Every finding on record at Divine Hospice Services, Inc

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding the Initial and Comprehensive Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) of Patient was met as follows: --- 2. The HA nursing staff failed to ensure a completed pressure wound assessment was conducted that included the location, stage, size, surrounding skin, exudates (drainage), and signs of infection for one of 14 sampled patients (Patient 1) and HA failed to accurately have the correct diet for one of 14 sampled patients (Patient 10).  This deficient practice had the potential to result in the delayed provision of wound treatment that could lead to infection and deterioration of the wound causing patient's discomfort and/or pain for Patient 1 and result in Patient 10 not receiving accurate nutrition. (Refer to L524) Findings: 1. The HA failed to ensure the Interdisciplinary Group (IDG – composed of a Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians {MD} who meet regularly to discuss patients’ plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessments no later than 5 calendar days after election of hospice care for four of 14 sampled patients (Patient 2, Patient 3, Patient 5, and Patient 6). These failures had the potential to result in the patients' decline of well-being as a result of incomplete comprehensive assessment of the spiritual and psychosocial needs of the patients. (Refer to L523)2. The HA nursing staff failed to ensure a completed pressure wound assessment was conducted that included the location, stage, size, surrounding skin, exudates (drainage), and signs of infection for one of 14 sampled patients (Patient 1).This deficient practice had the potential to result in the delayed provision of wound treatment that could lead to infection and deterioration of the wound causing patient's discomfort and/or pain. Refer to L524)3. The HA staff failed to review and reconcile (the process of comparing a patient's medication orders to all of the medications that the patient has been taking) all medications the patients were taking and update their medication profile with the currently used medications for three of 14 sampled patients (Patient 2, Patient 5, and Patient 10). This failure had the potential to place patients at risk for medication errors and adverse drug reactions. (Refer to L 530)4. The HA failed to provide an initial bereavement assessment for 2 of 14 sampled patients (Patient 2 and Patient 3). This deficient practice has the potential to impact a family members' abilities to cope with the patients' death.  (Refer to L531) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily (written law) mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based on interview and record review the Hospice Agency (HA) failed to ensure the Interdisciplinary Group (IDG – composed of a Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians {MD} who meet regularly to discuss patients’ plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessments no later than 5 calendar days after election of hospice care for four of 14 sampled patients (Patient 2, Patient 3, Patient 5, and Patient 6). For Patient 2, the MSW failed to conduct an initial psychosocial assessment, and the Chaplain failed to conduct an initial spiritual assessment within 5 days after the patients' start of care (SOC) date.For Patient 3, Patient 5 and Patient 6, the Chaplain failed to conduct an initial spiritual assessment within 5 days after the patients' SOC date. These failures resulted in not meeting the hospice patients identified psychological and spiritual needs related to their terminal illness and related conditions that could affect the patients and/or family members their inability to cope with the terminal illness and wellbeing. --- c. During a review of Patient 5’s face sheet, the face sheet indicated a SOC date of 7/9/2025 with a terminal diagnosis of metabolic encephalopathy (a condition where the brain’s function is impaired due to chemical imbalances in the body, often caused by underlying medical issues or organ dysfunction). During a review of Patient 5’ EMR, Patient 5’s EMR indicated there was no documented evidence a spiritual assessment was conducted within 5 days from the SOC date. During a concurrent interview and record review, on 7/22/2025 at 11: 40 a.m., with the ADM/DPCS, the ADM/DPCS reviewed Patient 5’s EMR. The ADM/DPCS stated and confirmed the Chaplain did not conduct an initial spiritual assessment within 5 days from the SOC for Patient 5. The ADM/DPCS stated an initial spiritual assessment should be conducted within 5 days of admission to hospice care to identify the spiritual needs of the patient and patient's family. d. During a review of Patient 6’s face sheet, the face sheet indicated a SOC date of 6/18/2025 with a terminal diagnosis of Alzheimer’s disease with late onset (characterized by a gradual decline in memory, language, and cognitive abilities usually developing after age 65 if it's late onset).  During a review of Patient 6’ EMR, Patient 6’s EMR indicated there was no documented evidence a spiritual assessment was conducted within 5 days from the SOC date. During a concurrent interview and record review, on 7/22/2025 at 11:50 a.m., with the ADM/DPCS, the ADM/DPCS reviewed Patient 6’s EMR. The ADM/DPCS stated and confirmed the Chaplain did not conduct an initial spiritual assessment within 5 days from the SOC for Patient 6. The ADM/DPCS stated an initial spiritual assessment should be conducted within 5 days of admission to hospice care to identify the spiritual needs of the patient and patient's family.   Findings: a. During a review of Patient 2’s face sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a SOC date of 6/29/2025 with a terminal diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities) with late onset.  During a review of Patient 2’s Electronic Medical Record (EMR) on 7/18/2025, Patient 2’s EMR indicated there was no documented evidence a psychosocial assessment and spiritual assessment were conducted within 5 days from the SOC date.  During a concurrent interview and record review, on 7/22/2025 at 11:15 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 2’s EMR. The ADM/DPCS stated and confirmed the MSW and the Chaplain did not conduct an initial assessment within 5 days from the patient’s SOC. The ADM/DPCS stated an initial psychosocial and spiritual assessment should be conducted within 5 days of admission to hospice care to identify the social and spiritual needs of the patient and patient's family.  b. During a review of Patient 3’s face sheet, the face sheet indicated a SOC date of 6/21/2025 with a terminal diagnosis of senile degeneration of brain (a neurological disorder that is tied to cognitive decline, memory impairment, and changes in behavior), not elsewhere classified.  During a review of Patient 3’ EMR on 7/18/2025, Patient 3’s EMR indicated there was no documented evidence a spiritual assessment was conducted within 5 days from the SOC date.  During a concurrent interview and record review, on 7/22/2025 at 11:15 a.m., with the ADM/DPCS, the ADM/DPCS reviewed Patient 3’s EMR. The ADM/DPCS stated and confirmed the Chaplain did not conduct an initial spiritual assessment within 5 days from the SOC for Patient 3. The ADM/DPCS stated an initial spiritual assessment should be conducted within 5 days of admission to hospice care to identify the spiritual needs of the patient and patient's family. During a review of the agency's policy and procedure (P&P) titled Comprehensive Assessment, revised November 2021, the P&P indicated a comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with the attending physician. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient’s clinical record, including at least the following information: -          The patient's psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source and adequacy of environmental and other resources, coping mechanisms, and the patient’s and family/caregiver’s reaction to illness.-          An assessment of the patient’s and family/caregiver’s spiritual orientation, including, as appropriate, any involvement in a religious group such as a church or synagogue or a support group such as Alcoholic Anonymous and spiritual concerns or needs such as despair, suffering, guilt, etc.  During a review of the agency's P&P titled Psychosocial Assessment, revised November 2021, the P&P indicated a thorough psychosocial assessment will be initiated at the time of admission and continued throughout the course of care. Psychosocial assessment will be completed by a qualified hospice social worker or hospice registered nurse. The assessment includes, but is not limited to coping with and adjusting to the patient's terminal illness, making final arrangements, and reaction to the terminal illness and bereavement needs.  During a review of the agency's P&P titled Spiritual Assessment, revised November 2021, the P&P indicated a spiritual assessment will be completed for each patient/family by the hospice Chaplain. The assessment will include, but not be limited to, evaluation of the following:  -          Coping with and adjusting to the patient’s terminal illness-          Assessing bereavement needs-          Religious and/or spiritual reactions to terminal illness

Based on interview and record review, the hospice nursing staff failed to ensure a completed comprehensive assessment was conducted for two of 14 patients (Patient 1 and 10) by failing to:-Ensure Patient 1's wound pressure assessment was completed that included wound location, stage, size, surrounding skin, exudates (drainage), and signs of infection.-Ensure Patient 14's diet was accurately provided and documented as prescribed on the plan of care (POC).  This deficient practice had the potential to result in the delayed provision of wound treatment that could lead to infection and deterioration of the wound causing patient's discomfort and/or pain for Patient 1 and Patient 10 not receiving the prescribed and accurate nutrition. --- b. During a review of Patient 10’s face sheet, the face sheet indicated a start of care date (SOC) of 2/19/2025, with diagnosis of malignant neoplasm of colon (growth of cells that begins in a part of the large intestine called the colon).During review of Patient 10's Recertification Assessment (the process by which a hospice patient's eligibility for continued hospice care is reviewed and confirmed) dated 05/19/2025, indicated that patient was on a mechanical soft diet.During an interview on 7/22/2025 at 12:48 p.m., with the Patient 10's Primary Caregiver (PCG 2), the PCG 2 stated that Patient 10 is not on a mechanical soft diet and has no diet restrictions.During an interview on 7/22/2025 at 1:00 p.m., with Patient 10's, the patient stated that she has no dietary restriction and she is not a a mechanical soft diet. During an on 7/22/2025 at 11:30 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that Patient 10 was on a mechanical soft diet. The ADM/DPCS stated that she is the one responsible to makes sure that all patient information was accurate.      Findings: During a closed record review of Patient 1's face sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a start of care (SOC) date of 9/27/2023, with a terminal diagnosis of metabolic encephalopathy (a condition where the brain does not function properly due to chemical imbalances in the body). During a review of Patient 1’s Comprehensive Nursing Assessment (a thorough evaluation of a patient's overall health status, encompassing physical, psychological, social, and spiritual aspects) dated 9/27/2023, the assessment indicated Patient 1 had a right heel wound stage II pressure ulcer (partial-thickness loss of skin, presenting as a shallow open sore or wound)  with surrounding erythema (redness of the skin caused by increased blood flow and inflammation ) and mild exudate. During a review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 9/27/2023, the POC/IDG Review form indicated the frequency of visits of the skilled nurse to daily visits until further notice to monitor patient’s vital signs (are measurements of the body's most basic functions, that includes body temperature, pulse {heart rate}, respiratory rate {breathing}, and blood pressure), to assess safety concerns/issues, assess and monitor effectiveness of medications, to assess alteration in skin integrity every visit, and to assess/monitor effectiveness of wound treatments on the patient’s Stage II pressure ulcer wound on the right heel.   During a concurrent interview and record review, on 7/22/2025 at 11:15 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 1’s SN daily visit notes from 9/28/2023 to 10/14/2023. The ADM/DPCS stated and confirmed there was no documented evidence wound assessment was conducted to Patient 1’s right heel stage 2 pressure ulcer wounds from 9/28/2023 to 10/14/2023. The ADM/DPCS stated patient’s wound should have been assessed and then documented on every visit that includes wound size, color, drainage and signs of infection. The ADM/DPCS further stated wound assessment was very important to monitor wound healing, to evaluate if treatment was effective, and preventing complications like wound infection.  During a review of the agency's policy and procedure (P&P) titled Ongoing Assessments, revised November 2021, the P&P indicated the scope and intensity of ongoing hospice patient assessments will be determined by the patient’s prognosis, diagnoses, condition, desire for care, response to previous care, and the care setting. During each home visit, the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. The nurse will assess each patient on each visit, for: skin integrity and current treatment related to the identified symptoms and the patient’s response.

Based on observation, interview, and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) staff failed to review and reconcile (the process of comparing a patient's medication orders to all of the medications that the patient has been taking) all medications the patients were taking and update their medication profiles with the currently used medications for three of 14 sampled patients (Patient 2, Patient 5, and Patient 10).This failure had the potential to place patients at risk for medication errors and adverse drug reactions. --- c. During a review of Patient 10’s face sheet, the face sheet indicated a start of care date (SOC) of 2/19/2025, with diagnosis of malignant neoplasm of colon (growth of cells that begins in a part of the large intestine called the colon).During a review of Patient 10's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 7/16/2025, the POC/IDG Review form indicated the frequency of visit of the skilled nurse (SN) LVN) to one visit per week to monitor and assess effectiveness of current and new medication/treatment, and instruct patient caregiver (pcg) regarding new medication/treatment order and side effects (unwanted, usually unpleasant, effects caused by medicines).During a joint home visit, on 7/18/2025 at 11:45 a.m. with the Licensed Vocational Nurse (LVN 1) at Patient 10’s residence, Patient 10 was observed laying in a hospital bed, awake and  alert, accompanied by a caregiver (PCG 2). During a review of Patient 10’s current medication, on 7/18/2025 at 12:25 p.m. with LVN 1 and PCG 2, the following medications were available in Patient 10’s residence but not listed in Patient 10’s medication list provided by the hospice agency: Aspirin 81 mg (milligrams - unit of measurement) take 1 tablet orally dailyAlign Probiotics tablet take 1 capsule orally dailyD3 125 mcg (microgram - unit of measurement) take 1 tablet orally dailyDuring a review of Patient 10’s current medication, on 7/18/2025 at 12:25 p.m. with LVN 1 and PCG 2, the following medications were not available in Patient 10’s residence but were listed in Patient 10’s medication list provided by the hospice agency:Fexofenadine Hydrochloride (used to treat allergy symptoms) 180 mg take 1 tablet orally dailyRobitussin (used to relieve cough and chest congestion) 110mg/5ml syrup take 10 ml orally every 6 hours daily as needed for coughIbuprofen (used to reduce pain, fever, and inflammation) 800 mg take orally every 8 hours as needed for moderate painMetformin Hydrochloride (used to help lower blood sugar levels in people with type 2 diabetes) 500 mg take 1 tablet orally dailyDuring an interview on 7/18/2025 at 12:35 p.m., with Primary Caregiver (PCG 2), the PCG2 stated that Patient 10 was no longer was taking Fexofenadine Hydrochloride, Robitussin,  Ibuprofen and Metformin Hydrochloride. During an interview on 7/22/2025 at 11:30 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that every visit medication reconciliation should be conducted. The ADM/DPCS stated that it is important to do medication reconciliation every visit to decrease medication error.   b. During a review of Patient 5’s face sheet, the face sheet indicated a SOC date of 7/9/2025 with a terminal diagnosis of metabolic encephalopathy (a condition where the brain’s function is impaired due to chemical imbalances in the body, often caused by underlying medical issues or organ dysfunction). During a review of Patient 5's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 7/16/2025, the POC/IDG Review form indicated the frequency of visit of the skilled nurse (SN) LVN) to one visit per week to monitor and assess effectiveness of current and new medication/treatment, and instruct patient caregiver (pcg) regarding new medication/treatment order and side effects (unwanted, usually unpleasant, effects caused by medicines).During a joint home visit, on 7/18/2025 at 10:30 a.m. with the ADM/DPCS at Patient 5’s residence, Patient 5 was observed laying in a hospital bed, sleeping, accompanied by a caregiver (PCG 3).  During a review of Patient 5’s current medication, on 7/18/2025 at 10:50 a.m. with ADM/DPCS and PCG 3, the following medications were available in Patient 5’s residence but not listed in Patient 5’s medication list provided by the hospice agency ; Senna (a stool softener used for constipation) 8.6 mg tabs take 1 tablet orally two times a day as needed for constipation.During an interview on 7/18/2025 at 10:52 a.m. with PCG 3, PCG 3 stated Patient 5 is still using the Senna for constipation as needed. During an interview on 7/18/2025 at 10:55 a.m. with ADM/DPCS at Patient 5’s residence, ADM/DPCS stated the visiting nurse is supposed to do a medication reconciliation on every visit. ADM/DPCS stated the Senna was missed and needs to be updated to reflect accurately in Patient 5’s medication list.   Findings:a. During a review of Patient 2’s face sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a start of care (SOC) date of 6/29/2025 with a terminal diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities) with late onset.  During a review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 7/16/2025, the POC/IDG Review form indicated the frequency of visit of the skilled nurse (SN) LVN) to one visit per week to monitor and assess effectiveness of current and new medication/treatment, and instruct patient caregiver (pcg) regarding new medication/treatment order and side effects (unwanted, usually unpleasant, effects caused by medicines). During a joint home visit, on 7/18/2025 at 11:30 a.m. with the registered nurse (RN 1) at Patient 2’s residence, Patient 2 was observed laying in a hospital bed, awake, alert, disoriented and confused, accompanied by a caregiver (PCG 1).   During a review of Patient 2’s current medication, on 7/18/2025 at 11:46 a.m. with RN 1 and PCG 1, the medications Trintellix (a prescription medicine used in adults to treat depression, a mood disorder that causes a persistent feeling of sadness and loss of interest) 10 milligrams (mg, a unit of measurement) oral once daily, and Triamcinolone Acetonide (used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions.) 0.05% topical ointment could not be found. However, the patient’s current medication profile list provided by the HA indicated Patient 2 was still on these medications. During an interview with PCG 1, PCG 1 stated Patient 2 was not using these medications for several weeks.        During an interview on 7/22/2025 at 11:15 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated the HA nursing staff should check and reconcile patient’s medications on every visit. The ADM/DPCS stated there will be an increased risk of medication errors if medication reconciliation was not being conducted frequently or on every nurse’s visit.   During a review of the hospice agency’s policy and procedure (P&P) titled, Medication Profile revised November 2021, the P&P indicated patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

Based on interview and record review, the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to provide an initial bereavement assessment for two of 14 sampled patients (Patient 2 and Patient 3). This deficient practice has the potential to impact a family members' abilities to cope with the patients' death. --- Findings: a. During a review of Patient 2’s face sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a start of care (SOC) date of 6/29/2025 with a terminal diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities) with late onset. During a review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 7/16/2025, the POC/IDG Review form indicated the frequency of visit of the skilled nurse (SN) to one visit per week. The spiritual counselor (SC), social worker (MSW), and volunteer (VOL) services were declined. During a review of the Patient 2’s electronic medical record (EMR) on 7/18/2025, the EMR indicated that there was no documented evidence an initial bereavement assessment was conducted for Patient 2. b. During a review of Patient 3’s face sheet, the face sheet indicated a SOC date of 6/21/2025 with a terminal diagnosis of senile degeneration of brain (a neurological disorder that is tied to cognitive decline, memory impairment, and changes in behavior), not elsewhere classified.  During a review of Patient 3's POC/IDG Review form dated 7/2/2025, the POC/IDG Review form indicated the frequency of visit of the skilled nurse to one visit per week, and the MSW to one visit per month for support and counseling. The spiritual counselor and volunteer services were declined.  During a review of the Patient 3’s EMR on 7/18/2025, the EMR indicated that there was no documented evidence an initial bereavement assessment was conducted for Patient 3. During a concurrent interview and record review, on 7/22/2025 at 11:15 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 2 and Patient 3’s EMR. The ADM/DPCS stated and confirmed Patient 2 and Patient 3 did not have an initial bereavement assessment conducted on admission. The ADM/DPCS stated an initial bereavement assessment should be conducted on admission to identify the spiritual and cultural needs of the patient's family who may be impacted by the patient's death.  During a review of the agency's policy and procedure (P&P) titled Bereavement Services, revised November 2021, the P&P indicated Divine Hospice Services, Inc will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for up to one (1) year following the death of the patient. Services will be provided by personnel who have received training and have experience in dealing with grief. A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding Interdisciplinary Group, Care Planning, and Coordination of Services was met as follows: --- f Findings:1. The hospice agency failed to have every member of the interdisciplinary group (IDG) participate in the interdisciplinary group meeting for 4 of 14 sample patients (Patient10, Patient 11, Patient 12, and Patient 13).This deficient practice had the potential for members of the IDG not to contribute to the patient’s comprehensive and ongoing assessments and care planning process. (Refer to L541)2. The hospice agency skilled nurse failed to provide wound care treatment in accordance with the plan of care, for one of 14 sampled patients (Patient 1). This deficient practice had the potential to result in slow wound healing and possible wound complications.  (Refer to L543) The cumulative effect of these systemic practices resulted in the HA not providing the services/care as ordered and had the potential for the patient not receiving appropriate healthcare services that could affect their quality of life.

Based on interview and record review, the hospice agency failed to ensure every member of the interdisciplinary group (IDG- hospice Medical Director and all hospice interdisciplinary group members, including volunteers and attending physician) participated in the interdisciplinary group meeting for 4 of 14 sample patients (Patient10, Patient 11, Patient 12, and Patient 13).This deficient practice had the potential for members of the IDG not to contribute to the patient’s comprehensive and ongoing assessments and care planning process. --- Findings:a. During a review of Patient 10's face sheet indicated a start of care date (SOC) of 2/19/2025, with diagnosis of malignant neoplasm of colon (growth of cells that begins in a part of the large intestine called the colon).During a review of Patient 10's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 7/16/2025, indicated the physician and Registered Nurse (RN) signatures were blank.There was no documented evidence the physician and RN had participated in the IDG meeting. b. During a review of Patient 11's clinical record indicated a start of care date (SOC) of 5/14/2025, with diagnosis of with diagnosis of Alzheimer’s disease (progressive disease that destroys memory and other important mental functions).During a review of Patient 10's Plan of Care (POC)/Interdisciplinary Group Review form dated 7/16/2025 indicated the physician's signature was blank. There was no documented evidence the physician had participated in the IDG meeting. c. During a review of Patient 12's clinical record indicated a start of care date (SOC) of 1/28/2025, with diagnosis of with diagnosis of Alzheimer’s disease.During a review of Patient 12's Plan of Care (POC)/Interdisciplinary Group Review form dated 7/16/2025, indicated that the physician and Registered Nurse (RN) signatures were blank.There was no documented evidence the physician and RN had participated in the IDG meeting. d. During a review of Patient 13's clinical record indicated a start of care date (SOC) of 2/4/2025, with diagnosis of with diagnosis of Alzheimer’s disease.During a review of Patient 13's Plan of Care (POC)/Interdisciplinary Group Review form dated 7/16/2025 indicated that the physician signature was blank.There was no documented evidence the physician had participated in the IDG meeting. During an interview with the Director of Patient Care Services (DPCS) on 7/22/2025 at 11:30 a.m., she stated that the IDG members should sign the day of the meeting to verify attendance.   A review of the agency’s policy and procedure titled “Interdisciplinary Group Meeting,” revised 11/2021, indicated that the hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available.

Based on interview and record review, the hospice agency (HA) skilled nurse failed to provide wound care treatment in accordance with the plan of care for one of 14 sampled patients (Patient 1). This deficient practice had the potential to result in slow wound healing and possible wound complications. --- Findings:During a closed record review of Patient 1's face sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a start of care (SOC) date of 9/27/2023, with a terminal diagnosis of metabolic encephalopathy (a condition where the brain does not function properly due to chemical imbalances in the body). During a review of Patient 1’s Comprehensive Nursing Assessment (a thorough evaluation of a patient's overall health status, encompassing physical, psychological, social, and spiritual aspects) dated 9/27/2023, the assessment indicated Patient 1 had a right heel pressure ulcer Stage II (partial-thickness loss of skin, presenting as a shallow open sore or wound)  with surrounding erythema (redness of the skin caused by increased blood flow and inflammation )and mild exudate (a fluid released by an organism through pores or a wound).During a review of Patient 1's Plan of Care (POC, a comprehensive and individualized plan outlining the medical, emotional, psychosocial, and spiritual care for a terminally ill patient) Summary form, the POC summary included a treatment order dated 9/27/023, to perform treatment to pressure ulcer Stage II right heel as follows: cleanse with normal saline (a solution of 0.9% sodium chloride and water, is a common and effective solution for wound cleansing), apply hydrogel (a type of primary dressing that creates and maintains a moist wound environment to promote healing) with non-adherent dressing, cover with foam dressing and secure with soft wrap. During a review of Patient 1 skilled nurse’s  Visit Note CC (or continuous care, a type of hospice care that provides around-the-clock nursing care for patients who are experiencing severe symptoms and require frequent monitoring and intervention ), dated 10/6/2023, 10/12/2203, 10/13/2023, and 10/14/2023, the visit notes did not indicate documented evidence that wound care treatment was provided as indicated in the plan of care to Patient 1’s right heel pressure ulcer Stage II.  During a phone interview, on 7/18/2025 at 9:53 a.m., with the licensed vocational nurse (LVN 2), LVN 2 stated she visited and cared for Patient 1 for several days while the patient was on continuous care. LVN 2 stated she was not aware and did not perform wound care treatment to Patient 1’s right heel pressure ulcer Stage II during her visits.   During a concurrent interview and record review, on 7/22/2025 at 11:15 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 1’s SN daily visit notes from 9/28/2023 to 10/14/2023. The ADM/DPCS confirmed there was no documented evidence wound treatment was performed on those dates. The ADM/DPCS stated the nursing staff should have specified in their visit notes indicating wound care treatment was provided each visit in accordance with the plan of care.  During a review of the agency's policy and procedure (P&P) titled The Plan of Care, revised November 2021, the P&P indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.

Based on interview and record review, the Hospice Agency (HA- agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Clinical Records was met as follows: --- Findings:1. The hospice agency failed to ensure the agency staff submitted complete clinical notes in a timely manner and pertinent clinical records were included to reflect the care and assessment provided for two of 14 sampled patients (Patient 2 and Patient 3).This failure resulted in patient’s incomplete clinical record that could lead to misinformation and lack of care and services provided to the patient. (Refer to L672)2. The hospice agency failed to ensure documentation for two of 14 sampled patients (Patient 1 and Patient 10) was accurate and authentic.This deficient practice resulted in the failure to document accurately and ensure authenticity of the patients' clinical records and had the potential to result in an unauthorized and inaccurate patient information or assessment that could affect Patient 1 and Patient10’s quality of care and well-being. (Refer to L679) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily (written law) mandated compliance with Federal regulations for Clinical Records to ensure patients’ medical records were safeguarded from unauthorized access by any individual or hospice staff and were maintained complete and accurate. 1. The hospice agency failed to ensure the agency staff submitted complete clinical notes in a timely manner and pertinent clinical records were included to reflect the care and assessment provided for three of 14 sampled patients (Patient 2, Patient 3 and Patient 10).This failure resulted in patient’s incomplete clinical record that could lead to misinformation and lack of care and services provided to the patient. (Refer to L672)  The hospice agency (HA) failed to ensure patients clinical records included staffs completed clinical notes submitted in a timely manner and completed assessments of every patient to reflect the care and services provided for three of 14 sampled patients (Patient 2, Patient 3, and Patient 10).This failure resulted in patient’s incomplete clinical record that could lead to misinformation and lack of care and services provided to the patient. (Refer to L672). 2.  The Hospice Agency (HA) failed to ensure documented entries for two of 14 sampled patients (Patient 1 and Patient 10) clinical records were accurate and authentic (original). This deficient practice resulted in the unauthorized and inaccurate patient information or assessment entered in the clinical records that could affect the patient's quality of care and wellbeing. (Refer to L679). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily (written law) mandated compliance with Federal regulations for Clinical Records to ensure patients’ medical records were safeguarded from unauthorized access by any individual or hospice staff and were maintained complete and accurate.

Based on interview and record review, the hospice agency (HA) failed to ensure patients clinical records included staffs completed clinical notes submitted in a timely manner and completed assessments of every patient to reflect the care and services provided for three of 14 sampled patients (Patient 2, Patient 3, and Patient 10). This failure resulted in patient’s incomplete clinical record that could lead to misinformation and lack of care and services provided to the patient. --- c. During a review of Patient 10's face sheet indicated a start of care date (SOC) of 2/19/2025, with diagnosis of malignant neoplasm of colon (growth of cells that begins in a part of the large intestine called the colon). Patient 10’s face sheet indicated that the patient’s religion was Christian, and denomination was Church of Christ.During a review of Patient 10’s Recertification Assessment (process by which a hospice patient's eligibility for continued hospice care is reviewed and confirmed) dated 2/19/2025 that patient was on a mechanical soft diet (a texture-modified diet where foods are prepared to be easier to chew and swallow). Patient 10’s Recertification Assessment dated 2/19/2025 indicated that in the supervisory note the Licensed Vocational Nurse (LVN) listed was a different name from the LVN that was visiting the patient. During a review of Patient 10’s Supervisory Visit Notes dated 6/25/2025 and 7/9/2025 indicated that LVN listed was a different name from the LVN that was visiting the patient. During a review of Patient 10’s LVN Visit Notes dated 6/20/2025, 6/27/2025, 7/4/2025 and 7/11/2025 indicated that Patient 10’s diet was mechanical soft. During an interview on 7/22/2025 at 12:48 p.m., with the Patient 10's Primary Caregiver (PCG 2), the PCG 2 stated that Patient 10 is not on a mechanical soft diet and has no diet restrictions.During an interview on 7/22/2025 at 1:00 p.m., with Patient 10's, the patient stated that she has no dietary restriction and she is not a a mechanical soft diet. During an on 7/22/2025 at 11:30 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that Patient 10 was on a mechanical soft diet.During an interview and record review, on 7/22/2025 at 11:30 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that the nurse listed on Patient 10’s supervisory notes was wrong and that Patient 10 has always had LVN 1 as her nurse. ADM/DPCS stated that Patient 10 is Jewish and that information on the face sheet is not accurate. The ADM/DPCS stated that Patient 10 was on a mechanical soft diet. The ADM/DPCS stated that she is responsible for making sure visit documentation are accurate and posted correctly. ADM/DPCS stated that it is important to have accurate notes and documentation so that it does not cause confusion. Findings:a. During a review of Patient 2’s face sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a SOC date of 6/29/2025 with a terminal diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities) with late onset. During a review of Patient 2’s Electronic Medical Record (EMR) on 7/18/2025, Patient 2’s EMR indicated there was no documented evidence a psychosocial assessment and spiritual assessment were conducted within 5 days from the SOC date. During a concurrent interview and record review, on 7/22/2025 at 11:15 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 2’s EMR. The ADM/DPCS stated and confirmed the MSW and the Chaplain did not conduct an initial assessment within 5 days from the patient’s SOC. The ADM/DPCS stated an initial psychosocial and spiritual assessment should be conducted within 5 days of admission to hospice care to identify the social and spiritual needs of the patient and patient's family. b. During a review of Patient 3’s face sheet, the face sheet indicated a SOC date of 6/21/2025 with a terminal diagnosis of senile degeneration of brain (a neurological disorder that is tied to cognitive decline, memory impairment, and changes in behavior), not elsewhere classified. During a review of Patient 3's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 6/21/2025, the POC/IDG Review form indicated the frequency of visits of the skilled nurse to one visit per week to monitor patient’s vital signs (are measurements of the body's most basic functions, that includes body temperature, pulse {heart rate}, respiratory rate {breathing}, and blood pressure), to assess safety concerns/issues, assess and monitor effectiveness of medications, to assess overall condition of the skin, and to instruct on sign and symptoms of impending exacerbation and how to manage.   During a review of Patient 3’ EMR on 7/18/2025, Patient 3’s EMR indicated there was no documented evidence a spiritual assessment was conducted within 5 days from the SOC date. EMR further indicated Patient 3 was visited by a registered nurse (RN 2) on 6/28/2025 and 7/5/2025, but no visit notes were submitted. During a phone interview, on 7/18/2025 at 3:20 pm, with RN 2, RN 2 stated and confirmed she visited Patient 3 on 6/28/2025 and 7/5/2025, but she was delayed in submitting her visit notes for those days. RN 2 stated that per agency’s policy, she was supposed to submit her clinical notes within 24 hours from the visit.      During a concurrent interview and record review, on 7/22/2025 at 11:15 a.m., with the ADM/DPCS, the ADM/DPCS reviewed Patient 3’s EMR. The ADM/DPCS stated and confirmed the Chaplain did not conduct an initial spiritual assessment within 5 days from the SOC for Patient 3. The ADM/DPCS stated an initial spiritual assessment should be conducted within 5 days of admission to hospice care to identify the spiritual needs of the patient and patient's family. The ADM/DPCS further stated field staff need to submit their visit notes within one week from the visit in accordance with the agency’s policy. During a review of the agency's policy and procedure (P&P) titled Clinical/Service Data Collection, revised November 2021, the P&P indicated home care personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday.

Based on interview and record review, the Hospice Agency (HA) failed to ensure documented entries for two of 14 sampled patients (Patient 1 and Patient 10) clinical records were accurate and authentic (original). This deficient practice resulted in the unauthorized and inaccurate patient information or assessment entered in the clinical records that could affect the patient's quality of care and wellbeing. --- During a review of Patient 10's face sheet indicated a start of care date (SOC) of 2/19/2025, with diagnosis of malignant neoplasm of colon (growth of cells that begins in a part of the large intestine called the colon).During a review of Patient 10's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 7/16/2025, the POC/IDG Review form indicated that the Skilled Nurse (SN) was scheduled to visit the patient one time a week, Home Health Aid  (HHA) two times a week and was receiving routine care.During a review of Patient 10’s Certified Home Health Aide (CHHA) visit notes history indicated that Patient 10 had CHHA visits twice a week on Tuesdays and Thursdays for the month of 06/2025 to 07/2025.During a review of Patient 10’s Certified Home Health Aide (CHHA) notes dated 7/10/2025 and 7/17/2025 indicated that the CHHA had visited Patient 10 for one hour on each day. During a review of Patient 10’s Master of Social Work (MSW) visit dated 07/15/2025, the MSW visit note indicated that Patient 10 was visited for 30 minutes. A review of the hospice agency’s Electronic Medical Records (EMR) Audit Log (a chronological record of user activity within an EMR system), indicated that on 07/16/2025 at 10:50 a.m., the Administrator/Director of Patient Care Services (ADM/DPCS) modified the MSW visit not dated 7/15/2025. Route sheet for CHHA and MSW visits requested on 07/22/2025 and not provided. During an interview with Patient 10 and Patient 10’s Primary Caregiver (PCG 2) on 7/18/2025 at 12:47 p.m., she stated that the CHHA came and visited her once a week not twice a week. During an interview with Patient 10 on 07/21/2025 at 1:21 p.m., Patient 10 stated that the CHHA has not come to visit her and give her bath for the last two week due to her shingles. Patient 10 stated that she told the CHHA 1 not to come and give her baths because she did not want her shingles to spread. Patient 10 stated that she did not receive a visit from the MSW on 7/15/2025 and she has never received a visit or phone call from the MSW. During an interview with CHHA 1 on 07/21/2025 at 2:40 p.m., CHHA 1 stated that she visits Patient 10 once a week not twice a week and its usually on a Tuesday or a Thursday depending on the patient’s schedule. CHHA 1 stated that she has not visited Patient 10 for the last week because Patient 10 told her not to come because of her shingles. During an interview and record review, on 7/22/2025 at 11:30 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that Patient 10 use to have CHHA twice a week but it changed to once a week. The ADM/DPCS stated that she did not have a physician order indicated the change in CHHA visits and she is unaware when the changed happened. ADM/DPCS stated that she is not sure why there are CHHA notes for Patient 10 on 07/10/2025 and 07/17/2025 if visit was not done and that maybe CHHA 1 made a mistake. ADM/DPCS stated that she is responsible for making sure visit documentation are accurate and posted correctly. ADM/DPCS stated that it is important to have accurate notes and documentation so that it does not cause confusion. During an interview and record review, on 7/22/2025 at 12:13 p.m., with the ADM/DPCS, the ADM/DPCS stated that it was not her who entered and modified the MSW visit notes on 7/15/2025 and that it was not her. ADM/DPCS stated that it was the QI (Quality Improvement) and that she is unsure who they are because the agency uses a company. Observed that ADM/DPCS login for the agency’s EMR is saved on the desktop computer that other employees use. Findings: a. During a closed record review of Patient 1's face sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a start of care (SOC) date of 9/27/2023, with a terminal diagnosis of metabolic encephalopathy (a condition where the brain does not function properly due to chemical imbalances in the body). During a review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 9/27/2023, the POC/IDG Review form indicated the frequency of visits of the skilled nurse (SN) to daily visits until further notice to monitor patient’s vital signs (are measurements of the body's most basic functions, that includes body temperature, pulse {heart rate}, respiratory rate {breathing}, and blood pressure), to assess safety concerns/issues, assess and monitor effectiveness of medications, to assess alteration in skin integrity every visit, and to assess/monitor effectiveness of wound treatments on the patient’s Stage II pressure ulcer wound on the right heel.   During a review of Patient 1 skilled nurse’s Visit Note CC (or continuous care, a type of hospice care that provides around-the-clock nursing care for patients who are experiencing severe symptoms and require frequent monitoring and intervention), dated 10/14/2023, the visit note indicated licensed vocational nurse (LVN 2) visited the patient from 6:30 p.m. to 1:00 a.m. the next day.  During a phone interview, on 7/18/2025 at 9:53 a.m., with the LVN 2, LVN 2 stated she did not care for or visited Patient 1 on 10/14/2023 or 10/15/2023.   During a concurrent interview and record review, on 7/22/2025 at 11:15 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 1’s SN visit notes CC dated 10/14/2023. The ADM/DPCS was unable to provide an explanation as to why there was a visit note dated 10/14/2023 and signed by LVN 2, when LVN 2 stated during an interview that she did not visit Patient 1 on that day.   During a review of the agency's policy and procedure (P&P) titled Clinical/Service Data Collection, revised November 2021, the P&P indicated home care personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical/service record will be clear, concise, and specific statements of fact.

Upon patient record review 1 of 14 (Patient 4) did not have evidence that the hospice Registered Nurse completed an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Clients “Election of Hospice Medicare Benefit & Patient Auth” form signed with Hospice election date noted as 12/20/23. RN initial assessment completed on 12/28/23.

Upon patient record review, 2 of 14 (Patient 1 & 11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1 medication profile included “Clonidine 0.1 mg/24 hr transdermal system 0.1 mg percutaneous 1 tab by mouth daily”; unclear route. Patient 11 medication profile included "Bactroban 2% topical ointment apply small amount to affected areas 3 times daily” with no location identified.

Upon patient record review, 2 of 14 (Patient 1 & 11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1 plan of care included “Clonidine 0.1 mg/24 hr transdermal system 0.1 mg percutaneous 1 tab by mouth daily”; unclear route. Patient 11 plan of care included "Bactroban 2% topical ointment apply small amount to affected areas 3 times daily” with no location identified.

Upon patient record review, 1 of 14 (Patient 2) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 2 with bedside commode, wheelchair and bedside table in the home confirmed by caregiver rec’d from hospice but not on plan of care