Every finding on record at Aid & Care Hospice, Inc

Based on interview and record review, the hospice failed to ensure one of eight sampled patients (Patient 9) was given information that was explained in a language that she could understand about hospice services.   This failure posed a risk of not meeting Patient 9’s needs of care and well-being.Findings: --- Review of the hospice's P&P titled Patient Bill of Rights/ Responsibilities revised 4/2020 showed The Patient Bill of Rights/Responsibilities will be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services.  This explanation will be in a language and manner he/she can reasonably be expected to understand.  Patient and family/caregiver responsibilities will be explained upon admission and as needed.  In the event a communication barrier exists, if possible, special devices or interpreters will be made available.  Written information will be provided to patients in the predominant languages of the population served.Clinical record review for Patient 9 was initiated on 12/10/25.  The clinical record showed the SOC was 12/11/24.  The patient was certified for hospice services during the certification periods from 12/11/24 to 3/10/24, 3/11/25 to 6/8/25, 6/9/25 to 8/7/25, 8/8/25 to 10/6/25, 10/7/25 to 12/5/25, and 12/6/25 to 2/3/25.  Patient 9's primary diagnosis was unspecified chronic kidney disease.Review of Patient 9's Hospice Coverage and Rights, Informed Consent on telehealth visit, physician's Care, Photography Consent Form, HIPPA Notice of Privacy Practices, Hospice Admission Service Agreement, Advance Directives Information Sheet and  Election of Medicare Hospice Benefit dated 12/11/25, showed all of them were in English.Review of Patient 9's SN nursing clinical notes showed Patient 9 was oriented to name/person, time, and place.On 12/15/25 at 1038 hours, a telephone interview was conducted with Patient 9.  Patient 9 was asked how the services rendered by the hospice.  Patient 9 stated no person came who talked about her health on hospice and stated further she always needed a Spanish translator for complete understanding on any kind of conversation or documentation.  Informed Patient 9 that this writer will be calling her back with a Spanish translator on another phone line. On 12/15/25 at 1405 hours, a follow-up phone interview was conducted on Patient 9  with a Spanish translator from the translator services on the phone.  Patient 9 was asked if she was satisfied with hospice services.  Patient 9 stated she was satisfied with the services.  Patient 9 was further asked if hospice care was explained to her during the first nurse visit.  Patient 9 stated the reason why she was in hospice was not explained and she did not even know why she was in hospice and was not able to recall the nurse’s name at that time.  Patient 9 further stated she received a letter stating that she was in hospice care, and she surprised why she was in hospice care. On 12/16/25 at 1502 hours, a concurrent clinical record review and interview was conducted with RN 1.  RN 1 was asked about the hospice process when a patient’s primary language was not English but Spanish.  RN 1 stated there should be Spanish language translator and the hospice had staff available for translation.  RN 1 was informed of the following: Patient 9 did not know why she was in hospice, Patient 9’s consent form was in English and not Spanish, and there was no documentation that if the patient understood all the hospice care and if the translation was used in all SN visits.  RN 1 was further asked if the hospice had Spanish consent forms.  RN 1 acknowledged everything should have been explained well to Patient 9 and would further inquire with the hospice staff if they had the Spanish consent forms.On 12/16/25 at 1518 hours, an interview was conducted with the Administrator.  The Administrator was informed on Patient 9’s concern that she did know why she was in hospice care, was also asked if they had translators, and if they use consents in Spanish language.  The Administrator stated they had Spanish speaking staff available for translation and verified the consents in Spanish language should have been used for Patient 9.

Based on observation, record review and interview, the hospice failed to ensure the comprehensive assessments were completed and updated to identify the patient's need for hospice care and services as evidenced by:Findings: --- 1. The hospice failed to include all current medications and the medication profile was reviewed and updated to reflect the current medications. Cross reference to L530.2. The hospice failed to ensure the updated comprehensive assessments were completed no less than every 15 days and included the changes that had occurred since the initial assessment, information on the patient’s progress, and reassessment of the patient’s responses.  Cross reference to L533.The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the update of the medications and comprehensive assessments to meet the patients' care needs.

Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments were completed no less than every 15 days and included the changes that had occurred since the initial assessment, information on the patient’s progress, and reassessment of the patient’s responses for eight of eight sampled patients (Patients 1, 2, 6, 9, 15, 16, 17, and 19).  This failure created the risk of not addressing the care needs for these patients.Findings: --- Review of Patient 15’s clinical record was initiated on 12/10/25.  The clinical record showed the SOC was 9/24/25.   The patient was certified for hospice services during the certification period from 9/4/25 to 12/22/25.Review of Patient 15's MD order dated 9/24/25 showed skilled nurse may perform rectal examination, manual removal of impaction and follow up enema  as needed. Record of Patient 15's  Sn visit notes from 10/30/25 to 11/27/25 showed no indication of bowel movement issues. However, review of the IDT Plan of Care & Review of Comprehensive Assessment dated 11/27/25 and 12/11/25 failed to show an updated assessment was completed to reflect Patient 15's progress or decline on bowel movement impaction.On 12/16/25 at 1455 H, a concurrent clinical record review and an interview was conducted with RN 1.  RN 1 was asked if there was any documentation for Patient 15 on any revised plan of care reporting progress or decline on bowel movement impaction.  RN 1 acknowledged above findings and verified it should have been done. . The hospice failed to update the comprehensive assessment for Patients 1,2,6, 9,15,15,17 and 19 for example: 1. Review of Patient 1’s clinical record was initiated on 12/10/25.  The clinical record showed the SOC was 11/14/25.  The patient was certified for hospice service during the certification period from 11/14/25 to 2/11/26.  Review of the Nursing Clinical Note dated 11/21/25 showed the RN 2 had performed a cardiovascular assessment.  The assessment showed the patent heart sound was irregular, fatigue easily and a +2 pitting edema to the bilateral lower extremities. However, review of the IDT Plan of Care & Review of Comprehensive Assessment dated 11/27/25 failed to show an updated assessment was completed to reflect the patients cardiovascular concerns.      crossed ref. L- 545.On 12/16/25 at 1528 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings. Review of the clinical records for Patients 1, 2, 6, 9, 15, 16, 17 and 19 showed the IDT notes were incomplete as several sections of the notes were blank.  Cross reference to L552.  There were no documented evidence the comprehensive assessment was updated by the IDT no less than every 15 days for these patients.  For example: 1.  Review of Patient 1’s clinical record was initiated on 12/10/25.  The clinical record showed the SOC was 11/14/25.  The patient was certified for hospice service during the certification period from 11/14/25 to 2/11/26.  Review of the Nursing Clinical Note dated 11/21/25, showed RN 2 had performed a cardiovascular assessment.  The assessment showed the patient's heart sound was irregular.  The patient was fatigue easily and had a +2 pitting edema to the bilateral lower extremities. However, review of the IDT Plan of Care & Review of Comprehensive Assessment dated 11/27/25, failed to show an updated assessment was completed to reflect the patient's cardiovascular concerns.      In addition, the IDT Plan of Care & Review of Comprehensive Assessment also included the following sections: - Medication profile review, -RN/LVN Report, -Spiritual Care report, -SW report,- Volunteer Report, -Eligibility Assessment,-This plan of care has been discussed with and presented to the patient and caregiver(s) and -The following IDT members/updated/reviewed the interdisciplinary team plan of care. However, these sections were left blank.  There was no documented evidence the IDT had updated the comprehensive assessment On 12/16/25 at 1528 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.2.  Review of Patient 15’s clinical record was initiated on 12/10/25.  The clinical record showed the SOC was 9/24/25.   The patient was certified for hospice services during the certification period from 9/4/25 to 12/22/25.Review of Patient 15's MD order dated 9/24/25, showed SN may perform rectal examination, manual removal of impaction, and follow up enema  as needed. Record of Patient 15's  Nursing Clinical Notes from 10/30/25 to 11/27/25, showed no indication of bowel movement issues. However, review of the IDT Plan of Care & Review of Comprehensive Assessment dated 11/27/25 and 12/11/25, failed to show an updated assessment was completed to reflect Patient 15's progress or decline on bowel movement impaction.On 12/16/25 at 1455 hours, a concurrent clinical record review and an interview was conducted with RN 1.  RN 1 was asked if there was any documentation for Patient 15 on any revised plan of care reporting progress or decline on bowel movement impaction.  RN 1 acknowledged above findings and verified it should have been done. .

Based on interview and record review, the hospice failed to ensure the IDT, care planning, and coordination of services were provided to meet the patient’s care needs as evidenced by:Findings: --- 1.  The hospice failed to ensure that care and services were provided in accordance with an individualized written plan of care.  Cross reference to L543.2.  The hospice failed to ensure the written POCs were developed to reflect the patient and family goals and interventions based on the problems identified.  Cross reference to L545.3.  The hospice failed to ensure the initial and revised POC included a detailed statement of the scope and frequency of services necessary.  Cross reference to L547.4.  The hospice failed to ensure the IDG had reviewed/revised the patients' POCs no less frequently than every 15 calendar days.  Cross reference to L552.5.  The hospice failed to ensure the revised POC included the patient's updated comprehensive assessment.  Cross reference to L553.6.  The hospice failed to ensure the IDG maintained the responsibility for directing and supervising the care and services provided.  Cross reference to L554.The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the interdisciplinary team, care planning and coordination of services to meet the patients' care needs.

Based on interview and record review, the hospice failed to ensure the initial and revised POC included a detailed statement of the scope and frequency of services necessary for five of eight sampled patients (Patients 1, 6, 9, 17, and 19).   This failure had the potential of not providing necessary services for these patients.Findings: --- 3. Review of Patient 6’s clinical record was initiated on 12/10/25.  The clinical record showed the SOC was 11/13/24.   The patient was certified for hospice services during the certification period from 11/8/25 to 1/6/26.Review of the certification of Plan of care period 11/8/25 to 1/6/26, showed a section for orders for discipline and treatments.  The disciplines included SN visit.  However, there was no documented evidenced of the SN visit frequency and the orders for treatment as the sections were left blank. In addition, review of the clinical record showed the SN visit the patient one time a week on Week 6.However, there was no documented evidenced of the MD order for the SN visit frequency and SN visit. On 12/16/25 at 1345 hours, an interview and concurrent clinical record review was conducted with RN 1   RN 1 was informed and acknowledged the findings. RN 1 verified the findings. 4. Review of Patient 9's clinical record was initiated on 12/10/25.  The clinical record showed the SOC was 12/11/24.   The patient was certified for hospice services during the certification period from 12/6/25 to 2/3/226.Review of the certification of Plan of care period 12/6/25 to 2/3/26, showed a section for orders for discipline and treatments.  The disciplines included SN visit.  However, there was no documented evidenced of the SN visit frequency and the orders for treatment as the sections were left blank. In addition, review of the clinical record showed the SN visit the patient one time a week on Week 2 (12/12/25). However, there was no documented evidenced of the MD order for the SN visit frequency and SN visit.On 12/16/25 at 1345 hours, an interview and concurrent clinical record review was conducted with RN 1   RN 1 was informed and acknowledged the findings. RN 1 verified the findings.  5.  Review of Patient 17’s clinical record was initiated on 12/10/25.  The clinical record showed the SOC was 12/3/24.  The patient was certified for hospice services during the certification period from 12/3/24 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, 9/29/25 to 11/27/25 and 11/28/25 to 1/26/25. Review on Patient 17’s Certification Plan of Care for the certification period from 11/28/25 to 1/26/25 showed a section for orders for discipline and treatments.  The disciplines included SN visit.  However, there was no documented evidenced of the SN visit frequency and the orders for treatment as the sections were left blank. On 12/16/25 at 1417 hours, a concurrent clinical record review on Patient 17 and an interview was conducted with RN 1.  RN 1 was informed on the above findings and acknowledged it should have been completed. 6.  Review on Patient 19’s clinical record was initiated on 12/10/25.  The clinical record showed the SOC was 10/2/25.  The patient was certified for hospice services during the certification period from 10/2/24 to 12/30/24, 12/31/24 to 3/30/25, 3/31/25 – 5/29/25, 5/30/25 -7/28/25, 7/29/25 – 9/26/25, 9/27/25 to 11/25/25 and 11/26/25 to 1/24/25.Review on Patient 19’s Certification Plan of Care for the certification period from 11/26/25 to 1/24/25 showed a section for orders for discipline and treatments.  The disciplines included SN visit.  However, there was no documented evidenced of the SN visit frequency and the orders for treatment as the sections were left blank. On 12/16/25 at 1435 hours, a concurrent clinical record review on Patient 17 and an interview was conducted with RN 1.  RN 1 was informed of the above findings and acknowledged it should have been completed.   1.Review of Patient 1’s clinical record was initiated on 12/10/25.  The clinical record showed the SOC was 11/14/25.  The patient was certified for hospice service during the certification period from 11/14/25 to 2/11/26.  The Initial Orders and Plan of Care for the certification period from 11/14/25 to 2/11/26 showed a section for orders for discipline and treatments.  The disciplines included SN visit.  However, there was no documented evidenced of the SN visit frequency and the orders for treatment as the sections were left blank. In addition, review of the clinical record showed the SN visit the patient one time a week on Weeks 1 and 3.However, there was no documented evidenced of the MD order for the SN visit frequency. On 12/16/25 at 1528 hours, an interview and concurrent clinical record review was conducted with the Administrator.   The Administrator was informed and acknowledged the findings. 1.Review of Patient 1’s clinical record was initiated on 12/10/25.  The clinical record showed the SOC was 11/14/25.  The patient was certified for hospice service during the certification period from 11/14/25 to 2/11/26.  The Initial Orders and Plan of Care for the certification period from 11/14/25 to 2/11/26, showed the order section for discipline and treatments.  The disciplines included SN visit.  However, there was no documented evidenced of the SN visit frequency and the treatment order sections were left blank. In addition, review of the clinical record showed the SN visited the patient one time a week during Week 3 (11/23/25 to 11/29/25).However, there was no documented evidenced of the MD order for the SN visit frequency. On 12/16/25 at 1528 hours, an interview and concurrent clinical record review was conducted with the Administrator.   The Administrator was informed and acknowledged the findings. 2. Review of Patient 6’s clinical record was initiated on 12/10/25.  The clinical record showed the SOC was 11/13/24.   The patient was certified for hospice services during the certification period from 11/8/25 to 1/6/26.Review of the certification of Plan of care period 11/8/25 to 1/6/26, showed the order sections for discipline and treatments.  The disciplines included SN visit.  However, there was no documented evidenced of the SN visit frequency and the treatment orders were left blank. In addition, review of the clinical record showed the SN visited the patient one time a week during Week 6 (12/7/25-12/22/25).However, there was no documented evidence of the MD order for the SN visit and frequency. On 12/16/25 at 1345 hours, an interview and concurrent clinical record review was conducted with RN 1   RN 1 was informed and verified the findings. 3. Review of Patient 9's clinical record was initiated on 12/10/25.  The clinical record showed the SOC was 12/11/24.   The patient was certified for hospice services during the certification period from 12/6/25 to 2/3/226.Review of the certification of Plan of care period 12/6/25 to 2/3/26, showed the order sections for discipline and treatments.  The disciplines included SN visit.  However, there was no documented evidence of the SN visit frequency and treatment as the sections were left blank. In addition, review of the clinical record showed the SN visit the patient one time a week during Week 2 (12/7/25-12/13/25). However, there was no documented evidence of the MD order for the SN visit and frequency.On 12/16/25 at 1345 hours, an interview and concurrent clinical record review was conducted with RN 1   RN 1 was informed and verified the findings. 4.  Review of Patient 17’s clinical record was initiated on 12/10/25.  The clinical record showed the SOC was 12/3/24.  The patient was certified for hospice services during the certification period from 12/3/24 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, 9/29/25 to 11/27/25 and 11/28/25 to 1/26/25. Review on Patient 17’s Certification Plan of Care for the certification period from 11/28/25 to 1/26/25, showed the order sections for discipline and treatments.  The disciplines included SN visit.  However, there was no documented evidence of the SN visit frequency and treatment orders as the sections were left blank. On 12/16/25 at 1417 hours, a concurrent clinical record review and an interview was conducted with RN 1.  RN 1 was informed of the above findings and stated it should have been completed. 5.  Review on Patient 19’s clinical record was initiated on 12/10/25.  The clinical record showed the SOC was 10/2/25.  The patient was certified for hospice services during the certification period from 10/2/24 to 12/30/24, 12/31/24 to 3/30/25, 3/31/25 to 5/29/25, 5/30/25 to 7/28/25, 7/29/25 to 9/26/25, 9/27/25 to 11/25/25, and 11/26/25 to 1/24/25.Review on Patient 19’s Certification Plan of Care for the certification period from 11/26/25 to 1/24/25, showed the order sections for discipline and treatments.  The disciplines included SN visit.  However, there was no documented evidenced of the SN visit frequency and treatment orders as the sections were left blank. On 12/16/25 at 1435 hours, a concurrent clinical record review on Patient 17 and an interview was conducted with RN 1.  RN 1 was informed of the above findings and verified it should have been completed.

Based on interview and record review, the hospice failed to ensure the IDT maintained the responsibility for directing and supervising the care and services provided for one of eight sampled patients (Patient 2).  This failure created the risk of not addressing the care needs for these patients. --- Findings:Review of the hospice's P&P titled Care/Service Coordination dated 4/20 showed all organization personnel involved in patient care/service, including those providing contracted services, will have access to the plan of care/service and all other relevant patient information to ensure coordination and continuity.  All personnel will be knowledgeable regarding patient needs, goals of care, and services.Review of Patient 2’s clinical record was initiated on 12/10/25.  The clinical record showed the SOC was 10/28/25.   The patient was certified for hospice services during the certification period from 10/28/25 to 1/25/26.On 12/10/25 at 1035 hours, an interview was conducted with the Patient 2's family member and LVN 1.  The family member was upset and expressed concern that the nurse did not visit at the scheduled time. The family member stated she had to drive from their home to the patient’s home to open the door, as the patient was unable to do so.  Patient 2 was not able to walk.  The family member mentioned that they had already informed the nurse and the office last month regarding the nurse visit.  They preferred that the nurse coordinated the visit with them in advance.  They reported an occasion when the nurse did not arrive at the scheduled time and did not inform them ahead of time. The family member also asked LVN 1 if they could speak with hospice staff to discuss the medication prescribed by the hospice physician and their primary physician.  Later, LVN 1 stated he would inform the office regarding the concern.On 12/10/25 at 1400 hours, an interview and concurrent medical record review was conducted with Receptionist 1.  Receptionist 1 was asked if any concerns were expressed by the family member of Patient 2.  The receptionist stated that around last month, RN 3 called the office and informed her that Patient 2's family member had expressed concern regarding the nurse visits and requested to be informed when the nurse would visit the patient, since the patient was unable to open the door.  Receptionist 1 was asked if there were any communication notes regarding the family’s request for the nurse visits. Receptionist 1 stated she was unable to locate the notes and confirmed that it should have been documented. Receptionist 1 verified the findings.     On 12/10/25 at 1430 hours, an interview was conducted with RN 3.  RN 3 was asked if the patient’s family member had expressed any concern regarding the nurse visits.  RN 3 stated the family wanted to know the visit time in advance so they could assist the patient in opening the door as Patient 2 was bedridden. RN 3 stated she communicated this to the office but was unsure if it was documented in the communication log.  RN 3 stated the staff should have documented in the communication log or notes to coordinate care with the family and patient.On 12/16/25 at 1345 hours, an interview was conducted with RN 1.  RN 1 was asked if the nurse had communicated with the office regarding the home visit on 12/10/25, for the resident’s concern about the nurse visits and the request to speak with the hospice staff regarding medication from hospice and Patient 2’s family member.  RN 1 was unable to locate any documentation on 12/10/25, addressing the coordination of care for Patient 2.  RN 1 stated the nurse should have documented in the communication log, notes, or visit notes. RN 1 verified the findings.

Based on interview and record review, the hospice failed to manage and administer its resources to provide the hospice care and service as evidenced by:  Findings: --- The hospice's GB and Administrator failed to be responsible for the day-to-day operations of the organization and maintain the administrative responsibility.  Cross reference to L651.  The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the Administrator to assumes responsibility for the management of the hospice and the provision of all hospice services to meet the patients' care needs.

Based on interview and record review, the Medical Director failed to assume overall responsibility for the medical component of the hospice's patient care program.   This failure created a risk of not meeting the patients and families care needs.Findings: --- 1.  The hospice failed to ensure the updated comprehensive assessments were completed no less than every 15 days and included the changes that had occurred since the initial assessment, information on the patient’s progress, and reassessment of the patient’s responses for eight of eight sampled patients (Patients 1, 2, 6, 9, 15, 16, 17, and 19).  Cross reference to L533.2.  The IDG failed to review/revise the patients' POCs no less frequently than every 15 calendar days for eight of eight sampled patients (Patients 1, 2, 6, 9, 15, 16, 17, and 19).  Cross reference L552.  3.   The hospice failed to ensure the IDG maintained the responsibility for directing and supervising the care and services provided.  Cross reference to L554.4.   The hospice Administrator failed to be responsible for the day-to-day operations of the organization and maintain the administrative responsibility.  Cross reference to L6515.   The hospice failed to ensure the Medical Director or physician completed the written certification of terminal illness for four of eight sampled patients.  Cross reference to L668.On 12/16/25 at 1138 hours, a telephone interview was conducted with the Medical Director.  The Medical Director was asked as to who was overseeing the hospice since the DPCS was on leave and the DPCS Designee resigned.  The Medical Director replied he was the one overseeing but needed help.  The Medical Director also replied, the concern was shared with the owners of the agency.  The Medical Director reported the frustrations for the hospice service provided by the hospice.  The Medical Director also stated he validated the findings/concerns that was discussed during the telephone interview.

Based on interview and record review, the hospice failed to ensure the revised POCs included the patients’ progress toward goals specified in the POCs for five of eight sampled patients (Patients 6, 9, 17, 18, and 19). This failure created the risk of not identifying the care needs and providing necessary care and services to meet the care needs for these patients.Findings: --- 1. Review of Patient 18’s clinical record was initiated on 10/2225.  The clinical record showed the SOC was 5/1/25.  The patient was certified for hospice service during the certification periods from 5/1/25 to 7/29/25 and 7/30/25 to 10/27/25.   The IDT Plan of Care & Review of Comprehensive Assessment dated 10/2 and 10/16/25, showed the patient's identified problems included cardiac output/circulatory function.  The goal was established for the identified problem.  However, there was no documented evidenced the POC included the patients' progress towards the goal for the care plan problem identified. On 10/24/25 at 0950 hours, a telephone interview and concurrent clinical record review was conducted with the QA/LVN.  The QA/LVN was informed and acknowledged the finding. 2.  Review of Patient 19’s clinical record was initiated on 10/2225.  The clinical record showed the SOC was 10/2/24.  The patient was certified for hospice service during the certification periods from 10/2/24 to 12/30/24, 12/31/24 to 3/30/25, 3/31/25 to 5/29/25, 5/30/25 to 7/28/25, 7/29/25 to 9/26/25 and 9/27/25 to 11/25/25. The IDT Plan of Care & Review of Comprehensive Assessment dated 10/2 and 10/16/25, showed the patient's identified problems included cardiac output/circulatory function.  The goal was established for the identified problem.  However, there was no documented evidenced the POC included the patients' progress towards the goal for the care plan problem identified. On 10/24/25 at 0933 hours, a telephone interview and concurrent clinical record review was conducted with the QA/LVN.  The QA/LVN was informed and acknowledged the finding. 3.  Review of Patient 17's clinical record was initiated on 10/22/25.  The clinical record showed the SOC was 12/3/24.  The patient was certified for hospice services during the periods from 12/3/24 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25 and 9/29/25 to 11/27/25.The IDT Plan of Care & Review of Comprehensive Assessment dated 10/9/25 showed the patient's identified problems included cardiac output/circulatory function.  The goal was established for the identified problem.  However, there was no documented evidenced the POC included the patients' progress towards the goal for the care plan problem identified. On 10/24/25 at 0944 hours, a telephone interview and concurrent closed record review was conducted with the QA/LVN.  The QA/LVN was informed and acknowledged the findings.   crossed ref L -548 xx. Review of Patient 6’s clinical record was initiated on 10/23/25. The clinical record showed the SOC was 11/13/24. The patient was certified for hospice services during the period from 9/9/25 to 11/7/25.The IDT Plan of Care & Review of the Comprehensive Assessment dated 10/2/25 and 10/16/25 showed, the patient’s identified problems included impaired gas exchange. The goal was established for the identified problem.*However, there was no documented evidence the POC included the patient’s progress towards the goals for the care plan problem identified.On 10/23/25 at 1053 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN acknowledged and confirmed the findings.xx. Review of Patient 9’s clinical record was initiated on 10/23/25. The clinical record showed SOC was 12/11/24. The patient was certified for hospice during the period from 8/8/25 to 10/6/25 and 10/7/25 to 12/5/25.The IDT Plan of Care & Review of the Comprehensive Assessment dated 10/2/25 and 10/16/25  showed hospice identified patient care problems, including cardiac output/circulatory function, impaired activity and mobility and pain/discomfort. The goals were established for these identified problems.*However, there was no documented evidence the POCs included the patient’s progress towards the goals for each of the care plan problem identified.On 10/23/25 at 1100 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN acknowledged and confirmed the findings. 1. Review of Patient 18’s clinical record was initiated on 10/22/25.  The clinical record showed the SOC was 5/1/25.  The patient was certified for hospice service during the certification periods from 5/1/25 to 7/29/25 and 7/30/25 to 10/27/25.   The IDT Plan of Care & Review of Comprehensive Assessment dated 10/2 and 10/16/25, showed the patient's identified problems included cardiac output/circulatory function.  The goal was established for the identified problem.  However, there was no documented evidence the POC included the patient’s progress towards the goal for the care plan problem identified. On 10/24/25 at 0950 hours, a telephone interview and concurrent clinical record review was conducted with the QA/LVN.  The QA/LVN was informed and acknowledged the finding.2.  Review of Patient 19’s clinical record was initiated on 10/22/25.  The clinical record showed the SOC was 10/2/24.  The patient was certified for hospice service during the certification periods from 10/2/24 to 12/30/24, 12/31/24 to 3/30/25, 3/31/25 to 5/29/25, 5/30/25 to 7/28/25, 7/29/25 to 9/26/25, and 9/27/25 to 11/25/25. The IDT Plan of Care & Review of Comprehensive Assessment dated 10/2 and 10/16/25, showed the patient's identified problem included cardiac output/circulatory function.  The goal was established for the identified problem.  However, there was no documented evidence the POC included the patients' progress towards the goal for the care plan problem identified. On 10/24/25 at 0933 hours, a telephone interview and concurrent clinical record review was conducted with the QA/LVN.  The QA/LVN was informed and acknowledged the finding. 3.  Review of Patient 17's clinical record was initiated on 10/22/25.  The clinical record showed the SOC was 12/3/24.  The patient was certified for hospice services during the periods from 12/3/24 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25, 7/31/25 to 9/28/25, and 9/29/25 to 11/27/25.The IDT Plan of Care & Review of Comprehensive Assessment dated 10/9/25, showed the patient's identified problem included cardiac output/circulatory function.  The goal was established for the identified problem.  However, there was no documented evidence the POC included the patient’s progress towards the goal for the care plan problem identified. On 10/24/25 at 0944 hours, a telephone interview and concurrent closed record review was conducted with the QA/LVN.  The QA/LVN was informed and acknowledged the findings.    4.   Review of Patient 6’s clinical record was initiated on 10/23/25. The clinical record showed the SOC was 11/13/24. The patient was certified for hospice services during the period from 9/9/25 to 11/7/25.The IDT Plan of Care & Review of the Comprehensive Assessment dated 10/2/25 and 10/16/25, showed the patient’s identified problem included impaired gas exchange. The goal was established for the identified problem.*  However, there was no documented evidence the POC included the patient’s progress towards the goal for the care plan problem identified.On 10/23/25 at 1053 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN acknowledged and confirmed the findings.5. Review of Patient 9’s clinical record was initiated on 10/23/25. The clinical record showed SOC was 12/11/24. The patient was certified for hospice during the period from 8/8/25 to 10/6/25 and 10/7/25 to 12/5/25.The IDT Plan of Care & Review of the Comprehensive Assessment dated 10/2/25 and 10/16/25, showed patient’s identified problems included cardiac output/circulatory function, impaired activity and mobility, and pain/discomfort. The goals were established for these identified problems.*  However, there was no documented evidence the POCs included the patient’s progress towards the goals for each of the care plan problems identified.On 10/23/25 at 1100 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN acknowledged and confirmed the findings.

Based on interview and record review, the hospice failed to ensure the discharge summary was sent to the physician after the patient revoked hospice services for one of eight sampled patients (Patient 10).  This failure had the potential of not communicating the post-discharge care needs of this patient to the physician.Findings: --- The hospice's P&P titled Discharge from Hospice Program revised 4/2020 showed the Case Manager will ensure that necessary paperwork is completed at the time of discharge.  This will include a signed revocation form.   A copy of the discharge summary will be sent to the attending physician.Review of Patient 10's closed clinical record was initiated on 10/22/25.  The clinical record showed the SOC was 11/13/24.  The patient was certified for hospice services during the periods from 11/13/24 to 2/10/25, 2/11/25 to 4/11/25, 4/12/25 to 6/10/25, 6/11/25 to 8/9/25, and 8/10/25 to 10/8/25.  The patient was discharged from hospice services on 10/8/25.The Physician Order Details dated 10/8/25, showed the “patient discharge from the hospice revoked services.”The End of Care Summary dated 10/8/25, and the Hospice End of Care Summary dated 10/8/25, showed the section for the discharge summary sent to the physician was blank.Review of the closed clinical record failed to show documented evidence of a discharge summary was sent to the attending physician as per the hospice's P&P.On 10/24/25 at 0925 hours, a telephone interview and concurrent closed record review was conducted with the QA/LVN.  The QA/LVN was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to develop a written emergency communication plan that outlines how it would coordinate patient care within the hospice, across healthcare providers, and with state and local public health departments and emergency management systems.  This failure had the potential in the delay of coordination and delivery of care to the patients during an emergency. Findings: --- Review of The hospice’s Emergency Plan was initiated on 9/8/25.  The plan did not include an emergency preparedness communication plan that outlines how it would coordinate patient care within the hospice, across healthcare providers, and with state and local public health departments and emergency management systems. On 9/9/25 at 1530 hours, an interview with Receptionist 1 was conducted.  Receptionist 1 was informed and confirmed that the facility’s Emergency Plan did not include an emergency preparedness communication plan. During an interview with the Administrator on 9/9/25 at 1600 hours, the Administrator was informed and verified the above finding.

Based on interview and record review, the hospice failed to develop and maintain an emergency preparedness communication plan that included the names and contact information of staff, entities providing services under arrangement, patients' physicians, other facilities and volunteers.  This failure had the potential for not coordinating patient care timely. Findings: --- Review of the Emergency Preparedness Plan was initiated on 9/8/25.  The plan did not include the names and contact information for staff, entities providing services under arrangement, patients' physicians, other facilities, and volunteers.On 9/9/25 at 1500 hours, an interview and concurrent hospice document review was conducted with Receptionist 1.  Receptionist 1 was informed and acknowledged that the hospice did not have a communication plan that included the names and contact information for staff, entities providing services under arrangement, patients' physicians, other facilities, and volunteers.  During an interview with the Administrator on 9/9/25 at 1600 hours, the Administrator was informed and verified the finding.

Based on interview and record review, the hospice failed to develop and maintain an emergency preparedness training and testing program that was based on the emergency plan, its risk assessment, and communication plan.  This failure had the potential for not providing appropriate to the patients during an emergency.   Findings: --- Review of the Emergency Preparedness Plan was initiated on 9/8/25.  The plan failed to show documented evidence the emergency preparedness training and testing program were completed. On 9/9/25 at 1530 hours, an interview and concurrent hospice document review was conducted with Receptionist 1.  Receptionist 1 stated she were not aware of any emergency preparedness training and testing program completed. During an interview with the Administrator on 9/9/25 at 1600 hours, the Administrator was informed and verified the finding.

Based on interview and record review, the hospice failed to participate in a full-scale community-based exercise or an additional tabletop exercise to test the effectiveness of its emergency preparedness program, as required by regulation.  This failure had the potential to negatively impact the hospice's ability to respond effectively in an actual emergency situation. Findings: --- Review of the hospice’s Emergency Preparedness plan was initiated on 9/8/25.  There was no documented evidence the hospice had participated in at least one other full-scale community-based exercise or tabletop exercise. On 9/9/25 at 1530 hours, an interview and concurrent hospice document review was conducted with Receptionist 1. Receptionist 1 stated she was unable to provide documented evidence the hospice had participated in a full-scale community-based exercise or a tabletop exercise.  During an interview with the Administrator on 9/9/25 at 1600 hours, the administrator was informed and verified the finding.

Based on interview and record review, the hospice failed to ensure a written notice of the patient's rights and responsibilities was provided to one of 14 sampled patients (Patient 4) in a language and manner that the patient understands.  This failure had the potential of violating the patient's rights and not providing quality of care and services to this patient.  Findings: --- The hospice's P&P titled Patient Bill of Rights/Responsibilities revised 4/2020 showed upon admission, the admitting clinician will provide each patient or his/her representative with a written copy of the Patient Bill of Rights/Responsibilities in advance of furnishing care.  The Patient Bill of Rights/Responsibilities will be explained (verbally/orally) and distributed to the patient prior to the initiation  of services.  This explanation will be in a language and manner he/she can reasonably be expected to understand.  On 9/2/25 at 1057 hours, a telephone call was placed to Patient 4.  Patient 4 picked up the phone and stated, "No English, only Spanish."  The patient gave the phone to an English-speaking caregiver.   Review of Patient 4's closed clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/15/25.  The patient was certified for hospice services during the period from 5/5/25 to 8/12/25.  The patient was discharged from the hospice on 7/21/25. Review of Patient 4's face sheet showed the primary language was Spanish.  Review of Patient 4's Election of Medicare Hospice Benefit and Patient's Bill of Rights and Responsibilities showed it was signed and dated by the patient on 5/15/25.  However, the documents were in English instead of Spanish as per the hospice's P&P.  On 9/5/25 at 0912 hours, an interview was conducted with the Administrator.  The Administrator verified the patient was a Spanish speaking patient.  On 9/9/25 at 1406 hours, a follow-up interview and concurrent closed record review was conducted with the Administrator.  The Administrator was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the grievance log was updated for one nonsampled patient (Patient C) who had filed a grievance against the hospice.  This failure had the potential of violating the patient's rights and not providing quality of care and services to this patient.  Findings: --- The hospice's P&P titled Complaint/Grievance Process revised 4/2020 showed complaints and any action taken will be documented on a complaint form.  All complaints will be logged, tracked , trended and filed in the performance improvement office.   Review of the hospice's grievance log was conducted on 9/2/25.  The grievance log included the Grievance Statistics monthly for the years of 2023, 2024, and 2025. Review of the Grievance Statistics for the year of 2025 showed no complaint from January to May. On 9/2/25 at 0956 hours, an interview and concurrent hospice document review was conducted with the Administrator.  The Administrator was asked if they received any complaint for this year.  The Administrator replied yes, in May.  On 9/9/25 at 0930 hours, a follow-up interview and concurrent hospice document review was conducted with the Administrator.  The Administrator was asked about the nature of the complaint. The Administrator replied it was regarding Patient C's insurance and the inability of the hospice to discharge timely.   The Administrator was also asked if they needed to document Patient C's complaint on the grievance log.  The Administrator replied yes, it should have been documented. On 9/9/25 at 0946 hours, an interview and concurrent hospice document review was conducted with the Administrator and Receptionist 1.  Receptionist 1 was asked as to the time she had received the call from Patient C.  The Receptionist 1 replied it was May of this year.  Receptionist 1 was also asked if they needed to document the complaint in the grievance log.  Receptionist 1 replied yes, it should have been documented.  They were informed and acknowledged the finding.

Based on observation, record review and interview, the hospice failed to ensure the initial and comprehensive assessments were completed, reviewed, and revised to address and meet the patients' care needs as evidenced by: --- 1.The hospice failed to ensure the comprehensive assessments were completed no later than five calendar days after the election of hospice care. Cross reference to L523.2.The hospice failed to ensure the comprehensive assessments had identified the physical, psychological, and spiritual and volunteer needs. Cross reference to L524.3.The hospice failed to ensure the comprehensive assessments had identified the imminence of death. Cross reference to L528.4.The hospice failed to include all current medications’ side effects, actual or potential drug interactions, and duplicate drug therapy in the comprehensive assessments; and the medication profiles were reviewed and updated to reflect the current medications. Cross reference to L530.5.The hospice failed to ensure the comprehensive assessments included the initial bereavement assessments to address the needs of the patient’s family and other individuals/PCG focusing on the social, religious, and cultural factors which may impact their ability to cope with the patient’s death. Cross reference to L531.6.The hospice failed to ensure the updated comprehensive assessments were completed no less than every 15 days and included the changes that had occurred since the initial assessment, information on the patient’s progress, and reassessment of the patient’s responses. Cross reference to L533.The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the initial and comprehensive assessments to meet the patients' care needs.

Based on interview and record review, the hospice failed to ensure the comprehensive assessments were completed no later than five calendar days after the election of hospice care for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11, 13, and 14).  This failure had the potential risk of not identifying and addressing the care needs timely for these patients.Findings: --- f. Review of Patient 1's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/2/24.  The patient was certified for hospice services during the period from 5/2/24 to 7/30/24.   The Election of Medicare Hospice Benefit dated 5/2/24, showed the patient elected for hospice benefit.However, further review of the clinical record failed to show documented evidenced of the psychosocial and spiritual comprehensive assessments were completed later than five calendar days after the  hospice election of benefits. On 9/9/25 at 1500 hours, a follow up interview and concurrent record review was conducted with Receptionist 1.  She was informed and acknowledged the findings. g. Review of Patient 11's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 1/16/25.  The patient was certified for hospice services during the period from 1/16/25 to 3/16/25. The Election of Medicare Hospice Benefit dated 1/16/25, showed the patient elected for hospice benefit.However, further review of the clinical record failed to show documented evidenced of the psychosocial and spiritual comprehensive assessments were completed later than five calendar days after the  hospice election of benefits. On 9/9/25 at 1500 hours, a follow up interview and concurrent record review was conducted with Receptionist 1.  She was informed and acknowledged the findings.  #.   Review of Patient 4's closed clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/15/25.  The patient was certified for hospice services during the period from 5/15/25 to 8/12/25.  The patient was discharged from the hospice service on 7/21/25.Review of the closed clinical record showed the EOB (election of benefit) was signed and dated by the patient on 5/15/25.Further, review of the closed clinical record failed to show documented evidenced of the psychosocial and spiritual comprehensive assessments were completed later than five calendar days after the  hospice election of benefits. On 9/9/25 at 1406 hours, a follow up interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #.  Review of Patient 8's clinical record was initiated on 9/4/25.  The clinical record showed the SOC was 10/15/24. The patient was certified for hospice services during the periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25. Review of the clinical record showed the EOB (election of benefit) was signed and dated by the patient on 10/15/25.Further review of the clinical record failed to show documented evidenced of the psychosocial and spiritual comprehensive assessments were performed no later than five calendar days after the hospice election of benefits. On 9/9/25 at 1157 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #.  Review of Patient 10's clinical record was initiated on 9/5/25.  The clinical record showed the SOC was 11/13/24. The patient was certified for hospice services during the periods from 6/11/25 to 8/9/25 and 8/10/25 to 10/8/25. Review of the clinical record showed the EOB (election of benefit) was signed and dated by the patient on 11/13/24.Further review of the clinical record failed to show documented evidenced of the psychosocial and spiritual comprehensive assessments were performed no later than five calendar days after the hospice election of benefits. On 9/9/25 at 1329 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #. Review of Patient 5's closed clinical record was initiated on 9/3/25.  The clinical record showed the SOC was 5/21/23. The patient was certified for hospice services during the periods from 5/21/23 to 8/18/23, 8/19/23 to 11/16/23, 11/17/23 to 1/15/24 and 1/6/24 to 3/15/24.  The patient was discharged from the hospice service on 3/5/24.  Review of the clinical record showed the EOB (election of benefit) was signed and dated by the patient on 5/21/23.Further review of the clinical record failed to show documented evidenced of the psychosocial and spiritual comprehensive assessments were performed no later than five calendar days after the hospice election of benefits. On 9/9/25 at 1108 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  Review of the clinical records for Patients 3, 7,13, XXX,  showed no documented evidence the comprehensive assessments were completed no later than five calendar days after the election of hospice care for these patients. For example:a. Review of Patient 13's closed clinical record was initiated on 9/8/25.  The clinical record showed the SOC was 3/26/24.  The patient was certified for hospice service during the certification period from 1/20/25 to 3/20/25.    The Election of Medicare Hospice Benefit dated 3/26/24, showed the patient elected for hospice benefit.However, further review of the closed clinical record showed no documented evidence the initial comprehensive physical, psychosocial, and spiritual assessments were completed no later than five calendar days after the election of hospice care.On 9/9/25 at 1100 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the comprehensive assessments had identified the physical, psychosocial, and spiritual needs for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,13, and 14); and the volunteer needs for three of 14 sampled patients (Patients 1, 9, and 13).  This failure had the potential risk of not identifying and addressing the care needs for these patients.Findings: --- #.Review of Patient 2’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was 6/9/25. The patient was certified for hospice services during the certification period from 6/9/25 to 9/6/25.Review of the initial comprehensive nursing assessment dated 6/9/25, showed the nursing assessment for patient’s POLST, advance directive, respirations, cough, psychosocial status, need for comprehensive assessment and attending physician were incomplete.On 9/9/25 at 1055 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN acknowledged and confirmed the findings.#.Review of Patient 6’s clinical record was initiated on 9/4/25. The clinical record showed the SOC was 11/13/24. The patient was certified for hospice during the certification periods from 7/11/25 to 9/8/25.The initial nursing assessment dated 11/13/24, showed the comprehensive pain assessment, current bowel and pain program were blank. Furthermore, the psychosocial status was incomplete.On 9/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN acknowledged and confirmed the findings.#.Review of Patient 12’s clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/28/24. The patient was certified for hospice services during the certification period 7/23/25 to 9/20/25,Review of the initial nursing assessment dated 7/28/24, showed the spiritual assessment was incomplete. Furthermore, the MAC, coordination of care and need for comprehensive assessment were blank.On 9/9/25 at 1330 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN acknowledged and confirmed the findings.  #.Review of Patient 14’s clinical record was initiated on 9/5/25. The closed clinical record showed the SOC was 7/8/24. The patient was certified for hospice services during the certification period 7/8/24 to 10/5/24. Patient 14 expired on 9/22/24.Review of the initial nursing assessment dated 7/8/24, showed MAC, Abuse Screen and Comprehensive Pain Assessment were blank.On 9/9/25 at 1400 hours, an interview and concurrent closed clinical record review was conducted with the QA/LVN. The QA/LVN acknowledged and confirmed the findings. #   Review of Patient 1’s clinical record was initiated on 9/2/25. The Clinical record showed that the Start of Care (SOC) date was 5/2/24. The patient was certified for hospice services during the certification period from 05/02/2024 to 7/30/24.The initial comprehensive nursing assessment, dated 5/2/24, showed  a comprehensive pain assessment, current bowel and pain program were blank. In addition, the assessment did not address the need for volunteer services.Further review of the clinical record failed to show that the patient’s initial comprehensive psychosocial, spiritual, and volunteer assessments were completed.On 9/3/25 at 1320 hours, Patient 1 was observed lying in bed and reported experiencing intermittent headaches to the RN. However, the RN was observed not assessing the patient’s pain.On 9/3/25 at 1400 hours, an interview was conducted with the RN. When asked whether she had assessed the pain level of Patient 1’s headache, the RN acknowledged that she had not. RN stated she should have assessed the pain.  RN verified the findings.On 9/9/25 at 1500 hours, an interview and concurrent clinical record review were conducted with Receptionist 1. She was informed of the findings and acknowledged them.#   Review of Patient 9’s clinical record was initiated on 9/2/25. The Clinical record showed that the Start of Care (SOC) date was 12/11/24. The patient was certified for hospice services during the certification period from 12/11/24 to 3/10/25.The initial comprehensive nursing assessment, dated 12/11/24, showed no documented evidence that a pain assessment was completed.Further review of the clinical record failed to show that the patient’s initial comprehensive psychosocial, spiritual, and volunteer assessments were completedOn 9/9/25 at 1500 hours, an interview and concurrent clinical record review were conducted with Receptionist 1. She was informed of the findings and acknowledged them.#  Review of Patient 11’s clinical record was initiated on 9/2/25. The Clinical record showed that the Start of Care (SOC) date was 1/16/25. The patient was certified for hospice services during the certification period from 1/16/25 to 3/16/25.The initial comprehensive nursing assessment, dated 1/16/25, showed no documented evidence that a pain assessment, spiritual and psychosocial was completed.Further review of the initial comprehensive nursing assessment failed to show documented evidence that the patient's bereavement risks were assessed, as those sections were left blank.On 9/9/25 at 1500 hours, an interview and concurrent clinical record review were conducted with Receptionist 1. She was informed of the findings and acknowledged them.On 9/9/25 at 1600 hours, The administrator was informed of above findings of Patient 1, 9 and 11. The administrator verified the findings.  #.   Review of Patient 4's closed clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/15/25.  The patient was certified for hospice services during the period from 5/15/25 to 8/12/25.  The patient was discharged from the hospice service on 7/21/25.The Initial Nursing Comprehensive Assessment dated 5/15/25, failed to show documented evidence the body systems assessments, including Skin, Gastro intestinal related to last bowel movement were completed.In addition, the assessment for ADL's and teachings were left blank.Further review of the Initial Nursing Comprehensive assessment failed to show documented evidenced of the patients psychosocial and bereavement risk were assessed as the sections were left blank. On 9/9/25 at 1406 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #.  Review of Patient 10's clinical record was initiated on 9/5/25.  The clinical record showed the SOC was 11/13/24. The patient was certified for hospice services during the periods from 6/11/25 to 8/9/25 and 8/10/25 to 10/8/25. The Initial Nursing Comprehensive Assessment dated 11/13/24, showed the DPCS/Administrator Designee had performed the initial comprehensive assessment.   The comprehensive assessment included the section for height and weight. However, initial comprehensive assessment was not completed as the section for the height and weight was left blank.On 9/9/25 at 1329 hours, an interview and concurrent closed record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings. #. Review of Patient 5's closed clinical record was initiated on 9/3/25.  The clinical record showed the SOC was 5/21/23. The patient was certified for hospice services during the periods from 5/21/23 to 8/18/23, 8/19/23 to 11/16/23, 11/17/23 to 1/15/24 and 1/6/24 to 3/15/24.  The patient was discharged from the hospice service on 3/5/24.  The Initial Nursing Comprehensive Assessment dated 11/13/24, showed the DPCS Designee/NP had performed the initial comprehensive assessment.  The assessment included the section for psychosocial, spiritual and bereavement risk assessment.However, the initial comprehensive assessment was not completed as the section for psychosocial, spiritual and bereavement risk assessment were left blank.On 9/9/25 at 1108 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  1.  Review of XXXX sampled patients' clinical records (Patients 13, XXX) was conducted and showed the comprehensive assessments did not identify the volunteer needs for these patients. For example:a. Review of Patient 13’s closed clinical record was initiated on 9/8/25.  The clinical record showed the SOC was 3/26/24.  The patient was certified for hospice service during the certification period from 1/20/25 to 3/20/25.    However, further review of the clinical records failed to show documented evidence the initial comprehensive assessment included the assessment of the patient's need for volunteer services.On 9/9/25 at 1100 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the findings.2. Review of Patient 13’s clinical record was initiated on 9/8/25.  The clinical record showed the SOC was 3/26/24.  The patient was certified for hospice service during the certification period from 1/20/25 to 3/20/25.    The initial comprehensive nursing assessment dated 3/26/24, showed no documented evidence of the patient’s functional limitation, mental status, skin, musculoskeletal, sensory, cardiovascular, gastrointestinal, nutrition/hydration, genitourinary, reproductive system, and ADLs were completed.The closed clinical record failed to show the patient’s initial comprehensive psychosocial and spiritual assessments were completed.On 9/9/25 at 1100 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the findings.3. Review of Patient 3’s clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 3/7/25.  The patient was certified for hospice services during the certification period from 6/5/25 to 9/2/25.    The clinical record failed to show the patient’s initial comprehensive psychosocial and spiritual assessments were completed.On 9/9/25 at 1148 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the findings.4. Review of Patient 7’s clinical record was initiated on 9/4/25.  The clinical record showed the SOC was 11/13/24.  The patient was certified for hospice services during the certification period from 7/11/25 to 9/8/25.    The clinical record showed the patient had left and right knee pain. Documentation showed rest/relaxation and decreased mobility were pain relief measures.  However, there was no information on how long the pain lasted.The closed clinical record failed to show the patient’s initial comprehensive psychosocial and spiritual assessments were completed.On 9/9/25 at 1220 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the comprehensive assessments had identified the imminence of death for two of 14 sampled patients (Patients 4 and 13).  This failure had the potential for not appropriately addressing the patient's needs.Findings: --- #.   Review of Patient 4's closed clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/15/25.  The patient was certified for hospice services during the period from 5/15/25 to 8/12/25.  The patient was discharged from the hospice service on 7/21/25.The initial nursing comprehensive assessment dated 5/15/25, failed to show documented evidence the imminence of death was assessed as section was left blank. On 9/9/25 at 1406 hours, an interview and concurrent closed record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  The hospice's P&P titled Comprehensive Assessment revised April 2020 showed during comprehensive assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient's clinical record including imminence of death.#.  Review of Patient 13’s closed clinical record was initiated on 9/8/25.  The clinical record showed the SOC was 3/26/24.  The patient was certified for hospice services during the certification period from 1/20/25 to 3/20/25.    Review of the initial comprehensive nursing assessment dated 3/29/24, showed no documented evidence the patient’s imminence of death was identified.On 9/9/25 at 1100 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the finding.

Based on observation, interview, and record review, the hospice failed to include all current medications' side effects, actual or potential drug interactions, and duplicate drug therapy in the comprehensive assessments; and failed to ensure the medication profiles were reviewed and updated to reflect the current medications for five of 14 sampled patients (Patients 1, 2, 3, and 6).  These failures created the risk for the patients not receiving the appropriate care and services necessary to improve the patients' health conditions.Findings: --- #. Review of Patient 10's clinical record was initiated on 9/5/25.  The clinical record showed the SOC was 11/13/24. The patient was certified for hospice services during the periods from 6/11/25 to 8/9/25 and 8/10/25 to 10/8/25. Review of the IDT Plan of Care & Review of Comprehensive Assessment dated 8/14/25 on the section of narrative notes showed the patient will be maintained on supplemental oxygen therapy and diuretic therapy will be adjusted to manage symptoms of fluid retention. However, review of the clinical record failed to show documented evidenced of a list of medications/ medication profile was developed for the patient.On 9/9/25 at 1329 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked they needed to complete the medication profile.  The Administrator replied, yes, should be completed and updated.  The Administrator was also asked if the patient was on diuretic.  The Administrator replied, will check the medication profile but it was not created on the system.  The Administrator was informed and acknowledged the findings. #. Review of Patient 1's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/2/24.  The patient was certified for hospice services during the period from 8/25/25 to 10/23/25. Review of the medication profile for the certification period from 8/25/25 to 10/23/25, showed the following medications listed:Rosuvastatin 10 mg, one tablet by mouth daily for hyperlipidemiaMetoprolol Succinate Extended Release 50 mg, by mouth three times a day at bedtimeMylanta Maximum Strength Suspension, 30 mL by mouth every 6 hours as neededLosartan 100 mg, by mouth once dailyLasix 20 mg, by mouth every other dayDocusate Sodium 100 mg, by mouth once dailyOn 9/3/25 at 1320 hours, an interview was conducted with Patient 1 and their family. The family reported that Patient 1 had been taking calcium supplements for the past three months. A bottle of Oyster Shell Calcium 500 mg with Vitamin D 200 IU, to be taken by mouth twice daily, was observed at the patient's bedside.On 9/3/25 at 1400 hours, an interview and concurrent record review were conducted with the Director of Patient Care Services (DPCS). When asked about the calcium supplement, the DPCS stated they were unaware of it. The calcium supplement had not been documented in the medication profile, nor had it been communicated to the hospice Medical Director.    #.  Review of Patient 3's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 3/7/25.  The patient was certified for hospice services during the certification period from 6/5/25 to 9/2/25.The Patient Medication Profile during the certification period from 6/5/25 to 9/2/2, showed the patient’s medications included Daily-Vite (supplement) one tablet PO once a day and sertraline (antidepressant) 25 mg PO at bedtime.On 9/4/25 at 1200 hours, a joint home visit was conducted with HA 2 to Patient 3’s home.  Review of the medication profile was conducted with the family member. The family member stated the patient never took sertraline and the Daily-Vite was no longer being taken by the patient since last month.The hospice failed to ensure the medication profile was updated.On 9/9/25 at 1144 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged of the finding. Review of the hospice’s P&P titled Medication Profile revised 4/2020 showed patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications. Deviations from taking medications as ordered will be documented in clinical notes, and the physician (or other authorized independent practitioner) will be notified.#.Review of Patient 2’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was 6/9/25. The patient was certified for hospice services during the certification period from 6/9/25 to 9/6/25.A joint home visit with LVN 2 was conducted on 9/4/25 at 1030 hours, to Patient 2’s home.Review of the Patient Medication Profile included the following physician order:a.As of 6/9/25, Prednisone (medication used to treat a wide range of inflammatory and autoimmune conditions) tablet, administered as:-5 mg, administer 1 tablet by mouth once a day times three days to start on 6/16/25 then stop Prednisone after last dose.-10 mg by mouth once a day times three days to start on 6/16/25.-20 mg by mouth once a day times three days to start on 6/13/25.-30 mg by mouth once a day times three days to start on 6/10/25.-20 mg by mouth once a day times one day to start on 6/9/25.However, the PCG stated the patient was not sent home with the prednisone. The medication was taken at the hospital. The LVN 2 verified the medication was not among the bottled medications in the patient’s home during visits, however, the medication was still listed in the patient’s medication profile.b.As of 6/9/25, oxygen at two to five liters per minute vias nasal canula as needed. However, per PCG, the patient was on continuous oxygen at two liters per minute. The LVN 2 confirmed the oxygen had always been continuous and the patient’s medication profile was not updated.c.As of 6/13/25, Lantus Solostar Insulin Pen (medication used to manage blood sugar levels), inject 15 units subcutaneously at bedtime. However, per PCG the lantus was discontinued two months ago due to patient’s low blood sugar level. The LVN 2 confirmed the medication was discontinued and still listed in the patient’s medication profile.d.As of 7/2/25, Erythromycin ophthalmic ointment (used to treat infections of the eye) 5 mg/gram, apply one cm ribbon into affected eye four times a day for five days. The LVN 2 verified the ointment was discontinued after five days of use. Furthermore, the LVN 2 stated the medication should be listed as discontinued in the patient’s medication profile.On 9/9/25 at 1055 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the findings.#. Review of Patient 6’s clinical record was initiated on 9/4/25. The clinical record showed the SOC was 11/13/24. The patient was certified for hospice during the certification periods from 7/11/25 to 9/8/25.a.Review of the nursing clinical note dated 8/15 25, showed the patient was on OTC Pepto-Bismol (medication to provide relief from nausea, diarrhea and upset stomach). However, the medication was not listed on the medication profile.b.As of 3/7/25, patient was on Augmentin (used to treat bacterial infection) 875 mg by mouth every 12 hours times five days. However, the medication was still on the medication profile. On 9/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the comprehensive assessments included the initial bereavement assessments to address the needs of the patient's family and other individuals/PCG focusing on the social, religious, and cultural factors which may impact their ability to cope with the patient's death for 13 of 14 sampled patients (Patients 1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14).  This failure created the risk of not addressing the bereavement needs for these patients' family/PCG.Findings: --- #.   Review of Patient 4's closed clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/15/25.  The patient was certified for hospice services during the period from 5/15/25 to 8/12/25.  The patient was discharged from the hospice service on 7/21/25.Review of the closed clinical record failed to show documented evidenced of the bereavement assessment was completed.On 9/9/25 at 1406 hours, an interview and concurrent closed record review was conducted with the Administrator.  The Administrator was informed and acknowledged the finding.  #. Review of Patient 10's clinical record was initiated on 9/5/25.  The clinical record showed the SOC was 11/13/24. The patient was certified for hospice services during the periods from 6/11/25 to 8/9/25 and 8/10/25 to 10/8/25. Review of the clinical record failed to show documented evidenced of the bereavement assessment was completed.On 9/9/25 at 1329 hours, an interview and concurrent closed record review was conducted with the Administrator.  The Administrator was informed and acknowledged the finding.  d. Review of Patient 1’s closed clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/2/24.  The patient was certified for hospice service during the certification period from 5/2/24 to 7/30/24.   Review of the clinical record showed no documented evidence the initial bereavement assessment was completed.On 9/9/25 at 1500 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the finding.e.  Review of Patient 11's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 1/16/25.  The patient was certified for hospice services during the period from 1/16/25 to 3/16/25. Review of the clinical record showed no documented evidence the initial bereavement assessment was completed.On 9/9/25 at 1500 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the finding.f. Review of Patient 9’s clinical record was initiated on 9/2/25. The Clinical record showed that the Start of Care (SOC) date was 12/11/24. The patient was certified for hospice services during the certification period from 12/11/24 to 3/10/25.Review of the clinical record showed no documented evidence the initial bereavement assessment was completed.On 9/9/25 at 1500 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the finding Review of the clinical records for Patients XXX, showed no documented evidence the comprehensive assessments for these patients included the initial bereavement assessment.  For example:a.  Review of Patient 13’s closed clinical record was initiated on 9/8/25.  The clinical record showed the SOC was 3/26/24.  The patient was certified for hospice services during the certification period from 1/20/25 to 3/20/25.    Review of the closed clinical record showed no documented evidence the initial bereavement assessment was completed.On 9/9/25 at 1100 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the finding.

Based on interview and clinical record review, the hospice failed to ensure the updated comprehensive assessments were completed no less than every 15 days and included the changes that had occurred since the initial assessment, information on the patient's progress, and reassessment of the patient's responses for seven of 14 sampled patients (Patients 2, 3, 4, 6, 8, 13 and 14).  This failure created the risk of not addressing the care needs for these patients.Findings: --- #.  Review of Patient 4's closed clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/15/25.  The patient was certified for hospice services during the period from 5/15/25 to 8/12/25.  The patient was discharged from the hospice service on 7/21/25.The Initial Orders and Plan of Care, for the certification periods from 5/15/25 to 8/12/25, cited SN to assess patient needs.The Nursing Clinical Notes dated 5/28, 6/3, 6/10, 6/17, 6/24 and 7/1/25 showed the patient was assessed to have an elevated blood sugar.Further review of the closed clinical record showed the IDG was conducted on 5/29 and 6/12/25.However, there was no documented evidence the IDG had updated the comprehensive assessment to address the patients elevated blood sugar level. On 9/9/25 at 1406 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the finding. #.  Review of Patient 8's clinical record was initiated on 9/4/25.  The clinical record showed the SOC was 10/15/24. The patient was certified for hospice services during the periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25. Review of the Nursing Clinical Note dated 8/15/25, showed the RN 3 had performed the Genito- urinary/reproductive system assessment.  The assessment showed the other symptoms of nocturia and urgency.However, review of the IDT Plan of Care & Review of Comprehensive Assessment dated 8/21/25 failed to show documented evidenced of the IDG was updated to address the patients Genito -urinary symptoms of nocturia and urgency.On 9/9/25 at 1157 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  Review of the clinical records for Patients XXXXX showed the hospice failed to ensure the updated comprehensive assessments were completed no less than every 15 days  For example:#.  Review of Patient 13’s closed clinical record was initiated on 9/8/25.  The clinical record showed the SOC was 3/26/24.  The patient was certified for hospice service during the certification period from 1/20/25 to 3/20/25.The POC for the certification period from 1/20/25 to 3/20/25, showed the patient's identified problems included pain/discomfort.The IDT Plan of Care & Review of the Comprehensive Assessment showed the IDT conducted meetings on 1/30, 1/16, 2/13/25.  However, there was no documented evidence the IDT had updated the comprehensive assessment no less than every 15 days to identify if there were any changes or no changes on the patient’s identified problem of painOn 9/9/25 at 1100 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the finding#.  Review of Patient 3's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 3/7/25.  The patient was certified for hospice service during the certification period from 6/5/25 to 9/2/25.The Collaboration Note dated 7/24/25, showed the visiting nurse noted a skin tear on the right forearm during assessment.  Documentation showed the area will be monitored for healing and any changes.The Collaboration Note dated 7/31/25, showed the visiting nurse noted an increase on the size of the right forearm skin tear.  Documentation showed the physician had new orders for evaluation and treatment by a wound providerThe IDT Plan of Care & Review of the Comprehensive Assessment showed the IDT conducted meetings on 6/5 and 6/19/25.  There was no documented evidence the IDT conducted meetings after 6/19/25.  There was no documented evidence the IDG had updated the comprehensive assessment no less than every 15 days to identify if there were any changes or no changes on the patient’s right forearm skin tear.On 9/9/25 at 1144 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged of the finding.  Review of the hospice’s P&P titled The Plan of Care revised April 2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individua admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and on-going comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen days.#. Review of Patient 2’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was 6/9/25. The patient was certified for hospice services during the certification period from 6/9/25 to 9/6/25.Review of The Collaboration Note dated 7/2/25, showed LVN 2 reported patient noted with left eye redness with small amount of yellow discharge. Documentation showed the physician was informed and ordered medication. However, there was no documented evidence the IDG had discussed the patient’s eye problem.On 9/9/25 at 1055 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the finding. #.Review of Patient 6’s clinical record was initiated on 9/4/25. The clinical record showed the SOC was 11/13/24. The patient was certified for hospice during the certification periods from 7/11/25 to 9/8/25.a.Review of the nursing clinical note dated 7/17/25, showed a documentation patient had reported episodes of chest pain occurring approximately two times a day when not taking medication. Furthermore, the patient was recently diagnosed with dementia and neurologist reportedly plan to determine the severity of the cognitive decline. However, there was no documented evidence the IDG had discussed the patient’s episodes of chest pain and new diagnosis of dementia.   b.Review of the nursing clinical note dated 8/15/25, showed a documentation patient had reported an ongoing upset stomach and reflux symptoms for approximately two weeks. However, there was no documented evidence the IDG had discussed the patient’s change of condition.On 9/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the findings.#. Review of Patient 14’s clinical record was initiated on 9/5/25. The closed clinical record showed the SOC was 7/8/24. The patient was certified for hospice services during the certification period 7/8/24 to 10/5/24. Patient 14 expired on 9/22/24.Review of the nursing clinical note dated 9/2/24, showed a documentation patient had a restless behavior. However, there was no documented evidence the IDG had discussed the patient’s behavior.On 9/9/25 at 1400 hours, an interview and concurrent closed record review was conducted with the QA/LVN. The QA/LVN stated there was no coordination with the Medical Director. The QA/LVN acknowledged and confirmed the finding.

Based on interview and record review, the hospice failed to ensure the IDT, care planning, and coordination of services were provided to meet the patient’s care needs as evidenced by: --- 1.  The hospice failed to ensure the care and services were provided in accordance with the POC.  Cross reference to L543.2.  The hospice failed to ensure the written POCs were developed to reflect the patient and family goals and interventions based on problems identified. Cross reference to L545.3.  The hospice failed to ensure the POCs included the detailed statement of the scope and frequency.  Cross reference to L547.4.  The hospice failed to ensure the POCs included measurable outcomes.  Cross reference to L548.5.  The hospice failed to ensure the IDG had reviewed/revised the patient’s POCs no less frequently than every 15 calendar days.  Cross reference to L552.6.  The hospice failed to ensure the IDG maintained the responsibility for directing and supervising the care and services provided.  Cross reference L554.7.  The hospice failed to ensure the IDG maintained a system of communication and integration to ensure care and services were provided in accordance with the POC.  Cross reference to L555. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the interdisciplinary team, care planning and coordination of services to meet the patients' care needs.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for nine of 14 sampled patients (Patients 4, 6, 7, 8, 9, 10, 11, 12 and 14).  This failure created the risk of not providing appropriate, consistent, and quality care to the patients. Findings: --- #.  Review of Patient 4's closed clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/15/25.  The patient was certified for hospice services during the period from 5/15/25 to 8/12/25.  The patient was discharged from the hospice service on 7/21/25.Review of the Initial Orders and Plan of Care for the certification period from 5/15/25 to 8/12/25 cited SN visit:  1st week - 1 to 2 visits, 1 PRN  for pain and symptom management and following weeks: 1 visit/week and 1 PRN for symptom management.Review of the closed clinical record failed to show documented evidenced of the SN visit was conducted on Week 2 (5/18 to 5/24/25) as ordered on the POC. Further review of the closed clinical record failed to show documented evidenced of an attempt to re-schedule a visit for the week.In addition, there was no documented evidenced of the physician was notified of the missed visit on Week 2.On 9/9/25 at 1406 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the finding.  #.  Review of Patient 8's clinical record was initiated on 9/4/25.  The clinical record showed the SOC was 10/15/24. The patient was certified for hospice services during the periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25. a.  The Physicians Order dated 6/11/25 for the certification period 6/12/25 to 8/10/25, cited SN 1 time a week and PRN for pain, symptom management and crisis intervention.However, review of clinical record failed to show documented evidenced of the SN visit one time a week as ordered by the physician during the following weeks:-On Week 7 (7/20 to 7/26/25),-On Week 8 ( 7/27 to 8/2/25) and-On Week 9 (8/3 to 8/9/25).In addition, there were no documented evidenced of the physician was notified of the missed visits.Further review of the clinical record failed to show documented evidenced of an attempt to re-schedule the visit for those weeks. b. The Physicians Order dated 7/30/25 for the certification period 8/11/25 to 10/9/25, cited SN 1 time a week and PRN for pain, symptom management and crisis intervention.However, review of clinical record failed to show documented evidenced of the SN visit on Week 2 (8/17 to 8/23/25) and on Week 4 (8/31 to 9/6) as ordered by the physician.In addition, there was no documented evidenced of the physician was notified of the missed visits.Further review of the clinical record failed to show documented evidenced of an attempt to re-schedule the visit for those weeks.On 9/9/25 at 1157 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #.  Review of Patient 10's clinical record was initiated on 9/5/25.  The clinical record showed the SOC was 11/13/24. The patient was certified for hospice services during the periods from 6/11/25 to 8/9/25 and 8/10/25 to 10/8/25. a. The Physicians Order dated 6/10/25 for the certification period 6/10/25 to 8/10/25, cited SN 1 time a week and PRN for pain, symptom management and crisis intervention.However, review of clinical record failed to show documented evidenced of the SN visit one time a week as ordered by the physician during the following weeks:-On Week 1 (6/11 to 6/14/25),-On Week 2 (6/15 to 6/21/25),-On Week 4 (6/29 to 7/5/25),-On Week 5 (7/6 to 7/12/25) and-On Week 7 ( 7/20 to 7/26/25)In addition, there was no documented evidenced of the physician was notified of the missed visits.Further review of the clinical record failed to show documented evidenced of an attempt to re-schedule the visit for those weeks.Moreover, review of the Nursing Clinical Note dated 6/27/25 showed the RN 6 had performed a body system assessment.  The assessment included Pain.However the RN 6 failed to performed pain assessment as ordered by the physician. b.  The Physicians Order dated 8/9/25 for the certification period 8/10/25 to 10/8/25, cited SN 1 time a week and PRN for pain, symptom management and crisis intervention.However, review of clinical record failed to show documented evidenced of the SN visit one time a week as ordered by the physician during the following weeks:-On Week 1 ( 8/10 to 8/16/25),-On Week 3 ( 8/24 to 830/25) and-On Week 4 ( 8/31 to 9/6/25).In addition, there was no documented evidenced of the physician was notified of the missed visits.Further review of the clinical record failed to show documented evidenced of an attempt to re-schedule the visit for those weeks.On 9/9/25 at 1355 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #.Review of Patient 6’s clinical record was initiated on 9/4/25. The clinical record showed the SOC was 11/13/24. The patient was certified for hospice during the certification periods from 7/11/25 to 9/8/25.The Physician Order Details dated 7/3/25 for recertification period 7/11/25 to 9/8/25, showed SN visit frequency one time a week and as needed for pain, symptom management and crisis intervention.However, the SN notes showed no documented evidence the SN conducted a visit on Week 3 (7/20/25 to 7/26/25), Week 5 (8/3/25 to 8/9/25) and Week 7 (8/17/25 to 8/23/25). Review of the Physician Order Details dated 7/2/25 showed the HA, MSW, Chaplain and Volunteer were declined. To continue to offer services on a monthly basis when services declined. However, there was no documented evidence the HA, MSW, Chaplain and Volunteer services were offered monthly.  On 9/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the findings.#.Review of Patient 12’s clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/28/25. The patient was certified for hospice during the certification period from 7/23/25 to 9/20/25.Review of the Physician Order Details dated 7/22/25 showed the HA, MSW, Chaplain and Volunteer were declined. To continue to offer services on a monthly basis when services declined.However, there was no documented evidence the HA, MSW, Chaplain and Volunteer services were offered monthly.  On 9/9/25 at 1330 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the finding.#.Review of Patient 14’s closed clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/8/24. The patient was certified for hospice during the certification period from 7/8/24 to 10/5/24. Patient 14 expired on 9/22/24.a.The Physician Order Details dated 7/8/24 showed SN visit frequency one time a week and as needed for pain, symptom management and crisis intervention.However, the SN notes showed no documented evidence the SN conducted a visit on Week 11 (9/15/24 to 9/21/24). b.Review of the Physician Order Details dated 7/8/24 showed the HA, MSW, Chaplain and Volunteer were declined. To continue to offer services on a monthly basis when services declined.However, there was no documented evidence the HA, MSW, Chaplain and Volunteer services were offered monthly.  On 9/9/25 at 1400 hours, an interview and concurrent clinial record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the findings. #.  Review of Patient 7’s clinical record was initiated on 9/4/25.  The clinical record showed the SOC was 11/13/24.  The patient was certified for hospice services during the certification period from 7/11/25 to 9/8/25.   The recertification CTI during 7/11/25 to 9/8/25, showed SN visits 1-2 visits for the first week and 1 PRN visits for pain and symptom management, then 1 visit per week and 1 PRN visits per week  for symptom management for the following weeksThe SN notes during Week 3 (7/20/25 to 7/26/25), Week 5 (8/3/25 to 8/9/25), Week 7 (8/17/25 to 8/23/25) and Week 8 (8/24/25 to 8/30/25), showed no documented evidence of a SN visit instead of one visit per week.On 9/9/25 at 1220 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the findings. #.  Review of Patient 9's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 12/11/24.  The patient was certified for hospice services during the period from 12/11/24 to 3/10/25.Review of the Initial Orders and Plan of Care for the certification period from 12/11/24 to 3/10/25 cited SN visit:  1st week - 1 to 2 visits, 1 PRN  for pain and symptom management and following weeks: 1 visit/week and 1 PRN for symptom management.Review of the clinical record failed to show documented evidenced of the SN visit was conducted on Week 3 (12/22/25 to 12/28/25), Week 6 (1/12/25 to 1/18/25 ), Week 7 ( 1/19/25 to 1/25/25) ,Week 9 (2/2/25 to 2/8/25) and week 11 (2/16/25 to 2/22/25) as ordered on the POC. Further review of clinical record failed to show documented evidenced of an attempt to re-schedule a visit for the week.In addition, there was no documented evidenced of the physician was notified of the missed visit on Week 3, Week 6, Week 7, Week 9,and Week 11.On 9/9/25 at 1500 hours, an interview and concurrent clinical record review was conducted with the Receptionist 1.  Receptionist 1 was informed and acknowledged the finding.# Review of Patient  11's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 1/16/25.  The patient was certified for hospice services during the period from 1/16/25 to 3/16/25.  Review of the Initial Orders and Plan of Care for the certification period from 1/16/25 to 3/16/25 cited SN visit:  1st week - 1 to 2 visits, 1 PRN  for pain and symptom management and following weeks: 1 visit/week and 1 PRN for symptom management.Review of the clinical record failed to show documented evidenced of the SN visit was conducted on Week 2 (1/19/25 to 1/25/25), Week 4 (2/2/25 to 2/8/25 ), Week 6 ( 2/16/25 to 2/22/25) and Week 8 (3/2/25 to 3/8/25) as ordered on the POC. Further review of clinical record failed to show documented evidenced of an attempt to re-schedule a visit for the week.In addition, there was no documented evidenced of the physician was notified of the missed visit on Week 2, Week 4, Week 6 and Week 8.On 9/9/25 at 1500 hours, an interview and concurrent clinical record review was conducted with the Receptionist 1.  Receptionist 1 was informed and acknowledged the finding.

Based on record review and interview, the hospice failed to ensure the written POCs were developed to reflect the patient and family goals and interventions based on the problems identified for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14).  This failure created the risk of not addressing the care needs for these patients.Findings: --- #. Review of Patient 5's closed clinical record was initiated on 9/3/25.  The clinical record showed the SOC was 5/21/23. The patient was certified for hospice services during the periods from 5/21/23 to 8/18/23, 8/19/23 to 11/16/23, 11/17/23 to 1/15/24 and 1/6/24 to 3/15/24.  The patient was discharged from the hospice service on 3/5/24.  Review of the Certification of Plan of Care for the certification period from 8/19/23 to 11/16/23 showed the patients admission date and the primary diagnosis.However, the POC failed to show an individualized care plan was completed to address the patients care needs and services. On 94/25 at 0823 hours, an interview and concurrent closed clinical record review was conducted with the Receptionist 1.  The Receptionist 1 was asked if a plan of care was developed for the certification period.  The Receptionist 1 replied, no it was not done.On 9/9/25 at 1108 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the finding.  #.  Review of Patient 1's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/2/24. The patient was certified for hospice services during the periods from 5/2/24 to 7/30/24. Review of the Nursing Comprehensive Assessment dated 5/2/24 showed that Patient 1 had musculoskeletal limitations, including reduced range of motion and joint stiffness. Gastrointestinal issues included indigestion, and the patient also experienced bowel and bladder incontinence. Regarding activities of daily living (ADLs), the patient was unable to perform meal preparation, grocery shopping, or light housekeeping.Review of the Certification of Plan of Care for the certification period from 5/2/24 to 7/30/24 showed the patient's admission date and primary diagnosis.However, the Plan of Care (POC) failed to show that an individualized care plan was developed to address the patient’s specific care needs, including musculoskeletal, gastrointestinal, and bowel/bladder issues.On 9/9/25 at 1500 hours, an interview and concurrent clinical record review were conducted with Receptionist 1. When asked whether a plan of care had been developed for the certification period, Receptionist 1 stated that the plan of care was incomplete and did not address the patient’s care issues or needs.  Receptionist 1 verified the findings. #.  Review of Patient 9's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 12/11/24.  The patient was certified for hospice services during the periods from 12/11/24 to 3/10/25.Review of the Nursing Comprehensive Assessment dated 12/11/24 showed Patient 9 had endocrine blood glucose meter use and neuropathyReview of the Certification of Plan of Care for the certification period from 12/11/24 to 3/10/25 showed the patient's admission date and primary diagnosis.Review of Medication Profile from 12/11/24 to 3/10/25 showed Patient 9 had alendronate 70 mg once weekly at morning and aspirin  81 mg po once a day.However, the Plan of Care (POC) failed to showed  an individualized care plan was developed to address the patient’s specific care needs, including diabetes, the use of high-risk medication such as aspirin, and the potential for serious side effects associated with alendronate. On 9/9/25 at 1500 hours, an interview and concurrent clinical record review were conducted with Receptionist 1. When asked whether a plan of care had been developed for the certification period, Receptionist 1 stated that the plan of care was incomplete and did not address the patient’s care issues or needs.  Receptionist 1 verified the findings. #. Review of Patient 11's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 1/16/25. The patient was certified for hospice services during the periods from 1/16/25 to 3/16/25. Review of the Nursing Comprehensive Assessment dated 1/16/25 showed Patient 11's pain severity was mild.Review of Medication profile from 1/16/25 to 3/16/25 showed Patient 11 had Aspirin 81 mg by mouth once a day,  Clonidine 0.1mg 1 tablet by mouth once a day as needed for high blood pressure  and Tylenol 650mg by mouth every 6 hours as needed. Review of the Certification of Plan of Care for the certification period from 1/16/25 to 3/16/25 showed the patient's admission date and primary diagnosis.  However, the Plan of Care (POC) failed to showed  an individualized care plan was developed to address the patient’s specific care needs, including high blood pressure, pain and high risk use of medication such as aspirin. On 9/9/25 at 1500 hours, an interview and concurrent clinical record review were conducted with Receptionist 1. When asked whether a plan of care had been developed for the certification period, Receptionist 1 stated that the plan of care was incomplete and did not address the patient’s care issues or needs.  Receptionist 1 verified the findings. On 9/9/25 at 1545 hours, an interview was conducted with QA nurse. QA nurse was informed above finding and verified the findings.    The hospice's P&P titled the Plan of Care revised April 2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program.Review of the clinical records for Patients 3,, 7, 13, /XXXX showed the hospice failed to develop an individualized written plan of care for these patients. For example:#.  Review of Patient 13’s closed clinical record was initiated on 9/8/25.  The clinical record showed the SOC was 3/26/24.  The patient was certified for hospice service during the certification period from 1/20/25 to 3/20/25.    The SN note dated 2/1, 2/18, and 2/11/25, showed the patient had an indwelling catheter connected to bedside drainage.The IDT Plan of Care & Review of the Comprehensive Assessment dated 1/16, 1/30, 2/13/25, showed the patient had a Foley catheter in place.However, there was no documented evidence of an individualized written POC developed addressing the patient’s use of indwelling catheter.On 9/9/25 at 1100 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the finding.

Based on record review and interview, the hospice failed to ensure the POCs included the detailed statement of the scope and frequency of services for two of 14 sampled patient (Patient 8 and 10).  This failure created the risk of not providing necessary services for these patients.Findings: --- The hospice's P&P titled The Plan of Care revised 4/2020, showed the plan of care will identify the patients needs and services to meet those needs. It must state in detail the scope and frequency of services needed to meet the patients and family/caregivers' needs, goals, and outcome achievements. 1.  Review of Patient 8's clinical record was initiated on 9/4/25.  The clinical record showed the SOC was 10/15/24. The patient was certified for hospice services during the certification periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25. *  The Certification of Plan of Care dated 6/11/25, for the certification period from 6/12/25 to 8/10/25, and The Certification of Plan of Care dated 7/30/25, for the certification period from 8/11/25 to 10/9/25, showed the orders for disciplines and treatment which included the SN, HA, PT/OT/ST, Social Worker, Spiritual Care, Volunteer, and Bereavement.  However, the POC failed to include the specific scope and frequency of services as per the hospice's P&P. On 9/9/25 at 1157 hours, a follow-up interview and concurrent closed record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings. 2.  Review of Patient 10's clinical record was initiated on 9/5/25.  The clinical record showed the SOC was 11/13/24. The patient was certified for hospice services during the certification periods from 6/11/25 to 8/9/25 and 8/10/25 to 10/8/25. * The Certification of Plan of Care dated 6/10/25, for the certification period from 6/11/25 to 8/9/25, and the Certification of Plan of Care dated 8/9/25, for the certification period from 8/10/25 to 10/8/25, showed the orders for disciplines and treatment which included the SN, HA, PT/OT/ST, Social Worker, Spiritual Care, Volunteer, and Bereavement. However, the POC failed to include specific scope and frequency of services as per the hospice's P&P. On 9/9/25 at 1355 hours, a follow up interview and concurrent closed record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the POCs included measurable outcomes for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14).  This failure had the potential risk of not evaluating the POC and providing appropriate care and services to these patients.Findings: --- 2. Review of Patient 1's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/2/24.  The patient was certified for hospice services during the period from  5/2/24 to 7/30/24.*The plan of care during the certification period from 5/2/24 to 7/30/24, showed the patient's identified problems included cardiac output/circulatory.   The goals were established for each identified problem.However, the goals listed were not measurable and specific to the patient’s needs.  For example, the goal for cardiac output/circulatory function was to display hemodynamic stability e.g. blood pressure, cardiac output, peripheral pulse, and renal perfusion. However, there was no documented evidence of the measurable outcome as to what the hemodynamic stability would be related to blood pressure, cardiac output, peripheral pulse, and renal perfusion.3.  Review of Patient 9's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 12/11/24.  The patient was certified for hospice services during the period from  12/11/24 to 3/10/25. The plan of care during the certification period from 12/11/24 to 3/10/25, showed the patient's identified problems included pain or discomfort.   The goals were established for each identified problem.  However, the goals listed were not measurable and specific to the patient’s needs.  For example, the goal for verbalizing understanding of non-pharmacological pain management techniques. the intervention included determine Patient's acceptable level of pain and teach Patient/Family/CG non-pharmacological techniques or alternate method of pain control.  However, there was no documented what was acceptable pain level for resident and non pharmacological intervention was effective for Patient.  4.  Review of Patient 11's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 1/16/25.  The patient was certified for hospice services during the period from  1/16/25 to 3/16/25.  The plan of care during the certification period from 1/16/25 to 3/16/25., showed the patient's identified problems included Impaired Gas Exchange (Dyspnea).   The goals were established for each identified problem. However, the goals listed were not measurable or specific to the patient’s needs. For example, the goal stated that the patient would demonstrate adequate breathing within their usual parameters and show no signs of respiratory distress. However, the care plan did not document what the patient’s usual respiratory parameters were.On 9/9/25 at 1500 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  Receptionist 1 was informed and acknowledged the finding.On 9/9/25 at 1545 hours, an interview  was conducted with QA.  QA was informed and acknowledged the finding.    Review of Patients 3, 7, 13 XXX clinical records were conducted and showed the POCs did not include measurable outcomes for the patients' identified problems.  For example: 1.  Review of Patient 13’s closed clinical record was initiated on 9/8/25.  The clinical record showed the SOC was 3/26/24.  The patient was certified for hospice service during the certification period from 1/20/25 to 3/20/25.    The plan of care during the certification period from 1/20/25 to 3/20/25, showed the patient's identified problems included cardiac output/circulatory; and pain/discomfort.  The goals were established for each identified problem.However, the goals listed were not measurable and specific to the patient’s needs.  For example, the goal for cardiac output/circulatory function was to display hemodynamic stability e.g. blood pressure, cardiac output, peripheral pulse, and renal perfusion. However, there was no documented evidence of the measurable outcome as to what the hemodynamic stability would be related to blood pressure, cardiac output, peripheral pulse, and renal perfusion.On 9/9/25 at 1100 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patients' POCs no less frequently than every 15 calendar days for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14).  This failure had the potential for not providing appropriate, consistent, and quality care to these patients.Findings: --- #. The hospice's P&P titled Interdisciplinary Group Meeting revised 4/2020, showed the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care and changes in the patients circumstances and recertification of patients on the hospice program.  Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires.  The procedure includes the members at the interdisciplinary group meetings will sign an attendance form that will be kept by the hospices' clinical supervisor. Review of Patient 4's closed clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/15/25.  The patient was certified for hospice services during the period from 5/15/25 to 8/12/25.  The patient was discharged from the hospice service on 7/21/25.Review of the closed clinical record showed the IDT Plan of Care & Review of the Comprehensive Assessment was conducted on 5/15, 5/29 and 6/12/25. However, review of the closed clinical record failed to show documented evidenced of an IDT was conducted after 6/12/25.In addition, review of the IDT Plan of Care & Review of the Comprehensive Assessment dated 5/15, 5/29 and 6/12/25, showed the members of the IDT.  The members includes RN, Physician, Social Worker, Spiritual Care, Volunteer, LVN, Hospice Aide and Others.  However, the IDT members were incomplete as the section for Social Worker, Spiritual Care, Volunteer, LVN, Hospice Aide and Others were left blank.On 9/9/25 at 1406 hours, an interview and concurrent closed record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #. Review of Patient 10's clinical record was initiated on 9/5/25.  The clinical record showed the SOC was 11/13/24. The patient was certified for hospice services during the periods from 6/11/25 to 8/9/25 and 8/10/25 to 10/8/25. Review of the clinical record for the certification periods from 8/10/25 to 10/8/25, showed the IDT Plan of Care & Review of Comprehensive Assessment was conducted on 8/14 and 8/28/25.  The members of the IDT showed the name of two RNs, the Medical Director and the Physician.  However, the IDT members were incomplete as the section for Social Worker, Spiritual Care, Volunteer, LVN, Hospice Aide and Others were left blank.On 9/9/25 at 1329 hours, an interview and concurrent closed record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #. Review of Patient 5's closed clinical record was initiated on 9/3/25.  The clinical record showed the SOC was 5/21/23. The patient was certified for hospice services during the periods from 5/21/23 to 8/18/23, 8/19/23 to 11/16/23, 11/17/23 to 1/15/24 and 1/6/24 to 3/15/24.  The patient was discharged from the hospice service on 3/5/24.  Review of the clinical record for the certification period from 8/19/23 to 11/16/23 failed to show documented evidenced of the IDG meeting was conducted every 15 days as per P&P. On 9/9/25 at 1108 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the finding.  The hospice’s P&P titled Interdisciplinary Group Membership and Responsibilities revised April 2020, showed the hospice interdisciplinary group membership includes at a minimum:a.  Physicianb.  Registered Nursec.  Social Workerd.  Pastoral or other counselorThe hospice’s P&P titled Interdisciplinary Group Meeting revised April 2020 showed the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths, and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program, Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently than every 15 days or more frequently if the patient condition requires. Members at the interdisciplinary group meeting will sign an attendance from that will be kept by the hospice Clinical Supervisor.Review of the clinical records for Patients XXXX  showed no documented evidence all IDG members had reviewed/revised the patient's POCs at least every 15 days.  For example:#.  Review of Patient 13’s closed clinical record was initiated on 9/8/25.  The clinical record showed the SOC was 3/26/24.  The patient was certified for hospice services during the certification period from 1/20/25 to 3/20/25.    The IDT Plan of Care & Review of the Comprehensive Assessment dated 1/16, 1/30, and 2/13/25, showed the IDT conducted the meetings.  Documentation showed the care plans were not updatedThere was no documented evidence all IDG members participated in the IDG meeting as the names of the MSW and Chaplain were not included.  There was also no documented evidence of the signatures of the RN and the physician.The 2025 IDT binder showed IDG meeting was conducted on 1/9, 1/23, and 2/6/25 with the Administrator, Medical Director, RN, MSW, and Chaplain, which were not consistent with the patient’s clinical record on the day the IDT meetings were held.On 9/8/24 at 1600 hours, an interview was conducted with the Administrator.  She stated the IDT meeting was conducted monthly. She stated the IDT was held at the office and attended by the Medical Director, another physician, RNs, LVNs, and Administrator.  She stated the MSW and Chaplain joined the IDT meeting via virtual communication. She stated the IDT discussed patient condition, medications, patient issues.  She stated the last IDT meeting was last held on 6/27/25.On 9/9/25 at 1100 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the finding.#.  Review of Patient 3's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 3/7/25.  The patient was certified for hospice services during the certification period from 6/5/25 to 9/2/25.The IDT Plan of Care & Review of the Comprehensive Assessment dated 6/5 and 6/19/25, showed the IDT conducted the meetings.   However, there was no documented evidence all IDT members participated in the IDT meetings as the names of the MSW and Chaplain were not included.  There was also no documented evidence of the signatures of the RN and the physicians.The 2025 IDT binder showed IDT meeting was conducted on 6/13 and 6/27/25 with the Administrator, Medical Director, RN, MSW, and Chaplain, which was not consistent with the patient’s clinical record on when the day the IDT meetings were held.Further review of the clinical record showed no documented evidence IDT meetings were held after 6/19/25 in the patient's clinical record.On 9/9/25 at 1144 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged of the finding.

Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing and supervising the care and services provided for nine of 14 sampled patients (2, 3, 5, 6, 8,10, 11, 12, and 14).  This failure created the risk of not addressing the care needs for these patients.Findings: --- #.  Review of Patient 8's clinical record was initiated on 9/4/25.  The clinical record showed the SOC was 10/15/24. The patient was certified for hospice services during the periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25. Review of the Physicians Order dated 6/11/25 showed an order for  "APP " to prevent pressure sore formation (Stage 1 and Stage 2 pressure "sores") and use Low Air Loss Mattress for wound Care Management.However, review of the clinical record failed to show documented evidenced of the patient was assessed to have pressure injury.Further review of the clinical record failed to show documented evidenced of the IDG had discussed and verified the use of " APP and LAL" mattress.On 9/9/25 at 1157 hours, a follow up interview and concurrent closed record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #.  Review of Patient 10's clinical record was initiated on 9/5/25.  The clinical record showed the SOC was 11/13/24. The patient was certified for hospice services during the periods from 6/11/25 to 8/9/25 and 8/10/25 to 10/8/25. Review of the Physicians Order dated 6/10/25 showed an order for  "APP " to prevent pressure sore formation (Stage 1 and Stage 2 pressure "sores") and use Low Air Loss Mattress for wound Care Management.However, review of the clinical record failed to show documented evidenced of the patient was assessed to have pressure injury.Further review of the clinical record failed to show documented evidenced of the IDG had discussed and verified the use of " APP and LAL" mattress.On 9/9/25 at 1355 hours, a follow up interview and concurrent closed record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.   #. Review of Patient 5's closed clinical record was initiated on 9/3/25.  The clinical record showed the SOC was 5/21/23. The patient was certified for hospice services during the periods from 5/21/23 to 8/18/23, 8/19/23 to 11/16/23, 11/17/23 to 1/15/24 and 1/6/24 to 3/15/24.  The patient was discharged from the hospice service on 3/5/24.  *Review of the clinical record for the certification period from 8/19/23 to 11/16/23 showed an SN visit.  However, there was no documented evidenced of the physicians order for the frequency of the SN visits.In addition, there was no documented evidenced for the visit frequency was coordinated with the physician. *Moreover, review of the clinical record for the recertification period from 8/19/23 to 11/16/23 failed to show documented evidenced of the coordination with the physician to address the patients services and care needs for the benefit period. On 9/9/25 at 1108 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the finding.  The agency’s P&P titled Interdisciplinary Group Plan of Care revised 4/2020, showed the hospice will utilize a case management system to guide an interdisciplinary group to provide comprehensive, coordinated health care to patients and families/caregivers service by the hospice. It will be the responsibility of the Clinical Supervisor to assign a Case Manager who is a registered nurse. The Case Manager will be responsible for coordination of services with the interdisciplinary group from referral to discharge. The type and scope of services provided by the interdisciplinary group will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goal and interventions.#. Review of Patient 2’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was 6/9/25. The patient was certified for hospice services during the certification period from 6/9/25 to 9/6/25.a.The initial nursing assessment dated 6/9/25 showed skin integrity was impaired with wound care on scrotum and perineal area. However, documentation does not show the patient’s status was reported to the attending physician.In addition, the IDT Plan of Care & Review of Comprehensive Assessment dated 6/12/25, showed moisture-associated skin damage (MASD) was present on the scrotum (part of the male reproductive system) and perineal area (skin located between the anus and external genitalia). The skin was managed with routine cleansing and moisture barrier application. However, there was no documented evidence the RN coordinated and followed up with the IDT regarding the recommended treatment plan to address Patient 2’s MASD.On 9/9/25 at 1055 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN stated there was no order for the wound care and confirmed the IDG did not discussed the MASD and eye problem.#.Review of Patient 6’s clinical record was initiated on 9/4/25. The clinical record showed the SOC was 11/13/24. The patient was certified for hospice during the certification periods from 7/11/25 to 9/8/25.a.Review of the Physician Order Details dated 7/3/25 showed an order for APP to prevent pressure sore formation (Stage 1 or 2 pressure sores) and use Low Air Loss mattress for wound care management.However, review of the clinical record failed to show documented evidence of the patient was assessed to have pressure injury.Further review of the clinical record failed to show documented evidence of the IDT had discussed and verified the use of APP and LAL mattress.b.Review of the nursing clinical note dated 7/17/25, showed a documentation patient had reported episodes of chest pain occurring approximately two times a day when not taking medication. Furthermore, the patient was recently diagnosed with dementia and neurologist reportedly plan to determine the severity of the cognitive decline. However, there was no documented evidence the RN 2 had coordinated and followed up with the IDT to address the patient’s episodes of chest pain and new diagnosis of dementia.   c.Review of the nursing clinical note dated 8/15/25, showed a documentation patient had reported an ongoing upset stomach and reflux symptoms for approximately two weeks. However, there was no documented evidence the RN 2 had coordinated and followed up with the IDT to address the patient’s ongoing upset stomach and reflux symptoms. On 9/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the findings.#.Review of Patient 12’s clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/28/24. The patient was certified for hospice during the certification period from 7/23/25 to 9/20/25.Review of the Physician Order Details dated 7/22/25 showed an order for APP to prevent pressure sore formation (Stage 1 or 2 pressure sores) and use Low Air Loss mattress for wound care management.However, review of the clinical record failed to show documented evidence of the patient was assessed to have pressure injury.Further review of the clinical record failed to show documented evidence of the IDT had discussed and verified the use of APP and LAL mattress.On 9/9/25 at 1330 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the findings.#.Review of Patient 14’s clinical record was initiated on 9/5/25. The closed clinical record showed the SOC was 7/8/24. The patient was certified for hospice services during the certification period 7/8/24 to 10/5/24. Patient 14 expired on 9/22/24.a. Review of the nursing clinical note dated 9/2/24, showed a documentation patient had a restless behavior. However, there was no documented evidence the LVN 1 had coordinated and followed up with the IDT to address the patient’s restless behavior.    b. Review of the Physician Order Details dated 7/8/24 showed an order for APP to prevent pressure sore formation (Stage 1 or 2 pressure sores) and use Low Air Loss mattress for wound care management.However, review of the clinical record failed to show documented evidence of the patient was assessed to have pressure injury.Further review of the clinical record failed to show documented evidence of the IDT had discussed and verified the use of APP and LAL mattress.c. a.Review of the initial nursing assessment dated 7/8/25, showed a coordination of care with the MSW. The narrative also showed the MSW will call and offer their services/support in about five days of admission. However, there was no documented evidence the MSW had called or visited the patient. On 9/9/25 at 1400 hours, an interview and concurrent closed record review was conducted with the QA/LVN. The QA/LVN stated there was no coordination with the Medical Director. The QA/LVN acknowledged and confirmed the finding. #.  Review of Patient 11's closed clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 1/16/25. The patient was certified for hospice services during the periods from 1/16/25 to 3/16/25 and 07/15/2025 - 09/12/2025. a.Review of the Initial Orders and Plan of Care for the certification period from 1/16/25 to 3/16/25 cited SN visit:  1st week - 1 to 2 visits, 1 PRN  for pain and symptom management and following weeks: 1 visit/week and 1 PRN for symptom management.Review of the clinical record failed to show documented evidenced of the SN visit was conducted on Week 2 (1/19/25 to 1/25/25), Week 4 (2/2/25 to 2/8/25 ), Week 6 ( 2/16/25 to 2/22/25) and Week 8 (3/2/25 to 3/8/25) as ordered on the POC. In addition, there was no documented evidenced of the physician was notified of the missed visit on Week 2, Week 4, Week 6 and Week 8.Further review of clinical record for the recertification period from 1/16/25 to 3/16/25 failed to show documented evidenced of an attempt to re-schedule a visit for the week and address the missing SN visit. Review of the clinical record for the recertification period from 1/26/25 to 4/16/25 failed to show IDT documented evidenced of the coordination with the physician regarding missing SN visit for the benefit period. b.Review of the clinical record for the certification period from 07/15/2025 to 09/12/2025 showed an SN visit. However, the clinical record failed to show documented evidenced of the SN visit was conducted on Week 2 (7/20/26 to 7/26/25), week 5 ( 8/10/25 - 8/16/25), and week 8 (8/31/25 to 9/6/25) as ordered by physician. Review of Certification Plan of care from 07/15/2025 to 09/12/2025 showed SN visit was left blank. Review of Physician order dated 7/14/25 showed Skilled Nursing visit frequency: 1 x week and as needed for pain, symptom management and crisis intervention.Review of the clinical record for the recertification period from 7/15/25 - 9/12/25 failed to show IDT documented evidenced of the coordination with the physician to address missing SN visits. On 9/9/25 at 1500 hours, an interview and concurrent closed clinical record review was conducted with Receptionist 1.  Receptionist 1 was informed and acknowledged the finding.  The P&P titled Interdisciplinary Group Membership and Responsibilities revised April 2020, showed the interdisciplinary group responsibilities include but are not limited to:a. Participation in the establishment of the plan of care for each patient admitted to hospice serviceb.  Participate in the periodic review and updating of the plan of care for each patient receiving hospice servicesc.  Taking a proactive approach in developing/revising the plan of care by planning ahead for anticipated patient changes and needs.  POC decisions should reflect the patient/family preferences rather than be solely a response to crisisd.  Provision and/or supervision and coordination of hospice care and servicese. 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 groupf. Establishment and implementation of policies and procedures governing the day-to-day provision of hospice care and services.g.  Reviewing and solving conflict of care and ethical issues.h.  Planning for community education regarding hospice services.i.  Participating in performance improvement activities. #.  Review of Patient 3's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 3/7/25.  The patient was certified for hospice services during the certification period from 6/5/25 to 9/2/25.The physician’s order dated 6/4/25, showed SN visit one time a week and PRN for pain, symptom management, and crisis interventionThe Collaboration Note dated 7/24/25, showed the visiting nurse noted a skin tear on the right forearm.  Documentation showed the physician was aware and a new order for wound treatment.  Documentation showed to cleanse right forearm skin tear with normal saline, pat dry, apply non adherent dressing, cover and secure with gauze, and change dressing as ordered or when soiled.The Collaboration Note dated 7/31/25, showed the visiting nurse noted an increase in the size of the right forearm skin tear.  Documentation showed the physician was made aware with a new order for the evaluation and treatment of the right posterior forearm wound by Wound Care Provider 1.The Wound Care Provider 1’s progress notes dated 8/5/25,  showed the plan and wound orders for the right arm wound included the following:-apply “TAO” and Xeroform (wound dressing) to the wound bed and cover with island dressing.  Change dressing three times a week (once by the wound specialist and twice by the home health nurse/staff) and as needed for soiled and dislodged dressing.The Wound Care Provider 2’s progress notes dated 8/11/25,  showed the treatment orders/notes for the right arm wound included the following:-cleanse the wound with wound cleanser and pat dry with gauze. Apply Tetracyte (antibiotic) to the wound bed, followed by Alginate Silver (wound dressing), cover with foam with silicone bordered dressing three times weekly and PRN for soiled or loose dressing.  Use bordered gauze between scheduled dressing changes and PRN for soiled or loose dressing.The Wound Care Provider 1’s progress notes dated 8/19 and 8/25/25, showed the plan and wound orders for the right arm wound included the following: apply silver calcium alginate to the wound bed and cover with island dressing.  Change dressing three times weekly  (once by the wound specialist and twice by the home health nurse/staff) and as needed for soiled or dislodged dressing.The clinical record showed the SN visited one time a week during the certification period from 6/5/25 to 9/2/25.However, there was no documented evidence the SN coordinated the right forearm wound care with Wound Cre Provider 1 and 2 related to the frequency of visits and the treatment to be provided.The IDT failed to provide supervision and coordination related on the care of the right forearm wound.On 9/9/25 at 1144 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged of the finding.

Based on interview and record review, the hospice failed to maintain a system of communication and integration to ensure the care and services were provided in accordance with the POC for nine of 14 sampled patients (Patients 4, 6, 7, 8, 9, 10, 11, 12 and 14).  This failure created the risk of not providing appropriate, consistent, and quality care to the patients. --- 1.  Review of Patient 9's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 12/11/24.  The patient was certified for hospice services during the period from 12/11/24 to 3/10/25.Review of the Initial Orders and Plan of Care for the certification period from 12/11/24 to 3/10/25, cited SN visit 1 to 2 visits and1 PRN visit for pain and symptom management for the first week and 1 visit/week and 1 PRN visit for symptom management for the following weeks.Review of the clinical record failed to show documented evidence of the SN visit conducted during Week 3 (12/22/25 to 12/28/25), Week 6 (1/12/25 to 1/18/25 ), Week 7 ( 1/19/25 to 1/25/25) ,Week 9 (2/2/25 to 2/8/25), and Week 11 (2/16/25 to 2/22/25) as cited in the POC. Further review of clinical record failed to show documented evidence of an attempt to re-schedule the visits for the above weeks.On 9/9/25 at 1500 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  Receptionist 1 was informed and acknowledged the finding.2.  Review of Patient 11's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 1/16/25.  The patient was certified for hospice services during the period from 1/16/25 to 3/16/25.  Review of the Initial Orders and Plan of Care for the certification period from 1/16/25 to 3/16/25, cited SN visits 1 to 2 visits and 1 PRN visit for pain and symptom management for the first week and 1 visit/week and 1 PRN visit for symptom management for the following weeks.Review of the clinical record failed to show documented evidence of the SN visit conducted during Week 2 (1/19/25 to 1/25/25), Week 4 (2/2/25 to 2/8/25 ), Week 6 ( 2/16/25 to 2/22/25), and Week 8 (3/2/25 to 3/8/25) as cited in the POC. Further review of clinical record failed to show documented evidence of an attempt to re-schedule for the visits for the above weeks.On 9/9/25 at 1500 hours, an interview and concurrent clinical record review was conducted with the Receptionist 1.  Receptionist 1 was informed and acknowledged the finding.3.  Review of Patient 7’s clinical record was initiated on 9/4/25.  The clinical record showed the SOC was 11/13/24.  The patient was certified for hospice services during the certification period from 7/11/25 to 9/8/25.   The recertification CTI during 7/11/25 to 9/8/25, showed SN visits 1-2 visits for the first week and 1 PRN visits for pain and symptom management, then 1 visit per week and 1 PRN visit per week for symptom management for the following weeksThe SN notes showed no documented evidence of SN visits for Week 3 (7/20/25 to 7/26/25), Week 5 (8/3/25 to 8/9/25), Week 7 (8/17/25 to 8/23/25) and Week 8 (8/24/25 to 8/30/25).On 9/9/25 at 1220 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the findings.4. Review of Patient 6’s clinical record was initiated on 9/4/25.  The clinical record showed the SOC was 11/13/24.  The patient was certified for hospice during the certification periods from 7/11/25 to 9/8/25.The Physician Order Details dated 7/3/25, for the recertification period 7/11/25 to 9/8/25, showed SN visit frequency one time a week and as needed for pain, symptom management, and crisis intervention.However, the SN notes showed no documented evidence the SN conducted a visit during Week 3 (7/20/25 to 7/26/25), Week 5 (8/3/25 to 8/9/25), and Week 7 (8/17/25 to 8/23/25). Review of the Physician Order Details dated 7/2/25, showed the HA, MSW, Chaplain, and Volunteer were declined.   Documentation showed to continue to offer services on a monthly basis when services were declined. However, there was no documented evidence the HA, MSW, Chaplain and Volunteer services were offered monthly.  On 9/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the QA/LVN.  The QA/LVN was informed and acknowledged the findings.5. Review of Patient 12’s clinical record was initiated on 9/5/25.  The clinical record showed the SOC was 7/28/25.  The patient was certified for hospice during the certification period from 7/23/25 to 9/20/25.Review of the Physician Order Details dated 7/22/25, showed the HA, MSW, Chaplain, and Volunteer were declined.  Documentation showed to continue to offer services on a monthly basis when services were declined.However, there was no documented evidence the HA, MSW, Chaplain and Volunteer services were offered monthly.  On 9/9/25 at 1330 hours, an interview and concurrent clinical record review was conducted with the QA/LVN.  The QA/LVN was informed and acknowledged the finding.6. Review of Patient 14’s closed clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/8/24. The patient was certified for hospice during the certification period from 7/8/24 to 10/5/24.  Patient 14 had expired on 9/22/24.a.  The Physician Order Details dated 7/8/24, showed SN visit frequency one time a week and as needed for pain, symptom management, and crisis intervention.However, the SN notes showed no documented evidence the SN conducted a visit during Week 11 (9/15/24 to 9/21/24). b.  Review of the Physician Order Details dated 7/8/24, showed the HA, MSW, Chaplain, and Volunteer were declined.  Documentation showed to continue to offer services on a monthly basis when services were declined.However, there was no documented evidence the HA, MSW, Chaplain and Volunteer services were offered monthly.  On 9/9/25 at 1400 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the findings.7. Review of Patient 4's closed clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/15/25.  The patient was certified for hospice services during the period from 5/15/25 to 8/12/25.  The patient was discharged from the hospice on 7/21/25.Review of the Initial Orders and Plan of Care for the certification period from 5/15/25 to 8/12/25, cited SN visit 1 to 2 visits and 1 PRN visit for pain and symptom management for the first week and 1 visit/week and 1 PRN visit for symptom management for the following weeks.Review of the closed clinical record failed to show documented evidenced the SN visit was conducted during Week 2 (5/18 to 5/24/25) as cited in the POC. Further review of the closed clinical record failed to show documented evidence of an attempt to re-schedule a visit for the week.On 9/9/25 at 1406 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the finding. 8. Review of Patient 8's clinical record was initiated on 9/4/25.  The clinical record showed the SOC was 10/15/24. The patient was certified for hospice services during the periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25. a. The Physicians Order dated 6/11/25, for the certification period 6/12/25 to 8/10/25, cited SN visit 1 time a week and PRN visits for pain, symptom management, and crisis intervention.However, review of clinical record failed to show documented evidence of the SN visit one time a week as ordered by the physician during the following weeks:-Week 7 (7/20/25 to 7/26/25)-Week 8 ( 7/27/25 to 8/2/25)-Week 9 (8/3/25 to 8/9/25).Further review of the clinical record failed to show documented evidence of an attempt to re-schedule the visit for those weeks. b. The Physicians Order dated 7/30/25, for the certification period 8/11/25 to 10/9/25, cited SN 1 time a week and PRN visits for pain, symptom management, and crisis intervention.However, review of clinical record failed to show documented evidence of the SN visits during Week 2 (8/17/25 to 8/23/25) and Week 4 (8/31/25 to 9/6/25) as ordered by the physician.  There was no documented evidence of an attempt to re-schedule the visit for those weeks.  In addition, there was no documented evidence of the physician was notified of the missed visits.On 9/9/25 at 1157 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings. 9.  Review of Patient 10's clinical record was initiated on 9/5/25.  The clinical record showed the SOC was 11/13/24. The patient was certified for hospice services during the periods from 6/11/25 to 8/9/25 and 8/10/25 to 10/8/25. a. The Physicians Order dated 6/10/25, for the certification period 6/10/25 to 8/10/25, cited SN 1 time a week and PRN visits for pain, symptom management, and crisis intervention.However, review of clinical record failed to show documented evidence of the SN visit one time a week as ordered by the physician during the following weeks:- Week 1 (6/11/25 to 6/14/25),- Week 2 (6/15/25 to 6/21/25),- Week 4 (6/29/25 to 7/5/25),- Week 5 (7/6/25 to 7/12/25) and- Week 7 (7/20/25 to 7/26/25)Further review of the clinical record failed to show documented evidence of an attempt to re-schedule the visit for those weeks.b.  The Physicians Order dated 8/9/25 for the certification period 8/10/25 to 10/8/25, cited SN 1 time a week and PRN visits for pain, symptom management, and crisis intervention.However, review of clinical record failed to show documented evidence of the SN visit one time a week as ordered by the physician during the following weeks:-Week 1 ( 8/10/25 to 8/16/25),-Week 3 ( 8/24/25 to 830/25) and-Week 4 ( 8/31/25 to 9/6/25).Further review of the clinical record failed to show documented evidence of an attempt to re-schedule the visit for those weeks.On 9/9/25 at 1355 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to measure and track quality indicators including aspects of performance that enabled the hospice to assess processes of care, hospice services, and operations for their QAPI program for the years of 2023, 2025, and 2025.  This failure created the risk of not identifying areas for performance improvement to improve care and services provided to the patients.Findings: --- The hospice’s P&P QAPI revised April 2020 showed senior management, as designed by the Governing Body, will have the responsibility of quality management: to guide the organizational efforts in improving organizational performance in governance, management, clinical, and support activities; to define expectations of hospice’s performance improvement activities; and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications.Review of the hospice's quarterly QAPI meeting minutes for the years of 2023, 2024, and 2025 was conducted on 9/8/25.The 1st, 2nd, 3rd, and 4th Quarterly Performance Improvement Report undated showed the topics discussed in the meetings included pain management, fall risk assessment, medication reconciliation, infection control monitoring, and business operations.  Documentation showed the same information for all the quarters of 2023.The 1st, 2nd, 3rd, and 4th quarters of 2023 QAPI/PIP Committee Meeting dated 3/20, 6/20, 9/20, and 12/20/23, showed the QAPI committee discussed several topics. However, in all quarters of the 2023 QAPI/PIP Committee Meeting, there was no documented evidence of the measuring and tracking of some of the quality indicators.  For example:The 1st quarter of 2023 dated 3/20/25, showed the QAPI discussed the following: annual QAPI plan review, infection control baseline, high risk medication safety project launch, census and patient data review, staff education needs, and satisfaction survey review.However, there was no documented evidence of the measuring and tracking of some of the quality indicators such as high-risk medication safety project launch, census and patient data review, staff education needs, and satisfaction survey review which would enable the hospice to assess processes of care, hospice services, and operation.The Attendance Sheet for the QAPI/Meeting/Annual Program Review dated 1/3/23, 1/3/24, and 6/27/25, showed the Medical Director, Administrator, and DPCS attended the meeting, wherein the dates documented as attendance were annual.However, there was no documented evidence of who attended the quarterly QAPI meetings as there was no attendance sheet provided.On 9/8/25 at 1600 hours, an interview and document review was conducted with the Administrator.  She stated the QAPI meetings were conducted quarterly and attended by the Administrator, DPCS, and sometimes the Medical Director.  She stated the QAPI committee discussed pain management, complaints, visits, issues with the nurses, wound, delivery of the DMEs, and medications.  When asked if the hospice had documentation of audits conducted.  She was unable to provide documentation of audits.  She stated the QAPI nurse would go online and message the nurses via the EMR.  On 9/9/25 at 1530 hours, an interview and concurrent record review was conducted with the QA/LVN.  He was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the hospice’s performance improvement activities for the QAPI programs for 2023 and 2025 were focused on high risk, high volume, or problem-prone areas.  This failure created the risk of not including relevant data for performance improvement to improve care and services provided to the patients.Findings: --- Review of the hospice's QAPI programs for the years of 2023, 2024, and 2025 was conducted on 9/8/25.The 2023 QAPI project was for the high risk medication safety.The 2025 QAPI project was for preventing and managing skin infections in the hospice patients.Documentation showed the QAPI committee identified the above QAPI projects as high priority/focus.However, there was no documented evidence showing the hospice’s performance improvement projects for 2023 and 2025 were high risk, high volume or problem prone areas as there was no data/information collected on these areas.On 9/9/25 at 1530 hours, an interview and concurrent record review was conducted with the QA/LVN.  He was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to document measurable progress achieved on the 2023 and 2025 PIPs.  This failure created the risk of not identifying the opportunity for improvement for care and services provided to the patients.Findings: --- Review of the QAPI program for the years of 2023, 2024,and 2025 was conducted on 9/8/25The QAPI project for 2023 was for high risk medication safety.The QAPI project for 2025 was for preventing and managing skin infections in hospice patients.Review of the QAPI documents showed no documented evidence the measurable progress achieved were conducted on these PIPs. There was no documented evidence of data monitoring/collection for the 2023 and 2024 PIPs.On 9/9/25 at 1530 hours, an interview and concurrent record review was conducted with the QA/LVN.  He was informed and acknowledged the findings.

Based on observation, interview, and record review, the hospice failed to implement infection control practices related bag technique for one of 14 sampled patients (Patient 3).  This failure had the potential to spread the risk of infection.Findings: --- The hospice’s P&P titled Bag Technique revised April 2020 showed when the visit is completed, reusable equipment will be cleansed using alcohol, soap and water, or other appropriate solution, hands will be washed and equipment and supplies will be returned to the bag.  Hands will be decontaminated prior to returning the clean equipment to the bag.Review of Patient 3's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 3/7/25.  The patient was certified for hospice service during the certification period from 6/5/25 to 9/2/25.On 9/4/25 at 1200 hours, a joint home visit was conducted with HA 2  to Patient 3’s home.HA 2 performed hand washing and donned gloves.  HA 2 removed the BP machine and pulse oximeter from the bag and placed the BP cuff on the patient’s left wrist.  HA 2 took the BP reading. HA 2 removed the BP machine from the patient, cleansed the BP machine with the disinfecting wipe, and placed the BP machine back inside the bag.  HA 2 placed the pulse oximeter on the patient’s right thumb and took the reading. HA 2 removed the pulse oximeter from the patient, cleansed the pulse oximeter with the disinfecting wipe, and placed the oximeter back inside the bag.However, HA 2 utilized the same gloves when the BP machine and pulse oximeter were taken out, utilized, cleansed, and returned back to the bag.  HA 2 did not decontaminate the hands prior to returning the clean equipment to the bag.On 9/4/25 at 1320 hours, the HA was informed of the finding.On 9/9/25 at 1144 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged of the finding.

Based on interview and record review, the hospice failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infections that was an integral part of the hospice's QAPI program.  This failure created the risk of spread of infections and not improving the infection control program.Findings: --- Review of the agency's P&P titled Evaluating and Maintaining Records of Infections Among Patients revised April 2020 showed:- All patients with a new, actual, or suspected infection will have a patient infection report completed within 24 hours of discovery.  If trends are discovered, target surveillance or problem-oriented surveillance may be initiated for specific high-risk patient populations if high volume, problem-prone areas are identified.- The Infection Identification-Patient Report Form is completed when any of the following occur:a.  A new, actual, or suspected infection is clinically observed by a personnelb.  A Culture is ordered and performed, and the results are positivec.  A new antibiotic is orderedd.  A patient is admitted to a hospital due to an actual or suspected infectione.  An unanticipated death due to an actual or suspected infectionf.  A major permanent loss of function associated with an actual or suspected infectiong.  A reportable, communicable infection is identifiedh. Patient has temperatures greater than 101 degrees Fi.  Patient has conjunctivitis- The Case Manager or the nurse caring for the patient in his/her absence should complete the Infection Identification Patient Report within 24 hours of discovering the infection.- Each section of the report should be completed in its entirety.-  If patient was admitted to home care from a hospital and a new infection was identified by the clinician within the first 48 hours of service, the source of the suspected infection may be nosocomial.-   After completion, the original form will be sent to the Performance Improvement Coordinator, and a copy will be submitted to the appropriate personnel for follow-up.- The Performance Improvement Coordinator summarizes, trends, and analyzes the reports.  The breakdown and summary may include, but will not be limited to:a.  Number of infection typesb.  Sources of infectionc.  Diagnosesd.  Age/sex of patientse.  Family/caregiverf.  Pathogens, if identifiedg.  Follow-up taken- The Performance Improvement Coordinator, in conjunction with the Program Supervisor, will investigate possible causal factors and recommend appropriate action to contain the transmission of the infection.  Actions may include implementing target or problem surveillance to aid in identifying causal factors and appropriate recommendations.- A report on infections will be given at each Performance Improvement Committee meeting.  A summary will be forwarded to the Professional Advisory Committee.- Information from the summary, analysis, and discussion will be used as part of the organization’s risk analysis and annual evaluation of the organization’s infection prevention and control activities. Review of Patient 13’s closed clinical record was initiated on 9/8/25.  The clinical record showed the SOC was 3/26/24.  The patient was certified for hospice service during the certification periods from 3/26/24 to 6/23/24, 6/2/24 to 9/21/24, 9/22/24 to 11/20/24, 11/21/24 to 1/19/25, and 1/20/25 to 3/20/25.  The physician’s order dated 6/21/24, showed nitrofurantoin (antibiotic) 100 mg one tablet daily for seven days “URINARY ANTI-INFECTIVES.”The physician’s order dated 8/18/24, showed ciprofloxacin hcl (antibiotic) 0.3% drops two drops to affected eye Q four hours for five days. Review of the 2024 infection control program documents showed the following:The Infection Control Report Statistics from 1/1/24 to 12/31/24, showed no infection for the year of 2024.The Infection Control Report from 1/1/24 to 12/31/24, showed no infection information.However, the information on the number of cases of infections in the Infection Control Report was inaccurate.  In addition, there was no documented evidence an individual Patient Report Form was completed for the antibiotics ordered for Patient 13.There was no documented evidence of tracking and trending the types of infection identified with Patient 13 and analyzed/investigated the possible causal factors.On 9/9/25 at 1432 hours, an interview and concurrent record review was conducted with the QA/LVN.  He was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the RN provided timely supervision to the LVNs to assess the quality of care and services provided for three of 14 sampled patients (Patient 2, 3, and 14). This failure had the potential of not providing the appropriate, consistent, and quality care to the patients.Findings: --- #.  Review of Patient 3's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 3/7/25.  The patient was certified for hospice services during the certification period from 6/5/25 to 9/2/25.The physician’s order dated 6/4/25, showed SN visit one time a week and PRN for pain, symptom management, and crisis intervention.Review of the clinical record during the certification period from 6/5/25 to 9/2/25, showed the LVN conducted the SN visits.  However, there was no documented evidence of a RN supervision for the LVN during the certification period 6/5/25 to 9/2/25.On 9/9/25 at 1144 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged of the finding. #. Review of Patient 2’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was 6/9/25. The patient was certified for hospice services during the certification period from 6/9/25 to 9/6/25.Further review of the clinical record showed an RN did not conduct a supervisory visit for LVN 2. On 9/9/25 at 1055 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN stated an LVN requires a supervisory visit every two weeks. The QA/LVN acknowledged the above finding. #. Review of Patient 14’s closed clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/8/24. The patient was certified for hospice services during the certification period 7/8/24 to 10/5/24. Patient 14 expired on 9/22/24.Further review of the clinical record showed and RN did not conduct a supervisor visit for LVN 1.On 9/9/25 at 1400 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN stated an LVN requires a supervisory visit every two weeks. The QA/LVN acknowledged the above finding.

Based on record review and interview, the hospice failed to develop and implement the bereavement program as per the hospice's P&P to address the needs of the bereaved family members for two of two sampled expired patients (Patients 13 and 14).  This failure created the increased risk of not addressing the bereavement needs of the bereaved family members.Findings: --- xx.Review of Patient 14’s closed clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/8/24. The patient was certified for hospice during the certification period from 7/8/24 to 10/5/24. Patient 14 expired on 9/22/24.Review of the bereavement binder showed a photocopy of a sympathy card sent to the patient’s family/caregiver dated September 2024. However, there was no documented evidence of the exact date when the sympathy card was mailed and if it was within two weeks after the death of the patient.On 9/9/25 at 1400 hours, an interview and concurrent closed clinical record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the findings. The hospice's P&P titled Bereavement Services revised 2020 showed the hospice will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for up to one year following the death of the patient. The program will be provided to the families/caregivers of the hospice patients both before and after the patient's death in accordance with the plan of care. A bereavement risk assessment will be completed by the hospice social worker at the time of admission to the hospice.  Information gathered will be incorporated into the plan of care and considered in the plan of care.  After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented as needed.  After a death has occurred, the bereavement assessment will be updated, and the family/caregiver needs will be discussed at the next interdisciplinary meeting.After a death has occurred, the bereavement assessment will be updated and the family/caregiver needs will be discussed at the next IDG meeting.- Within two weeks after death of a patient, a sympathy card will be sent to the bereaved.- After three weeks, a bereavement letter will be sent to the bereaved giving support and outlining the hospice bereavement services.- Within three to five weeks after the patient's death, a bereavement assessment will be completed by the bereavement counselor following the family caregiver.- If a person is noted as experiencing normal grief, the bereavement counselor will make contact with the bereaved person for ongoing assessment and support at three, six, and nine months after the patient's death and at the anniversary of the patient's death.- The bereavement counselor will make information available to the bereaved person regarding bereavement support groups, other support groups available in the community, and the availability of individual counseling by the hospice personnel.In addition to the services outline above, persons deemed to be experiencing moderate or severe grief will be followed by the bereavement program with increased services and contact offered as noted in the plan of care.Ongoing bereavement program will be concluded at the end of up to one year, if the bereaved is no longer in need of hospice bereavement services.Review of the hospice's bereavement program showed the following:1.  Review of Patient 13’s closed clinical record was initiated on 9/8/25.  The clinical record showed the SOC was 3/26/24.  The patient was certified for hospice service during the certification period from 1/20/25 to 3/20/25.  The patient expired on 2/24/25.There was no documented evidence of a bereavement risk assessment was completed by the hospice at the time of admission as per the hospice’s P&P.  Cross Reference L0531, Example #1.There was no documented evidence of an updated bereavement risk assessment completed by the hospice after the patient’s death had occurred, and the family/caregiver needs were discussed at the next interdisciplinary meeting as per the hospice’s P&P.There was a sympathy card sent to the bereaved.  However, there was no documented evidence when it was sent.There was no documented evidence a bereavement letter was sent three weeks after the patient’s death to the bereaved giving support and outlining the hospice bereavement services as per the hospice’s P&P.There was no documented evidence a bereavement assessment was completed by the bereavement counselor within three to five weeks after the patient's death as per the hospice’s P&P.On 9/9/25 at 1100 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the finding.2.  Review of Patient 14’s closed clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/8/24. The patient was certified for hospice during the certification period from 7/8/24 to 10/5/24. Patient 14 expired on 9/22/24.Review of the bereavement binder showed a photocopy of a sympathy card sent to the patient’s family/caregiver dated September 2024. However, there was no documented evidence of the exact date when the sympathy card was mailed and if it was within two weeks after the death of the patient.On 9/9/25 at 1400 hours, an interview and concurrent closed clinical record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the written patient care instructions for the HAs were developed accurately and timely by the RN who was responsible for the supervision of the HAs for two of 14 sampled patients (Patient 2 and 3). This failure had the potential of not addressing the care needs for these patients.Findings: --- xx. Review of Patient 2’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was 6/9/25. The patient was certified for hospice services during the certification period from 6/9/25 to 9/6/25.Review of the HA Assignment dated 6/9/25 showed the HA assignment included bath. The task showed a checked mark on tub, bed-partial, bed-complete. Review of HA 1 visit notes dated 6/19/25, 6/11/25, 6/13/25, 6/16/25, 6/18/25, 6/20/25, 6/25/25, 6/27/25, 6/30/25, 7/2/25, 7/4/25, 7/7/25, 7/9/25, showed HA 1 had completed and marked the section for bath for tub, bed-partial and bed-complete. However, the assignment completed was inaccurate.A joint home visit with LVN 2 was conducted on 9/4/25 at 1030 hours, to Patient 2’s home. The patient and PCG was asked what kind of bath was provided to the patient. Both stated complete bed bath because patient was unable to get up from bed. The LVN 2 had acknowledged the finding.On 9/9/25 at 1055 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the finding. Review of Patient 3's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 3/7/25.  The patient was certified for hospice services during the certification period from 6/5/25 to 9/2/25.The Hospice Aide Care Plan dated 3/10/25, showed HA twice a week to perform assigned tasks.Review of the clinical record during the certification period from 6/5/25 to 9/2/25, showed the HA conducted visits.  However, there was no documented evidence the RN updated the Hospice Aide Care Plan during the certification period from 6/5/25 to 9/2/25, as the Hospice Aide Care Plan was developed on 3/10/25.On 9/9/25 at 1144 hours, an interview and concurrent clinical record review was conducted with Receptionist 1. She stated there should be an updated HA care plan for the certification period from 6/5/25 to 9/2/25.  She was informed and acknowledged of the finding.

Based on observation, interview, and record review, the hospice failed to ensure the HA reported changes in the patient's nursing needs to the RN for one of 14 sampled patients (Patient 3).  This failure created the risk of not providing appropriate, consistent, and quality care to the patient.Findings: --- The hospice's P&P titled Hospice Aide Services revised April 2020 showed hospice aide assignments, plan of care, and interventions will be documented and included in the patient’s clinical record.  Hospice aide duties include reporting changes in the patient’s condition and needs.Review of Patient 3's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 3/7/25.  The patient was certified for hospice services during the certification period from 6/5/25 to 9/2/25.On 9/4/25 at 1200 hours, a joint home visit was conducted with HA 2 to Patient 3’s home.Patient 3’s hands were closed tightly with the fingers inwards the palm and hand rolls were inside the patient’s hands.   HA 2 removed both hand rolls from the patient’s hands. HA 2 cleaned both of the patient's hands. The patient had episodes of yelling when the right and left hands were cleaned. HA 2 stated the patient got agitated and screamed when both hands were cleaned.  HA 2 stated she thought the patient would have pain level of 8 (on a 0-10 pain scale with 0=no pain and 10 =worst pain) when cleaning the patient’s hands.  HA 2 stated the patient’s hands were closed fist and the left hand is tighter than the right.  HA  2 stated the family member told HA 2 that the patient was pre-medicated with pain medication prior to HA 2’s care.  HA 2 stated the family member wanted both hands to be cleaned.  HA 2 stated the licensed nurse was aware of the patient’s response when the hands were being cleaned but unable to provide the name of the licensed nurse.However, further review of the clinical record showed no documented evidence HA 2 coordinated with the RN/LVN about the patient’s yelling and agitation when both hands were cleaned.On 9/9/25 at 1144 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged of the finding.

Based on observation, interview, and record review, the hospice failed to ensure the RN provided timely supervision to the HAs to assess the quality of care and services provided for two of 14 sampled patients (Patients 2 and 3).  This failure had the potential of not providing the appropriate, consistent, and quality care to the patients.Findings: --- xx. Review of Patient 2’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was 6/9/25. The patient was certified for hospice services during the certification period from 6/9/25 to 9/6/25.Further review of the clinical record showed an RN did not conduct a supervisory visit for HA 1.On 9/9/25 at 1055 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN stated an HA requires a supervisory visit every two weeks. The QA/LVN acknowledged the above finding.  Review of Patient 3's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 3/7/25.  The patient was certified for hospice services during the certification period from 6/5/25 to 9/2/25.The Hospice Aide Care Plan dated 3/10/25, showed HA twice a week to perform assigned tasks.Review of the clinical record during the certification period from 6/5/25 to 9/2/25, showed the HA conducted visits.  However, there was no documented evidence the RN conducted HA supervision every 14 days during the certification period from 6/5/25 to 9/2/25.On 9/9/25 at 1144 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged of the finding.

Based on interview and record review, the hospice failed to ensure the volunteer services were provided to meet the patient’s care needs as evidenced by: --- 1.The hospice failed to maintain, document, and provide the training to the volunteer.  Cross reference to L643.2.The hospice failed to ensure the Volunteer was used in day-to-day administrative role.  Cross reference to L644.3.The hospice failed to document and demonstrate viable and ongoing efforts to recruit volunteers for the years of 2023, 2024 and 2025.  Cross reference to L645.4.The hospice failed to ensure the volunteers provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals five percent of the total care hours of all paid hospice employees and contract staff.  Cross reference to L647.The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with volunteer services to ensure the provision of quality healthcare provided to meet the patients' needs.

Based on record review and interview, the hospice failed to maintain, document, and provide the training to the volunteer.  This failure created the increased risk of having inadequate knowledge of hospice program to meet the patients' needs.Findings: --- The hospice's P&P titled Volunteer Services dated April 2020 showed the Volunteer Coordinator will develop, implement, and evaluate the volunteer services program on an ongoing basis but at least annually.  The Volunteer Coordinator will develop and implement a specialized volunteer orientation and training program that is sufficient to meet the needs of the patients and families and will include but will not be limited to history, philosophy, and structure of the hospice concept; volunteers' roles and responsibilities; and volunteer program policies.  The Volunteer Coordinator will document ongoing efforts to recruit. train and retain volunteers of all ages and ethnic backgrounds.Review of the Volunteer's personnel file showed the volunteer's start date was 6/5/23. The file showed the volunteer had an orientation on 6/5/23.* Further review of the personnel file showed no documented evidence of the volunteer training since 2023.An interview was conducted with the Administrator on 9/8/25 at 1500 hours.  When asked who the Volunteer Coordinator was, the Administrator stated the Chaplain was also the Volunteer Coordinator.On 9/8/25 at 1500 hours, an interview was conducted with the Chaplain.  When asked if he was the Volunteer Coordinator, the Chaplain stated not to his knowledge.On 9/9/25 at 1432 hours, an interview and concurrent record review was conducted with the QA/LVN.  He was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the volunteer was used in day-to-day administrative role.  This failure created the risk of operational strain on the hospice.Findings: --- Review of the Volunteer's personnel file showed the Volunteer's start date was 6/5/23.  The file showed the Volunteer had an orientation on 6/5/23.  The job description of the Volunteer included as an Office Services Volunteer.Further review of the hospice’s document showed no documented evidence the Volunteer was utilized as an Office Services Volunteer from the Volunteer's start date.On 9/9/25 at 1432 hours, an interview and concurrent record review was conducted with the QA/LVN.  He was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to document and demonstrate viable and ongoing efforts to recruit volunteers for the years of 2023, 2024, and 2025. This failure created the increased risk of not having an adequate number of volunteers to meet the patients' needs.Findings: --- Review the hospice's volunteer program for was conducted on 9/8/25.  The hospice's documents showed no recruitment activity records for the years of 2023, 2024, and 2025.  The hospice had one volunteer at this time.  An interview was conducted with the Administrator on 9/8/25 at 1500 hours.  When asked who the Volunteer Coordinator was, the Administrator stated the Chaplain was also the Volunteer Coordinator.On 9/8/25 at 1500 hours, an interview was conducted with the Chaplain.  When asked if he was the Volunteer Coordinator, the Chaplain stated not to his knowledge.On 9/9/25 at 1432 hours, an interview and concurrent record review was conducted with the QA/LVN.  He was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the volunteers provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff.  This failure created the risk of not addressing the patient’s needs.Findings: --- Review the hospice's volunteer program was conducted on 9/8/25.  The hospice's documents showed no documented evidence the volunteers provided day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff for the years of 2023, 2024, and 2025.On 9/9/25 at 1432 hours, an interview and concurrent record review was conducted with the QA/LVN.  He was informed and acknowledged the findings.

Based on interview and record review, the hospice's GB failed to assume full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operation, and continuous QAPI.  The Administrator failed to perform day-to-day operation to ensure compliance with the COPs under 418.54 (Initial & Comprehensive Assessment of Patient); 418.56 (Interdisciplinary Group, Care Planning, and Coordination of Services); and 418.78 (Volunteers).  In addition, the hospice's Administrator failed to be responsible for the day-to-day operations of the organization and maintain administrative and supervisory responsibility for all the care provided as follows: - The Administrator failed to ensure the written agreement for one  of five contractors (Medical Director) included the required elements related to supervision and evaluation of services in the contract as per the Standards of Quality Hospice Care, 2005. - The Administrator failed to ensure the performance evaluations were completed for two of seven employee files reviewed (MSW and HA 1). - The Administrator failed to ensure the job descriptions and certifications were included as part of the employee files for four of seven employee files reviewed (Chaplain, RN 3, LVN 2, and HA 1). - The Administrator failed to ensure the employee health screening were completed timely for two of seven employees (RN 2 and LVN 2) These failures had the potential to negatively impact the hospice's operational performance. Findings: --- #.  According to Standards of Quality Hospice Care, 2005 Article 6 Section 6.2 B(2) c (7), Contractual Service : Roles and responsibilities of the program and the contracted individual or organization in the following: Bereavement follow-up.Review of the Medical Director's contractual agreement was initiated on 9/8/25. However, there was no documented evidence that bereavement was included in the roles and responsibilities of the Medical Director in the agreement.on 9/9/25 at 1530 hour, an interview and concurrent record review with Receptionist 1.  The receptionist stated that she was unable to provide documentation outlining the roles and responsibilities of the Medical Director related to bereavement follow-up in the contractual agreement.  Receptionist 1 verified the findings.On 9/9/25 at 1600 hours, an interview  was conducted with the Administrator. The Administrator was informed of finding and verified the findings. b. Review of Hospice's P and P titled "Job Description" dated 4/20 showed Job descriptions for each category of employee will include information on: A. Lines of authority and reporting responsibilities, B.  Duties of the position, .    Qualifications including education, experience, knowledge, and skill set, D.  Continuing education requirements, E.   Environmental and working conditions F.    Physical requirements 2.    At the time of hire, each individual will receive and sign a job description specific to his/her position. 3.    By the end of orientation, personnel will be able to state his/her job responsibilities and identify the organization's chain of command.Review of RN 3’s personnel file was initiated on 9/8/25.  However, it was noted that the TB testing records, physical examination documentation, and signed job description were not available.On 9/9/25 at 1600 hours, an interview and concurrent personnel file review was conducted with the Administrator. The Administrator was informed of finding and verified the findings.  The hospice's P&P titled Governing Body revised April 2020 showed the Governing Body will appoint a qualified Executive Director/Administrator and establish procedures of systemic communication between the two.  Performance of the Executive Director/Administrator will be monitored annually through a procedure established by the Governing Body The hospice’s P&P titled Hospice Administrator revised April 2020 showed the Executive Director/Administrator shall be responsible for the direction, coordination, and general supervision of all hospice services.  Responsibilities of the position will include but are not limited to:-Planning, organizing, directing, and evaluating operations to ensure the provision of adequate and appropriate care and services.-Ensuring organizational compliance with legal, regulatory, and accreditation requirement.-Ensuring program personnel have current clinical information and current practices.-Directing and monitoring of quality assessment and performance improvement activities-Ensuring staff development including orientation, in-service education, continuing education, and competency evaluation.-Ensuring appropriate service policies are developed and implemented to accomplish identified outcomes-Assuring the development and qualifications for professional services and the assignment of personnel.-Ensuring the interdisciplinary care is promoted and provided and ensuring support services are available to staff. #.  The hospice failed to ensure the COPs under 418.54 (Initial & Comprehensive Assessment of Patient); 418.56 (Interdisciplinary Group, Care Planning, and Coordination of Services); 418.58 (Quality Assessment & Performance Improvement); 418.78 (Volunteers) and 418.100 (Organization and Administration of Services) were met.  Cross references to L520, L530, L559, L641, and L648. #. The hospice’s P&P titled Performance Evaluations revised April 2020, showed all organization personnel will be evaluated at periodic intervals by their supervisor based on the appropriate job description to determine strengths and areas requiring performance improvement. Performance evaluations will be completed (and dated) on all personnel as follows:-during the probationary period-at the end of the first three months of employment-annually based on personnel's annual evaluation date-after promotion/or transfer-other occasions, as performance warrants a.  Review of the employee file for MSW was initiated on 9/9/25.  MSW was hired on 10/20/21.However, the employee file showed no documented evidence the annual performance evaluations were completed from 2023 to 2024.b.  Review of the employee file for HA 1 was initiated on 9/9/25.  HA 1 was hired on 3/3/25.However, the employee file showed no documented evidence the performance evaluation at the end of the first three months of employment was completed.On 9/9/25 at 1500 hours, an interview and concurrent record review was conducted with the Administrator.  She was informed and acknowledged the findings. #.  The Hospice’s P&P titled Personnel Record Contents revised April 2020, showed the hospice will maintain current personnel files on all personnel.The content of the personnel files for regular full or part-time personnel will include-verified professional licensure or certification-signed job descriptiona.  Review of the employee file for Chaplain was initiated on 9/9/25.  Chaplain was hired on 1/1/23.However, the employee file showed no documented evidence of the signed job description for the Chaplain.On 9/9/25, an interview and employee file review was conducted with the Administrator.  She stated the Chaplain was also the Bereavement and Volunteer Coordinator.However, the employee file showed no documented evidence of the signed job description for the Bereavement and Volunteer Coordinator.b. Review of the employee file for HA 1 was initiated on 9/9/25.  HA 1 was hired on 3/3/25.However, the employee file showed no documented evidence of the HA’s certification.c. Review of the employee file for LVN 2 was initiated on 9/9/25.  LVN 2 was hired on 6/1/25.However, the employee file showed no documented evidence of the signed job description for LVN 2.On 9/9/25 at 1500 hours, an interview and concurrent record review was conducted with the Administrator.  She was informed and acknowledged the findings. #.  According to Standards of Quality Hospice Care, 2005 Article 6 Section 6.3 A(1) (2), all persons providing physician, nursing or home health aide services shall have a health examination by a physician, nurse practitioner or physician’s assistant six months prior to employment or within 14 days of the date of employment. Each examination shall include confirmation by the person performing the examination that the employee is physically and medically qualified to perform the duties to be assigned, and that employee has no health condition that would create a hazard to patients.The initial health examination shall include a tuberculosis screening. Tuberculosis screening shall occur annually thereafter. a.  Review of the employee file for LVN 2 was initiated on 9/9/25.  LVN 2 was hired on 6/1/25.The employee file of LVN 2 showed the employee health physical examination was performed on 7/10/25, which was more than 14 days of the date of employment.  In addition, there was no documented evidence of a TB screening performed.On 9/9/25 at 1500 hours, an interview and concurrent record review was conducted with the Administrator.  She was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the Certificate of Terminal Illness included a brief narrative explanation of the clinical findings for terminal illness for two of 14 patients (Patients 12 and 14).  This failure had the potential of not identifying the patient care needs for these patients. Findings: --- Review of the hospice’s P&P titled Certification of Terminal Illness revised 4/2020 showed hospice services will be provided in two 90-day periods and an unlimited number of 60-day periods, if the patient is recertified at the beginning of each benefit period.  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. 1.Review of Patient 12’s clinical record was initiated on 9/5/25.  The clinical record showed SOC was 7/28/24.  The patient was certified for hospice services during the certification period from 7/23/25 to 9/20/25. The Certification of Terminal Illness for the certification period from 7/28/24 to 10/25/24, showed the Medical Director’s brief narrative explanation did not include the clinical findings that supported a life expectancy of six months or less.  On 9/9/25 at 1330 hours, an interview and concurrent clinical record review was conducted with the QA/LVN.  The QA/LVN was informed and acknowledged the finding. 2. Review of Patient 14’s closed clinical record was initiated on 9/5/25.  The clinical record showed the SOC was 7/8/24.  The patient was certified for hospice during the certification period from 7/8/24 to 10/5/24.  Patient 14 had expired on 9/22/24. The Certification of Illness for the certification period 7/8/24 to 10/5/24, showed the section for the Medical Director's brief narrative explanation of the clinical findings that supported a life expectancy of six months or less was left blank.  On 9/9/25 at 1400 hours, an interview and concurrent clinical record review was conducted with the QA/LVN.  The QA/LVN was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the Medical Director or physician performed the face to face assessments and recertification of terminal illness for nine of 14 sampled patients (Patient 1, 5, 6, 7, 8, 9, 10, 12 and 13).  This failure had the potential of not providing necessary services for these patients. Findings: --- #.  Review of Patient 8's clinical record was initiated on 9/4/25.  The clinical record showed the SOC was 10/15/24. The patient was certified for hospice services during the periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25. Review of the clinical record showed a Physician Face -to -Face Encounter dated 4/10, 6/9, 8/8/25.  The Physician Face to Face Encounter showed the section for the benefit period, NP name/signature, hospice physicians name, signature and date was left  blank. However, the Physician Face -to-Face Encounter was not completed within 30 days prior to the benefit period as those sections were left blank.  In addition, the section for discipline showed the name of the Medical Director.  However the status showed "Not started".On 9/9/25 at 1157 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #.  Review of Patient 10's clinical record was initiated on 9/5/25.  The clinical record showed the SOC was 11/13/24. The patient was certified for hospice services during the periods from 6/11/25 to 8/9/25 and 8/10/25 to 10/8/25. a. Review of the clinical record failed to show documented evidenced of the Physician Face to face was completed within 30 days for the benefit period from 6/11/25 to 8/9/25. In addition, review of the clinical record failed to show documented evidenced of a Certification of Terminal Illness was completed for the benefit period from 6/11/25 to 8/9/25. b. Review of the clinical record showed a Physician Face -to -Face Encounter dated 8/7/25.  The Physician Face to Face Encounter showed the section for the benefit period, NP name/signature and date was blank.In addition, the section for the name, signature and date of the Hospice Medical Director or Designee was left blank. However, the Physician Face - to- Face Encounter was not completed within 30 days prior to the benefit period as those sections were left blank. Further review of the clinical record failed to show documented evidenced of the Certification of Terminal Illness was completed for the benefit period.On 9/9/25 at 1355 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings. #.  Review of Patient 5's closed clinical record was initiated on 9/3/25.  The clinical record showed the SOC was 5/21/23. The patient was certified for hospice services during the periods from 5/21/23 to 8/18/23, 8/19/23 to 11/16/23, 11/17/23 to 1/15/24 and 1/6/24 to 3/15/24.  The patient was discharged from the hospice service on 3/5/24.  Review of the clinical record for the certification period from 8/19/23 to 11/16/23 failed to show documented evidenced of a CTI was completed for the benefit period. Further review of the clinical record failed to show documented evidenced of a Physicians face to face encounter was completed for the benefit period. On 94/25 at 1102 hours, an interview and concurrent closed clinical record review was conducted with the Receptionist 1.  The Receptionist 1 was asked if the CTI and the face to face was completed for the benefit period.  The Receptionist 1 replied, it was not done. On 9/9/25 at 1108 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the finding.  #.Review of Patient 6’s clinical record was initiated on 9/4/25. The clinical record showed the SOC was 11/13/24. The patient was certified for hospice services during the certification period from 5/12/25 to 7/10/25 and 7/11/25 to 9/8/25.Review of Patient 6’s clinical record showed the certification periods from 5/12/25 to 7/10/25 and 7/11/25 to 9/8/25, however, there was no documented evidence of the face-to-face encounter performed by the Medical Director within the 30 days prior to the third and fourth benefit period certification.On 9/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN verified  there was no face-to-face done because there was no evidence or documentation of a face-to-face in the clinical record. #. Review of Patient 12’s clinical record was initiated on 9/5/25. The clinical record showed SOC was 7/28/24. The patient was certified for hospice services during the certification period from 7/23/25 to 9/20/25.Review of Patient 12’s clinical record showed the Certification of Terminal Illness for the certification periods from 10/26/24 to 1/23/25, 1/24/25 to 3/24/25, 3/25/25 to 5/23/25, and 7/23/25 to 9/20/25 showed a section of the form the hospice physician written certification which includes a brief explanation of the clinical findings that supports a life expectancy of six months or less. *However, the Medical Director’s brief narrative explanation did not include Patient 12’s clinical findings that supported a life expectancy of six months or less.In addition, the Certification of Terminal Illness for the certification period from 5/24/25 to 7/22/25 showed a section of the form the physician brief narrative statement that reviews the patient’s clinical circumstances and synthesize the medical information to provide clinical justification for continued hospice services.  *However, the section for the Physician Narrative Statement was blank.Review of Patient 12’s clinical record showed the certification periods from 1/24/25 to 3/24/25, 3/25/25 to 5/23/25, 5/24/25 to 7/22/25 and 7/23/25 to 9/20/25, however, there was no documented evidence of the face-to-face encounter performed by the Medical Director within the 30 days prior to the third, fourth, fifth and sixth benefit period certifications.On 9/9/25 at 1330 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN verified  there was no face-to-face done because there was no evidence or documentation of a face-to-face in the clinical record. #. Review of Patient 1’s clinical record was initiated on 5/2/24.  The clinical record showed the SOC was 5/2/24.  The patient was certified for hospice services during the certification periods from 5/2/24 to 7/30/24, 4/27/25 to 6/25/25, 6/26/25 to 8/24/25, 8/25/25 to 10/23/25. Review of the clinical record showed Physician Face-to-Face Encounters dated 10/28/24, 12/23/24, 2/24/25, 6/23/25 (listed twice), and 8/21/25. The Physician Face-to-Face Encounter forms had blank sections for the benefit period, NP name/signature, hospice physician’s name, signature, and date.However, the Physician Face -to-Face Encounter was not completed within 30 days prior to the benefit period as those sections were left blank.  In addition, the section for discipline showed the name of the Medical Director.  However the status showed "Not started".On 9/9/25 at 1500 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the findings. #.  Review of Patient 9’s clinical record was initiated on 9/4/25.  The clinical record showed the SOC was 12/11/24.  The patient was certified for hospice services during the certification periods from 12/11/24 to 3/10/25, 6/9/25 to 8/7/25, 8/8/25 to 10/6/25. Review of the clinical record showed Physician Face-to-Face Encounters dated 6/3/25, 8/5/25, and 10/3/25. The Physician Face-to-Face Encounter forms had blank sections for the benefit period, NP name/signature, hospice physician’s name, signature, and date.However, the Physician Face-to-Face Encounter was not completed within 30 days prior to the benefit period as those sections were left blank.  In addition, the section for discipline showed the name of the Medical Director.  However the status showed "Not started".On 9/9/25 at 1500 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the findings.  The hospice's P&P titled face to Face Encounter revised date April 2020 showed a face-to-face encounter will be performed for patients entering the third and all subsequent benefit periods. The hospice director or hospice employed nurse practitioner will perform face-to-face encounter within 30 days prior to the hospice certification for the third and all subsequent benefit periods.  The physician/NP who performs the face-to-face encounter will attest in writing that he/she had face to face encounter, including the date of the visit.  The NP must also attest that the clinical findings were provided to the certifying physician.   The face-to-face attestation must be signed and dated by the individual who performed the visit#.  Review of Patient 13’s closed clinical record was initiated on 9/8/25.  The clinical record showed the SOC was 3/26/24.  The patient was certified for hospice services during the certification periods from 3/26/24 to 6/23/24, 6/2/24 to 9/21/24, 9/22/24 to 11/20/24, 11/21/24 to 1/19/25, and 1/20/25 to 3/20/25. The patient expired on 2/24/25.* However, there was no documented evidence of the face to face encounter performed by the physician within the 30 days prior to the hospice certification for the third (9/22/24 to 11/20/24), fourth (11/21/24 to 1/19/25), and fifth (1/20/25 to 3/20/25) benefit period  as per the hospice's P&P.On 9/9/25 at 1100 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the finding.#.  Review of Patient 7’s clinical record was initiated on 9/4/25.  The clinical record showed the SOC was 11/13/24.  The patient was certified for hospice services during the certification periods from 11/13/24 to 2/10/25, 2/11/25 to 5/11/25, 5/12/25 to 7/10/25, 7/11/25 to 9/8/25.* However, there was no documented evidence of the face to face encounter performed by the physician within the 30 days prior to the hospice certification for the third (5/12/25 to 7/10/25) and fourth (7/11/25 to 9/8/25) benefit period as per the hospice's P&P.On 9/9/25 at 1220 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the clinical records were complete and accurate for nine of 14 sampled patients (Patients 1, 2, 4, 5, 6, 8, 11, 12, and 14).  This failure had the potential risk of substandard care provided to the patients as their clinical information were not accurate and complete.  Findings: --- #.  Review of Patient 4's closed clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/15/25.  The patient was certified for hospice services during the period from 5/15/25 to 8/12/25.  The patient was discharged from the hospice service on 7/21/25.The Initial Orders and Plan of Care for the certification period from 5/15/25 to 8/12/25, showed the orders for disciplines and treatment.  The section for the CHHA visits was checked "No". Review of the Nursing Clinical Notes dated 5/28, 6/3, 6/10, 6/17, 6/24, 7/1, 7/8 and 7/15/25 includes a section for Coordination and Collaboration of Care.  However, there was a check mark on the section for Hospice Aide which was inconsistent with the POC.On 9/9/25 at 1406 hours, a follow up interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was asked if the patient has seen by the hospice aide. The Administrator replied, it was an inaccurate documentation, the patient doesn't have an HA order.  The Administrator was informed and acknowledged the findings.  #.  Review of Patient 8's clinical record was initiated on 9/4/25.  The clinical record showed the SOC was 10/15/24. The patient was certified for hospice services during the periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25. a. Review of the Certification of Terminal Illness dated 7/30/25 for the certification period from 8/11/25 to 10/9/25, showed the names of RN 4 and RN 5. However, there was no documented evidenced of the specific RN who received the verbal certification as the section showed the names of RN 4 and RN 5. b. Review of the Certification of Plan of Care dated 7/30/25, showed the names of RN 4 and RN 5However, there was no documented evidenced of the specific RN who performed the initial plan of care as there were two names documented on the section for RN name and signature.c.  Review of the IDT Plan of Care & Review of Comprehensive Assessment showed the IDT Meeting date of 9/4/25.  The IDT members showed the RN 4, Medical Director and the Physician.However, based on observation and interview, there was no IDT meeting conducted on 9/4/25 as documented.On 9/4/25 at 1029 hours an interview and concurrent clinical record review was conducted with the Receptionist 1.  The Receptionist 1 was asked if there was an IDT meeting scheduled for the day.  The Receptionist 1 replied, No because the Medical Director is not available, the 9/4/25 IDT meeting notes auto populates. On 9/9/25 at 1157 hours, a follow up interview and concurrent closed record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #. Review of Patient 5's closed clinical record was initiated on 9/3/25.  The clinical record showed the SOC was 5/21/23. The patient was certified for hospice services during the periods from 5/21/23 to 8/18/23, 8/19/23 to 11/16/23, 11/17/23 to 1/15/24 and 1/6/24 to 3/15/24.  The patient was discharged from the hospice service on 3/5/24.  The Initial Nursing Comprehensive Assessment dated 11/13/24, showed the DPCS Designee/NP had performed the initial comprehensive assessment.  However, the visit verification signature was dated 10/27/23 which was more than five days from the initial comprehensive assessment. On 9/9/25 at 1108 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #. Review of Patient 1’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was 5/2/24. The patient was certified for hospice during the certification period from 5/2/24 to 7/30/24a. Review of the Consult for Release of Medical Info, showed the document was incomplete. The name of the patient, the recipient and the effective date of the authorization were blank.b. Review of the Covid-19 Vaccine Requirement was signed by the patient, however, the document was incomplete. The name of the patient and if the patient would request, refuse vaccination or would provide a written proof of vaccination or medical contraindication were not filled out.c .Review of the patient’s consent and statement regarding his/her physician’s care was signed by the patient, however the document was incomplete. The patient had not chosen for a primary care physician, or if physician does not want or does not have a primary care physician.d. Review of the photography consent form was signed by the patient, however, the document was incomplete. The date of birth was blank and patient did not check any of the appropriate boxes to give or refuse consent for photograph. #. Review of Patient 11’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was 1/16/25. The patient was certified for hospice during the certification period from 1/16/25 to 3/16/25. a. Review of the Consult for Release of Medical Info, showed the document was incomplete. The name of the patient, the recipient and the effective date of the authorization were blank.b. Review of the Covid-19 Vaccine Requirement was signed by the patient, however, the document was incomplete. The name of the patient and if the patient would request, refuse vaccination or would provide a written proof of vaccination or medical contraindication were not filled out.c .Review of the patient’s consent and statement regarding his/her physician’s care was signed by the patient, however the document was incomplete. The patient had not chosen for a primary care physician, or if physician does not want or does not have a primary care physician.d. Review of the photography consent form was signed by the patient, however, the document was incomplete. The date of birth was blank and patient did not check any of the appropriate boxes to give or refuse consent for photograph.On 9/9/25 at 1500 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  Receptionist 1 was informed above findings and acknowledged the findings. Receptionist 1 verified the findings.  Review of the hospice’s P&P titled Contents of Clinical Record  revised 4/2020, showed the clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel.#. Review of Patient 2’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was 6/9/25. The patient was certified for hospice services during the certification period from 6/9/25 to 9/6/25.a.Review of the initial nursing assessment dated 6/9/25, showed a coordination of care with the chaplain. However, the Initial Orders and Plan of Care dated 6/9/25, showed the spiritual care visit was declined which was inconsistent.b.Review of the Consult for Release of Medical Info, showed a blank document.c.Review of the Election of Medicare Hospice Benefit dated 6/9/25 showed a patient/responsible party signature dated 6/9/25. However, the patient name and SOC date were not indicated in the form.  On 9/9/25 at 1055 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN stated the inconsistency on the clinical records. The QA/LVN acknowledged the above finding. #. Review of Patient 6’s clinical record was initiated on 9/4/25. The clinical record showed the SOC was 11/13/24. The patient was certified for hospice during the certification periods from 7/11/25 to 9/8/25.a.Review of the Hospice Admission Service Agreement dated 11/13/24 showed Patient 6’s electronic signature on the form. However, the document was not under the name of Patient 6.  b.Review of the Photography Consent Form dated 11/13/24 showed Patient 6’s electronic signature on the form. However, the document was not under the name of Patient 6. Furthermore, the date of birth was blank and appropriate boxes for consenting or refusing for photograph were not checked.c.Review of the Consult for Release of medical Info, showed the document was incomplete. The name of the patient, the recipient and the effective date of the authorization were blank.d.Review of the Covid-19 Vaccine Requirement was signed by the patient, however, the document was incomplete. The name of the patient and if the patient would request, refuse vaccination or would provide a written proof of vaccination or medical contraindication were not filled out.On 9/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the findings.#.Review of Patient 12’s clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/28/25. The patient was certified for hospice during the certification period from 7/23/25 to 9/20/25.a.Review of the Consult for Release of Medical Info, showed the document was incomplete. The name of the patient, the recipient and the effective date of the authorization were blank.b. Review of the Covid-19 Vaccine Requirement was signed by the patient, however, the document was incomplete. The name of the patient and if the patient would request, refuse vaccination or would provide a written proof of vaccination or medical contraindication were not filled out.c.Review of the patient’s consent and statement regarding his/her physician’s care was signed by the patient, however the document was incomplete. The patient had not chosen for a primary care physician, or if physician does not want or does not have a primary care physician.d.Review of the photography consent form was signed by the patient, however, the document was incomplete. The date of birth was blank and patient did not check any of the appropriate boxes to give or refuse consent for photograph.On 9/9/25 at 1330 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the finding.#. Review of Patient 14’s closed clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/8/24. The patient was certified for hospice during the certification period from 7/8/24 to 10/5/24. Patient 14 expired on 9/22/24.a.Review of the Consult for Release of Medical Info, showed the document was incomplete. The name of the patient, the recipient and the effective date of the authorization were blank.b. Review of the Covid-19 Vaccine Requirement was signed by the patient, however, the document was incomplete. The name of the patient and if the patient would request, refuse vaccination or would provide a written proof of vaccination or medical contraindication were not filled out.c. Review of the patient’s consent and statement regarding his/her physician’s care was signed by the patient, however the document was incomplete. The patient had not chosen for a primary care physician, or if physician does not want or does not have a primary care physician.d.Review of the photography consent form was signed by the patient, however, the document was incomplete. The date of birth was blank and patient did not check any of the appropriate boxes to give or refuse consent for photograph.On 9/9/25 at 14000 hours, an interview and concurrent clinical record review was conducted with QA/LVN. The QA/LVN was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the physician's CTIs for 14 of 14 sampled patients (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14) included the date of the verbal certification and/or the signatures of the RN and Medical Director.  This failure had the potential for substandard care provided to the patients as their clinical information were not complete.  Findings: --- #.  Review of Patient 4's closed clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/15/25.  The patient was certified for hospice services during the period from 5/15/25 to 8/12/25.  The patient was discharged from the hospice service on 7/21/25.Review of the Certification of Terminal Illness for the certification period from 5/15/25 to 8/12/25, showed Hospice Physician Verbal Certification.   The CTI includes the verbal certification date.  However, there was no documented evidenced of the hospice physicians signature and date as the section was left blank.Further review of the CTI showed the RN 1 received the verbal certification.   However, the section for the RN signature was left blank.On 9/9/25 at 1406 hours, a follow up interview and concurrent closed record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings. #.  Review of Patient 8's clinical record was initiated on 9/4/25.  The clinical record showed the SOC was 10/15/24. The patient was certified for hospice services during the periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25. Review of the Certification of Terminal Illness dated 7/30/25 for the certification period from 8/11/25 to 10/9/25, showed the Medical Directors' recertification statement and narrative notes.   However, there was no documented evidenced of the hospice physicians signature and date as the section was left blank. Further review of the CTI includes the date of verbal certification.  However, the date of the verbal certification was left blank.In addition, on the section for the RN name showed the names of RN 4 and RN 5.  However, the section for the RNs' signature and date was left blank.On 9/9/25 at 1157 hours, a follow up interview and concurrent closed record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings. #.  Review of Patient 10's clinical record was initiated on 9/5/25.  The clinical record showed the SOC was 11/13/24. The patient was certified for hospice services during the periods from 6/11/25 to 8/9/25 and 8/10/25 to 10/8/25. Review of the Certification of Terminal Illness dated 8/9/25 for the certification period from 8/10/25 to 10/8/25, showed the recertification statement, the physician brief narrative statement and the attestation.    However, there was no documented evidenced of the hospice physicians name, signature and date as the section was left blank. Further review of the CTI includes the date of verbal certification.  However, the date of the verbal certification was left blank.In addition, on the section for the RN name, signature and date was left blank.On 9/9/25 at 1355 hours, a follow up interview and concurrent closed record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings. #.  Review of Patient 1's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/2/24.  The patient was certified for hospice services during the period from 5/2/24 to 7/30/24. Review of the Certification of Terminal Illness for the certification period from 05/02/2024 to 07/30/2024 showed Hospice Physician Verbal Certification.   The CTI includes the verbal certification date.  However, the Medical Director failed to electronically signed and dated the CTI as the section was left blank.  On 9/9/25 at 1500 hours, an interview and concurrent record review was conducted with Receptionist 1.  Receptionist 1 was informed and verified the findings. On 9/9/25  at 1600 hours, an interview was conducted with the administrator. The administrator was informed and  acknowledged the findings. Review of Patients XXX, failed to show the CTI included the information related to the date of the verbal certification; and the CTIs were signed and dated by the Medical Director and the RN.  For example:#.  Review of Patient 13’s closed clinical record was initiated on 9/8/25.  The clinical record showed the SOC was 3/26/24.  The CTI showed the patient was certified for hospices services during the certification periods from 3/26/24 to 6/23/24, 6/2/24 to 9/21/24, 9/22/24 to 11/20/24, 11/21/24 to 1/19/25, and 1/20/25 to 3/20/25.However, the CTI for certification periods from 3/26/24 to 6/23/24, 6/2/24 to 9/21/24, 9/22/24 to 11/20/24, 11/21/24 to 1/19/25, and 1/20/25 to 3/20/25, showed no date of verbal certification.The CTI for certification periods from 6/2/24 to 9/21/24, 9/22/24 to 11/20/24, 11/21/24 to 1/19/25, and 1/20/25 to 3/20/25, showed no documented evidence of the RN’s and Medical Director’s signature.On 9/9/25 at 1100 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the finding

Based on interview and record review, the hospice failed to authenticate the entries made into the clinical record for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13 and 14).   This failure had the potential to not have verified patient information. Findings: --- #.  Review of Patient 4's closed clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/15/25.  The patient was certified for hospice services during the period from 5/15/25 to 8/12/25.  The patient was discharged from the hospice service on 7/21/25.*Review of the Physicians Orders dated 7/21/25, showed a check mark on the section for Order Read Back and Verified with the Physician.  The Order was taken by the LVN 1.  However, the LVN 1 failed to electronically signed and dated the verbal order.In addition, the Medical Director failed to electronically signed and dated the verbal order. *Review of the closed clinical record showed the IDT Plan of Care & Review of the Comprehensive Assessment was conducted on 5/15, 5/29 and 6/12/25.  The members includes the name of the RN 1 and the Physicians (Medical Director and Physician).However, there was no documented evidenced of the RN 1 and the physicians had electronically signed and dated/ authenticated the IDT meeting notes.On 9/9/25 at 1406 hours, an interview and concurrent closed record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #.  Review of Patient 8's clinical record was initiated on 9/4/25.  The clinical record showed the SOC was 10/15/24. The patient was certified for hospice services during the periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25. a. Review of the Certification of Plan of Care dated 6/11/25 for the certification period from 6/12/25 to 8/10/25, showed the name of RN 3.  However, there was no documented evidenced of the RN 3 's signature and date as the sections were left blank. *Review of the Certification of Terminal Illness dated 6/11/25 for the certification period from 6/12/25 to 8/10/25, showed the name of RN 3. However, there was no documented evidenced of the RNs' signature and date as the sections were left blank. b. Review of the Certification of Plan of Care dated 7/30/25, showed the names of RN 4 and RN 5.  However, there was no documented evidenced of the RNs' signature and date as the sections were left blank. *Review of the Certification of Terminal Illness dated 7/30/25 for the certification period from 8/11/25 to 10/9/25, showed the names of RN 4 and RN 5. However, there was no documented evidenced of the RNs' signature and date as the sections were left blank. *The Physician Orders dated 6/11/25 showed a recertification order.  The order showed a check marked on "Order Read Back and Verified with Physician".  The verbal order was given by the Medical Director and was taken by the RN 3.  However, the physicians verbal order was not signed and dated as the sections were left blank.In addition, the Physician Orders dated 6/13/25 showed an order for "update medications".  The order showed a check marked on "Order Read Back and Verified with Physician".  The verbal order was given by the Medical Director and was taken by the RN 3.  However, the physicians verbal order was not signed and dated as the sections were left blank.On 9/9/25 at 1157 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #.  Review of Patient 10's clinical record was initiated on 9/5/25.  The clinical record showed the SOC was 11/13/24. The patient was certified for hospice services during the periods from 6/11/25 to 8/9/25 and 8/10/25 to 10/8/25. a.  The Physician Orders dated 6/10/25 showed a recertification order.  The order showed a check marked on "Order Read Back and Verified with Physician".  The verbal order was was taken by the RN 6.  However, the RN 6 failed to sign and date the verbal order.In addition, the Medical Director failed to sign and date the order as the sections were left blank.b. The Physician Orders dated 8/9/25 showed a recertification order.  The order showed a check marked on "Order Read Back and Verified with Physician".  The verbal order was was taken by the RN 6.  However, the RN 6 failed to sign and date the verbal order.On 9/9/25 at 1355 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings. #. Review of Patient 5's closed clinical record was initiated on 9/3/25.  The clinical record showed the SOC was 5/21/23. The patient was certified for hospice services during the periods from 5/21/23 to 8/18/23, 8/19/23 to 11/16/23, 11/17/23 to 1/15/24 and 1/6/24 to 3/15/24.  The patient was discharged from the hospice service on 3/5/24.  *The Physicians Order dated 11/2, 10/3 and 10/6/23 showed an order to update medication.  However, the Medical Director failed to sign and date the order as the sections were left blank. In addition, on the section for the discipline who received the verbal order was left blank.*The Physicians Order dated 11/16/25 showed an order for recertification.  However, the Medical Director failed to sign and date the order as the sections were left blank. In addition, on the section for the discipline showed the RN 1 had received the verbal order.  However, the RN 1 failed to sign and date the verbal order as the sections were left blank. *The Physicians Order dated 3/5/24, showed an order for discharge from hospice.  However, the Medical Director failed to sign and date the order as the sections were left blank. In addition, on the section for the discipline who received the verbal order was left blank.On 9/9/25 at 1108 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #. Review of Patient 2’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was 6/9/25. The patient was certified for hospice services during the certification period from 6/9/25 to 9/6/25.*The Certification of Terminal Illness for certification period 6/9/25 to 9/6/25 dated 6/9/25, showed no evidence of the Medical Director and RN’s electronic signatures.*The IDT Plan of Care & Review of Comprehensive Assessment dated 6/12/25, 6/26/25 and 7/10/25, showed no evidence of the Medical Director, RN, MSW and SCs electronic signatures.*The Nursing Clinical Notes dated 6/17/25, 6/24/25, 7/1/25, 7/8/25, 7/15/25 and 8/19/25, showed no evidence of the LVN 2’s electronic signature.*The Collaboration Note dated 6/13/25 and 7/2/25, showed no evidence of the Medical Director and LVN 2’s electronic signatures.On 9/9/25 at 1055 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN acknowledged and confirmed the above findings.#.Review of Patient 6’s clinical record was initiated on 9/4/25. The clinical record showed the SOC was 11/13/24. The patient was certified for hospice during the certification periods from 7/11/25 to 9/8/25.*The initial nursing assessment dated 11/13/24, showed no evidence of the RN 5’s electronic signature.*The Certification of Terminal Illness for certification periods 11/13/24 to 2/10/25, 2/11/25 to 5/11/25, 5/12/25 to 7/10/25 and 7/11/25 to 9/8/25, showed no evidence of the Medical Director and RN’s electronic signatures.*The Physician Order Details dated 2/10/25, 5/7/25 and 7/3/25, showed no evidence of the Medical Director and RN’s electronic signature.On 9/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the findings.#.Review of Patient 12’s clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/28/25. The patient was certified for hospice during the certification period from 7/23/25 to 9/20/25.*The Certification of Terminal Illness for certification periods 7/28/24 to 10/25/24, 10/26/24 to 1/23/25, 1/24/25 to 3/24/25, 3/25/25 to 5/23/25, 5/24/25 to 7/22/25 and 7/23/25 to 9/20/25, showed no evidence of the Medical Director and RN’s electronic signature.*The initial nursing assessment dated 7/28/24, showed no evidence of the RN 4’s electronic signature. *The nursing clinical note dated 8/19/25, 8/14/25, 8/5/25, 7/31/25, 7/22/25, 7/15/25, 7/8/25, 6/27/25, 6/17/25, 6/12/25, 6/5/25, and 5/27/25, showed no evidence of the RN’s electronic signature.On 9/9/25 at 1330 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the findings.#.Review of Patient 14’s closed clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/8/24. The patient was certified for hospice during the certification period from 7/8/24 to 10/5/24. Patient 14 expired on 9/22/24.*The initial nursing assessment dated 7/8/24, showed no evidence of the DPCS Designee/NP’s electronic signature. *The initial orders and plan of care dated 7/8/25, showed no evidence of the Medical Director, DPCS Designee/NP and LVN 1’s electronic signature.*The Certification of Illness for certification period 7/8/24 to 10/5/24, showed no evidence of the RN and Medical Director’s electronic signature. *The Physician Order Details for the following dates, showed no electronic signature: -On 7/16/24, no DPCS Designee/NP and Medical Director’s signature.-On 7/26/24, no discipline and Medical Director’s signature.-On 8/16/25, no LVN 1, DPCS and Medical Director’s signature.-On 9/9/24, no LVN 1 and Medical Director’s signature.-On 9/22/24, no RN 1 and Medical Director’s signature.On 9/9/25 at 1400 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the findings. #. Review of Patient 1's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/2/24.  The patient was certified for hospice services during the period from 5/2/24 to 7/30/24.  *Review of the Physicians Orders dated 5/2/24, showed a check mark on the section for Order Read Back and Verified with the Physician.  The Order was taken by the DPCS.  However, the DPCS and Physician failed to electronically signed and dated the verbal order.*Review of the clinical record showed the IDT Plan of Care & Review of the Comprehensive Assessment was conducted on 5/2/24, 5/16/24, and 5/30/24.  The members includes the name of the DPCS and the Medical Director. However, there was no documented evidence of the DPCS and the physician had electronically signed and dated/ authenticated the IDT meeting notes.*Review of Initial order and Plan of Care dated 5/2/24 showed no documented evidenced of the DPCS and the Medical Director's signature. On 9/9/25 at 1500 hours, an interview and concurrent record review was conducted with Receptionist 1. Receptionist 1 verified the findings. On 9/9/25 at 1600 hours, an interview was conducted with the Administrator.  The Administrator was informed and acknowledged the findings. #. Review of Patient 9's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 12/11/24.  The patient was certified for hospice services during the period from 12/11/24 to 3/10/25.  *Review of the Physicians Orders dated 12/11/24, showed a check mark on the section for Order Read Back and Verified with the Physician.  The Order was taken by the RN 1.  However, RN 1 and Medical Director failed to electronically signed and dated the verbal order. *Review of the clinical record showed the IDT Plan of Care & Review of the Comprehensive Assessment was conducted on 12/12/24, 12/26/24 and 1/9/25.  The members includes the name of RN 1 and the Medical Director. However, there was no documented evidence of RN 1 and the physician had electronically signed and dated/ authenticated the IDT meeting notes.*Review of Initial order and Plan of Care dated 12/11/24 showed no documented evidenced of the RN 1 and the Medical Director s signature.On 9/9/25 at 1500 hours, an interview and concurrent record review was conducted with Receptionist 1. Receptionist 1 verified the findings. On 9/9/25 at 1600 hours, an interview was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #.  Review of Patient 11's clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 1/16/25.  The patient was certified for hospice services during the period from 1/16/25 to 3/16/25.  *Review of the Physicians Orders dated 1/16/25, showed no documented evidence of the discipline's signature or the Medical Director's signature. *Review of the clinical record showed the IDT Plan of Care & Review of the Comprehensive Assessment was conducted on 1/16/25, 1/30/25, and 2/13/25.  The members includes the name of RN 7and the Medical Director. However, there was no documented evidence of the RN 7 and the physician had electronically signed and dated/ authenticated the IDT meeting notes.*Review of Initial order and Plan of Care dated 1/16/25 showed no documented evidenced of RN 7 and the Medical Director's signature. On 9/9/25 at 1500 hours, an interview and concurrent record review was conducted with Receptionist 1. Receptionist 1 verified the findings. On 9/9/25 at 1600 hours, an interview was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  The P&P titled Contents of the Clinical Records dated 4/2020, showed a clinical record will be maintained for each patient receiving care.  The clinical record will contain sufficient information to identify the patient, describe the patients’ problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel.  Documentation will include signed and dated clinical notes.  Each entry will be dated and signed, including title and credentials, by the person providing the care and service.The P&P titled Verification of Physician Orders revised April 2020, showed orders will be documented on a form provided by the hospice, dated and signed by the professional receiving the order.  The original of the order form will be delivered to the physician for signature.  Signed orders will be in the clinical order within 30 days of initiation of care or interim order, unless otherwise specified by applicable state law and regulation.#.  Review of Patient 13’s closed clinical record was initiated on 9/8/25.  The clinical record showed the SOC was 3/26/24.  The patient was certified for hospice service during the certification period from 1/20/25 to 3/20/25.*The physician’s order dated 1/22/25, showed an order for SN to remove and reinsert indwelling catheter 14 Fr 5 ml balloon using sterile technique once monthly and as needed if soiled or dislodged.  However, there was no documented evidence of a physician’s signature.On 9/9/25 at 1100 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the finding.#.  Review of Patient 3’s clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 3/7/25.  The patient was certified for hospice services during the certification period from 6/5/25 to 9/2/25.The initial nursing comprehensive assessment dated 3/7/25, showed no documented evidence the RN authenticated the assessment as there was no electronic signature in the patient’s clinical record.On 9/9/25 at 1144 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged of the finding.#.  Review of Patient 7’s clinical record was initiated on 9/4/25.  The clinical record showed the SOC was 11/13/24.  The patient was certified for hospice services during the certification period from 7/11/25 to 9/8/25.The physician’s order dated 7/3/25 showed recertification and medication orders. However, there was no documented evidence of a physician’s signature.On 9/9/25 at 1220 hours, an interview and concurrent clinical record review was conducted with Receptionist 1.  She was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the discharge summaries were completed for three of 14 sampled patients (Patients 4, 5, and 14).  This failure had the potential of not communicating the post-discharge care needs of these patients to the physician. Findings: --- #.Review of Patient 14’s closed clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/8/24. The patient was certified for hospice during the certification period from 7/8/24 to 10/5/24. Patient 14 expired on 9/22/24.The Physician Order Details for discharge death dated 9/22/24 was completed by RN 1. The order showed medications which were discontinued.*However, there was no documented evidence a discharge summary included relevant information such as the physical and psychosocial status at time of discharge, medical problems requiring intervention or follow-up and summary of the care provided.On 9/9/25 at 1400 hours, an interview and concurrent clinical record review was conducted with the QA/LVN. The QA/LVN was informed and acknowledged the findings. #.  The hospice's P&P titled Discharge Summary revised 4/2020 showed all patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record. Review of Patient 4's closed clinical record was initiated on 9/2/25.  The clinical record showed the SOC was 5/15/25.  The patient was certified for hospice services during the period from 5/15/25 to 8/12/25.  The patient was discharged from the hospice service on 7/21/25.The Physicians Order dated 7/21/25, showed an order for discharge from hospice.However, review of the closed clinical record failed to show documented evidenced of a discharge summary was completed as per P&P.On 9/9/25 at 1406 hours, a follow up interview and concurrent closed record review was conducted with the Administrator.  The Administrator was informed and acknowledged the finding.  #. Review of Patient 5's closed clinical record was initiated on 9/3/25.  The clinical record showed the SOC was 5/21/23. The patient was certified for hospice services during the periods from 5/21/23 to 8/18/23, 8/19/23 to 11/16/23, 11/17/23 to 1/15/24 and 1/6/24 to 3/15/24.  The patient was discharged from the hospice service on 3/5/24.  The Physicians Order dated 3/5/24, showed an order for discharge from hospice.However, review of the closed clinical record failed to show documented evidenced of a discharge summary was completed as per P&P.On 9/9/25 at 1108 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the safe disposal of the controlled drugs in the patient’s home for one of 14 sampled patients (Patient 14).  This failure had the potential for drug diversion. Findings: --- Review of the hospice’s P&P title Home use and Disposal of Controlled Substances revised 4/2020 showed when a hospice patient no longer has a need for controlled substance, the Case Manager will instruct the patient and family/caregiver regarding proper disposal of drugs in accordance with federal, state and local law/regulation.  The hospice nurse, social worker, or chaplain attending the death of a hospice patient will inform the family/caregiver of their responsibility to dispose of all the patient’s prescribed medications and will document this instruction in a clinical note.  If the family/caregiver requests assistance with the disposal, the hospice employee will observe and provide verbal assistance as the family/caregiver properly dispose of the prescribed medications. This disposal will be documented in a clinical note. Review of Patient 14’s closed clinical record was initiated on 9/5/25.  The clinical record showed the SOC was 7/8/24. The patient was certified for hospice during the certification period from 7/8/24 to 10/5/24.  Patient 14 expired on 9/22/24. Review of the Physician Order Details dated 9/22/25, showed Patient 14’s methadone (opioid analgesic) 10 mg tablet was discontinued on 9/22/24, due to discharge death. *However, there was no documented evidence the controlled medication was disposed.  On 9/9/25 at 1400 hours, an interview and concurrent closed clinical record review was conducted with the QA/LVN.  The QA/LVN was informed and acknowledged the finding.

Based on record review and interview, the hospice failed to ensure the emergency preparedness plan included a process for cooperation and collaboration with the State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, creating the risk of not providing appropriate, consistent, and quality care to the patients. Findings: Review of the hospice's emergency preparedness plan was conducted on 6/8/22. However, the hospice's emergency preparedness plan did not include a process for cooperation and collaboration with, tribal, State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. On 6/8/22 at 1436 hours, the Office Manager and Payroll Coordinator were informed of the finding. The Office Manager and Payroll Coordinator reviewed the agency's emergency preparedness plan and acknowledged the finding.

Based on record review and interview, the hospice failed to ensure the emergency preparedness P&P included a procedure to inform State of any on-duty staff or patients that they were unable to contact, creating the risk of not providing the necessary care and services to the patients during the emergency disaster events. Findings: Review of the hospice's emergency preparedness plan was conducted on 6/8/22. However, the hospice's emergency preparedness P&P did not include a procedure to inform the State of any on-duty staff or patients that they were unable to contact. On 6/8/22 at 1436 hours, the Office Manager and Payroll Coordinator were informed of the finding. The Office Manager and Payroll Coordinator reviewed the agency's emergency preparedness plan and acknowledged the finding.

Based on record review and interview, the hospice failed to ensure the emergency preparedness P&P included a system of medical documentation that preserved patient information, protects confidentiality of patient information, and secures and maintains availability of records, creating the risk of not providing the necessary care and services to the patients during the emergency disaster events. Findings: Review of the hospice's emergency preparedness plan was conducted on 6/8/22. However, the hospice's emergency preparedness P&P did not include a system of medical documentation that preserved patient information, protects confidentiality of patient information, and secures and maintains availability of records. On 6/8/22 at 1436 hours, the Office Manager and Payroll Coordinator were informed of the finding. The Office Manager and Payroll Coordinator reviewed the agency's emergency preparedness plan and acknowledged the finding.

Based on record review and interview, the hospice failed to develop the emergency preparedness communication plan that complied with the Federal, State, and local laws and must be reviewed and updated at least every two years, creating the potential risk of not providing the necessary care and services to the patients during the emergency disaster events. Findings: Review of the hospice's emergency preparedness plan was conducted on 6/8/22. However, the hospice's emergency preparedness plan did not include the communication plan that complied with the Federal, State, and local laws and must be reviewed and updated at least every two years. On 6/8/22 at 1436 hours, the Office Manager and Payroll Coordinator were informed of the finding. The Office Manager and Payroll Coordinator reviewed the agency's emergency preparedness plan and acknowledged the finding.

Based on record review and interview, the hospice failed to develop the emergency preparedness communication plan that included names and contact information of the hospice employees, entities providing services under arrangement, patient's physicians and other services, creating the potential risk of not providing the necessary care and services to the patients during the emergency disaster events. Findings: Review of the hospice's emergency preparedness plan was conducted on 6/8/22. However, the hospice's emergency preparedness plan did not include the names and contact information of the hospice employees, entities providing services under arrangement, patient's physicians, and other services. On 6/8/22 at 1436 hours, the Office Manager and Payroll Coordinator were informed of the finding. The Office Manager and Payroll Coordinator reviewed the agency's emergency preparedness plan and acknowledged the finding.

Based on record review and interview, the hospice failed to ensure the emergency preparedness communication plan included the contact information of the Federal, State, tribal, regional, and local emergency preparedness staff, creating the potential risk of not providing the necessary care and services to the patients during the emergency disaster events. Findings: Review of the hospice's emergency preparedness plan was conducted on 6/8/22. However, the hospice's emergency preparedness plan did not not include the contact information of the Federal, State, tribal, regional, and local emergency preparedness staff. On 6/8/22 at 1436 hours, the Office Manager and Payroll Coordinator were informed of the finding. The Office Manager and Payroll Coordinator reviewed the agency's emergency preparedness plan and acknowledged the finding.

Based on record review and interview, the hospice failed to ensure the emergency preparedness communication plan included the contact information for the primary and alternate means for communicating with the hospice's staff, Federal, State, tribal, regional, and local emergency management agencies, creating the potential risk of not providing the necessary care and services to the patients during the emergency disaster events. Findings: Review of the hospice's emergency preparedness plan was conducted on 6/8/22. However, the hospice's emergency preparedness communication plan did not not include the contact information for the primary and alternate means for communicating with the hospice's staff, Federal, State, tribal, regional, and local emergency management agencies. On 6/8/22 at 1436 hours, the Office Manager and Payroll Coordinator were informed of the finding. The Office Manager and Payroll Coordinator reviewed the agency's emergency preparedness plan and acknowledged the finding.

Based on record review and interview, the hospice failed to ensure the emergency preparedness communication plan included the method for sharing information and medical documentation for the patients with other health providers to maintain the continuity of care and means of providing information about the general condition and location of patients under hospice's care. This posed a potential risk of not providing appropriate, consistent, and quality care to the patients during the emergency events. Findings: Review of the hospice's emergency preparedness plan was conducted on 8/9/18. The hospice's emergency preparedness communication plan failed to include the method for sharing information and medical documentation for the patients with other health providers to maintain the continuity of care and means of providing information about the general condition and location of patients under hospice's care. On 6/8/22 at 1436 hours, the Office Manager and Payroll Coordinator were informed of the finding. The Office Manager and Payroll Coordinator reviewed the agency's emergency preparedness plan and acknowledged the finding.

Based on record review and interview, the hospice failed to ensure the emergency preparedness training and testing program was provided to the staff as per the emergency risk assessment and hospice's P&P and communication plan, creating the risk of the staff not knowing what to do in case of the emergency. Findings: Review of the hospice's emergency preparedness plan was conducted on 6/8/22. The hospice's emergency preparedness P&P titled Emergency Management Plan revised 4/14 showed the hospice shall test the emergency management plan at least annually either in response to an actual or planned drills. All actual responses and drills shall be critiques to identify the deficiencies and opportunities for improvement. These critiques shall be documented. However, the hospice failed to ensure the emergency preparedness training and testing program was provided to the staff as per the emergency risk assessment and hospice's P&P and communication plan. On 6/8/22 at 1436 hours, the Office Manager and Payroll Coordinator were informed of the finding. The Office Manager and Payroll Coordinator reviewed the agency's emergency preparedness plan and acknowledged the finding.

Based on record review and interview, the hospice failed to ensure the initial training in emergency preparedness was provided to all of the staff including the contracted staff and volunteers, consistent with their expected role; demonstrate staff knowledge of emergency procedures; provide emergency preparedness training at least every two years; periodically review and rehearse its emergency preparedness plan with hospice employee with special emphasis placed on carrying out the procedures necessary to protect patients and others; maintain documentation of all emergency preparedness training; and if emergency preparedness P&P was significantly updated, the hospice must conduct training on the updated P&P. This failure created the risk of the hospice's staff not knowing what to do in case of emergency. Findings: Review of the hospice's emergency preparedness plan was conducted on 6/8/22. The hospice's emergency preparedness P&P titled Emergency Management Plan revised 4/14 showed all actual responses and exercises will be documented and critique through a multidisciplinary process that includes administrative, clinical, and support staff. Documentation will be used to identify deficiencies and opportunities for improvement based on all monitoring activities and observations during the exercises or actual emergency. The documentation will identify the effectiveness of the preparedness, mitigation, response and recovery activities of the emergency operations plan. However, the hospice failed to provide training to all staff including the contracted staff and volunteers, consistent with their expected role; demonstrate staff knowledge of emergency procedures; provide emergency preparedness training at least every two years; periodically review and rehearse its emergency preparedness plan with the hospice employee with special emphasis placed on carrying out the procedures necessary to protect the patients and others; maintain documentation of all emergency preparedness training; and if emergency preparedness P&P was significantly updated, the hospice must conduct training on the updated P&P. On 6/8/22 at 1436 hours, the Office Manager and Payroll Coordinator were informed of the finding. The Office Manager and Payroll Coordinator reviewed the agency's emergency preparedness plan and acknowledged the finding.

Based on record review and interview, the hospice failed to conduct exercises to test the emergency plan at least annually and failed to participate in a full scale exercises that was a community-based every two years, or when a community based exercises was not accseesible, to conduct individual facility based functional exercises every two years. This posed the risk of the staff not knowing what to do in case of the emergency Findings: Review of the hospice's emergency preparedness plan was conducted on 6/8/22. The hospice failed to conduct exercises to test the emergency plan at least annually. There was no documented evidence the hospice had participated in a full scale exercises that is community-based every two years, or when a community based exercises was not accsessible, to conduct individual facility based functional exercises every two years. On 6/8/22 at 1436 hours, the Office Manager and Payroll Coordinator were informed of the finding. The Office Manager and Payroll Coordinator reviewed the agency's emergency preparedness plan and acknowledged the findings.

Based on observation, interview, and record review, the hospice agency failed to provide one of 12 sampled patients (Patient 2) written notice of patient's rights and responsibilities in a language that the patient and PCG could understand. This created the risk for the patient and PCG to be unaware of their rights before the start of hospice care. Findings: Review of Patient 2's clinical record was initiated on 6/7/22. The clinical record showed the SOC was 4/15/22. The patient was certified for hospice services during the period from 4/15/22 to 7/13/22. On 6/8/22 at 1000 hours, a joint home visit was conducted with RN 1 with Patient 2's PCG and another family member as a Spanish translator. Patient 2's PCG stated she and the patient understood and could read in Spanish only. Review of the hospice binder in Patient 2's home showed the hospice reading materials, including the patient rights and hospice information were in English. When asked about the hospice binder, the PCG stated she did not understand the information in the binder and preferred the information be presented in Spanish. Review of Patient 2's Election of Medicare Hospice Benefit signed and dated 4/15/22, showed the information was presented in English. Further review of Patient 2's Patient Bill of Rights and Responsibilities form signed and dated 4/15/22, also showed the information was presented in English. On 6/13/22 at 1107 hours, an interview was conducted with the Volunteer. The Volunteer was informed and acknowledged the finding.

Based on record review and interview, the hospice failed to ensure the initial and comprehensive assessments were completed, reviewed, and revised to address and meet the patients' care needs as evidenced by: 1. The hospice failed to ensure the comprehensive assessments were completed no later than five calendar days. Cross reference to L523. 2. The hospice failed to ensure the comprehensive assessments had identified the physical, psychosocial, and spiritual needs. Cross reference to L524. 3. The hospice failed to ensure the comprehensive assessments had identified the imminence of death. Cross reference to L528. 4. The hospice failed to include all current medications' side effects, actual or potential drug interactions, and duplicate drug therapy in the comprehensive assessments. Cross reference to L530. 5. The hospice failed to ensure the comprehensive assessment included the initial bereavement assessment to address the needs of the patient's family and other individuals/PCG focusing on the social, religious, and cultural factors. Cross reference to L531. 6. The hospice failed to ensure the updated comprehensive assessments were completed no less than every 15 days and included the changes that had occurred since the initial assessment, information on the patient's progress, and reassessment of the patient's responses. Cross reference to L533. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the initial and comprehensive assessments to meet the patients' care needs.

Based on record review and interview, the hospice failed to ensure the comprehensive assessments were completed no later than five calendar days for 12 of 12 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12), creating the risk of not identifying the care needs for these patients. Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12 showed no documented evidence the comprehensive assessments were completed for these patients. For example: a. Review of Patient 3's clinical record was initiated on 6/7/22. The clinical record showed the SOC was 4/8/22. The patient was certified for hospice services during the certification period from 4/8/22 to 7/6/22. Review of Patient 3's clinical record showed the Comprehensive Nursing Assessment was completed on 4/8/22. However, further review of the clinical record showed no documented evidence of the comprehensive psychosocial, emotional, and spiritual assessment were completed within five days from the election of hospice services. b. Patient 7's closed clinical record showed the SOC was 10/21/21. The patient was certified for hospice services during the certification period from 10/21/21 to 1/18/22. The initial comprehensive assessment dated 10/21/21, was completed. However, the clinical record showed no documented evidence of the comprehensive assessment of the patient's needs for volunteer services were completed within five days from the election of the hospice services. On 6/13/22 at 1008 hours, the Administrator/CEO was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the comprehensive assessments included the assessments of the volunteer services needs for 12 of 12 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12), creating the risk of not identify care needs for these patients. Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12 showed no documented evidence the patients' needs for volunteer services were assessed during the initial comprehensive assessment for these patients. For example: a. Patient 3's clinical record showed the SOC was 4/8/22. The patient was certified for hospice services during the certification period from 4/8/22 to 7/6/22. The initial comprehensive assessment dated 4/8/22, showed no documented evidence of the assessment of the patient's needs for volunteer services. b. Patient 7's closed clinical record showed the SOC was 10/21/21. The patient was certified for hospice service during the certification period from 10/21/21 to 1/18/22. The initial comprehensive assessment dated 10/21/21, showed no documented evidence of the assessment of the patient's needs for volunteer services. On 6/13/22 at 1008 hours, the Administrator/CEO was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the comprehensive assessments had identified the imminence of death for 12 of 12 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12), creating the risk of not appropriately addressing the patient's needs. Findings: Review of the hospice's P&P titled Comprehensive Assessment dated April 2014 showed during comprehensive assessment, all baseline data and other relevant information will be documented in the patient's clinical record including imminence of death. Review of 12 sampled patients' clinical records (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12) was conducted from 6/6/22 to 6/13/22. The clinical records showed these patients were certified for hospice services. However, further review of the clinical records showed the initial comprehensive assessments did not identify the imminence of death for these patients. On 6/13/22 at 1008 hours, the Administrator/CEO was informed of the findings.

Based on observation, interview, and record review, the hospice failed to include all current medications' side effects, actual or potential drug interactions, and duplicate drug therapy in the comprehensive assessments for 12 of 12 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12), creating the risk for substandard care. In addition, the hospice failed to ensure the identification of expired medications. Findings: Review of the hospice's P&P titled Medication Profile dated 4/14, showed patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. A drug regimen review will be performed at the time of initial and comprehensive assessment. The review will assist in evaluation effectiveness and appropriateness, identify potential and actual drug/food interactions, adverse reactions, duplicative therapy and non compliance issues, omissions, and unclear information. Each patient and/or family/caregiver will receive appropriate written teaching materials for specific medications he/she is receiving. the material should contain information on actions of the medication, potential side effects, contraindications, an any special instructions when taking the specific medication. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family PCG, as well as other clinicians, understand the medication regimen. This includes but not limited to using the medication profile to evaluate the use of drugs in the home setting; using the medication profile to teach drug purposes, dosages, routes, times, side effects, and contraindications; and using the medication profile as a communication tool for other clinicians involved in the care. 1. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12) showed no documented evidence the patients' medications were reviewed to include the following: effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy currently associated with laboratory monitoring for these patients. For example: a. Review of Patient 3's clinical record was initiated on 6/7/22. The clinical record showed the SOC was 4/8/22. The patient was certified for hospice services during the period from 4/8/22 to 7/6/22. The Medication Profile for the certification period 4/8/22 to 7/6/22, showed the patient's medications included acetaminophen (analgesic) 325 mg one tablet PO Q six hours PRN for mild pain, aspirin EC (for heart disease/CVA prophylaxis) 325 mg one tablet PO QD, glimepiride (antidiabetic) 2 mg one tablet PO QD, Jardiance (antidiabetic) 25 mg one tablet PO QD, and metformin hydrochloride (antidiabetic) 1000 mg one tablet PO BID. Further review of the clinical record failed to show documented evidence the comprehensive assessments had included a review of the patient's medications regarding its side effects, actual or potential drug interactions, and duplicate drug therapy. For example, the patient had three antidiabetic medications (glimeride, Jardiance, and metformin hydrochloride). According to Lexi-Comp's pharmacology website, the antidiabetic medications will cause low blood sugar. There was no documented evidence the potential drug interaction was identified and what preventative measures were implemented regarding the adverse reactions from the these medications. On 6/13/22 at 1008 hours, the Administrator/CEO was informed and acknowledged the findings. 3. Review of Patient 3's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 12/3/21. The patient was certified for hospice services during the certification period from 7/31/22 to 9/28/22. The medication profile dated 9/6/22, showed the patient's medication included hydralazine (antihypertensive) 25 mg one tablet PO Q eight hours PRN. * However, there was no documented evidence of the indication on when to administer hydralazine 25 mg one tablet PO Q eight hours PRN. 4. Review of Patient 7's clinical record was initiated on 9/8/22. The patient's clinical record showed the SOC was 8/11/22. The patient was certified for hospice services during the certification period from 8/11/22 to 11/8/22. The medication profile, for the certification period from 8/11/22 to 11/8/22, showed the patient's medication included lorazepam (anxiolytic) 1 mg one to two tablets Q four hours PRN for agitation/restlessness; morphine sulfate (opioid analgesic) 20 mg/ml 1-2 mg Q one hour PRN for pain/SOB; atropine sulfate (used for excessive secretions) 1% one to two "solution" ophthalmic Q four hours PRN * However, there was no documented evidence on when to administer lorazepam 1 mg one to two tablets; morphine sulfate 20 mg/ml 1-2 mg; and atropine sulfate 1% one to two "solution." On 9/19/22 at 1120 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 2. They were informed and acknowledged the findings. 5. Review of Patient 12's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 1/24/22. The patient was certified for hospice services during the certification period from 1/24/22 to 4/23/22. The medication profile, for the certification period from 1/24/22 to 4/23/22, showed the patient's medication included morphine sulfate 20 mg/ml 1-2 mg Q one hour PRN for pain/SOB; oxycodone (opioid analgesic) 10 mg one tablet PO Q eight hours PRN for pain; and Senna 8.6 mg one to two tablet QD PRN for constipation. * However, there was no directions on which pain medication to be administered first. In addition, there was no documented evidence on when to administer one or two tablet of Senna. On 9/19/22 at 1150 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 2 and RN 3. They were informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the comprehensive assessments included the initial bereavement assessments to address the needs of the patient's family and other individuals/PCG focusing on the social, religious, and cultural factors for 12 of 12 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12), creating the risk of not addressing the bereavement needs for these patients' family/PCG. Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12 showed no documented evidence the comprehensive assessments for these patients included the initial bereavement assessment to address the needs of the patient's family and other individuals/PCG focusing on the social, spiritual, and cultural factors that might impact their abilities to cope with the patient's death. For example: a. Review of Patient 4's clinical record was initiated on 6/7/22. The clinical record showed the SOC was 3/20/22. The patient was certified for hospice services during the certification period from 3/20/22 to 6/17/22. The initial comprehensive nursing assessment dated 3/20/22, showed a section for bereavement screening. Documentation showed the patient/PCG had no current bereavement concerns. However, there was no documented evidence the patient was assessed for social, spiritual, and cultural factors that might impact their abilities to cope with the patient's death which would include but not limited to family problem, financial concerns, communication issues, drug and alcohol use, health concerns, legal and financial concern, mental heath issues, presence or absence of support system, and feelings of despair, guilt or abandonment On 6/13/22 at 1108 hours, a concurrent clinical record review and interview with the Office Manager was conducted. She was informed and verified the findings. b. Review of Patient 6's clinical record was initiated on 6/7/22. The clinical record showed the SOC was 10/1/21 The patient was certified for hospice services during the period from 10/1/21 to 11/29/21. The patient's closed clinical record showed no documented evidence the patient was assessed for the comprehensive bereavement risk since admission. The SN note dated 10/1/21, showed the bereavement risk screening for the patient and PCG was documented as "None Identified." Further review of the clinical record showed no documented evidence of the initial bereavement assessment completed. On 6/13/22 at 1020 hours, concurrent clinical record review and interview with the Administrator/CEO was conducted. The Administrator/CEO was informed and verified the findings.

Please delete b. Review of Patient 7's closed clinical record was initiated on 6/6/22. The clinical record showed the SOC was 10/21/21. The patient was certified for hospice services during the period from 10/21/21 to 1/18/22. The POC, for the certification period from 10/21/21 to 1/18/22, showed HA visits two times a week (no task assignment documented). Further review of the closed clinical record showed the IDG had reviewed the POC and updated the comprehensive assessments on 10/21/21 and 11/8/21. However, there was no documented evidence the IDG had updated the comprehensive assessments to include the patient's response to the HA services provided. On 6/13/22 at 1008 hours, the Administrator/CEO was informed and acknowledged the findings. c. Review of Patient 9's closed clinical record was initiated on 6/7/22. The clinical record showed the SOC was 8/13/21. The patient was certified for hospice services during the period from 8/13/21 to 11/10/21. The POC dated 8/13/21, showed the patient's identified problems included hypertension, constipation, mobility related to the use of walker, musculoskeletal weakness, and pain requiring increase dose of analgesics. Further review of the clinical record showed the IDG had reviewed and updated the POC every 14 days. However, there was no documented evidence the IDG had updated the comprehensive assessments to include any changes that had occurred and the reassessments of the patient's response to care. On 6/13/22 at 1015 hours, the Administrator/CEO was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the IDG, care planning, and coordination of services were provided to meet the patients' care needs as evidenced by: 1. The hospice failed to ensure the care and services were provided in accordance with the POCs. Cross reference to L543. 2. The hospice failed to ensure the patient and PCG were provided education/training to meet the care needs. Cross reference to L544. 3. The hospice failed to develop an individualized written POCs that reflected goals and interventions based on the problems identified in the comprehensive assessments. Cross reference to L545. 4. The hospice failed to ensure the initial and revised POCs included the indication for the PRN visits. Cross reference to L547. 5. The hospice failed to develop an individualized written POCs with measurable outcomes. Cross reference to L548. 6. The hospice failed to develop the individualized POC that reflected the patient and family goals and interventions related to the medications necessary to meet the patients' needs. Cross reference to L549. 7. The hospice failed to ensure the IDG had reviewed and revised the POCs no less than every 15 calendar days. Cross reference to L552. 8. The hospice failed to ensure the revised POCs included progress toward the outcomes and goals specified in the POCs. Cross reference to L553. 9. The hospice failed to ensure the IDG had maintained responsibility for directing, coordinating, and supervising the care and services provided. Cross reference to L554. 10. The hospice IDG failed to ensure the care and services were provided in accordance with the POCs. Cross reference to L555. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the interdisciplinary team, care planning and coordination of services to meet the patients' care needs.

Based on record review and interview, the hospice failed to ensure the care and services were provided in accordance with the POC for 12 of 12 sampled patients (Patients 1, 2, 3,4, 5, 6, 7, 8, 9, 10, 11, and 12), creating the risk of not providing appropriate, consistent, and quality care to this patient. Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12 showed care and services related to the patients/PCG teaching and SN visits were not provided in accordance with the patients' POCs for these patients. For example: 1. Review of Patient 1's clinical record was initiated on 6/7/22. The clinical record showed the SOC was 11/2/21. The clinical record showed the patient was certified for hospice services during the period from 3/2/22 to 4/30/22. The POC, for the certification period 3/2/22 to 4/30/22, showed LVN visits once a week and as needed. However, further review of the clinical record failed to show a visit was conducted for the week of 3/27/22 to 4/2/22. On 6/13/22 at 1008 hours, an interview and concurrent clinical record review was conducted with the Volunteer. The Volunteer was informed and acknowledged the findings. 2. Review of Patient 3's clinical record was initiated on 6/7/22. The clinical record showed the SOC was 4/8/22. The patient was certified for hospice services during the certification period from 4/8/22 to 7/6/22. The POC, for the certification period 4/8/22 to 7/6/22, showed the following interventions for the patient's mobility problem: to instruct on proper body mechanics and and instruct on the for the patient to turn every two hours, positioning techniques with proper body mechanics. However, further review of the clinical record failed show documented evidence these interventions were provided during the SN visits. On 6/13/22 at 1008 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. 3. Review of Patient 7's closed clinical record was initiated on 6/7/22. The clinical record showed the SOC was 10/21/21. The clinical record showed the patient was certified for hospice services during the period from 10/21/21 to 1/18/22. The POC, for the certification period 10/21/21 to 1/18/22, showed HA visits two times a week. However, further review of the clinical record showed one HA visit was conducted during the week of 1/7/22 to 1/13/22, instead of two visits as cited. On 6/13/22 at 1008 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. 4. Review of Patient 6's closed clinical record was initiated on 6/7/22. The clinical record showed the SOC was 10/1/21. The clinical record showed the patient was certified for hospice services during the period from 1/29/22 to 3/29/22. The POC, for the certification period 1/29/22 to 3/29/22, showed LVN visits one time a week and RN visits for initial visit, reassessment, supervisory visit, and ongoing comprehensive assessment. However, further review of the clinical record showed no visit was conducted for the weeks of 1/30/22 to 2/5/22, 2/13/22 to 2/19/22, and 2/27/22 to 3/5/22. On 6/13/22/at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. 5. Review of Patient 9's closed clinical record was initiated on 6/7/22. The clinical record showed the SOC was 8/13/21. The clinical record showed the patient was certified for hospice services during the period from 8/13/21 to 11/10/21. The POC, for the certification period 8/13/21 to 11/10/21, showed SN visits one time a week. However, further review of the clinical record showed no SN visit was conducted for the weeks of 8/15/21 to 8/21/21, 8/22/21 to 8/28/21, 8/29/21 to 9/4/21, 9/12/21 to 9/18/21, 9/26/21 to 10/2/21, 10/10/21 to 10/16/21, 10/24/21 to 10/30/21, and 11/7/21 to 11/13/21. On 6/13/22/at 1015 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. 6. Review of Patient 10's closed clinical record was initiated on 6/7/22. The clinical record showed the SOC was 8/28/21. The clinical record showed the patient was certified for hospice services during the period from 8/28/21 to 11/25/21. The POC, for the certification period 8/28/21 to 11/25/21, showed LVN visits one time a week. However, further review of the clinical record showed no visit was conducted for the weeks of 9/12/21 to 9/18/21, 9/26/21 to 10/2/21, 10/10/21 to 10/16/21, 10/24/21 to 10/30/21, 11/7/21 to 11/13/21, and 11/14/21 to 11/20/21. On 6/13/22 at 1010 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the patient and PCG was provided education/training as per the patient's POC for -- of 13 patients (Patients --). the creating the risk of not providing appropriate instructions to address the care needs for these patients. Findings: 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The SN note dated 7/18/22, showed the SN instructed the family member to use A&D and Calmoseptine (moisture barrier) with each diaper change as skin barrier. The physician's order dated 8/19/22, showed Calmoseptine to coccyx and buttocks PRN for skin protection * However, there was no documented evidence the use of A&D and Calmoseptine was included in the patient's POC until 8/19/22. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 2. Review of Patient 10's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 4/15/22. The patient was certified for hospice services during the certification period from 4/15/22 to 6/13/22. The SN note dated 5/19/22, showed the family member had concerns about a small healing bed sore at patient's right buttock. Documentation showed the family member was advised "continuing with A&D ointment and cover with dry dressing with no paper tape." * However, there was no documented evidence the use of A&D ointment and to cover with dry dressing with no paper tape in the POC. On 9/19/22 at 1230 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 3. They were informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the written POCs were developed and updated to reflect the patient and family goals and interventions based on the problems identified for eight of 12 sampled patients (Patients 1, 2, 4, 5, 7, 8, 11, and 12), creating the risk of not addressing the care needs for these patients. Findings: The hospice's P&P titled the Plan of care dated 4/14 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. Review of the clinical records for Patients 1, 2, 4, 5, 7, 8, 11, and 12 showed the POCs did not reflect the care needs based on the problems identified for these patients. For example: 1. Review of Patient 2's clinical record was initiated on 6/7/22. The clinical record showed the SOC was 4/15/22. The patient was certified for hospice services during the certification period from 4/15/22 to 7/13/22. Review of the Comprehensive Nursing Assessment dated 4/15/22, showed the patient was continent with episodes of urinary incontinence. . Review of the POC/IDG Review dated 4/15 and 4/25/22, showed the patient's POC for the certification period for 4/15/22 to 7/13/22. However, there was no POC developed addressing Patient 2's incontinence. On 6/13/22 at 1107 hours, an interview and concurrent clinical record review was conducted with the Volunteer. The Volunteer was informed and acknowledged the findings. 2. Review of Patient 1's clinical record was initiated on 6/6/22. The clinical record showed the SOC was 11/2/21. The patient was certified for hospice services during the certification period from 11/2/21 to 12/31/21. Review of the Comprehensive Nursing Assessment dated 11/2/21, showed an assessment for nutrition noting weight loss of greater than 10% in six months. The patient was noted to have dysphagia (difficulty swallowing). Review of the POC/IDG Reviews dated 11/2, 11/8, 11/22, 12/6, and 12/20/21, showed the patient's POC for the certification period from 11/2/21 to 12/31/21. However, there was no POC developed addressing the patient's weight loss. On 6/13/22 at 1030 hours, an interview and concurrent clinical record review was conducted with the Volunteer. The Volunteer was informed and acknowledged the above findings. 3. Review of Patient 5's clinical record was initiated on 6/7/22. The clinical record showed the SOC was 3/11/22. The patient was certified for hospice services during the certification period from 3/11/22 to 6/8/22. Review of Patient 5's Comprehensive Nursing Assessment dated 3/11/22, showed for nutrition, the patient's appetite was fair and the patient was on aspiration precautions. Review of the Visit Notes dated 4/28, 5/6, and 5/13, and 5/27/22, showed the patient was noted to consume less than 60% of his meals. Review of the POC/IDG Review dated 5/9 and 5/23/22, failed to show a plan of care was developed to address the patient's decreased meal intake. On 6/13/22 at 1130 hours, an interview and concurrent clinical record review was conducted with the Volunteer. The Volunteer was informed and acknowledged the above findings. 4. Review of the clinical records for Patients 7 and 12 showed these patients were on oxygen therapy and psychotropic medications. However, the updated POC did not include the rate of oxygen to be administered, mode of oxygen delivery, and behaviors for psychotropic medication use. For example: a. Review of Patient 7's closed clinical record was initiated on 6/6/22. The clinical record showed the SOC was 10/21/21. The patient was certified for hospice services during the certification period from 10/21/21 to 1/18/22. Review of Patient 7's Treatment/Medication/DME List for the certification period from 10/21/21 to 1/18/22, showed the patient was on oxygen therapy at 2 to 5 liters per minute via nasal cannula. The POC/IDG Reviews dated 10/21 and 11/8/21, showed the patient's identified problem included respiratory system related to SOB. The intervention included oxygen as ordered. However, the initial and updated POC did not include the rate of oxygen to be administered and mode of oxygen delivery. b. Further review of Patient 7's Treatment/Medication/DME List for the certification period from 10/21/21 to 1/18/22, showed the patient's medications included quetiapine 50 mg one tablet PO Q 12 hours for schizoaffective disorder and sertraline hydrochloride 50 mg one tablet PO QD for depression. However, review of the initial and updated POCs for the certification period from 10/21/21 to 1/18/22, failed to show documented evidence a care plan problem was developed to address the patient's behaviors. On 6/13/22, the Administrator/CEO was made aware and acknowledged the findings.

Based on clinical record review and interview, the hospice failed to ensure the initial and revised POCs included the discipline visit frequencies and/or the indication for the PRN discipline visits for 12 of 13 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12), creating the risk of not providing necessary services for these patients. Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12 showed the initial and revised POCs did not include the discipline visit frequencies and the indication for the PRN discipline visits. For example: 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The physicians order dated 7/18/21, showed SN visits 3W and 3 PRN; HA 2W; MSW initial visit within 5 days from SOC and then 1 M and 1 PRN; and the patient does not wish for Chaplain services at this time. However, there was no documented evidence the indication for the PRN visit in the physician's order. The IDG Comprehensive Details dated 7/26/22, MSW visit 1 M and 1 PRN. However, there was no documented evidence of the visit frequency of the SN and HA; and indication for the PRN visit of the MSW in the POC. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the POCs included measurable outcomes for 12 of 12 sampled patients (Patients 1, 2. 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12), creating the risk of not evaluating the POC and providing appropriate care and services to these patients. Findings: Review of the clinical records for Patients 1, 2. 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12, showed the initial and updated/revised POCs did not include the measurable outcomes anticipated to evaluate the effectiveness of the plan of care to meet the patients' needs. For example: 1. Review of Patient 1's clinical record was initiated on 6/7/22. The clinical record showed the SOC was 11/2/21. The patient was certified for hospice services during the certification period from 3/2/22 to 4/30/22, and 5/1/22 to 6/29/22. The POC/IDG Review dated 6/6/22, showed the patient's identified problems included cardiovascular related to hypertension, with the goal for the patient to maintain optimum peripheral circulation. However, there was no documented evidence of the measurable outcome as to what the optimum peripheral circulation would be. On 6/13/22 at 1008 hours, an interview and concurrent clinical record review was conducted with the Volunteer. The Volunteer was informed and acknowledged the findings. 2. Patient 6's closed clinical record showed the SOC was 10/1/21. The patient was certified for hospice services during the certification period from 1/29/22 to 3/29/22. The Interdisciplinary Care Plan, for the certification period from 1/29/22 to 3/29/22, showed the patient's identified problems with the established goals and interventions. However, the POC failed to include measurable outcomes for the patient's identified problem. For example, the goal for gastrointestinal status was for the patient to have optimal bowel elimination and comfort with the help of bowel management medication. There was no measurable outcome as to what optimal level for the patient was. On 6/13/22 at 1020 hours, the Administrator/CEO was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to develop the individualized POC that reflected the patient and family goals and interventions related to the medications necessary to meet the patient's needs for one of 12 sampled patients (Patient 7), creating the risk of not addressing the care needs for this patient. Findings: Review of Patient 7's closed clinical record was initiated on 6/6/22. The clinical record showed the SOC was 10/21/21. The patient was certified for hospice services during the period from 10/21/21 to 1/18/22. The Medication Profile, for the certification period from 10/21/21 to 1/18/22, showed the patient's medications included quetiapine (antipsychotic medication) 50 mg one tablet PO Q 12 hours for Schozoaffective disorder, sertraline hydrochloride 50 mg one tablet PO QD for depression, and Ativan 2 mg/ml 0.25 ml SL Q two hours PRN for mild to moderate anxiety/agitation. Further review of the clinical record failed to show any documented evidence the POC was developed to address the patient's use of antianxiety, antidepressant, and antipsychotic medications. There was no documented evidence of non-pharmacological interventions to be used when the patient became anxious, depress, or with change in behavior. In addition, there was no documented evidence the hospice had developed a POC to address the interventions and goals regarding the potential for CNS depressant effects of antianxiety, antidepressant, and antipsychotic medications. On 6/13/22 at 1008 hours, the Administrator/CEO was informed of the finding. She reviewed the clinical record and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the IDG had reviewed/revised the patient's POCs at least every 15 days for -- of 13 sampled patients (Patients --), creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The physician's order dated 7/18/22, showed peritoneal drainage with sterile technique once a week not to exceed one liter. The SN note dated 8/1/22, showed the patient has been having "moderated ascites with order for peritoneal drainage 2 times a week. Drainage not to exceed 1 liter." On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator, RN 1, and LVN 1. The Demonstrator stated the physician's order for the peritoneal drainage should be done twice a week and should never have been one a week. They were informed and acknowledged the findings. * The IDG failed to update the POC to address the frequency of the peritoneal drainage. 2. Review of Patient 3's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 12/3/21. The patient was certified for hospice services during the certification period from 7/31/22 to 9/28/22. The IDG Comprehensive Assessment Details dated 8/23/22, showed HA visits 3W The HA notes showed the HA conducted five visits during Week 5 (8/28/22 to 9/3/22) * However, the HA visits conducted were not consistent with the POC On 9/19/22 at 1010 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. The Administrator stated the HA visit frequency should have been increased in the POC. They were informed and acknowledged the findings. 2. Review of Patient 10's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 4/15/22. The patient was certified for hospice services during the certification period from 4/15/22 to 6/13/22. The patient was transferred to another hospice on 5/23/22. The SOC-Recertification-Continuation of Service Order dated 4/15/22, showed the first week of frequency was HA 3W then for the next eight weeks "Re evaluation for hospice criteria" The HA notes showed the HA conducted two visits during Week 1 (4/15/22 to 4/16/22). However, the visit frequency was not consistent with the HA visits. Further review of the HA notes showed the HA conducted visits on Week 2 (4/17/22 to 4/23/22), Week 3 (4/24/22 to 4/30/22), Week 4 (5/1/22 to 5/7/22), Week 5 (4/8/22 to 4/14/22), and Week 6 (4/15/22 to 4/21/22). However, there was no documented evidence on what was the HA visit frequency after Week 1. On 9/19/22 at 1230 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 3. The Administrator stated the POC related to visit frequency should have been revised. They were informed and acknowledged the findings. On 9/19/22 at 1230 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 3. They were informed and acknowledged the findings. 2. Review of Patient 7's closed clinical record was initiated on 6/6/22. The clinical record showed the SOC was 10/21/21. The clinical record showed the patient was certified for hospice services during the period from 10/21/21 to 1/18/22. Review of Patient's clinical record showed the IDG conducted the review of the initial POC on 10/21/21. However, the next IDG reviewed was conducted on 11/8/21, more than 15 calendar days. On 6/13/22/at 1010 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO was informed and acknowledged the findings. 3. Review of Patient 3's clinical record was initiated on 6/7/22. The clinical record showed the SOC was 4/8/22. The patient was certified for hospice services during the certification period from 4/8/22 to 7/6/22. The POC, for the certification period 4/8/22 to 7/6/22, showed LVN visit 1W (one time a week). The POC/IDG Reviews dated 4/25, 5/9, and 5/23/22, showed LVN visit 1W. Further review of the clinical record showed the hospice RN had conducted the visit weekly instead of the LVN. However, the IDG failed to revise or update the POC for the staff discipline conducting the visits. On 6/13/22 at 1008 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO. The Administrator/CEO stated the hospice had only one LVN and more RNs that could do home visits. The Administrator/CEO was informed and acknowledged the findings. 4.a. Review of Patient 8's closed clinical record was initiated on 6/6/22. The closed clinical record showed the SOC was 6/17/21. The patient was certified for hospice services during the certification periods from 6/17/21 to 8/15/21, 8/16/21 to 10/14/21, and 10/15/21 to 12/13/21. The POC/IDG Review dated 6/17, 7/29, and 8/12/21, showed no documented evidence the IDG members had participated in the IDG meeting as there were no signatures of the IDG members. The POC/IDG Review dated 7/1 and 7/15/21, showed the RN's signature. However, there was no documented evidence of other IDG members showing they had participated in these IDG meetings. On 6/13/22 at 1014 hours, a concurrent clinical record review and interview with the Office Manager was conducted. She was informed and acknowledged the findings. b. Review of Patient 4's clinical record was initiated on 6/7/22. The clinical record showed the SOC was 3/20/22. The patient was certified for hospice services during the certification period from 3/20/22 to 6/17/22. The POC/IDG Review dated 3/20 and 3/28/22, showed the Volunteer Coordinator/Bereavement Coordinator/Spiritual Counselor's signature. However, there was no documented evidence of the signatures of the other IDG members in the POC/IDG Review forms. The POC/IDG Review dated 4/11, 4/25, 5/9, and 5/23/22, showed no documented evidence the IDG members had participated in these IDG meetings as there were no signatures of the IDG members. The POC/IDG Review dated 3/20 and 3/28/22, showed only the RN signature. However, there was no documented evidence of other IDG members participated in these IDG meetings as there were no signatures of the other IDG members in the POC/IDG Review forms. Review of the hospice's IDG Sign-In Sheet showed not all IDG members had attended or participated in the IDG meetings. There was no documented evidence the MSW and spiritual counselor had attended or participated in the IDG meetings. The sign-in sheet showed only the following IDG members' signatures: - On 3/24/22, the signatures of the, Medical Director, Office manager, Office Staff, Administrator, and DPCS. - On 4/7/22, the signatures of the Medical Director, Office Manager, LVN, and DPCS. - On 4/21/22, the signatures of the Medical Director, Office Manager, Administrator, and DPCS. - On 5/5/22, the signatures of the Medical Director, Office Manager, Administrator, DPCS, and RN. - On 5/19/22, the signatures of the Administrator, DPCS, RN, and Office Manager. On 6/13/22 at 1141 hours, an interview was conducted with the Office Manager. She stated in January 2022, the hospice started to have a signature sheet for every IDG meeting and placed the signature sheet in a binder. She stated the MSW would attend the IDG meeting via a telephone call; however, there was no documented evidence of all IDG members had attended or participated in those IDG meetings.

Based on record review and interview, the hospice failed to ensure the revised POCs included the patient's progress toward goals specified in the POCs for ten of 13 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 10, and 12), creating the risk of not identifying the care needs and providing necessary care and services to meet the care needs for these patients. Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 10, and 12 was conducted from 9/7/22 to 9/19/22. The clinical records showed the IDG had reviewed and revised the POCs every 14 days. However, the revised POCs did not include the patients' progress toward the goals as specified in the POCs. For example: 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The patient's care plan dated 7/19/22, showed the patient's identified problems included deficit related to fall, related to "Foley/Supra-pubic catheter/Renal Issues and or Incontinence," enterocolitis due to Clostridium difficile and/or disease process; COVID-19 precautions; initial plan of care prior to service provision; family/ patient /PCG needing assistance with burial /funeral arrangements; and grieving anticipatory related to expected loss of physio-psychosocial well being of the patient. The goals were established for these identified problems. Further review of the clinical record showed documented evidence the IDG had reviewed the POCs Q 14 days. However, there was no documented evidence the POCs included the patient's progress toward goals. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing and supervising the care and services provided for one of 13 sampled patients (Patient --), creating the risk of not addressing the care needs for this patient. Findings: The hospice's P&P titled Interdisciplinary Group (undated), showed the hospice agency designates an IDG composed of qualified individuals who assess, plan, provide, and evaluate the care and services provided to hospice patients/caregivers. The IDG is responsible for establishing, implementing, reviewing, and revising the plan of care; providing or coordinating care and services in accordance with the patient's plan of care. 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The SN note dated 7/21/22, showed the patient had redness to coccyx. Documentation showed Calmoseptine (moisture barrier) was applied routinely. However, there was no documented evidence the SN had assessed for the size of the redness to coccyx. In addition, The IDG failed to supervise the care and services provided to the patient. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 2. Review of Patient 10's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 4/15/22. The patient was certified for hospice services during the certification period from 4/15/22 to 6/13/22. The SN note dated 5/19/22, showed the family member had concerns about a small healing bed sore at patient's right buttock. Documentation showed the family member was advised "continuing with A&D ointment and cover with dry dressing with no paper tape." However, there was no documented evidence the SN had assessed for the size and wound bed of the small healing bedsore. The IDG failed to supervise the care and services provided to the patient. On 9/19/22 at 1230 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 3. They were informed and acknowledged the findings.

Based on record review and interview, the hospice IDG failed to ensure the care and services were provided in accordance with the POCs for 12 of 12 sampled patients (Patients 1, 2, 3,4, 5, 6, 7, 8, 9, 10, 11, and 12), creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: The hospice's P&P titled Interdisciplinary Group Coordination of Care dated 4/14 showed the IDG will maintain the responsibility for the provision and coordination of care, regardless of the setting where care is provided to its patients. The IDG failed to ensure the care and services were provided in accordance with the POCs for Patients 1, 2, 3,4, 5, 6, 7, 8, 9, 10, 11, and 12 as follows: - Care and services were not provided in accordance with the POC for 12 of 12 sampled patients (Patients ). Cross reference to L543. - The HA was not provided HA services in accordance with the POC for one of 12 sampled patients (Patient 8). Cross reference to L626. On 6/13/22 at 1010 hours, the Administrator/CEO was informed of the findings.

Based on record review and interview, the hospice failed to develop an effective, on-going, hospice-wide date-driven QAPI program as evidenced by: 1. The hospice failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven QAPI program. Cross reference to L560. 2. The hospice failed to measure, analyze, and track quality indicators including adverse events and other aspects of performance that enabled the hospice to assess processes of care, hospice services, and operations. Cross reference to L562. 3. The hospice failed to use quality indicator data, including patient care, and other relevant data, in the design of its QAPI program. Cross reference to L563. 4. The hospice failed to develop PI activities that included high risk, high volume, or problem-prone areas. Cross reference to L566. 5. The hospice failed to ensure the QAPI had analyzed, developed, and implemented preventive action plans to improve care and services. Cross reference to L569. 6. The hospice failed to ensure the QAPI had developed, implement, and evaluate PI projects. Cross reference to L571. 7. The hospice failed to document the reasons for conducting the 2021 PI project and measurable progress achieved on the project. Cross reference to L573. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the QAPI to ensure quality of care provided to the patients.

Based on record review and interview, the hospice failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven QAPI program, creating the risk of not providing quality of care to the patients. Findings: The hospice's P&P titled QAPI Plan showed the hospice approach to improve performance include data collection and analysis to improve identified processes and outcomes of care. The hospice's QAPI Plan showed the hospice will include to collect the following data: equipment used in providing care, quarterly clinical record review, infection control surveillance, annual aggregation data, priorities identified by leaders, incident reporting, review of the emergency operations plan, patient perception of care surveys, annual program evaluation, medication errors, adverse drug reactions, internal and external complaints, effectiveness of pain management, risk management activities and outcomes, patient falls requiring medical interventions, drug diversions, physician, nursing, medical social, and counseling services, patient rights, administrative services, contract services, volunteers, HAs, and DMEs. Review of the hospice's QAPI meeting minutes for 2019, 2020, 2021, and 2022 was conducted on 6/8 and 6/13/22. The QAPI meeting minutes showed the QAPI committee met on 3/1/19, 1/31/20, 1/29/21, and 1/31/22. The QAPI discussed the annual utilization report, personnel compliance, measures for the PI projects, and clinical record review. The clinical record review item reported during the meetings showed the SNs were always 80% range compliance. However, when asked to show how the hospice came up with the result and how the data was collected. There was no data available. On 6/9/22 at 1402 hours, an interview and concurrent document review was conducted with the Office Manager. She stated the RN assigned to do the chart audit did the review electronically and the note was sent to the SNs who needed some correction, then if done correcting, there was no way to track what was audited. The Office Manager verified there was no tracking of the patients whose clinical records were reviewed or when it was done. She stated the RN did the audit one time a week, no regular day. Further review of the QAPI program showed the following: * There were no action plans implemented to address the infection control related to 40 % refusal of flu vaccination of field staff for 2022. * The meeting minutes showed the reports discussed during the meetings were not accurate, for example: - The meeting conducted on 3/1/19, showed the clinical record audit was done including nursing, therapy (PT/OT/ST), and social worker services. However, there was no documented evidence the hospice provided therapy services. - The meeting conducted on 1/31/20, showed they would continue with the Patient Satisfaction for 2018 and monitor any trends. However,there were no data related to the Patient Satisfaction Survey for 2019 that was discussed during this meeting. - The meeting conducted on 1/29/21, showed documentation the result of the clinical record review for January to December 2021 was 80 to 90 %. However, it was for only January of 2021. * The hospice failed to measure and analyze the result of the chart audits. Cross reference to L562. * The hospice failed to utilize the quality indicator data to identify the opportunity for improvement. There were no quality indicator data being monitored for the PI projects for 2019, 2020, and 2021. Cross reference to L563. * The hospice had no PI projects for 2019, 2020, and 2022. Cross reference to L571. * The hospice failed to document the reason for conducting the project and measurable progress achieved on the pain PI project for 2021. Cross reference to L573. * The PI projects for 2021 failed to show documented evidence the action plan and recommendations were reevaluated to ensure the effectiveness of implemented plan to improve patient care and performance. There was no documentation when the PI projects were completed or continued for 2022. On 6/13/22 at 1100 hours, the Administrator/CEO was informed the findings. The Administrator/CEO was asked to provide any other records or documents for the QAPI programs including the data or tools used. However, no additional documents were provided for review. The Administrator/CEO reviewed the QAPI programs and verified the findings.

Based on record review and interview, the hospice failed to measure, analyze, and track quality indicators, including adverse events and other aspects of performance that enabled the hospice to assess processes of care, hospice services, and operations. This created the risk of not identifying areas for performance improvement to improve care and services provided to the patients. Findings: Review of the hospice's QAPI program for 2019, 2020, and 2021 was conducted on 6/8/22. The documents showed the QAPI committee met yearly to discuss the patient satisfaction survey, PI, personnel compliance, clinical record review, and quality improvement. The following was identified: For the years of 2019, 2020, and 2021, the documents showed the chart audits were discussed and the results were 80 to 90 % compliance. However, there were no data or reports regarding the results of the chart audits. For example, the Meeting Agenda and Minutes dated 3/1/19, showed the RN did quarterly clinical chart review with minimum of 10 charts per quarter. However, there was no documented evidence of the result of the chart audit, data, and action plans related to the discussion and findings. The QAPI programs for 2019, 2020, and 2021, failed to measure how care and services provided based on the quarterly clinical record review. On 6/8/22, the Office Manager was asked to provide the chart audit results for review. However, there was no documents presented for review. Further review of the QAPI programs failed to show documented evidence the hospice measured, analyzed, or tracked quality indicators. On 6/13/22 at 1100 hours, the Administrator/CEO was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to utilize the quality indicator data in the design of its program. This created the risk of not improving care and services provided to the patients. Findings: Review of the hospice's QAPI programs for Review of the hospice's QAPI program for 2019, 2020, and 2021 was conducted on 6/8/22. The following was identified: * For the 2019, 2020, and 2021 QAPI programs, the hospice did not have documented evidence to show they collected the data related to falls/incidents, infections, discharges, volunteer hours, or other care issues. There were no documented evidence of these quality indicator data being utilized or monitored. * The pain PI project for 2021 showed no documented evidence of the quality indicator data being monitored. On 6/9/22 at 1402 hours, a telephone interview was conducted with the Administrator/CEO. The Administrator/CEO verified and stated the QAPI documents presented were for all of their programs and meeting minutes. The Administrator/CEO stated they incorporated their meetings for the QA and PI programs. On 6/13/22 at 1100 hours, the Administrator/CEO was informed of no PI projects for 2019, 2020, and 2022; data to support the meeting minutes or what was actually presented during the meetings (i.e., quarterly clinical record review). The PI project for 2021 failed to show documented evidence how the hospice came up with the numbers or data quarterly. The hospice failed to show documented evidence of the tool used to collect the data. The Administrator/CEO acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the PI activities focused on high risk, high volume, and problem-prone areas. This failure had the potential to adversely affect the quality of care provided to the patients. Findings: Review of the hospice's P&P titled Quality Assessment/Performance Improvement Plan revised date 2018 showed the hospice's QAPI activities will focus on high risk, high volume, or problem prone areas. Review of the QAPI program binder for 2018, 2019, 2020, and 2021 was conducted on 6/8/22. The QAPI program binder showed the data collected from the QAPI studies and the meeting minutes for each year. The QAPI meetings were conducted on 3/1/19, 1/31/20, 1/29/21, and 1/31/22. There was no documented evidence of the PI projects discussed during these meetings. Review of the 2021 PI Plan dated 1/26/22, showed the Administrator presented findings of pain which was collected on the SOC and assessed within 48 hours if pain was relieved by the medication. The documentation showed 100 % of the patients' pain were relieved by the pain medications. However, there was no documented evidence to show if pain was the high risk, high volume, or problem area of the hospice. There was no documented evidence to explain why pain was selected as the PI project. There was no documented evidence of the action plan for this topic other than continue to monitor the patient's pain. There was no data available for review. On 6/9/22 at 1402 hours, a telephone interview and concurrent document review was conducted with the Administrator/CEO and Office Manager. When asked how the hospice chose which PI studies to focus on, the Administrator/CEO replied the QAPI members discussed during the annual meetings. On 6/13/22 at 1100 hours, the Administrator/CEO made aware and verified the above findings.

Based on record review and interview, the hospice failed to ensure the QAPI had analyzed, developed, and implemented preventive action plans to improve care and services. This created the risk of not identifying areas for performance improvement to improve care and services provided to the patients. Findings: Review of the hospice's QAPI program for 2019, 2020, and 2021 was conducted on 6/8/22. The documents showed the QAPI committee met yearly and discussed the patient satisfaction surveys, service comments, clinical record review, personnel compliance, and items to include for performance improvement, and risk management report. The following was identified: 1. For the years of 2019, 2020, and 2021, the documents showed 80 to 90 % compliance for the clinical record review. There was no documented evidence the QAPI had discussed other data including incidents or accidents, infections, other services such as volunteers, or bereavement to establish a PI project. 2. For the PI Plan for 2021, the documents showed the selected PI project was pain. The documentation showed all or 100 % believed that the current pain medications were effective. The documentation showed 100% of the patients were admitted with pain for the 1st and 2nd quarters, 75% for the 3rd quarter, and 85% for the 4th quarter. There was no documented evidence the QAPI had analyzed the data collected, no action plans to manage pain, and analyzed why the patients' pain were not managed without the pain medications. There were no documented evidence of the evaluation of this PI project and if this PI needed to be continued. 3. There was no documented evidence of the PI activities for 2019, 2020, and 2022. 4. There was no documented evidence the quarterly clinical record review data presented and discussed during the 2019, 2020, and 2021 QAPI meetings. There was no documented evidence what tool was used to perform the quarterly clinical record review or the result of the actual audit. On 6/13/22 at 1100 hours, the Administrator/CEO was informed and acknowledged the findings. The Administrator/CEO verified that the hospice had an audit tool for clinical record review but not being used.

Based on record review and interview, the hospice failed to ensure the QAPI had developed, implement, and evaluate PI projects. This created the risk of not identifying areas for performance improvement to improve care and services provided to the patients. Findings: Review of the hospice's QAPI program for 2019, 2020, and 2021 was conducted on 6/8/22. The documents showed the QAPI committee met yearly and patient satisfaction surveys, service comments, clinical record review, personnel compliance, and items to include for performance improvement, and risk management report. The following was identified: 1. There was no documented evidence of the PI activities for 2019, 2020, and 2022. 2. For the PI Plan for 2021, the documents showed the selected PI project was pain. There was no documented of the action plan to address this PI project. In addition, there was no documented evidence of the evaluation of the PI project. On 6/13/22 at 1100 hours, the Administrator/CEO was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to document the reasons for conducting the 2021 PI project and measurable progress achieved on this project. This created the risk of not identifying the opportunity for improvement for care and services provided the patients. Findings: On 6/9/22 at 1402 hours, a telephone interview was conducted with the Administrator/CEO, she stated the hospice had a PI project for 2021. Review of the hospice's performance improvement program for 2021 showed the hospice performance improvement project was pain. The document showed all patients admitted to the hospice had multiple sites of pain. However, there was no documentation of the reason why the hospice had decided to conduct this performance improvement project. There was no documented evidence of the result and progress of the performance improvement project conducted for 2021. On 6/13/22 at 1100 hours, an interview and record review was conducted with the Administrator/CEO. She acknowledged there should be documentation of the result and progress of the performance improvement project conducted.

Based on record review and interview, the hospice failed to ensure the quality of core services provide as evidenced by: Findings: 1. The hospice failed to perform the initial comprehensive needs of the patients. Cross reference to L531. 2. The hospice failed to develop and implement the bereavement program as per the hospice's P&P to address the needs of the bereaved family members for the years of 2020, 2021, and 2022. Cross reference to L596. The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Core Services to meet the patients' care needs.

Based on record review and interview, the hospice failed to develop and implement the bereavement program as per the hospice's P&P to address the needs of the bereaved family members for the years of 2020, 2021, and 2022 for three of three sampled expired patients (Patients 6, 7, and 12) and three nonsampled expired patients (Patients A, B, and C), creating the increased risk of not addressing the bereavement needs of the bereaved family members. Findings: The hospice's P&P titled Bereavement Services showed the hospice will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for up to one year following the death of the patient. The program will be provided to the families/caregivers of the hospice patients both before and after the patient's death in accordance with the plan of care. A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented as needed. After a death has occurred, the bereavement assessment will be updated and the family/caregiver needs will be discussed at the next IDG meeting. The following will be provided: - Within two weeks after death of a patient, a sympathy card will be sent to the bereaved. - After three weeks, a bereavement letter will be sent to the bereaved giving support and outlining the hospice bereavement services. - Within three to five weeks after the patient's death, a bereavement assessment will be completed by the bereavement counselor following the family caregiver. - If a person is noted as experiencing normal grief, the bereavement counselor will make contact with the bereaved person for ongoing assessment and support at three, six, and nine months after the patient's death and at the anniversary of the patient's death. - The bereavement counselor will make information available to the bereaved person regarding bereavement support groups, other support groups available in the community, and the availability of individual counseling by the hospice personnel. In addition to the services outline above, persons deemed to be experiencing moderate or severe grief will be followed by the bereavement program with increased services and contact offered as noted in the plan of care. Ongoing bereavement program will be concluded at the end of up to one year, if the bereaved is no longer in need of hospice bereavement services. Review of the hospice's bereavement program showed the following: 1. On 6/13/22, the Office Manager was asked to provide the hospice's bereavement logs for 2020, 2021, and 2022 for review. However, there were no bereavement logs for 2020 and 2021. The hospice had no system of tracking for the bereavement services provided to ensure the letters and bereavement cards were provided timely as per the hospice's P&P. 2. Review of the list of patients who had expired in 2020, 2021, and 2022 showed six expired patients (Patients A, B, C, 6, 7, and 12). However, review of the bereavement records for these expired patients showed the bereavement services were not provided to the bereaved families as per the hospice's P&P. For example: Patient 6's clinical record showed the SOC was 10/1/21, and the patient had expired on 3/13/22. A bereavement letter was sent to the patient's family member on 4/13/22. The log showed something was sent to the patient's family member on the 3rd month of the patient's death. However, there was documented evidence what was sent or when it was sent. There was no documented evidence the sympathy card was sent to the bereaved family as per the hospice's P&P. There was no documented evidence the bereavement assessment was completed by the bereavement counselor within three to five weeks after the patient's death as per in the hospice's P&P. In addition, there was no documented evidence of the ongoing assessment and support at three and six months after the patient's death as per the hospice's P&P. On 6/13/22 at 0910 hours, an interview and concurrent clinical record review was conducted with the Office Manager. The Office Manager stated the hospice would send the bereavement letter in the first month after the patient's death to the bereaved and any letters sent, they kept a copy. The Office Manager stated the bereavement letters would also be sent in the third, sixth, and ninth months, one year, and 13th month after the patient's death as per their log. The Office Manager stated the hospice followed the timelines listed in the electronic record for sending the bereavement letters (first, third, sixth, and nineth months, one year, and 13 months after the patient's death). The Office Manager was made aware these timelines were not the same as the hospice's P&P. The Office Manager acknowledge the findings.

Based on interview and record review, the agency failed to ensure the written patient care instructions for the HA were developed by the RN who was responsible for the supervision of the HA for two of 12 sampled patients (Patients 7 and 8), creating the risk of not addressing the care needs for these patients. Findings: 1. Review of Patient 8's closed clinical record was initiated on 6/6/22. The closed clinical record showed the SOC was 6/17/21. The patient was certified for hospice services during the certification periods from 6/17/21 to 8/15/21, 8/16/21 to 10/14/21, and 10/15/21 to 12/13/21. The patient was discharged on 12/3/21. The Physician's Certification for Hospice Benefit dated dated 10/15/21, showed the patient was certified for hospice services during the certification periods from 10/15/21 to 12/13/21. The POC/IDG Review dated 10/21, 11/4, 11/18, and 12/3/21, showed HA visits 2W Further review of the clinical record showed the HA Notes dated 10/25, 10/30, 11/4, 11/6, 11/10, 11/13, 11/16, 11/19, 11/23, 11/26, 11/30, 12/2, 12/7, 12/13, 12/14, 12/18, 12/21, 12/22, and 12/24/21. However, the patient was discharged from the hospice on 12/3/21. In addition, there was no documented evidence of a written patient care instructions for the HA to follow during the certification period from 10/15/21 to 12/13/21 (third certification period). On 6/13/22 at 1014 hours, a concurrent clinical record review and interview with the Office Manager was conducted. The Office Manager stated the HA visits were declined for the first certification period (6/17/21 to 8/15/21) which was documented on the POC/IDG Review dated 7/1/21. The Office Manager stated the HA visits were requested by the patient during the third certification period (10/15/21 to 12/13/21); however, there was no documented evidence of the patient's request. The Office Manager stated the patient had HA visits even after the patient was discharged from the hospice on 12/3/21. She was informed and acknowledged the findings. 2. Review of Patient 7's closed clinical record was initiated on 6/6/22. The closed clinical record showed the SOC was 10/21/21. The patient was certified for hospice services during the certification period from 10/21/21 to 1/18/22. The POC/IDG Review dated 10/21/21, showed HA visits two times per week. Review of the HA Notes dated 10/26, 10/29, 11/1, 11/5, 11/8, and 11/15/21, showed the HA performed tasks during these visits. However, there was no documented evidence of a written patient care instructions for the HA to follow during the certification period from 10/21/21 to 1/18/22. On 6/13/22 at 1008 hours, a concurrent clinical record review and interview with the Administrator/CEO was conducted. She was informed and acknowledged the findings.

3. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The physician's order dated 7/18/22, showed HA visits two times a week. * The HA notes showed the HA conducted one visit during Week 1 (7/18/22 to 7/23/22), instead of two visits. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 4. Review of Patient 3's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 12/3/21. The patient was certified for hospice services during the certification period from 7/31/22 to 9/28/22. The IDG Comprehensive Assessment dated 7/9/22, showed the HA's assigned tasks included to check if the patient has any pain; and if there was pain, on a scale from 0-10 (0- no pain and 10 -worst pain) what was the pain. The HA note dated 8/16/22, showed the an area in the clinical record to mark if the patient had any pain. Documentation showed the HA and acknowledged and completed the task. * However, there was no documented evidence if the the patient had pain. On 9/19/22 at 1010 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 5. Review of Patient 5's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 9/3/21. The patient was certified for hospice services during the certification periods from 6/30/22 to 8/28/22 and 8/29/22 to 10/27/22. Review of the HA Assignment History showed the HA's assigned tasks included to document last BM and output * The HA notes dated 6/30, 7/2, 7/5, 7/7, 7/9, 7/12, 7/14, 7/17, 7/19, 7/21, 7/26, 7/28, 7/31, 8/2, 8/4, 8/9, 8/13, 8/16, 8/18, 8/20, 8/21, 8/23, and 8/25/22, during the certification periods, 6/30/22 to 8/28/22, showed no documented evidence the HA had documented patient's last BM and output. On 9/19/22 at 1100 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 6. Review of Patient 12's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 1/24/22. The patient was certified for hospice services during the certification period from 1/24/22 to 4/23/22. Review of the HA Assignment History showed the HA's assigned tasks included check if the patient has any pain; and if there was pain, on a scale from 0-10 (0- no pain and 10 -worst pain) what was the pain; and to check temperature, report to Case Manager if abnormal. The HA note dated 1/27/22, showed an area in the clinical record to mark if the patient had any pain; and to check the temperature and report to the Case Manager if abnormal.. Documentation showed the HA and acknowledged and completed the task. * However, there was no documented evidence if the the patient had pain and what was the patient's temperature. On 9/19/22 at 1150 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 2 and RN 3. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the volunteer services were provided to meet the patients' care needs as evidenced by: 1. The hospice failed to maintain, document, and provide the training to the volunteer. Cross reference to L643. 2. The hospice failed to ensure the volunteers were used in the direct patient care roles. Cross reference to L644. 3. The hospice failed to document and demonstrate viable and ongoing efforts to recruit volunteers for the year 2019, 2020, 2021, and 2022. Cross reference to L645. 4. The hospice failed to document the identification of each position that was occupied by a volunteer, the work time by volunteers occupying those position, and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions for 2020, 2021, and 2022. Cross reference to L646. 5. The hospice failed to identify each position that was occupied by a volunteer, total hours provided by a volunteer, and the estimated dollar costs that the hospice would have incurred if paid employees occupied the positions for the 2020, 2021, and 2022. Cross reference to L647. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with volunteer services to ensure the provision of quality healthcare provided to meet the patients' needs.

Based on record review and interview, the hospice failed to maintain, document, and provide the training to the volunteer, creating the increased risk of having inadequate knowledge of hospice program to meet the patients' needs. Findings: The hospice's P&P titled Volunteer Services dated 4/14, showed the Volunteer Coordinator will develop and implement a volunteer orientation and training program that is sufficient to meet the the needs of the patients and families and will include but will not be limited to history, philosophy, and structure of the hospice concept; volunteers' roles and responsibilities; and volunteer program policies. The Volunteer Coordinator will document ongoing efforts to recruit. train, and retain volunteers of all ages and ethnic backgrounds. Review of the Volunteer's personnel file showed the volunteer's start date was 10/20/21. The file showed the volunteer had an orientation on 10/20/21. Further review of the personnel file showed no documented evidence of the volunteer training since 2021. On 6/9/22 at 1402 hours, an interview and concurrent personnel file review was conducted with the Office Manager. she confirmed the hospice had only one volunteer. She was asked about ongoing training provided to the volunteer. The Office Manager was unable to provide. On 6/13/22 at 1100 hours, the Administrator/CEO was made aware and verified the findings.

Based on record review and interview, the hospice failed to ensure the volunteers were used in direct patient care roles for 12 of 12 sampled patients (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12), creating the risk of not addressing the care needs for these patients. Findings: Review of the hospice's list of volunteers showed the hospice had only one active volunteer. Review of 12 sampled patients' clinical records was conducted from 6/6/22 to 6/13/22. The following was identified: * 12 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9 10, 11, and 12) did not have volunteer assessment completed during the initial comprehensive assessment. Cross reference to L524. For example: * The clinical records for Patients 3 and 6 showed the IDG had met Q 14 to 15 days. The IDG notes showed the IDG would monitor for the needs for volunteer services and for some the volunteer services was declined. However, there were no documented evidence the IDG had discussed why the volunteer services were not needed at the time, and why the patients declined the volunteer services. * Review of the list of volunteers for 2020, 2021, and 2022, showed the hospice had two volunteers from January 2020 to 5/2/20, one volunteer from 5/3/20 to 10/21/20, no volunteer from 10/22/20 to 10/19/21, and one volunteer currently. Review of the hospice's volunteer hours for the years of 2020, 2021, and 2022 showed the volunteer hours provided were less than 5% of the total patient care services provided. In addition, review of the sampled patients failed to show volunteer services were utilized for direct care to the patients. On 6/13/22 at 0836 hours, an interview was conducted with the Volunteer Coordinator/Bereavement Coordinator/Spiritual Counselor. The Volunteer Coordinator/Bereavement Coordinator/Spiritual Counselor was asked how many of the hospice patients received volunteer services. The Volunteer Coordinator/Bereavement Coordinator/Spiritual Counselor stated no patients received volunteer services. He stated the nurses could refer a patient who needed volunteer services. The Volunteer Coordinator/Bereavement Coordinator/Spiritual Counselor was made aware of the 12 sampled patients with no volunteer assessment or documentation of the reason declining the volunteer services. The clinical records failed to show documented evidence the volunteer were used for direct patient care. The Volunteer Coordinator/Volunteer Coordinator/Spiritual Counselor acknowledged the findings.

Based on record review and interview, the hospice failed to document and demonstrate viable and ongoing efforts to recruit volunteers for the year 2019, 2020, 2021, and 2022, creating the increased risk of not having adequate number of the volunteers to meet the patients' needs. Findings: The hospice failed to utilize the volunteers for direct patient care roles in 2019, 2020, 2021, and 2022. Cross reference to L644. On 6/8/22 at 0800 hours, the Office Manager was asked for the documents related to Volunteer program activities. Review the hospice's Volunteer program for 2019, 2020, 2021, 2022 was conducted on 6/8/22. The hospice's documents for 2019, 2020, 2021, and 2022 showed no recruitment activity records for these years. On 6/8/22 at 0800 hours, the Office Manager was asked for the documents related to the Volunteer program activities. On 6/13/22 at 0836 hours, a telephone interview was conducted with the Volunteer/Bereavement Coordinator/Spiritual Counselor. He was informed and acknowledged the findings. He stated he was just hired on 3/4/22.

Based on record review and interview, the hospice failed to document the identification of each position that was occupied by a volunteer, the work time by volunteers occupying those position, and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions for 2020, 2021, and 2022. Findings: Review of the hospice's volunteer programs for 2020, 2021, and 2022 was conducted on 6/8/22. The following was identified: 1. The documentation failed to show any documented evidence of the cost savings achieved through the use of volunteers for 2020. 2. The volunteer program for 2021 showed a total of 4.27 volunteer hours was recorded. The documentation also showed the volunteers had performed their work in the administrative position. There was no documentation of what was the task performed by the volunteer during this time. The documentation showed the estimates of the dollar cost saving was $151.84. There was no documentation how this cost savings was calculated based on the position occupied. 3. The volunteer program for 2022 showed a total of 7.5 volunteer hours was recorded. The documentation also showed the volunteers had performed their work in the administrative position. There was no documentation of what was the task performed by the volunteer during this time. The documentation showed the estimates of the dollar cost saving was $266.70. There was no documentation how this cost savings was calculated based on the position occupied. A telephone interview with the Volunteer/Bereavement Coordinator/Spiritual Counselor who was responsible for the volunteer program was conducted on 6/13/22 at 0836 hours. He stated she was assigned to manage the volunteer program in March 2022 when he was hired. He stated he was not aware of how the volunteer hours were recorded and calculated for this hospice. On 6/13/22 at 1100 hours, the Administrator/CEO made aware of the findings.

Based on record review and interview, the hospice failed to ensure the COP regarding Organization and Administration of Services was met. Findings: The GB failed to assume full legal authority and responsibility for the management of the hospice, provision of all hospice services, its fiscal operation, and continuous QAPI. The Administrator failed to perform day-to-day operation to ensure compliance with all COPs. Cross reference to L651. The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Organization and Administration of Services.

Based on interview and record review, the hospice's GB failed to assume full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operation, and continuous QAPI. The Administrator failed to perform day-to-day operation to ensure compliance with the COPs under 418.54 (Initial & Comprehensive Assessment of Patient); 418.56 (Interdisciplinary Group, Care Planning, and Coordination of Services); 418:58 (Quality Assessment & Performance Improvement); 418.64 (Core Services); 418.78 (Volunteers); and 418.100 (Organization and Administration of Services). Findings: 1. The hospice failed to ensure the COPs under 418.54 (Initial & Comprehensive Assessment of Patient); 418.56 (Interdisciplinary Group, Care Planning, and Coordination of Services); 418.58 (Quality Assessment & Performance Improvement); 418.64 (Core Services); 418.78 (Volunteers) and 418.100 (Organization and Administration of Services) were met. Cross references to L520, L530, L559, L587, L641, and L648. 2. The hospice's P&P titled Orientation dated 4/14 showed all staff will be required to attend an initial orientation program upon employment. All staff will demonstrate knowledge and profeciency in skills appropriate to their assigned roles and responsibilities during the orientation period. The hospice's P&P titled Competency Assessment dated 4/14 showed the competency of all hospice staff will be assessed during orientation, during the probationary period, periodically throughout the course of a year when job responsibilities or duties change and during the annual performance evaluation. Review of HA 1's personnel file showed the hiring date of 3/30/22. However, there was no documented evidence of the HA 1's orientation and competency checklist were completed. 3. On 6/13/22 at 1100 hours, during an interview and concurrent record review with the Administrator/CEO, she was informed and acknowledged the findings regarding not comprehensively assessing the patients; not developing the POCs to address the patients' identified problems and measurable goals; not reviewing and revising the POCs; not providing volunteer services to meet the patients' needs; not directing, coordinating, and supervising care and services by the hospice's IDG; not providing bereavement services as per the hospice's P&P, and not implementing effective PI project and QAPI programs. The Administrator/CEO stated the GB meeting was conducted once a year to discuss finance, patient care services, expenses, and annual program evaluation. Review of the QAPI meeting minutes for 2019, 2020, 2021, and 2022 showed no items or concerns were identified during the meetings, including QAPI, patient care, SN, volunteer, and bereavement services. However, the hospice failed to maintain, document, and provide the training to the volunteer; failed to ensure the volunteers were used in administrative and direct patient care roles; and failed to document and demonstrate viable and ongoing efforts to recruit volunteers. Cross references to L643, L644, and L645. In addition, the hospice failed to develop and implement the bereavement program as per the hospice's P&P to address the needs of the bereaved family members. Cross reference to L596. 4. The hospice's Job Description for the Administrator dated 4/2014 showed the Executive Director/Administrator is responsible for the overall direction of the day to day operations of the hospice services; is repsonsible for establishing standars of care to comply with federal and state regulations and guidelines. The essential job functions/responibilities included ensuring the appropriate service policies and procedures are developed and implemented to accomplish identidied outcomes. Review of Patient 4's clinical record was initiated on 6/7/22. The clinical record showed the SOC was 3/20/22. The patient was certified for hospice services during the certification period from 3/20/22 to 6/17/22. The Medication Profile for the certification period 3/20/22 to 6/17/22, showed the patient's medications included amlodipine besylate (antihypertensive) 10 mg one tablet PO QD, aspirin enteric coated (blood thinner) 81 mg one tablet PO QD, clonidine hydrochloride (antihyperstensive 0.2 mg one tab PO BID, Finesteride (urinary retention medication) PO QD, losartan (antihypertensive) 50 mg one tablet PO QD, naproxen EC (nonsteroidal anti-inflammatory drug) 375 mg one tablet PO BID PRN, pravastatin sodium (antilipemic) 20 mg one tab PO QD, and tamsulosin hydrochloride (urinary retention medication) 0.4 mg one capsule PO QD. A joint visit was conducted with RN 2 on 6/8/22 at 1000 hours, to Patient 4's home. Review of the patient's medication was conducted with RN 2 and the patient. The bottle of finesteride had an expiration date of 2020. Patient 4 stated he would transfer his medications from the new bottles to the old bottles. Patient 4 stated he still had calcium carbonate (supplement) and Os-Cal (supplement) which the patient was no longer taking them. RN 2 placed the old bottles containing the medications, including the calcium and Os-Cal bottles in a plastic bag. RN 2 told the patient that RN 2 would take care of it. At the end of the visit, RN 2 took the plastic bag containing the medication bottles. RN 2 was asked what her plan was for the plastic bag containing the patient's medication bottles. RN 2 stated she had a destruction bin and would dispose the medications. RN 2 stated she would place the medications in the plastic bag with water and put it in the destruction bin. RN 2 stated once the destruction bin fulled, RN 2 would bring the destruction bin in the office. On 6/8/22 at 1620 hours, a telephone call was conducted with RN 2. RN 2 stated the old medication bottles that she took from the patient's home were one bottle of finsteride, three bottles of amlodipine, one bottle of clonidine, one bottle of flomax, one bottle of calcium carbonate, and one bottle of Os-Cal (supplement). On 6/13/21 at 1150 hours, an interview was conducted with the Administrator. The Administrator stated non-controlled medications were disposed at the patient's house. The Administrator and Office Manager was asked for the P&P related to disposal of non-controlled medications; however, he were not able to provide. * The hospice failed to ensure a P&P was developed for disposal of non-controlled medications.

Based on interview and record review, the hospice's governing body failed to assume full legal authority and responsibility for the management of the hospice and the provision of all hospice services. The Administrator failed to perform day-to-day operation to ensure the written agreements for the contracted providers included the roles in the bereavement follow up, rights and responsibilities in the implementation, coordination, supervision and evaluation of the care services. Findings: Review of the written agreements between the hospice and the contracted providers was conducted on 6/8/22, and showed the following: - The written agreement between the hospice and contracted Pharmacy 1 providing pharmacy services failed to include the rights and responsibilities of the hospice and Pharmacy 1 for the implementation and evaluation of the services provided. - The written agreement between the hospice and contracted Pharmacy 2 providing pharmacy services failed to include the rights and responsibilities of the hospice and Pharmacy 2 for the implementation, supervision, and evaluation of the services provided. - The written agreement between the hospice and contracted DME providing medical equipments failed to include the rights and responsibilities of the hospice and DME for the implementation of the services provided. - The written agreement between the hospice and contracted Medical Director providing medical services failed to include the roles and responsibilities of the hospice and Medical Director for the bereavement follow up. On 6/8/22 at 1414 hours, and 6/9/22 at 1311 hours, the Office Manager and Payroll Coordinator was informed of the finding. The Office Manager and Payroll Coordinator reviewed the hospice's written agreements and acknowledged the finding.

Based on record review and interview, the hospice failed to ensure the Certificate of Terminal Illness included a brief narrative explanation of the clinical findings for termincal illness as per the hospice's P&P for three of 12 patients (Patients 8, 11, and 12), creating the risk of not identified the patient's care needs for these patients. Findings: The hospice's P&P titled Certification of Terminal Illness showed hospice services will be provided in two 90 day periods and unlimited number of 60 day periods. At the time of admission to hospice, the hospice medical director 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 director or, if applicable, examination of the patient. Review of Patients 8, 11, and 12 showed no documented evidence the medical director included narrative explanation of the clinical findings that supports a life expectancy of six months or less. For example: 1. Review of Patient 8's closed clinical record was initiated on 6/6/22. The closed clinical record showed the SOC was 6/17/21. The patient was certified for hospice services during the certification periods from 6/17/21 to 8/15/21, 8/16/21 to 10/14/21, and 10/15/21 to 12/13/21. The patient was discharged on 12/3/21. The Physician's Certification for Hospice Benefit for the certification period 6/17/21 to 8/15/21, showed a section of the form the physician had certified "this patient has a life expectancy of six months or less if the terminal illness run its normal course." The form showed by the physician's signature, "the physician confirm that the physician personally composed the narrative based on the review of the medical records and examination of the patient." * However, the section for Physician Narrative Statement was blank. In addition, the patient was certified for 60 days instead of 90 days. On 6/13/22 at 1014 hours, a concurrent clinical record review and interview with the Office Manager was conducted. She was informed and acknowledged the findings. 2. Review of Patient 11's closed clinical record was initiated on 6/7/22. The closed clinical record showed the SOC was 3/2/21. The patient was certified for hospice services during the certification periods from 3/2/21 to 5/30/21 and 5/31/21 to 7/29/21. The patient was discharged on 7/13/21. The Physician's Certification for Hospice Benefit for the certification period 3/2/21 to 5/30/21, showed a section of the form the physician had certified "this patient is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course." The form showed by the physician's signature, "the physician confirm that the physician personally composed the narrative based on the review of the medical records, team assessment and/or and examination of the patient." * However, the section for Physician Narrative Statement was blank. On 6/13/22 at 1130 hours, a concurrent clinical record review and interview with the Office Manager was conducted. She was informed and acknowledged the findings. 3. Review of Patient 12's closed clinical record was initiated on 6/8/22. The closed clinical record showed the SOC was 1/28/22. The patient was certified for hospice services during the certification period from 1/28/22 to 4/27/22. The Physician's Certification for Hospice Benefit for the certification period 1/28/22 to 4/27/22, showed a section of the form the physician had certified "this patient is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course." The form showed by the physician's signature, "the physician confirm that the physician personally composed the narrative based on the review of the medical records, team assessment and/or and examination of the patient." * However, the section for Physician Narrative Statement showed, "the patient meets the LCD Guidelines to receive hospice services." There was no narrative summary of the clinical findings identified by the physician specific for the patient's condition to met the guidelines mentioned. On 6/13/22 at 1100 hours, a concurrent clinical record review and interview with the Administrator/CEO was conducted. She was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the medical director or physician designee reviewed the patient's clinical information to certify the patient for hospice services as per the hospice's P&P for three of 12 patients (Patient 6, 8, and 11), creating the risk of not identified the patient's care needs for these patients. In addition, the hospice failed to ensure a face to face encounter was conducted prior to the third benefit period recertification for Patient 8. Findings: The hospice's P&P titled Certification of Terminal Illness showed the hospice services will be provided in two 90 day periods and unlimited number of 60 day periods. At recertification, the hospice medical director must compose and sign the narrative based on review of the patient's medical record or, if applicable, examination of the patient. The hospice physician or nurse practitioner must have a face to face encounter with the patient within the 30 days prior to the third benefit period certification and within 30 days prior to each subsequent recertification. The hospice's P&P titled face to Face Encounter showed a face to face enounter will be performed for patients entering the third and all subsequent benefit periods. The hospice director or hospice employed nurse practitioner will perform face to face encounter within 30 days prior to the hospice certification for the third and all subsequent benefit period. 1. Review of Patients 6, 8, and 11 showed no documented evidence the medical director composed a narrative based on review of the patients' clinical records as per the hospice's P&P. For example: Review of Patient 8's closed clinical record was initiated on 6/6/22. The closed clinical record showed the SOC was 6/17/21. The patient was certified for hospice services during the certification periods from 6/17/21 to 8/15/21, 8/16/21 to 10/14/21, and 10/15/21 to 12/13/21. The patient was discharged on 12/3/21. The Physician's Certification for Hospice Benefit for the certification period 8/16/21 to 10/14/21, showed the physician had certified "this patient has a life expectancy of six months or less if the terminal illness run its normal course." The form showed by the physician's signature, "the physician confirm that the physician personally composed the narrative based on the review of the medical records and examination of the patient." * However, the section for Physician Narrative Statement was blank. In addition, the patient was certified for 60 days instead of 90 days. 2. Review of Patients 6, 8, and 11 showed no documented evidence of the face to face encounter performed by the physician within the 30 days prior to the third benefit period certification as per the hospice's P&P. For example: Review of Patient 8's clinical record showed the following: - The Physician's Certification for Hospice Benefit for the certification period from 6/17/21 to 8/15/21, showed documentation the certification was based on face to face encounter. - The Physician's Certification for Hospice Benefit for the certification period from 8/16/21 to 10/14/21, showed documentation the certification was based on the team assessment and face to face encounter. - The Physician's Certification for Hospice Benefit for the certification periods from 10/15/21 to 12/13/21, showed documentation the certification was based on the medical history, record, and patient status; and team assessment. * However, there was no documented evidence of the face to face encounter performed by the physician within the 30 days prior to the third benefit period certification as per the hospice's P&P. On 6/13/22 at 1014 hours, a concurrent clinical record review and interview with the Office Manager was conducted. She was informed and acknowledged the findings. The Office Manager was asked for documentation of the physician's face to face encounter; however, the Office Manager was unable to provide. On 6/13/22 at 1014 hours, a concurrent clinical record review and interview with the Office Manager was conducted. She was informed and acknowledged the findings.

3. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. a. The SN note dated 7/19/22, showed the patient had a drain site on the right side of the abdomen. The SN note dated 8/1/22, showed the patient had hospital stay a peritoneal drain was placed in the left abdomen. * However, the location of the peritoneal drain was not consistent. b. The IDG Comprehensive Assessment dated 7/26/22, included PT visit notes dated 8/3 and 8/8/22; SN visit notes 8/5 and 8/15/22; and MSW note dated 8/15/22, instead of visit notes prior to the IDG Comprehensive Assessment dated 7/26/22. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. LVN 1 stated the peritoneal drain was located on the right side of the abdomen. They were informed and acknowledged the findings. 4. Review of Patient 7's clinical record was initiated on 9/8/22. The patient's clinical record showed the SOC was 8/11/22. The patient was certified for hospice services during the certification period from 8/11/22 to 11/8/22. The IDG Comprehensive Assessment Details dated 9/6/22, showed SN visits 3W. Further review of the clinical record showed no documented evidence of SN visits during Week 4 (8/28/22 to 9/3/22). On 9/19/22 at 1120 hours, a concurrent clinical record review and interview was conducted with the Administrator. The Administrator stated the patient had a SN visit during Week 4. She stated the SN who visted the patient was a substitute nurse. She was informed of the findings 5.. Review of the clinical records for Patients 1, 2, 3, 6, 7, and 10 showed medications as pending instead of current on the IDG Comprehensive Assessment. For example: a. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The IDG Comprehensive Assessment dated 8/23/22, showed patient's pending medications included the following: - an order dated 7/22/22, showed Actos (anti-diabetic) 30 mg one tablet Q 24 hours - an order dated 7/22/22, showed cholecalciferol (supplement) 2000 u one tablet Q 24 hours - an order dated 7/18/22, showed diclofenac sodium (NSAID) gel 1% 4 gm QID topical PRN - an order dated 7/18/22, showed ertapenem sodium (antibiotic) 500 mg one time a day - an order dated 7/22/22, showed finasteride (urinary retention medication) 5 mg one tablet Q 24 hours - an order dated 7/18/22, showed lactobacillus (probiotic) one package one time a day - an order dated 7/18/22, showed midodrine (antihypotensive) 5 mg one tablet TID - an order dated 8/2/22, showed Norco (opioid analgesic) 5-325 mg one tablet one times a day -an order dated 7/18/22, showed octreotide acaetate (synthetic hormone) 50 mcg/ml Q eight hours SC - an order dated 7/18/22, showed pantoprazole (used to treat GERD) 40 mg Q 24 hours - an order dated 7/22/22, showed sodium bicarbonate (antacid) 650 mg one tablet Q 12 hours - an order dated 7/22/22, showed tamsulosin (urinary retention medication) 0.4 mg two tablet Q 24 hours - an order dated 7/22/22, showed Vitamin B plus C Complex (supplement) one tablet Q 24 hours On 9/20/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator. The Administrator stated the above medications are all current and not pending. She stated the nurse need to click the "software" to remove the medications listed as pending and become current.

Based on record review and interview, the hospice failed to timely authenticate entries made into the clinical record for -- of 13 patients (Patients --), creating the risk of not having a complete and accurate information Findings: The hospice's P&P titled Entries into Medical records and Authentication revised dated 3/1/15, showed hospice personnel providing direct patient care and supervisory functions will have access to make entries into the electronic record database. Those who are nit fully trained to use the electronic medical record software/database may use manual paper documentation. These records will be scanned into the electronic software attached to patient's file. Documentation shall be placed in the patient's medical record within 7 days except for the initial start of care for "HIS" is within 5 days. The entries will be authenticated by user name and credential. All entries will reflect the date care/service was provided. The software requires these entries. the electronic software records the date and time of the entries. QA personnel might access the record for review and correction as necessary. Each entry is recorded by the software the time, date, and name of the user. 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The SN note dated 8/1/22, showed the SN electronically signed the clinical record on 9/5/22. The HA note dated 7/21/22, showed the HA electronically signed the clinical record on 8/3/22. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. The Administrator stated the clinical record should be electronically signed within 48 hours from the discipline's visit. The Administrator stated sometimes the staff have to go back to correct the clinical record after the QA staff opened the clinical record. They were informed and acknowledged the findings. 2. Review of Patient 3's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 12/3/21. The patient was certified for hospice services during the certification period from 7/31/22 to 9/28/22. The HA notes dated 8/1 and 8/2/22, showed the HA electronically signed the clinical record on 8/12/22. The HA notes dated 8/16, 8/17, 8/18/22, showed the HA electronically signed the clinical record on 8/28/22 The HA notes dated 8/29, 8/30, and 8/31/22, showed the HA electronically signed the clinical record on 9/11/22. On 9/19/22 at 1010 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 3. Review of Patient 12's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 1/24/22. The patient was certified for hospice services during the certification period from 1/24/22 to 4/23/22. The HA notes dated 1/27 and 1/31/22, showed the HA electronically signed the clinical record 6/26/22 The HA notes dated 2/2, 2/4, 2/7, 2/9, and 2/11/22, showed the HA electronically signed the clinical record on 6/27/22. On 9/19/22 at 1150 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 2 and RN 3. They were informed and acknowledged the findings. 4. Review of Patient 10's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 4/15/22. The patient was certified for hospice services during the certification period from 4/15/22 to 6/13/22. The SN note dated 4/15/22, showed the SN electronically signed the clinical record 5/29/22. The SN note dated 4/19/22, showed the SN electronically signed the clinical record 5/30/22. The SN note dated 4/28/22, showed the SN electronically signed the clinical record 5/13/22. The SN note dated 5/12/22, showed the SN electronically signed the clinical record 5/24/22. On 9/19/22 at 1230 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 3. They were informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the discharge summaries were completed for seven of 12 sampled patients (Patients 6, 7, 8, 9, 10, 11, and 12), creating the risk of of not providing the necessary information for aftercare. Findings: The hospice's P&P titled Discharge Summary dated 4/14 showed each patient discharged from a service and from hospice will have a discharge summary filed in the clinical record. Hospice personnel who provide care will complete a discharge summary at the time the discipline is continued, which may include as appropriate: the date of discharge including the date the physician and the patient were informed of discharge; the reason for discharge including the name of the organization to which the patient was being transferred; the status of problems identified at admission and during provision of care; resolution of identified problems; continuing management needs; overall status of the patient; summary of care or service provided; patient's current plan of care; and the patient's latest physician's orders. The discharge summary and other relevant clinical documents will be completed and submitted within 72 hours of discharge from service Review of the clinical records for Patients 6, 7, 8, 9, 10, 11, and 12 showed the discharge summary was not completed for these patients. For example: a. Review of Patient 8's closed clinical record was initiated on 6/6/22. The closed clinical record showed the SOC was 6/17/21. The patient was certified for hospice services during the certification periods from 6/17/21 to 8/15/21, 8/16/21 to 10/14/21, and 10/15/21 to 12/13/21. The patient was discharged on 12/3/21. The Discharge Summary dated 12/13/21, showed the patient's age and the patient had COPD. The patient was admitted on 12/3/21, under the care of the Medical Director for routine level of care. Documentation showed the hospice received a call from the PCG and the patient went to the hospital. The IDG was notified. However, there was no documented evidence the discharge summary included summary of the patient's stay, including treatments,symptoms and pain management; name of the organization to which the patient was being transferred; status of problems identified at admission and during provision of care; resolution of identified problems; continuing management needs; and overall status of the patient. On 6/13/22 at 1014 hours, a concurrent clinical record review and interview with the Office Manager was conducted. She was informed and acknowledged the findings. b. Review of Patient 11's closed clinical record was initiated on 6/7/22. The closed clinical record showed the SOC was 3/2/21. The patient was certified for hospice services during the certification periods from 3/2/21 to 5/30/21 and 5/31/21 to 7/29/21. The patient was discharged on 7/13/21. The Discharge Summary dated 7/13/21, showed the patient reported that the patient would like to revoke the service. The patient did not have any complaint and did not need the service. The patient notified the hospice office of an upcoming appointment. Documentation showed the physician and IDG were notified. However, there was no documented evidence the discharge summary included summary of the patient's stay, including treatments, symptoms and pain management; name of the organization to which the patient was being transferred; status of problems identified at admission and during provision of care; resolution of identified problems; continuing management needs; and overall status of the patient. On 6/13/22 at 1130 hours, a concurrent clinical record review and interview with the Office Manager was conducted. She was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure their written agreement with the SNF included a provision stating the hospice must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source and misappropriation of patient property by anyone unrelated to the hospice to the SNF Administrator within 24 hours of the hospice becoming aware of the alleged violation. This created the risk for not reporting the abuse allegations timely. Findings: Review of the written agreement between the hospice and SNF was conducted on 6/8/22. The written agreement failed to show documented evidence the written agreement included a provision stating the hospice must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF Administrator within 24 hours of the hospice becoming aware of the alleged violation. On 6/8/22 at 1414 hours, the Office Manager and Payroll Coordinator was informed of the finding. The Office Manager and Payroll Coordinator reviewed the hospice's written agreement and acknowledged the finding.

Based on record review and interview, the hospice failed to ensure the written agreement with the SNF included a delineation of the responsibilities of the hospice and SNF to provide bereavement services to the SNF staff. Finding: Review of the written agreement between the hospice and SNF was conducted on 6/8/22. The written agreement did not include a delineation of the responsibilities of the hospice and SNF to provide bereavement services to the SNF staff. On 6/8/22 at 1414 hours, the Office Manager and Payroll Coordinator was informed of the finding. The Office Manager and Payroll Coordinator reviewed the hospice's written agreement and acknowledged the finding.

Based on record review and interview, the hospice failed to obtain the criminal background checks for three employees (MSW, HAs 1, and 2) who had direct patient contact and access to the patients' clinical records. Findings: Review of the personnel files was conducted on 6/13/22, and showed the following: - HAs 1 and 2's personnel files showed the hiring dates of 4/1/20 and 10/20/21, respectively. - MSW 2's personnel file showed the hiring date of 10/20/21. * However, there were no documented evidence of criminal background check for the above personnel. On 6/13/22 at 1503 hours, the Office Manager was informed and acknowledged the finding of the finding.