Every finding on record at Aaa Hospice Care & Nursing, Inc

Based on interview and record review, the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure the comprehensive assessment identified and addressed the needs for hospice care and services for nine of nine sample patients (Patient 7, Patient 20, Patient 22, Patient 25, Patient 30, Patient 31, Patient 32, Patient 33, and Patient 34). Patient 7, Patient 20, Patient 22, Patient 25, Patient 30, Patient 31, Patient 32, Patient 33, and Patient 34 did not have life expectancy of six months or less.  This deficient practice had the potential to result in Patient 7, Patient 20, Patient 22, Patient 25, Patient 30, Patient 31, Patient 32, Patient 33, and Patient 34 losing their medical benefit and not receiving appropriated healthcare services that could affection their quality of life. --- 1. During a record review of Patient 7’s Personal Information, indicated a start of care date of 5/12/2205, with a terminal diagnosis of atherosclerosis heart disease (buildup of plaque in the arteries) of native coronary artery with unstable angina pectoris (chest pain due to insufficient oxygen).  During an interview on 10/22/2025, at 12:45 p.m., with Patient 7, Patient 7 stated she was not receiving nursing services at home and was not a patient of the HA. Patient 7 stated a nurse visited her twice since May, 2025, and she was receiving supplies from an agency. When asked about other services receiving from the agency such as Medical Social Worker, Spiritual Counselor, Patient 7 stated “they” called and checked on Patient 7 to make sure she was okay. Patient 7 stated she had a primary care doctor whom she sees regularly. Patient 7 stated the HA offered oxygen, but she did not need it. Patient 7 stated she was able to go outside, go shopping, go to doctor’s appointments without any issues. Patient 7 stated she did not have shortness of breath. Patient 7 stated she had high blood pressure, but her heart was not failing. Patient 7 stated her primary care doctor told Patient 7 her health was stable and was not worsening. Patient 7 stated she became aware of the HA through a friend who told her about a program that offered diapers and supplies.  During an interview on 10/23/2025, at 10:30 a.m., with Patient 7’s primary care doctor clinic representative (REP 1), REP 1 stated Patient 7 had an upcoming appointment on 10/28/2025. REP 1 stated Patient 7 received care at the clinic on 9/25/2025, 7/2025, and 6/2025.  During a concurrent interview and record review on 10/23/2025, at 11:05 a.m., with Registered Nurse 5 (RN 5), RN 5 reviewed Patient 7’s record titled, Comprehensive Nursing Assessment, dated 5/12/2025. The record indicated Patient 7 qualified for hospice care based on the LCD (Local Coverage Determination, a tool used to indicate if patient qualifies for hospice care) for heart disease. The LCD indicated Patient 7 had NYHA (New York Heart Association classification system) class 4 (the most severe heart failure. Shortness of breath experienced at rest. Movement causes symptoms) heart failure. Further review of the record indicated Patient 7 was dependent on more than 2 ADL (activities of daily living such as bathing, dressing, eating, etc.), was using oxygen as needed, had weight loss greater than 10% in the last 6 months, and “Patient’s physical, functional, and cognitive abilities have rapidly declined.” RN 5 stated there was no supporting documentation of Patient 7’s heart failure. RN 5 stated the HA determined Patient 7 had heart disease based on patient and family report. Patient 7 told the HA she was not feeling good. RN 5 stated usually patients have multiple emergency visits. RN 5 stated she did not have information on Patient 7’s hospitalization dates.  During an interview on 10/23/2025, at 11:19 a.m. with Patient 7’s primary care doctor clinic representative 2 (REP 2), REP 2 stated Patient 7’s last visit was on 9/2025. REP 2 stated he was reviewing the clinic notes and the notes indicated Patient 7 did not have difficulty dressing or bathing and was independent with her ADL’s. REP 2 stated the clinic records did not indicate Patient 7 had a terminal diagnosis or that Patient 7 was referred to hospice care. REP 2 stated Patient 7 had not used oxygen in the last 6 months. 2. During a review of Patient 20’s Personal Information, the Personal Information indicated a start of care (SOC) date of 5/4/2025, with a terminal diagnosis of heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat), unspecified.  During a review of Patient 20’s Comprehensive Nursing Assessment, dated 5/24/2025, the Nature and Condition of Terminal Illness/LCD Eligibility (LCD/Local Coverage Determination; a decision by a Medicare Administrative Contractor [a regional entity that handles Medicare claims] to cover a particular medical service or item, or to consider it not covered, based on criteria of medical necessity within its specific jurisdiction) section indicated that Patient 20 was qualified to receive hospice services due to heart disease. The LCD Eligibility section indicated that Patient 20 had declined surgical procedures (related to heart disease) and had NYHA IV (a classification of heart failure by the New York Heart Association – class IV indicates the most severe form of heart failure, characterized by an inability to perform any physical activity without discomfort and the presence of symptoms, such as shortness of breath, even at rest).   During a review of Patient 20’s clinical records, there was no documented evidence that Patient 20 needed surgical procedures related to his heart condition, and that he had declined it. There was no documented evidence that Patient 20 had been diagnosed with NYHA IV heart failure.   During a telephone interview with Patient 20 on 10/23/2025 at 9:37 a.m., Patient 20 stated he had poor memory, therefore he could not remember who referred him to hospice, or what heart condition he had.  3. During a record review of Patient 22’s medical record form titled “Personal Information” indicated a start of care date of 6/5/2025, with a primary diagnosis of heart disease (a condition that affects the heart and heart vessels), unspecified.   During a record review of Patient 22’s medical record form titled “Physician's Certification for Hospice Benefits (CTI)” dated from 9/3/2025 to 12/1/2025, indicated the certification was based on Patient 22’s medical history, record, and patient status.   During a record review on 10/21/2025 at 12:35 p.m. of Patient 22’s electronic medical record (EMR), the EMR indicated Patient 22 had three files uploaded into the Document/Image section. The three files downloaded into Patient 22’s EMR were her (Patient 22) consents, identification card, and POLST (provider orders for life-sustaining treatment – a medical form that indicates a patient's medical care preference).  During a concurrent interview and record review on 10/23/2025 at 12:01 p.m. with the Director of Patient Care Services (DPCS) or Patient 22’s EMR, the DPCS stated that Patient 22’s LCD indicated that Patient 22 was qualified to receive hospice services due to heart disease. The DPCS stated that Patient 22 had declined surgical procedures and met the criteria for NYHA IV. The DPCS stated that the HA did not have a History and Physical (H&P) for Patient 22. The DPCS stated Patient 22 was admitted to hospice services based on what Patient 22 and her (Patient 22) family stated, as well as the Medical Director (MD) referral assessment or any other doctors admitting notes. The DPCS was requested to provide Patient 22’s H&P, diagnostics and MD notes. The DPCS stated that the HA does not have any H&P, diagnostics or MD notes for Patient 22. The DPCS stated that the admitting Registered Nurse 3 (RN3) based Patient 22’s admitting information on what Patient 22’s family said.   4. During a review of Patient 25’s Personal Information, the Personal Information indicated a start of care (SOC) date of 6/23/2025, with a terminal diagnosis of unspecified diastolic heart failure (heart failure that occurs when the left ventricle [one of the four chambers of the heart, located in the bottom left portion] becomes stiff), unspecified.  During a review of Patient 25’s Comprehensive Nursing Assessment, dated 6/23/2025, the Nature and Condition of Terminal Illness/LCD Eligibility section indicated that Patient 25 was qualified to receive hospice services due to heart disease. The LCD Eligibility indicated that Patient 25 had been ruled out as a candidate for surgery and had declined surgical procedures related to his heart condition. The LCD also indicated that Patient 25 met the criteria for NYHA IV.  During a telephone interview with Patient 25 on 10/22/2025 at 2:24 p.m., Patient 25 stated that he had never been diagnosed with a terminal illness with 6 months or less to live. Patient 25 stated, “I’m not terminally ill.” Patient 25 stated that he had high blood pressure, which was treated with medications. Patient 25 stated that he regularly saw his primary care physician (PCP – a healthcare professional who acts as a patient’s main point of contact for non-emergency medical needs, coordinating the patient’s overall health and wellness), who was monitoring his blood pressure. Patient 25 stated that he was seen by his PCP less than two weeks prior. When Patient 25 was asked if he knew why he was referred to hospice, Patient 25 stated, “My doctor referred me to home care so I can get help with showers. I’m in a wheelchair; I can’t shower on my own. The agency sends somebody to help me with showers.” Patient 25 stated that he was not on hospice, that the service he was currently receiving from the HA was home care.  During a telephone interview with a staff at Patient 25’s physician’s office on 10/23/2024 at 10:51 a.m., the staff confirmed that Patient 25 was under the care of Physician Assistant 1 (PA 1), who had been providing care for him . The staff stated that Patient 25 was last seen by PA 1 on 10/10/2025.   On 10/22/2025, at 2:46 p.m., Patient 25 called the surveyor. Patient 25 stated that he called the HA to confirm if he was receiving home care or hospice. Patient 25 stated, “Turns out I’m on hospice. The agency said I’m on hospice because I have COPD (chronic obstructive pulmonary disease – an ongoing lung condition caused by damage to the lungs; the damage results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs).”   During a concurrent interview and record review with the DPCS on 10/23/2025 at 12:27 p.m., the DPCS reviewed Patient 20’s and Patient 25’s Comprehensive Nursing Assessment, dated respectively 5/24/2025 and 6/23/2025. The DPCS further reviewed Patient 20’s and Patient 25’s other clinical records on the HA’s electronic health record system, such as the Document/Image section and Communication Log. The DPCS stated the HA did not have documented evidence, such as H & P, diagnostics, or studies that supported the terminal diagnosis for Patient 20 and Patient 25. The DPCS stated that she did not remember reviewing relevant clinical records for Patient 20 and Patient 25. The DPCS stated, “I always document in the communication note after I reviewed records. There’re no communication notes that I reviewed Patient 20’s and Patient 25’s medical records before the recertification. I don’t remember reviewing their medical records. It fell through the loop.”  5. During a record review of patient 30’s Personal Information, indicated a start of care date of 8/26/2025, with a terminal diagnosis of Chronic obstructive pulmonary disease (a lung disease that makes breathing difficult).  During an observation of the home visit on 10/22/2025, at 11:20 a.m., with RN 5, Patient 30 was awake, alert and oriented. Patient 30 was breathing normally, without distress, without oxygen use. An observation of the living area indicated an oxygen machine (oxygen concentrator) that was not connected to an electrical outlet. Further observation of the oxygen machine indicated the tubing was in its original packaging, unwrapped, unopened.  During a concurrent observation and interview at the home visit on 10/22/2025, at 11:25 a.m., with RN 5, RN 5 assessed Patient 30’s oxygen level. RN 5 stated Patient 30’s oxygen level (oxygen saturation) was at 95% (normal range) while breathing ambient air (RA-room air).  During an interview at the home visit on 10/22/205, at 12:00 p.m., with Patient 30’s caregiver (CG 7), CG 7 stated Patient 30 was in really bad shape when she was hospitalized in February of this year (2025). CG 7 stated Patient 30 had gotten better since being in hospice care.  During an interview at the home visit on 10/22/2025, at 12:01 p.m., Patient 30 stated she had seen her primary care doctor a few months ago. Patient 30 stated she has an upcoming appointment next month to have lung studies done.  During a concurrent observation and interview at the home visit on 10/22/2025, at 12:01 p.m., with RN 5, RN 5 noticed the oxygen machine was not set up. RN 5 stated to Patient 30 if she would like the oxygen set up. Patient 30 stated to RN 5 she agreed on having the oxygen set up.  During a concurrent interview and record review on 10/23/2025, at 10:45 a.m., with RN 5, RN 5 reviewed Patient 30’s record titled, Comprehensive Nursing Assessment, dated 8/26/2025. The record indicated Patient 30’s oxygen level was 90% while using continuous oxygen at 2 liters per minute (2L/min-how much oxygen is delivered a minute). RN 5 stated Patient 30’s records did not have any medical documents to support her terminal diagnosis.   6. During a record review of patient 31’s Personal Information, indicated a start of care date of 10/3/2205, with a terminal diagnosis of Chronic combined systolic and diastolic heart failure (heart cannot pump enough blood, and cannot relax the heart muscle).  During a concurrent interview and record review on 10/23/2025, at 11:00 a.m., with RN 5, RN 5 reviewed Patient 31’s record titled, Comprehensive Nursing Assessment, dated 10/3/2025. The record indicated Patient 31 was admitted to hospice care due to NYHA 4 heart failure. RN 5 stated Patient 31’s records did not have any history and physical documentation to support the heart failure and there were no cardiology progress notes, no diagnostic tests. RN 5 stated the only document she had for Patient 31 was the progress note from the Nurse Practitioner (NP 1) on behalf of Medical Doctor 2 (MD 2). RN 5 stated MD 2 had certified Patient 31 for hospice care.  A record review of Patient 31’s document titled, Referring MD Certification, dated 10/3/2025 to 12/31/2025, indicated Medical Doctor 2 (MD 2) name. The document was not signed, nor dated.  7. During a review of Patient 32’s Personal Information, the Personal Information indicated a start of care (SOC) date of 9/25/2025, with a terminal diagnosis of acute combined systolic and diastolic heart failure (a condition where the heart is simultaneously unable to pump blood effectively [systolic dysfunction] and fill with enough blood [diastolic dysfunction]).  During a review of Patient 32’s LCD Hospice Eligibility Determination, dated 9/25/2025, the LCD indicated that Patient 32 was qualified to receive hospice services due to heart disease. The LCD indicated that Patient 32 had been optimally treated with diuretics (medications that increase urine output, often used to lower blood pressure) and vasodilators (medications that cause the blood vessels to widen [dilate], often used to lower blood pressure). The LCD also indicated that Patient 32 met the criteria for NYHA IV.  During a review of Patient 32’s Comprehensive Nursing Assessment, dated 9/25/2025, the Comprehensive Nursing Assessment indicated that Patient 32 had normal respirations with mild exertion (low intensity physical activity that involves little to no physical stress), no cough, with diminished lung sounds. Respiration rate was 19 per minute. During a review of Patient 32’s H & P from Skilled Nursing Facility 1 (SNF 1), the H & P indicated that Patient 32 was discharged from SNF 1 on 6/25/2025. There was no documentation in the H & P that indicated Patient 32 was referred to hospice.   During a joint home visit with RN 8 on 10/22/2025 at 11:30 a.m., Patient 32 was observed sitting at the edge of his bed, alert and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 32 lives in a board and care facility (a small, residential home that provides non-medical assistance and personal care services to seniors). Observed Patient 32 on 3.5 liters per minute of oxygen via nasal cannula (a medical device that delivers supplemental oxygen through a flexible tube with two prongs that sit in the nostrils). Patient 32 denied shortness of breath.  During a concurrent interview and record review with the DPCS on 10/23/2025 at 12:27 p.m., the DPCS reviewed Patient 32’s LCD and Comprehensive Nursing Assessment, both were dated 9/25/2025. The DPCS stated that the HA did not have any hospice referral, diagnostics, or medical reports in his clinical records that supported the qualifying terminal diagnosis in the LCD.   8. During a record review of Patient 33’s medical record form titled “Personal Information” indicated a start of care date of 9/27/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (heart arteries are narrow due to build up of plaque) without angina pectoris (no pain).  During a record review of Patient 33’s medical record form titled “Individual Patient Emergency Preparedness Plan” dated 9/27/2025, indicated Patient 33 was not oxygen dependent and was able to independently self-administer medications.    During a record review of Patient 33’s medical record form untitled, dated 9/27/2025, indicated Patient 33 was wheelchair bound due to gout and peripheral neuropathy (condition that affects the nerves). The untitled form also indicated Patient 33 was homebound and was requesting an electric wheelchair.  During a record review of Patient 33’s medical record form titled “Face to Face Encounter” indicated it was undated, and the certification period dates were left blank. The Face-to-Face Encounter also indicated that Patient 33 was involved in a motor vehicle accident and was unable to ambulate, therefore Patient 33 was wheelchair bound.    During a record review of Patient 33’s medical record titled “Comprehensive Nursing Assessment” dated 9/27/2025, indicated Registered Nurse 7 (RN7) completed and signed the form. The Comprehensive Nursing Assessment indicated Patient 33 depended on a walker or cane and walked occasionally. The Comprehensive Nursing Assessment indicated Patient 33 needed complete assistance with toileting and transferring. The Comprehensive Nursing Assessment indicated Patient 33’s conditions exist as evidence in or reported by medical history, patient, and family. The Comprehensive Nursing Assessment did not indicate Patient 33’s diagnosis included congestive heart failure (CHF – a condition where the heart is unable to pump correctly causing fluid buildup).  The Comprehensive Nursing Assessment indicated that Patient 33’s secondary diagnosis of CHF was likely to contribute to less than 6 months life expectancy. Lastly, the Comprehensive Nursing Assessment narrative section indicated that Patient 33 was dependent on supplemental oxygen, and his (Patient 33) heart condition was getting worse.   During a record review of Patient 33’s medical record form titled “LCD Hospice eligibility Determination” dated 9/27/2025, indicated Patient 33 met the LCD guidelines by being ruled out as a candidate and declining surgical procedures, and meets the NYHA (New York Heart Association – system used to categorize the severity of heart failure based on symptoms and physical limitations) Class IV (patient unable to carry on any physical activity without discomfort. Heart failure symptoms are present even at rest and discomfort increases with any activity) level. Section 2 indicated “Does this CHF or angina patient meet the criteria for NYHA class IV level? - YES”.  During a concurrent interview and record review on 10/23/2025 at 11:30 a.m. with the Director of Patient Care Services (DPCS) of Patient 33’s medical record, the DPCS stated that the HA does not have any of Patient 33’s hospital records, diagnostics, or history and physical (H&P). The DPCS stated that Patient 33 qualified for hospice services based on the NP1’s evaluation and findings.   During a concurrent observation and interview on 10/22/2025 at 2:10 p.m. with Patient 33 at his (Patient 33) home, Patient 33 was fully dressed, sitting in a wheelchair, and was awake, alert, and oriented to name, place, time, and situation. Patient 33 stated that he was in a motor vehicle accident and had surgery on both knees. Patient 33 stated that he (Patient 33) resided at a post-acute center for the past 2 years and was recently discharged home in July 2025 because he (Patient 33) was able to be taken care of at home. Patient 33 stated that he was unaware he (Patient 33) had heart issues. Patient 33 stated “I have heart issues? I know I have high blood pressure but that is about it.” Patient 33 stated “No doctor or anyone has told me that I was dying. I would remember something like that. No, no one has told me that I had six months or less to live.” Patient 33 stated he (Patient 33) does not recall the last time he (Patient 33) used oxygen.   During an interview on 10/23/2025 at 1:39 p.m. with the DPCS, the DPCS states she (DPCS) has never personally visited Patient 33. The DPCS stated that she (DPCS) knew about Patient 33 from speaking with the visiting nurse. The DPCS stated that she (DPCS) changed Patient 33’s visiting notes for the visiting nurse. The DPCS stated that she (DPCS) should have sent the documentation back to the visiting nurse for corrections.   9. During a record review of Patient 34’s medical record form titled “Personal Information” indicated a start of care date of 2/4/2025 and an end of care date of 9/2/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (heart arteries are narrow due to build up of plaque) with unstable angina pectoris (chest pain).  During a record review of an untitled and undated form with Patient 34’s name on top, the form indicated a word document that contained Patient 34’s name, date of birth, and assessment information and had a darker color signature above the name of the Medical Doctor 3 (MD3). Lastly, the form indicated “Based on patient status, medical condition, team assessment including face to face encounter, patient qualifies for hospice, meeting hospice criteria with poor prognosis and a life expectancy of six months or less, if the terminal illness runs its normal course.   During a concurrent interview and record review on 10/21/2025 at 3:58 p.m. with Medical Doctor 3 (MD3), of Patient 34’s untitled and undated medical record form, MD3 stated that the dark color electronic signature looked like it was hers (MD3), but the format of the rest of the document she (MD3) did not recognize. MD3 stated that her (MD3) patient assessments had her (MD3) contact information and are dated.  MD3 stated that the untitled/undated form was not her note. MD3 stated that she did not recall Patient 34’s name but will contact the Nurse Practitioner working with her (MD3) and her (MD3) patient notes. MD3 stated that she (MD3) did not refer Patient 34 for hospice services. MD3 stated that she (MD3) left the HA after hearing “sketchy things” about the HA. MD3 stated that her (MD3) name has been passed around hospice agencies and for that reason there were things “happening that were unbeknownst to me”.   During an interview on 10/21/2025 at 4:28 p.m. with Patient 34, Patient 34 stated that she (Patient 34) had Alzheimer’s. Patient 34 was asked if she (Patient 34) had a prognosis of 6 months or less to live. Patient 34 stated that no one had ever informed her (Patient 34) that she was dying.   During an interview on 10/21/2025 at 5:21 p.m. with Patient 34’s caregiver (CG6), CG6 stated he (CG6) did not recall Patient 34’s referring physician. CG6 stated he believes a doctor from Mexico diagnosed Patient 34. CG6 stated that they heard about the HA from a family friend and decided to join. CG6 stated Patient 34 did have heart issues.     During a concurrent interview and record review on 10/23/2025 at 12:10 p.m. with the Director of Patient Care Services (DPCS) and review of Patient 34’s EMR, the DPCS stated that the HA did not have Patient 34’s H&P or diagnostics. The DPCS stated that the HA did have MD3’s assessment, but that it did not have a date or time. The DPCS stated the form did have MD3s electronic signature.  During an interview with the Director of Patient Care Services (DPCS) on 10/23/2025 at 12:48 p.m., the DPCS stated that due to the lack of history and physical (H&P, a foundational document in healthcare that combines a patient's medical history with a physical examination to inform diagnosis and treatment planning), diagnostics, studies, and hospice referral, it was possible that the patients were not eligible for hospice services. When the DPCS was asked if there could be any negative outcome if ineligible patients were admitted to hospice, the DPCS stated that the patient may not be eligible. During a review of the HA’s policy and procedure titled “Admission Criteria and Process” revised 11/2024, indicated “(HA) will admit any patient with a life-limiting illness that mees the admission criteria. The patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary’s Local Coverage Determination (LCD). The patient must desire hospice services and be aware of the diagnosis and prognosis.”  During a review of the HA’s policy and procedure titled “Clinical Directo/Director of Patient Care Services (DPCS) – Job Description Summary” revised 11/2024, indicated “The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services. The Clinical Director/Director of Patient Care Services establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy. The Clinical Directo/Director of Patient Care Services – Job Description Summary also indicated that one of the DPCSs job function was to “Assures compliance with all local, state and federal laws...”.

Based on observation, interview, and record review, the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to review all medications the patients were taking and update their medication profiles with the currently used medications for one of nine sample selected patients (Patient 33). This deficient practice has the potential risk for medication errors and adverse drug reactions. --- During a record review of Patient 33’s medical record form titled “Personal Information” indicated a start of care date of 9/27/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (heart arteries are narrow due to build up of plaque) without angina pectoris (no pain).   During a record review of Patient 33’s medical record form titled “Current Treatment/Medication/DME List” indicated, Patient 33 was prescribed Metformin (medication to treat high blood sugar levels), and Levsin (medication to treat excessive secretions).    During a concurrent observation and record review on 10/22/2025 at 2:10 p.m., with Registered Nurse 7 (RN7) reconciling Patient 33’s medications at his (Patient 33) home, Patient 33’s HA medication profile indicated Patient 33 was taking Metformin 1000mg one tab twice a day. Patient 33’s metformin medication bottle label indicated Metformin 500mg take one tab twice a day. Patient 33’s medication profile indicated Patient 33 was also prescribed Levsin and Zofran (antiemetic medication). During the medication reconciliation Levsin was not in Patient 33’s home and there were two individually wrapped Zofran tablets that did not have a patient label to indicate the name of the patient, the dose that is prescribed, the time that it is supposed to be given, and the physician who ordered it.   During an interview on 10/22/2025 at 3:10 p.m. with RN7, RN7 stated that she (RN7) conducts home visits and reconciles Patient 33’s medications every other week. RN7 stated that medication reconciliation is done to ensure Patient 33 “can do good”. RN7 stated that there was a possibility that Patient 33 used all the Levsin and that is why it was not at his (Patient 33) home. RN7 stated that Metformin was transcribed wrong, because she (RN7) wrote the order herself. RN7 stated that it was important to reconcile patients' medications to prevent medication errors. RN7 stated that she (RN7) did not know why the Zofran was not labeled, and that maybe they (Patient 33/family) threw away the packet.  During a record review of HA’s form titled “Physician Services – Medical Director” revised 11/2024, indicated “The duties and responsibilities of the Medical Director will include, but not be limited to, the following: “Managing oversight of the patient's medications and treatments”.  During a record review of the HA’s form titled “Clinical Directo/Director of Patient Care Services (DPCS) – Job Description Summary” revised 11/2024, indicated “The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services. The Clinical Director/Director of Patient Care Services establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy. The Clinical Directo/Director of Patient Care Services – Job Description Summary also indicated that one of the DPCSs job function was to “Assures compliance with all local, state and federal laws...”.

Based on observation, interview, and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure one of nine sample selected patients (Patient 33) individualized plan of care was followed. The Medical Director (MD) was not notified of Patient 33’s high blood pressure reading as indicated in the plan of care. This failure has the potential to result in the delay in patient care which could result in patient's hospitalization due to stroke, or death. --- During a record review of Patient 33’s medical record form titled “Personal Information” indicated a start of care date of 9/27/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (heart arteries are narrow due to build up of plaque) without angina pectoris (no pain). The Personal Information form also indicated Patient 33’s secondary diagnoses included essential hypertension (high blood pressure).   During a record review of Patient 33’s medical record form titled “POC (plan of care) Summary” dated as of 10/21/2025, indicated skilled nurse to perform vital signs during every assessment and notify if systolic blood pressure greater that 160 mmHg (millimeters of mercury – unit of measure) and/or diastolic blood pressure greater than 90 mmHg.   During a record review of Patient 33’s medical record form titled “POC (plan of care) / IDG (interdisciplinary group) Review” dated 9/27/2025, indicated skilled nurse to perform vital signs during every assessment and notify if systolic blood pressure greater that 160 mmHg (millimeters of mercury – unit of measure) and/or diastolic blood pressure greater than 90 mmHg.  During a record review of Patient 33’s medical record form titled “POC (plan of care) / IDG (interdisciplinary group) Review” dated 10/10/2025, indicated skilled nurse to perform vital signs during every assessment and notify if systolic blood pressure greater that 160 mmHg (millimeters of mercury – unit of measure) and/or diastolic blood pressure greater than 90 mmHg.  During a record review of Patient 33’s medical record form titled “Visit Note RN (Registered Nurse)” dated 10/22/2025, indicated Registered Nurse 7 (RN7) completed and signed the form on 10/22/2025. RN7 documented Patient 33’s blood pressure at 179/84.   During a concurrent observation and interview on 10/22/2025 at 2:10 p.m., with Patient 33 at his home, Patient 33 stated he was unaware he (Patient 33) had heart issues. Patient 33 stated “I have heart issues? I know I have high blood pressure but that's about it.”   During a joint home visit with Registered Nurse 7 (RN7) on 10/22/2025 at 2:10 p.m., at Patient 33’s home, Patient 33 was observed sitting on a wheelchair, alert and oriented to person, place, and time (aware of own identity, location, and the current date and time). Caregiver 4 (CG4) was present during the home visit. RN7 was noted measuring Patient 33’s blood pressure with a result of 190/80 mmHg. Patient 33 stated the blood pressure reading was high and requested to use Patient 33's personal blood pressure machine. Patient 33’s blood pressure reading using his own personal machine was 178/85 mmHg. RN7 suggested and handed Patient 33's blood pressure medication, Metoprolol. Patient 33 took one tablet of Metoprolol and stated he did not take Metoprolol this morning. Patient 33’s home visit was completed, per RN7 at 3:10 p.m., RN7 was not observed rechecking Patient 33’s blood pressure.   During a concurrent interview and record review on 10/23/2025 at 11:30 a.m. with the Director of Patient Care Services (DPCS) of Patient 33’s electronic medical record (EMR), the DPCS stated that she (DPCS) was unaware and not notified by RN7 of Patient 33’s blood pressure reading during the home visit. The DPCS stated that the Medical Doctor (MD) needed to be notified of Patient 33’s high blood pressure reading because it was over the noted parameters. The DPCS stated the MD, if informed, could have assess the current medications and order more medications if needed. The DPCS that the incident should have been taken care of.   During a concurrent interview and record review on 10/23/2025 at 11:50 a.m. with Registered Nurse Case Manager (RN5) of Patient 33’s EMR, RN5 stated that RN7 did not document anything about Patient 33’s high blood pressure reading. RN5 stated is she (RN5) was informed, she (RN5) would have informed MD and done something about it.   During a record review of the HA’s form titled “Clinical Director/Director of Patient Care Services (DPCS) – Job Description Summary” revised 11/2024, indicated “The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services. The Clinical Director/Director of Patient Care Services establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy. The Clinical Director/Director of Patient Care Services – Job Description Summary also indicated that one of the DPCSs job function was to “Assures compliance with all local, state and federal laws...”.

Based on observation, interview, and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure two of nine sample selected patients (Patient 32 and Patient 33) hospice plans of care were provided to patients and patients family/caregiver. This failure had the potential to result in missed care, duplication of care, and/or miscommunications among patient care providers. --- During a review of Patient 32’s Personal Information, the Personal Information indicated a start of care (SOC) date of 9/25/2025, with a terminal diagnosis of acute combined systolic and diastolic heart failure (a condition where the heart is simultaneously unable to pump blood effectively [systolic dysfunction] and fill with enough blood [diastolic dysfunction]).  During a review of Patient 32’s POC Summary (Plan of Care Summary – a summary of the plan of care [a document  detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved]), as of 10/21/2025, the POC Summary included permitted activities, diet, medications, treatments, DMEs (durable medical equipment – reusable medical devices, equipment, or supplies prescribed by a healthcare provider for a patient's use at home), supplies, interventions, and frequency of visit.  During a joint home visit with RN 8 on 10/22/2025 at 11:30 a.m., Patient 32 was observed sitting at the edge of his bed, alert and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 32 lives in a board and care facility (a small, residential home that provides non-medical assistance and personal care services to seniors). Caregiver 5 (CG 5) was present during the home visit.  During the joint home visit, Patient 32’s home folder was reviewed with RN 8. There was no copy of the Plan of Care observed inside the home folder. CG 5 stated that all the documents provided by the HA was kept inside the home folder. CG 5 stated she did not know what the plan of care looked like. During an interview with RN 8 on 8/27/2025 at 11:30 a.m., RN 8 stated the care plan provides guidance for nurses who visit the patient so that they know what to do for the patient. RN 8 stated the care plan also provided information for the patient regarding what the HA  was doing for them and what they could expect. RN 8 stated the HA needed to provide a copy of the plan of care to each patient; if the plan of care was updated, then the patient should be provided with an updated one.   2.  During a record review of Patient 33’s medical record form titled “Personal Information” indicated a start of care date of 9/27/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (heart arteries are narrow due to build up of plaque) without angina pectoris (no pain).  During a joint home visit with Registered Nurse 7 (RN7) on 10/22/2025 at 2:10 p.m., at Patient 33’s home, Patient 33 was observed sitting on a wheelchair, alert and oriented to person, place, and time (aware of own identity, location, and the current date and time). Caregiver 4 (CG4) was present during the home visit. RN7 was requested to provide Patient 33’s HAs patient folder. Patient 33’s HAs patient folder did not include Patient 33’s individualized plan of care.   During an interview on 10/22/2025 at 2:30 p.m. with Patient 33’s CG4, CG4 stated that she (CG4) has been with Patient 33 for a “long time” including while he (Patient 33) was receiving hospice services from a different agency.  During an interview on 10/22/2025 at 3:10 p.m. with RN7, RN7 stated that she (RN7) has “never seen” patients plans of care in their home folder. RN7 stated that she (RN7) was not sure if the patients needed their plans of care at home. RN7 stated patients plans of care are followed by the HA staff to provide the best care. RN7 stated it was important to provide patients their HA plans of care, so that the patients are made aware of their care.    During a record review of the HA’s form titled “Clinical Director/Director of Patient Care Services (DPCS) – Job Description Summary” revised 11/2024, indicated “The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services. The Clinical Director/Director of Patient Care Services establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy. The Clinical Directo/Director of Patient Care Services – Job Description Summary also indicated that one of the DPCSs job function was to “Assures compliance with all local, state and federal laws...”.

Based on observation, interview, and record review, the Hospice Agency (HA – agency providing care to terminally ill patients who have six months or less to live) failed to meet the Condition of Participation (COP - conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people 65 years of age or more and for certain younger people with disabilities]) for compliance with the Medical Director as follows: --- 1      MD 1 failed to review the clinical information and provided an accurate initial Certification of Terminal Illness (CTI – a physician's written statement confirming a patient has a life expectancy of six months or less, if the illness runs its natural course, which is required for the patient to be eligible for hospice benefits) that reflected the patient’s current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for four of nine sampled patients (Patient 7, Patient 30, Patient 32, Patient 33). (Refer to L667). 2      MD 1 failed to document an accurate CTI before the recertification period that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for five of nine sampled patients (Patient 7, Patient 20, Patient 22, Patient 25, and Patient 34). (Refer to L668).As a result, the affected patients were placed at increased risk for losing their hospice eligibility/hospice benefits, not receiving hospice care when needed in the future, and had the potential to not receive the necessary care and services that could lead to potential hospitalization and death. The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulation for Medical Director services to ensure highest quality of care are provided to patients certified to receive the hospice care benefits.

Based on interview, observation, and record review the Hospice Agency’s (HA – agency providing care to terminally ill patients who have six months or less to live) Medical Director (MD 1) failed to review the clinical information and provided an accurate initial Certification of Terminal Illness (CTI – a physician's written statement confirming a patient has a life expectancy of six months or less, if the illness runs its natural course, which is required for the patient to be eligible for hospice benefits)  the patient’s current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for four of nine sampled patients (Patient 7, Patient 30, Patient 32, and Patient 33). As a result, patients were placed at increased risk for losing their hospice eligibility/hospice benefits, not receiving hospice care when needed in the future, and had the potential to not receive the necessary care and services that could lead to hospitalization and/or death. --- During an interview on 10/22/2025 at 1:13 p.m., with the Medical Doctor 3 (MD 3), stated she was no longer associated with the HA, does not refer patient to the HA anymore since 6/2025. MD 3 stated, she disassociated herself from “problematic” agencies.  During an interview with the Director of Patient Care Services (DPCS) on 10/23/2025 at 12:48 p.m., the DPCS stated that due to the lack of history and physical (H & P – a foundational document in healthcare that combines a patient's medical history with a physical examination to inform diagnosis and treatment planning), diagnostics, studies, and hospice referral, it was possible that the patients were not eligible for hospice services. When the DPCS was asked if there could be any negative outcome if ineligible patients were admitted to hospice, the DPCS stated that the patient may not be eligible for other medical services, which could prevent them from getting the care or treatment they needed.  During an interview on 10/23/2025 at 10:42 a.m., with the Medical Doctor 2 (MD2), stated that he does not see the patients personally and that his Nurse Practitioner (NP1) sees the patients and MD2 joins in via telehealth. MD2 stated that he does not have any notes for any patient and would have to contact NP1 for her notes. MD2 stated he does not have access to the HA’s electronic medical record (EMR) system.   During an interview on 10/23/2025 at 10:58 a.m. with MD2, MD2 was informed that his (MD2) name appeared as the referring MD for sample selected Patients 22, 25, 30, 31, and 33. MD2 stated that he (MD2) was only familiar with Patient 33. MD2 stated “No, I don't know these patients and I did not refer them to that hospice. They are lying.” During an interview on 10/23/2025 at 11:13 a.m. with Nurse Practitioner 1 (NP1), NP1 was informed that MD2 was the referring MD for Patients 22, 25, 30, 31, and 33. NP1 stated that she (NP1) works as an attending for the HA. NP1 stated that she recognizes the names of some of the patients mentioned but was unable to access the HA’s EMR system at this time. NP1 stated she visits patients at their (patients) residence and reviews their (patients) medical records and labs. NP1 stated that she also orders their medications. NP1 stated that she coordinates the patients visits with the HA’s nurse.   During an interview on 10/23/2025 at 1:52 p.m. with Nurse Practitioner 1 (NP1), NP1 stated that her internet wires were vandalized and she (NP1) does not have access to the internet where she can retrieve patients' files/documents. NP1 stated that she did not have access to the HA’s EMR system. NP1 stated that she gives the HA her patient notes and HA upload them into their EMR system.  During an interview on 10/23/2025, at 12:18 p.m., with MD, MD stated the admission process as follows: Nursing staff gives MD information about patients, including the referral. MD stated he required the past medical history and current information to determine if patient was hospice qualified. MD stated he asks for the medical records to review them. During the initial visit, the nurse calls the MD, and reports all the assessment information. MD stated he sometimes spoke to the patient and if he was able to face time (a phone, video communication tool) the patients, he would do it. The MD stated, “I don’t do any referrals for these patients. I have no involvement with that; if these patients are being misled into what hospice service is, I’m not involved with that. My job is to make sure they have a hospice diagnosis, for example, if they have elevated BMP (basic metabolic panel – a routine screening test that can help detect or monitor various health conditions, such as kidney disease, electrolyte imbalances, diabetes, hypothyroidism, and liver problem) then they have heart failure.”  1. During a record review of Patient 7’s Personal Information, indicated a start of care date of 5/12/2205, with a terminal diagnosis of atherosclerosis heart disease (buildup of plaque in the arteries) of native coronary artery with unstable angina pectoris (chest pain due to insufficient oxygen). A record review of Patient 7’s, Certificate of Terminal Illness, for certification period 1, dated 5/12/2025 to 8/9/2025, indicated, “Based on my clinical findings patient continues to be eligible for hospice care and the next hospice benefit period aeb (as evidenced by): Progressive functional decline due to increased weakness. Dependence on assistance for 2/6 (2 out of 6) Activities of Daily Living (ADLs)...unable to maintain sufficient oxygen at RA (room air) due to worsening disease, dependent on O2 (oxygen). Worsening dyspnea (shortness of breath) with rest or minimal exertion.” The record indicated it was signed by the Medical Director (MD). During an interview on 10/22/2025, at 12:45 p.m., with Patient 7, Patient 7 stated she was not receiving nursing services at home and was not a patient of the HA. When told that medical records indicated nursing care visits, Patient 7 then stated a nurse visited her twice only, and she was receiving supplies from an agency. When asked about other services receiving from the agency such as Medical Social Worker, Spiritual Counselor, Patient 7 stated “they” call and checked on Patient 7 to make sure she was okay. But to come to Patient 7’s, home for a visit, it was only “twice” since May 2025.  During an interview on 10/22/2025, at 12:45 p.m., with Patient 7 stated she had a primary care doctor who she sees regularly. Patient 7 stated the HA offered oxygen, but Patient 7 did not need it. Patient 7 stated she was able to go outside, go shopping, go to doctor’s appointments without any issues. Patient 7 stated she did not have shortness of breath. Patient 7 stated she had high blood pressure, but her heart was not failing. Patient 7 stated her primary care doctor told Patient 7 her health was stable and was not worsening. Patient 7 stated she became aware of the HA through a friend who told her about a program that offered diapers and supplies.  During an interview on 10/22/2025, at 1:13 p.m., with MD 3, MD 3 was informed there was a document for Patient 7, with medical information. MD 3 was informed the document was signed by MD 3, but it was not dated. MD 3 was informed there was no title, name of company/clinic on the document. MD 3 stated she expected for the document to be dated and have identifying information for the doctor. MD 3 stated as the referring doctor, she expected the HA to request supporting documentation of the terminal illness. MD 3 stated she has advised, as medical director at other agencies, to get a cardiologist report or cardiology studies to support the diagnosis of heart failure. During an interview on 10/23/2025, at 10:30 a.m., with Patient 7’s primary care doctor clinic representative (REP 1), stated Patient 7 had an upcoming appointment on 10/28/2025. REP 1 stated Patient 7 received care at the clinic on 9/25/2025, 7/2025, and 6/2025.  During a concurrent interview and record review on 10/23/2025, at 11:05 a.m., with Registered Nurse 5 (RN 5), RN 5 reviewed Patient 7’s record titled, Comprehensive Nursing Assessment, dated 5/12/2025. The record indicated Patient 7 qualified for hospice care based on the LCD (Local Coverage Determination, a tool used to indicate if patient qualifies for hospice care) for heart disease. The LCD indicated Patient 7 had NYHA (New York Heart Association classification system) class 4 (the most severe heart failure. Shortness of breath experienced at rest. Movement causes symptoms) heart failure. Further review of the record indicated Patient 7 was dependent on more than 2 ADL (activities of daily living such as bathing, dressing, eating, etc.), was using oxygen as needed, had weight loss greater than 10% in the last 6 months, and “Patient’s physical, functional, and cognitive abilities have rapidly declined.” RN 5 stated there was no supporting documentation of Patient 7’s heart failure. RN 5 stated the HA determined Patient 7 had heart disease based on patient and family report. Patient 7 told the HA she was not feeling good. RN 5 stated usually patients have multiple emergency visits. RN 5 stated she did not have information on Patient 7’s hospitalization dates.  During an interview on 10/23/2025, at 11:19 a.m., with Patient 7’s primary care doctor clinic representative 2 (REP 2), stated Patient 7’s last visit was on 9/2025. REP 2 stated he was reviewing the clinic notes and the notes indicated Patient 7 did not have difficulty dressing or bathing and was independent with her ADL’s. REP 2 stated the clinic records did not indicate Patient 7 had a terminal diagnosis or that Patient 7 was referred to hospice care. REP 2 stated Patient 7 had not used oxygen in the last 6 months. REP 2 stated Patient 7 weight on 7/31/2025 was 200 pounds, an increase from Patient 7’s weight on 6/18/2025 of 189 pounds.  During an interview on 10/23/2025, at 12:24 p.m., with the MD, stated he was very confident he had read Patient 7’s medical records. MD stated there must have been cardiology (heart doctor) reports that must have been there. MD stated he reviewed everything. When MD was told that Patient 7 did not report heart failure, was not using oxygen, had a primary care doctor, and reported being stable in health, MD stated that Patient 7 must have had a heart issue. Patient 7 could have had an exacerbation due to illness. When MD was told there was no medical records to support Patient 7’s terminal illness, the MD stated he reviewed whatever records the HA gave him.  2. During a record review of Patient 30’s Personal Information, indicated a start of care date of 8/26/2205, with a terminal diagnosis of Chronic obstructive pulmonary disease (a lung disease that makes breathing difficult). During an observation of the home visit on 10/22/2025, at 11:20 a.m., with Registered Nurse 5 (RN 5), Patient 30 was awake, alert and oriented. Patient 30 was breathing normally, without distress, without oxygen use. An observation of the living area indicated an oxygen machine (oxygen concentrator) that was not connected to an electrical outlet. Further observation of the oxygen machine indicated the tubing was in its original packaging, unwrapped, unopened.  During a concurrent observation and interview at the home visit on 10/22/2025, at 11:25 a.m., with RN 5, RN 5 assessed Patient 30’s oxygen level. RN 5 stated Patient 30’s oxygen level (oxygen saturation) was at 95% (normal range) while breathing ambient air (RA-room air).  During an interview at the home visit on 10/22/205, at 12 p.m., with Patient 30’s caregiver (CG 7), CG 7 stated Patient 30 was in really bad shape when she was hospitalized in February of this year (2025). CG 7 stated Patient 30 had gotten better since being in hospice care.  During an interview at the home visit on 10/22/2025, at 12:01 p.m., Patient 30 stated she had seen her primary care doctor a few months ago. Patient 30 stated she has an upcoming appointment next month to have lung studies done.  During a concurrent observation and interview at the home visit on 10/22/2025, at 12:01 p.m., with RN 5, RN 5 noticed the oxygen machine was not set up. RN 5 stated to Patient 30 if she would like the oxygen set up. Patient 30 stated to RN 5 she agreed on having the oxygen set up.  During a concurrent interview and record review on 10/23/2025, at 10:45 a.m., with RN 5, RN 5 reviewed Patient 30’s record titled, Comprehensive Nursing Assessment, dated 8/26/2025. RN 5 stated this was the admission nursing assessment, used to determine eligibility for hospice services. RN 5 stated the nurse gathers all the information during the admission assessment visit and face times the doctor. The doctor then asks the patient questions and makes sure the patient is eligible for hospice care. RN 5 stated face time was done 100% (percent) of the time during the admission assessment visit.  During a concurrent interview and record review on 10/23/2025, at 10:45 a.m., with RN 5, RN 5 reviewed Patient 30’s record titled, Comprehensive Nursing Assessment, dated 8/26/2025. The record indicated Patient 30’s oxygen level was 90% while using continuous oxygen at 2 liters per minute (2L/min-how much oxygen is delivered a minute), Patient 30 had the following answered “yes” for the LCD assessment (Local Coverage Determination, a tool used to indicate if patient qualifies for hospice care): Poorly responsive or unresponsive to bronchodilators (lung medication that makes breathing easier), resulting in decreased functional capacity (the ability to walk, stand, move, etc.), increasing visits to the emergency room, Hospitalization for pulmonary(lung) infections, O2 (oxygen) sats (levels measured in percentage) less  than or equal to 88% determined either by arterial blood gases (a blood test) or O2 saturation monitors, unintentional progressive weight loss greater than or equal to 10% of body weight over last six months. RN 5 stated all the assessment information documented was obtained from Patient 30. When asked how it was determined that Patient 30 had an oxygen saturation of 90% while using oxygen, if the oxygen was recently set up on 10/22/2025, during the home visit?, RN 5 stated Patient 30 had the oxygen from the hospital discharge. RN 5 stated Patient 30’s records did not have any medical documents to support her terminal diagnosis.   During a concurrent interview and record review on 10/23/2025, at 10:45 a.m., with RN 5, RN 5 reviewed Patient 30’s medical records. RN 5 stated Patient 30 had been referred from a nurse practitioner. RN5 stated, the nurse practitioner worked with MD 2. During an interview on 10/23/2025, at 10:59 a.m., with RN 5, RN 5 stated MD 2 had certified Patient 30 for hospice care. During a record review of Patient 30’s document titled, CTI, for certification period 8/26/2025 to 11/23/2025, the record indicated Physician narrative: “Patient has terminal illness with poor life expectancy if the disease process will take its normal course. Patient is to be hospice eligible and meets LCD guidelines.” The record indicated it was signed by MD. Further review of the physician narrative portion of the record did not indicate objective and subjective clinical findings.  3. During a record review of Patient 31’s Personal Information, indicated a start of care date of 10/3/2205, with a terminal diagnosis of Chronic combined systolic and diastolic heart failure (heart cannot pump enough blood, and cannot relax the heart muscle). During a concurrent interview and record review on 10/23/2025, at 11 a.m., with RN 5, RN 5 reviewed Patient 31’s record titled, Comprehensive Nursing Assessment, dated 10/3/2025. The record indicated Patient 31 was admitted to hospice care due to NYHA 4 heart failure. When asked to provide evidence of Patient 31’s heart failure, RN 5 stated Patient 31’s records did not have any history and physical documentation to support the heart failure. There was no cardiology progress notes, no diagnostic tests. RN 5 stated the only document she had for Patient 31 was the progress note from the Nurse Practitioner (NP 1) on behalf of Medical Doctor 2 (MD 2). RN 5 stated MD 2 had certified Patient 31 for hospice care.  A record review of Patient 31’s document titled, West Coast Quality Care, dated 10/3/2025, indicated the NP1  documented, “I confirm that I had a face-to-face encounter…the clinical findings of the encounter have been provided to the certifying physician for use in determining continued eligibility for hospice care.”. Further review of the record did not indicate the name of the certifying physician  A record review of Patient 31’s document titled, Referring MD Certification, dated 10/3/2025 to 12/31/2025, indicated Medical Doctor 2 (MD 2) name. However, the document was not signed, nor dated. A record review of Patient 31’s document titled, CTI, for certification period 10/3/2025 to 12/31/2025, indicated Medical Director (MD) had signed the document. The document indicated, “Patient is appropriate for hospice care with supporting information from H&P (history and physical), and nursing assessment.  4. During a review of Patient 32’s Personal Information, the Personal Information indicated a start of care (SOC) date of 9/25/2025, with a terminal diagnosis of acute combined systolic and diastolic heart failure (a condition where the heart is simultaneously unable to pump blood effectively [systolic dysfunction] and fill with enough blood [diastolic dysfunction]). During a review of Patient 32’s CTI, for the first certification period, from 9/25/2025 to 12/23/2025, the physician narrative indicated that per referring physician and durable power of attorney (DPOA – a legal document that allows an individual to appoint someone else to make decisions on their behalf, particularly in financial or healthcare matters), the patient condition had progressively deteriorated. The CTI indicated that the DPOA had opted for hospice care. The CTI indicated that the MD signed the CTI on 9/25/2025.  During a review of Patient 32’s LCD Hospice Eligibility Determination (LCD/Local Coverage Determination; a decision by a Medicare Administrative Contractor [a regional entity that handles Medicare claims] to cover a particular medical service or item, or to consider it not covered, based on criteria of medical necessity within its specific jurisdiction), dated 9/25/2025, the LCD indicated that Patient 32 was qualified to receive hospice services due to heart disease. The LCD indicated that Patient 32 had been optimally treated with diuretics (medications that increase urine output, often used to lower blood pressure) and vasodilators (medications that cause the blood vessels to widen [dilate], often used to lower blood pressure). The LCD also indicated that Patient 32 met the criteria for NYHA IV (a classification of heart failure by the New York Heart Association – class IV indicates the most severe form of heart failure, characterized by an inability to perform any physical activity without discomfort and the presence of symptoms, such as shortness of breath, even at rest).  During a review of Patient 32’s H & P from Skilled Nursing Facility 1 (SNF 1), the H & P indicated that Patient 32 was discharged from SNF 1 on 6/25/2025. There was no documentation in the H & P that indicated Patient 32 was referred to hospice.  During a joint home visit with RN 8 on 10/22/2025 at 11:30 a.m., Patient 32 was observed sitting at the edge of his bed, alert and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 32 lives in a board and care facility (a small, residential home that provides non-medical assistance and personal care services to seniors). Caregiver 5 (CG 5) was present during the home visit. Patient 32 refused to be interviewed during the home visit. Patient 32 stated, “I don’t feel good.”  During an interview with CG 5 on 10/22/2025 at 12:43 p.m., CG 5 stated she was the primary caregiver for Patient 32. CG 5 stated that Patient 32 did not have any family members or relatives that visited him. During a concurrent interview and record review with the DPCS on 10/23/2025 at 12:27 p.m., the DPCS reviewed Patient 32’s CTI for the first certification period and LCD, dated 9/25/2025. The DPCS stated that the HA did not have any hospice referral, documentation or copy of the DPOA, diagnostics, or medical reports in his clinical records that supported the qualifying terminal diagnosis in the LCD and the statement regarding the DPOA in the CTI.    During a review of the HA’s policy and procedure (P&P), titled “Certification of Terminal Illness,” revised November 2024, the P & P indicated that clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification.  During a review of the HA’s P & P, titled “Admission Criteria and Process”, revised November 2024, the P & P indicated that the HA would admit a patient only on recommendation of the medical director in consultation with, or input from, the patient’s attending physician, if any.  5. During a record review of Patient 33’s medical record form titled “Personal Information” indicated a start of care date of 9/27/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (heart arteries are narrow due to build up of plaque) without angina pectoris (no pain).  During a record review of Patient 33’s medical record form untitled, dated 9/27/2025, indicated Patient 33 was wheelchair bound due to gout and peripheral neuropathy (condition that affects the nerves). The untitled form also indicated Patient 33 was homebound and was requesting an electric wheelchair.  During a record review of Patient 33’s medical record form titled “LCD Hospice eligibility Determination” dated 9/27/2025, indicated Patient 33 met the LCD guidelines by being ruled out as a candidate and declining surgical procedures, and meets the NYHA (New York Heart Association – system used to categorize the severity of heart failure based on symptoms and physical limitations) Class IV (patient unable to carry on any physical activity without discomfort. Heart failure symptoms are present even at rest and discomfort increases with any activity) level.  During a record review of Patient 33’s medical record form titled “Face to Face Encounter” indicated it was undated and the certification period dates were left blank. The Face-to-Face Encounter also indicated that Patient 33 was involved in a motor vehicle accident and was unable to ambulate, therefore Patient 33 was wheelchair bound.  During a record review of Patient 33’s medical record form titled “Physician's Certification for Hospice Benefits – Sta tement for first 90-day period” dated from 9/27/2025 to 12/25/2025, indicated the Medical Doctor 2 (MD2) was the referring physician, but did not contain MD2’s signature. The Physician's Certification for Hospice Benefits – Statement for first 90-day period also indicated it was unknow if MD2 was going to follow Patient 33 or not.   During a record review of Patient 33’s medical record form titled “Physician's Certification for Hospice Benefits (CTI)” dated from 9/27/2025 to 12/25/2025, indicated the certification was based on Patient 33’s medical history, record, and patient status. The CTI also indicated the Medical Director (MD) signed and stated that Patient 33’s Durable Power of Attorney (DPOA – a designated person that has the legal authority to make decisions on behalf of the patient) opted for hospice care and declined aggressive treatment. Lastly the CTI indicated “Patient has terminal illness with life expectancy of six months or less if the disease process will take its normal course. Patient is hospice eligible and meets LCD (Local Coverage Determination – set of o guidelines used to determine a patient's eligibility for the Medicare hospice benefits) guidelines bases on initial nursing assessment and H&P (History and Physical) reviewed.”  During a concurrent interview and record review on 10/23/2025 at 11:30 a.m., with the Director of Patient Care Services (DPCS) of Patient 33’s medical record, the DPCS stated that the HA does not have any of Patient 33’s hospital records, diagnostics, or history and physical (H&P). The DPCS stated that MD2 was the referring physician. The DPCS stated that Patient 33 qualified for hospice services based on the NP1’s evaluation and findings.   During an interview on 10/23/2025 at 1:39 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated that she has never seen Patient 33. During an interview on 10/22/2025 at 2:30 p.m. with Patient 33’s caregiver (CG4), CG4 stated that she has been with Patient 33 for a “long time” including while Patient 33 was receiving hospice services from a different agency.   During a concurrent observation and interview on 10/22/2025 at 2:10 p.m. with Patient 33 at his home, Patient 33 was fully dresses, sitting on a wheelchair, and was awake, alert, and oriented to name, place, time, and situation. Patient 33 stated that he was in a motor vehicle accident and had surgery on both knees. Patient 33 stated that he resided at a post-acute center for the past 2 years and was recently discharged home in July 2025 because he (Patient 33) was able to be taken care of at home. Patient 33 stated his primary physician at the veterans' affairs retired and will be seeing his new primary physician in November 2025. Patient 33 stated that he was unaware he had heart issues. Patient 33 stated “I have heart issues? I know I have high blood pressure but that is about it.” Patient 33 stated “No doctor or anyone has told me that I was dying. I would remember something like that. No, no one has told me that I had six months or less to live.” Patient 33 stated he did not know MD or MD2.  During a record review of HA’s form titled “Certification of Terminal Illness” revised 11/2024, indicated “At the time of admission to hospice, the hospice Medical Director or the patient's attending physician will complete a certification narrative that reflects the patient's individual circumstances based on: his/her review of the patient's medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice services forms.) The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election.” The Certification of Terminal Illness form also indicated “Both the attending physicians and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim.” The P & P also indicated that clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification.  During a record review of HA’s form titled “Physician Services – Medical Director” revised 11/2024, indicated “The duties and responsibilities of the Medical Director will include, but not be limited to, the following: Reviewing patients' medical eligibility for hospice services, in accordance with hospice program policies and procedures...”. During a record review of the HA’s form titled “Clinical Directo/Director of Patient Care Services (DPCS) – Job Description Summary” revised 11/2024, indicated “The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services. The Clinical Director/Director of Patient Care Services establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy. The Clinical Directo/Director of Patient Care Services – Job Description Summary also indicated that one of the DPCSs job function was to “Assures compliance with all local, state and federal laws...”.  During a review of the HA’s P & P, titled “Admission Criteria and Process”, revised November 2024, the P & P indicated that the HA would admit a patient only on recommendation of the medical director in consultation with, or input from, the patient’s attending physician, if any. Eligibility criteria would be continually reviewed on an ongoing basis by the interdisciplinary team to assure appropriateness of hospice care.

Based on interview and record review, the Hospice Agency’s (HA – agency providing care to terminally ill patients who have six months or less to live) Medical Director (MD 1) failed to document an accurate Certification of Terminal Illness (CTI – a physician's written statement confirming a patient has a life expectancy of six months or less, if the illness runs its natural course, which is required for the patient to be eligible for hospice benefits)  that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for five of nine sampled patients (Patient 7, Patient 20, Patient 22, Patient 25, and Patient 34). As a result, the affected patients were placed at increased risk for losing their hospice eligibility/hospice benefits, not receiving hospice care when needed in the future, and had the potential to not receive the necessary care and services that could lead to potential hospitalization and death. --- During an interview with the Director of Patient Care Services (DPCS) on 10/23/2025 at 12:18 p.m., the DPCS stated that due to the lack of history and physical (H & P – a foundational document in healthcare that combines a patient's medical history with a physical examination to inform diagnosis and treatment planning), diagnostics, studies, and hospice referral, it was possible that the patients were not eligible for hospice services. When the DPCS was asked if there could be any negative outcome if ineligible patients were admitted to hospice, the DPCS stated that the patient may not be eligible for other medical services, which could prevent them from getting the care or treatment they needed.  During an interview on 10/23/2025 at 10:42 a.m. with the Medical Doctor 2 (MD2), MD2 stated that he does not see the patients personally and that his Nurse Practitioner (NP1) sees the patients and he joins in via telehealth. MD2 stated that he does not have any notes for any patient and would have to contact NP1 for her NP1 notes. MD2 stated that he does not have access to the HA’s electronic medical record (EMR) system.   During an interview on 10/23/2025 at 10:58 a.m., with MD2, MD2 was informed that his (MD2) name appeared as the referral MD for sample Patients 22, 25, 30, 31, and 33. MD2 stated that he (MD2) was only familiar with Patient 33. MD2 stated “No, I don't know these patients and I did not refer them to that hospice. They are lying.”  During an interview on 10/23/2025 at 11:13 a.m. with Nurse Practitioner 1 (NP1), NP1 was informed that MD2 was the referring MD for Patients 22, 25, 30, 31, and 33. NP1 stated that she works as an attending for the HA. NP1 stated that she recognizes the names of some of the patients mentioned but was unable to access the HA’s EMR system at this time. NP1 stated she visits patients at their (patients) residence and reviews their (patients) medical records and labs. NP1 stated that she also orders their medications. NP1 stated that she coordinates the patients visits with the HA’s nurse.   During an interview on 10/23/2025 at 1:52 p.m. with Nurse Practitioner 1 (NP1) stated that her internet wires were vandalized and she (NP1) does not have access to the internet where she can retrieve patients' files/documents. NP1 stated that she did not have access to the HA’s EMR system. NP1 stated that she gives the HA her patient notes and HA upload them into their EMR system.  1. During a record review of Patient 7’s Personal Information, indicated a start of care date of 5/12/2205, with a terminal diagnosis of atherosclerosis heart disease (buildup of plaque in the arteries) of native coronary artery with unstable angina pectoris (chest pain due to insufficient oxygen). A record review of Patient 7’s, Certificate of Terminal Illness, for certification period 2, dated 9/10/2025 to 11/7/2025, indicated, “the patient continues to meet criteria for hospice recertification for the next benefit period, supported by the following clinical indicators: Decline in mental state, increased confusion, anxiety...High risk for falls...Dependence on assistance for 5/6 (5 out of 6) Activities of Daily Living (ADLs –bathing, dressing, eating, etc.)...eating declined to 40-50% (percent), requiring assistance, presence of angina (chest pain) and dyspnea (shortness of breath) with activities.” The record indicated it was signed by the Medical Director (MD).  During an interview on 10/22/2025, at 12:45 p.m., with Patient 7, stated she was not receiving nursing services at home and was not a patient of the HA. When told that medical records indicated nursing care visits, Patient 7 then stated a nurse visited her twice only, and she was receiving supplies from an agency. When asked about other services receiving from the agency such as Medical Social Worker, Spiritual Counselor, Patient 7 stated “they” call and checked on Patient 7 to make sure she was okay. But to come to Patient 7’s home for a visit, it was only “twice” since May 2025.  During an interview on 10/22/2025, at 12:45 p.m., with Patient 7, stated she had a primary care doctor who she sees regularly. Patient 7 stated the HA offered oxygen, but Patient 7 did not need it. Patient 7 stated she was able to go outside, go shopping, go to doctor’s appointments without any issues. Patient 7 stated she did not have shortness of breath. Patient 7 stated she had high blood pressure, but her heart was not failing. Patient 7 stated her primary care doctor told Patient 7 her health was stable and was not worsening. Patient 7 stated she became aware of the HA through a friend who told her about a program that offered diapers and supplies.  During an interview on 10/23/2025, at 10:30 a.m., with Patient 7’s primary care doctor clinic representative (REP 1), REP 1 stated Patient 7 had an upcoming appointment on 10/28/2025. REP 1 stated Patient 7 received care at the clinic on 9/25/2025, 7/2025, and 6/2025.  During a concurrent interview and record review on 10/23/2025, at 11:05 a.m., with Registered Nurse 5 (RN 5), RN 5 reviewed Patient 7’s record titled, Re-Cert Assessment, dated 8/4/2025. The record indicated Patient 7 qualified for hospice care based on the LCD (Local Coverage Determination, a tool used to indicate if patient qualifies for hospice care) for heart disease. The LCD indicated Patient 7 had NYHA (New York Heart Association classification system) class 4 (the most severe heart failure. Shortness of breath experienced at rest. Movement causes symptoms) heart failure. RN 5 stated the reason Patient 7 was recertified for hospice care was due to declining. RN 5 stated Patient 7 became more dependent on her ADL’s (Activities of Daily Living such as bathing, dressing, eating, etc.) going from 2 out 6 in the initial assessment, to 5 out of 6. RN 5 stated Patient 7 was more dependent on oxygen, now using 2 liters of oxygen per minute as needed, progressive decline mentally, and had lost 5 pounds from her admission weight of 170 pounds. RN5 stated she did not have any supporting documents to support Patient 7’s heart disease.  During an interview on 10/23/2025, at 11:19 a.m., with Patient 7’s primary care doctor clinic representative 2 (REP 2), REP 2 stated Patient 7’s last visit was on 9/2025. REP 2 stated he was reviewing the clinic notes and the notes indicated Patient 7 did not have difficulty dressing or bathing and was independent with her ADL’s. REP 2 stated the clinic records did not indicate Patient 7 had a terminal diagnosis or that Patient 7 was referred to hospice care. REP 2 stated Patient 7 had not used oxygen in the last 6 months. REP 2 stated Patient 7 weight on 7/31/2025 was 200 pounds, an increase from Patient 7’s weight on 6/18/2025 of 189 pounds. During an interview on 10/23/2025, at 12:24 p.m., with the MD, the MD stated he was very confident he had read Patient 7’s medical records. MD stated there must have been cardiology (heart doctor) reports that must have been there. MD stated he reviewed everything. When MD was told that Patient 7 did not report heart failure, was not using oxygen, had a primary care doctor, and reported being stable in health, MD stated that Patient 7 must have had a heart issue. Patient 7 could have had an exacerbation due to illness. When MD was told there was no medical records to support Patient 7’s terminal illnes, the MD stated he reviewed whatever records the HA gave him.  2. During a review of Patient 20’s Personal Information, the Personal Information indicated a start of care (SOC) date of 5/4/2025, with a terminal diagnosis of heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat), unspecified. During a review of Patient 20’s CTI for the second certification period, from 8/22/2025 to 11/19/2025, the physician narrative indicated that the MD recertified Patient 20 based on his review of the patient’s medical record, team assessment, and/or examination of the patient. The CTI indicated that the MD signed the CTI on 8/22/2025. During a review of Patient 20’s LCD Hospice Eligibility Determination (LCD/Local Coverage Determination; a decision by a Medicare Administrative Contractor [a regional entity that handles Medicare claims] to cover a particular medical service or item, or to consider it not covered, based on criteria of medical necessity within its specific jurisdiction), dated 8/7/2025, the LCD indicated that Patient 20 was qualified to receive hospice services due to heart disease. The LCD indicated that Patient 20 had declined surgical procedures. The LCD also indicated that Patient 20 met the criteria for NYHA IV (a classification of heart failure by the New York Heart Association – class IV indicates the most severe form of heart failure, characterized by an inability to perform any physical activity without discomfort and the presence of symptoms, such as shortness of breath, even at rest).  During further review of Patient 20’s clinical records, there was no documented evidence that Patient 20 needed surgical procedures related to his heart condition, and that he had declined it. There was no documented evidence that Patient 20 had been diagnosed with NYHA IV heart failure.  During a telephone interview with Patient 20 on 10/23/2025 at 9:37 a.m., Patient 20 stated he had poor memory, therefore he could not remember who referred him to hospice, or what heart condition he had.  During a concurrent interview and record review with the DPCS on 10/23/2025 at 12:27 p.m., the DPCS reviewed Patient 20’s CTI for the second certification period and LCD, dated 8/7/2025. The DPCS further reviewed Patient 20’s other clinical records on the HA’s electronic health record system, such as the Recert Assessment (recertification assessment – a process to confirm a patient's continued eligibility for hospice care, which requires a physician to re-evaluate their condition to ensure the terminal illness is still life-limiting with a prognosis of six months or less), dated 8/7/2025, and Communication Log since admission. The DPCS stated the HA did not have any documented evidence, such as H & P, diagnostics, or studies that supported the terminal diagnosis for Patient 20.   3. During a record review of Patient 22’s medica record form titled “Personal Information” indicated a start of care date of 6/5/2025, with a primary diagnosis of heart disease (a condition that affects the heart and heart vessels), unspecified.  During a record review of Patient 22’s medical record form titled “Physician's Certification for Hospice Benefits (CTI)” dated from 9/3/2025 to 12/1/2025, indicated the certification was based on Patient 22’s medical history, record, and patient status. The CTI also indicated the Medical Director (MD) signed and attest/confirm that he (MD) composed the narrative based on Patient 22’s medical records, team assessment, and/or examination of the Patient 22.  During a record review of Patient 22’s medical record form titled “Audit Log” dated from 6/4/2025 to 10/23/2025, indicated that MD signed Patient 22’s CTI dated 9/3/2025 on 9/11/2025. During a record review on 10/21/2025 at 12:35 p.m. of Patient 22’s electronic medical record (EMR), the EMR indicated Patient 22 had three files uploaded into the Document/Image section. The three files downloaded into Patient 22’s EMR were her (Patient 22) consents, identification card, and POLST (provider orders for life-sustaining treatment – a medical form that indicates a patient's medical care preference).  During an interview on 10/21/2025 at 4:41 p.m. Patient 22 was called to the number provided on her (Patient 22) EMR. A woman (WM1) answered and stated that Patient 22 was not at home but will give her (Patient 22) a message to return call.  During a concurrent interview and record review on 10/23/2025 at 12:01 p.m. with the Director of Patient Care Services (DPCS) or Patient 22’s EMR, the DPCS stated that Patient 22’s LCD indicated that Patient 22 was qualified to receive hospice services due to heart disease. The DPCS stated that Patient 22 had declined surgical procedures and met the criteria for NYHA IV. The DPCS stated that the HA did not have a History and Physical (H&P) for Patient 22. The DPCS stated Patient 22 was admitted for hospice services based what Patient 22 and her (Patient 22) family stated, as well as the Medical Direcor (MD) referral assessment or any other doctors admitting notes. The DPCS was requested to provide Patient 22’s H&P, diagnostics and MD notes. The DPCS stated that the HA does not have any H&P, diagnostics or MD notes for Patient 22. The DPCS stated that the admitting nurse (RN3) based Patient 22’s admitting information on what Patient 22’s family said.   4. During a review of Patient 25’s Personal Information, the Personal Information indicated a start of care (SOC) date of 6/23/2025, with a terminal diagnosis of unspecified diastolic heart failure (heart failure that occurs when the left ventricle [one of the four chambers of the heart, located in the bottom left portion] becomes stiff), unspecified. During a review of Patient 25’s CTI for the second certification period, from 9/21/2025 to 12/19/2025, the physician narrative indicated that MD 1 recertified Patient 25 based on his review of the patient’s medical record, team assessment, and/or examination of the patient. The CTI indicated that the MD signed the CTI on 9/21/2025.  During a review of Patient 25’s LCD, dated 9/15/2025, the LCD indicated that Patient 20 was qualified to receive hospice services due to heart disease. The LCD indicated that Patient 25 had been ruled out as a candidate for surgical procedures and had declined surgical procedures related to his heart condition. The LCD also indicated that Patient 20 met the criteria for NYHA IV. During a telephone interview with Patient 25 on 10/22/2025 at 2:24 p.m., Patient 25 stated that he had never been diagnosed with a terminal illness with 6 months or less to live. Patient 25 stated, “I’m not terminally ill.” Patient 25 stated that he had high blood pressure, which was treated with medications. Patient 25 stated that he regularly saw his primary care physician (PCP – a healthcare professional who acts as a patient’s main point of contact for non-emergency medical needs, coordinating the patient’s overall health and wellness), who was monitoring his blood pressure. Patient 25 stated that he was seen by his PCP less than two weeks prior. When Patient 25 was asked if he knew why he was referred to hospice, Patient 25 stated, “My doctor referred me to home care so I can get help with showers. I’m in a wheelchair; I can’t shower on my own. The agency sends somebody to help me with showers.” Patient 25 stated that he was not on hospice, that the service he was currently receiving from the HA was home care. During a telephone interview with a staff at Patient 25’s physician’s office on 10/23/2024 at 10:51 a.m., the staff confirmed that Patient 25 was under the care of Physician Assistant 1 (PA 1), who had been providing care for him . The staff stated that Patient 25 was last seen by PA 1 on 10/10/2025.   On 10/22/2025, at 2:46 p.m., a phone call from Patient 25 was received. Patient 25 stated that he called the HA to confirm if he was receiving home care or hospice. Patient 25 stated, “Turns out I’m on hospice. The agency said I’m on hospice because I have COPD (chronic obstructive pulmonary disease – an ongoing lung condition caused by damage to the lungs; the damage results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs).”   During a concurrent interview and record review with the DPCS on 10/23/2025 at 12:27 p.m., the DPCS reviewed Patient 25’s CTI for the second certification period and LCD, dated 9/15/2025. The DPCS further reviewed Patient 25’s other clinical records on the HA’s electronic health record system, such as the Recertification Assessment, dated 9/15/2025, and Communication Log since admission. The DPCS stated the HA did not have documented evidence, such as H & P, diagnostics, or studies that supported the terminal diagnosis for Patient 20. The DPCS stated there was no hospice referral for Patient 25. The DPCS stated, “We need the patient’s medical records so that we know what’s going on with the patient, verify if there is a DPOA. Patient’s medical records are important for the agency protection, to make sure the patient is eligible.”  The DPCS stated that she did not remember reviewing relevant clinical records for Patient 20 and Patient 25. The DPCS stated, “I always document in the communication note after I reviewed records. There’re no communication notes that I reviewed Patient 20’s and Patient 25’s medical records before the recertification. I don’t remember reviewing their medical records. It fell through the loop.”  5. During a record review of Patient 34’s medica record form titled “Personal Information” indicated a start of care date of 2/4/2025 and an end of care date of 9/2/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (heart arteries are narrow due to build up of plaque) with unstable angina pectoris (chest pain).  During a record review of Patient 34’s medical record form titled “Physician Orders” indicated Patient 34 had one admission ordered for the first benefit period from 2/4/2025 to 5/4/2025. The Physician Order form did not indicate Patient 34 had a recertification/readmit to hospice ordered documented after 5/4/2025.  During a record review of an untitled and undated form, indicated it had Patient 34’s name on top. The form appears to be a word document that contained Patient 34’s name, date of birth, and assessment information and had a darker color signature above the name of the Medical Doctor 3 (MD3). The untitled and undated form also indicated it had the same verbiage as Patient 34’s Recertification Nursing Assessment dated 4/29/2025. Lastly, the form indicated “Based on patient status, medical condition, team assessment including face to face encounter, patient qualifies for hospice, meeting hospice criteria with poor prognosis and a life expectancy of six months or less, if the terminal illness runs its normal course.  During a record review of Patient 34’s medical record form titled “Audit Log” dated from 2/3/2025 to 10/23/2025, and a module ID of 2521480, indicated License Vocational Nurse 3 (LVN3) created and documented Patient 34’s Recert Nursing Assessment dated 4/29/2025 on 6/26/2025. Lastly, the Audit Log noted to have the same verbiage that is documented on Patient 34’s untitled and undated form.    During a concurrent interview and record review on 10/21/2025 at 3:58 p.m. with Medical Doctor 3 (MD3), of Patient 34’s untitled and undated medical record form, MD3 stated that the dark color electronic signature looked like it was hers but the format of the rest of the document she did not recognize. MD3 also stated that her patient assessments had her contact information and are dated.  MD3 stated that the untitled/undated form was not her note. MD3 stated that she did not recall Patient 34’s name but will contact the Nurse Practitioner working with her and her patient notes. MD3 stated that she did not refer Patient 34 for hospice services. MD3 stated that she left the HA after hearing “sketchy things” about the HA. MD3 stated that her name has been passed around hospice agencies and for that reason there were things “happening that were unbeknownst (unknown) to me”.   During an interview on 10/21/2025 at 4:28 p.m. with Patient 34, Patient 34 stated that she had Alzheimer’s and was unable to answer questions. Patient 34 was asked if she had a prognosis of 6 months or less to live. Patient 34 stated that no one had ever informed her that she was dying.  During an interview on 10/21/2025 at 5:21 p.m. with Patient 34’s son/caregiver (CG6), CG6 stated he did not recall Patient 34’s referring physician. CG6 stated he believes a doctor from Mexico diagnosed Patient 34. CG6 stated that they heard about the HA from a family friend and decided to join. CG6 stated Patient 34 did have some kind of heart issues but was unable to stated anything further on it.     During a concurrent interview and record review on 10/23/2025 at 12:10 p.m., with the Director of Patient Care Services (DPCS) or Patient 34’s EMR, the DPCS stated that the HA did not have Patient 34’s H&P or diagnostics. The DPCS stated that the HA did have MD3’s assessment, but that it did not have a date or time. The DPCS the form did have MD3s electronic signature. The DPCS stated that Patient 34 did not have a revocation form on file. The DPCS stated that a revocation form was a form signed by a patient when the patient wants to discontinue hospice services. The DPCS stated that Patient 34 required a revocation form to be able to prove that Patient 34 was safely discharged. The DPCS stated that Patient 34 did not have a discharge order on file.  During an interview on 10/23/2025 at 1:06 p.m. with License Vocational Nurse (LVN3), LVN3 stated that she documented patient's comprehensive assessment with the information provided by the visiting Registered Nurses.   During a record review of HA’s form titled “Certification of Terminal Illness” revised 11/2024, indicated “At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patient's medical record or, if applicable, examination of the patient.” The P & P also indicated that clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification.  During a record review of HA’s form titled “Physician Services – Medical Director” revised 11/2024, indicated “The duties and responsibilities of the Medical Director will include, but not be limited to, the following: Reviewing patients' medical eligibility for hospice services, in accordance with hospice program policies and procedures...”.  During a record review of the HA’s form titled “Clinical Directo/Director of Patient Care Services (DPCS) – Job Description Summary” revised 11/2024, indicated “The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services. The Clinical Director/Director of Patient Care Services establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy. The Clinical Directo/Director of Patient Care Services – Job Description Summary also indicated that one of the DPCSs job function was to “Assures compliance with all local, state and federal laws...”.

Based on interview and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure contents and information in the patients’ clinical records were safeguarded from unauthorized access by HA staff to make any alterations or modifications for six of nine sample selected patients (Patient 7, Patient 22, Patient 25, Patient 30, Patient 33, and Patient 34). This failure has the potential to result in unauthorized and inaccurate patient information being entered in the patients’ clinical record that could affect the quality of care and patient’s well-being. --- During an interview on 10/23/2025 at 12:27 p.m., with the Medical Director (MD), the MD stated the Director of Patient Care Services (DPCS) and DPCS designee wrote the Certification of Terminal Illness (CTI) physician narrative for the MD. The MD stated he had provided his username and password to access the electronic medical record (EMR) to document the CTIs to the DPCS and DPCS designee. The MD stated he (MD) reviewed everything documented, then the MD would sign the document.  1. During a record review of Patient 7’s Personal Information, indicated a start of care date of 5/12/2205, with a terminal diagnosis of atherosclerosis heart disease (buildup of plaque in the arteries) of native coronary artery with unstable angina pectoris (chest pain due to insufficient oxygen).  During a record review of Patient 7’s Audit Log (a document that lists all the entries, modifications, made to a medical record), dated 5/15/2025 to 10/23/2025, indicated the MD had initially documented on Patient 7’s CTI (Certificate of Terminal Illness), dated 5/12/2025, on 6/11/2025. Further review of the record indicated Licensed Vocational Nurse 3 (LVN 3), deleted the document on 6/26/2025, and wrote the physician narrative on the same day, 6/26/2025. The MD then signed the document on 6/26/2025.  2. During a record review of Patient 22’s medical record form titled “Personal Information” indicated a start of care date of 6/5/2025, with a primary diagnosis of heart disease (a condition that affects the heart and heart vessels), unspecified. During a record review of Patient 22’s medical record form titled “Revocation of Medicare/Medi-Cal Hospice Benefit” undated, indicated the form was left blank except for Patient 22’s name and signature.  During a concurrent interview and record review on 10/23/2025 12:10 p.m. with the Director of Patient Care Services (DPCS) of Patient 22’s medical record, the DPCS stated that a revocation form should be signed by the patient when they elect to discontinue hospice services and not before. The DPCS stated that a revocation form should not be signed in advance anticipating a revocation. The DPCS stated that Patient 22’s revocation form was signed, and she (DPCS) did not know why it was signed. The DPCS stated “probably the nurse asked the patient to sign all the forms.”  3. During a review of Patient 25’s Personal Information, the Personal Information indicated a start of care (SOC) date of 6/23/2025, with a terminal diagnosis of unspecified diastolic heart failure (heart failure that occurs when the left ventricle [one of the four chambers of the heart, located in the bottom left portion] becomes stiff), unspecified. During a review of Patient 25’s CTI (Certification of Terminal Illness – a physician's written statement confirming a patient has a life expectancy of six months or less, if the illness runs its natural course, which is required for the patient to be eligible for hospice benefits) for the first certification period, from 6/23/2025 to 9/20/2025, the physician narrative indicated that Patient 25 was eligible to receive hospice services. The CTI indicated the HA’s Medical Director (MD) signed it on 6/23/2025. During a review of Audit Log conducted on 10/23/2025, the Audit Log (indicates all the changes, edits, entries made into an electronic medical record) indicated that on 7/8/2025, at 4:44 a.m., Registered Nurse 6 (RN 6) input the content of the Physician Narrative/Certifying Physician Summary section of the CTI dated 6/23/2025. The Audit Log indicated the MD electronically signed it on 7/8/2025.  During a concurrent interview and record review with the DPCS on 10/23/2025 at 1:36 p.m., the DPCS reviewed Patient 25’s CTI for the first certification period and the Audit Log for Certification MD/CTI, from 6/23/2025 to 10/23/2025. During the concurrent interview and record review, the DPCS stated that only a physician or physician designee was supposed to document the CTI, including the Physician Narrative/Certifying Physician Summary. The DPCS stated that RN 6 was not a physician or physician designee.  4. During a record review of Patient 30’s Personal Information, indicated a start of care date of 8/26/2025, with a terminal diagnosis of Chronic obstructive pulmonary disease (a lung disease that makes breathing difficult). During a concurrent interview and record review on 10/23/2025, at 1:28 p.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 reviewed Patient 30’s record titled Audit Log, dated 8/21/2025 to 10/23/2025. The record indicated Registered Nurse 3 (RN 3) had documented the Nursing Assessment on 8/26/2025. Further review of the record indicated LVN 3 had made changes to the Nursing Assessment, dated 8/26/2025. The changes included changing the answer “attempt CPR (resuscitation) to DNR (do not resuscitate) as well as changing the nursing narrative. When asked the reasons why LVN 3 changed RN 3’s nursing note, LVN 3 stated she had probably spoken to RN 3 and changed the record because there was a change of condition. LVN 3 stated she wouldn’t have changed something on the record by her own thought. Someone told her to change something. Otherwise, she would have not changed it. LVN 3 stated her understanding is the staff was supposed to document everything on their own. If there is an error, the person who wrote the document was supposed to make the change.  During a concurrent interview and record review on 10/23/2025, at 1:35 p.m., with the DPCS, the DPCS reviewed Patient 30’s record titled Audit Log, dated 8/21/2025 to 10/23/2025. The record indicated the DPCS had made changes to the document Nursing Assessment, dated 8/26/2025. These changes included modifying answers from false to true, true to false, and nursing narrative changes. The DPCS stated she had not assessed Patient 30 and should have had RN 3 make the corrections. The DPCS stated she made corrections to the document based on what RN 3 reported to her.  5. During a record review of Patient 33’s medical record form titled “Personal Information” indicated a start of care date of 9/27/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (heart arteries are narrow due to build up of plaque) without angina pectoris (no pain). During a record review of Patient 33’s medical record form titled “Revocation of Medicare/Medi-Cal Hospice Benefit” undated, indicated the form was left blank except for Patient 33’s name and signature. During a record review of Patient 33’s medical record form titled “Benefit Transfer of Services” undated, indicated the form was left blank except for Patient 33’s name and signature. During a concurrent interview and record review on 10/23/2025 12:10 p.m. with the Director of Patient Care Services (DPCS) of Patient 33’s medical record, the DPCS stated that a revocation form should be signed by the patient when they elect to discontinue hospice services and not before. The DPCS stated that a revocation form should not be signed in advance anticipating a revocation. The DPCS stated that Patient 33’s revocation form was signed, and she (DPCS) did not know why it was signed. The DPCS stated “probably the nurse asked the patient to sign all the forms.”  6. During a record review of Patient 34’s medical record form titled “Personal Information” indicated a start of care date of 2/4/2025 and an end of care date of 9/2/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (heart arteries are narrow due to build up of plaque) with unstable angina pectoris (chest pain). During a record review of an untitled and undated form, indicated it had Patient 34’s name on top. The form appears to be a word document that contained Patient 34’s name, date of birth, and assessment information and had a darker color signature above the name of the Medical Doctor 3 (MD3). Lastly, the form indicated “Based on patient status, medical condition, team assessment including face to face encounter, patient qualifies for hospice, meeting hospice criteria with poor prognosis and a life expectancy of six months or less, if the terminal illness runs its normal course.  During a concurrent interview and record review on 10/21/2025 at 3:58 p.m. with Medical Doctor 3 (MD3), of Patient 34’s untitled and undated medical record form, MD3 stated that the dark color electronic signature looked like it was hers (MD3), but the format of the rest of the document she (MD3) did not recognize. MD3 also stated that her (MD3) patient assessments had her (MD3) contact information and are dated.  MD3 stated that the untitled/undated form was not her note. MD3 stated that she did not recall Patient 34’s name but will contact the Nurse Practitioner working with her (MD3) and her (MD3) patient notes. MD3 stated that she (MD3) did not refer Patient 34 for hospice services. MD3 stated that she (MD3) left the HA after hearing “sketchy things” about the HA. MD3 stated that her (MD3) name has been passed around hospice agencies and for that reason there were things “happening that were unbeknownst to me”.  During a record review of HA’s form titled “Submission of Notes” with an effective date of 1/8/2025, indicated “All clinical staff must complete and submit visit notes within 72 hours from the date of the visit. Documentation must be submitted to the agency office and incorporated into the patient's medical record within this timeframe.” During a record review of the HA’s form titled “Clinical Director/Director of Patient Care Services (DPCS) – Job Description Summary” revised 11/2024, indicated “The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services. The Clinical Director/Director of Patient Care Services establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy. The Clinical Director/Director of Patient Care Services – Job Description Summary also indicated that one of the DPCSs job function was to “Assures compliance with all local, state and federal laws...”.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to meet the Condition of Participation  (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people 65 years of age or more and for certain younger people with disabilities]) for compliance with Initial and Comprehensive Assessments of the patients as follows: --- 2. Provide documented evidence the physician order for wound care referral for one of sampled Patients (Patient 11) was completed. This failure had the potential for Patient 11 to experience a delay in diagnosis and treatment; potentially worsening his medical condition and resulting in inadequate pain management and increased risk of infection and avoidable hospitalization. (Refer to L-tag 532).3. Ensure the comprehensive assessment of two of two sampled Patients (Patient 4 and Patient 11) were updated to include changes that have taken place since the initial assessment by:a. Failing to ensure a complete and accurate wound assessment was documented for Patient 4 and Patient 11.b. Failing to ensure an accurate Plan of Care (POC) was implemented for Patient 4 and Patient 11.c. Failing to ensure the Interdisciplinary Group (IDG) Review was conducted to discuss changes, progress, and reassessment for Patient 11. These failures had the potential for Patient 4 and Patient 11 to experience inadequate treatment; potentially worsening medical conditions and resulting in inadequate symptom management. (Refer to L-tag 533).The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Initial and Comprehensive Assessments are provided to patients certified to receive home health benefits. The HA failed to1. Ensure the comprehensive assessment identified and addressed the needs of 3 of 10 sampled patients (Patient 1, Patient 2, and Patient 3). This failure had the potential for Patient 1, Patient 2, and Patient 3 to experience severe pain or distress, agitation, emergency hospitalization and potentially experience an undignified and avoidable traumatic death. (Refer to L-tag 524) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Initial and Comprehensive Assessments are provided to patients certified to receive home health benefits.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the comprehensive assessment identified and addressed the needs of 3 of 15 sampled patients (Patient 1, Patient 2, and Patient 3).   This failure had the potential for Patient 1, Patient 2, and Patient 3 to experience severe pain or distress, agitation, emergency hospitalization and potentially experience an undignified and avoidable traumatic death. --- Findings: 1. During a review of Patient 1’s “Personal Information,” (page of the medical chart containing a summary of basic patient information) undated, the “Personal Information” indicated the HA admitted Patient 1, a 73-year-old female, on 8/15/2025 with diagnosis that included atherosclerosis heart disease (plaque buildup in the heart’s arteries), shortness of breath (SOB, a subjective sensation of not being able to get enough air, often accompanied by feelings of tightness in the chest, rapid breathing, and wheezing [a high-pitched, whistling sound that occurs when air flows through narrowed airways]), and dependance on supplemental oxygen (a condition requiring the use of a device to deliver extra oxygen). During a review of Patient 1’s “Visit Note LVN,” dated 9/10/2025, the “Visit Note LVN” indicated Patient 1 experienced heavy breathing, diminished lung sounds in bilateral (affecting both sides) lobes, and moderate SOB with exertion.  During Patient 1’s home visit with Registered Nurse 3 (RN 3) on 9/10/2025 at 9:32 AM, a medication reconciliation (a process on comparing patient’s current medication against medication ordered by the physician) was conducted. Patient 1’s “Current Treatment/ Medication/ DME List” did not include oxygen for SOB and dependence on supplemental oxygen. During Patient 1’s home visit with Registered Nurse 3 (RN 3) on 9/10/2025 at 9:32 AM, Patient 1’s Caregiver 1 (CG 1) stated the HA did not provide Patient 1 with oxygen for home use.   During a concurrent interview and record review on 9/11/2025 at 10:07 AM with the Director of Patient Care Services Designee (DPCS Designee), Patient 1’s “Comprehensive Nursing Assessment,” dated 8/15/2025 was reviewed. The “Comprehensive Nursing Assessment” indicated mild SOB and wheezing on room air. The DPCS Designee stated an order for oxygen should have been entered to treat SOB, wheezing, and diminished lung sounds. The DPCS Designee stated failure to provide oxygen therapy placed Patient 1 at increased risk of respiratory distress (a life-threatening condition that causes severe difficulty breathing) and hospitalization.  During an interview on 9/11/2025 at 2:20 PM with the Medical Director (MD), the MD stated that Patient 1 required an order for oxygen based on her clinical symptoms of SOB and diminished lung sounds.   2. During a review of Patient 2’s Comprehensive Nursing Assessment: Primary/Secondary Diagnosis & Comorbidities, dated 8/6/2025, the Comprehensive Nursing Assessment: Primary/Secondary Diagnosis & Comorbidities indicated secondary diagnosis including hypothyroidism (thyroid gland does not produce enough thyroid hormones) and SOB. During a concurrent observation and interview on 9/10/2025 at 1:10 PM with CG 2 at Patient 2’s home, no oxygen tank or supplies were observed.  CG 2 stated we have been requesting oxygen since she was admitted on 8/6/2025 but has not received it yet.  However, hospice called this morning and said they would deliver it this afternoon (9/10/2025). During a concurrent interview and record review on 9/15/2025 at 11:21 AM with RN 5, Patient 2’s Comprehensive Nursing Assessment: Body System: Head-to-Toe: Respiratory, dated 8/6/2025 was reviewed.  The Comprehensive Nursing Assessment: Body System: Head-to-Toe: Respiratory indicated moderate dyspnea (difficulty breathing) with mild and moderate exertion; “Even though SOB is present, does patient decline treatment – No”; diminished lung sounds (decrease in the intensity or volume of breath sounds); and no oxygen therapy. There were no recommendations for oxygen therapy, strategies to reduce SOB, suggestions for patient/family goals to manage SOB, or patient teaching on SOB.  RN 5 stated, oxygen therapy should have been ordered on admission for Patient 2 who has a diagnosis of SOB and symptoms of moderate dyspnea. During a concurrent interview and record review on 9/15/2025 at 11:21 AM with RN 5, Patient 2’s “Current Treatment/Medication/DME List” was reviewed.  Patient 2’s “Current Treatment/Medication/DME List” indicated no orders for oxygen therapy prior to 9/13/2025.  RN 5 stated, oxygen therapy was not, but should have been, ordered on admission for Patient 2. During a concurrent interview and record review on 9/15/2025 at 11:30 AM with RN 5, Patient 2’s Comprehensive Nursing Assessment: Body System: Head-to-Toe, dated 8/6/2025 was reviewed.  Patient 2’s Comprehensive Nursing Assessment: Body System: Head-to-Toe indicated no Endocrine section to screen for Patient 2’s needs with a diagnosis of hypothyroidism. RN 5 stated, the Endocrine section of the Comprehensive Nursing Assessment should be completed for patients with a diagnosis of hypothyroidism.   3. During a review of Patient 3’s “Personal Information”, undated, the “Personal Information” indicated the hospice agency admitted Patient 3, an 86-year-old female, on 8/11/2025 with diagnoses including, but not limited to, heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), SOB, and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance (patterns of behaviors, thoughts and moods that are considered unusual for a person’s age and context). During a review of Patient 3’s “Comprehensive Nursing Assessment”, dated 8/11/2025, the “Comprehensive Nursing Assessment” indicated Patient 3 has mild anxiety (a mental condition characterized by excessive worry, fear and nervousness that can interfere with daily life), has SOB with moderate exertion and diminished lung sounds.  During Patient 3’s home visit with Medical Social Worker (MSW, a person to provide support to patients and families) on 9/10/2025 at 3:20 PM, a medication reconciliation was conducted. Patient 3’s “Current Treatment/ Medication/ DME List” did not include any treatment or medication for anxiety. During an interview on 9/10/2025 at 3:20 PM, with Patient 3’s care giver (CG 3), CG 3 stated Patient 3 feels short of breath even with small movements. CG 3 stated she requested for Patient 3 to have an oxygen concentrator (medical device that delivers oxygen rich air to a person who has difficulty breathing) from the last nurse visit (9/8/2025) and that the facility will be delivering Patient 3’s oxygen tomorrow (9/11/2025).   During a review of Patient 3’s “Physician Order”, dated 9/10/2025, the “Physician Order” indicated Oxygen 5 liters via nasal canula (oxygen was ordered a month after Patient 3 was admitted).  During an interview on 9/15/2025 at 10:20 AM with RN 5, RN 5 stated any concerns or change of condition should be addressed as soon as it was assessed by the nurse. RN 5 stated interventions for anxiety can include non-pharmacological techniques and medications. During a review of HA’s policy and procedure (P&P), titled “Initial Assessment”, undated, the P&P indicated the admitting registered nurse will identify and address patient’s and caregiver’s concerns, goals and immediate needs based on their assessments. During a review of the HA’s P&P titled, “Policy and Procedure: Ordering Medications and Supplies,” dated 12/19/2025, the P&P indicated, “The DPCS, case manager, or hospice nurse identifies the need for medications or supplies based on patient assessment, physician plan of care, or IDG [interdisciplinary group] recommendations.” The P&P indicated, “Hospice physician/medical director: reviews, approves, and finalizes all mediation and supply orders” and “all orders, including drafts and finalized version, must be documented in the patient’s clinical record.” During a review of the facility’s policy and procedure titled, “Oxygen Safety in the Home Policy,” undated, indicated, “All oxygen safety education, assessments, and interventions will be documented in the patient’s record” and “Documentation of teaching and patient/caregiver understanding will be placed in the patient’s medical record.”   1

Based on interview and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to provide documented evidence the comprehensive assessment included a physician's order for wound care referral for one of 15 sampled Patients (Patient 11).  This failure had the potential for Patient 11's identified needs will not be met causing a delay in diagnosis and treatment, worsening medical condition, inadequate pain management and increased risk of infection and avoidable hospitalization. --- Findings: During a review of Patient 11’s “Personal Information,” (page of the medical chart containing a summary of basic patient information) undated, the “Personal Information” indicated the HA admitted Patient 11 on 3/10/2025 with diagnosis that included hypertensive heart disease with heart failure (high blood pressure damaged the heart over time, making it unable to pump blood effectively causing shortness of breath, fatigue, and swelling in the legs), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (elevated cholesterol level). During a review of Patient 11’s “Physician Order,” dated 4/3/2025, the “Physician Order” indicated on 4/3/2025 the Medical Director (MD) indicated an order for wound care evaluation and treatment. During an interview on 9/16/2025 at 11:38 AM with Registered Nurse 5 (RN 5), stated physician orders for referral of evaluation and treatment of wounds should take place within 72 hours of the order being placed.  During an interview on 9/17/2025 at 10:40 AM with RN 5 stated Patient 11’s medical record did not include documented evidence to suggest the physician’s order dated 4/3/2025 for referral of wound care services was completed. During a review of the facility’s policy and procedure (P&P) titled, “Policy & Procedure: Referrals and Logs,” undated, the P&P indicated the following: Each referral entry must include the status of the referral and the outcome. The Referral Log must be reviewed weekly by the Administrator/ Director of Nursing and any delays or missed follow-ups must be investigated.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the comprehensive assessment of two of 15 sampled Patients (Patient 4 and Patient 11) were updated to include changes that have taken place since the initial assessment by:Failing to ensure a complete and accurate wound assessment was documented for Patient 4 and Patient 11.Failing to ensure an accurate Plan of Care (POC) was implemented for Patient 4 and Patient 11.Failing to ensure the Interdisciplinary Group (IDG) Review was conducted to discuss changes, progress, and reassessment for Patient 11.  These failures had the potential for Patient 4 and Patient 11 to experience inadequate treatment, worsening medical conditions, and resulting in inadequate symptom management. --- Findings: 1. During a review of Patient 4’s “Personal Information,” (page of the medical chart containing a summary of basic patient information) undated, the “Personal Information” indicated the HA admitted Patient 4, a 85-year-old female, on 4/18/2025 with diagnosis that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), bladder and bowel incontinence (the involuntary loss of urine and stool) and bed confinement status (a person being physically restricted to their bed due to a medical condition, injury, or physical limitation).During a review of Patient 11’s “Personal Information,” undated, the “Personal Information” indicated the HA admitted Patient 11, a 76-year-old male, on 3/9/2025 with diagnosis that included hypertensive heart disease with heart failure (high blood pressure damaged the heart over time, making it unable to pump blood effectively causing shortness of breath, fatigue, and swelling in the legs), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (elevated cholesterol level).a. During a review of Patient 4’s “Comprehensive Nursing Assessment,” dated 4/18/2025, the “Comprehensive Nursing Assessment” indicated Patient 4 did not have any wounds at the time of admission to the HA. During a concurrent interview and record review on 9/17/2025 at 11:08 AM with Registered Nurse 5 (RN 5) Patient 4’s “Visit Note LVN” dated 9/1/2025 was reviewed. The “Visit Note LVN” indicated the presence of a pressure ulcer/injury stage 2 (partial-thickness loss of skin, presenting as a shallow open sore or wound) on the right buttocks that presented red in color, with serosanguinous draining and odor. The “Visit Note LVN” did not indicate wound size, inflammation, and undermining (the destruction of tissue or ulcer extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface) / tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound). RN 5 stated that the incomplete assessment prevented accurate wound staging (a classification system that describes how deep a wound is, used to assess the severity of pressure injuries) and determine the best treatment), proper treatment, and measurement of progression. RN 5 stated Patient 4 was at increased risk of infection, sepsis (a life-threatening blood infection), pain, anxiety, and agitation.  b. During a review of Patient 11’s “Visit Note LVN,” dated 3/11/2025, the “Visit Note LVN” indicated Patient 11 had a stage 1 wound (pressure ulcer/ injury stage 1, intact skin with a localized area of redness and/or change in sensation, temperature, or firmness). During an interview on 9/17/2025 at 10:35 AM with RN 5, RN 5 stated there was no documented evidence that a Registered Nurse (RN) completed a wound assessment for Patient 11 after LVN 6 identified the wound on 3/11/2025. RN 5 stated the wound should be assessed by an RN to ensure proper wound staging and treatment, complete assessment of contributing risk factors, to provide patient/ patient care giver education, and ensure optimal patient outcomes. RN 5 stated Patient 11 was at increased risk of skin breakdown and infection. During a review of the facility’s Policy and Procedure (P&P) titled, “Wound Care Policy & Procedure,” undated, the P&P indicated wounds will be evaluated and documented at each visit. The Registered Nurse completes the initial and ongoing wound assessment: assessing wound size, depth, drainage, odor, pain, tissue type, and signs of infection. Wound care documentation in the EMR (electronic medical record) includes wound assessment, treatment, patient response, and teaching provided.  2. a. During a review of Patient 4’s “Visit Note LVN,” dated 9/1/2025, the “Visit Note LVN” indicated the presence of a pressure ulcer/injury stage 2 on the right buttocks.During a review of Patient 4’s “Plan of Care (POC),” dated 9/5/2025, the “POC” indicated, “Patient has alteration of skin integrity: Moisture associated skin damage (MASD) to sacrum.” The “POC” did not indicate additional integumentary/ skin problems. During an interview on 9/16/2025 at 12:30 PM with RN 5, RN 5 stated Moisture Associated Skin Damage (MASD, moisture associated skin damage caused from prolonged exposure to moisture) and pressure injuries were different wound classifications. RN 5 stated that documenting pressure injuries as MASD results in inaccurate classification preventing proper treatment and monitoring.During an interview on 9/17/2025 at 11:22 AM with RN 5, RN 5 stated Patient 4’s POC was inaccurate and did not address Patient 4’s diagnosis of pressure ulcer/injury stage 2 on the right buttocks. RN 5 stated that failure to maintain an accurate POC placed Patient 4 at risk for further skin breakdown, inaccurate treatment, and insufficient education of the patient and caregiver.  2. b. During a review of Patient 11’s “Comprehensive Nursing Assessment (initial assessment),” dated 3/9/2025, the “initial assessment did not indicate the presence of wounds or skin impairment. During a review of Patient 11’s “Visit Note LVN,” dated 3/11/2025, the “Visit Note LVN” indicated the presence of a pressure ulcer/injury stage 1.During a concurrent interview and record review on 9/17/2025 at 11:03 AM with RN 5, Patient 11’s “POC” dated 9/17/2025 was reviewed. The “POC” indicated the POC for integumentary/ skin was created on 3/9/2025. RN 5 stated Patient 11’s POC for integumentary/ skin was not updated on or after 3/11/2025, following the discovery of the pressure ulcer/injury stage 1. RN 5 stated failure to update and maintain an accurate POC placed Patient 11 at risk of receiving inadequate treatment, improper supplies, and compromised quality of care. During a review of the facility’s P&P titled, “The Plan of Care,” undated, the P&P indicated the following:- “The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions.”- “The plan of care will identify the patient’s needs and services to meet those needs”- The written plan of care will contain diagnosis, identification of patient and family/caregiver needs, prognosis (the predicted future course of a disease or condition), DME (durable medical equipment) and medical supplies necessary to meet patient needs, frequency/ amount/ duration and type of services, and placement at the appropriate level of care and referrals as needed.  - “Any change in the patient’s condition must result in a change in the plan of care, prior to implementation of the new service.”- “Care provided to the patient will be in accordance with the plan of care.” 3. During a concurrent interview and record review on 9/17/2025 at 10:55 AM with RN 5 Patient 11’s “POC/IDG Review” dated 3/14/2025 was reviewed. The “POC/IDG Review” did not indicate Patient 11’s POC included interventions for the treatment of a pressure ulcer/injury stage 1 on the left foot nor that the IDG (composed of the Medical Director (MD), Registered Nurse 6 (RN 6), Social Worker 1 (SW 1), and Chaplain 2) discussed the wound. RN 5 stated failure to discuss Patient 11’s wound in the IDG Review and update the POC placed Patient 11 at risk for improper treatment, inaccurate monitoring and further harm. During a concurrent interview and record review on 9/17/2025 at 10:55 AM with RN 5 Patient 11’s “POC/IDG Review” dated 3/28/2025 was reviewed. The “POC/IDG Review” did not indicate Patient 11’s POC included interventions for treatment of a pressure ulcer/injury stage 1 on the left foot nor that the interdisciplinary group (composed of MD, RN 6, SW 1, and Chaplain 2) discussed the wound. RN 5 stated failure to discuss Patient 11’s wound in the IDG Review and update the POC placed Patient 11 at risk for improper treatment, inaccurate monitoring and further harm. During a review of the facility’s P&P titled, “Interdisciplinary Group Membership and Responsibilities,” undated, the P&P indicated, “The interdisciplinary group responsibilities include but are not limited to: Participation in the establishment of the plan of care for each patient admitted to the hospice service… Participation in the periodic review and updating of the plan of care for each patient receiving hospice services… Provision and/or supervision and coordination of hospice care and services… Reporting any unusual change in the patient’s physical, mental, spiritual or emotional status to the primary caregiver(s), the attending physician and the interdisciplinary group.” a

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live), failed to ensure the Condition of Participation (COP, the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) for Interdisciplinary Group (IDG, a team composed of professionals from different discipline who work together collaboratively to provide comprehensive care for patients), Care Planning, and Coordination of Services for Patients was met as follows: --- The HA failed to:1. Ensure the Director of Patient Care Services (DPCS) coordinates the services and care for 4 of 10 sampled patients (Patient 1, Patient 2, Patient 3 and Patient 11) as discussed by the interdisciplinary group (IDG). This failure had the potential for Patient 1, Patient 2, Patient 3 and Patient 11 to experience severe pain or distress, agitation, emergency hospitalization and potentially experience an undignified and avoidable traumatic death.  (Refer to L-tag 540)2. Ensure the Plan of Care (POC)  for 4 of 15 sampled patients (Patient 1, Patient 2, Patient 3, and Patient 11) includes symptom management and other related condition identified during patient’s assessments. This failure had the potential for patients to receive inadequate treatment and monitoring that may lead to severe pain or distress, agitation, emergency hospitalization and potentially experience an undignified and avoidable traumatic death. (Refer to L-tag 545)3. Ensure the Comfort Kit (set of medications intended for symptoms and pain management such as: morphine [treatment for pain], Ativan [medication for agitation and anxiety], Levsin [medication for excessive secretions], albuterol inhaler [medication  for shortness of breath and/or wheezing], Zofran (medication for nausea and vomiting), and acetaminophen [medication for mild pain and/or fever]) was ordered and available for three of three sampled patients (Patient 1, Patient 2, and Patient 3) at home, as needed for the management of  end of life symptoms, in accordance with the patients’ assessment and Interdisciplinary Group (IDG) discussion /review, and ensure an oxygen concentrator (medical device that delivers oxygen rich air to a person who has difficulty breathing), via nasal canula (a thin flexible tube that wraps around the head and sits on the nose to deliver oxygen), was ordered and available for three of three sampled patients (Patient 1, Patient 2, and Patient 3) at home, as needed for shortness of breath (SOB, difficulty breathing), in accordance with the patients’ assessment and IDG discussion / review. As a result of the noncompliance described above, Patient 1, Patient 2, and Patient 3 were placed at high risk to experience unmanaged pain, severe pain or distress, agitation, emergency hospitalization, exposure to unsafe environments, and potentially experience an undignified and avoidable traumatic death. (Refer to L556)4. Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the ongoing sharing of information with non-hospice healthcare providers furnishing services for two of two sampled Patients (Patient 1 and Patient 11) by:Failing to ensure documentation of communications with the Primary Care Physician (PCP) related to a change in dose for Mounjaro (tirzepatide, an injectable prescription drug used to treat type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing)) in the medical record for Patient 1. Failing to ensure services provided during wound care referral were documented in the medical record for Patient 11.Failing to ensure the results of the wound culture were documented in the medical record for Patient 11.These failures had the potential to place Patient 1 at risk for medication administration errors, increased side effects, uncontrolled blood glucose, and compromised safety, and Patient 11 at risk for inadequate treatment, worsening medical conditions, insufficient symptom management, and avoidable hospitalization.(Refer to L558)The cumulative effect of these systemic practices resulted in the failure of the Hospice Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Comprehensive Assessment of Patients to ensure the quality of care are provided to patients certified to receive hospice benefits.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Director of Patient Care Services (DPCS) coordinates the services and care for four of 10 sampled patients (Patient 1, Patient 2, Patient 3 and Patient 11) as discussed by the interdisciplinary group (IDG).   This failure had the potential for Patient 1, Patient 2, Patient 3 and Patient 11 to experience severe pain or distress, agitation, emergency hospitalization and potentially experience an undignified and avoidable traumatic death. --- Findings:  1. During a review of Patient 1’s “Personal Information,” (page of the medical chart containing a summary of basic patient information) undated, the “Personal Information” indicated the HA admitted Patient 1, on 8/15/2025 with diagnosis that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), depression (characterized by persistent feelings of sadness, hopelessness, and loss of interest), shortness of breath (SOB, a subjective sensation of not being able to get enough air, often accompanied by feelings of tightness in the chest, rapid breathing, and wheezing [a high-pitched, whistling sound that occurs when air flows through narrowed airways]), and dependance on supplemental oxygen (a condition requiring the use of a device to deliver extra oxygen). During a review of Patient 1’s “POC (Plan of Care)/ IDG Review,” dated 8/29/2025, the “POC/IDG Review” physician’s plan indicated, “assess, monitor, and control end of life symptoms with medications.” The “POC/IDG Review” did not include provision or use of the Comfort Kit (set of medications intended for symptoms and pain management such as: morphine (treatment for pain), Ativan (treatment for agitation and anxiety), Levsin (treatment for excessive secretions), albuterol inhaler (treatment for shortness of breath (SOB, a subjective sensation of not being able to get enough air, often accompanied by feelings of tightness in the chest, rapid breathing, and wheezing [a high-pitched, whistling sound that occurs when air flows through narrowed airways]) and/or wheezing), Zofran (treatment for nausea and vomiting), and Tylenol (treatment for mild pain and/or fever). During a review of Patient 1’s “POC/IDG Review,” dated 8/29/2025, the “POC/IDG Review” nursing discussion indicated, “mild SOB persists with activity. Lung sounds remain diminished on SN [skilled nurse] assessment.” The “POC/IDG Review” did not include provision or use of oxygen for SOB and dependence on supplemental oxygen. During a review of Patient 1’s “POC/IDG Review,” dated 8/29/2025, the “POC/IDG Review” indicated on 8/15/2025 medication orders for Paxil (treatment for depression) and Mounjaro (treatment for elevated blood sugar) 5 milligrams (mg, unit of measurement) were entered. During joint home visit at Patient 1’s with Registered Nurse 3 (RN 3) on 9/10/2025 at 9:32 AM, a medication reconciliation (a process on comparing patient’s current medication against medication ordered by the physician) was conducted. Patient 1’s “Current Treatment/ Medication/ DME List” did not include the Comfort Kit or oxygen. Patient 1’s Caregiver 1 (CG 1) stated the HA did not provide Patient 1 with the Comfort Kit or oxygen for home use. During Patient 1’s home visit with RN 3 on 9/10/2025 at 9:23 AM, the medication reconciliation was conducted. Patient 1’s “Current Treatment/ Medication/ DME List” included Paxil 30 mg tablet and Mounjaro 5 mg injection. Patient 1 stated she was not taking Paxil and could not recall the last time she had taken the medication.  Patient 1 stated the Mounjaro medication dose was 7.5 mg not 5 mg. During a concurrent interview and record review on 9/11/2025 at 10:07 AM with the Director of Patient Care Services Designee (DPCS Designee), Patient 1’s “Comprehensive Nursing Assessment,” dated 8/15/2025 was reviewed. The “Comprehensive Nursing Assessment” indicated mild SOB and wheezing on room air. The DPCS Designee stated an order for oxygen should have been entered to treat SOB, wheezing, and diminished lung sounds. The DPCS Designee stated failure to provide oxygen therapy placed Patient 1 at increased risk of respiratory distress (a life-threatening condition that causes severe difficulty breathing) and hospitalization. During a concurrent interview and record review on 9/11/2025 at 10:07 AM with the DPCS Designee, Patient 1’s “Current Treatment/ Medication/ DME List,” undated was reviewed. The DPSC Designee stated Paxil 30 mg and Mounjaro 5 mg were listed as active medications. The DPCS stated an accurate and up-to-date medication list is essential to ensure patient safety and avoid medication administration errors, duplicate medication therapy, and potential drug-to-drug interactions. During a concurrent interview and record review on 9/11/2025 at 2:20 PM with the Medical Director, the “POC/IDG Review”, dated 8/29/2025 was reviewed. The MD stated the IDG discussion and updated comprehensive assessment review that indicated the treatment plan “Other/ Physician: Assess, monitor, and control end of life symptoms with medications,” included the patient’s use of the Comfort Kit and if the Comfort Kit was not needed it would reflect on the POC/ POC/IDG Review.  During an interview on 9/15/2025 at 10:28 AM with RN 5, RN 5 stated IDG meets to review patient events, and additional orders and interventions are implemented based on assessment findings obtained during nursing home visits.  2. During a review of Patient 2’s Comprehensive Nursing Assessment: Primary/Secondary Diagnosis & Comorbidities, dated 8/6/2025, the Comprehensive Nursing Assessment: Primary/Secondary Diagnosis & Comorbidities indicated secondary diagnosis including shortness of breath (SOB, not being able to get enough air to breath). During a review of Patient 2’s “POC/IDG Review Aug 06, 2025 – Cert #1”, dated 8/6/2025, the “POC/IDG (Plan of Care/Interdisciplinary Group) Review Aug 06, 2025 – Cert #1” indicated “Secondary DX (diagnosis):…Anxiety disorder …Shortness of breath”, no comfort kit medications for anxiety or SOB, precautions for oxygen, and “Nursing: Anxiety disorder” with no reference to SOB. During a review of Patient 2’s “POC/IDG Review Aug 15, 2025 – Cert #1”, dated 8/15/2025, the “POC/IDG Review Aug 15, 2025 – Cert #1” indicated “Secondary DX:… Anxiety disorder…Shortness of breath”, no comfort kit medications for anxiety or SOB, precautions for oxygen, and “Nursing: …moderate SOB with mild exertion.  Lung sounds remain diminished on SN (skilled nursing) visits” with no reference to anxiety disorder, and no goals/interventions for anxiety or SOB. During a review of Patient 2’s “POC/IDG Review Aug 29, 2025 – Cert #1”, dated 8/29/2025, the “POC/IDG Review Aug 29, 2025 – Cert #1” indicated “Secondary DX… Anxiety disorder…Shortness of breath”, no comfort kit medications for anxiety or SOB, Nursing: “…Patient observed with mild SOB [shortness of breath] during exertion.  Lung sounds diminished…Education provided on oxygen use…medications are reconciled and approved” with no reference to anxiety disorder, precautions for oxygen, and no goals/interventions for anxiety or SOB. During a review of Patient 2’s “POC/IDG Review Sep 12, 2025 – Cert #1”, dated 9/12/2025, the “POC/IDG Review Sep 12, 2025 – Cert #1” indicated “Secondary DX…Anxiety disorder….Shortness of breath”, Ativan, ipratropium bromide/Albuterol Sulfate, and morphine (comfort kit medications) for anxiety and SOB, DME (durable medical equipment): oxygen concentrator 5L (stationary) with nasal cannula, Nursing: “…New orders include oxygen at 2 LPM,…Patient continues to experience mild to moderate SOB with exertion; lung sounds remain diminished….”, “Precautions:…oxygen,…”, no goals/interventions for anxiety or SOB, and no required signature by the Chaplain. During a concurrent observation and interview on 9/10/2025 at 1:10 PM with CG 2 at Patient 2’s home, no oxygen tank or supplies, and no comfort kits were observed.  CG 2 stated, we have been requesting oxygen since she was admitted on 8/6/2025 but have not received it yet.  However, hospice called this morning and said they would deliver it this afternoon [9/10/2025].  CG 2 stated she had no comfort kits. During a record review of the facility’s policy and procedure titled, “Comfort Kit for the Imminently Dying Patient,” undated, indicated, “Comfort Kits is intended to address urgent and distressing symptoms such as pain, agitation, dyspnea (SOB), nausea, secretions, or anxiety, and to prevent unnecessary suffering…” and morphine sulfate or alternative opioid may be ordered for shortness of breath and lorazepam may be ordered for anxiety. During a concurrent interview and record review on 9/15/2025 at 11:21 AM with RN 5, Patient 2’s Comprehensive Nursing Assessment: Body System: Head-to-Toe: Respiratory, dated 8/6/2025 was reviewed.  The Comprehensive Nursing Assessment: Body System: Head-to-Toe: Respiratory indicated moderate dyspnea (difficulty breathing) with mild and moderate exertion; “Even though SOB is present, does patient decline treatment – No”; diminished lung sounds (decrease in the intensity or volume of breath sounds); and no oxygen therapy. There were no recommendations for oxygen therapy, strategies to reduce SOB, suggestions for patient/family goals to manage SOB, or patient teaching on SOB.  RN 5 stated, oxygen therapy should have been ordered on admission for Patient 2 who has a diagnosis of SOB and symptoms of moderate dyspnea. During a concurrent interview and record review on 9/15/2025 at 11:21 AM with RN 5, Patient 2’s “Current Treatment/Medication/DME List” was reviewed.  Patient 2’s “Current Treatment/Medication/DME List” indicated no orders for oxygen therapy prior to 9/13/2025.  RN 5 stated, oxygen therapy was not, but should have been, ordered on admission for Patient 2. During a review of the facility’s policy and procedure titled, “Oxygen Safety in the Home Policy,” undated, indicated, “All oxygen safety education, assessments, and interventions will be documented in the patient’s record” and “Documentation of teaching and patient/caregiver understanding will be placed in the patient’s medical record.”  3. During a review of Patient 3’s “Personal Information”, undated, the “Personal Information” indicated the hospice agency admitted Patient 3, on 8/11/2025 with diagnoses including, but not limited to, heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), shortness of breath, and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance (patterns of behaviors, thoughts and moods that are considered unusual for a person’s age and context). During Patient 3’s home visit with Medical Social Worker (MSW, a person to provide support to patients and families) on 9/10/2025 at 3:20 PM, a medication reconciliation (a process on comparing patient’s current medication against medication ordered by the physician) was conducted. Patient 3’s “Current Treatment/ Medication/ DME List” did not include the “Comfort Kit”: morphine sulfate, Zofran, Levsin, acetaminophen, Ativan, and bisacodyl. During an interview on 9/10/2025 at 3:20 PM, with Patient 3’s care giver (CG 3), CG 3 stated Patient 3 feels short of breath even with small movements. CG 3 stated she requested for Patient 3 to have an oxygen concentrator (medical device that delivers oxygen rich air to a person who has difficulty breathing) from the last nurse visit (9/8/2025) and that the facility will be delivering Patient 3’s oxygen tomorrow (9/11/2025). During a review of Patient 3’s “POC/IDG Review”, dated 8/29/2025, the “POC/IDG Review” Physician’s assessment review indicated “Assess, monitor, and control end of life symptoms with medications.”. The IDG review indicated Patient 13 remains with moderate shortness of breath on exertion and lung sounds diminished. The plan of care discussed during the IDG review did not include concerns regarding Patient 13’s SOB. During a concurrent interview and record review on 9/11/2025 at 2:20 PM with the MD. the “POC/IDG Review”, dated 8/29/2025 was reviewed. The MD stated the “POC/ IDG Review” that indicated “Other/ Physician: Assess, monitor, and control end of life symptoms with medications,” this treatment plan included the patient’s use of Comfort Kit medications and if the Comfort Kit was not needed it would reflect on the POC/ IDG Review. During an interview on 9/15/2025 at 10:20 AM with RN 5, RN 5 stated the DPCS was the one attending the IDG meeting and reports on the hospice patients’ nursing care and needs. RN 5 stated the visiting nurses would report nursing updates, patient condition and patient needs/concerns to the DPCS, and the DPCS will collaborate with the MD for any treatments and services to provide on the patient based on nurse’s report during the IDG meeting. RN 5 stated the DPCS will coordinate the updates and changes regarding patient care and treatments to the healthcare team for implementation. During an interview on 9/15/2025 at 10:20 AM with RN 5, RN 5 stated any concerns or change of condition should be addressed as soon as it was assessed by the nurse. RN 5 stated these interventions should be reflected on Patient 3’s Plan of care and should be discussed in the IDG meeting. RN 5 stated when the physician indicated Comfort Kits on his notes, the nurse should place an order of Comfort Kit for the patient. 4. During a review of Patient 11’s “Personal Information,”  the “Personal Information” indicated the HA admitted Patient 11, on 3/10/2025 with diagnosis that included hypertensive heart disease with heart failure (high blood pressure damaged the heart over time, making it unable to pump blood effectively causing shortness of breath, fatigue, and swelling in the legs), type 2 diabetes mellitus, and hyperlipidemia (elevated cholesterol level). During a review of Patient 11’s “Visit Note LVN,” dated 3/11/2025, the “Visit Note LVN” indicated, “wounds: stage 1” (pressure ulcer/injury stage 1 (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness). During a review of Patient 11’s “Physician Order,” dated 4/3/2025, the “Physician Order” indicated the Medical Director (MD) entered an order for wound care evaluation and treatment on 4/3/2025. During a review of Patient 11’s “POC/IDG Review,” dated 4/11/2025, the “POC/IDG Review” did not indicate the creation and implementation of a plan of care for skin/ integumentary. The “POC/IDG Review” nursing discussion did not include a review of the referral for wound care evaluation and treatment entered on 4/3/2025. During a concurrent interview on 9/17/2025 at 10:55 AM with Registered Nurse 5 (RN 5), Patient 11’s “POC/IDG Review,” dated 3/14/2025 and 3/28/2025 were reviewed. RN 5 stated that Patient 11’s wound was identified on 3/11/2025 and IDG discussions held on 3/14/2025 and 3/28/2025 did not include a review of Patient 11’s wound. RN 5 stated failure to discuss wound care placed Patient 11 at increased risk of inadequate treatment and monitoring of wound progression. During a review of Patient 11’s “Discharge Summary,” dated 5/6/2025, the “Discharge Summary” indicated Patient 11 was discharged from the HA due to hospitalization. During a review of HA’s P&P, titled “Interdisciplinary Group Membership and Responsibilities”, undated, the P&P indicated the IDG responsibilities include establishment, reviewing and updating of plan of care and “taking proactive approach in developing/revising the plan of care by planning ahead for anticipated patient changes and needs.” ... “provision and/or supervision and coordination of hospice care and services” During a review of “Clinical Director’s Job Description”, undated, the “Clinical Director’s Job Description” indicated essential job functions include “Coordinate and oversee all direct and indirect patient services provided by clinical organization personnel.” ... “If the DPCS is also acting as the clinical manager, the clinical manager’s oversight must also include coordinating patient care, assuring the development, implementation and updates in the individualized POC.”

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Plan of Care (POC)  for 4 of 15 sampled patients (Patient 1, Patient 2, Patient 3, and Patient 11) includes symptom management and other related condition identified during patient’s assessments.  This failure had the potential for patients to receive inadequate treatment and monitoring that may lead to severe pain or distress, agitation, emergency hospitalization and potentially experience an undignified and avoidable traumatic death. --- Findings:  1. During a review of Patient 1’s “Personal Information,” (page of the medical chart containing a summary of basic patient information) undated, the “Personal Information” indicated the HA admitted Patient 1, on 8/15/2025 with diagnosis that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), depression (characterized by persistent feelings of sadness, hopelessness, and loss of interest), shortness of breath (SOB, a subjective sensation of not being able to get enough air, often accompanied by feelings of tightness in the chest, rapid breathing, and wheezing [a high-pitched, whistling sound that occurs when air flows through narrowed airways]), and dependance on supplemental oxygen (a condition requiring the use of a device to deliver extra oxygen).  During a review of Patient 1’s “Comprehensive Nursing Assessment,” dated 3/9/2025, the “Comprehensive Nursing Assessment” indicated Patient 1 had mild SOB with exertion, diminished lung sounds, type 2 diabetes mellitus, and depression.   During a review of four of Patient 1’s “Visit Note LVN,” dated 9/10/2025, 9/3/2025, 8/27/2025, and 8/20/2025, the “Visit Note LVN” indicated heavy breathing, mild to moderate SOB, and diminished lung sounds.  During Patient 1’s home visit with Registered Nurse 3 (RN 3) on 9/10/2025 at 9:32 AM, a medication reconciliation (a process on comparing patient’s current medication against medication ordered by the physician) was conducted. Patient 1’s “Current Treatment/ Medication/ DME List” did not include the Comfort Kit or oxygen. Patient 1’s Caregiver 1 (CG 1) stated the HA did not provide Patient 1 with the Comfort Kit or oxygen for home use. During Patient 1’s home visit with RN 3 on 9/10/2025 at 9:23 AM, the medication reconciliation was conducted. Patient 1’s “Current Treatment/ Medication/ DME List” included Paxil (treatment for depression) 30 mg tablet and Mounjaro (treatment for elevated blood sugar) 5 mg injection. Patient 1 stated she was not taking Paxil and could not recall the last time she had taken the medication.  Patient 1 stated the Mounjaro medication dose was 7.5 mg and not 5 mg.   During a concurrent interview and record review on 9/11/2025 at 10:07 AM with the Director of Patient Care Services Designee (DPCS Designee), Patient 1’s “Comprehensive Nursing Assessment,” dated 8/15/2025 was reviewed. The “Comprehensive Nursing Assessment” indicated mild SOB and wheezing on room air. The DPCS Designee stated an order for oxygen should have been entered to treat SOB, wheezing, and diminished lung sounds. The DPCS Designee stated failure to provide oxygen therapy placed Patient 1 at increased risk of respiratory distress (a life-threatening condition that causes severe difficulty breathing) and hospitalization.   During an interview on 9/11/2025 at 2:40 PM with the MD, MD stated, a patient with a diagnosis of “dependence on supplemental oxygen” requires oxygen, and there should be an order for oxygen.  During a review of Patient 1’s “Plan of Care,” dated 9/12/2025, the “POC” did not indicate the creation or implementation of a POC for respiratory, SOB, or dependence on supplemental oxygen. The endocrine POC indicated Mounjaro 5 mg and not 7.5 mg. The neurological/ mental POC indicated Paxil was an active medication order.  During an interview on 9/15/2025 at 10:28 AM with RN 5, RN 5 stated the HA must create and implement a POC for each patient assessment finding.   2. During a record review of Patient 2’s “Personal Information”, undated, “Personal Information” indicated the Hospice agency admitted Patient 2, on 8/6/2025 with diagnoses that included hypothyroid (low levels of thyroid hormone that is necessary to sustain life), shortness of breath (difficulty breathing), and anxiety (excessive worry).  During a review of three of Patient 2’s POC/IDG, dated 8/6/2025, 8/15/2025, and 8/29/2025, Patient 2’s POC/IDG indicated no medications for comfort measures for anxiety or nausea were ordered.  During an interview on 9/10/2025 at 1:00 PM with CG 2, CG 2 stated, she had no comfort kits.  During a concurrent interview and record review on 9/11/2025 at 11:20 AM with MD, Patient 2’s “POC/IDG Review”, dated 8/6/2025 was reviewed.  Patient 2’s “POC/IDG (Plan of Care/Interdisciplinary Group) Review” indicated “Patient will be provided with comfort measures…”.  The MD stated comfort measures include medications for anxiety and nausea.  During a concurrent interview and record review on 9/15/2025 at 11:21 AM with RN 5, Patient 2’s Plan of Care (POC), dated 9/15/2025 was reviewed. The POC indicated secondary diagnosis of hypothyroidism and shortness of breath with no interventions or goals for these diagnoses.  RN 5 stated, there should be an endocrine section for hypothyroidism on the POC, and the cardiovascular section of the POC should include a POC for SOB.  During a review of Hospice Agency’s (HA) Policy and Procedure (P&P), titled, “The Plan of Care”, undated, the P&P indicated, “This plan [of care] will focus on identified problems, goals, and interventions” and “The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments…”   During a review of Patient 6’s “Comprehensive Nursing Assessment,” dated 7/11/2025, the “Comprehensive Nursing Assessment,” indicated Patient 6’s secondary diagnosis of Dependence on supplemental oxygen.   During an interview on 9/11/2025 at 10:06 AM with the DPCS Designee, DPCS Designee stated, a patient with a diagnosis of “dependence on supplemental oxygen” needs to have oxygen, and not having oxygen can be life-threatening.  During an interview on 9/11/2025 at 2:40 PM with the MD, MD stated, a patient with a diagnosis of “dependence on supplemental oxygen” requires oxygen, and there should be an order for oxygen.  During a concurrent interview and record review on 9/15/2025 at 11:21 AM with RN 5, Patient 6’s “Current Treatment/Medication/DME List” dated 9/15/2025 was reviewed.  The “Current Treatment/Medication/DME List” indicated, no orders for oxygen since patient was ordered since Patient 6 was admitted on 7/11/2025.  RN 5 stated, oxygen should have been delivered on the day the patient was assessed, and if the patient does not have oxygen, they could die.  3. During a review of Patient 3’s “Personal Information”, the “Personal Information” indicated the hospice agency admitted Patient 3, on 8/11/2025 with diagnoses including, but not limited to, heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), shortness of breath, and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance (patterns of behaviors, thoughts and moods that are considered unusual for a person’s age and context).   During a review of Patient 3’s “Comprehensive Nursing Assessment”, dated 8/11/2025, the “Comprehensive Nursing Assessment” indicated Patient 3 has mild anxiety, has shortness of breath with moderate exertion and diminished lung sounds.    During Patient 3’s home visit with Medical Social Worker (MSW, a person to provide support to patients and families) on 9/10/2025 at 3:20 PM, a medication reconciliation (a process on comparing patient’s current medication against medication ordered by the physician) was conducted. Patient 3’s “Current Treatment/ Medication/ DME List” did not include the “Comfort Kit”: morphine sulfate, Zofran, Levsin, acetaminophen, Ativan, and bisacodyl. Patient 3’s “Current Treatment/ Medication/ DME List” did not include any treatment or medication for anxiety.  During an interview on 9/10/2025 at 3:20 PM, with Patient 3’s care giver (CG 3), CG 3 stated Patient 3 feels short of breath even with small movements. CG 3 stated she requested for Patient 3 to have an oxygen concentrator (medical device that delivers oxygen rich air to a person who has difficulty breathing) from the last nurse visit (9/8/2025) and that the facility will be delivering Patient 3’s oxygen tomorrow (9/11/2025).     During a review of Patient 3’s “Physician Order”, dated 9/10/2025, the “Physician Order” indicated Oxygen 5 liters via nasal canula (oxygen was ordered a month after Patient 3 was admitted).    During a review of Patient 3’s “Visit Note”, dated 8/14/2025, 8/21/2025, 8/24/2025, 8/252025, 8/31/2025, 9/7/2025, 9/8/2025 and 9/10/2025, the “Visit Note” indicated Patient 3 has mild anxiety, shortness of breath with exertion, and diminished lung sounds.    During a concurrent interview and record review on 9/11/2025 at 10:10 AM with the Director of Patient Care Services Designee (DPCS Designee), Patient 3’s “Plan of Care”, dated 9/11/2025 was reviewed. The PDCS Designee stated Patient 3 does not include a plan of care related to shortness of breath. The DPCS Designee stated plan of care should reflect concerns regarding patient such as shortness of breath. The DPCS Designee stated having oxygen concentrator at patient’s home is one of the interventions for shortness of breath.   During an interview on 9/15/2025 at 10:20 AM with RN 5, RN 5 stated any concerns or change of condition should be addressed as soon as it was assessed by the nurse. RN 5 stated these interventions should be reflected on Patient 3’s Plan of Care. RN 5 stated Patient 3 should have a plan of care regarding shortness of breath and anxiety. RN 5 stated these concerns may not be addressed if they are not included in patient’s plan of care and may result in delay of care.  4. During a review of Patient 11’s “Personal Information,” the “Personal Information” indicated the HA admitted Patient 11, on 3/10/2025 with diagnosis that included hypertensive heart disease with heart failure (high blood pressure damaged the heart over time, making it unable to pump blood effectively causing shortness of breath, fatigue, and swelling in the legs), type 2 diabetes mellitus, and hyperlipidemia (elevated cholesterol level).  During a review of Patient 11’s “Physician Order,” dated 4/3/2025, the “Physician Order” indicated the Medical Director (MD) entered an order for wound care evaluation and treatment on 4/3/2025.   During a review of Patient 11’s “POC/IDG Review,” dated 4/11/2025, the “POC/IDG Review” did not indicate the creation and implementation of a plan of care for skin/ integumentary. The “POC/IDG Review” nursing discussion did not include a review of the referral for wound care evaluation and treatment entered on 4/3/2025.  During a concurrent interview on 9/17/2025 at 10:55 AM with Registered Nurse 5 (RN 5), Patient 11’s “POC/IDG Review,” dated 3/14/2025 and 3/28/2025 were reviewed. RN 5 stated failure to create, update, and implement a POC for skin/ integumentary  placed Patient 11 at increased risk of inadequate treatment and monitoring of wound progression.   During a review of Patient 11’s “Discharge Summary,” dated 5/6/2025, the “Discharge Summary” indicated Patient 11 was discharged from the HA due to hospitalization.  During a review of HA’s P&P, titled “The Plan of Care”, undated. The P&P indicated “the plan of care will be based on the initial, comprehensive and ongoing assessments performed by the members of the interdisciplinary group” … this plan will focus on identified problems, goals and interventions.” … “The plan of care will identify the patient’s needs and services to meet those needs, including management of pain, discomfort and symptom relief.”

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to:1. Ensure the Comfort Kit (set of medications intended for symptoms and pain management such as: morphine [treatment for pain], Ativan [medication for agitation and anxiety], Levsin [medication for excessive secretions], albuterol inhaler [medication  for shortness of breath and/or wheezing], Zofran (medication for nausea and vomiting), and acetaminophen [medication for mild pain and/or fever]) was ordered and available for three of three sampled patients (Patient 1, Patient 2, and Patient 3) at home, as needed for the management of  end of life symptoms, in accordance with the patients’ assessment and Interdisciplinary Group (IDG) discussion /review.  2. Ensure an oxygen concentrator (medical device that delivers rich air to a person who has difficulty breathing), via nasal canula (a thin flexible tube that wraps around the head and sits on the nose to deliver oxygen), was ordered and available for three of three sampled patients (Patient 1, Patient 2, and Patient 3) at home, as needed for shortness of breath (SOB, ), in accordance with the patients’ assessment and IDG discussion / review. As a result of the noncompliance described above, Patient 1, Patient 2, and Patient 3 to experience unmanaged pain, severe pain or distress, agitation, emergency hospitalization, exposure to unsafe environments, and potentially experience an undignified and avoidable traumatic death.  On 9/16/2025, at 9:57 AM, the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient), in the presence of the agency’s Chief Financial Officer (CFO) and Registered Nurse Case Manager (RN 5), related to the hospice agency failure to demonstrate a process and provide documented evidence that the facility ensure the care and services provided  for Patient 1, Patient 2, and Patient 3 are based on assessments of the patient and family needs, by failing to ensure the Comfort Kit were ordered, available, and ready for use, and to ensure an oxygen concentrator ready to use, at home, as needed for shortness of breath (SOB).  On 9/17/2025, at 3:30 PM, the survey team completed the survey tasks and conducted an exit conference in the presence of the agency’s CFO, with the Director of Patient Care Services (DPCS) Designee and RN 5 via telephone with the IJ situations not removed. On 9/23/2025 at 12:51 PM, the agency provided an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The IJ removal plan was accepted. --- Findings:A. During a review of Patient 1’s “Personal Information,” (containing a summary of basic patient information), the “Personal Information” indicated the hospice agency admitted Patient 1 on 8/15/2025 with diagnosis that included atherosclerosis heart disease (plaque buildup in the heart’s arteries), SOB, and dependance on supplemental oxygen (a condition requiring the use of a device to deliver extra oxygen).During a joint home visit observation on 9/10/2025 at 9:23 AM, with Registered Nurse 3 (RN 3) at  Patient 1’s home, Patient 1 was lying on the couch and stated she felt nauseous and had a pain level of nine (out of 10, on the 0-10 pain scale, 0 indicating the absence of pain and 10 representing the worst pain imaginable) in her stomach and lower back.  During an observation and interview on 9/10/2025 at 9:23 AM, with Patient 1’s Caregiver 1 (CG 1), CG1 stated Patient 1 did not have in-home oxygen provided by the HA available for use.During an interview and record review on 9/10/2025 at 9:23 AM, of Patient 1’s "Current Treatment/ Medication/ DME List,” undated was reviewed. The “Current Treatment/ Medication/ DME List”, did not include the Comfort Kit: morphine sulfate, Zofran, Levsin, acetaminophen, Ativan, bisacodyl, ipratropium. CG 1 stated Patient 1 did not have the Comfort Kit.    During a review of Patient 1’s “Comprehensive Nursing Assessment,” dated 8/15/2025, the “Comprehensive Nursing Assessment” indicated Patient 1 was assessed with moderate shortness of breath with moderate exertion, diminished breath sounds bilaterally, wheezing, “chest wall asymmetry noted; unequal rise”, and “O2 [oxygen] PRN [as needed] per protocol.” During a review of Patient 1’s “Visit Note,” dated 9/10/2025, 9/3/2025, 8/29/2025, 8/27/2025, and 8/20/205, the Visit Notes indicated Patient 1 experienced heavy breathing and mild to moderate abnormal lung sounds.  During a review of Patient 1’s “Physician Orders” on 9/11/2025 at 9 AM, the orders did not include oxygen nor Comfort Kit.   During a review of Patient 1’s “POC/IDG Review,” dated 8/29/2025, the IDG Review indicated “Nursing: Mild SOB persists with activity. Lung sounds remain diminished on SN [skilled nurse] assessments.” The IDG Review indicated “Other/ Physician: Assess, monitor, and control end of life symptoms with medications. [...] Provide symptoms management, pain control and comfort measures.”  During an interview on 9/11/2025 at 10:07 AM., with the Director of Patient Care Services Designee (DPCS Designee), the DPCS Designee stated the Comfort Kit should be ordered upon admission for all patients. The DPCS Designee stated the Comfort Kit should be readily available in the patient’s home to use during emergencies.  During an interview on 9/11/2025 at 10:07 AM., with the DPCS Designee, the DPCS Designee stated Patient 1 required oxygen because of her diagnosis of dependence on supplemental oxygen. The DPCS designee stated Patient 1’s admitting nurse should have reported Patient 1’s symptoms of SOB and diminished lung sound to the DPCS and the Medical Director (MD). The DPCS Designee stated failure to provide oxygen, if needed, could potentially result in Patient 1 experiencing respiratory distress (a severe medical condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide, or both) and other life-threatening emergencies.  During an interview on 9/11/2025 at 2:20 PM., with the MD, the MD stated nurses should report SOB and diminished lung sounds so that he [MD] could order appropriate treatment.  The MD stated the “POC/ IDG Review” that indicated “Other/ Physician: Assess, monitor, and control end of life symptoms with medications,” the MD stated this treatment plan included the patient’s use of Comfort Kit medications and if the Comfort Kit was not needed it would reflect on the POC/ IDG Review.   B. During a review of Patient 2’s “Personal Information”, undated, the “Personal Information” indicated the hospice agency admitted Patient 2, on 8/6/2025, with diagnoses including, but not limited to, atherosclerosis heart disease, anxiety disorder (excessive and persistent worry, fear, and unease), and shortness of breath. During a joint home visit observation and interview on 9/10/2025 at 1 PM, with RN 4, at Patient 2’s home, Patient 2 did not have an oxygen tank at home to use if needed.  During a review of Patient 2’s “Current Treatment/ Medication/ DME List”, dated 9/9/2025, the “Current Treatment/ Medication/ DME List” indicated the following Comfort Kit medications were not ordered: morphine sulfate, Zofran, Levsin, acetaminophen, Ativan, bisacodyl, ipratropium, and oxygen.During concurrent observation and interview on 9/9/2025 at 1:20 PM with Patient 2’s Care Giver (CG 2) in Patient 2’s home, no Comfort Kit medications were observed on the table with Patient 2’s medications.  CG2 stated, the medications on the table are all her [Patient 2’s] medications.  We have not received a Comfort Kit.During an interview on 9/10/2025 at 1:10 PM, with CG 2, CG 2 stated Patient 2 has had shortness of breath since she was admitted to hospice and that she [CG 2] was told the oxygen would be delivered today (9/10/2025).   During a review of Patient 2’s “Comprehensive Nursing Assessment” dated 8/6/2025, the “Comprehensive Nursing Assessment” indicated Patient 2’s assessment included diminished lung sounds.  During a review of Patient 2’s “Visit Notes”, dated 8/19/2025, 8/20/2025, 8/26/2025, 9/2/2025, and 9/3/2025, the “Visit Notes” indicated Patient 2 had mild to moderate SOB on exertion and mild abnormal to diminished lung sounds on bilateral lobes. During a review of Patient 2’s “POC/IDG Review,” dated 8/15/2025 and 8/29/2025, the “POC/IDG Review” indicated “Nursing: Continues to be observed with moderate SOB with mild exertion. Lung sounds remain diminished on SN [skilled nurse] visits.” The IDG Review indicated “Other/ Physician: Assess, monitor, and control end of life symptoms with medications. [...] Provide symptoms management, pain control and comfort measures.”  During a review of Patient 2’s “Physician Orders,” dated 9/10/2025, indicated Oxygen 5L via nasal canula (oxygen was ordered a month after Patient 2 was admitted). The order did not include “Comfort Kit.”  During an interview on 9/11/2025 at 10:07 AM., with the DPCS Designee, the DPCS Designee stated the Comfort Kit should be ordered upon admission for all patients and should be available for patients to use in case of emergencies.  During an interview on 9/11/2025 at 2:20 PM., with the MD, the MD stated nurses should report SOB and diminished lung sounds so that he [MD] could order appropriate treatment.  The MD stated the “POC/ IDG Review” that indicated “Other/ Physician: Assess, monitor, and control end of life symptoms with medications,” the MD stated this treatment plan included the patient’s use of Comfort Kit medications and if the Comfort Kit was not needed it would reflect on the POC/ IDG Review.   C. During a review of Patient 3’s “Personal Information”, undated, the “Personal Information” indicated the hospice agency admitted Patient 3, on 8/11/2025, with diagnoses including, but not limited to, heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), shortness of breath, and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance (patterns of behaviors, thoughts and moods that are considered unusual for a person’s age and context). During a joint home visit on Patient 3’s home visit with Medical Social Worker (MSW, a person to provide support to patients and families) on 9/10/2025 at 3:20 PM, a medication reconciliation (a process on comparing patient’s current medication against medication ordered by the physician) was conducted. Patient 3’s “Current Treatment/ Medication/ DME List” did not include the “Comfort Kit”: morphine sulfate, Zofran, Levsin, acetaminophen, Ativan, and bisacodyl. Patient 3 did not have the “Comfort Kit”.   During an interview on 9/10/2025 at 3:20 PM, with Patient 3’s care giver (CG 3), CG 3 stated Patient 3 feels short of breath even with small movements. CG 3 stated she requested for Patient 3 to have an oxygen concentrator (medical device that delivers rich air to a person who has difficulty breathing) from the last nurse visit (9/8/2025) and that the facility will be delivering Patient 3’s oxygen tomorrow (9/11/2025).  During a review of Patient 3’s “Comprehensive Nursing Assessment”, dated 8/11/2025, the “Comprehensive Nursing Assessment” indicated Patient 3 has mild anxiety, has shortness of breath with moderate exertion and diminished lung sounds. During a review of Patient 3’s “Visit Note”, dated 8/14/2025, 8/21/2025, 8/24/2025, 8/252025, 8/31/2025, 9/7/2025, 9/8/2025 and 9/10/2025, the “Visit Note” indicated Patient 3 has mild anxiety, shortness of breath with exertion, and diminished lung sounds. During a review of Patient 3’s “Physician Order”, dated 9/10/2025, the “Physician Order” indicated Oxygen 5 liters via nasal canula (oxygen was ordered a month after Patient 3 was admitted). The order did not include “Comfort Kit”.  During a review of Patient 3’s “POC/IDG Review”, dated 8/29/2025, the “POC/IDG Review” under IDG Discussion/Updated Comprehensive Assessment Review of Physician indicated plan to assess and control end-of-life symptoms with medications. During a concurrent interview and record review on 9/11/2025 at 2:20 PM with the MD. the “POC/IDG Review”, dated 8/29/2025 was reviewed. The MD stated the “POC/ IDG Review” that indicated “Other/ Physician: Assess, monitor, and control end of life symptoms with medications,” this treatment plan included the patient’s use of Comfort Kit medications and if the Comfort Kit was not needed it would reflect on the POC/ IDG Review.  During an interview on 9/15/2025 at 10:20 AM with RN 5, RN 5 stated the DPCS was the one attending the IDG meeting and reports on the hospice patients’ nursing care and needs. RN 5 stated the visiting nurses would report nursing updates, patient condition and patient needs/concerns to the DPCS, and the DPCS will collaborate with the MD for any treatments and services to provide on the patient based on nurse’s report during the IDG meeting. RN 5 stated the DPCS will coordinate the updates and changes regarding patient care and treatments to the healthcare team for implementation. During an interview on 9/15/2025 at 10:20 AM with RN 5, RN 5 stated any concerns or change of condition should be addressed as soon as it was assessed by the nurse. RN 5 stated interventions for anxiety can include non-pharmacological techniques and medications. RN 5 stated these interventions should be reflected on Patient 3’s Plan of care and should be discussed in the IDG meeting. RN 5 stated when the physician indicated Comfort Kits on his notes, the nurse should place an order of Comfort Kit for the patient. During a review of the facility’s policies and procedures (P&P) titled, “Comfort Kit for the Imminently Dying Patient,” undated, the P&P indicated, “It is the policy of AAA Hospice Care Inc to provide timely symptom management for patients who are imminently dying by ensuring access to a pre-approved Comfort Kit…The Comfort Kit is intended to address urgent and distressing symptoms such as pain, agitation, dyspnea, nausea, secretions, or anxiety, and to prevent unnecessary suffering or emergency room transfers at the end of life. The Comfort Kit will be dispensed, stored, and administered in compliance with federal, state, and local regulations, as well as hospice standards of practice.”  During a review of the facility’s P&P titled, “The Plan of Care,” undated, the P&P indicated the following:  - “The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care…” - “The Case Manager (or admitting registered nurse) will then notify the attending physician and a core member of the interdisciplinary group of the initial assessment findings, the identification of patient needs and the recommended services to meet those needs. The plan of care will be reviewed prior to care being delivered.” - “Orders for the start of care will be verbally received by the Case Manager (or hospice registered nurse) from the attending physician (or other authorized independent practitioner) and documented on the plan of care/physician order form.”  - “The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief..”

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the ongoing sharing of information with non-hospice healthcare providers furnishing services for two of two sampled Patients (Patient 1 and Patient 11) by: Failing to ensure documentation of communications with the Primary Care Physician (PCP) related to a change in dose for Mounjaro (tirzepatide, an injectable prescription drug used to treat type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing)) in the medical record for Patient 1. Failing to ensure services provided during wound care referral were documented in the medical record for Patient 11.Failing to ensure the results of the wound culture were documented in the medical record for Patient 11. These failures had the potential to place Patient 1 at risk for medication administration errors, increased side effects, uncontrolled blood glucose, and compromised safety, and Patient 11 at risk for inadequate treatment, worsening medical conditions, insufficient symptom management, and avoidable hospitalization. --- Findings: During a review of Patient 1’s “Personal Information,” (page of the medical chart containing a summary of basic patient information) undated, the “Personal Information” indicated the HA admitted Patient 1, a 73-year-old female, on 8/15/2025 with diagnosis that included atherosclerosis heart disease (plaque buildup in the heart’s arteries), shortness of breath (SOB, a subjective sensation of not being able to get enough air, often accompanied by feelings of tightness in the chest, rapid breathing, and wheezing [a high-pitched, whistling sound that occurs when air flows through narrowed airways]), and dependance on supplemental oxygen (a condition requiring the use of a device to deliver extra oxygen). During a review of Patient 11’s “Personal Information,” undated, the “Personal Information” indicated the HA admitted Patient 11 on 3/9/2025 with diagnosis that included hypertensive heart disease with heart failure (high blood pressure damaged the heart over time, making it unable to pump blood effectively causing shortness of breath, fatigue, and swelling in the legs), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (elevated cholesterol level). 1. During a review of Patient 1’s “Current Treatment/ Medication/ DME List,” undated, the “Current Treatment/ Medication/ DME List” indicated Mounjaro 5 milligrams (mg, unit of measurement) subcutaneous injection once a week for type 2 diabetes mellitus.During a home visit observation on 9/10/2025 at 9:32 AM, Patient 1’s medications included Mounjaro 7.5 mg/ 0.5 milliliters (mL, unit of measurement) injection pen. During an interview on 9/11/2025 at 2:20 PM, with the Medical Director (MD), the MD stated he does not collaborate with other physicians to develop HA patient’s treatment plans. During a concurrent interview and record review on 9/17/2025 at 11:29 AM, with Registered Nurse 5 (RN 5), Patient 1’s “Patient Consent for Primary Care Physician (consent form),” dated 8/15/2025 was reviewed. The consent form indicated Patient 1 elected to continue care with her PCP. RN 5 stated that when a patient elects to continue care with their PCP, the HA must fax the consent form to the Patient’s PCP and request continued communication including medical visits, updates, and changes in treatment or medication. During an interview on 9/17/2025 at 11:37 AM with RN 5 stated there was no documented evidence in Patient 1’s medical record to indicate the consent form was faxed to Patient 1’s PCP. RN 5 stated there was no documented evidence in Patient 1’s medical record to indicate the HA communicated with Patient 1’s PCP regarding a change in dose for Mounjaro from 5 mg to 7.5 mg. RN 5 stated failure to maintain communication with the PCP placed Patient 1 at risk of medication administration errors, drug-to-drug interactions, and increased side effects including constipation, nausea, vomiting, headache, and fatigue. During a review of the facility’s policy and procedure (P&P) titled, “Policy & Procedure: Ordering Medications and Supplies,” dated 12/19/2024, the P&P indicated the following:·       “All orders, including drafts and finalized versions, must be documented in the patient’s clinical record.”·        “The DPCS [Director of Patient Care Services] is responsible for ensuring that orders are accurate, clinically appropriate, and compliant with regulations.”·       DPCS coordinates with physicians, ensures documentation and oversees the process. During a review of the facility’s P&P titled, “Interdisciplinary Group Membership and Responsibilities,” undated, the P&P indicated, “The interdisciplinary group [IDG] will collaborate with the patient’s attending physician to develop an individualized written plan of care. The P&P indicated the IDG is responsible for the provision and/or supervision and coordination of hospice care and services. 2. During a review of Patient 11’s “Physician Order,” dated 4/3/2025, the “Physician Order” indicated on 4/3/2025 the Medical Director (MD) entered an order for wound care evaluation and treatment. During a concurrent interview and record review on 9/16/2025 at 10:55 AM with RN 5, Patient 11’s electronic medical record (EMR) was reviewed. The EMR did not contain documentation of wound care services furnished by the HA’s wound care service provider. RN 5 stated notes from the wound care specialist should be uploaded into the EMR and stated Patient 11’s EMR did not contain documentation of wound care referral visits. RN 5 stated the HA is required to obtain records from healthcare providers furnishing services to the HA’s patients. During a concurrent interview and record review on 9/16/2025 at 11:38 AM with RN 5, Patient 11’s electronic medical record (EMR) was reviewed. The EMR did not contain documentation of refusal of wound care services. RN 5 stated Patient 11’s EMR did not contain documented evidence to indicate he refused care with the HA’s wound care service provider. During an interview on 9/17/2025 at 10:40 AM with RN 5, RN 5 stated Patient 11’s medical record did not include documented evidence to suggest the physician’s order dated 4/3/2025 for referral of wound care services was completed. RN 5 stated she would contact the HA’s wound care service provider and request documentation of any visits.During a review of Patient 11’s “Progress Note Details (progress note)” dated 3/10/2025, the “progress note” indicated the initial home visit for wound care referral was attempted on 3/10/2025. The HA was unable to provide documentation of wound care referral for evaluation and treatment dated on or after 4/3/2025, when the physician order was entered. During a review of the facility’s P&P titled, “Policy: Submission of Notes,” dated 1/8/2025, the P&P indicated, “All notes must be submitted to the agency office no later than 72 hours from the date of the visit […] The medical records department will review, process, and file the submitted notes into the patient’s medical record.”During a review of the facility’s P&P titled, “Policy & Procedure: Referrals and Logs,” undated, the P&P indicated the following:·       Each referral entry must include the status of the referral and the outcome.    ·       The Referral Log must be reviewed weekly by the Administrator/ Director of Nursing and any delays or missed follow-ups must be investigated.  3. During a review of Patient 11’s “Current Treatment/ Medication/ DME List,” undated, the “Current Treatment/ Medication/ DME List” indicated on 4/21/2025 a laboratory order for wound culture was entered. During a review of Patient 11’s EMR, the EMR did not contain documentation of wound culture collection or results. During an interview on 9/16/2025 at 12:40 PM with RN 5, RN 5 stated she would attempt to obtain Patient 11’s wound culture results from the HA’s laboratory service provider. During an interview on 9/17/2025 at 1:40 PM with RN 5, RN 5 stated the HA had not obtained wound care culture results from the laboratory service provider. RN 5 stated Patient 11’s medical record did not indicate the HA received and reviewed the wound culture results. RN 5 stated failure to communicate with the laboratory service provider placed Patient 11 at risk of delayed or inappropriate treatment and increased complications. During a review of the facility’s P&P titled, “Policy: Submission of Notes,” dated 1/8/2025, the P&P indicated, “All notes must be submitted to the agency office no later than 72 hours from the date of the visit […] The medical records department will review, process, and file the submitted notes into the patient’s medical record.”During a review of the facility’s P&P titled, “Policy & Procedure: Referrals and Logs,” undated, the P&P indicated the following:·       Each referral entry must include the status of the referral and the outcome.    ·       The Referral Log must be reviewed weekly by the Administrator/ Director of Nursing and any delays or missed follow-ups must be investigated.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to meet the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) compliance with Quality Assessment and Performance Improvement (QAPI, a data driven approach to improve the quality of care and services provided to patients) for the provided services to the patients as follows: --- The HA failed to:1. Provide evidence that the Performance Improvement Program (PIP, a data driven approach to improve the quality of care and services provided to patients) has measurable improvement related to palliative (a form of medical care focuses on providing comfort and support to patients with serious or life-threatening illness) outcomes and hospice services. (Refer to L-tag 561)2. Provide evidence that the PIP was designed based on patient care assessments and the services HA provides. (Refer to L-tag 563)3. Provide evidence that data was collected to identify opportunities and priorities for improvement and monitor the effectiveness of the PIP. (Refer to L-tag 564)4. Provide documented evidence of the PIP being conducted and the progress achieved. (Refer to L-tag 573)These failures had the potential for patients to receive inconsistent symptom management, safety concerns and poor quality of life.The cumulative effect of these systemic practice resulted in the failure of the Hospice Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Quality Assessment and Performance Improvement for the provided services to patients certified to receive hospice benefits.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to provide evidence that the Performance Improvement Program (PIP, a data driven approach to improve the quality of care and services provided to patients) has measurable improvement related to palliative (a form of medical care focuses on providing comfort and support to patients with serious or life-threatening illness) outcomes and hospice services. This failure had the potential for patients to receive inconsistent symptom management, safety concerns and poor quality of life. --- Findings:During a concurrent interview and record review on 9/17/2025 at 2:15 PM with Registered Nurse Case Manager (RN 5), HA’s “Performance Improvement Plans / Projects for 2025-2026”, undated was reviewed. RN 5 stated the PIP risk focus is on hand washing, medication management and personal care for patients with dementia (a progressive state of decline in mental abilities). RN 5 stated the PIP is led by the Director of Patient Care Services (DPCS) and acts as the Quality Assurance Nurse.During an interview on 9/17/2025 at 2:40 PM with RN 5, RN 5 stated she usually attends the PIP meeting, but she is not familiar with the current PIP in place. RN 5 stated there were no available staff to answer questions regarding the PIP for 2025.During a concurrent interview and review on 9/17/2025 at 2:40 PM with RN 5. The HA’s “Performance Improvement Project (PIP) for 2025”, dated 3/21/2025 was reviewed. The PIP indicated for the first quarter (January 2025 – March 2025) of the quality assessment and performance project focuses on hand washing, bathing and personal care for patients with dementia. RN5 was unable to provide evidence that the PIP improved the palliative outcome, or the services HA provides.During a concurrent interview and review on 9/17/2025 at 2:45 PM with RN 5. The HA’s “Performance Improvement Project (PIP) for 2025”, dated 6/20/2025 was reviewed. The PIP indicated for the second quarter (April 2025 – June 2025) of the quality assessment and performance project focuses on developing a plan and conducting emergency preparedness evacuation drills for hospice patients. R RN5 was unable to provide evidence that the PIP improved the palliative outcome, or the services HA provides.During a review of HA’s policy and procedures (P&P) titled “Reducing Risk of Infection: Hand Hygiene, HA Service Performance Improvement Project”, undated. The P&P indicated “The program involves all hospice services, focus on indicators related to improved palliative outcomes and takes action to improve hospice performances” … “the PIP sustains an improvement in the quality of care by measuring previous review assessment” … “the hospice documents the measurable progress achieved on PIP in quarterly QAPI report. The evaluation process demonstrates effectiveness by assessing the established standards are met and palliative outcomes improved.”

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to provide evidence that the Performance Improvement Plans (PIP, a data driven approach to improve the quality of care and services provided to patients) was designed based on patient care assessments and the services HA provides. This failure had the potential for patients to receive inconsistent symptom management, safety concerns and poor quality of life. --- Findings:During a concurrent interview and record review on 9/17/2025 at 2:15 PM with Registered Nurse Case Manager (RN 5), the HA’s “Performance Improvement Plans / Projects for 2025-2026”, undated was reviewed. RN 5 stated the PIP risk focus is on hand washing, medication management and personal care for patients with dementia (a progressive state of decline in mental abilities). RN 5 stated the PIP is led by the Director of Patient Care Services (DPCS) and acts as the Quality Assurance Nurse. RN 5 stated the risk focus should be based on gathered data evidence related to patient care and services provided. RN 5 stated medication management was included as a risk focus due to medication errors from the previous year (2024). RN 5 was unable to provide documented evidence why handwashing and personal care for dementia patients are the current risk focus for PIP related to the services the HA provides.During a review of facility’s “Medication Error” log, dated 2024-2025. The “Medication Error” log indicated there were no medication error from January 2024 to August 2025.During a review of HA’s “Performance Improvement Project (PIP) for 2024”, dated 12/18/2024. The PIP indicated 50 percent (%) of the patients admitted to the HA were diagnosed with heart disease (conditions affecting the heart or blood vessels), 18 % were diagnosed with autoimmune disease (conditions that the body mistakenly attacks its own healthy tissue and organ) and 12 % were diagnosed with respiratory disease (illness that affects the lungs and airways).During an interview on 9/17/2025 at 2:40 PM with RN 5, RN 5 stated she usually attends the PIP meeting, but she is not familiar with the current PIP in place and the reason why it was selected as the current focus for this year. RN 5 stated there were no available staff to answer questions regarding the PIP for 2025.During a review of HA’s policy and procedures (P&P) titled “Reducing Risk of Infection: Hand Hygiene, HA Service Performance Improvement Project”, undated. The P&P indicated “The hospice agency maintains an effective, ongoing hospice-wide data-driven quality assessment and performance improvement program” … “the program involves all hospice services, focus on indicators related to improved palliative outcomes and takes action to improve hospice performances.”

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to provide evidence that data were collected to identify opportunities and priorities of improvement and monitor the effectiveness of the Performance Improvement Program (PIP, a data driven approach to improve the quality of care and services provided to patients). This failure had the potential for patients to receive inconsistent symptom management, safety concerns and poor quality of life. --- Findings:During a concurrent interview and record review on 9/17/2025 at 2:15 PM with Registered Nurse Case Manager (RN 5), HA’s “Performance Improvement Plans / Projects for 2025-2026”, undated was reviewed. RN 5 stated the PIP risk focus is on handwashing, medication management and personal care for patients with dementia (a progressive state of decline in mental abilities). RN 5 stated the PIP is led by the Director of Patient Care Services (DPCS) and acts as the Quality Assurance Nurse. RN 5 stated the risk focus should be based on gathered data evidence related to patient care and services provided. RN 5 was unable to provide documented evidence why handwashing and personal care for dementia patients are the current risk focus for PIP related to the services the HA provides.During a review of facility’s “Medication Error” log, dated 2024-2025. The “Medication Error” log indicated there were no medication error from January 2024 to August 2025.During an interview on 9/17/2025 at 2:40 PM with RN 5, RN 5 stated she usually attends the PIP meeting, but she is not familiar with the current PIP in place and the reason why it was selected as the current focus for this year. RN 5 stated there were no available staff to answer questions regarding the PIP for 2025.During a concurrent interview and review on 9/17/2025 at 2:45 PM with RN 5. The HA’s “Performance Improvement Project (PIP) for 2025”, dated 3/21/2025 was reviewed. The PIP indicated for the first quarter (January 2025 – March 2025) of the quality assessment and performance project focuses on handwashing and personal care for patients with dementia. The PIP indicated that the project resulted in staff demonstrating improved adherence to hand hygiene and more consistent dementia appropriate care. RN 5 was unable to provide data collected evidence that the staff demonstrated improved adherence to hand hygiene and more consistent dementia appropriate care and how the program improved the hospice services provided to patients.During a review of HA’s “Performance Improvement Project (PIP) for 2024”, dated 12/18/2024. The PIP indicated 50 percent (%) of the patients admitted to the HA were diagnosed of heart disease, 18 % were diagnosed with autoimmune disease and 12 % were diagnosed with respiratory disease.During a concurrent interview and review on 9/17/2025 at 2:45 PM with the Chief Financial Officer (CFO). The HA’s “Performance Improvement Project (PIP) for 2025”, dated 6/20/2025 was reviewed. The PIP indicated for the second quarter (April 2025 – June 2025) of the quality assessment and performance project focuses on developing a plan and conducting emergency preparedness evacuation drills for hospice patients. The PIP indicated the project resulted in “Staff demonstrated improved response times, stronger knowledge on of evacuation protocols, and greater confidence in executing preparedness procedures”. The CFO stated the project was selected due to the recent incident in the Loas Angeles county fire early this year. The CFO was unable to provide data collected evidence that demonstrated staff’s improvement with response time and stronger knowledge on evacuation protocol and how the program improved the hospice services provided to patients.During a review of HA’s policy and procedures (P&P) titled “Reducing Risk of Infection: Hand Hygiene, HA Service Performance Improvement Project”, undated. The P&P indicated the following:1. “The hospice agency maintains an effective, ongoing hospice-wide data-driven quality assessment and performance improvement program”2. “The program involves all hospice services, focus on indicators related to improved palliative outcomes and takes action to improve hospice performances.”3. “The hospice documents the measurable progress achieved on PIP in the quarterly report.”4. “The evaluation process demonstrates effectiveness by assessing the established standards are met and palliative outcomes are improved.”

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to provide documented evidence of the Performance Improvement Program’s (PIP, a data driven approach to improve the quality of care and services provided to patients) being conducted and the progress achieved. This failure had the potential for patients to receive inconsistent symptom management, safety concerns and poor quality of life. --- Findings:During a record review the HA’s “Performance Improvement Plans / Projects for 2025-2026”, undated was reviewed. The PIP indicated that the risk focus is on hand washing and medication management. The PIP indicated the “Hand Hygiene Audit tool” and “Chart Review and Medication Management Audit Tool” will be used in conducting the PIP.During a concurrent interview and review on 9/17/2025 at 2:45 PM with RN 5. The HA’s “Performance Improvement Project (PIP) for 2025”, dated 3/21/2025 was reviewed. The PIP indicated for the first quarter (January 2025 – March 2025) of the quality assessment and performance project focuses on handwashing and personal care for patients with dementia (a progressive state of decline in mental abilities). The PIP indicated that the project resulted in staff demonstrating improved adherence to hand hygiene and more consistent dementia appropriate care. RN 5 was unable to provide evidence that the staff demonstrated improved adherence to hand hygiene and more consistent dementia appropriate care and how the program improved the hospice services provided to patients. RN 5 was unable to provide evidence that “Hand Hygiene Audit tool” were used for this quarter.During a concurrent interview and review on 9/17/2025 at 2:45 PM with the Chief Financial Officer (CFO). The HA’s “Performance Improvement Project (PIP) for 2025”, dated 6/20/2025 was reviewed. The PIP indicated for the second quarter (April 2025 – June 2025) of the quality assessment and performance project focuses on developing a plan and conducting emergency preparedness evacuation drills for hospice patients. The PIP indicated the project resulted in “Staff demonstrated improved response times, stronger knowledge on of evacuation protocols, and greater confidence in executing preparedness procedures”. The CFO was unable to provide evidence that the staff demonstrated improvement with response time and stronger knowledge of evacuation protocol and how the program improved the hospice services provided to patients.During a review of HA’s policy and procedures (P&P) titled “Reducing Risk of Infection: Hand Hygiene, HA Service Performance Improvement Project”, undated. The P&P indicated the following:1. “The hospice agency maintains an effective, ongoing hospice-wide data-driven quality assessment and performance improvement program”2. “The program involves all hospice services, focus on indicators related to improved palliative outcomes and takes action to improve hospice performances.”3. “The hospice documents the measurable progress achieved on PIP in the quarterly report.”4. “The evaluation process demonstrates effectiveness by assessing the established standards are met and palliative outcomes are improved.”

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) for Clinical Records of Patients were met as follows: --- The HA failed to:To ensure the clinical records of 20 of 20 sampled patients (Patient 1, Patient 2, Patient 3, Patient 12, Patient 13, Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, and Patient 28) reflect the actual date the information was entered in accordance to the facility’s policy and procedure.  This failure resulted in actual and potential harm for Patient 1, Patient 2, Patient 3, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, and Patient 28 to have inappropriate and inaccurate medication and treatment orders; unsafe patient care; increased the risk for hospice patients to suffer from unmanaged pain, distress, agitation; and increased the risk for emergency hospitalization and avoidable traumatic and/or undignified death and Patient 12, Patient 13, and Patient 14’s medical record not accurately reflecting the care provided and increased the risk for patient safety and compromised care. (Refer to L-tag 679)(Refer to L-tag 683) The cumulative effect of this systemic practice resulted in the failure of the Hospice Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Clinical Records for the provided services to patients certified to receive hospice benefits.  2. Provide documented evidence the Discharge Summary for five of five sampled Patients (Patient 11, Patient 12, Patient 13, Patient 14, and Patient 29) were sent to the attending physician.  These failures had the potential for Patient 11, Patient 12, Patient 13, Patient 14, and Patient 29 to experience discontinuity of care; potentially resulting in delayed treatment, medication errors, and missed opportunities for follow up.  (Refer to L683)

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed:1.  To ensure the physician’s orders of oxygen and Comfort Kit (set of medications intended for symptoms and pain management such as: Morphine (treatment for pain), Ativan (treatment for agitation and anxiety), Levsin (treatment for excessive secretions), albuterol inhaler (treatment for shortness of breath and/or wheezing), Zofran (treatment for nausea and vomiting), and Tylenol (treatment for mild pain and/or fever)) for 17 of 17 sampled patients (Patient 1, Patient 2, Patient 3, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, and Patient 28) were accurately entered to reflect the actual date of physician’s order of the oxygen and Comfort Kit, and in accordance to the facility’s policy and procedure.  2.   To ensure Licensed Vocational Nurse 3 (LVN 3) did not back date and entered the discharged summary notes and plan of care for the three of five sampled discharged patients’ (Patient 12, Patient 13, and Patient 14) medical records.These failures resulted in actual and potential harm for:1.   Patient 1, Patient 2, Patient 3, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, and Patient 28 to have inappropriate and inaccurate medication and treatment orders; unsafe patient care; increased the risk for hospice patients to suffer from unmanaged pain, distress, agitation; and increased the risk for emergency hospitalization and avoidable traumatic and/or undignified death.2.   Patient 12, Patient 13, and Patient 14’s medical record not accurately reflecting the care provided and increased the risk for patient safety and compromised care. On 9/12/2025, at 4:38 PM., the Department called an Immediate Jeopardy  (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient), in the presence of the agency’s Chief Financial Officer (CFO) present in person and Director of Patient Care Services Designee (DPCSD) via telephone, related to failing to demonstrate a process and provide documented evidence that the agency ensured the physician’s orders for oxygen and Comfort Kit were accurately entered to reflect the actual date of physician’s order of the oxygen and Comfort Kit orders  for 17 of 17 sampled patients (Patient 1, Patient 2, Patient 3, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, and Patient 28). On 9/16/2025, at 6:52 PM, the Department called an IJ addendum, the IJ addendum was with the CFO and Registered Nurse Case Manager 5 (RN 5) present in person for failing to demonstrate a process and provide documented evidence that the facility ensured LVN 3 entered the actual date the discharge summary and plan of care was created for three of five sampled discharged patient’s (Patient 12, Patient 13, and Patient 14) medical records. On 9/17/2025, at 3:30 PM, the survey team completed the survey tasks and conducted an exit conference while onsite in the presence of the CFO, and DPCS Designee and RN 5 via telephone with the IJ situations not removed. On 9/17/2025 at 3:42 PM, the HA was unable to submit an acceptable IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The IJ removal plan was not accepted. --- Findings:During a review of Patient 1’s “Personal Information,” (containing a summary of basic patient information) undated, the “Personal Information” indicated the hospice agency (HA) admitted Patient 1, on 8/15/2025 with diagnosis that included atherosclerosis heart disease (plaque buildup in the heart’s arteries), shortness of breath (SOB), and dependance on supplemental oxygen (a condition requiring the use of a device to deliver extra oxygen).During a review of Patient 2’s “Personal Information”, the “Personal Information” indicated Patient 2, admitted on 8/6/2025, with diagnoses including, but not limited to, atherosclerosis heart disease, anxiety disorder (excessive and persistent worry, fear, and unease), and shortness of breath.During a review of Patient 3’s “Personal Information”, the “Personal Information” indicated  Patient 3, was admitted on 8/11/2025 with diagnoses including, but not limited to, heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), shortness of breath, and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance (patterns of behaviors, thoughts and moods that are considered unusual for a person’s age and context). During a review of Patient 12’s “Personal Information,” the “Personal Information” indicated  Patient 12, was admitted on 7/17/2025, with diagnoses including hypertensive heart disease with heart failure (high blood pressure damaged the heart over time, making it unable to pump blood effectively), acute respiratory failure with hypoxia (a sudden condition where the lungs cannot get enough oxygen into the blood for the body's organs to function), and chronic kidney disease (a condition where the kidneys are damaged and cannot filter waste and extra fluid from the blood effectively, leading to a buildup of toxins in the body) . Patient 12’s end of care date was 8/17/2025 due to hospitalization.During review of Patient 13’s “Personal Information”, undated, the “Personal Information” indicated Patient 13, admitted on 3/12/2025 with diagnoses including, but not limited to, dementia (a group of brain disorders that cause a gradual decline in cognitive abilities, including memory, thinking, language, and problem-solving), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and shortness of breath. Patient 13 expired and was discharged from hospice on 4/16/2025. During a review of Patient 14’s “Personal Information”, the “Personal Information” indicated Patient 14, was admitted on 3/8/2025, with diagnoses including, but not limited to, malignant neoplasm of cervix uteri, unspecified (cervical cancer that develops in the lower part of the uterus), shortness of breath, and dependence on supplemental oxygen.During a review of Patient 15’s “Personal Information”, the “Personal Information” indicated Patient 15, was admitted on 4/4/2025, with diagnoses including, but not limited to, atherosclerosis heart disease, and essential hypertension (high blood pressure).During a review of Patient 16’s “Personal Information”, the “Personal Information” indicated Patient 16, was admitted on 4/19/2025, with diagnoses including, but not limited to, atherosclerosis heart disease, and essential hypertension.During a review of Patient 17’s “Personal Information”, the “Personal Information” indicated Patient 17 was admitted on 4/24/2025, with diagnoses including, but not limited to, atherosclerosis heart disease, constipation (common digestive condition characterized by infrequent or difficult bowel movements), and weakness (generalized weakness with no precise underlying cause).During a review of Patient 18’s “Personal Information”, the “Personal Information” indicated Patient 18, admitted on 5/6/2025, with diagnoses including, but not limited to, atherosclerosis heart disease, shortness of breath, and essential hypertension.During a review of Patient 19’s “Personal Information”, the “Personal Information” indicated Patient 19, was admitted on 5/7/2025, with diagnoses including, but not limited to, atherosclerosis heart disease, shortness of breath, and essential hypertension.During a review of Patient 20’s “Personal Information,” the “Personal Information” indicated Patient 20 was admitted on 5/24/2025 with diagnoses including heart failure and shortness of breath.During a review of Patient 21’s “Personal Information,” the “Personal Information” indicated the hospice agency admitted Patient 21 on 6/3/2025 with diagnoses including heart failure and anxiety disorder.During a review of Patient 22’s “Personal Information,” the “Personal Information” indicated Patient 22, was admitted on 6/5/2025 with diagnoses including heart disease, shortness of breath, and dependance on supplemental oxygen.During a review of Patient 23’s “Personal Information,” the “Personal Information” indicated Patient 23 was admitted on 6/13/2025 with diagnoses including atherosclerosis heart disease and anxiety disorder.During a review of Patient 24’s “Personal Information,” the “Personal Information” indicated Patient 24, was admitted on 6/13/2025 with diagnoses including chronic systolic heart failure (a long-term condition where the heart’s main pumping chamber is too weak to squeeze forcefully enough to pump sufficient blood to the body) and dementia.During review of Patient 25’s “Personal Information”, the “Personal Information” indicated the hospice agency admitted Patient 25, on 6/23/2025 with diagnoses including, but not limited to, heart failure, diabetes mellitus and respiratory failure (a condition where the lungs are unable to exchange oxygen and carbon dioxide adequately) with hypoxia (a condition where there is an inadequate supply of oxygen to the body).During review of Patient 26’s “Personal Information”, the “Personal Information” indicated the hospice agency admitted Patient 26, on 6/23/2025 with diagnoses including, but not limited to, heart failure, anxiety and hypertension.During review of Patient 27’s “Personal Information”, the “Personal Information” indicated the hospice agency admitted Patient 27, on 7/7/2025 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), essential hypertension, and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).During review of Patient 28’s “Personal Information”, the “Personal Information” indicated the hospice agency admitted Patient 28, on 3/25/2025 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and shortness of breath.1. During a concurrent interview and record review on 9/10/2025 at 9:23 AM, Patient 1’s "Current Treatment/ Medication/ DME List,” undated, was reviewed along side Caregiver 1 (CG1- Patient 1’s care giver). The “Current Treatment/ Medication/ DME List” for Patient 1 did not include the Comfort Kit: morphine sulfate, Zofran, Levsin, acetaminophen, Ativan, bisacodyl, ipratropium. Patient 1’s Caregiver 1 (CG 1) stated that Patient 1 did not have the Comfort Kit.     During a review of Patient 1’s “Visit Note LVN,” dated 9/10/2025, the “Visit Note LVN” indicated Patient 1 had heavy breathing and mild abnormal lung sounds. During a review of Patient 1’s “Current Treatment/ Medication/ DME List,”  undated, the “Current Treatment/ Medication/ DME List”  indicated the following medication were ordered on 8/15/2025: “Comfort Pack: morphine sulfate 100 milligram (mg, unit of measurement) /5 milliliter (mL, unit of measurement) solution 0.25, Zofran 4 mg tablet, Levsin 0.125 mg sublingual tablet (to place under the tongue and let dissolve in mouth), acetaminophen 650 mg rectal suppository (medication inserted into the rectum), Ativan 2 mg tablet, bisacodyl 10 mg rectal suppository, and ipratropium bromide/ albuterol sulfate 0.5 mg 3 mL solution.”  During an interview on 9/11/2025 at 1:20 PM., with the Chief Financial Officer (CFO),  the CFO stated the agency was starting to do corrections on the medication orders. The CFO stated the Director of Patient Care Services (DPCS), DPCS Designee and LVN 3 entered “Comfort Kit” and oxygen orders on 9/11/2025 for several patients  and back dated the order using the patients’ respective start of care (SOC) date.  A review of Patient 2’s Visit Note, authored by Licensed Vocational Nurse 1 (LVN 1), dated 9/8/2025, indicated “Pt [Patient 2] was anxious and angry.” During joint home visit on 9/10/2025 at 1:10 PM, at Patient 2’s home, with Registered Nurse 4 (RN 4), a medication reconciliation was conducted.  Patient 2’s “Current Treatment/ Medication/ DME List,” did not include the following medications in the Comfort Kits: morphine sulfate, Zofran, Levsin, acetaminophen, Ativan, and bisacodyl. Patient 2’s Caregiver (CG 2) stated Patient 2 did not have a Comfort Kit.   During a review of Patient 2’s Current Treatment/Medication/DME List, dated 9/11/2025, the Current Treatment/Medication/DME List indicated the following medications were ordered on 8/6/2025: Acetaminophen 650 mg rectal suppository; Ativan 2 mg tablet; Bisacodyl 10 mg Rectal suppository; Levsin SL 0.125 Sublingual tablet; Morphine Sulfate 100mg/5mL solution 0.25; Zofran 4 mg tablet. During an interview on 9/11/2025 at 1:20 PM., with the Chief Financial Officer (CFO),  the CFO stated the agency was starting to do corrections on the medication orders. The CFO stated the Director of Patient Care Services (DPCS), DPCS Designee and LVN 3 entered “Comfort Kit” and oxygen orders on 9/11/2025  back dated the order using the patients’ respective start of care (SOC) date.  During a joint home visit observation on 9/10/2025 at 3:20 PM, a medication reconciliation (a process on comparing patient’s current medication against medication ordered by the physician) was conducted with Medical Social Worker (MSW). Patient 3’s “Current Treatment/ Medication/ DME List” did not include the “Comfort Kit”: morphine sulfate, Zofran, Levsin, acetaminophen, Ativan, and bisacodyl. Patient 3 did not have the “Comfort Kit”.   During an interview on 9/10/2025 at 3:20 PM, with Patient 3’s Caregiver 3 (CG 3), CG 3 stated Patient 3 feels short of breath even with small movements. CG 3 stated she requested for Patient 3 to have an oxygen concentrator (medical device that delivers rich air to a person who has difficulty breathing) from the last nurse visit (9/8/2025) and that the facility will be delivering Patient 3’s oxygen tomorrow (9/11/2025).  During a review of Patient 3’s “Visit Note”, dated 9/8/2025, the “Visit Note” indicated Patient 3 has “moderate shortness of breath”, has “heavy breathing” (increased effort in inhaling and exhaling air), and “moderate abnormal lung sounds”. During a review on 9/11/2025 at 10:30 AM, Patient 3’s “Physician Order” was reviewed, the following medications were ordered on 8/11/2025: Acetaminophen 650 mg rectal suppository; Ativan 2 mg tablet; Bisacodyl 10 mg Rectal suppository; Levsin SL 0.125 Sublingual tablet; Morphine Sulfate 100mg/5mL solution 0.25; Zofran 4 mg tablet. The Physician Order indicated “Oxygen Concentrator” were ordered on 9/10/2025.During a review on 9/11/2025 at 1:15 PM, Patient 3’s “Physician Order”, dated 8/11/2025, the “Physician Order” indicated, “Oxygen 5L with nasal cannula” (a thin flexible tube that wraps around the head and sits on the nose to deliver oxygen). During an interview on 9/11/2025 at 1:18 PM with the Chief Financial Officer (CFO), the CFO stated the facility was starting to do corrections on the medication orders. The CFO stated the DPCS, DPCS Designee and LVN 3 entered “Comfort Kit” and oxygen orders today on several patients and back dated the order from patients’ respective start of care. The CFO was heard talking on the phone and stated, “Stop what you are doing, do not touch anything anymore.” The CFO stated he was on the phone with the DPCS Designee. During a concurrent interview and record review on 9/11/2025 at 3:05 PM with LVN 3. Patient 3’s “Physician Order”, dated 9/10/2025, was reviewed. LVN 3 stated she made an error of entering the order and putting 8/11/2025 (Patient 3’s SOC). LVN 3 stated she should not back date the order and enter the date the order was put in.   1.D. During an interview on 9/11/2025 at 1:18 PM., with the Chief Financial Officer (CFO), the CFO stated the agency was starting to do corrections on the medication orders. The CFO stated the DPCS, DPCS Designee and LVN 3 entered “Comfort Kit” and oxygen orders today on several patients and back dated the order from patients’ respective start of care. The CFO was heard talking on the phone and stated, “Stop what you are doing, do not touch anything anymore.” The CFO stated he was on the phone with the DPCS Designee. During an interview on 9/11/2025 at 1:20 PM with the CFO, the CFO provided the list of patients (Patient 1, Patient 2, Patient 3, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, Patient 20, Patient 21. Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, and Patient 28) that the DPCS, DPCS Designee and LVN 3 entered the “Comfort Kit” and back dated from the patients’ start of care.  2.During a concurrent interview and record review on 9/16/2025 at 12:02 PM., with RN 5 and)  Representative 2 (HMR 2), the electronic medical record audit trail log for Patient 12 was reviewed. HMR 2 stated that based on Patient 12’s audit trail log, LVN 3 accessed Patient 12’s record and updated Patient 12’s Plan of Care (POC) on 9/11/2025 (one month after Patient 12 was discharged). HMR 2 stated Patient 12’s audit trail log indicated the following Focus Areas of Patient 12’s POC were closed (resolved) and backdated to reflect 8/18/2025: cardiovascular, gastro-intestinal, genitourinary, musculoskeletal, neurological/ mental, nutrition, pain, and respiratory. HMR 2 stated the actual date of the POC edit was 9/11/2025.During an interview with LVN 3 on 9/16/2025 at 1:22 PM, LVN 3 stated she does not conduct patient visits. LVN 3 stated she accessed Patient 12’s POC one month after Patient 12 was discharged discharge to ensure the medical chart was “done correctly” and if it “needed to be fixed”. , LVN 3 stated closed Patient 12’s POC to ensure completeness of the record. LVN 3 stated she backdated the closure of POC to 8/18/25 to “make it look right”.During a review of Patient 13’s “Discharge Summary”, dated 4/16/2025, the “Discharge Summary” did not include a signature of who completed the discharge summary narrative. During a concurrent interview and record review on 9/16/2025 at 11:28 AM, with Representative 1 (HMR 1) and RN 5, Patient 13’s electronic medical record  audit trail log was reviewed. HMR 1 stated that based on Patient 13’s electronic medical record audit trail log, LVN 3 access Patient 13’s “Discharge Summary” and entered the discharge summary narrative on 9/9/2025 (five months after Patient 13 was discharged from hospice). During an interview on 9/16/2025 at 1:22 PM, with LVN 3, LVN 3 stated she is an LVN Case manager and part of her responsibility was to write discharge summary narrative for the discharge patients.  LVN 3 stated she did not visit patients and the narrative for discharge summary she entered was based on the report given to her by the visiting nurse. LVN 3 stated the discharge summary narrative should be done within 7 days, but she usually completes the discharge summary within 24 hours. LVN 3 stated she accessed the record of Patient 13 to make sure everything is done correctly LVN 3 stated when she entered Patient 13’s discharge summary, and she back dated (use the date the patient was discharge) to reflect 4/16/25 “to make it look right.” During a concurrent interview and record review on 9/16/2025 at 11:28 AM, with HMR 1 and RN 5, Patient 14’s audit trail log was reviewed. HMR 1 stated based on the audit trail log, LVN 3 access Patient 14’s “Discharge Summary” and entered the discharge summary narrative on 9/9/2025 (five months after Patient 14 was discharged from hospice on 4/5/2025). During an interview on 9/16/2025 at 1:22 PM, with LVN 3, LVN 3 stated she is an LVN Case manager and part of her responsibility was to write discharge summary narrative for the discharge patients.  LVN 3 stated she does not visit patients and the narrative for discharge summary she entered was based on the report given to her by the visiting nurse. LVN 3 stated the discharge summary narrative should be done within 7 days, but she usually completes the discharge summary within 24 hours. LVN 3 stated she accessed the record of Patient 14 to make sure everything is done correctly. LVN 3 stated when she entered Patient 14’s discharge summary, and she back dated (use the date the patient was discharge) to reflect 4/5/25 “to make it look right.” During a review of the facility’s policy and procedure (P&P) titled, “Discharge From Hospice Program,” undated, the P&P indicated, “The Case Manager will ensure that necessary paperwork is completed at the time of discharge…When a patient is discharged, transferred, or referred to another organization, relevant information will include…summary of the care provided and progress toward achieving goals, including both positive and adverse patient responses to treatment or services…Documentation will be filed in the clinical record. Information will be documented on a discharge/transfer form, which is to be completed within 72 hours…”  During a review of the facility’s policy and procedure titled, “Late Entry Policy,” undated, the P&P indicated the following:  -    “All entries in the patient record must be made at the time care or services are provided.” -    “If an entry is not made on the date and time services were rendered, a late entry is permissible under the following conditions: The information is accurate, factual, and relevant to the case and services provided. The late entry is clearly identified as such. The entry includes the actual date and time the service was provided and the date and time of the late documentation.”-    “Late entries must never be used to falsify records, alter prior documentation, or cover up errors.”

Based on interview and record review the Hospice Agency failed to provide documented evidence the Discharge Summary for five of five sampled Patients (Patient 11, Patient 12, Patient 13, Patient 14, and Patient 29) were sent to the attending physician.  These failures had the potential for Patient 11, Patient 12, Patient 13, Patient 14, and Patient 29 to experience discontinuity of care; potentially resulting in delayed treatment, medication errors, and missed opportunities for follow up. --- Findings: During a review of Patient 11’s “Personal Information,” undated, the “Personal Information” indicated the HA admitted Patient 11, a 76-year-old male, on 3/10/2025 with diagnosis that included hypertensive heart disease with heart failure (high blood pressure damaged the heart over time, making it unable to pump blood effectively causing shortness of breath, fatigue, and swelling in the legs), type 2 diabetes mellitus, and hyperlipidemia (elevated cholesterol level). Patient 11’s end of care (EOC) date was 5/6/2025 due to hospitalization. During a review of Patient 12’s “Personal Information,” undated, the “Personal Information” indicated the hospice agency admitted Patient 12, a 76-year-old male, on 7/17/2025 with diagnoses including hypertensive heart disease with heart failure (high blood pressure damaged the heart over time, making it unable to pump blood effectively causing shortness of breath, fatigue, and swelling in the legs), acute respiratory failure with hypoxia (a sudden condition where the lungs cannot get enough oxygen into the blood for the body's organs to function), and chronic kidney disease (a condition where the kidneys are damaged and cannot filter waste and extra fluid from the blood effectively, leading to a buildup of toxins in the body) . Patient 12’s EOC date was 8/17/2025 due to hospitalization. During a review of Patient 13’s Comprehensive Nursing Assessment: Primary/Secondary Diagnosis & Comorbidities, dated 3/28/2025, the Comprehensive Nursing Assessment: Primary/Secondary Diagnosis & Comorbidities indicated Alzheimer`s disease (a disease characterized by a progressive decline in mental abilities), Type 2 diabetes mellitus without complications (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN-high blood pressure) During a review of Patient 14’s Comprehensive Nursing Assessment: Primary/Secondary Diagnosis & Comorbidities, dated 4/6/2025, the Comprehensive Nursing Assessment: Primary/Secondary Diagnosis & Comorbidities indicated anxiety disorder (excessive worrying and fear), shortness of breath (SOB, difficulty breathing), and insomnia (trouble falling asleep or staying asleep). During a review of Patient 29’s “Personal Information,” undated, the “Personal Information” indicated the hospice agency admitted Patient 29, a 71-year-old female, on 7/2/2025 with diagnoses including multiple sclerosis (a disease that affects the central nervous system), HTN, and SOB. Patient 29’s EOC date was 7/25/2025 due to transfer to a different Hospice Agency.  During a review of Patient 11, Patient 12, Patient 13, Patient 14, and Patient 29’s “Discharge Summary,” undated, Patient 11, Patient 12, Patient 13, Patient 14, and Patient 29’s “Discharge Summary” indicated the discharge summaries were not specifically sent to the attending physician. During an interview on 9/17/2025 at 11:45 AM with the Director of Patient Care Services Designee (DPCS Designee), the DPCS Designee stated the discharge summary is not sent to the attending physician when the patient is discharged, and HospiceMD (patient care charting monitoring and management system used by the facility) does not document the route or when any documents were sent. During an interview with the DPCS Designee, on 9/17/2025 at 12:07 PM, the DPCS Designee stated failure to send the Discharge Summary to the attending physician placed Patient 11, Patient 12, Patient 13, Patient 14, and Patient 29 at risk of delayed treatment and aspects of the Patient's medical history may not be conveyed to the receiving physician.  During a review of the facility’s policy and procedure titled, “Discharge From Hospice Program,” undated, indicated “A copy of the discharge summary will be sent to the attending physician.”  f

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (CoP-conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people 65 years of age or more and for certain younger people with disabilities]) for Drugs and biologicals, medical supplies and durable medical equipment were met as follows: --- The HA failed to ensure the physician’s telephone order for the use of oxygen was received, read back, and entered by the Director of Patient Care Services (DPCS) Designee or the Registered Nurse (RN) Designee for three of 10 sampled patients (Patient 2, Patient 3 and Patient 8) in accordance with the HA’s policy and procedure (P&P).This failure had the potential to result in inappropriate and inaccurate ordering of medication and treatment for the hospice patients which can result in an unsafe patient care and increased risk in medical errors and adverse event that can lead to emergency hospitalization and may contribute to an avoidable traumatic death of the hospice patients. (Refer to L690).The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Drugs and biologicals, medical supplies and durable medical equipment are provided to patients certified to receive home health benefits.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the physician’s telephone order for the use of oxygen was received, read back, and entered by the Director of Patient Care Services (DPCS) Designee or the Registered Nurse (RN) Designee for three of 10 sampled patients (Patient 2, Patient 3 and Patient 8) in accordance with the HA’s policy and procedure (P&P). This failure had the potential to result in inappropriate and inaccurate ordering of medication and treatment for the hospice patients which can result in an unsafe patient care and increased risk in medical errors and adverse event that can lead to emergency hospitalization and may contribute to an avoidable traumatic death of the hospice patients.  On 9/12/2025, at 12:02 PM, the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient), in the presence of the agency’s Chief Financial Officer (CFO) and Director of Patient Care Services Designee (DPCSD) via telephone, for failure to ensure the physician’s telephone order for the use of oxygen was received, read back, and entered by a licensed nurse. On 9/17/2025 at 3:08 PM, the survey team lifted the IJ in the presence of the CFO and Office Administrator (OADM, a non-licensed staff) after implementation of an acceptable IJ Removal Plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) was verified. --- Findings:1. During a record review of Patient 2’s “Personal Information”, the “Personal Information” indicated the hospice agency (HA) admitted Patient 2, on 8/6/2025 with diagnoses included atherosclerotic heart disease (hardening of the arteries), shortness of breath (SOB, difficulty breathing), and anxiety (excessive worry).During a review of Patient 2’s “Visit Note”, authored by Licensed Vocational Nurse 1 (LVN 1), dated 9/8/2025, the “Visit Note” indicated Patient 2 had mild shortness of breath, mild abnormal lung sounds, and oxygen saturation of 91% on room air.  During a review of Patient 2’s “Physician Order,” dated 9/10/2025, the “Physician’s Order” indicated “Oxygen Concentrator five liter ([5L, unit of measurement],  Stationary [oxygen concentrators are designed for home use, providing a consistent and reliable supply of oxygen therapy]) with nasal cannula (a medical device consisting of a thin, flexible tube with two prongs that sit in a patient's nostrils to deliver supplemental oxygen)” the order indicated “phone order/read back order by Office Administrator (OADM), non-licensed staff)].”  During concurrent interview and record review, on 9/11/2025 at 10:07 AM, with the DPCS Designee, Patient 2’s “Physician Order,” dated 9/10/2025 was reviewed.  The “Physician’s Order” indicated, “Oxygen 5L (Stationary) via nasal cannula” was entered and “phone order/read back order by OADM.” The DPCS Designee stated the OADM was not licensed staff and was not qualified to receive and enter medications or treatment orders.  During a concurrent interview and record review, on 9/11/2025 at 11:39 AM, with the OADM, Patient 2’s order Physician Order,” dated 9/10/2025 was reviewed.  The “Physician’s Order” indicated, “Oxygen 5L (Stationary) via nasal cannula” was entered and “phone order/read back order by OADM.”  The OADM stated, “I entered the order for Oxygen 5L with nasal canula for Patient 2….”  During an interview on 9/11/2025 at 3:28 p.m. with the OADM, the OADM stated, the DPCS Designee instructed her on 9/10/2025 to enter a physician’s order for Patient 2’s oxygen.  2. During a review of Patient 3’s “Personal Information”, the “Personal Information” indicated the HA admitted Patient 3 on 8/11/2025, with diagnoses included heart failure (a heart disorder which causes the heart to not pump the blood efficiently), shortness of breath, and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance (patterns of behaviors, thoughts and moods that are considered unusual for a person’s age and context). During an interview on 9/10/2025 at 3:20 PM, with Patient 3’s caregiver (CG 3), CG 3 stated Patient 3 feels short of breath even with small movements. CG 3 stated she requested for Patient 3 to have an oxygen concentrator (medical device that delivers oxygen rich air to a person who has difficulty breathing) during the last nurse visit (9/8/2025) and the HA will be delivering Patient 3’s oxygen tomorrow (9/11/2025).  During a concurrent interview and record review on 9/11/2025 at 11:39 AM, with the OADM, Patient 3’s order indicated on 9/10/2025, Oxygen Concentrator 5 L (Stationary) with nasal cannula was entered and “phone order/read back order by OADM” The OADM stated, “I entered the order of Oxygen 5 L with nasal canula for Patient 3.”   During a record review on 9/11/2025 at 1:50 p.m., Patient 3’s Physician order, dated 9/10/2025, indicated the order “Oxygen 5 L via nasal cannula,” entered by Licensed Vocational Nurse 3 (LVN 3). During an interview on 9/11/2025 at 3:28 p.m. with the OADM, the OADM stated the DPCS Designee gave her (OADM) instructions on 9/10/2025 to enter a physician’s order for Patient 3’s oxygen. During an interview on 9/12/2025 on 9:54 a.m., with   LVN 3, LVN 3 stated the Patient 3’s daughter called her (LVN3) a couple days ago (9/10/2025) informing LVN 3 that Patient 3 needed oxygen. LVN 3 stated that Patient 3 has a diagnosis of heart failure and when a patient is diagnosed with heart failure, oxygen should be ordered and available. LVN 3 stated she (LVN3) took it upon herself to order the oxygen for Patient 3. LVN 3 stated she notified the DPCS but did not notify Patient 3’s physician. LVN 3 stated she notified everyone (DPCS and Medical Director) after she entered the order.  3. During a review of Patient 8’s “Personal Information”, the “Personal Information” indicated the HA admitted Patient 8, on 7/10/2025 with diagnoses that included Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), SOB, and dependence on supplemental oxygen. During a review of Patient 8’s “Physician Order”, dated 7/18/2025, the “Physician Order” indicated “order, note 2 L” the order indicated “phone order/ read back order by [OADM].” During an interview on 9/11/2025 at 11:10 with DPCS Designee, the DPCS Designee stated supplies such as oxygen concentrators were entered by OADM. The DPCS Designee stated having “2 L”, “5 L” or “with nasal cannula” are treatment orders. The DPCS Designee stated treatment orders should be entered by the licensed nurse (in general).During a concurrent interview and record review, on 9/12/2025 at 10:30 a.m., with the DPCS Designee, the facility’s Policy and Procedure (P&P), titled “Ordering Medication and Supplies”, dated 12/19/2024, was reviewed. the P&P indicated the following:  -    “the Director of Patient Care Services (DPCS) or designee may initiate written orders for medications and supplies based on the individualized plan care and patient assessment.” -    “The DPCS (or designee RN [Registered Nurse]) may draft written/ verbal orders for medications and supplies.”  -    “DPSC: Drafts orders, coordinates with physicians, ensures documentation, and oversees the process.” The P&P indicated “Hospice Nurse/ Case Manager: Monitors patient needs, communicates with DPCS, and implements finalized orders.”  -    “The DPSC is responsible for ensuring that orders are accurate, clinically appropriate, and compliant with regulations.”  The DPCS designee stated based on the P&P, the DPCS and RN designee may initiate orders for medication and supplies. The DPCS Designee stated based on the P&P, the DPCS and RN designee may draft written/verbal orders for medication and supplies.     1. During a record review of Patient 2’s “Personal Information”, undated, “Personal Information” indicated the Hospice agency admitted Patient 2, 89-year-old female, on 8/6/2025 with diagnoses that included Atherosclerotic heart disease (hardening of the arteries), shortness of breath (SOB, difficulty breathing), and anxiety (excessive worry).During a review of Patient 2’s “Visit Note”, authored by Licensed Vocational Nurse 1 (LVN 1), dated 9/8/2025, the “Visit Note” indicated Patient 2 had mild shortness of breath, mild abnormal lung sounds, and oxygen saturation of 91% on room air.  During a review of Patient 2’s “Physician Order,” dated 9/10/2025, the “Physician’s Order” indicated “Oxygen Concentrator 5L (Stationary) with nasal cannula” the order indicated “phone order/read back order by OADM (Office Administrator, non-licensed staff)].”  A concurrent interview and record review, on 9/11/2025 at 10:07 AM, with the DPCS Designee, Patient 2’s “Physician Order,” dated 9/10/2025 was reviewed.  The “Physician’s Order” indicated, “Oxygen 5L (Stationary) via nasal cannula” was entered and “phone order/read back order by OADM.” The DPCS Designee stated the OADM was not licensed staff and was not qualified to receive and enter medications or treatment orders.  A concurrent interview and record review, on 9/11/2025 at 11:39 AM, with the OADM, Patient 2’s order Physician Order,” dated 9/10/2025 was reviewed.  The “Physician’s Order” indicated, “Oxygen 5L (Stationary) via nasal cannula” was entered and “phone order/read back order by OADM.”  The OADM stated, “I entered the order for Oxygen 5L with nasal canula for Patient 2….”  During an interview on 9/11/2025 at 3:28 p.m. with the OADM, the OADM stated, the DPCS Designee instructed her on 9/10/2025 to enter a physician’s order for Patient 2’s oxygen.   2. During a review of Patient 3’s “Personal Information”, undated, the “Personal Information” indicated the Hospice agency admitted Patient 3 on 8/11/2025, an 86 year old female, with diagnoses that included heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), shortness of breath, and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance (patterns of behaviors, thoughts and moods that are considered unusual for a person’s age and context). During an interview on 9/10/2025 at 3:20 PM, with Patient 3’s caregiver (CG 3), CG 3 stated Patient 3 feels short of breath even with small movements. CG 3 stated she requested for Patient 3 to have an oxygen concentrator (medical device that delivers oxygen rich air to a person who has difficulty breathing) from the last nurse visit (9/8/2025) and the HA will be delivering Patient 3’s oxygen tomorrow (9/11/2025).  During a concurrent interview and record review on 9/11/2025 at 11:39 AM, with the OADM, Patient 3’s order indicated on 9/10/2025, Oxygen Concentrator 5 L (Stationary) with nasal cannula was entered and “phone order/read back order by OADM” The OADM stated, “I entered the order of Oxygen 5 L with nasal canula for Patient 3.”   During a review on 9/11/2025 at 1:50 p.m., Patient 3’s Physician order, dated 9/10/2025, indicated the order “Oxygen 5 L via nasal cannula,” entered by LVN 3. During an interview on 9/11/2025 at 3:28 p.m. with the OADM, the OADM stated the DPCS Designee gave her instructions on 9/10/2025 to enter a physician’s order for Patient 3’s oxygen.  During an interview on 9/12/2025 on 9:54 a.m., with   LVN 3, LVN 3 stated the daughter called her a couple days ago (9/10/2025) that Patient 3 needs oxygen sometime. LVN 3 stated Patient 3 has a diagnosis of heart failure and when a patient was diagnosed with heart failure, oxygen should be ordered and available for them. LVN 3 stated she took it upon herself to order the oxygen for Patient 3. LVN 3 stated she notified the DPCS but did not notify the physician. LVN 3 stated she notified everyone (DPCS and Medical Director) after she entered the order.   3. During a review of Patient 8’s “Personal Information”, undated, the “Personal Information” indicated the HA admitted Patient 8, 82 year-old female, on 7/10/2025 with diagnoses that included Alzheimer’s disease  (a disease characterized by a progressive decline in mental abilities), SOB, and dependence on supplemental oxygen. During a record review of Patient 8’s “Physician Order”, dated 7/18/2025, the “Physician Order” indicated “order, note: 2 L” the order indicated “phone order/ read back order by [OADM].” During an interview on 9/11/2025 at 11:10 with DPCS Designee, the DPCS Designee stated supplies such as oxygen concentrators were entered by OADM. The DPCS Designee stated having “2 L”, “5 L” or “with nasal cannula” are treatment orders. The DPCS Designee stated treatment orders should be entered by licensed nurse.During a concurrent interview and record review, on 9/12/2025 at 10:30 a.m., with the DPCS Designee, the facility’s Policy and Procedure (P&P), titled “Ordering Medication and Supplies”, dated 12/19/2024, was reviewed. the P&P indicated the following:  - “the Director of Patient Care Services (DPCS) or designee may initiate written orders for medications and supplies based on the individualized plan care and patient assessment.” - “The DPCS (or designee RN [Registered Nurse]) may draft written/ verbal orders for medications and supplies.”  - “DPSC: Drafts orders, coordinates with physicians, ensures documentation, and oversees the process.” The P&P indicated “Hospice Nurse/ Case Manager: Monitors patient needs, communicates with DPCS, and implements finalized orders.”  - “The DPSC is responsible for ensuring that orders are accurate, clinically appropriate, and compliant with regulations.”  The DPCS designee stated based on the P&P, the DPCS and RN designee may initiate orders for medication and supplies. The DPCS Designee stated based on the P&P, the DPCS and RN designee may draft written/verbal orders for medication and supplies.

Based on observation, interview and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to meet the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) for compliance with Federal, State, and local laws and regulations as follows: --- The Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the hospice agency's license is active to operate as a Hospice agency issued by the State of California Department of Public Health (CDPH). This failure had the potential risk to result in the provision of a substandard quality of care that could impact the health and safety to all patients certified to receive the hospice benefits. (Refer to L799). This systemic practice resulted in the failure of the Hospice Agency to deliver statutorily mandated (a legal obligation established by a statute or law) Compliance with Federal, State, and local laws and regulations to ensure health and safety, and quality of care are provided to patients certified to receive hospice benefits.

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the hospice agency's license is active to operate as a Hospice agency issued by the State of California Department of Public Health (CDPH).  This failure had the potential risk to result in the provision of a substandard quality of care that could impact the health and safety to all patients certified to receive the hospice benefits. --- Findings: During a concurrent observation and interview on 9/9/2025 at 11:20 AM, with the Chief Financial Officer (CFO), the State license issued by CDPH expired on 7/15/2025. The CFO stated he recently issued a check to pay the renewal application. During a review of a letter sent by CDPH to HA, dated 9/4/2025, the letter indicated CDPH has not received payment for the license renewal and the HA has a total unpaid amount of $5,560.50. During a concurrent interview and record review on 9/9/2025 at 11:40 AM, with the CFO, the facility’s check transaction register was reviewed. The check register indicated the facility issued check number 1888 to CDPH for license renewal on 7/29/2025 with the total amount of $5,055.00. The CFO stated the facility’s account did not reflect the check numbered 1888 has been charged. The CFO stated no documentation or proof of evidence the check number 1888 was mailed to CDPH for license renewal. During a concurrent interview and record review on 9/9/2025 at 2 PM with the CFO, the HA mail with shipping label addressed to CDPH, dated 9/9/2025 with expected delivery date of 9/10/2025. The CFO stated a new check was issued to pay the remaining balance to renew the license of the HA. During an interview on 9/10/2025 at 1:30 PM, with the CFO stated the mail was delivered. The CFO stated he spoke with someone from CDPH and was informed that the license renewal process may take 10 business days. During a concurrent interview and record review on 9/17/2025 at 11:46 AM, with the CFO, a copy of check number 1962, dated 9/8/2025 was reviewed. The check indicated the amount of $6,100.00 addressed to CDPH for license renewal 550006540 was received on 9/16/2025. During a concurrent interview and record review on 9/17/2025 at 11:46 AM, with the CFO, the facility’s policy and procedure (P&P) regarding HA licensing and renewal was requested. The CFO was unable to provide a P&P related to license renewal.

Upon patient record review 1 of 14 (Patient #11) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. #11-The initial psychosocial assessment was not completed within 5 calendar days of stare of care.

Upon client record review, 1 of 14 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. #2-LVN tested patient blood glucose on visits dated 8/29/24 and 9/6/24. There was no order for blood glucose testing on the plan of care.