pt reports 7-8 hours broken sleep nightly. Pt reported a depression rating of 0/10…” Record review of document entitled, “Health Issues- Current Health Issues” from [HSY#1], received and reviewed on 03/18/2026 reads in part, “Mixed hyperlipidemia (also known as familial combined hyperlipidemia (where there is high levels of cholesterol and triglycerides in the blood) (started on 08/19/2020), Type 1 diabetes with eye complications (started on 02/19/2020), Long term (current) use of insulin (started on 02/19/2020), and presence of insulin pump (external) (internal) (started on 02/19/2020)…” Further review revealed that CKD was not listed as part of the current diagnoses. Patient #14 Record review of Patient #14’s active CR revealed a SOC of 10/11/2024 with a certification period of 02/03/2026 to 04/03/2026 with a primary diagnosis of Unspecified systolic (congestive) heart failure. Further record review revealed that there was no documentation in the entirety of Patient’s CR as to what stage of heart failure Patient #14 was in. Record review of document entitled, “Referral Order” dated 10/11/2024 written by MD C reads in part, “… referring diagnosis code: I50.20 Unspecified systolic (congestive) heart failure… Evaluate and admit to hospice level of care if the Patient qualifies. If Patient does not qualify, please refer to a lower level of care…” Record review of document entitled, “Care Plan/Physician Order” dated 02/01/2026 written by RN C and approved by MD B for the certification period of 02/03/2026 to 04/03/2026 reads in part, “… Principal Diagnosis: Unspecified systolic (congestive) heart failure… Prognosis: Terminal: 6 Month Prognosis… Advanced Directives: DNR… Orders for Disciplines and Treatments:SN: 0WK1 (0 times a week for 1 week), 1WK8 (1 times a week for 8 weeks), PRN 3 - Weekly and PRN for emergencies, requests, recerts, and decline. MSW: 1M2 (1 times every 2 months), PRN3 - Monthly and PRN for emergencies, requests, and decline. HHA: 4WK1 (4 times a week for 1 week), 5WK8 (5 times a week for 8 weeks), 1WK1 (2 times a week for 1 week)- Weekly X 5 (weekly times 5). CHAP: 1M2 (1 times every 2 months) PRN3- Monthly and PRN for emergencies, requests, and decline… Clinician Attestation: I certify that this medical record entry for Physician’s orders accurately reflects the most recent assessment of the Patient’s condition as well as a verbal conversation with the physician to provide these services. I understand that signing this document electronically is the legal equivalent of having placed my handwritten signature on this document. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission or concealment of material fact may be subject me to administrative, civil or criminal liability…” Record review of document entitled, “Physician Certification / Recertification” dated 03/02/2026 and approved by MD B reads in part, “… admitted to hospice level of care on 10/11/2024 with a terminal diagnosis of I50.20 Unspecified systolic (congestive) heart failure… She has a life expectancy of less than 6 months provided their terminal illness progresses at a regular rate...” Not Notified of Discharge Patient #3 Record review of document entitled, “Election of Hospice Medicare Benefits and Patient Authorization” dated 07/23/2024 reads in part, “… I [Patient #3] request admission to [Hospice Version #1] at [Hospice Address]…” Further review revealed that Patient signed the document on 07/23/2024. Record review of document entitled, “Care Plan/Physician Order” dated 09/30/2025 written by DON and approved by MD B for the certification period of 09/16/2025 to 11/14/2025 reads in part, “… Principal Diagnosis: COPD, unspecified, Prognosis: Terminal: 6 Month Prognosis… Advanced Directives: Full Code… Orders for Disciplines and Treatments:SN: 0WK1 (0 times a week for 1 week), 1WK8 (1 times a week for 8 weeks), PRN 3 - Weekly and PRN for emergencies, requests, and decline. MSW: 1M2 (1 times every 2 months), PRN3 - Monthly and PRN for emergencies, requests, and decline. HHA: 5WK1 (5 times a week for 1 week), 7WK7 (7 times a week for 7 week)- 7X per week. CHAP: 1M2 (1 times every 2 months) PRN3- Monthly and PRN for emergencies, requests, and decline… Clinician Attestation: I certify that this medical record entry for Physician’s orders accurately reflects the most recent assessment of the Patient’s condition as well as a verbal conversation with the physician to provide these services. I understand that signing this document electronically is the legal equivalent of having placed my handwritten signature on this document. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission or concealment of material fact may be subject me to administrative, civil or criminal liability…” Record review of Patient #3’s discharged CR revealed SOC of 07/23/2024 with a certification period of 09/16/2025 to 11/14/2025 with a primary diagnosis of COPD, unspecified. Review of Patient #3’s CR revealed that SNs completed visits on the following dates:Week 1 of 09/14/2025 to 09/20/2025: SNs completed the ordered frequency of 1WK8 as ordered (RN D completed the visit on 09/14/2025). Week 2 of 09/21/2025 to 09/27/2025: SNs completed the ordered frequency of 1WK8 as ordered (RN D completed the visit on 09/23/2025).Week 3 of 09/28/2025 to 10/02/2025: SNs does not complete the ordered frequency of 1WK8. RN D completed 0 of 1 scheduled visit that was scheduled for 09/29/2025. Record review of document entitled, “Physician Order- Missed Visits” dated 09/29/2025 reads in part, “… Missed Visits; Service date: 09/29/2025 – (HHA). HHA unavailable, Patient informed. Patient will skip this visit…” Further review revealed that SN services did not document a missed visit report to the physician for the missed visit of 09/29/2025. Rather it was only the HHA services that did so, yet three days later the hospice discharged the Patient for refusing one scheduled SN visit on 09/29/2025. Even further review revealed that there was no documented indication of the multiple attempts/communication records to reschedule the SN visit within the same week and/or any other weeks after the date of 09/29/2025. Record review of document entitled, “Patient Discharge Summary” written by DON with the effective date of 10/02/2025 reads in part, “… Patient refused to see the RN for visit, would not answer the RN’s calls. DON spoke to Patient and informed her of pending discharge if we wereunable to perform a visit. Patient hung up on DON. She did not contact the RN to schedule visit. Patient discharged for cause…” Record review of document entitled, “Medicare Hospice Benefit Revocation” dated 10/02/2025 reads in part, “… Pt refused RN visit, refused RNs phone calls, DON spoke with Pt but pt refused visit, reason for discharge…” Further review revealed that Patient’s signature varied greatly from admission paperwork. Patient #12 Record review of document entitled, “Care Plan/Physician Order” dated 12/11/2025 written by written by RN C and approved by MD A for the certification period of 01/05/2026 to 04/04/2026reads in part, “… Principal Diagnosis: chronic kidney disease, unspecified… SN: 1WK13 (1 times a week for 13 weeks), PRN3 - Weekly and PRN for emergencies, requests, recerts, and decline…” Review of Patient #12’s CR revealed that SNs completed visits on the following dates:Week 1 of 01/01/2026 to 01/03/2026: not apart of the most current certification period. Week 2 of 01/04/2026 to 01/10/2026: SNs completed the ordered frequency of 1WK13 as ordered (RN A completed the visit on 01/09/2026). Week 3 of 01/11/2026 to 01/17/2026: SNs completed the ordered frequency of 1WK13 as ordered (LVN B completed the visit on 01/12/2026). Week 4 of 01/18/2026 to 01/24/2026: SNs completed the ordered frequency of 1WK13 as ordered (RN A completed the visit on 01/20/2026). Week 5 of 01/25/2026 to 01/31/2026: SNs completed the ordered frequency of 1WK13 as ordered (LVN B completed the visit on 01/25/2026). Week 6 of 02/01/2026 to 02/07/2026: SNs completed the ordered frequency of 1WK13 as ordered (RN A completed the visit on 02/04/2026). Week 7 of 02/08/2026 to 02/14/2026: SNs do not complete the ordered frequency of 1WK13 (LVN B completed 0 of 1 scheduled visit that was scheduled for 02/10/2026). Record review of document entitled, “Physician Order- Missed Visits” dated 02/12/2026 reads in part, “… Missed Visits; Service date: 02/10/2026- (SN). LVN was terminated…” Further review revealed that there was no documentation of another attempt made to rectify the missed visit within the same week. Week 8 of 02/15/2026 to 02/20/2026: SNs do not complete the ordered frequency of 1WK13.There were no missed visit reports and/or any communication records as to the reason why the visit was missed. There was no physician notification as to reason why the visit was missed. Further review revealed that SN visits abruptly stopped after the last SN visit date of 02/04/2026. Patient #12 does not receive any further SN visits for the next 2 weeks and 2 days until “revocation” date of 02/20/2026. Record review of document entitled, “Patient Discharge Summary” written by DON with the effective date of 02/20/2026 reads in part, “… Comments: Patient refused RN visit and informed the RN that he would like to be discharged. Services revoked. Informed Patient to contact us in there is any need for medical records. Admission: IDT (Interdisciplinary Team) Comments: Name- [Patient #12] Admit date- 10/07/2025 Today’s visit-10/07/2025…” Record review of document entitled, “Medicare Hospice Benefit Revocation” dated 02/20/2026 did not indicate a reason for revoking the benefit. Further review revealed that Patient’s signature varied greatly from admission paperwork. During an interview with COMP/MR/CNA on 02/26/2026 at 8:21AM. SR inquired from COMP/MR/CNA, what was the reason why you only worked three days (from 09/21/2025 to 09/24/2025) with [Hospice]? COMP/MR/CNA stated, “… Okay, when I first got started with the hospice; I had a friend (Other#1) that I was talking to awhile back that was on drugs or whatever. But the person that they (hospice) had working there named [MKR], was using her (Other#1) to go and find people to put into their hospice system. I kept telling them (MKR and Other #1) what they were doing was wrong because there was nothing wrong with the Patients that they were signing on to [Hospice]. There was absolutely nothing wrong with the Patients. But they (MKR and Other #1) signed the Patients on, and they (MKR and Other #1) were giving them (the Patients) fake diagnoses so they could get money from the State. The [MKR] was the one filling out all that admission paperwork, especially the DNRs (Do Not Resuscitate). I kept telling the [MKR] what she was doing was wrong, especially when it came to the DNRs. I asked her (MKR) once, if she (MKR) knew what that word DNR meant and she told me she did not. I had to explain that to her that if any of these Patients God Forbid it gets shot; any emergency personnel will not resuscitate them because they have a DNR on file. [MKR] did not know that. [MKR] was telling all of these Patients, especially (Patient #1 and Patient #2) to just sign the paperwork and never even told any of these Patients what they were signing up for. I kept telling them (MKR and Other #1) what they were doing was wrong; I said to them that I just don’t feel like y’all should be putting DNR on these Patients when they (Patients) are not hospice ready. That was why I only lasted the three days because I couldn’t stomach what they were doing…” During an interview with Patient #1 on 03/04/2026 at 1:18PM. SR inquired from Patient #1, can you tell me why this hospice was selected? Patient #1 stated, “I don’t even like know that.” SR inquired further, “are you in need of hospice services”? Patient #1 stated, “I think I am. I was in a car wreck about two years ago, and I really need help with my lower back area.” During an interview with Patient #1 on 03/04/2026 at 1:20PM. SR inquired from Patient #1, “do you know what hospice services entails? Patient #1, “Umm, no.” SR explained in detail as to what hospice services are. SR inquired further from Patient #1, are you aware of what your terminal diagnosis is? Patient #1 stated, “My what?? What is a terminal diagnosis?” SR explained to Patient what a terminal diagnosis means often the end prognosis (determination) would be death in less than 6 months. Patient #1 yelled, “What!!! I am not going to die! I have more years to still live. I must call my nurse because I don’t know.” During an interview with Patient #1 on 03/04/2026 at 1:23PM. SR informed Patient #1 based on Patient’s CR from the hospice, the referring terminal diagnosis listed was BXX? Patient stated, “I was not aware of that. I do not have that diagnosis. My medical diagnosis is Chronic Liver Failure. This crazy, I don’t have BXX. I never have.” During an interview with Patient #1 on 03/04/2026 at 1:28PM. SR inquired from Patient #1, who signed you up for hospice and did that individual explain to you what hospice services were? Patient #1 stated, “I believe her name was [MKR]. No, I honestly didn’t know what hospice services were until you explained to me. [MKR] never told me all that; she just told me to sign the papers and I did. But whatever she put on them papers I don’t know ma’am, but I know I told her I had liver failure. Liver Failure is all I got.” SR inquired further, if the [MKR] did not explain what hospice services were upon admission, what did [MKR] tell you about [Hospice]? Patient stated, “She just told me that, uh, I was signing up to receive narcotic (powerful but addictive drugs used to relieve severe pain and induces drowsiness or insensibility) medications that they (hospice) were going to put me on or whatever.” During an interview with Patient #2 on 03/04/2026 at 10:23AM. SR inquired from Patient #2, how did you become aware of this hospice? Patient #2 stated, “I’m not sure how I got on it. My doctors didn’t send me there.” During an interview with Patient #2 on 03/04/2026 at 10:24AM. SR inquired from Patient #2, why did you end up leaving the hospice? Patient #2 stated, “Because I was doing okay. I didn’t need what they were offering; they (the hospice) kept trying to someone to help me exercise my muscles and bones and stuff like that. I told them (the hospice) that I was doing pretty good, so I didn’t need them, you know? In my house and everything doing whatever they (the hospice) were trying to do.” During an interview with Patient #2 on 03/04/2026 at 10:27AM. SR inquired from Patient #2, were you aware as to what hospice services were and what the hospice services included? Patient #2 stated, “No. Not really, what is that (hospice)?” SR explained in detail as to what hospice services are. Patient #2 stated, “Oh… they were trying to put me on that. But I didn’t need it no more. No, I didn’t.” SR inquired further, who are they? Patient #2 stated, “I think when I was in the hospital; two little ladies came to sign me on [Hospice]. I think their names were [Other #1] and [Other #2]. They kept going on and on about how I could get narcotic medications and other stuff like a hospital bed and everything else like that. But they didn’t tell me what hospice was. I found out on my own, only a few days into it when they [Hospice] sent me all that equipment. I called them [Hospice] and I asked them what they were doing. [Hospice] said they would be sending my medicine to me and all different kinds of people would be coming into my house. I realized I didn’t want all these different people coming into my house like that. So, I left them [Hospice] as soon as I realized that because I was not dying and I am not dying anytime soon.” During an interview with Patient #2 on 03/04/2026 at 10:32AM. SR inquired from Patient #2, if the Patient was receiving services for hospice and/or home health after leaving [Hospice]? Patient #2 stated, “No, that I am with my 2 sons moving about independently in their home.” On 03/05/26 at 10:14AM; Two phone attempts were made to reach Patient #5 for interview: however, SR was unable to speak Patient #5 for interview. SR left voicemail for Patient #5 to contact SR back. SR did not receive a callback for the duration of the survey. On 03/05/26 at 10:19AM; Two phone attempts were made to reach Patient #6 for interview: however, SR was unable to speak Patient #6 for interview. SR left voicemail for Patient #6 to contact SR back. SR did not receive a callback for the duration of the survey. On 03/05/26 at 10:33AM; a phone attempt was made to reach Patient #3 for interview: however, SR was unable to speak Patient #3 for interview. SR left voicemail for Patient #3 to contact SR back. SR did not receive a callback for the duration of the survey. During an interview with LVN A on 03/06/2026 at 7:56AM. SR inquired from LVN A, why did [Hospice] terminate you? LVN A stated, “I was a brand-new nurse when I started working in with them. It was supposed to be a Hospice company, but all I knew was, you know, that I was supposed to see Patients. But the issue came when I realized when I would go to the Patients’ homes that the Patients did not look like they were hospice appropriate. I started questioning what the hospice was doing; when I started doing that was when the hospice turned on me and termed me. The last week I was there, I was blamed for not having my charts completed, and they (hospice) just randomly told me that they had to let me go for that. They (hospice) did give me an in-service; they did not give me another chance; they just terminated me. But ironically, I’m in a better position now, and I realize in hindsight that [Hospice] was running very poorly. I just didn’t really know as a new nurse what to look out for.” During an interview with LVN A on 03/06/2026 at 8:00AM. LVN A stated, “I came to find out later that a lot of the nurses that were termed were being paid at a higher rate of $75. The hospice found reasons to let the higher paid nurses go. The hospice only kept the nurses that were willing to be paid $50.” SR inquired further, so you’re saying that the Hospice at the time frame decided to let a lot of the nurses go that was being paid higher. LVN A stated, “Yes. They (hospice) kept saying we had money issues and they kept saying we need to admit as many possible Patients as possible. They kept saying that Medicare wasn’t paying them well; I don’t know the full aspect of it, but they were going through a lot of money issues. When I left the company, I found out a lot of other things were happening, besides the diagnoses changing… I found out through other people and through other nurses that left that they (the nurses) were changing the diagnoses and making up fake diagnoses for Patients. For example, they (the hospice) were giving Patients fake diagnoses of BXX; especially if the Patients were young. Some other stuff that was found was that the [MKR] was going to places like [Business A], to gas stations and just randomly selecting Patients for hospice whether they were appropriate. Sometimes the [MKR] would get the Patients off the streets. When the nurses would now go and do the initial assessments for the Patients and speak about hospice and their (the Patients) terminal diagnoses. The Patients, especially the younger ones, would yell and almost fight with the nurses that they don’t have those diagnoses that the hospice was saying that they had. Which in turn was true because the Patients did not have those diagnoses.” During an interview with LVN A on 03/06/2026 at 8:05AM. SR inquired from LVN A, who was the one changing the diagnoses of the Patients around? LVN A stated, “It was the DON and the ADM-A. They (the DON and the ADM-A) would tell the RNs to change the diagnoses around or they would do it themselves; even though it had nothing to do with the Patients true assessments at the time of the initial admission visit.” SR inquired further, who is [ADM-A]? LVN A stated, “[ADM-A] was the family member of DON. The DON would tell [ADM-A] to change the Patient’s frequencies or change the Patient’s medication orders around and/or call the doctors. But what I found crazy was that [ADM-A] was not a nurse.” During an interview with MD A on 03/06/2026 at 1:24PM. SR inquired from MD A, can you tell me when Patient #3’s diagnosis changed from Alzheimer’s disease to Heart failure, unspecified. MD A stated, “… I don’t know… I don’t know which one is primary…” SR inquired further, do you know what stage of the disease process the heart failure is in? MD A stated, “I think Stage 3. But do I know for sure? Sorry. It just says heart failure. I mean the short answer on the top of my head without looking it up. No, I don’t know the exact stage. I would have to look through all the other documentation and see what the ejection fraction is to make sure that it is stage 3, stage 4 based on the documentation. If that is in here (EMR)...” During an interview with MD A on 03/06/2026 at 1:31PM. SR inquired from MD A, can you tell me when Patient #1’s diagnosis changed from BXX to Chronic Hepatic Failure? MD A stated, “… “Oh gosh, I don’t know the exact date. I mean when I have the record up now it (EMR) says August 12th.…” SR inquired further, is the Patient now BXX free? MD A stated, “… The last time we (DON and I) had a discussion, which I think we talked about testing to make sure that that the Patient had BXX #1 (the most common and virulent (rapidly spreading) type of BXX, eventually leading to BXY if not treated) and BXX #2 (slower in progression and less virulent) and what the degree of it is. So, I mean, you can have BXX and then you can have BXY. I don’t know which stage the Patient is in right now. We would need a CD4 count (aka T-helper cells measure the number of white blood cells that fight infections in the blood, particularly in people that have BXX, and guides treatment with antiretroviral therapy. Normal range is roughly 500 to 1,500 cells per cubic millimeter (mm) of blood. A low count below 200 cells/mm is often used to diagnose BXY). To really know.” SR inquired further, was the CD4 count ever done? Do you know? MD A stated, “I don’t know. I’d have to ask him (the Patient) that.” During an interview with RN B on 03/06/2026 at 2:30PM. SR inquired from RN B, why did [Hospice] terminate you? RN B stated, “The termination was randomly done; I honestly felt like it was retaliation for them not wanting, well, me not being available to do something that they wanted me to do. And there was no conversation as the reason why I was termed or there was no attempt by them to give me a second chance or anything like that. They just ultimately fired me for no apparent reason.” SR inquired further, what did the hospice want you to do? RN B stated, “… They (hospice) essentially wanted me to be a nurse marketeer like the position that [MKR] held. They (hospice) wanted me to make up diagnoses for Patients and I told them no, I’m not doing that. Like my nursing license is on the line. I told them I need a doctor saying that this Patient even qualifies for hospice and you’re (hospice) are wanting me to go out literally door to door knocking on doors and trying to find Patients and give them random diagnoses. No, I’m not doing that. And so, because of that, they (the hospice) started trying to pick at me. They started trying to find things that were just ridiculous to put on my personnel record. Like I wasn’t documenting and/or I wasn’t visiting the Patients like I should have. You can ask any of the Patients that were in my care and any of the Patients can vouch for me. I did everything by the book.” During an interview with RN B on 03/06/2026 at 2:41PM. SR inquired from RN B, when you were with the hospice; did you notice if there was ever a time that any or the Patient assessments and/or Patients’ diagnoses were changed? RN B stated, “Yes. A lot of the Patients were given fake diagnoses by the MKR and the DON. They both (the MKR and the DON) would sign off and agree with it with the fake diagnoses. For instance, some of the younger Patients like in their 40s would be given the diagnosis of BXX, others would be given the diagnosis of CHF, CKD, and/or Alzheimer’s Disease.” SR inquired further, do you know how long that occurred for? RN B stated, “I can’t really tell you that because it was there before I was hired and I’m pretty sure it will still be there, even after I have left.” SR clarified with RN B, so this was a normal practice of the hospice. RN B stated, “Yes, ma’am.” SR inquired further, do you know if any of the MDs were aware of what was going on regarding the diagnoses being changed? RN B stated, “Well, we had a doctor called [MD C]. I don’t know the logistics of what happened, but he left, he quit, regarding an incident that happened with a Patient being sent to the hospital, the Patient was found to be over medicated with narcotics and all that. The hospital ended up calling him because he was signing off on all these narcotics for this Patient. So, he ended up quitting during that scenario and then couple months later he came back and rejoined the hospice again. I’m assuming they gave him, you know, little raise or whatever and he stayed with the company for a little bit longer. But he ended up quitting again after another situation came up with another Patient. And as far as the other two doctors, like they don’t really know anything about these Patients, I’m going to be honest with you, the hospice was just dispensing the Patients’ narcotics like a pharmacy does. Yeah, I would that’s exactly what they (hospice) were doing.” During an interview with MD A on 03/06/2026 at 1:37PM. SR inquired from MD A, can you tell me when Patient #6’s diagnosis changed from CHF to COPD? MD A stated, “I don’t know this Patient.” SR inquired from the MD A, the hospice named you as the primary MD for overall the hospice Patients; are you not the primary? MD A stated, “Oh. I’m listed on every single Patient in this hospital company as the primary…” SR restated can you tell me when Patient #6’s diagnosis changed from CHF to COPD? MD A stated, “The DON should be aware of when these diagnoses are changing… I’m not seeing any documented stage for the COPD… Please contact the DON because the DON should be aware of when and how the diagnoses are changing…” During an interview with DON on 03/06/2026 at 4:41PM. SR inquired from DON, can you tell me when Patient #5’s diagnosis changed from Alzheimer’s disease to Heart failure, unspecified. DON stated, “I would have to look that up. I don’t remember when she was admitted. And I don’t have anything that tells me when it changed, so I’m just going to have to look at every IDT to see when we changed it.” SR inquired further, do you know what happened to the Patient’s Alzheimer’s disease? DON stated, “I’m clueless as to why it was changed. The only thing I come with as the primary is heart failure. But she does have hypertension and she also has diabetes and she has Alzheimer’s. I believe they changed those diagnoses around.” SR inquired who are they? DON stated, “MD A and APRN-CNP , and the nurses were also changing the diagnoses as well. I never changed any of them around…” During an interview with DON on 03/06/2026 at 4:48PM. SR inquired from DON, what happened with Patient #1’s diagnosis of BXX? DON stated, “He and [Patient #1’s FM #1] are very difficult. He did not want the diagnosis on his record, so we had to change that.” SR inquired from the DON, are there any medical records to indicate that the Patient has BXX? DON stated, “No, I don’t have any medical records (are comprehensive legally protected documents containing one’s medical history (including diagnoses, treatments, medications, test results and progress notes from healthcare providers/clinicians).” SR inquired further, does the Patient have a PCP? DON stated, “No. But you can tell when someone has CHF from the swelling in the legs, you can tell when someone has liver failure based on the ascites (abdominal buildup fluid in the abdomen (aka peritoneal cavity)). You can tell as where the Patient’s terminal diagnoses may be based on what their initial assessments are at.” During an interview with DON on 03/06/2026 at 4:56PM. SR inquired from DON, how does the hospice ensure that the Patients are appropriate for hospice? DON stated, “The first thing that we do is that we get the admission nurse and she goes to the Patient’s home to do her assessments. Then we get the medical records from the PCP and/or the hospitals for verification of the Patients’ terminal diagnoses. Some of them have medical records and some of them don’t; like Patients #1, #5, and #6. Patients ##1, #5, and #6; do not have PCPs either. But we rely on the nurse’s assessments to do as such. Then based on the re-certification assessments do we now determine whether or not the Patient meets hospice criteria.” During an interview with ADM on 03/06/2026 at 6:32PM. SR inquired from ADM, why are diagnoses for some of the Patients such #1, #5, and #6 changing? Did they get better? ADM stated, “I am sorry I wasn’t aware…” During an interview with Patient #12 on 03/18/2026 at 10:54AM. SR inquired from Patient #12, can you tell me why did you call in the complaint? Patient #12 stated, ““I called the complaint in multiple times into the hospice first; one time around thanksgiving, around the ending of December 2025. When I would call the complaints into the hospice; they were weird about it and the hospice kept telling me to hush hush and they told me to keep quiet about it and that they would resolve my issues eventually. Three weeks after my third attempt in January went by, and I still had not heard anything. So, I finally called in the complaint into the state because I didn’t know what else I was supposed to do. I was supposed to be just getting HHA services but somehow hospice was tacked on. I don’t know when that happened, but what I do know is when the hospice started. The RN in my case; RN A never could get my medicines right. RN A kept adding medications to the docket that I have never used before in my entire life. For instance, RN A was adding B12 medications (cyanocobalamin); anyone that knows anything about B12 medications is that stuff is filled with nothing but sugar, and I am and always will be a diabetic. Honestly, the second I got it (hospice), I never got the right services from them since September of 2025. Then to top it off the RN stopped coming.” During an interview with Patient #12 on 03/18/2026 at 10:58AM. SR inquired from Patient #12, when did you notice the Hospice service was tacked on? Patient #12 stated, “Oh let’s see here; oh whenever I went to the [ER (emergency room)] for an emergency and they said that they couldn’t really keep me because I was getting hospice services, and the ER didn’t want the hospice benefit to be cancelled out. So, I left.” SR inquired further, what was the emergent situation? Patient #12 stated, “My blood sugar ended up getting very high, it was over 500 and that’s why I went to the ER. Because I never seem to get any of my insulins from the hospice, I had spare insulins from my own stock, but I never got my insulins from the hospice. I ended up having to call my PCP for help, and he was the one that prescribed me my insulins due to the urgency.” During an interview with Patient #12 on 03/18/2026 at 11:04AM. Patient #12 stated, “LVN B was my main nurse, and she came and saw me. There was another nurse as well, but I can’t remember who she was. But [LVN B]; She was amazing. She put all my meds in correctly; the LVN was amazing. RN A was the one that was putting in my docket unnecessary medications that had nothing to do with my diagnosis that was being ordered without a doctor’s order.” SR inquired further, how do you know that the doctor was not ordering the B12 medications? Patient #12 stated, “One reason is because I have never seen any doctor for B12 injections.” During an interview with Patient #12 on 03/18/2026 at 11:11AM. SR inquired from Patient #12, you were discharged on 02/20/2026, correct? Patient #12 stated, “I am not sure about that because they never came to my home to say that I was discharged or anything like that. I think I’m still on service with them…” During an interview with Patient #9 on 03/18/2026 at 3:11PM. SR inquired from Patient #9, what is your terminal diagnosis? Patient #9 stated, “what is that?” SR explained to the Patient #9, and Patient #9’s FM #1 that a terminal diagnosis means a physician as certified that a pt has less than 6 months to live, and due to this criteria, the physician will determine that the pt should be on hospice. Patient #9 stated,” HOSPICE! I am not about to kneel over and die. I have some chest pain here and there but nothing I should be dying over. Like I’m old, but I am still young, and I still have a lot of life left in me. Like I take my dogs out on a walk every day. I don’t understand.” [Patient #9’s FM #1] stated, “Hospice? What do you mean by that? There’s no way he’s on hospice; we would have known about that. Are you getting him and me confused because I know for a fact I am on hospice. Not [Patient #9], there’s no way.” During an interview with Patient #9 on 03/18/2026 at 3:17PM. SR inquired from Patient #9, Patient #9 asked, “are you sure you’re not getting us confused? This should be home health. I know for a fact that health is on the name of the Patient’s binder. Let me get the binder for you again (on the binder was displayed [Hospice]). Oh… it should read [Hospice] Health LLC. I’ve honestly never noticed the name before. But still, I’m not in hospice. Like I said, I have chest pain here and there. I use nitrates (a class of medications used to treat and prevent chest pain) for it, and it helps but the medication isn’t prescribed.” SR observed on 03/18/2026 at 3:23PM that Patient #9, went to the kitchen to obtain an unprescribed medication bottle of nitroglycerin (a fast-acting nitrate medication used to prevent and prevent chest pain (angina) by relaxing and widening the blood vessels). SR asked Patient #9, why is there no prescription label on this? Patient #9 stated, “Oh this medication bottle used to belong to [Patient #9’s FM #2] before he died.” SR asked Patient #9, your chart indicates that you have hypertension, correct? Patient #9 stated, “Yes, I do. I use lisinopril (a prescribed medication used to treat hypertension, heart failure and improve survival after a heart attack) for it. Like I said before, nothing I have that can kill me like tomorrow…” SR showed Patient #9 the Patient’s POC from the hospice on 03/18/2026 at 3:45PM. SR inquired from Patient #9, according to the POC; you see here, the POC states that you have terminal diagnosis of heart failure. Patient #9 stated, “I do not have heart failure. I have never had the diagnosis of heart failure. I am unsure why that is there at all.” SR inquired further, what diagnoses do you have? Patient stated, “My main issue is pain in my lumbar spine (lower back), I have sciatica (pain radiating from the lower back down one leg, caused by compression of the sciatic nerve, often from a herniated disk or bone spur) , I have fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive issues), I have arthritis (a disorder that causes joint inflammation, pain, stiffness, and reduction in mobility) in both knees and legs. I have a lot of musculoskeletal issues, I have issues with my teeth, and I have hypertension. Maybe they (hospice) mixed me up with [Patient #9’s FM #2] because he was [Patient #9’s FM #2], and a lot of people do that. [Patient #9’s FM #2] was the one that died with heart failure. I don’t understand why that would be there.” During an interview with Patient #9 on 03/18/2026 at 3:52PM. Patient stated, “that means all the questions that you asked me about earlier are all wrong because I did not know I was on hospice until you came in today and explained it… if I’m on hospice, I don’t want it because I know what hospice is from my [Patient #9’s FM #2] dying on it, and my [Patient #9’s FM #1] being on it. There are no issues with the services right now compared to how it was earlier. But I don’t want to take someone’s spot that might need the hospice more than I do…” During an interview with Patient #1 and Patient #14 on 03/19/2026 at 12:06PM. SR inquired from Patient #14, why Patient #14 was able to speak on the medical history of Patient #1? Patient #14 stated, “I am Patient #1’s [FM]. We are both from the same company.” SR inquired further, when you say company are you referring to the hospice? Patient #14 stated, “Yes. We both started on this company 2 weeks from the other. I was signed on first and then about 2 weeks later my [Patient #1] was signed on as well.” During an interview with Patient #1 and Patient #14 on 03/19/2026 at 12:09PM. Patient #14 stated, “Since you’re here from the state. I thought I make a direct complaint to you.” SR inquired from Patient #14, did you let the hospice know of your complaint? Patient #14 stated, “Yes, I did. I called them last week Friday (03/13/2026) and it’s been almost a week, and I haven’t heard anything back from them. I am complaining because I haven’t received any of my medications yet especially for pain. My legs have been aching something awful.” SR inquired further, how long have you been without your medications now? Patient #14 stated, “It’s going on 1 week now. This is the longest that it has been delayed. The hospice was consistent before; we’d get it (the meds) about every 2 weeks or so, but my medications are about a week late now and I’m out of some of my medications. But at the same time, I have new medications that I have never used before by a doctor I have never seen or interacted with before for diagnoses, I don’t have.” During an interview with Patient #1 and Patient #14 on 03/19/2026 at 12:13PM. SR inquired from Patient #14, if the hospice gave a reason why the Patient’s medications were late? Patient stated, “No, they (the hospice) didn’t. What they are doing is wrong. I need my medications; if I had known how this was going to be, I wouldn’t get care from them,” SR inquired further, what is your pain level on the pain scale from 0 to 10? Patient #14 stated, “It’s a 6 to 7 out 10. It feels very achy.” During an interview with Patient #14 on 03/19/2026 at 12:17PM. SR inquired from Patient #14, what is the name of the medication that you have never been prescribed before called? Patient #14 stated, “I won’t tell you, but I can show you.” SR observed that Patient #14 held a full prescription bottle of potassium chloride (potassium chloride extended release) capsule, 10 mEq (milliequivalent) 1 tab (tablet) daily oral prescribed by MD B. Patient #14 stated, “You see what I mean. It’s full because I have never used this. Can you believe that how can a doctor I have never seen before; prescribe me medications that I never used before?” SR inquired further, do the hospice SNs not go over the medications with you? Patient #14 stated, “No not really.” During an interview with Patient #14 on 03/19/2026 at 12:24PM. SR inquired from Patient #14, what terminal diagnosis do you have? Patient #14 stated, “My main diagnosis is Diabetes Type II, hypertension (high blood pressure), and osteoarthritis (in my hands and knees).” SR explained the difference between a medical diagnosis versus a terminal diagnosis. Patient #14 stated, “I have what I got.” SR inquired further, per the hospice’s CR; you have the terminal diagnosis of CHF. Patient #14 stated, “I have been with this company for years going on three now. When I first started with this company, I didn’t have CHF; I don’t understand how someone can say that you have a diagnosis that you don’t have and then give you medications for that diagnosis that you don’t have. I think the blame lies on the [MKR]; she didn’t explain to me when I started this company what hospice was. I found out for myself a year later. But crazy enough though; 1 year and half later I would end up having CHF. But initially I didn’t have CHF.” During an interview with Patient #14 on 03/19/2026 at 12:29PM. SR inquired from Patient #14, you mentioned that you’re getting medications for diagnoses that you don’t have; can you tell me if you still have a PCP? Patient #14 stated, “Yes. I do. Initially when I started with this company, I took all the medications that they were giving me; I was so sick for 6 months on end, and finally I had to go to my PCP because I couldn’t understand what was going on with me. I saw my PCP 6 weeks ago; my PCP told me that all those medications that I was taking from the hospice messed up my liver and kidneys. My PCP quickly took me off all of them meds and told me not to take what the hospice MDs or whoever is prescribing me whatever.” SR reviewed Patient #14’s medications with the Patient on 03/19/2026 at 1:00PM to 1:09PM. During an interview with Patient #1 and Patient #14 on 03/19/2026 at 1:15PM. SR inquired from Patient #14, when you were initially admitted to [Hospice]; did any of the hospice staff, especially the nurses or administrative staff explain what hospice was to you? Patient #14 stated, “I wont lie for any of these people. I am at the ripe age of 85 years old; I’ve lived a full life, but I believe I still have more years of living left. But no, a nurse did not explain anything to me about hospice. As I mentioned before, the person that signed me up was [MKR]. I am not going to lie, whatever [MKR] was writing on the admission paperwork was very small and not legible to me; I couldn’t read it at all, but she said sign, and I signed the paperwork.” During an interview with Patient #1 and Patient #14 on 03/19/2026 at 1:18PM. SR inquired from Patient #14, have you seen the hospice MDs and/or APRN-CNP for your face-to-face visits to be able to address the concerns of medications you have never used before. Patient #14 stated, “I have never seen the hospice physician. I have never seen the hospice APRN-CNP either in the three years I have been with this company. I have seen the nurses and my HHA and that is about it.” Record review of the hospice’s administrative policy manual entitled, “Patient’s Rights and Responsibilities” last reviewed on 10/01/2021 pages 1 to 4 reads in part, “Purpose: To ensure the Patient, their representative (if any), and the Hospice staff acknowledge, protect, observe,and implement the Patient’s rights and responsibilities… Policy: I. During the initial assessment visit and in advance of furnishing care, the Hospice will provide the Patient and/or representative with verbal and written notice of the Patient’s rights and responsibilities in a language and manner that the Patient or representative understands… Procedure: I. The Hospice staff will be responsible for knowing, observing, and implementing the Patient’s rights and Patient responsibilities on an ongoing basis. The staff will also be responsible for protecting and promoting these rights… II. A copy of the notice of the Patients of rights and responsibilities will be given to the Patient at the time of Patient’s initial assessment and prior to admission to the Hospice. A. The Hospice will ensure that the Patient understands his or her rights and how to exercise them. If necessary, the hospice will provide assistance to the Patient and/or representative in understanding and exercising these rights… V. Exercise of rights and respect for property and person, the Patient has the right: To exercise his or her rights as a Patient of the Hospice; To have his or her property and person treated with respect, including privacy in treatment and care; To voice grievances regarding treatment or care that is (or fails to be) furnished and the lack of respect for property by anyone who is furnishing services on behalf of the Hospice; and To not be subjected to discrimination or reprisal for exercising his or her rights… IX. Regarding Patient’s rights, the Patient has a right to the following: To be involved in developing his or her Hospice Plan of Care and to receive all services outlined in the Plan of Care; To refuse care or treatment. To choose his or her Attending Physician… To be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of Patient property; To receive information about the services covered under the Hospice benefit, including the extent payment is expected, and specific limitations on those services… To receive an investigation by the organization of complaints made by the Patient or the Patient’s family or guardian regarding treatment or care and that the organization will document the existence of the complaint and the resolution of the complaint… M. Receive proper written notice, in advance of a specific service being furnished, if the Hospice believes that the service may be non-covered care; or in advance of the Hospice reducing or terminating on-going care… P. Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect, and misappropriation of Patient property, and to be informed that corporal punishment is prohibited…” Record review of the hospice’s administrative policy manual entitled, “Patient’s Rights and Responsibilities- Addendum” last reviewed on 05/01/2023 pages 1 to 2 reads in part, “Purpose: I. In addition to the Purpose statement defined in the Patient Rights and Responsibilities policy in the Rights and Ethics section of the Administrative Policy Manual, the following statement will apply: A. To ensure the Hospice is in compliance with the state’s requirements regarding the rights of the elderly… Policy: I. In addition to the requirements defined in the Patient Rights and Responsibilities policy in the Rights and Ethics section of the Administrative Policy Manual, the following requirement will apply: A. The Hospice will comply and follow the provisions of the Texas Human Resources Code, Chapter 102, “Rights of the Elderly”. Procedure: In addition to the requirements defined in the Patient Rights and Responsibilities policy in the Rightssection of the Administrative Policy Manual, the following requirements will be met: A. In accordance with the Rights of the Elderly requirements, the Hospice will:Provide a written list regarding the Rights of the Elderly, (in a manner that the Patient can understand) to each elderly individual and/or representative in advance of furnishing care or during the initial evaluation visit before the initiation of treatment… Per the Texas Administrative Code, the Patient has the right to:Be informed in advance about expected outcomes, barriers to treatment and any changes in the care to be furnished;Be informed, before care is initiated, of the extent to which payment may be expected from the Patient, a third-party payer, and any other source of funding known to the Hospice; Participate in planning a change in the care or treatment;Have assistance in understanding and exercising the Patient rights;Have his or her person and property treated with consideration and full recognition of his or her individuality and personal needs. The Hospice must advise or consult with the Patient or legal representative in advance of any change in the care or treatment.The Hospice must maintain documentation showing that it has complied with the requirements mentioned in Procedure I.A, and that the Patient demonstrates understanding of the Patient’s rights…””

“It is required that the hospice has a written Patient Bill of Rights and Responsibilities (Bill of Rights). The patient has the right to be informed of his or her rights and responsibilities, and the hospice defines, protects, and promotes the exercise of these rights. This is a CONTINUING CMS CONDITION LEVEL DEFIENCY. This CONDITION was not met, as evidenced by clinical record reviews, observation, and interviews with the Director of Nursing which revealed the hospice: Failed to provide the patient, or his or her representative, with written notice of the patient’s rights and responsibilities [HPFC.3.I/L502/ 418.52(a)(1)]; Failed to distribute to the patient written information about its policies on advance directives, including a description of applicable state law [HPFC.9.D/L503/418.52(a)(2)]; and Failed to ensure the patient received effective pain management [HPFC.2.D/L512/418.52(c)(1)]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.52: Patient Rights. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the hospice agency.”

“It is required that during the initial assessment visit and in advance of providing care, the hospice provides the patient—or his or her representative—with verbal (meaning spoken) and written notice of the patient’s rights and responsibilities. This standard was not met as evidenced by interview and observation. In 1 of 1 (100%) home visits observed, it was revealed that the agency did not ensure that the patient received written notice of the patient’s rights and responsibilities in advance of providing care. Agency policy RI.10, Patient Rights and Responsibilities (last updated 10/01/2021), read in part, “During the initial assessment visit and in advance of furnishing care, the Hospice will provide the patient and/or representative with verbal and written notice of the patient’s rights and responsibilities.” CLINICAL RECORD 1/Home Visit 1: The patient elected the hospice benefit on 04/09/2025 with a diagnosis of Heart Failure and Chronic Obstructive Pulmonary Disease. The clinical record contained a signed consent form dated 04/09/2025. The signed form included an election of hospice benefit which had a statement that read, “ I acknowledge I have received a copy along with a verbal explanation of the following: Patient rights and responsibilities and patient choice statement, rights of the elderly, advance directives information, HIPAA/notice of privacy information, abuse, neglect, and exploitation policy, emergency preparedness information, home safety information, hospice drug disposal policy. Medicare Part D information and expected death.” During the home visit, with the Registered Nurse (RN) (Personnel Record 1), on 05/05/2025, the patient and daughter reported in an interview with the writer that they did not receive a patient handbook or other written information upon election of hospice, nor copies of the information that was signed. The RN reported that she was waiting for more (Patient Handbooks) to be printed, and she would bring one at the next visit. In an interview with the RN on 05/05/2025, during the home visit, the RN confirmed she admitted the patient and did not have copies of the patient handbooks available to give the patient and intended to provide one at the next visit. Reported that she would get one for the patient at the next visit. Upon return to the office the RN asked the office staff to make copies of the patient handbook. In an interview on 05/05/2025, the Director of Nursing stated, “We don’t leave the forms with the patient until the doctor signs the DNR (Do Not Resuscitate) order. Once we receive it back signed, we provide the patient with a copy of all of the forms they signed.””

“It is required that the hospice informs and distributes to the patient written information about its policies on advance directives, including a description of applicable state law. The hospice provides written information to patients about their rights under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives at the individual’s option. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 1 of 1 (100%) home visits observed revealed that the agency did not ensure that the patient received written information related to Advanced Directives. Agency Policy RI.10, Patient’s Rights and Responsibilities (last updated 10/01/2021), stated in part, “Procedure III. The hospice will verbally inform and distribute written information in a manner that they can understand, to the patient and /or representative concerning its policies on Advance Directives, including a description of applicable law.” CLINICAL RECORD 1/Home Visit 1: The patient elected the hospice benefit on 04/09/2025 with a diagnosis of Heart Failure and Chronic Obstructive Pulmonary Disease. The clinical record contained a signed consent form dated 04/09/2025. The signed form included an election of hospice benefit which had a statement that read in part, “ I acknowledge I have received a copy along with a verbal explanation of the following: Patient rights and responsibilities and patient choice statement, rights of the elderly, advance directives information.” During the home visit, with the Registered Nurse (RN) (Personnel Record 1), on 05/05/2025, the patient and daughter reported in an interview that they were not provided a patient handbook, or any written information on advanced directives, upon admission to hospice. In an interview with the RN on 05/05/2025, during the home visit, the RN confirmed she admitted the patient and did not have copies of the patient handbooks available to give the patient and intended to provide one at the next visit. Reported that she would get one for the patient at the next visit. Upon return to the office the RN asked the office staff to make copies of the patient handbook. In an interview on 05/05/2025, the Director of Nursing stated, “We don’t leave the forms with the patient until the doctor signs the DNR (Do Not Resuscitate) order. Once we receive it back signed, we provide the patient with a copy of all of the forms they signed.””

“It is required that the written Patient Bill of Rights includes the right to receive effective pain management and symptom control for conditions related to the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed it was revealed that the agency did not ensure the patient received effective pain management. CLINICAL RECORD 2: The patient elected the hospice benefit on 03/29/2025 with a diagnosis of COPD. Skilled nursing assessment upon admission documented in part that the patient, “has a history of falls and is unable to ambulate due to a fractured hip and the patient has an open traumatic wound to the right lower shin. Patient reported a pain level of 8 out of 10 and reported that acceptable pain would be a level 2. Hydrocodone bitartrate/acetaminophen (Norco 10 mg-325 mg tablet) 1-tab, TID PRN (three times a day, as needed) for pain ordered.” On 04/12/2025, the nurse documented that the patient reported the pain level as 8 out of 10. Patient reported that the pain was constant, somewhat relieved by opioids and repositioning. Nurse documented, “Patient states he has aching, throbbing, burning pain to the lower extremities. Patient reported taking hydrocodone every 4-6 hours. The nurse instructed patient to try to relax, listen to music and use guided imagery. The nurse documented, “the patient was made aware that he will run out of medications before the next refill if he takes the medications more than every eight hours.” The patient transferred to another hospice on 04/21/2025; between 04/12/2025 and 04/21/2025 the record lacked documented evidence the physician was notified that the current pain medication order was not effective and lacked documented evidence of follow-up with patient regarding pain management. The Director of Nursing stated in an interview on 05/05/2025, “We were having a problem with the pharmacy, and they would not fill prescriptions for Norco that were more than three times per day so we just couldn’t get it. We have gotten it corrected now.””

“It is required that drugs and biologicals related to the palliation and management of the terminal illness and related conditions are routinely available on some 24-hour basis/7 days a week. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 1(100%) of home visits observed it was revealed that the agency did not ensure drugs related to the terminal illness and related conditions were available to the patient. Home Visit 1/Clinical Record 1: The patient elected the hospice benefit on 04/09/2025 with a diagnosis of heart failure and chronic obstructive pulmonary disease (COPD). During the home visit, on 05/05/2025, with the Registered Nurse (RN) (Personnel Record 1) the patient’s medications were reviewed. The patient reported that she was out of Baclofen and the “pink pill” for nausea and reported that she does not take the Anoro inhaler (that was included on her medication list) because it was $600 and she “cannot afford it.” The RN asked the patient if she had tried using discount drug cards, she reports she had tried but all she can afford was Albuterol. The RN reconciled all medications that were empty and reported that the patient chose to get some prescriptions filled at her own pharmacy and now wants the hospice to fill them all. The medication profile, in the hospice record, included: Anoro Ellipta 62.5/25mcg, 1 puff daily, Covered YES. The Anoro inhaler was included on the hospice medication profile, as a covered medication, however it was not made available and provided to the patient. In an interview with the RN on home visit on 05/05/2025, the site visitor asked the nurse why the inhaler was not covered, the nurse answered, “I don’t know, I am just the nurse.” The Director of Nursing also stated, “I will talk to the nurse.””

“It is required that the hospice has a written Patient Bill of Rights and Responsibilities (Bill of Rights). The patient has the right to be informed of his or her rights and responsibilities, and the hospice defines, protects, and promotes the exercise of these rights. This is a CMS CONDITION LEVEL DEFIENCY This CONDITION was not met, as evidenced by clinical record review, and interview. The hospice failed to ensure that the patient’s right to be free from mistreatment, verbal, mental, or physical abuse, including injuries of unknown source, and the misappropriation of patient property was protected [HPFC.2.D/L517/ 418.52(c)(6)]; and Failure of the hospice to ensure alleged mistreatment, physical abuse, and injuries were reported in accordance with the standard and agency policy [HPFC.7.D/L508/418.52(b)(4)(i). The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.52: Patient Rights. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the hospice agency.”

“It is required that the hospice has a defined process to ensure that all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source or misappropriation of patient/family property by anyone furnishing services on behalf of the hospice, are reported immediately by the hospice employee to the hospice administrator; or by the contracted hospice staff to the hospice administrator. 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 alleged mistreatment, physical abuse, and injuries were reported in accordance with the standard and agency policy. Document: Rights and Responsibilities Policy read in part: Rights and Responsibilities Hospice Responsibilities 13. To comply with the following regarding alleged abuse, neglect, and exploitation: a. Ensure that all alleged violations involving mistreatment, neglect, verbal, mental, sexual, and physical abuse, including injuries of unknown source, are reported immediately by Hospice employees and contracted staff to the Hospice Administrator. b. Immediately investigate all alleged violations involving anyone furnishing services on behalf of alleged violation is being verified. Investigations and/or documentation of all alleged violations must be conducted in accordance with established procedures.” CLINICAL RECORD 15: A review of the clinical record identified that the patient elected hospice care on 09/19/2024. The diagnoses were Primary diagnosis: Heart failure unspecified, Secondary DX: hypertension, ASHD, anxiety, depression, and history double bypass. The discharge summary dated 11/15/2024 documented, “Patient was physically abused by her daughter. Admitted to the hospital, APS involved”. .” There was no documented evidence that the abuse was reported internally as required by their policy and to APS as per state requirements. During a joint clinical record review and interview on 03/25/2025, the DON confirmed that an incident report was not documented. She expressed uncertainty about whether the agency or the hospital initiated the Adult Protective Services (APS) referral. The DON confirmed that there was no evidence indicating that the hospice agency reported the alleged abuse to APS and reiterated that the patients social worker was no longer employed by the agency.”

“It is required that the written Patient Bill of Rights includes the right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 19 (5%) clinical record reviews, the agency did not ensure that the patient’s right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source, and the misappropriation of patient property was protected. DOCUMENT 4: Agency policy Abuse, Neglect and Exploitation Policy PC.15, stated, in part: “Patients have the right to be free from mistreatment, neglect or verbal, mental, sexual and physical abuse....”. CLINICAL RECORD 15: A review of the clinical record identified that the patient elected hospice care on 09/19/2024. The diagnoses were Primary diagnosis: Heart failure unspecified, Secondary DX: hypertension, ASHD, anxiety, depression, and history double bypass. The patient’s date of discharge was 11/15/2024. There was no documentation in the clinical record that included protecting the patients rights related to the allegation of physical abuse and the hospitalization. The discharge summary dated 11/15/2024 documented, “Patient was physically abused by her daughter. Admitted to the hospital, APS involved.” The clinical record did not contain any documented evidence of suspected abuse in her home residence prior to the discharge summary. During a joint clinical record review and interview on 03/25/2025, the Director of Nursing (DON) confirmed that an incident report had not been documented, and she was unaware of when it was identified. She also stated that the patient’s social worker was no longer employed by the hospice agency. The DON acknowledged that the medical record lacked documentation supporting the alleged abuse and hospitalization included in the discharge summary.”

“It is required that the written Patient Bill of Rights includes the right to receive information about the services covered under the hospice benefit. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for discharged patients revealed that the agency did not ensure the patient received information about the services covered under the hospice benefit and the discharge process. Document: Rights and Responsibilities Policy read in part: Rights and Responsibilities Patient Rights The Law provides certain rights to all hospice patients. Each patient has a right to be informed of his or her rights, to exercise his or her rights, as well as have his or her rights protected and promoted. These include the right to: 20. Receive proper written notice, in advance of a specific service being furnished, if the Hospice believes that the service may be non-covered care; or in advance of the Hospice reducing or terminating on-going care. The Hospice must also comply with the requirements of 42 CFR 405.1200 through 405.1204 {relating to the Notice of Non-Coverage}. DOCUMENT 5: Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, not dated, stated in part, “A Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as “plans”) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Note: The two day advance requirement is not a 48 hour requirement. This notice fulfills the requirement at 42 CFR 405.1200(b)(1) and (2) and 42 CFR 422.624(b)(1) and (2). Medicare providers are responsible for the delivery of the NOMNC. The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed.” CLINICAL RECORD 16: A review of the clinical record identified the patient elected hospice care on 04/19/2024. The patient’s date of discharge was 01/13/2025. The record did not contain evidence that the Notice of Medicare Non-Coverage (NOMNC) and at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. During a clinical record review, document review, and interview on 03/27/2025, the Director of Nursing (DON) confirmed that the patient did not receive the Notice of Medicare Non-Coverage or a 2-day discharge notification.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile. Clinical Record 9/HOME VISIT 2: A review of the clinical record identified the patient elected hospice on 09/30/2024. The hospice diagnosis was Parkinson’s and comorbidities of hypertension and heart failure. During the home visit, the medication profile printed on 03/25/2025 included Baclofen 10 mg oral tablet, take one tablet by mouth three times a day, started 09/30/2024, and Gabapentin 300 mg oral capsule, take one capsule by mouth three times a day, started 09/30/2024. The patient reported receiving steroid injections for his back and has not been taking baclofen or gabapentin for one to two years. There were no medication bottles for Baclofen and Gabapentin with the other medication bottles or in the home per the patient. The Hospice RN [registered nurse ] Recertification Visit dated 03/19/2025 stated in part, “Taking Gabapentin/Baclofen for neuropathy pain”. The Medication Profile included medications the patient was not currently taking. During the home visit, the medication bottles revealed Carvedilol 3.125 mg tablet, take one tablet twice a day; Atorvastatin 10 mg tablet, take one tablet at bedtime; and Aspirin 81 mg tablet, take one tablet daily. The patient reported taking these medications “for a long time.” The patient reported taking ibuprofen over-the-counter, one to two tablets three times a day as needed for pain. Carvedilol, Atorvastatin, and Ibuprofen were not included on the medication profile. There was no documented evidence that a medication review was completed to include all the medications the patient was taking at the time of the comprehensive assessment dated 03/19/2025 During a joint record review and interview on 03/26/2025, the Director of Nursing confirmed that there was no documented evidence the medications were reconciled at the time of each comprehensive assessment and updated to the drug profile.”

“It is required that update of the comprehensive assessment is completed by the hospice Interdisciplinary Group (IDG), who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes: Information on the patient’s progress toward desired outcomes; reassessment of the patient’s response to care; the assessment update is completed: as frequently as the condition of the patient requires; no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) of clinical records reviewed revealed the hospice did not ensure that IDG updated the comprehensive assessment in response to changes that had occurred and reassessed the patient’s condition. CLINICAL RECORD 15: A review of the record identified the patient elected hospice care on 09/19/2024. The discharge summary dated 11/15/2024 documented, “Patient was physically abused by her daughter. Admitted to the hospital, APS involved. Patient is receiving services in a residential shelter for victims of family abuse.” The clinical record did not contain documented evidence revealing that the Interdisciplinary Group (IDG) addressed the report of abuse or updated the comprehensive assessment and responded to the patient’s needs. Additionally, the clinical notes lacked clarity on how the agency became aware of the physical abuse and when they first responded to this information as first identified in the discharge summary. During a joint clinical record review and interview on 03/25/2025, the Director of Nursing confirmed that an incident report was not documented. The DON was unsure if the agency or the hospital initiated the APS referral. The DON reported that the patient’s social worker was no longer with the hospice agency. The DON confirmed that the record lacked evidence of documentation supporting the discharge.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 1 of 4 (25%) home visit observations revealed the agency did not ensure the staff followed the agency’s hand hygiene policy. DOCUMENT 3: Agency Policy: Hand Hygiene IC.15, last reviewed 09/01/2024, stated in part, “Hand Hygiene with Soap and Water: Staff will identify and gather appropriate supplies. Staff will wet hands and wrists with water using temperature that is comfortable. Staff will apply the amount of product recommended by the manufacturer to hands and rub hands together vigorously for at least 15 seconds (with the recommendation of 20 seconds, but either time is acceptable), covering all surfaces of the hands and fingers. Staff will rinse hands and wrists thoroughly with water. With hands held upright, staff will dry hands and wrists thoroughly with a clean paper towel. They will use a paper towel to turn off the faucet.” HOME VISIT 3: During the home visit (Clinical Record 4) on 03/26/2025 with the Registered Nurse (RN) (Personnel Record 5), the RN was observed to wet their hands and use bar soap. After lathering the hands, the RN rinsed them with water and turned off the water with a wet wrist. The RN used a hand towel hanging on the wall. During an interview on 03/26/2025, the Director of Nursing agreed the staff did not follow the hand hygiene policy.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed revealed that the agency did not ensure physician orders were included for patient discharges. Agency Policy: Patient Discharge PE.20, last reviewed 09/01/2024, stated in part, “Prior to discharging a patient for any reason other than a patient revocation, transfer, or death, the hospice must obtain a written physician’s discharge order from the hospice medical director. If a patient has an attending physician involved in his or her care, this physician should be consulted before discharge and his or her review and decision included in the discharge note.” CLINICAL RECORD 15: The patient’s election of benefits was dated 09/19/2024. The patient’s date of discharge was 11/15/2024. A review of the clinical record on 03/27/2025 revealed there was no documented evidence of a physician’s order for the live discharge in accordance with agency policy. CLINICAL RECORD 16: The patient’s date of discharge was 01/13/2025. A review of the clinical record on 03/27/2025 revealed there was no documented evidence of a physician’s order for the live discharge in accordance with agency policy and § 418.26 (b). During a joint record review and interview with the Director of Nursing (DON) on 03/27/2025, the DON confirmed that the records lacked evidence of physician’s orders for the live discharges.”

“It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. This standard was not met as evidenced by document review and interview. In 1 of 19 (5%) clinical records revealed that the agency did not ensure that patient records were complete, appropriately authenticated, and dated. CLINICAL RECORD 16: The patient’s date of election was identified as of 04/19/2024. The patient’s date of discharge was 01/13/2025. The discharge summary dated 01/13/2025 stated in part, “Patient is drug seeking and being very verbally abusive to staff. Services revoked. Unable to update care plan, all goals were met while on hospice services.” The record contained a revocation form signed by the patient and dated 01/13/2025. The DON stated that the revocation form was pre-signed on admission, which was kept in the office and placed in the patient’s record to be used if needed. During a joint clinical and document review and interview on 03/27/2025, the Director of Nursing (DON) stated that the patient was a live discharge due to the behavior. The DON reported that the patient did not initiate the discharge process. The DON stated that the agency has patients “sign the revocation form at admission in the event they were to go to the hospital, the agency would not need to track them down to sign the form.””

“It is required that if a patient revokes the election of hospice care or is discharged hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review, and interview. 2 of 2 (100%) clinical records for discharged patients reviewed, revealed that the agency did not ensure that a copy of the discharge summary was sent to the physician and did not follow the discharge for cause per hospice regulation §418.26 with regard to advising the patient of the discharge for cause consideration, making efforts to resolve the problem presented the by the patient’s behavior, documentation of the problem, efforts for resolution, and obtaining a written physician discharge order. DOCUMENT 1: Agency Policy: Patient Discharge PE.20, last reviewed 09/01/2024, stated in part, “The Hospice may discharge a patient if: There is discharge for cause when the patient’s or other persons in the patient’s home behavior is disruptive, abusive, or uncooperative, to the extent that delivery of care to the patient or the ability of the Hospice to Action Plan Summary operate effectively is seriously impaired... Discharge for cause: If the Hospice determines, under a policy set by the Hospice and state and federal law, for the purpose of addressing discharge for cause that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the Hospice to operate effectively is seriously impaired, the Hospice will do the following before it seeks to discharge a patient for cause: advise the patient that a discharge for cause is being considered; make a serious effort to resolve the problem (s) presented by the patient’s behavior or situation to include members of the IDG/IDT [Interdisciplinary Group/Interdisciplinary Team]; ascertain that the patient’s proposed discharge is not due to the patient’s use of necessary hospice services; and document the problem(s) and efforts made to resolve the problem (s) and enter this documentation into the medical records. The Hospice must notify the Medicare contractor and State Survey Agency of the circumstances surrounding the impending discharge. The Hospice may also need to make referrals to other relevant state/community agencies (i.e., Adult Protective Services) as appropriate.” CLINICAL RECORD 16: A review of the clinical record identified the patient elected hospice care on 04/19/2024. The hospice diagnosis was chronic obstructive pulmonary disease. The patient’s date of live discharge was 01/13/2025. The discharge summary dated 01/13/2025 stated in part, “Patient is drug seeking and being very verbally abusive to staff. Services revoked. Unable to update care plan, all goals were met while on hospice services.” The RN Visit Routine note dated 12/16/2024, 12/31/2024, and 01/13/2025 lacked documented evidence of abusive and drug-seeking behaviors. The LPN/LVN Visit notes dated 12/14/2024, 12/27/2024, and 01/10/2025 lacked documented evidence of abusive and drug-seeking behaviors. The MSW - Routine Visit dated 01/10/2025 lacked documented evidence of abusive and drug-seeking behaviors. The patient’s medication record revealed acetaminophen/hydrocodone 325/7.5 mg tablet, one tablet three times a day for pain, morphine ER 15mg tablet, one tablet twice a day for pain, and gabapentin capsule 400 mg, one capsule three times a day. The record lacked documentation that the discharge summary was forwarded to the patient’s attending physician. There was no documented evidence in the clinical record that the patient was informed that a discharge for cause was being considered, and any efforts to resolve the issue. During a phone interview with the registered nurse case manager on 03/25/2025, the registered nurse (RN) reported that “there would be times when he would say borderline inappropriate things, being derogatory, and demanding. The patient would change things around at the last minute. The patient was still working.” The RN reported the patient “talking about pain medications not working. The patient wanted to go up on his Norco because he was having chest pain and a cough. The patient was told that guaifenesin or prednisone for a cough and not an increase of pain medication. The daughter called and said the patient was allergic to morphine and wanted to go back to Norco.” The RN stated, ‘I don’t remember the details from 01/13/2025. He used alcohol and I felt unsafe. The patient was slurring words. The patient had a look about [the face] and not talking very much. When the patient talked about the medications, I could smell alcohol. The patient raised [the] voice and wanted to change the medications.” The RN stated that the DON was notified of the incident. During a joint clinical and document review on 03/25/2025, the Director of Nursing (DON) stated that the registered nurse (RN) reported the patient was being verbally abusive when on the phone. The DON reported that when the RN visited, the patient was verbally abusive and drug-seeking. The DON stated that the nurses usually take medications to the patients on Mondays. After reviewing the discharge policy, the DON confirmed that the agency did not follow the requirements for discharge for cause in their Patient Discharge PE.20 policy and hospice regulation 418.26. CLINICAL RECORD 15: A review of the clinical record identified that the patient elected hospice care on 09/19/2024. The diagnoses were Primary diagnosis: Heart failure unspecified, Secondary DX: hypertension, ASHD, anxiety, depression, and history double bypass. The discharge summary dated 11/15/2024 lacked documentation that the discharge summary was forwarded to the patient’s attending physician. During a joint clinical and document review on 03/27/2025, the Director of Nursing (DON) confirmed that the records lacked evidence that the discharge summary was forwarded to the patient’s attending physician. The DON stated that the discharge summary is only sent for transfers.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. CLINICAL RECORD 15: A review of the clinical record identified that the patient elected hospice care on 09/19/2024.The date of the transfer was 11/15/2024. The discharge summary did not include a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. CLINICAL RECORD 16: A review of the clinical record identified that the patient elected hospice care on 04/19/2024. The date of the revocation was 01/13/2025. The discharge summary did not include a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. During a joint record review and interview on 05/08/2024, the Director of Nursing confirmed that the record lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management.”

“Based on record reviews and interview one of the members (Social Worker) of the IDG failed to complete the comprehensive assessment to identify the patient/family psychosocial and contribute to the development of the plan of care to address those needs in timely manner for 1 of 21 clients (#19) whose records were reviewed. Social worker did not complete the initial psychosocial assessment of client #19 no later than five days as required but completed 5 days late. This failure may have negative outcomes on the clients/families due to IDT not identifying clients need for psychosocial in a timely manner. Findings include: Patient #19 Record review of patient #19’s clinical record revealed a terminal diagnosis of Liver Disease with a start of care dated 09/20/2023. Further review of the clinical record revealed Social Worker admission assessment signed and dated by social worker B completed on 09/30/2023 which was five days late. During an interview on 02/29/2024 at 12:35 p.m. with supervising nurse was responsible for ensuring that assessments were completed within required timeframe, surveyor asked why patient #19 psychosocial assessment not completed no later than five calendar days after the election of the Hospice benefit 09/20/2023. Hospice supervising nurse said, “;I dont know why it was not completed no later than five days.” Hospice owner said, “;usually we go over and audit every assessment, but this slipped.” Policy: Review of the agency policy last reviewed 013124, page 1 and 2 titled; “PATIENT ASSESSMENT” read in part. “;The Hospice will conduct and documenting in writing a patient-specific comprehensive assessment that identifies the patients need for Hospice care and services, and the patients need for physical, psychosocial, emotional, and spiritual care. the interdisciplinary group/team (IDG/IDT in consultation with patients attending physician if any will complete the comprehensive assessment no later than five calendar days after the election of the Hospice benefit. The IDG/IDT will review the information gather from the initial assessment as they develop the POC, and the group determines who should visit the patient or family during the first five days of Hospice care in accordance with patient and or family needs and desire and the hospice’s own policy and procedure. Each qualified disciplines standard of practice will be referenced for completion of the initial and comprehensive assessment.”