Life Wave Hospice Care LLC

“Based on interview and record review the Hospice Agency failed to retain death and discharge patient clinical records following initial certification in 2022, in that:The agency could did not retain patient’s records for at least 6 years for 5 of 5 patients (Patients #1, # 2, 3, 4, and #5) discharged in 2022.This failure could place the agency’s future Hospice patients at risk of harm due to failure of the agency to protect and maintain service information. Findings include:On 10/28/25 at 11:50 AM during the entrance conference the administrator informed the surveyor that there were no active patients, and the last patients were when the accreditation organization did the initial certification in 2022. The surveyor requested for the list of patients surveyed by AO from 10/24/2022 to 10/26/2022.At 2:00pm Adm/DON informed the surveyor that the consultant used by the agency for the initial survey with AO went with all the patient’s records and the agency did not have access to all five clinical records except the consents signed for service.At 2:17pm Adm/DON provided a list of five patients Adm/DON obtained from the AO website.Review of the list of patients revealed:Patient #1’s SOC date of 03/08/2022 and discharge/transferred date of 10/28/2022. Terminal diagnosis of CVA (CEREBROVASCULAR ACCIDENT (CVA) is the medical term for stroke. A stroke occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) with visits frequencies of SN once a week, 2 as needed visits, MSW once a month; chaplain once a month, Aide two times a week.Patient #2’s SOC date of 09/06/2022 and discharge/deceased date of 10/06/2022. Terminal diagnosis of colon cancer (also known as colorectal cancer, is a type of cancer that begins in the large intestine) with visits frequencies of SN once a week, two as needed visits, MSW once a month; chaplain once a month, Aide two times a week.Patient #3’s SOC date of 09/09/2022 and discharge/hospitalized date of 10/27/2022. Terminal diagnosis of COPD (Chronic obstructive pulmonary disease (COPD) is an ongoing lung condition caused by damage to the lungs.) with visits frequencies of SN once a week, two as needed visits, MSW once a month; chaplain once a month, Aide two times a week.Patient #4’s SOC date of 09/28/2022 and discharge/transferred date of 10/27/2022. Terminal diagnosis of heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and oxygen.) with visits frequencies of SN once a week, 2 as needed visits, MSW once a month; chaplain once a month, Aide two times a week.Patient #5’s SOC date of 10/11/2022 and discharge/transferred date of 10/26/2022. Terminal diagnosis of COPD (Chronic obstructive pulmonary disease (COPD) is an ongoing lung condition caused by damage to the lungs.) with visits frequencies of SN once a week, two as needed visits, MSW once a month; chaplain once a month, Aide two times a week. During interview on 10/29/2025 with the Adm/DON at 11:25am, the surveyor asked for the person in charge of the patient’s clinical records. Adm/DON stated that former Adm and consultant (CN/ADM) was responsible during the survey in 2022 and discovered that the records, except consents for services were not in each patient’s chart during an audit on or before September 2023. Adm/DON added that she was present during the survey in 2022, but the former consultant (CN/ADM) was in charge. During a telephone interview on 10/29/2025 with the former consultant (CN/ADM) at 2:27pm, the former consultant (CN/ADM) validated that she consults for the agency and other agencies owned by the Adm/DON and was hired as the Adm/DON for hospice agency’s initial survey in 2022. The surveyor asked for the number of patients, services provided, and staff that saw the patients in 2022. The former consultant (CN/ADM) stated five non-billable patients were seen for the purpose of the initial survey of the hospice agency. The former consultant (CN/ADM) stated the patients were seen by the group of staff that collaborated with her, including a chaplain, social worker, and an Aide. CN/ADM indicated she was the nurse and conducted home visit with the AO staff in 2022. The former consultant (CN/ADM) narrated that she and her consulting members were only hired to conduct the initial survey for the agency, and the contract was terminated at the completion of the 3-day survey conducted by the AO. The surveyor requested clinical records of the five non-billable patients. The former consultant (CN/ADM) stated that she did not have or have access to the records after the survey. The surveyor asked for who had the records and who was responsible for retention of the records. The former consultant (CN/ADM) stated, “It is the agency that is responsible for retaining patient’s records. I never took any of those records, everything was printed out and kept in the office inside a filing cabinet. How can I take something that has the agency names written all over and against the law? It is HIPAA violation, and we do not even have the key to the cabinet.” The former consultant (CN/ADM) added that Adm/DON had contacted her for clinical records of the patients, and she had told Adm/DON the same thing. The former consultant (CN/ADM) stated Adm/DON was present during the initial survey and very much aware of everything about the survey.During a follow up interview on 10/29/2025 with the Adm/DON at 3:20 p.m., the surveyor asked for the agency’s policy on discharged patient’s clinical record retention and who was responsible for retention of records. Adm/Don stated, “we are to keep the records 10 years after death or discharge. I know it is my responsibility, but the consultant took them.” The surveyor informed the Adm/DON that the former consultant (CN/ADM) denied having the records. Adm/DON stated, “the consultant has them, although she denied it and we don’t have access to the records. Our legal team is involved and working on it.” The surveyor asked for storage location of the patient’s CR for both active and discharged records. Adm/DON stated that the agency maintains paper charting CR that are stored in the office, inside cabinets with locks, and accessible by authorized persons only. Review of the agency policy titled “Hospice Policy and Procedure Manual Clinical Record” dated 01/31/15, read in part, “Policy: The Hospice must establish and maintain a clinical record system to ensure the care and services provided to each patient are completely accurately documented, readily accessible and systematically organized to facilitate the compilation and retrieval of information. The clinical record may be maintained electronically. Retention and Storage: D. The hospice will ensure patient clinical records are retained for 10 years after the death or discharge of the patient ...””

“Based on interview and record review, the clinical record, whether hard copy or in electronic form, was not made readily available at the request of the surveyor during a recertification/re-licensure survey for 5 of 5 (Patients 1, 2, 3, 4, and 5) discharged patients, in that: The agency could not provide patient #1, # 2, #3, #4, and #5 records discharged in 2022. This failure could place the agency’s future Hospice patients at risk of harm due to failure of the agency to protect and maintain service information. Findings include: On 10/28/25 at 11:50 AM during the entrance conference the administrator informed the surveyor that there were no active patients, and the last patients were when the accreditation organization did the initial certification in 2022. The surveyor requested for the list of patients surveyed by AO from 10/24/2022 to 10/26/2022. At 2:00pm Adm/DON informed the surveyor that the consultant used by the agency for the initial survey with AO went with all the patient’s records and the agency did not have access to all five clinical records except the consents signed for service. At 2:17pm Adm/DON provided a list of five patients Adm/DON reported obtained from the AO website. Review of the list of patients revealed:Patient #1’s SOC date of 03/08/2022 and discharge/transferred date of 10/28/2022. Terminal diagnosis of (CEREBROVASCULAR ACCIDENT (CVA) is the medical term for stroke. A stroke occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) with visits frequencies of SN once a week, 2 as needed visits, MSW once a month; chaplain once a month, Aide two times a week. Patient #2’s SOC date of 09/06/2022 and discharge/deceased date of 10/06/2022. Terminal diagnosis of colon cancer (also known as colorectal cancer, is a type of cancer that begins in the large intestine) with visits frequencies of SN once a week, two as needed visits, MSW once a month; chaplain once a month, Aide two times a week. Patient #3’s SOC date of 09/09/2022 and discharge/hospitalized date of 10/27/2022. Terminal diagnosis of COPD (Chronic obstructive pulmonary disease (COPD) is an ongoing lung condition caused by damage to the lungs.) with visits frequencies of SN once a week, two as needed visits, MSW once a month; chaplain once a month, Aide two times a week. Patient #4’s SOC date of 09/28/2022 and discharge/transferred date of 10/27/2022. Terminal diagnosis of heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and oxygen.) with visits frequencies of SN once a week, 2 as needed visits, MSW once a month; chaplain once a month, Aide two times a week. Patient #5’s SOC date of 10/11/2022 and discharge/transferred date of 10/26/2022. Terminal diagnosis of COPD (Chronic obstructive pulmonary disease (COPD) is an ongoing lung condition caused by damage to the lungs.) with visits frequencies of SN once a week, two as needed visits, MSW once a month; chaplain once a month, Aide two times a week. During interview on 10/29/2025 with the Adm/DON at 11:25am, the surveyor asked for the person in charge of the patient’s clinical records. Adm/DON stated that former Adm and consultant (CN/ADM) was responsible during the survey in 2022 and discovered that the records, except consents for services were not in each patient’s chart during an audit on or before September 2023. Adm/DON added that she was present during the survey in 2022, but the former consultant (CN/ADM) was in charge. During a telephone interview on 10/29/2025 with the former consultant (CN/ADM) at 2:27pm, The former consultant (CN/ADM) validated that she consults for the agency and other agencies owned by the Adm/DON and was hired as the Adm/DON for hospice agency’s initial survey in 2022. The surveyor asked for the number of patients, services provided, and staff that saw the patients in 2022. The former consultant (CN/ADM) stated five non-billable patients were seen for the purpose of the initial survey of the hospice agency. The former consultant (CN/ADM) stated the patients were seen by the group of staff that collaborated with her, including a chaplain, social worker, and an Aide. CN/ADM indicated she was the nurse and conducted home visit with the AO staff in 2022. The former consultant (CN/ADM) narrated that she and her consulting members were only hired to conduct the initial survey for the agency, and the contract was terminated at the completion of the 3-day survey conducted by the AO. The surveyor requested clinical records of the five non-billable patients. CN/ADM stated that she did not have or have access to the records after the survey. The surveyor asked for who had the records and who was responsible for retention of the records. The former consultant (CN/ADM) stated, “It is the agency that is responsible for retaining patient’s records. I never took any of those records, everything was printed out and kept in the office inside a filing cabinet. How can I take something that has the agency names written all over and against the law? It is HIPAA violation, and we do not even have the key to the cabinet.” CN/ADM added that Adm/DON had contacted her for clinical records of the patients, and she had told Adm/DON the same thing. The former consultant (CN/ADM) stated Adm/DON was present during the initial survey and very much aware of everything about the survey.During a follow up interview on 10/29/2025 with the Adm/DON at 3:20 p.m., the surveyor asked for the agency’s policy on discharged patient’s clinical record retention and who was responsible for retention of records. Adm/Don stated, “we are to keep the records 10 years after death or discharge. I know it is my responsibility, but the consultant took them.” The surveyor informed the Adm/DON that the former consultant (CN/ADM) denied having the records. Adm/DON stated, “the consultant has them, although she denied it and we don’t have access to the records. Our legal team is involved and working on it.” The surveyor asked for storage location of the patient’s CR for both active and discharged records. Adm/DON stated that the agency maintains paper charting CR that are stored in the office, inside cabinets with locks, and accessible by authorized persons only. The surveyor asked for the impacts of the agency’s inability to safeguard the discharged CR. ADM/DON stated the action put the discharged patients at risk of having their identity stolen or misused by unauthorized people. Review of the agency policy titled “Hospice Policy and Procedure Manual Clinical Record” dated 01/31/15, read in part, “Policy: The Hospice must establish and maintain a clinical record system to ensure the care and services provided to each patient are completely accurately documented, readily accessible and systematically organized to facilitate the compilation and retrieval of information. The clinical record may be maintained electronically. Retention and Storage: D. The hospice will ensure patient clinical records are retained for 10 years after the death or discharge of the patient ...””