Every finding on record at Exquisite Touch Hospice

Based on observation, interview, and record review, the hospice agency failed to implement its policy and procedure titled “Safe/Effective Use of Medications” by failing to teach one of one sampled patient (Patient 16) and the patient’s caregiver to discard the Novolog Flex Pen (a pre-filled, disposable, dial a dose injection pen containing insulin aspart [a rapid acting insulin used to manage blood sugar levels]) and Lantus SoloStar prefilled syringe (a disposable, prefilled insulin pen containing long-acting insulin for managing blood sugar) 28 days after its initial use, as recommended by the manufacturer.  This failure had the potential to compromise the efficacy of the medication after expiration, which could adversely affect the patient’s health. --- Findings: During a review of Patient 16’s medical record form titled “Personal Information,” the form indicated a start of care (SOC) date of 10/8/2025, with a primary diagnosis of chronic obstructive pulmonary disease (COPD, a chronic lung disease that causes difficulty in breathing).   During a review of Patient 16’s Current Treatment/Medication/ DME (Durable Medical Equipment, refers to reusable medical devices and supplies prescribed by a healthcare provider for long-term use at home, helping patients manage conditions or disabilities and improve daily life) List, the list included the following prescribed medications: Novolog FlexPen prefilled syringe (100 units/mL solution for injection) twice to four times daily and Lantus SoloStar (100 units/mL prefilled pen solution for injection) once a day.    During an observation in the room of Patient 16 on 12/12/2025 at 12 PM, the Novolog FlexPen and Lantus SoloStar insulin pens used by Patient 16 that were placed at the bedside table did not have an open date marked to indicate when the medication was first used.   During a concurrent interview with the patient’s caregiver (PCG), the PCG stated they were not aware that it was necessary to mark the date when the Novolog FlexPen and Lantus SoloStar insulin pens were first used to determine when to discard them after 28 days. The PCG further stated that the hospice nurse did not inform them that documenting the initial use date was required to ensure timely disposal of the medication.   During an interview with RN 1 on 12/12/2025 at 12:30 PM, RN 1 stated that they did not instruct the patient’s caregiver to mark the open date on the Novolog FlexPen and Lantus SoloStar insulin pens to ensure the medication would be discarded after 28 days. RN 1 added that it was crucial to discuss with the patient the importance of marking the date an insulin pen was first used to ensure proper disposal after 28 days.   During a review of the packaging of the Novolog FlexPen and the Lantus SoloStar prefilled syringes, the packaging indicated, “Use within 28 days after initial use.”   During a review of the agency’s policy and procedure titled “Safe/Effective Use of Medications,” revised in April 2020, the P&P indicated that patients and family/caregivers will receive information regarding the safe and effective use of medications, in accordance with applicable hospice policies.

Based on observation, interview and record review, the Hospice Agency (HA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure that Patient 16, who had diagnosis of diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), was provided with the medication and treatment necessary for one of one sample patient (Patient 16) by: 1. Failing to ensure that Patient 16’s physician order to administer 100 units of Novolog Flex pen (a pre-filled, disposable, dial a dose injection pen containing insulin aspart [a rapid acting insulin used to manage blood sugar levels]) two to four times a day was clarified. 2. Failing to ensure the HA Licensed Nurses provided instructions to Patient 16 on when and how much insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) to administer. 3. Failing to ensure that HA licensed nurses obtained a physician order for Novolog Insulin Sliding Scale (a method of managing blood sugar levels where the dose of rapid- or short-acting insulin is adjusted based on the patient's current blood sugar reading).      This failure put Patient 16 at increased risk of episodes of hypoglycemia (low blood sugar level) and hyperglycemia (high blood sugar level) with regards to the administration of unprescribed doses of insulin and for ineffective drug therapy, noncompliance with drug therapy, and adverse drug reactions (unwarranted and unintended responses to medications that can range from mild to severe and occasionally pose life-threatening risks) that could lead to serious harm, hospitalization and death. On 12/12/2025, at 4 p.m., the  department called an Immediate Jeopardy (IJ, a situation in which the provider’s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident), in the presence of the  Administrator Designee (ADMD), related to the Hospice Agency's (HA, medically focused care provided by skilled professionals like nurses and therapists in a patient home) failure to ensure that Patient 16, who has a diagnosis of diabetes was provided the medication and treatment necessary by: 1. Failing to ensure that Patient 16’s physician order to administer 100 units of Novolog Flex pen insulin two to four times a day was clarified.  2. Failing to ensure the HA Licensed Nurses provided instructions to Patient 16 on when and how much insulin to administer. 3. Failing to ensure that HA licensed nurses obtained a physician order for Novolog Insulin Sliding Scale.      This failure put Patient 16 at increased risk of episodes of hypoglycemia and hyperglycemia with regards to the administration of unprescribed doses of insulin and for ineffective drug therapy, noncompliance with drug therapy, and adverse drug reactions that could lead to serious harm, hospitalization and death.  On 12/12/2025, the HA was unable to submit an IJ removal Plan (IJRP, a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation).   On 12/12/2025 at 4:15 p.m., the Department completed the survey tasks and conducted an exit conference while onsite in the presence of the Director of Patient Care Services (DPCS) and the Administrator Designee (ADMD) with the IJ situation not removed.    On 12/22/2025 at 1:13 PM, the agency submitted an acceptable IJ removal plan (include all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment or death likely) was reviewed and accepted.  On 12/23/2025, the survey team conducted an onsite visit to the agency and verified the IJ implementation. The IJ was removed on 12/23/2025 at 1 pm, in the presence of the Human Resources/Office Manager. --- Findings: During a review of Patient 16’s admission record, the record indicated the start of care (SOC) date of 10/8/2025,  had primary diagnosis of chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), and secondary diagnosis of Type 2 diabetes mellitus (a chronic condition where the body does not produce enough insulin [a hormone produced by the pancreas that helps regulate blood sugar levels] or cannot properly use the insulin it produces, leading to high blood sugar levels).  During a review of Patient 16's Plan of Care (POC)/Interdisciplinary Group (IDG - a team responsible for the holistic care of the hospice beneficiary) form, dated 12/3/2025, indicated the frequency of visits of skilled nurse (SN) to one (1) visit per week plus one (1) visit as needed for pain, comfort and symptom management, hospice aide two visit per week, and the MSW (Social worker) to one (1) visit per month and to perform an initial assessment within five (5) days from SOC. Spiritual counselor (SC) service to one visit per month . A review of Patient 16’s admission order dated 10/8/2025 indicated to administer Novolog Flex pen 100 unit/ml solution to inject 100 units subcutaneously twice to four times a day. However, there were no physician orders or instructions on how to administer the Novolog Flex pen insulin to indicate when to give and how much insulin to administer. During an interview on 12/9/2025, at 11 a.m., with the Medical Director (MD), the MD stated that he was aware Patient 16 was diabetic, and she takes Novolog insulin. The MD also stated that there should be a sliding scale to follow when administering Novolog insulin for Patient 16. The MD stated that the nursing staff contacts him if they were unable to get a hold of the primary doctors for any concerns related to patients. The MD stated the visiting nurse should call the on-call doctor for clarifications, obtaining physician’s orders and address discrepancies on the same day of their visit if a patient was administered a wrong dose.  During a concurrent observation and record review on 12/12/2025, at 11 a.m., with the Registered Nurse (RN 1), in Patient 16's residence during a joint home visit, the following insulin medications were checked. There was one Novolog Flex pen 100 unit/ml solution that was being used but there was no date label when opened.   During an interview on 12/12/2025, at 11:30 a.m., with Family member 1 (FM 1), FM 1 stated that she administers Novolog insulin three times a day before meals to Patient 16. FM 1 stated she does not administer Novolog 100 units at all but she used the Google application to look up the sliding scale for blood sugar result taken to determine insulin dosage to give to Patient 16. FM 1 also stated that the visiting nurse did not provide patient teaching on how many units of insulin to administer for the blood sugar readings Patient 16 may have. During a review of Patient 16’s Blood Sugar Reading Test results notes from dates 11/26/2025 to 12/12/2025, indicated a blood sugar reading between 108 to 236 milligrams per deciliter (mg/dl-unit of measurement). On 12/12/2025, at 12 p.m., during an interview with RN 1, RN 1 stated that she was aware that Patient 16’s had a prescribed order for the Novolog Flex pen 100 unit/ml solution to inject 100 units subcutaneously twice to four times a day in which she thought that the insulin order was a correct order. RN 1 stated that she was the one who took the verbal order for the Novolog insulin from the medical director and did not realize the order was incorrect and needed clarification.  RN 1 also stated that she did not know that there should be a sliding scale order when giving Novolog insulin to Patient 16.  RN 1 stated she did not provide teaching on Novolog insulin administration to Patient 16 and Patient 16’s care giver (FM 1). During an interview on 12/12/2025, at 1 p.m., with the Director of Patient Care Services (DPCS), he stated he reviewed Patient 16’s electronic medical chart every week but he missed checking the Novolin insulin medication and confirmed that the Novolin insulin dosage order was incorrect and the order was missing a sliding scale. The DPCS stated that Patient 16 should be taking at least Novolog 10 units at the minimum dosage subcutaneously twice to four times a day and not 100 units twice to four times a day.  A review of the HHA's policy dated 11/2023 entitled" Administration and Documentation of Medications", indicated that the license nurse will administer medications as ordered by the physician that can be safely administered and monitored during a home visit.  License nursing personnel will administer and document medications which have been ordered as part of the plan of care and have been approved for safe administration and monitoring during a home visit.   During a review of the agency’s policy and procedure titled “Medication Profile”, with a revised date of May 2024, the policy and procedure indicated that 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 specialized care to terminally ill patients with six months or less to live), failed to ensure the Condition of Participation (specifies requirements that healthcare organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) regarding Patient’s Rights was met as follows: --- The HA failed to provide documented evidence that four of 15 sampled patients (Patient 11, 12, 13, & 14) received a copy of and were informed about the patients’ rights and responsibilities. This failure had the potential to result in lower quality of care, potential health risks, and unnecessary costs related to the lack of understanding of the patient’s rights and responsibilities, including making informed decisions about own health. (Refer to L502)  The HA failed to ensure that four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15) were informed of the hospice eligibility requirements, hospice services to be provided, and the limitations of hospice services. This failure had the potential to result in lower quality of care related to the inability to access life-prolonging or curative treatments, potential out-of-pocket care costs, and potential fraud. (Refer to L519)  The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulations for patient’s rights to ensure provision of quality care and services to patients.   the Hospice Agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure to inform four out of 14 sampled patients (Patients 1, Patient 6, Patient 10, and Patient 15 ), about the services the HA provided and the limitations of those services. (Refer to (514).

Based on interview and record review, the Hospice Agency (HA, an agency providing specialized care to terminally ill patients with six months or less to live) failed to provide documented evidence that four of 15 sampled patients (Patient 11, Patient 12, Patient 13, and Patient 14) received a copy of and were informed about the patients’ rights and responsibilities.This failure had the potential to compromise patient autonomy, reduce the quality of care, increase health risks, and lead to unnecessary costs related to the lack of understanding of the patient’s rights and responsibilities, including making informed decisions about own health. --- Findings:During a review of Patient 11’s admission record, the record indicated Patient 11’s start of care (SOC) date of 1/22/2025 and end of care (EOC) date of 2/27/2025. The record indicated Patient 11’s primary diagnosis was hypertensive heart disease (HHD, heart problem due to the constant high force against artery walls, making the heart work harder and affecting its ability to pump blood effectively) with heart failure (HF).During a review of Patient 12’s admission record, the record indicated Patient 12’s SOC date of 3/1/2025 and EOC date of 4/19/2025. The record indicated Patient 12’s primary diagnosis of HHD with HF.During a review of Patient 13’s admission record, the record indicated Patient 13’s SOC date of 3/1/2025 and EOC date of 4/22/2025. The record indicated Patient 13’s primary diagnosis of HHD with HF.During a review of Patient 14’s admission record, the record indicated Patient 14’s SOC date of 4/15/2025 and EOC date of 6/16/2025. The record indicated Patient 14’s primary diagnosis of HHD with HF.During an interview and concurrent review of medical records on 8/26/2025 at 1:04 p.m. with the Director of Patient Care Services Designee (DPCSD), the medical records of Patient 11, Patient 12, Patient 13, and Patient 14 were reviewed. The DPCSD stated there was no documented evidence that Patient 11, Patient 12, Patient 13, and Patient 14 were informed and provided a copy of the Patient’s Rights and Responsibilities to ensure they know their rights and could make informed decisions about their care.During a review of the HA’s policy and procedures (P&P), titled “Patient Bill of Rights/Responsibilities,” dated 4/2020, the P&P indicated the following:1.      The purpose of the policy is to encourage awareness of patient rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning.2.      Each patient must be an active, informed participant in his/her plan of care.3.      The Patient Bill of Rights and Responsibilities must be explained (verbally/orally) and distributed to the patient prior to the initiation of organizational services in a language and manner the patient can reasonably be expected to understand.

Based on observation, interview, and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to inform four of 15 sampled patients (Patients 1, Patient 6, Patient 10, and Patient 15 ), what hospice is, the care and services it provides, and the limitations of those services.  This deficient practice resulted in Patient 1, Patient 6, Patient 10, and Patient 15 being unaware about the care and services the HA provided. Patient 1, Patient 6, Patient 10, and Patient 15 were not given the opportunity to make informed decisions about accepting and refusing hospice care, which had the potential to cause misinformation, misunderstanding, and miscommunication, and lack of informed consent regarding their treatment options. --- Findings:1. During a review of Patient 1’s admission record, the record indicated the start of care (SOC) date of 4/1/2025 with a primary diagnosis of atherosclerosis heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls).During a review of Patient 1’s Comprehensive Nursing Assessment, dated 4/1/2025, the Comprehensive Nursing Assessment indicated Patient 1 had a terminal diagnosis of heart disease and was dependent on assistance for two or more activities of daily living (ADLs, including ambulation, continence, transfer, dressing, feeding). The Comprehensive Nursing Assessment indicated Patient 1 met the criteria for New York Heart Association (NYHA) functional classification (medical standard for categorizing the severity of heart failure) for Class IV congestive heart failure (Class IV CHF, severely advanced stage when a patient experiences symptoms of breathlessness, fatigue, and heart failure indicators even when at rest, and experiences severe discomfort with any level of physical activity).During a review of Patient 1’s Physician’s Certification for Terminal Illness (CTI) form, dated 4/1/2025, the medical director indicated that Patient 1 was appropriate for hospice/palliative care and met the criteria for Local Coverage Determination (LCD) eligibility (criteria a patient must meet to be deemed eligible for hospice care).  During a review of Patient 1’s LCD Hospice Eligibility Determination, dated 4/1/2025, the LCD indicated Patient 1 met the criteria for NYHA functional classification.  During an interview on 8/22/2025 at 10:15 AM, the HA Medical Director (MD) stated he had no hospice experience prior to being hired by the HA in 11/2022. The HA MD stated he would sign the patients’ Certification of Terminal Illness (CTI) based on the patients’ nursing assessment by the Registered Nurse (RN). The HA MD stated he did not communicate with the patients’ primary care physician (PCP) or attending physician to discuss the patients’ terminal condition. The HA MD stated he did not request from the PCP or attending physician or review any clinical records of patients, if missing from the HA health records.During an interview and a concurrent review of Patient 1’s medical records on 8/22/2025 at 1:25 p.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated there was no documented evidence that any clinical records were reviewed to support Patient 1’s LCD Hospice Eligibility Determination and justify Patient 1’s eligibility for hospice.During an interview on 8/28/2025 at 1:43 p.m. Patient 1 stated a social worker from a medical office recommended hospice services to her, but she was not informed that hospice was for patients who have six (6) months or less to live. Patient 1 stated she was “always sick” but not dying within six months.  2. During a review of Patient 6’s admission record, the record indicated the SOC date of 4/25/2025 with a primary diagnosis of atherosclerosis heart disease.During an observation and a concurrent interview on 8/28/2025 at 12:35 p.m. while on a joint home visit with the DPCSD, Patient 6 was observed dressed, alert, well-groomed and ambulated independently in the kitchen/dining area of his residence.  Patient 6 stated someone recommended hospice to him but did not inform him that hospice was for those who have six (6) months or less to live. 3. During a review of Patient 10’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (artery that supplies blood to the heart muscle) with angina pectoris (chest pain).During an observation and a concurrent interview on 8/28/2025 at 12:35 p.m. while on a joint home visit with the DPCSD, Patient 6 was observed dressed, alert, well-groomed and ambulated independently in the kitchen/dining area of his residence.  Patient 6 stated someone recommended hospice services to him but did not inform him that hospice was for those who have six (6) months or less to live.  4. During a review of Patient 15’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of hypertensive heart disease with heart failure (condition wherein prolonged high blood pressure damages the heart muscle, leading to impaired pumping function and heart failure).During an interview on 8/29/2025 at 9:13 a.m., Patient 15 stated she did not have a terminal diagnosis of six (6) months or less to live. Patient 15 stated the HA nurses did not explain the hospice care and services and eligibility qualifications to receive hospice care and services. Patient 15’s caregiver stated Patient 15 was alert and oriented, ambulatory, able to feed, groom, and bathe herself.   During a telephone interview on 8/29/2025 at 9:30 a.m., the DPCSD stated that she did not explain to the patients (in general) that being in hospice means that the patient has a terminal diagnosis with a life expectancy of six (6) months or less.During a review of the HA’s policy and procedures (P&P), titled “Patient Bill of Rights/Responsibilities,” dated 4/2020, the P&P indicated the Patient Bill of Rights/Responsibilities statement defines the following rights of the patient:1.      To be informed in advance of service about the care to be furnished, the organization’s scope of services and services under Medicare Hospice Benefit and any limitations on these services.2.      Be advised in advance of the right to participate in planning the care or service and in planning changes in the care and service.3.      Refuse care or treatment after the consequences of refusing care or treatment are fully presented.During a review of HA’s agency P&P, titled “Admission Criteria and Process,” dated 11/2024, the P&P indicated the HA would admit any patient with a life-limiting illness that meets the admission criteria. The P&P indicated the patient’s life-limiting illness with a life expectancy of six months or less must be determined by utilizing a standard clinical prognosis criteria developed by the fiscal intermediary’s Local Coverage Determinations (LCDs) by the attending physician and hospice medical director. The P&P indicated the patient must desire hospice services and be aware of the diagnosis and prognosis. The P&P indicated the hospice registered nurse must contact the physician for clinical information in writing to certify patient for hospice care.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients with six months or less to live), failed to ensure that four of 15 sampled patients (Patient 1, Patient 6, Patient 10, and Patient 15) were informed of the hospice eligibility requirements, hospice services to be provided, and the limitations of hospice services.This failure had the potential to compromise the quality of care by leaving patients uninformed about the nature and limitations of hospice services, which could result in the inappropriate forgoing of life-prolonging or curative treatments, unexpected out-of-pocket expenses, and increased risk of billing errors or potential fraud. --- Findings:1. During a review of Patient 1’s admission record, the record indicated the start of care (SOC) date of 4/1/2025 with a primary diagnosis of atherosclerosis heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls). During a concurrent interview of Patient 1 on 8/28/2025 at 1:43 p.m. while on a joint home visit with the Director of Patient Care Services Designee (DPCSD), Patient 1 stated a social worker from the medical office recommended hospice services to her but was she was not informed that hospice was for patients who have six (6) months or less to live. Patient 1 also stated she was “always sick” but not dying within six months.  2. During a review of Patient 6’s admission record, the record indicated the SOC date of 4/25/2025 with a primary diagnosis of atherosclerosis heart disease. During an observation and a concurrent interview on 8/28/2025 at 12:35 p.m., while on a joint home visit with the DPCSD, Patient 6 was observed dressed, alert, well-groomed and ambulated independently in the kitchen/dining area of his residence.  Patient 6 stated someone recommended hospice services to him but did not inform him that hospice was for those who have six (6) months or less to live.3. During a review of Patient 10’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (artery that supplies blood to the heart muscle) with angina pectoris (chest pain).During an observation and a concurrent interview on 8/28/2025 at 12:35 p.m., while on a joint home visit with the DPCSD, Patient 6 was observed dressed, alert, well-groomed and ambulated independently in the kitchen/dining area of his residence.  Patient 6 stated someone recommended hospice services to him but did not inform him that hospice was for those who have six (6) months or less to live. 4. During a review of Patient 15’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of hypertensive heart disease with heart failure (condition wherein prolonged high blood pressure damages the heart muscle, leading to impaired pumping function and heart failure).During an interview on 8/29/2025 at 9:13 a.m., Patient 15 stated she did not have a terminal diagnosis of six (6) months or less to live. Patient 15 stated the HA nurses did not explain the hospice care and services, and eligibility qualifications to receive hospice care and services. Patient 15’s caregiver stated Patient 15 was alert and oriented, ambulatory, able to feed, groom, and bathe herself.   During a telephone interview on 8/29/2025 at 9:30 a.m., the DPCSD stated that she did not explain to the patients (in general) that being in hospice means that the patient has a terminal diagnosis with a life expectancy of six (6) months or less.During a review of the HA’s policy and procedures (P&P), titled “Patient Bill of Rights/Responsibilities,” dated 4/2020, the P&P indicated the Patient Bill of Rights/Responsibilities statement defines the following rights of the patient:1.      To be informed in advance of service about the care to be furnished, the organization’s scope of services and services under Medicare Hospice Benefit and any limitations on these services.2.      Be advised in advance of the right to participate in planning the care or service and in planning changes in the care and service.3.      Refuse care or treatment after the consequences of refusing care or treatment are fully presented.

Based on observation, interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) for Initial & Comprehensive Assessment of Patient was met as follows: --- The HA failed to ensure the comprehensive assessments accurately reflected the patient's current health condition related to hospice eligibility and management of terminal illness and identified the patients' need for hospice care and services for four of fifteen sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15). This failure resulted in the HA admitted patient’s ineligible to receive hospice care and services and Patient 1, Patient 6, Patient 10 and Patient 15 were placed at an increased risk for not having access to needed specialists, medications, and medically necessary treatments that could result in delay in care, decline in health, serious harm, hospitalization, and death. This failure could result in potential issues with billing, reimbursement, and/or fraud.  (Refer to L525). The HA failed to provide an initial bereavement assessment for three of 14 sampled patients (Patient 1, Patient 6, & Patient 15).This failure had 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 observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients with six months or less to live) failed to ensure the comprehensive assessments accurately reflected the patient's current health condition related to hospice eligibility and management of terminal illness and identified the patients' need for hospice care and services for four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15). This failure resulted in the HA admitted patient’s ineligible to receive hospice care and services and Patient 1, Patient 6, Patient 10 and Patient 15 were placed at an increased risk for not having access to needed specialists, medications, medically necessary treatments, delay in care, decline in health, serious harm, hospitalization, and death. This failure could result in potential issues with billing, reimbursement, and/or fraud.    On 8/29/2025 at 3:34 p.m., the California Department of Health (CDPH) called Immediate jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the HA's Human Resources Manager (HRM), related to the HA's noncompliance due to: The HA failed to ensure the comprehensive assessments accurately reflected the patient's current health condition related to hospice eligibility and management of terminal illness and identified the patients' need for hospice care and services for four of four sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15).   On 8/30/2025 at 1 p.m., the survey team completed the survey tasks and conducted an exit conference while onsite in the presence of the HRM, Administrator (via virtual videoconference), and Director of Patient Care Services Designee (DPCSD, via virtual videoconference).   On 8/30/2025 the HA was unable to submit IJ removal Plan (IJRP, includes all actions the agency has taken or would take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The survey team exited the HA with IJ not removed.    On 9/12/2025 at 2:10 p.m., after confirming the agency's implementation of the immediate corrective actions from the accepted IJ removal plan (IJRP-steps an agency will take to immediately address a noncompliance situation that has created or is likely to create serious harm to patients), the Department removed the Immediate Jeopardy while onsite, in the presence of the human resource manager. The IJRP included the following:Immediate Corrective Action Taken:Upon review and reassessment of Patient 1, Patient 6, Patient 10, and Patient15, the HA determined that Patient 1, Patient 6, Patient 10, and Patient15 no longer met the eligibility criteria for hospice care in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. The following actionswere taken immediately: During a scheduled teleconference via FaceTime, the assigned visiting registered nurse collaborated with the newly appointed medical director to review the clinical statusof Patients 1, Patient 6, Patient 10, and Patient 15. The registered nurse conducted in-person assessments while the medical director actively participated in real time via teleconference, reviewing each patient's medical records, recent clinical findings, and the nurse’s observations.  Patient 1:Patient 1 was discharged from hospice services due to extended prognosis and ineligibility per Medicare Local Coverage Determination (LCD) guidelines. After thorough interdisciplinary review, it has been determined that Patient 1’s condition no longer meets the criteria indicating a life expectancy of six months or lessif the disease runs its normal course. As such, hospice services will be discontinued effective 08/30/2025. Throughout the hospice enrollment:o There have been no new hospitalizations, emergency room visits, or acute medical events.o Patient’s symptoms have remained relatively stable, with some variability in pain and exertional dyspnea.o No recent weight loss marked nutritional decline, or significant decrease in mobility was observed.o Oral intake and ambulation have remained stable, and in some cases, have improved slightly compared to baseline.o Based on clinical evaluation and interdisciplinary input, the patient's stabilization and absence of disease progression no longer support a prognosis of six months or less, as required under the Medicare hospice benefit guidelines. Patient 6:Reason for Discharge: Patient 6 discharged from hospice services due to ineligibility under Medicare’s Local Coverage Determination (LCD) guidelines. Based on clinical assessment, Patient 6’s current condition does not indicate a prognosis of six months or less if the disease runs its normal course. There has been an observed stabilization andimprovement in certain functional domains, warranting discharge from hospice services.Over the course of care, the following clinical observations were noted:The patient remains alert and oriented.·         No new hospitalizations, acute medical events, or rapid functional decline have occurred since admission.·         Improvement in ambulation and physical activity noted over the past four weeks.·         Patient’s oral intake has improved, with increased appetite and nutritional intake compared to baseline.·         ADL (Activities of Daily Living) performance remains largely unchanged with no new dependencies or increased caregiver burden.These findings, in aggregate, support the determination that Patient6 no longer meets Medicare hospice eligibility criteria. Patient 10:Reason for Discharge: Patient 10 was discharged from hospice services due to extended prognosis and ineligibility based on Medicare Local CoverageDetermination (LCD) guidelines. After a comprehensive reassessment and review by the interdisciplinary team, it has been determined that Patient 10’s condition has stabilized and does not indicate a life expectancy of six months or less if the diseasefollows its normal course. Hospice services will be discontinued effective 08/30/2025.Throughout the hospice enrollment period, the patient has remained:·         Alert and oriented to person, place, time and event.·         Functionally stable with no significant decline in Activities of Daily Living (ADLs)·         Without any new hospitalizations, emergency room visits, or acute medical episodesFree of new symptoms indicating disease progression.·         The patient’s overall condition is clinically stable, with intermittent pain managed effectively and no evidence of rapidly advancing disease.Based on current findings, Patient 10 does not meet LCD eligibilitycriteria for continued hospice care. Patient 15:Reason for Discharge: Patient 15 was discharged from hospice services due to ineligibility under Medicare's Local Coverage Determination (LCD) guidelines, specifically due to prolonged prognosis. After a comprehensive reassessment by the interdisciplinary hospice team, it was determined that Patient 15’s clinical condition has stabilized and does not support a prognosis of six months or less if the diseaseruns its normal course. Hospice services will therefore be discontinued effective 08/30/2025. Over the course of hospice enrollment:·         There have been no new hospitalizations, emergency department visits, or acute exacerbations of heart failure.·         ADL performance has remained stable with no new dependence orfunctional regression.·         Pain and edema have been managed with the existing care plan. The patient has reported less shortness of breath on exertion compared to the initial baseline assessment.·         No significant cognitive or nutritional decline has been observed. Given the patient’s overall stabilized condition and absence of recent decline, she is no longer considered to have a terminal prognosis as defined under the Medicare hospice benefit.Care Coordination & Notifications for Patient 1, Patient 6, Patient 10 and Patient 15Patient/Family and Caregivers Notification: ·         The patient and their caregivers were informed of the upcoming discharge. ·         The Notice of Medicare Non-Coverage (NMNOC) was thoroughly reviewed by the assigned registered nurse and signed by the patient and/or family. ·         Both the patient and caregiver expressed understanding of the discharge and were receptive to transitioning ongoing care to the primary care physician. The discharge summary includes the name, phone number, fax number, and the point of contact for the primary care provider to ensure continuity of care following discharge. To further ensure continuity of care, the office manager promptly contacted each patient's previous Primary Care Provider (PCP) to facilitate a seamless handoff. Complete and up-to-date medical records were securely transferred to the receiving providers, allowing for informed follow-up and uninterrupted care coordination.Medications: The patients have an adequate supply of all prescribed medicationsfor 2 weeks. A current medication list has been provided to the patient/family and faxed to the PCP. If needed, the hospice team will coordinate with the family’s preferred pharmacy to ensure uninterrupted access to medications and timely administration.DME (Durable Medical Equipment): Equipment vendors have been notified of the discharges. Pickup or transfer instructions have been communicated to the caregivers.Pharmacy and all Interdisciplinary Group (IDG) members, including nursing, social work, chaplaincy, CHHA’s, and volunteers have been notified of the discharges.  Discharge Plan: Appropriate resources and community referrals have been provided to support a safe and smooth transition from hospice care. This includes information on local palliative care providers, home health agencies (if needed), and support services. Post-Discharge Recommendations: Follow up with PCP, for ongoing medical management. Monitor for any new or worsening symptoms and seek medicalattention as necessary. Consider evaluation for palliative care services if symptoms increase or new needs arise. Re-referral to hospice may be appropriate in the future if patient’s condition declines and eligibility criteria are met.Date of Implementation: 8/30/2025Date of Completion: 9/2/2025Responsible Parties: Medical Director, Visiting Nurse, OfficeManager• The newly appointed Director of Patient Care Services (DPCS) conducted an independent and comprehensive assessment and review of Patients 1, 6, 10, and 15 clinical records, interdisciplinary documentation, and the most recent updatesfrom the visiting nurse. Upon this detailed review, the newly appointed DPCS fully concurred with the decision to discharge these patients, based on the determination that they no longer met the eligibility criteria for hospice services as outlined byCMS Local Coverage Determinations (LCDs) and associated guidelines for terminal prognosis.Date of Implementation: 9/16/2025Date of Completion: 9/17/2025Responsible Parties: Director of Patient Care Services (DPCS) Systemic Changes to Prevent RecurrenceA. Policy and Procedure Review and RevisionThe “Initial and Comprehensive Assessment” policy was thoroughly reviewed and revised to align with the Conditions of Participation (CoP) under §418.54.Updates include:• Clear eligibility criteria consistent with CMS and LCD guidelines• Defined scope and expectations for comprehensive assessments (physical, psychosocial, emotional, and spiritual domains)• Detailed documentation standards, including rationale forhospice eligibility and ongoing appropriatenessImplementation: 9/1/2025Completion Date: All updates were presented by the newly reinstated Administrator and approved by the Governing Body disseminated to staff on 9/15/2025.Responsible Party/s: AdministratorB. Staff Education and Competency ValidationAll clinical personnel—including RNs, Social Worker, Chaplain,Certified Home Health Aides (CHHAs), Administrator andVolunteer participated in mandatory re-education sessions on 9/15/2025.Training content included:• Hospice eligibility requirements under §418.54• Comprehensive assessment expectations and required documentation• Common deficiencies and best practices in charting andreassessment• Use of case studies to enhance practical application• Post-training evaluations and return demonstrationsvalidated staff competency.• All new hires will complete this training duringonboarding.Implementation: 9/1/2025Completion Date: 9/15/2025Responsible Party/s: Medical DirectorC. Interdisciplinary Review Process EnhancementTo strengthen admission practices and ensure regulatorycompliance, all new admissions will now undergo IDT review within48 hours to validate the initial assessment and confirm eligibility.The referral policy was revised to require:• Detailed documentation of the principal terminal condition• Review of the patient’s medical history by the Medical Director• Verification of clinical appropriateness with the referring providerThis policy was presented by the newly reinstated Administratorand was approved by the Governing Body. These safeguards willprevent inappropriate admissions and reduce risk of harm ornoncompliance. The Administrator and compliance officer willoversee and monitor all admission practices to ensure fullcompliance with applicable regulations.Implementation Date: 9/12/2025Completion Date: 9/15/2025Responsible Party/s: Administrator and Governing BodyMonitoring and Quality AssuranceTo ensure sustained compliance: 100% of new admissions will be audited by the Compliance Officer for a 60-day period. Thereafter, 50% of monthly admissions will berandomly audited. Audit results will be reviewed in monthly QAPI meetings. If compliance falls below 95%, immediate re-education and increased audit frequency will be triggered. Audit Focus Areas included: • Eligibility documentation• Timeliness and completeness of comprehensive assessments• IDT involvement and plan of care integrationImplementation Date: 9/12/2025Completion Date: OngoingResponsible Party/s: Compliance and Quality AssuranceOfficer --- Findings:A. During a review of Patient 1’s admission record, the record indicated the start of care (SOC) date of 4/1/2025 with a primary diagnosis of atherosclerosis heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls). During a review of Patient 1’s Comprehensive Nursing Assessment, dated 4/1/2025, the Comprehensive Nursing Assessment indicated Patient 1 had a terminal diagnosis of heart disease and was dependent on assistance for two or more activities of daily living (ADLs, including ambulation, continence, transfer, dressing, feeding). The Comprehensive Nursing Assessment indicated Patient 1 met the criteria for New York Heart Association (NYHA) functional classification (medical standard for categorizing the severity of heart failure) for Class IV congestive heart failure (Class IV CHF, severely advanced stage when a patient experiences symptoms of breathlessness, fatigue, and heart failure indicators even when at rest, and experiences severe discomfort with any level of physical activity).  During a review of Patient 1’s Physician’s Certification for Terminal Illness (CTI) form, dated 4/1/2025, the medical director indicated that Patient 1 was appropriate for hospice/palliative care and met the criteria for Local Coverage Determination (LCD) eligibility (criteria a patient must meet to be deemed eligible for hospice care).   During a review of Patient 1’s LCD Hospice Eligibility Determination, dated 4/1/2025, the LCD indicated Patient 1 met the criteria for NYHA functional classification.   During an interview on 8/22/2025 at 10:15 AM, the HA Medical Director (MD) stated he had no hospice experience prior to being hired by HA in 11/2022. The HA MD stated he would sign the patients’ Certification of Terminal Illness (CTI) based on the patients’ nursing assessment by the Registered Nurse (RN). The HA MD stated he did not communicate with the patients’ PCP or attending physician to discuss the patients’ terminal condition. The HA MD stated he did not request from the PCP or attending physician or review any clinical records of patients, if missing from the HA health records.  During an interview and a concurrent review of Patient 1’s medical records on 8/22/2025 at 1:25 p.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated there was no documented evidence that any clinical records were reviewed to support Patient 1’s LCD Hospice Eligibility Determination and justify Patient 1’s eligibility for hospice.  During an interview on 8/28/2025 at 1:43 p.m. Patient 1 stated a social worker from medical office recommended hospice to her, but she was not informed that hospice was for patients who have six (6) months or less to live. Patient 1 stated she was “always sick” but not dying within six months.   B. During a review of Patient 6’s admission record, the record indicated the SOC date of 4/25/2025 with a primary diagnosis of atherosclerosis heart disease. During a review of Patient 6’s Comprehensive Nursing Assessment, dated 4/25/2025, the Comprehensive Nursing Assessment indicated Patient 6 had a terminal diagnosis of heart disease and was dependent on assistance for two or more ADLs. The Comprehensive Nursing Assessment indicated Patient 6 met the criteria for NYHA Class IV CHF. During a review of Patient 6’s Physician’s CTI form, dated 4/25/2025, the medical director indicated that Patient 6 was appropriate for hospice/palliative care and met the criteria for LCD eligibility. During a review of Patient 6’s LCD Hospice Eligibility Determination, dated 4/25/2025, the LCD indicated Patient 6 met the criteria for NYHA functional classification.   During an interview and a concurrent review of Patient 6’s medical records on 8/22/2025 at 1:25 p.m. with the DPCS, the DPCSD stated there was no documented evidence that any clinical records were reviewed to support Patient 6’s LCD Hospice Eligibility Determination and justify Patient 6’s eligibility for hospice.  During an observation and a concurrent interview on 8/28/2025 at 12:35 p.m. with DPCSD, Patient 6 was observed dressed, alert, well-groomed and ambulated independently in the kitchen/dining area of his residence.  Patient 6 stated someone recommended hospice to him but did not inform him that hospice was for those who have six (6) months or less to live.  During a telephone interview and a concurrent record review on 8/29/2025, at 9:30 a.m., the DPCSD stated that the hospice agency admitted the patient on 4/25/2025 with a terminal diagnosis of atherosclerotic heart disease and a functional capacity of NYHA Class IV.  The DPCSD stated that she did not explain to the patients (in general) that being in hospice means that the patient has a terminal diagnosis with a life expectancy of six (6) months or less.  The DPCSD stated that she observed Patient 6 ambulating in his residence without any shortness of breath (SOB).  C. During a review of Patient 10’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (artery that supplies blood to the heart muscle) with angina pectoris (chest pain). Patient 10’s admission record indicated Patient 10’s secondary diagnoses included orthopnea (shortness of breath when lying flat), diabetes (chronic disease characterized by high blood sugar levels), seizures, and anxiety disorder (mental disorder characterized by persistent, excessive worry that interferes with daily life).  During a review of Patient 10’s Comprehensive Nursing Assessment, dated 3/1/2025, the Comprehensive Nursing Assessment indicated Patient 10 had a terminal diagnosis of heart disease and was dependent on assistance for two or more ADLs. The Comprehensive Nursing Assessment indicated Patient 10 met the criteria for NYHA Class IV CHF. During a review of Patient 10’s Physician’s CTI form, dated 3/1/2025, the medical director determined Patient 10 was “exhibiting imminent signs of death within six months and thus appropriate for hospice care services.” During a review of Patient 10’s LCD Hospice Eligibility Determination, dated 3/1/2025, the LCD indicated Patient 10 met the criteria for NYHA functional classification.   During an interview and a concurrent review of Patient 10’s medical records on 8/26/2025 at 1:04 p.m. with the DPCSD, Patient 10’s nursing assessments, LCD Hospice Eligibility, and primary care physician (PCP) notes were reviewed. The DPCSD stated she conducted and documented Patient 10’s initial comprehensive nursing assessment, dated 3/1/2025, and nursing recertification assessment, dated 5/29/2025. However, the DPCSD was unable to define NYHA Class IV CHF. The DPCSD stated Patient 10 had moderate SOB with activity during nursing assessments. The DPCSD stated there was no documented evidence that any clinical records were reviewed to support Patient 10’s LCD Hospice Eligibility Determination and justify Patient 10’s eligibility for hospice.  During an observation on 8/27/2025 at 11:31 a.m., Patient 10 was observed ambulatory (able to walk), independent with ADLs, and alert and oriented (no impairment in mental processes).   During an interview on 8/27/2025 at 12:02 p.m., Patient 10 stated her caregiver wanted “extra money” and referred her to the HA. Patient 10 stated she was invited to meet with “them (unable to specify name or title)” in a fast-food restaurant to talk about hospice care. Patient 10 stated, “I don’t need hospice care. All I need is someone to make sure I take my seizure medications. I am not dying, but I need the nurse to come and check my blood pressure (force exerted by the blood against the walls of the arteries) and blood sugar. I have been with them for 2 years come October.”  D. During a review of Patient 15’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of hypertensive heart disease with heart failure (condition wherein prolonged high blood pressure damages the heart muscle, leading to impaired pumping function and heart failure).  During a review of Patient 15’s Comprehensive Nursing Assessment, dated 3/1/2025, the Comprehensive Nursing Assessment indicated Patient 15 had a terminal diagnosis of heart disease and was dependent on assistance for two or more ADLs. The Comprehensive Nursing Assessment indicated Patient 15 met the criteria for NYHA Class IV CHF.  During a review of Patient 15’s Physician’s CTI form, dated 3/1/2025, the medical director determined Patient 15 “exhibits imminent signs suggestive of imminent death within the next six months, thus qualifying her for hospice care services.” During a review of Patient 15’s LCD Hospice Eligibility Determination, dated 3/1/2025, the LCD indicated Patient 15 met the criteria for NYHA functional classification.   During an interview on 8/29/2025 at 9:13 a.m., Patient 15 stated she did not have a terminal diagnosis of six (6) months or less to live. Patient 15 stated the HA nurses did not explain the hospice care and services and eligibility qualifications to receive hospice care and services. Patient 15’s caregiver stated Patient 15 was alert and oriented, ambulatory, able to feed, groom, and bathe herself.   During an interview and a concurrent review of Patient 15’s medical records on 8/29/2025 at 9:28 a.m. with the DPCSD, the DPCSD stated Patient 15 was alert and oriented, able to ambulate with a cane with mild SOB, and able to feed, groom, and bathe self. However, the DPCSD stated Patient 15’s initial comprehensive nursing assessment, dated 3/1/2025, and nursing recertification assessment, dated 5/29/2025, indicated Patient 15 met the criteria for NYHA Class IV CHF, but there was no documented evidence to support Patient 15’s terminal diagnosis. The DPCSD stated there was no documented evidence that any clinical records were reviewed to support Patient 15’s LCD Hospice Eligibility Determination and justify Patient 15’s eligibility for hospice. The DPCSD stated inaccurate patient assessments would not be valid in determining if a patient (in general) was eligible to receive hospice care and services. During a review of HA’s agency policies and procedures (P&P), titled “Admission Criteria and Process,” dated 11/2024, the P&P indicated the HA would admit any patient with a life-limiting illness that meets the admission criteria. The P&P indicated the patient’s life-limiting illness with a life expectancy of six months or less must be determined by utilizing a standard clinical prognosis criteria developed by the fiscal intermediary’s Local Coverage Determinations (LCDs) by the attending physician and hospice medical director. The P&P indicated the patient must desire hospice services and be aware of the diagnosis and prognosis. The P&P indicated the hospice registered nurse must contact the physician for clinical information in writing to certify patient for hospice care.

Based on observation, interview and record review, the hospice agency (HA) failed to provide an initial bereavement assessment for three of 15 sampled patients (Patient 1, Patient 6, & Patient 15).This failure had the potential to impact a family members' abilities to cope with the patients' death. --- During a review of Patient 15’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of hypertensive heart disease with heart failure (condition wherein prolonged high blood pressure damages the heart muscle, leading to impaired pumping function and heart failure).During an interview on 8/26/2025 at 11:55 a.m., Spiritual Counselor (SC) 1 stated the initial bereavement assessment was conducted to assess the patient’s (in general) family, the primary bereaved and secondary bereaved, the risks for stressors, if they show signs of spiritual stress, are unprepared for the death of the patient, has suicidal intents, any children would be affected if the patient passes away. SC 1 stated if these factors were identified, he would present options to support the bereaved, such as referral to a counselor or connecting them with their church organization by talking with their pastor/priest.  SC 1 stated the initial bereavement assessment must be conducted the same day as the initial assessment of the patient, if possible, or the next following day. SC 1 stated the SC visit must be completed within 5 days from the patient’s SOC.During an interview and a concurrent review of the medical records of Patient 15 on 8/26/2025 at 1:04 p.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated there was no documented evidence that an initial bereavement assessment was conducted for Patient 15.During a review of the HA’s policy and procedures (P&P), titled “Bereavement Assessment,” dated 4/2020, the P&P indicated the following:1.      On admission, the social worker or hospice registered nurse must complete a bereavement risk assessment that would include, at a minimum, the patient and family caregiver loss issues; survivor needs; social, spiritual, and cultural factors; services to be provided including individual counseling, support groups, and letters and cards; referrals to be made; and grief risk factors and potential for pathological grief reactions.2.      The bereavement counselor must review the bereavement risk assessment to determine the potential needs of the survivors.3.      The bereavement coordinator must develop a plan intervention based on the findings of the bereavement follow-up assessment.  b. During a review of Patient 6’s admission record, the record indicated Patient 6’s start of care (SOC) date was on 4/25/202 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without unspecified angina pectoris (a buildup of fats, cholesterol, and other substances in the arteries of the heart without causing chest pain).During a review of Patient 6’s medical form titled “Current Treatment Medication DME List,” the medical form indicated a physician’s order, dated 4/25/2025, for the Spiritual Chaplain (SC) to assess and evaluate, recertify if appropriate, visit patient once a month and as needed to identify spiritual needs/support to the patient, family and primary caregiver for the entire benefit period. During a review of Patient 6's clinical record, there was no indication that an initial bereavement assessment was conducted.During a review of Patient 6’s History of Visit Notes, the notes indicated that the SC tried to see Patient 6 for an assessment and evaluation on 5/11, 6/23, 7/9, and 8/2/2025, but the patient was not available.  There was no indication that the SC made a follow-up visit each time the patient was not available. During a telephone interview and a concurrent record review of Patient 6’s History of Visit Notes with the SC on 8/26/2025 at 12 p.m., the SC stated that he did not see Patient 6 when he made a home visit to conduct an assessment on 5/11, 6/23, 7/9, and 8/2/2025.  He stated he attempted to visit the patient for an initial assessment to provide spiritual support, but the patient was always not at home during the monthly visits.  He stated he did not do a follow-up visit and just waited for the next monthly scheduled visit to see the patient. a.     During a review of the agency's  policy and procedure titled "Bereavement Assessment," revised in 11/2022, the policy indicated that on admission, the social worker, chaplain or hospice registered nurse will complete a bereavement risk assessment that will be given to the bereavement coordinator. All bereavement documentation will be submitted for filing in the patient’s permanent clinical record.  During a review of Patient 1’s admission record, the record indicated the start of care (SOC) date of 4/1/2025 with a primary diagnosis of atherosclerosis heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls). During a review of Patient 1's Plan of Care (POC)/IDG ( (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form, dated 8/6/2025, indicated the frequency of visits of skilled nurse (SN) to 1 visit per week plus 1 visit as needed for pain, comfort and symptom management, hospice aide (HA) to two visit per week, and the MSW (Social worker) to 1 visit per month and  to perform an initial assessment within 5 days from SOC. Spiritual counselor (SC) service to one visit per month . During a joint home visit on 8/28/2025, at 1:45 p.m., with the Director of Patient Care Services Designee (DPCSD), Patient 1 was observed sitting on a couch with both legs were swollen.  During a further review of Patient 1's clinical record indicated that there was no initial bereavement assessment conducted. During an interview and a concurrent review of Patient 1’s medical records on 8/22/2025 at 1:25 p.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated  that an initial bereavement assessment should be conducted on admission and then documented on the patient’s clinical record. The DPCS further stated that Patient 1 did not have an initial bereavement assessment conducted on admission. During a review of the agency's  policy and procedure titled "Bereavement Assessment," revised November 2022, indicated that on admission, the social worker, chaplain or hospice registered nurse will complete a bereavement risk assessment that will be given to the bereavement coordinator. All bereavement documentation will be submitted for filing in the patient’s permanent clinical record.

Based on observation, interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients with six months or less to live), failed to ensure the Condition of Participation (specifies requirements that healthcare organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Interdisciplinary group, care planning, and coordination of services was met as follows: --- Findings: 1.   The HA failed to ensure the interdisciplinary group ()IDG meetings were held by all the members of IDG to discuss the patient’s comprehensive and ongoing assessments and care planning process for XXX out of 15 sampled patients (Patient 1, XX). This failure had the potential to missed and not identified Patient 8 and Patient 9 progress or decline by the IDG, interventions not be implemented, and patient care goals not be achieved. 2. The HA failed to ensure an individualized written CPs to address bereavement, bleeding risk, and seizure diagnosis were developed for five of 15 sampled patients (Patient 10, Patient 11, Patient 12, Patient 13, & Patient 14). These failures had the potential to result in the patients’ decline in health and/or spiritual/emotional distress of the patients’ family/caregiver related to the lack of evaluation of their support system to cope with loss. (Refer to L545) 3.      The HA failed to ensure the RN conducted home visits as indicated on the CP of one of 15 sampled patients (Patient 13). This failure had the potential to cause the patient’s decline in health related to inconsistency of home visits. (Refer to L547) 4.      The HA failed to ensure the IDG reviewed and revised the individualized CPs and collaborated with the primary care physician of XXX of 15 sampled patients. This failure had the potential to result in the patients’ health decline related to lower quality of care and lack of coordination of care and services. (Refer to L552) – IDG 5.      The HA failed to ensure the Medical Director communicated with the non-hospice primary care providers/attending physicians and coordinated care and services unrelated to the terminal illness for four of 15 sampled patients. This failure had the potential to result in the patients’ health decline related to lower quality of care and lack of coordination of care and services (Patient 1, 6, 10, & 15). (Refer to L558) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulations for Interdisciplinary group, care planning, and coordination of services, to ensure provision of quality care and services to patients. the hospice agency failed to ensure the IDG meetings were held by all members of interdisciplinary group to discuss the patient’s comprehensive and ongoing assessments and care planning process for two of 14 sampled patients (Patients 1 and Patient 6). This deficient practice had the potential to compromise the safety and well-being of the patients. (Refer to L541) the HA nursing staff failed to coordinate care and ensure the IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) were notified and the notification were documented when ordered home visit service was missed for two of 14 sampled patients (Patient 1 and Patient 6). This failure had the potential to result in patient’s end of life care needs not being met. (Refer to L554).   the HA failed to ensure home visit was conducted according to the plan of care (POC) for two of 15 sampled patients (Patients 1 and Patient 6). This deficient practice had the potential to negatively affect the patients' physical comfort, psychosocial well-being, and not receiving the needed and necessary services timely. (Refer to L555).

Based on interview and record review, the hospice agency (HA, agency providing specialized care to terminally ill patients with six months or less to live) failed to ensure the Interdisciplinary Group (IDG - a team responsible for the holistic care of the hospice beneficiary) meetings were held by all members of the interdisciplinary group to discuss the patient’s comprehensive and ongoing assessments and care planning process for five of 15 sampled patients (Patients 1, Patient 6, Patient 7, Patient 8, and Patient 9).This deficient practice had the potential to compromise the coordination, continuity, and quality of care. Patient 1, Patient 6, Patient 7, Patient 8, and Patient 9 had the potential to receive care that was not fully reflective of their plan of care, increasing the risk of unmet needs and unmet goals, and, fragmented services. --- a. During a review of Patient 1’s admission record, the record indicated the start of care (SOC) date of 4/1/2025 with a primary diagnosis of atherosclerosis heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls). During a review of Patient 1's Plan of Care (POC)/IDG ( (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form, dated 8/6/2025, indicated the frequency of visits of skilled nurse (SN) to 1 visit per week plus 1 visit as needed for pain, comfort and symptom management, hospice aide (HA) to two visit per week, and the MSW (Social worker) to 1 visit per month and  to perform an initial assessment within 5 days from SOC. Spiritual counselor (SC) service to one visit per month . A review of Patient 1's  POC/IDG forms dated 4/1, 4/16, 4/30/25, 5/14, 5/28/2025, 6/11, 6/25/2025, 7/8, 7/23/2025, and 8/6/2025, had no signatures from the Chaplain and Director Of Patient Care Services (DPCS) that indicated they attended the IDG meeting.    During a concurrent interview and record review of Patient 1's POC/IDG form,, on 8/22/2025 at 1:25 p.m. with the Director of Patient Care Services Designee(DPCSD), the DPCSD stated the agency holds IDG meetings every two weeks. The DPCS stated the IDG members attending the meetings include the DPCS, RN, LVN, MSW, MD, and SC. The DPCSD stated the IDG members were expected to sign the IDG Plan of Care after the meeting because their signature means they attended the meeting. The DPCSD was not able to provide documented evidence all the IDG members had participated in the IDG meetings for Patient 1on the above days. During a review of the agency's policy and procedure titled, "Interdisciplinary Group Meeting," revised November 2022, indicated 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. 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 if the patient’s condition requires. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor.  b. During a review of Patient 6’s admission record, the record indicated Patient 6’s start of care (SOC) date was on 4/25/202 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without unspecified angina pectoris (a buildup of fats, cholesterol, and other substances in the arteries of the heart without causing chest pain).During a review of Patient 6’s Comprehensive Nursing Assessment, dated 4/25/2025, the nursing assessment indicated that Patient 6 did not need assistance when performing activities of daily living including ambulation, toileting, dressing, bathing, feeding, and transferring.  The Comprehensive Nursing Assessment indicated Patient 6 met the criteria for New York Heart Association (NYHA) class level 4 (severely advanced stage when a patient experiences symptoms of breathlessness, fatigue, and heart failure indicators even when at rest, and experiences severe discomfort with any level of physical activity). During a record review of Patient 6’s medical records, the Interdisciplinary Group (IDG) meetings (a team of various healthcare professionals and support staff who collaboratively develop and oversee a comprehensive care plan for patients with a terminal illness and their families) indicated that the medical director did not have a signature during the IDG meetings on 8/20/2025 and 8/30/2025.During a review of Patient 7’s admission record, the record indicated Patient7’s SOC date was on 4/15/2024 and ended on 6/19/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (a buildup of fats, cholesterol, and other substances in the arteries of the heart without causing chest pain). During a review of Patient 7’s Comprehensive Nursing Assessment, dated 4/15/2024, the nursing assessment indicated that Patient 7 needed assistance when performing activities of daily living including ambulation, toileting, dressing, bathing, feeding, and transferring.  The Comprehensive Nursing Assessment indicated Patient 1 met the criteria for NYHA class level 4. During a record review of Patient 7’s medical records, the IDG meetings indicated that the registered nurse (RN 2) assigned to Patient 7 had no signature during the IDG meetings on 4/15, 4/17, 5/1, 5/15, 5/29 and 6/15/2024.  The medical director also did not have a signature during the IDG meeting on 6/19/2024. During a review of Patient 8’s admission record, the record indicated Patient 8’s SOC date was on 7/22/2024 and ended on 1/17/2025 with a primary diagnosis of heart disease, unspecified (the specific type of heart disease has not yet been determined or documented). During a review of Patient 8’s Comprehensive Nursing Assessment, dated 7/22/2024, the nursing assessment indicated that Patient 8 needed assistance when performing activities of daily living including ambulation, toileting, dressing, bathing, feeding, and transferring.  The Comprehensive Nursing Assessment indicated Patient 8 met the criteria for NYHA class level 4. During a record review of Patient 8’s medical records, the IDG meetings  indicated that the chaplain (CHAP 3) assigned to Patient 8 had no signature during the IDG meetings on 7/22, 8/7, 8/21, 9/4, 9/18, 10/2, 10/16, 10/30, 11/13, 11/27, 12/11, 12/26/24, 1/9/25, and 1/17/25.  The medical director also did not have a signature during the IDG meeting on 10/16 and 12/11/2024. During a review of Patient 9’s admission record, the record indicated that Patient 9’s SOC date was on 2/4/2025 and ended on 5/4/2025 with a primary diagnosis of hypertensive heart disease with heart failure (chronic high blood pressure that leads to structural and functional changes that eventually causes the heart to ineffectively pump blood). During a review of Patient 9’s Comprehensive Nursing Assessment, dated 2/4/2025, the nursing assessment indicated that Patient 9 needed assistance when performing activities of daily living including ambulation, toileting, dressing, bathing, feeding, and transferring.  The Comprehensive Nursing Assessment indicated Patient 8 met the criteria for NYHA class level 4. During a record review of Patient 9’s medical records, the IDG meetings indicated that the chaplain (CHAP 2) assigned to Patient 8 had no signature during the IDG meetings on 2/4, 2/19, 3/5, 3/19, 4/2, 4/16, 4/30, and 5/5/25.  During an interview with the Director of Patient Care Services Designee (DPCS D) on 8/26/2025 at 2 p.m., The DPCS D stated that a missing signature from an IDG member indicates their absence from the meeting.During a telephone interview and a concurrent record review of the medical records of Patients 6, 7, 8, and 9 with the DPCS D on 8/29/2025 at 9:30 a.m., the DPCS D confirmed the following:There was no physician and social worker signatures on Patient 6's IDG meeting on 8/20/2025.There were no RN signatures on Patient 7's IDG meetings from 4/15/2024 to 6/19/2024.There were no chaplain signatures on Patient 8's IDG meetings from 7/22/2024 to 1/17/2025 and no physician signatures on IDG meetings on 10/16/2024 and 12/11/2024.There were no chaplain signatures on Patient 9's IDG meetings from 2/4/2025 to 5/5/2025. During a review of the agency's policy and procedure titled "Interdisciplinary Group Meeting," revised in 11/2022, the policy indicated that 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. 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 if the patient’s condition requires. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor.

Based on observation, interviews, and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients with six months or less to live), failed to ensure individualized written care plans (CPs) to address bleeding risk and seizure (uncontrolled jerking, loss of consciousness, blank stares caused by abnormal electric activity in the brain) diagnosis were developed for four of 15 sampled patients (Patient 10, Patient 11, Patient 12, and Patient 14).1. For Patients 11, Patient 12, and Patient 14, the HA did not develop an individualized plan of care (CP) to address the bleeding risk related to the use of aspirin (a medication to prevent blood clots).2. For Patient 10, the HA did not develop an individualized CP to address the seizure diagnosis.This failure had the potential to result in the patients’ decline in health and to cause spiritual and emotional distress for the patients’ family or caregiver due to the lack of evaluation of their support system to cope with loss or end-of-life challenges. --- Findings:1a. During a review of Patient 11’s admission record, the record indicated Patient 11’s start of care (SOC) date of 1/22/2025 and end of care (EOC) date of 2/27/2025. The record indicated Patient 11’s primary diagnosis was hypertensive heart disease (HHD, heart problem due to the constant high force against the artery walls, making the heart work harder and affecting its ability to pump blood effectively) with heart failure (HF).During a review of Patient 11’s medical form, titled “Current Treatment/Medication/DME List,” the medical form indicated a physician’s order with order date 2/26/2025 for Aspirin 81 milligrams (mg, unit of measurement) 1 tab once a day.During an interview and a concurrent review of Patient 11’s medical records on 8/26/2025 at 1:04 p.m. with the Director of Patient Care Services Designee (DPCSD), Patient 11’s plan of care was reviewed. The DPCSD stated there was no documented evidence that an individualized CP was developed and implemented to address Patient 11’s bleeding risks. The DPCSD stated it was important to have a CP to address the patients on aspirin or other anticoagulants (medications that stop the blood from clotting too easily) because they are at a higher risk for bleeding. 1b. During a review of Patient 12’s admission record, the record indicated Patient 12’s SOC date of 3/1/2025 and EOC date of 4/19/2025. The record indicated Patient 12’s primary diagnosis of HHD with HF.During a review of Patient 12’s medical form, titled “Current Treatment/Medication/DME List,” the medical form indicated a physician’s order with order date 3/1/2025 for Aspirin 81 mg 1 tab once a day.During an interview and a concurrent review of Patient 12’s medical records on 8/26/2025 at 1:04 p.m. with the DPCSD, Patient 12’s plan of care was reviewed. The DPCSD stated there was no documented evidence that an individualized CP was developed and implemented to address Patient 12’s bleeding risks. 1c. During a review of Patient 14’s admission record, the record indicated Patient 14’s SOC date of 4/15/2025 and EOC date of 6/16/2025. The record indicated Patient 14’s primary diagnosis of HHD with HF.During a review of Patient 14’s medical form, titled “Current Treatment/Medication/DME List,” the medical form indicated a physician’s order with order date 4/15/2025 for Aspirin 81 mg enteric-coated tablet 1 tab once a day.During an interview and a concurrent review of Patient 14’s medical records on 8/26/2025 at 1:04 p.m. with the DPCSD, Patient 14’s plan of care was reviewed. The DPCSD stated there was no documented evidence that an individualized CP was developed and implemented to address Patient 14’s bleeding risks. 2. During a review of Patient 10’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (artery that supplies blood to the heart muscle) with angina pectoris (chest pain). Patient 10’s admission record indicated Patient 10’s secondary diagnoses included seizures and anxiety disorder (mental disorder characterized by persistent, excessive worry that interferes with daily life).  During a review of Patient 10’s medical form, titled “Current Treatment/Medication/DME List,” the medical form indicated a physician’s order with order date 7/16/2025 for Levetiracetam (medication to treat seizures) 750 mg 1 tablet orally twice a day for seizures.During an interview and a concurrent review of Patient 10’s medical records on 8/26/2025 at 1:04 p.m. with the DPCSD, Patient 10’s plan of care was reviewed. The DPCSD stated there was no documented evidence that an individualized CP was developed and implemented to address Patient 10’s seizure diagnosis to ensure safety and proper management of the condition.During an observation and a concurrent interview on 8/28/2025 at 12:35 p.m. with DPCSD, Patient 10 was observed dressed, alert, well-groomed and ambulated independently in the kitchen/dining area of his residence.  During a review of the HA’s policy and procedures (P&P), titled “The Plan of Care,” dated 4/2020, the P&P indicated the following:a. A written individualized patient and family/caregiver plan of care must be established and maintained for each individual admitted to the hospice program. b. The plan of care must meet the documentation requirements of the physician-directed medical orders and the care planning process. c. The plan of care must focus on identified problems, goals, and interventions. d. Each patient must be monitored for his/her response to care or services provided against established patient goals and patient outcomes to evaluate progress towards goals.e. The written plan of care must contain, but not limited to, the following: a) diagnosis, b) reduction in risk factors, c) drugs and treatments, d) physician orders, and e) measurable outcomes anticipated from implementing and coordinating the plan of care.

Based on interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients with six months or less to live) failed to ensure the home visits indicated on the Plan of Care were in accordance with the physician’s orders for one of 15 sampled patients (Patient 13).This failure had the potential to contribute to a decline in patient's health due to inconsistent home visits. --- Findings:During a review of Patient 13’s admission record, the record indicated Patient 13’s start of care (SOC) date of 3/1/2025 and end of care (EOC) date of 4/22/2025. The record indicated Patient 13’s primary diagnosis of hypertensive heart disease (HHD, heart problem due to the constant high force against the artery walls, making the heart work harder and affecting its ability to pump blood effectively) with heart failure (HF).During a review of Patient 13’s medical form, titled “Current Treatment/Medication/DME List,” the medical form indicated the following physician’s orders:a. Order Date 3/1/2025 – Skilled Nurse (SN, licensed nurse) to assess and evaluate, recertify, if appropriate, visit patient once a week, and as needed for pain management, assess vital signs during every visit.b. Order Date 3/1/2025 – Spiritual Counselor (SC) to assess and evaluate, recertify if appropriate, visit patient once a month and as needed to identify spiritual needs/support to the patient, family, and primary caregiver for the entire benefit periodc. Order Date 3/1/12025 – Medical Social Worker (MSW) to assess and evaluate, recertify if appropriate, may visit as needed to identify psychosocial needs/support to patient and family for the entire benefit periodDuring a review of Patient 13’s History of Visit Notes, the Visit Notes indicated the Registered Nurse (RN) home visits were done once a week and SC home visits were done once a month.During an interview and a concurrent review of Patient 13’s medical records on 8/26/2025 at 1:04 p.m. with the Director of Patient Care Services Designee (DPCSD), Patient 13’s physician orders and Plan of Care were reviewed. The DPCSD stated inaccurate Plan of Care could lead to lower quality care and the patient not being monitored properly and consistently. The DPCSD stated the Patient 13’s Plan of Care was not in accordance with the physician’s orders. The DPCSD stated the Plan of Care was incorrect when it indicated the frequency of home visits ordered was as follows:a. RN visits twice per week and 1 as needed visitb. SC visits twice per month and 1 as needed visitc. MSW visits twice per month and 1 as needed visitDuring a review of the HA’s policy and procedures (P&P), titled “The Plan of Care,” dated 4/2020, the P&P indicated the following:1. Care decisions and services to be provided must be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes.2. The plan of care must be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group, with input form the attending physician, the patient, and the family/caregiver. Review of the plan of care must be documented in the clinical record. Revision dates must be noted on the plan of care.3. The written plan of care must contain the frequency/amount/duration and type of services.

Based on observation, interview and record review, the hospice agency (HA, an agency providing specialized care to terminally ill patient with six months or less to live) nursing staff failed to coordinate care and ensure the Interdisciplinary Group (IDG - a team responsible for the holistic care of the hospice beneficiary) were notified and the notification were documented when ordered home visit service was missed for two of 15 sampled patients (Patient 1 and Patient 6). This failure had the potential to result in patient’s end of life care needs not being met. --- c. During a review of Patient 6’s admission record, the record indicated Patient 6’s start of care (SOC) date was on 4/25/202 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without unspecified angina pectoris (a buildup of fats, cholesterol, and other substances in the arteries of the heart without causing chest pain).During a review of Patient 6’s medical form titled “Current Treatment Medication DME List,” the medical form indicated a physician’s order, dated 4/25/2025, to have a skilled nurse (SN, licensed nurse) assess and evaluate, recertify, if appropriate, visit patient once a week, and as needed for pain management, symptom management, and assess vital signs during every visit.During a review of Patient 6’s History of Visit Notes, the notes indicated that RN 1 visited Patient 6 on 7/14/2025 and visited the patient next on 7/30/2025. During a telephone interview and a concurrent record review of Patient 6’s medical records with the DPCS D on 8/25/2025 at 1:31 p.m., the DPCS D stated that according to Patient 6's Current Treatment Medication DME List, the patient should be visited once per week. The DPCS D added that RN 1, who was scheduled to see Patient 6 a week after her last visit on 7/14/2025, failed to do so because she got sick. The DPCS D also noted that RN 1 did not inform the physician, which is required within 24 hours of a missed scheduled visit.   During a review of Patient 1’s admission record, the record indicated the start of care (SOC) date of 4/1/2025 with a primary diagnosis of atherosclerosis heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls). During a review of Patient 1's Plan of Care (POC)/IDG ( (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form, dated 8/6/2025, indicated the frequency of visits of skilled nurse (SN) to 1 visit per week plus 1 visit as needed for pain, comfort and symptom management, hospice aide (HA) to two visit per week, and the MSW (Social worker) to 1 visit per month and  to perform an initial assessment within 5 days from SOC. Spiritual counselor (SC) service to one visit per month .During a joint home visit on 8/28/2025, at 1:45 p.m., with the Director of Patient Care Services Designee (DPCSD), Patient 1 was observed sitting on a couch with both legs were swollen.  During an interview on 8/28/2025 at 1:43 p.m. Patient 1 stated she needed a visit from a SC but she never got the bereavement  service.  During a review of Patient 1's history of Spiritual Counselor  (SC) Visit Notes dated 5/5/2025, 6/29/2025, 7/15/2025, and 8/12/2025, indicated the SC attempted to visit the patient at his residence but there was no one to answered the door, There was no follow up visit conducted made to check on Patient 1 status as per plan of care.  A further review of Patient 1's clinical record indicated no communication note entry to explain reason for missed visit nor if physician was notified regarding the missed visit.  During a telephone interview and a concurrent record review of Patient 1’s medical records with the DPCSD on 8/25/2025 at 1:31 p.m., the DPCSD stated that according to Patient 1'sPOC, the Spiritual Counselor should be visiting the patient once per month and the physician should be informed about the missed visits.  During a review of the agency’s policy and procedure titled, “Missed Visits”, revised November 2022, indicated missed visits will be communicated to the Interdisciplinary Group at the IDG meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. If a visit is missed and not rescheduled, the clinician will notify the IDG and clinical supervisor of the missed visit and reason for missed visit and will document in the patient’s clinical record. Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication.

Based on interview and record review, the Hospice Agency (HA, an agency providing specialized care to terminally ill patients with six months or less to live) failed to ensure home visit was conducted according to the plan of care (POC) for two of 15 sampled patients (Patients 1 and Patient 6). This deficient practice had the potential to negatively affect the patients' physical comfort, psychosocial well-being, and not receiving the needed and necessary services timely. --- c. During a review of Patient 6’s admission record, the record indicated Patient 6’s start of care (SOC) date was on 4/25/202 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without unspecified angina pectoris (a buildup of fats, cholesterol, and other substances in the arteries of the heart without causing chest pain).During a review of Patient 6’s medical form titled “Current Treatment Medication DME List,” the medical form indicated a physician’s order, dated 4/25/2025, for a silled nurse (SN, licensed nurse) to assess and evaluate, recertify, if appropriate, visit patient once a week, and as needed for pain management, symptom management, and assess vital signs during every visit.During a review of Patient 6’s History of Visit Notes, the notes indicated that RN 1 visited Patient 6 on 7/14/2025 and visited the patient next on 7/30/2025. During a telephone interview and a concurrent record review of Patient 6’s medical records with the Director of Patient Care Services Designee (DPCS D) on 8/25/2025 at 1:31 p.m., the DPCS D stated that according to Patient 6's Current Treatment Medication DME List, the patient should be visited once per week. The DPCS D added that RN 1, who was scheduled to see Patient 6 a week after her last visit on 7/14/2025, failed to do so because she got sick. The DPCS D also noted that RN 1 did not inform the physician, which is required within 24 hours of a missed scheduled visit. a. During a review of Patient 1’s admission record, the record indicated the start of care (SOC) date of 4/1/2025 with a primary diagnosis of atherosclerosis heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls). During a review of Patient 1's Plan of Care (POC)/IDG ( (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form, dated 8/6/2025, indicated the frequency of visits of skilled nurse (SN) to 1 visit per week plus 1 visit as needed for pain, comfort and symptom management, hospice aide (HA) to two visit per week, and the MSW (Social worker) to 1 visit per month and  to perform an initial assessment within 5 days from SOC. Spiritual counselor (SC) service to one visit per month .During a joint home visit on 8/28/2025, at 1:45 p.m., with the Director of Patient Care Services Designee (DPCSD), Patient 1 was observed sitting on a couch with both legs were swollen.  During an interview on 8/28/2025 at 1:43 p.m. Patient 1 stated she needed a visit from a SC but she never got the bereavement  service.  During a review of Patient 1's history of Spiritual Counselor  (SC) Visit Notes dated 5/5/2025, 6/29/2025, 7/15/2025, and 8/12/2025, indicated the SC attempted to visit the patient at his residence but there was no one to answered the door, There was no follow up visit conducted made to check on Patient 1 as per plan of care.    During a review of the agency's policy and procedure titled, "The Plan of Care", revised November 2022, 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 interviews and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Core Services (physician services, nursing services, medical social services, and counseling services [bereavement, dietary, and spiritual]) was met as follows: --- 1.    The HA failed to ensure the Medical Director consulted with the primary care provider (PCP)/attending physician of four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15) to determine the patients’ eligibility to receive hospice care and services and manage the terminal illness and conditions as necessary. This failure had the potential to result in the decline of the patients’ health related to the lack of coordination of care and services patients receiving hospice care and services and lower quality of care related to the patients’ inability to access life-prolonging or curative treatments, potential out-of-pocket care costs, and potential fraud. (Refer to L590) 2.     The HA failed to ensure a bereavement plan of care was developed for three of 15 sampled patients (Patient 12, Patient 13, & Patient 14). This failure had the potential to result in the spiritual/emotional distress of the patients’ family/caregiver related to the lack of evaluation of their support system to cope with loss. (Refer to L596) The cumulative effect of these systemic practices resulted in the failure of the HA to provide core services in compliance with the federal regulations and had the potential to lower the quality of care for and quality of life of the patients.

Based on interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients with six months or less to live) failed to ensure the Medical Director consulted with the primary care provider (PCP)/attending physician of four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15) to determine the patients’ eligibility to receive hospice care and services and manage the terminal illness and conditions as necessary. This failure had the potential to result in the decline of the patients’ health related to the lack of coordination of care and services and lower quality of care related to the patients’ inability to access life-prolonging or curative treatments, and potential out-of-pocket care costs. --- Findings: A. During a review of Patient 1’s admission record, the record indicated the start of care (SOC) date of 4/1/2025 with a primary diagnosis of atherosclerosis heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls).   During a review of Patient 1’s Comprehensive Nursing Assessment, dated 4/1/2025, the Comprehensive Nursing Assessment indicated Patient 1 had a terminal diagnosis of heart disease and was dependent on assistance for two or more activities of daily living (ADLs, including ambulation, continence, transfer, dressing, feeding). The Comprehensive Nursing Assessment indicated Patient 1 met the criteria for New York Heart Association (NYHA) functional classification (medical standard for categorizing the severity of heart failure) for Class IV congestive heart failure (Class IV CHF, severely advanced stage when a patient experiences symptoms of breathlessness, fatigue, and heart failure indicators even when at rest, and experiences severe discomfort with any level of physical activity).    During a review of Patient 1’s Physician’s Certification for Terminal Illness (CTI) form, dated 4/1/2025, the medical director indicated that Patient 1 was appropriate for hospice/palliative care and met the criteria for Local Coverage Determination (LCD) eligibility (criteria a patient must meet to be deemed eligible for hospice care).     During a review of Patient 1’s LCD Hospice Eligibility Determination, dated 4/1/2025, the LCD indicated Patient 1 met the criteria for NYHA functional classification.     During an interview and a concurrent review of Patient 1’s medical records on 8/22/2025 at 1:25 p.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated there was no documented evidence that any clinical records to support Patient 1’s LCD Hospice Eligibility Determination and justify Patient 1’s eligibility for hospice.    During a concurrent interview of Patient 1 on 8/28/2025 at 1:43 p.m. while on a joint home visit with DPCSD, Patient 1 stated a social worker from medical office recommended hospice to her but was she was not informed that hospice was for patients who have six (6) months or less to live. Patient 1 also stated she was “always sick” but not dying within six months.     B.  During a review of Patient 6’s admission record, the record indicated the SOC date of 4/25/2025 with a primary diagnosis of atherosclerosis heart disease.   During a review of Patient 6’s Comprehensive Nursing Assessment, dated 4/25/2025, the Comprehensive Nursing Assessment indicated Patient 6 had a terminal diagnosis of heart disease and was dependent on assistance for two or more ADLs. The Comprehensive Nursing Assessment indicated Patient 6 met the criteria for NYHA Class IV CHF.   During a review of Patient 6’s Physician’s CTI form, dated 4/25/2025, the medical director indicated that Patient 6 was appropriate for hospice/palliative care and met the criteria for LCD eligibility.   During a review of Patient 6’s LCD Hospice Eligibility Determination, dated 4/25/2025, the LCD indicated Patient 6 met the criteria for NYHA functional classification.     During an interview and a concurrent review of Patient 6’s medical records on 8/22/2025 at 1:25 p.m. with the DPCS, the DPCSD stated there was no documented evidence that any clinical records were reviewed to support Patient 6’s LCD Hospice Eligibility Determination and justify Patient 6’s eligibility for hospice.    During an observation and a concurrent interview on 8/28/2025 at 12:35 p.m. while on a joint home visit with DPCSD,  Patient 6 was observed dressed, alert, well-groomed and ambulated independently in the kitchen/dining area of his residence.  Patient 6 stated someone recommended hospice to him but did not inform him that hospice was for those who have six (6) months or less to live.    During a telephone interview and a concurrent record review on 8/29/2025, at 9:30 a.m., the DPCSD stated that the hospice agency admitted the patient on 4/25/2025 with a terminal diagnosis of atherosclerotic heart disease and a functional capacity of NYHA Class IV.  The DPCSD stated that she did not explain to the patients (in general) that being in hospice means that the patient has a terminal diagnosis with a life expectancy of six (6) months or less.  The DPCSD stated that she observed Patient 6 ambulating in his residence without any shortness of breath (SOB).   C.  During a review of Patient 10’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (artery that supplies blood to the heart muscle) with angina pectoris (chest pain). Patient 10’s admission record indicated Patient 10’s secondary diagnoses included orthopnea (shortness of breath when lying flat), diabetes (chronic disease characterized by high blood sugar levels), seizures, and anxiety disorder (mental disorder characterized by persistent, excessive worry that interferes with daily life).    During a review of Patient 10’s Comprehensive Nursing Assessment, dated 3/1/2025, the Comprehensive Nursing Assessment indicated Patient 10 had a terminal diagnosis of heart disease and was dependent on assistance for two or more ADLs. The Comprehensive Nursing Assessment indicated Patient 10 met the criteria for NYHA Class IV CHF.   During a review of Patient 10’s Physician’s CTI form, dated 3/1/2025, the medical director determined Patient 10 was “exhibiting imminent signs of death within six months and thus appropriate for hospice care services.  During a review of Patient 10’s LCD Hospice Eligibility Determination, dated 3/1/2025, the LCD indicated Patient 10 met the criteria for NYHA functional classification.    During an interview and a concurrent review of Patient 10’s medical records on 8/26/2025 at 1:04 p.m. with the DPCSD, Patient 10’s nursing assessments, LCD Hospice Eligibility, and primary care physician (PCP) notes were reviewed. The DPCSD stated she conducted and documented Patient 10’s initial comprehensive nursing assessment, dated 3/1/2025, and nursing recertification assessment, dated 5/29/2025. However, the DPCSD was unable to define NYHA Class IV CHF. The DPCSD stated Patient 10 had moderate SOB with activity during nursing assessments. The DPCSD stated there was no documented evidence that any clinical records were reviewed to support Patient 10’s LCD Hospice Eligibility Determination and justify Patient 10’s eligibility for hospice.    During an observation on 8/27/2025 at 11:31 a.m. while on a joint home visit with DPCSD, Patient 10 was observed ambulatory (able to walk), independent with ADLs, and alert and oriented (no impairment in mental processes).     During an interview on 8/27/2025 at 12:02 p.m., Patient 10 stated her caregiver wanted “extra money” and referred her to the HA. Patient 10 stated she was invited to meet with “them (unable to specify name or title)” in a fast-food restaurant to talk about hospice care. Patient 10 stated, “I don’t need hospice care. All I need is someone to make sure I take my seizure medications. I am not dying, but I need the nurse to come and check my blood pressure (force exerted by the blood against the walls of the arteries) and blood sugar. I have been with them for two years come October.”    D. During a review of Patient 15’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of hypertensive heart disease with heart failure (condition wherein prolonged high blood pressure damages the heart muscle, leading to impaired pumping function and heart failure).    During a review of Patient 15’s Comprehensive Nursing Assessment, dated 3/1/2025, the Comprehensive Nursing Assessment indicated Patient 15 had a terminal diagnosis of heart disease and was dependent on assistance for two or more ADLs. The Comprehensive Nursing Assessment indicated Patient 15 met the criteria for NYHA Class IV CHF.    During a review of Patient 15’s Physician’s CTI form, dated 3/1/2025, the medical director determined Patient 15 “exhibits imminent signs suggestive of imminent death within the next six months, thus qualifying her for hospice care services.”   During a review of Patient 15’s LCD Hospice Eligibility Determination, dated 3/1/2025, the LCD indicated Patient 15 met the criteria for NYHA functional classification.    During an interview on 8/22/2025 at 10:15 AM, the HA Medical Director (MD) stated he had no hospice experience prior to being hired by HA in 11/2022. The HA MD stated he was not the primary care provider (PCP) or attending physician of Patient 1, Patient 6, Patient 10, and Patient 15. The HA MD stated he would sign the patients’ Certification of Terminal Illness (CTI) based on the patients’ nursing assessment by the Registered Nurse (RN). The HA MD stated he did not communicate with the patients’ PCP or attending physician to discuss the patients’ terminal condition or to have the PCP sign as the referring physician. The HA MD stated he did not request from the PCP or attending physician or review any clinical records of patients, if missing from the HA health records.   During an interview on 8/29/2025 at 9:13 a.m., Patient 15 stated she did not have a terminal diagnosis of six (6) months or less to live. Patient 15 stated the HA nurses did not explain the hospice care and services and eligibility qualifications to receive hospice care and services. Patient 15’s caregiver stated Patient 15 was alert and oriented, ambulatory, able to feed, groom, and bathe herself.     During an interview and a concurrent review of Patient 15’s medical records on 8/29/2025 at 9:28 a.m. with the DPCSD, the DPCSD stated Patient 15 was alert and oriented, able to ambulate with a cane with mild SOB, and able to feed, groom, and bathe self.  The DPCSD stated Patient 15’s initial comprehensive nursing assessment, dated 3/1/2025, and nursing recertification assessment, dated 5/29/2025, indicated Patient 15 met the criteria for NYHA Class IV CHF, but there was no documented evidence to support Patient 15’s terminal diagnosis. The DPCSD stated there was no documented evidence that any clinical records were reviewed to support Patient 15’s LCD Hospice Eligibility Determination and justify Patient 15’s eligibility for hospice. The DPCSD stated that inaccurate patient assessments would not be valid in determining if a patient (in general) was eligible to receive hospice care and services.  During a review of HA’s agency policy and procedures (P&P 1), titled “Certification of Terminal Illness (CTI),” dated 4/2020, P&P 1 indicated the following:1. At the time a patient and family/caregiver chooses hospice care, the HA MD and the patient’s attending physician, if any, must certify the patient’s terminal illness.2. Both the patient’s PCP or attending physician and the HA MD must sign and date the CTI and authorization for hospice services forms. The CTI form must be completed no more than 15 calendar days prior to the effective date of the hospice election.3. When certifying the patient as terminally ill, the HA MD must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis.4. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. During a review of HA’s agency policies and procedures (P&P 2), titled “Admission Criteria and Process,” dated 11/2024, P&P 2 indicated the HA would admit any patient with a life-limiting illness that meets the admission criteria. The P&P indicated the patient must desire hospice services and be aware of the diagnosis and prognosis. The P&P indicated the hospice registered nurse must contact the physician for clinical information in writing to certify patient for hospice care.

Based on interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients with six months or less to live) failed to ensure a bereavement plan of care was developed for three of 15 sampled patients (Patient 12, Patient 13, & Patient 14). This failure had the potential to result in the spiritual/emotional distress of the patients’ family/caregiver related to the lack of evaluation of their support system to cope with loss. --- Findings: During a review of Patient 12’s admission record, the record indicated Patient 12’s start of care (SOC) date of 3/1/2025 and end of care (EOC) date of 4/19/2025. The record indicated Patient 12’s primary diagnosis of hypertensive heart disease (HHD, heart problem due to the constant high force against the artery walls, making the heart work harder and affecting its ability to pump blood effectively) with heart failure (HF, a condition where the heart cannot pump enough blood to meet the body's needs). During a review of Patient 13’s admission record, the record indicated Patient 13’s SOC date of 3/1/2025 and EOC date of 4/22/2025. The record indicated Patient 13’s primary diagnosis of HHD with HF. During a review of Patient 14’s admission record, the record indicated Patient 14’s SOC date of 4/15/2025 and EOC date of 6/16/2025. The record indicated Patient 14’s primary diagnosis of HHD with HF. During an interview and a concurrent review on 8/26/2025 at 11:55 a.m, with Chaplain 1, the medical records of Patient 12, Patient 13, & Patient 14 was reviewed. Chaplain 1 stated there was no documented evidence that an initial bereavement assessment was conducted or a bereavement plan of care developed for Patient 12, Patient 13, and Patient 14. Chaplain 1 stated the initial bereavement assessment was conducted to assess the patient’s (in general) family, the primary bereaved and secondary bereaved, the risks for stressors, if they show signs of spiritual stress, are unprepared for the death of the patient, has suicidal intents, any children would be affected if the patient passes away. Chaplain 1 stated if these factors were identified, he would present options to support the bereaved, such as referral to a counselor or connecting them with their church organization by talking with their pastor/priest.  During a review of the HA’s policy and procedures (P&P 1), titled “The Plan of Care,” dated 4/2020, P&P 2 indicated the following:a. The plan of care must be initiated at the start of care.b. The written plan of care must contain, but will not be limited to, a) identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, educational, bereavement, and counseling; b) end-of-life preferences; and c) anticipated discharge and bereavement care needs of the family. During a review of the HA’s policy and procedures (P&P 2), titled “Bereavement Assessment,” dated 4/2020, P&P 2 indicated the following:a.      On admission, the social worker or hospice registered nurse must complete a bereavement risk assessment that would include, at a minimum, the patient and family caregiver loss issues; survivor needs; social, spiritual, and cultural factors; services to be provided including individual counseling, support groups, and letters and cards; referrals to be made; and grief risk factors and potential for pathological grief reactions.b.      The bereavement counselor must review the bereavement risk assessment to determine the potential needs of the survivors.c.      The bereavement coordinator must develop a plan intervention based on the findings of the bereavement follow-up assessment.

Based on interview and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients with six months or less to live), failed to ensure the Condition of Participation (specifies requirements that healthcare organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Volunteers program was met as follows: --- The HA failed to provide documentation of Volunteers orientation and training of the specific tasks that volunteers performed for four out of 15 sample patients (Patient 1, Patient 6, Patient 10 and Patient 15). (Refer to L643). This failure had the potential to result in hospice patients not receiving Volunteer services as required. The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulations for Volunteers to ensure provision of quality care and services to patients.

Based on interview and record review, the hospice agency (HA) failed to provide documentations of Volunteer orientation and training of the specific tasks that volunteers perform for four out of 15 sample patients (Patient 1, Patient 6, Patient 10 and Patient 15).  This failure had the potential to result in hospice patients not receiving Volunteer services as required. --- a. During a review of Patient 1’s admission record, the record indicated the start of care (SOC) date of 4/1/2025 with a primary diagnosis of atherosclerosis heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls). During a review of Patient 1's Plan of Care (POC)/IDG ( (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form, dated 8/6/2025, indicated the frequency of visits of skilled nurse (SN) was one visit per week plus one visit as needed for pain, comfort and symptom management, hospice aide (HA) was two visit per week, volunteers was one visit per month, and the MSW (Social worker) was one visit per month. The POC indicated to perform an initial assessment within 5 days from SOC. The POC indicated Spiritual counselor (SC) service was one visit per month . b. During a review of Patient 6’s admission record, the record indicated Patient 6’s start of care (SOC) date was on 4/25/202 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without unspecified angina pectoris (a buildup of fats, cholesterol, and other substances in the arteries of the heart without causing chest pain). c. During a review of Patient 10’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (artery that supplies blood to the heart muscle) with angina pectoris (chest pain). Patient 10’s admission record indicated Patient 10’s secondary diagnoses included orthopnea (shortness of breath when lying flat), diabetes (chronic disease characterized by high blood sugar levels), seizures, and anxiety disorder (mental disorder characterized by persistent, excessive worry that interferes with daily life).  d. During a review of Patient 15’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of hypertensive heart disease with heart failure (condition wherein prolonged high blood pressure damages the heart muscle, leading to impaired pumping function and heart failure).  During an interview and a concurrent review of Patient 1’s medical records on 8/22/2025 at 2 p.m., with the Director of Patient Care Service Designee (DPCSD), the DPCSD stated the HA have hired Volunteer 1 to provide services for Patient 1, 6, 10 and 16. The DPCSD also stated that the HA had no monthly orientation and training for their agency's volunteers provided by the agency's volunteer coordinator. The DPCS was unable to provide the volunteer personnel files that included evidence of the required training indicating specific tasks the volunteers perform.  A review of the agency's Policy and Procedure (P&P) titled "Volunteer Services", undated, the P&P indicated the hospice will provide volunteer services under the direction of a volunteer coordinator or staff member responsible for planning, organizing and directing a comprehensive volunteer services program, and with the assistance of trained hospice volunteers.

Based on observation, interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) for Organizational & Administration of Services was met as follows: --- 1. The HA failed to ensure the governing body (a group of individuals who have responsibility for the overall management and operations, such as the legal, financial aspects of the organization, including oversight of the patient care, fiscal operations, and quality improvement activities) and administrator assumed full responsibility for the day-to-day operations of the hospice services and provision of care for four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15). The ADM, currently residing in another country, left the United States of America (US) on 4/1/2025. The ADM Designee (ADM D) went on leave of absence (LOA) on 8/15/2025. 2. The governing body failed to ensure the Director of Patient Care Services (DPCS) and the DPCS designee were qualified for the DPCS position to provide hospice care and services for four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15). The DPCS and the DPCS designee did not have three years of nursing experience and one year of supervisory nursing experience prior to being hired as a DPCS:a. The HA hired the DPCS on 3/4/2025, went on LOA in 8/2025, and resigned on 9/1/2025.  The DPCS had four years of Registered Nurse (RN) experience with no supervisory experience prior to becoming the DPCS. b. The HA appointed the DPCS designee on 3/2025. At the time, the appointee had two years of RN experience but lacked supervisory experience. 3. The governing body failed to ensure that the medical director had hospice or palliative care (aimed to provide symptom relief and improved quality of life for patients with serious illnesses at any stage) experience or met the minimum applicable training requirements of end-of-life care, per HA policy, prior to being appointed to provide hospice care and services for four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15).4. The governing body failed to ensure four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15) met the criteria for hospice eligibility.This failure resulted in the HA admitting patients ineligible to receive hospice care and services and the patients were placed at an increased potential for decline in health that could lead to serious harm, hospitalization, and death due to not having proper medical oversight and access to needed specialists, medications, and medically necessary treatments related to potential issues with billing, reimbursement, and/or fraud.5. The governing body failed to ensure that Chaplain 1 and Chaplain 2 were qualified to meet the requirements to serve as hospice chaplains for four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15). Chaplain 1’s and Chaplain 2’s clinical pastoral education did not have pastoral accreditation (the action or process of officially recognizing someone as having a particular status or being qualified to perform a particular activity) from the US.6. The governing body failed to ensure that the HA provided a volunteer training program and that the volunteer coordinator (responsible for planning, coordinating, and managing all volunteer programs and activities in the organization) was qualified to provide hospice care and services for four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15). 7. The HA moved to another location to provide hospice care and services for four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15) without authorization from the State or local agency responsible for licensing.8. The governing body failed to renew the agency’s license to continue providing hospice care and services for four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15). The HA license expired on 7/12/2025, and the HA did not pay the renewal fee of the license until 8/15/2025. These failures resulted in the HA did not have qualified personnel to provide oversight of HA and has the potential to result of the hospice patients (Patient 1, Patient 6, Patient 10 and Patient 15) to suffer from inadequate quality of care and life, unsafe patient care, and adverse events (undesirable experience) that can lead to emergency hospitalization and may contribute to an avoidable traumatic death. (Refer to L651). 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 Organizational Environment of the Patient to ensure the highest quality of care were being provided to patients certified to receive the Medicare hospice benefits.

The Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the HA governing body (a group of individuals who have responsibility for the overall management and operations, such as the legal, financial aspects of the organization, including oversight of the patient care, fiscal operations, and quality improvement activities) assumed full authority and responsibility for the management of the HA to provide care and services for four of 15 patients (Patient 1, Patient 6, Patient 10, & Patient 15) when:  1. The HA failed to ensure the governing body and administrator assumed full responsibility for the day-to-day operations of the hospice services and provision of care. The Administrator (ADM) currently residing in another country, left the United States of America (US) on 4/1/2025. The ADM Designee (ADM D) went on leave of absence (LOA) on 8/15/2025.  2. The governing body failed to ensure the Director of Patient Care Services (DPCS) and the DPCS designee were qualified for the DPCS position. The DPCS and the DPCS designee did not have three years of nursing experience and one year of supervisory nursing experience prior to being hired as a DPCS:   a. The HA hired the DPCS on 3/4/2025, went on LOA in 8/2025, and resigned on 9/1/2025.  The DPCS had four years of Registered Nurse (RN) experience with no supervisory experience prior to becoming the DPCS.  b. The HA appointed (officially assigned) the DPCS designee in 3/2025. At the time of hire, the appointee had two years of RN experience but lacked supervisory experience.   3. The governing body failed to ensure that the medical director had hospice or palliative care (aimed to provide symptom relief and improved quality of life for patients with serious illnesses at any stage) experience or met the minimum applicable training requirements of end-of-life care, per HA policy, prior to being appointed to provide hospice care and services for four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15).  4. The governing body failed to ensure four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15) met the criteria for hospice eligibility. This failure resulted in the HA admitting patients ineligible to receive hospice care and services and the patients were placed at an increased potential for decline in health that could lead to serious harm, hospitalization, and death due to not having proper medical oversight and access to needed specialists, medications, and medically necessary treatments related to potential issues with billing, reimbursement, and/or fraud. 5. The governing body failed to ensure that Chaplain 1 and Chaplain 2 were qualified to meet the requirements to serve as hospice chaplains for four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15). Chaplain 1’s and Chaplain 2’s clinical pastoral education did not have pastoral accreditation (the action or process of officially recognizing someone as having a particular status or being qualified to perform a particular activity) from the US.  6. The governing body failed to ensure that the HA provided a volunteer training program and that the volunteer coordinator (responsible for planning, coordinating, and managing all volunteer programs and activities in the organization) was qualified to provide hospice care and services for four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15).    7. The HA moved to another location to provide hospice care and services for four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15) without authorization from the State or local agency responsible for licensing.  8. The governing body failed to renew the agency’s license to continue providing hospice care and services for four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15). The HA license expired on 7/12/2025, and the HA did not pay the renewal fee of the license until 8/15/2025. These failures resulted in the HA did not have qualified personnel to provide oversight of HA and has the potential to result of the hospice patients (Patient 1, Patient 6, Patient 10 and Patient 15) to suffer from inadequate quality of care and life, unsafe patient care, and adverse events (undesirable experience) that can lead to emergency hospitalization and may contribute to an avoidable traumatic death. On 8/29/2025 at 3:36 p.m., the California Department of Public Health (CDPH) called an  Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the HA's Human Resources Manager (HRM) related to the HA governing body failed to ensure: 1. The ADM assumed full responsibility for the day-to-day operations of the hospice services and provision of care, 2. The DPCS and the DPCS designee were qualified for the DPCS position. 3. The medical director had hospice or palliative care experience or met the minimum applicable training requirements of end-of-life care, per HA policy, prior to being appointed to provide hospice care and services. Ensure four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15) met the criteria for hospice eligibility. 5. Chaplain 1 and Chaplain 2 were qualified to meet the requirements to serve as hospice chaplains. 6. The HA provided a volunteer training program and that one of one volunteer employee (Volunteer Coordinator [VC] 1), was qualified to be a volunteer coordinator.7. The HA moved to another location to provide hospice care and services for four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15) without authorization from the State or local agency responsible for licensing. 8. The governing body failed to renew the agency’s license to continue providing hospice care and services for four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15). The HA license expired on 7/12/2025, and the HA did not pay the renewal fee of the license until 8/15/2025. These failures resulted in the HA did not have qualified personnel to provide oversight of HA and has the potential to result of the hospice patients (Patient 1, Patient 6, Patient 10 and Patient 15) to suffer from inadequate quality of care and life, unsafe patient care, and adverse events (undesirable experience) that can lead to emergency hospitalization and may contribute to an avoidable traumatic death.On 8/30/2025 at 1 p.m., the survey team completed the survey tasks and conducted an exit conference while onsite in the presence of the HRM, ADM, and the DPCS D via virtual video conference. On 8/30/2025 the HA was unable to submit an Immediate Jeopardy removal plan (IJRP, actions the agency has taken or will take to immediately address the noncompliance that may result in or has resulted in serious injury, serious harm, serious impairment, or death). As a result, the survey team exited the facility with the IJ status unremoved. On 9/12/2025 at 2:10 p.m., after confirming the agency's implementation of the immediate corrective actions from the accepted IJ removal plan (IJRP-steps an agency will take to immediately address a noncompliance situation that has created or is likely to create serious harm to patients), the Department removed the Immediate Jeopardy while onsite, in the presence of the human resource manager.The IJRP included the following:Corrective Actions:A. Leadership Appointments• The Governing Body was immediately notified• Reinstatement of the qualified full-time Administrator on 9/12/2025.• All staff were informed of the reinstatement, reporting structure, and leadership communication protocols on 9/12/2025Implementation Date: 9/12/2025Completed on: 9/12/2025Responsible Party/s: CEOB. The Administrative Policy was updated to:• Clarify requirements for on-site availability• Establish procedures for appointing and documenting acting administrators• Weekly reporting to the Governing Body by the administrator is now mandatory during absences.• Administrator logs will be reviewed quarterly.• Administrator orientation now includes training on on-site availability, emergency delegation, and documentation.Implementation Date: 9/12/2025Completed on: 9/16/2025Responsible Party/s: Governing BodyPersonnel Qualifications and Hiring PracticesDeficiency: Employment of unqualified personnel in critical roles (MD,DPCS, designees, etc.).Corrective Actions:• Governing Body conducted Root Cause Analysis (RCA) on 9/1/2025.• On 9/1/2025, the unqualified DPCS and DPCS Designee wereremoved from their positions.• A qualified DPCS and DPCS Designee were appointed toprovide clinical oversight.• DPCS – hired on 9/16/2025• DPCS Designee – hired on 9/1/2025Implementation Date: 9/1/2025Completed on: 9/16/2025Responsible Party/s: Human Resource Manager Updated Hiring Policy to require:• Verified documentation of qualifications, licensure, education, and background checks• Oversight and verification by the Administrator and HR Manager• Policy ratification scheduled for 9/16/2025 Governing Body meeting.Implementation Date: 9/16/2025Completed on: 9/16/2025Responsible Party/s: Governing BodyMonitoring Sustainability:• Monthly audits of all employee files for three months, followed by quarterly audits.• 100% compliance required for three consecutive quarters.• Findings reviewed during quarterly QAPI Committee andGoverning Body meetings.Implementation Date: 9/16/2025Completion Date: 9/16/2025Responsible Party/s: Human Resource Manager and AdministratorMedical Director QualificationDeficiency: Employment of an unqualified Medical Director.Corrective Actions:• Immediate termination of the previous Medical Director as of9/1/2025• Appointment of the qualified Medical Director who is currentlythe Medical Director Designee, and hired a new qualifiedMedical Director Designee as of 9/15/2025Implementation Date: 9/1/2025Completion Date: 9/15/2025Responsible Party/s: Human Resource ManagerMonitoring Sustainability:• Monthly audits of physician credentials for the first 3 months,then quarterly will be done by the human resource manager.• Governing Body will annually review and approve MedicalDirector hiring policies as part of QAPI to be presented by the administrator.Implementation Date: 9/16/2025Completion Date: 9/16/2025Responsible Party/s: Human Resource Manager and AdministratorPatient Eligibility and Admission ReviewDeficiency: Admission of ineligible patients to hospice care.Corrective Actions:• Immediate discharge of unqualified patients by the medicaldirector.• RN explaining NMNOC and patient signing the form.• Transfer of records and a two-week supply of medicationscoordinated with primary care.Implementation: 8/29/2025Completion Date: 9/3/2025Responsible Party/s: Medical Director, Assigned Visiting Nurse, Office ManagerNew Eligibility Policy adopted, including:• Standardized checklist for admission• Documentation of terminal diagnosis and related conditions• Required face-to-face encounter before the third benefit periodImplementation Date: 9/12/2025Completion Date: 9/15/2025Responsible Party/s: AdministratorSpiritual Care ComplianceDeficiency: Unqualified chaplain provided patient-facing spiritual counseling.Corrective Actions:• As of 9/1/2025, the unqualified chaplain was terminated.• As of 9/12/2025, a new chaplain was hired.• IDT reviewed and updated spiritual care plans.• Hiring policy updated with a qualifications checklist andverification process.• Chaplain job description revised to clarify requirements.Implementation: 9/1/2025Completion Date: 9/12/2025Responsible Party/s: Human Resource Manager andAdministratorVolunteer Services OversightDeficiency: Volunteer Coordinator did not meet CMS qualifications.Corrective Actions:• Previous coordinator removed on 9/1/2025.• New coordinator hired on 9/1/2025• New coordinator received training and orientation from the Compliance Officer• Job description updated with detailed qualifications and responsibilities.Implementation Date: 9/1/2025Completion Date: 9/1/2025Responsible Party/s: Compliance OfficerMonitoring C Sustainability:• Monthly audits of the volunteer program for 3 months.• Includes personnel file checks, 5% rule compliance, trainingdocumentation, and IDG meeting attendance.Implementation Date: 9/1/2025Completion Date: 9/1/2025Responsible Party/s: Compliance OfficerUnauthorized Location ChangeDeficiency: Relocation of operations without CMS approval.Corrective Actions:• All services and records returned to the certified location.• Services suspended at the unauthorized site until CMS approval.• Governing Body restructured to include compliance experts.• Mandatory training on Medicare Conditions of Participation (CoPs) and CMS-855A enrollment requirements implemented.• Governing Body to receive formal compliance reports each quarter.Implementation Date: 9/1/2025Completion Date: 9/12/2025Responsible Party/s: Compliance OfficerLicense s Certification OversightDeficiency: Failure to ensure licenses and permits were current and valid.Corrective Actions:• Formal audit of all licenses and certifications conducted.• Multi-tiered license tracking system implemented:• Digital calendar with 120/90/60-day reminders• Hard-copy binder maintained by Admin Assistant Monitoring C Sustainability:• License status will be reviewed during quarterly Governing Body meetings.• Compliance Officer will monitor monthly for three months, then quarterly for a year.• Administrator will report status and tracking outcomes.Implementation Date: 9/1/2025Completion Date: 9/15/2025Responsible Party/s: Compliance Officer and Governing --- Findings: 1. During a virtual video conference with the ADM on 8/27/2025 at 11 a.m., she stated that she had left the US on 4/1/2025. The ADM stated that the ADM D, who was covering her duties, went on leave of absence (LOA) on 8/15/2025, and that there were no qualified staff in charge at the time (since 8/15/2025).During a review of the HA’s ADM job description, the job description indicated that the ADM was responsible for employing qualified hospice personnel, evaluating them, establishing standards of care, and providing overall direction to ensure compliance with federal and state regulations and guidelines.During a review of the HA’s undated policy and procedure titled “Governing Body,” the policy indicated that the governing body would assume full legal authority, responsibility, decision-making, and accountability for the overall management and operations. The Governing Body will appoint a qualified Executive Director/Administrator and establish procedures for systematic communication between the two.During a review of the guidance from the California Hospice & Palliative Care Association titled “Standards of Quality of Hospice Care,” dated 2005, the guidance indicated the following:A. The administrator must be a person appointed in writing by the governing body of the program to organize and direct the services and functions of the hospice.B. The administrator has overall responsibility for day-to-day operations, complying with applicable rules and regulations, and reporting to the governing body.C. The administrator or qualified alternate should be available on the premises or by telecommunication during normal business hours.[Source: https://www.calhospice.org/assets/docs/Standards_of_Quality.pdf]  2. During a review of the HA's personnel files on 8/26/25 at 11 a.m., the records indicated that the HA hired the DPCS on 3/4/2025 and that her California Board of Registered Nursing (BRN) license was issued on 5/11/2021. The DPCS had an accredited Bachelor of Science in Nursing degree from a foreign country (outside of US) on 5/2008, however there was no documented evidence of any hospice experience from previous employer. The HA hired the DPCS designee on 7/1/2023, and her BRN license was issued on 1/3/2023. The DPCSD had no BSN degree or hospice experience from previous employers.   During a review of the HA’s DPCS and the DPCS D’s job description, the job description indicated that the DPCS and its designee are required to be a registered nurse with a baccalaureate degree in nursing or a health-related field. Additionally, they must possess three years of relevant experience within the last five years (including at least one year in a supervisory or administrative role) and have sufficient clinical decision-making experience.During an interview with the DPCS D on 8/26/2025 at 1 p.m., the DPCS D stated that she was covering for the DPCS who was on leave and that she only had two years of RN experience.  During a virtual video conference interview with the ADM on 8/27/2025 at 11 a.m., the ADM stated that she was not aware that the DPCS and the DPCS D were not qualified for their position when they (DPCS and DPCS D) were hired.During a review of the guidance from the California Hospice & Palliative Care Association titled “Standards of Quality of Hospice Care,” dated 2005, the guidance indicated the following:The Director of Patient Care Services shall qualify for the position by fulfilling the requirements under one of the following categories:A. A Registered Nurse with a baccalaureate or higher degree in nursing or another health-related field with three years of experience within the last five years in a hospice or home health agency, primary care clinic or health facility, at least one year of which was in a supervisory or administrative capacity.B. A Registered Nurse with four years’ experience within the last five years in a hospice, home health agency, primary care clinic or health facility, at least one year of which was in a supervisory or administrative capacity.[Source: https://www.calhospice.org/assets/docs/Standards_of_Quality.pdf]  3. During a review of the HA’s personnel files, the records indicated that the HA hired the medical director on 11/1/2022.During a review of the HA’s medical director’s job description, the job description indicated that the medical director must have experience in hospice and palliative care and/or training in end-of-life before employment.During an interview on 8/22/2025 at 10 a.m., the medical director (MD) stated that he was a general surgeon with no hospice experience before his employment at the hospice agency.  The medical director stated “it was not required” to have experience in hospice or palliative care or meet the minimum applicable training requirements in end-of-life care as determined by hospice policies and/or position description.During a review of the guidance from the California Hospice & Palliative Care Association titled “Standards of Quality of Hospice Care,” dated 2005, the guidance indicated the following:A. The medical director shall have experience in hospice or palliative care or meet the minimum applicable training requirements in end-of-life care as determined by hospice policies and/or position description.B. The responsibilities of the medical director, consistent with the organizational plan and structure of the program, shall include but are not limited to:      i.  Reviewing necessary data from the referral source to validate the diagnosis and life-limiting prognosis established by the attending physician.     ii. Reviewing the clinical record and/or performing a medical examination to confirm the appropriateness of services.[Source: https://www.calhospice.org/assets/docs/Standards_of_Quality.pdf] 4. During a review of Patient 1’s admission record, the record indicated that the facility admitted Patient 1 on 4/1/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (chest pain caused by a blockage in the coronary arteries due to the buildup of plaque from cholesterol, fat, and other substances). a. During a review of Patient 1’s Comprehensive Nursing Assessment, dated 4/1/2025, the Comprehensive Nursing Assessment indicated Patient 1 had a terminal diagnosis (a disease that cannot be cured or adequately treated and is expected to result in the death of the patient) of heart disease and was dependent on assistance for two or more activities of daily living (ADLs, including ambulation, continence, transfer, dressing, feeding). The Comprehensive Nursing Assessment indicated Patient 1 met the criteria for New York Heart Association (NYHA) functional classification (medical standard for categorizing the severity of heart failure) for Class IV congestive heart failure (Class IV CHF, severely advanced stage when a patient experiences symptoms of breathlessness, fatigue, and heart failure indicators even when at rest, and experiences severe discomfort with any level of physical activity).  During a review of Patient 1’s Physician’s Certification for Terminal Illness (CTI) form, dated 4/1/2025, the medical director indicated that Patient 1 was appropriate for hospice/palliative care and met the criteria for Local Coverage Determination (LCD) eligibility (criteria a patient must meet to be deemed eligible for hospice care).   During a review of Patient 1’s LCD Hospice Eligibility Determination, dated 4/1/2025, the LCD indicated Patient 1 met the criteria for NYHA functional classification.   During an interview and a concurrent review of Patient 1’s medical records on 8/22/2025 at 1:25 p.m. with the DPCS D, the DPCSD stated there was no documented evidence that any clinical records were reviewed to support Patient 1’s LCD Hospice Eligibility Determination and justify Patient 1’s eligibility for hospice.  During an interview on 8/28/2025 at 1:43 p.m. with DPCSD, Patient 1 stated a social worker from medical office recommended hospice to her, but she (Patient 1) was not informed that hospice was for patients who have six (6) months or less to live. Patient 1 also stated she was “always sick” but not dying within six months.   b. During a review of Patient 6’s admission record, the record indicated that the facility admitted Patient 6 on 4/25/2025 with a diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. During a review of Patient 6’s Comprehensive Nursing Assessment, dated 4/25/2025, the Comprehensive Nursing Assessment indicated Patient 6 had a terminal diagnosis of heart disease and was dependent on assistance for two or more ADLs. The Comprehensive Nursing Assessment indicated Patient 6 met the criteria for NYHA Class IV CHF. During a review of Patient 6’s Physician’s CTI form, dated 4/25/2025, the medical director indicated that Patient 6 was appropriate for hospice/palliative care and met the criteria for LCD eligibility. During a review of Patient 6’s LCD Hospice Eligibility Determination, dated 4/25/2025, the LCD indicated Patient 6 met the criteria for NYHA functional classification.   During an interview and a concurrent review of Patient 6’s medical records on 8/22/2025 at 1:25 p.m. with the DPCS, the DPCSD stated there was no documented evidence that any clinical records were reviewed to support Patient 6’s LCD Hospice Eligibility Determination and justify Patient 6’s eligibility for hospice.  During an observation and a concurrent interview on 8/28/2025 at 12:35 p.m. with DPCSD, Patient 6 was observed dressed, alert, well-groomed and ambulated independently in the kitchen/dining area of his residence.  Patient 6 stated someone recommended hospice to him but did not inform him that hospice was for those who have six (6) months or less to live.   During a telephone interview and a concurrent record review on 8/29/2025, at 9:30 a.m., the DPCSD stated that the hospice agency admitted the patient on 4/25/2025 with a terminal diagnosis of atherosclerotic heart disease and a functional capacity of NYHA Class IV.  The DPCSD stated that she did not explain to the patients (in general) that being in hospice means that the patient has a terminal diagnosis with a life expectancy of six (6) months or less.  The DPCSD stated that she observed Patient 6 ambulating in his residence without any shortness of breath (SOB). c. During a review of Patient 10’s admission record, the record indicated that the facility admitted Patient 10 on 3/1/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with angina pectoris. During a review of Patient 10’s Comprehensive Nursing Assessment, dated 3/1/2025, the Comprehensive Nursing Assessment indicated Patient 10 had a terminal diagnosis of heart disease and was dependent on assistance for two or more ADLs. The Comprehensive Nursing Assessment indicated Patient 10 met the criteria for NYHA Class IV CHF. During a review of Patient 10’s Physician’s CTI form, dated 3/1/2025, the medical director determined Patient 10 was “exhibiting imminent signs of death within six months and thus appropriate for hospice care services.” During a review of Patient 10’s LCD Hospice Eligibility Determination, dated 3/1/2025, the LCD indicated Patient 10 met the criteria for NYHA functional classification.  During an interview and a concurrent review of Patient 10’s medical records on 8/26/2025 at 1:04 p.m. with the DPCSD, Patient 10’s nursing assessments, LCD Hospice Eligibility, and primary care physician (PCP) notes were reviewed. The DPCSD stated she conducted and documented Patient 10’s initial comprehensive nursing assessment, dated 3/1/2025, and nursing recertification assessment, dated 5/29/2025. However, the DPCSD was unable to define NYHA Class IV CHF. The DPCSD stated Patient 10 had moderate SOB with activity during nursing assessments. The DPCSD stated there was no documented evidence that any clinical records were reviewed to support Patient 10’s LCD Hospice Eligibility Determination and justify Patient 10’s eligibility for hospice.   During an observation on 8/27/2025 at 11:31 a.m., Patient 10 was observed ambulatory (able to walk), independent with ADLs, and alert and oriented (no impairment in mental processes).   During an interview on 8/27/2025 at 12:02 p.m., Patient 10 stated her caregiver wanted “extra money” and referred her to the HA. Patient 10 stated she was invited to meet with “them (unable to specify name or title)” in a fast-food restaurant to talk about hospice care. Patient 10 stated, “I don’t need hospice care. All I need is someone to make sure I take my seizure medications. I am not dying, but I need the nurse to come and check my blood pressure (force exerted by the blood against the walls of the arteries) and blood sugar. I have been with them for 2 years come October.”  d. During a review of Patient 15’s admission record, the record indicated that the facility admitted Patient 15 on 3/1/2025 with a primary diagnosis of hypertensive heart disease with heart failure (condition wherein prolonged high blood pressure [force exerted by the blood against the walls of the walls of the arteries] damages the heart muscle, leading to impaired pumping function and heart failure). During a review of Patient 15’s Comprehensive Nursing Assessment, dated 3/1/2025, the Comprehensive Nursing Assessment indicated Patient 15 had a terminal diagnosis of heart disease and was dependent on assistance for two or more ADLs. The Comprehensive Nursing Assessment indicated Patient 15 met the criteria for NYHA Class IV CHF.  During a review of Patient 15’s Physician’s CTI form, dated 3/1/2025, the medical director determined Patient 15 “exhibits imminent signs suggestive of imminent death within the next six months, thus qualifying her for hospice care services.” During a review of Patient 15’s LCD Hospice Eligibility Determination, dated 3/1/2025, the LCD indicated Patient 15 met the criteria for NYHA functional classification.   During an interview with the MD on 8/22/2025 at 10:15 a.m., the MD stated he had no hospice experience prior to his HA employment on 11/2022. He also stated that he would sig n patients' Certifications of Terminal Illness (CTI) based on a registered nurse’s patient assessment, and that he did not communicate with patients' primary care providers (PCPs) to discuss the terminal condition or request clinical records if they were not already in the chart. During an interview and a record review of Patient 10’s LCD Hospice Eligibility Determination and PCP notes with the DPCS designee on 8/26/2025 at 1:04 p.m., the DPCS designee stated that she conducted and documented two assessments for Patient 10: an initial comprehensive nursing assessment dated 3/1/2025, and a nursing recertification assessment dated 5/29/2025. During these assessments, Patient 10 was reported to have moderate shortness of breath (SOB) with activity, but the DPCS designee was unable to define NYHA Class IV CHF and stated there was no documented evidence that Patient 10 met the criteria for it. During an interview on 8/29/2025 at 9:13 a.m., Patient 15 stated she did not have a terminal diagnosis of six (6) months or less to live. Patient 15 stated the HA nurses did not explain the hospice care and services and eligibility qualifications to receive hospice care and services. Patient 15’s caregiver stated Patient 15 was alert and oriented, ambulatory, able to feed, groom, and bathe herself.    During an interview and a concurrent review of Patient 15’s medical records on 8/29/2025 at 9:28 a.m. with the DPCSD, the DPCSD stated Patient 15 was alert and oriented, able to ambulate with a cane with mild SOB, and able to feed, groom, and bathe self. However, the DPCSD stated Patient 15’s initial comprehensive nursing assessment, dated 3/1/2025, and nursing recertification assessment, dated 5/29/2025, indicated Patient 15 met the criteria for NYHA Class IV CHF, but there was no documented evidence to support Patient 15’s terminal diagnosis. The DPCSD stated there was no documented evidence that any clinical records were reviewed to support Patient 15’s LCD Hospice Eligibility Determination and justify Patient 15’s eligibility for hospice. The DPCSD stated inaccurate patient assessments would not be valid in determining if a patient (in general) was eligible to receive hospice care and services. During a review of the HA’s undated policy and procedure titled “Admission Criteria and Process,” policy no. 1-009, the policy indicated that once a patient is admitted to service, the organization will be responsible for providing care and services within its financial and service capabilities, mission, and applicable law and regulations.  In instances, where patients do not meet the stated criteria for admission to the program, exceptions will be decided upon by the administrator in consultation with the medical director, upon the request of the referring party and/or the patient.   5. During a review of the HA’s personnel files on 8/26/25 at 11 a.m., the records indicated that the HA hired Chaplain 1 on 11/1/2022 and Chaplain 2 on 6/12/2023.  Chaplain 1 had a pastoral accreditation from a ministry from a foreign country (outside the US) on 5/22/1992 and an ongoing training “Credential of Ministry” certificate on 1/20/25, issued in US. Chaplain 2 had a pastoral accreditation from a ministry from a foreign country (outside the US) on 3/30/1997.  During a review of the HA’s chaplain job description, the job description indicated that the chaplain must come from an accredited seminary or school of theology (BD, MDiv or equivalent theological degree) to ensure the provision of spiritual care services to patients and families/caregivers, either directly or through the coordination of care with other spiritual counselors.During an interview with Chaplain 1 on 8/26/2025 at 11:55 a.m., Chaplain 1 stated that the HA hired him in 4/2022 and that he obtained his Bachelor of Arts in History and Philosophy and Pastoral of Religion from a college from a foreign country (outside of US) on 5/22/1992. Chaplain 1 stated he was not aware of the accreditation process of his post-secondary education from a foreign country (outside of US) to be able to provide spiritual and/or bereavement counseling services to the hospice patients in the US. During a review of the guidance from the California Hospice & Palliative Care Association titled “Standards of Quality of Hospice Care,” dated 2005, the guidance indicated the following:The designated person providing spiritual services shall have the following qualifications:A.    Demonstrated experience and training to support the spiritual needs of the patient and family.B.    Completion of an appropriate orientation and training program.[Source: https://www.calhospice.org/assets/docs/Standards_of_Quality.pdf] 6. During a review of the HA’s personnel files on 8/26/25, at 11 a.m., the records indicated that the HA hired VC 1on 11/1/2024.During a review of the HA’s undated policy and procedure titled “Volunteer Coordinator,” the policy indicated that a volunteer coordinator must have a minimum of two years’ experience. This experience can be in one of two areas: a health care setting with hospice, or as a volunteer coordinator.During an interview with the Volunteer Coordinator (VC 1) on 8/22/2025 at 12 p.m., VC 1 stated that he had no volunteer coordinator experience from previous employment or an online certificate of completion of a volunteer coordinator course. He said he has a full-time business as a concert producer and was just helping the hospice agency with their volunteer services. In addition, VC 1 stated that he does not develop or maintain the training and orientation programs that volunteer coordinators are expected to do.During a review of the guidance from the California Hospice & Palliative Care Association titled “Standards of Quality of Hospice Care,” dated 2005, the guidance indicated the following:A. The person responsible for coordinating volunteers shall exhibit knowledge and understanding of hospice philosophy and can supervise and maintain a volunteer program.B. There shall be a specialized volunteer orientation and training program that is sufficient to meet the needs of the patients and families This program shall include, but not limited to:            i. History, philosophy and structure of the hospice concept.           ii. Volunteers’ roles and responsibilities.          iii. Volunteer program policies.[Source: https://www.calhospice.org/assets/docs/Standards_of_Quality.pdf] 7. During a concurrent observation and interview on 8/19/2025 at 11 a.m. at the proposed new HA location in the city of West Covina, a signage was observed posted at the door entrance indicating the name of the HA. Staff 1 stated that he was in the process of moving the hospice agency’s furniture and office equipment from their “old office (currently approved HA location)” in Glendale to the new location in West Covina.During a review of the HA’s Business License Tax Certificate posted at the proposed new location, the certificate indicated it was issued to the HA on 7/23/2025, with the proposed new address in West Covina. During a review of the HA's CDPH License indicated the license was issued to Padre Pio Hospice with the currently approved HA location address in Glendale.During a virtual video conference with the ADM on 8/27/2025 at 11 a.m., the ADM stated that the HA has not yet received an authorization letter from CDPH to move to another location; however, the HA started moving to the new office in West Covina because the rent in the “old office” had risen significantly.During a review of an undated policy and procedure titled "Change of Location," the policy indicated that the HA would notify all appropriate regulatory bodies in a timely manner regarding any change of the agency's primary location. The agency will ensure continued compliance with all the applicable local, state, and federal regulations during and after the relocation process.  8. During a review of the HA’s license issued by CDPH, the license indicated that it expired on 5/7/2025. The HA sent a check to CDPH for renewal and the renewal receipt was dated 8/19/2025.During a virtual video conference interview with the ADM on 8/27/2025 at 11 a.m., the ADM stated that she failed to renew the license of the hospice agency because she left the country. During a review of the guidance from the California Hospice & Palliative Care Association titled “Standards of Quality of Hospice Care,” dated 2005, the guidance indicated that the license must be issued by the Department permitting the operation of a hospice program as it constitutes the authority to accept patients and to perform the services included within the scope of these regulations and as specified on the license.[Source: https://www.calhospice.org/assets/docs/Standards_of_Quality.pdf]

Based on observation,  interview and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients with six months or less to live), failed to ensure the Condition of Participation (specifies requirements that healthcare organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs), regarding Medical Records was met as follows: --- The hospice agency (HA) failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patient’s clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patient’s pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for four out of 14 sampled patients (Patient 1, Patient 6 , Patient 10 and Patient 16 ).  This deficient practice resulted in Patient 1, Patient 6 , and Patient 10 and Patient 16 , being admitted for hospice care with no documented evidence of patients’ written clinical information was being reviewed and evaluated by the Medical Director and/or physician designee to support their diagnoses of terminal illness. (Refer to L667). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulations for Medical Director , to ensure provision of quality care and services to patients.

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patient’s clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patient’s pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for four of 15 sampled patients (Patient 1, Patient 6 , Patient 10 and Patient 16 ).  This deficient practice resulted in Patient 1, Patient 6 , and Patient 10 and Patient 16 , being admitted for hospice care with no documented evidence of patients’ written clinical information was being reviewed and evaluated by the Medical Director and/or physician designee to support their diagnoses of terminal illness. --- b. During a review of Patient 6’s admission record, the record indicated Patient 6’s start of care (SOC) date was on 4/25/202 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without unspecified angina pectoris (a buildup of fats, cholesterol, and other substances in the arteries of the heart without causing chest pain).During a review of Patient 6’s Comprehensive Nursing Assessment, dated 4/25/2025, the nursing assessment indicated that Patient 6 did not need assistance when performing activities of daily living including ambulation, toileting, dressing, bathing, feeding, and transferring.  The Comprehensive Nursing Assessment indicated Patient 6 met the criteria for New York Heart Association (NYHA) class level 4 (severely advanced stage when a patient experiences symptoms of breathlessness, fatigue, and heart failure indicators even when at rest, and experiences severe discomfort with any level of physical activity). During a review of Patient 6’s Physician’s Certification for Hospice Benefit (CTI) form, dated 4/25/2025 and 7/24/2025, the medical director indicated that Patient 6 was appropriate for hospice/palliative care and met the criteria for Local Coverage Determination (LCD) eligibility (criteria a patient must meet to be deemed eligible for hospice care).  During a review of Patient 6’s LCD Hospice Eligibility Determination, dated 4/25/2025 and 7/22/2025, the LCD indicated that Patient 6 met the criteria for NYHA functional classification. During a review of Patient 6’s medical records, there were no clinical records to justify the patient's eligibility for hospice.During an observation on 8/28/2025 at 12:35 p.m., Patient 6 was observed dressed, alert, well-groomed, and ambulating independently in the kitchen/dining room area of his residence.During a concurrent interview with Patient 6, Patient 6 stated someone recommended hospice to him but was ot informed that hospice os for those who have six (6) months or less to live. During a telephone interview and a concurrent record review on 8/29/2025, at 9:30 a.m., the DPCSD stated that the hospice agency admitted the patient on 4/25/2025 with a terminal diagnosis of atherosclerotic heart disease and a functional capacity of NYHA Class 4.  The DPCSD stated that she does not explain to the patient that being in hospice means that the patient has a terminal diagnosis with a life expectancy of six (6) months or less.  The DPCSD stated that she observed Patient 6 ambulating in the dining area of his residence without shortness of breath during an observation 8/28/2025 at 12:35 p.m.     a. During a review of Patient 1’s admission record, the record indicated the start of care (SOC) date of 4/1/2025 with a primary diagnosis of atherosclerosis heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls). A review of Patient 1's Physician’s Certification for Hospice Benefit, dated  4/1/2025, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During a review of Patient 1’s Comprehensive Nursing Assessment, dated 4/1/2025, the Comprehensive Nursing Assessment indicated Patient 1 had a terminal diagnosis of heart disease and was dependent on assistance for two or more activities of daily living (ADLs, including ambulation, continence, transfer, dressing, feeding). The Comprehensive Nursing Assessment indicated Patient 1 met the criteria for New York Heart Association (NYHA) functional classification (medical standard for categorizing the severity of heart failure) for Class IV congestive heart failure (Class IV CHF, severely advanced stage when a patient experiences symptoms of breathlessness, fatigue, and heart failure indicators even when at rest, and experiences severe discomfort with any level of physical activity).  During a review of Patient 1’s LCD Hospice Eligibility Determination, dated 4/1/2025, the LCD indicated Patient 1 met the criteria for NYHA functional classification.   During an interview on 8/22/2025 at 10:15 AM, the HA Medical Director (MD) stated he had no hospice experience prior to being hired by HA in 11/2022. The HA MD stated he would sign the patients’ Certification of Terminal Illness (CTI) based on the patients’ nursing assessment by the Registered Nurse (RN). The HA MD stated he did not communicate with the patients’ PCP or attending physician to discuss the patients’ terminal condition. The HA MD stated he did not request from the PCP or attending physician or review any clinical records of patients, if missing from the HA health records.  During an interview and a concurrent review of Patient 1’s medical records on 8/22/2025 at 1:25 p.m. with the DPCSD stated there was no documented evidence that any clinical records were reviewed to support Patient 1’s LCD Hospice Eligibility Determination and justify Patient 1’s eligibility for hospice.  During a joint home visit on 8/28/2025, at 1:45 p.m., with the Director of Patient Care Services Designee (DPCSD), Patient 1 was observed sitting on a couch with both legs were swollen.  During an interview on 8/28/2025 at 1:43 p.m. Patient 1 stated a social worker from medical office recommended hospice to her, but she was not informed that hospice was for patients who have six (6) months or less to live. Patient 1 stated she was “always sick” but not dying within six months.    C. During a review of Patient 10’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (artery that supplies blood to the heart muscle) with angina pectoris (chest pain). Patient 10’s admission record indicated Patient 10’s secondary diagnoses included orthopnea (shortness of breath when lying flat), diabetes (chronic disease characterized by high blood sugar levels), seizures, and anxiety disorder (mental disorder characterized by persistent, excessive worry that interferes with daily life).  During a review of Patient 10’s Comprehensive Nursing Assessment, dated 3/1/2025, the Comprehensive Nursing Assessment indicated Patient 10 had a terminal diagnosis of heart disease and was dependent on assistance for two or more ADLs. The Comprehensive Nursing Assessment indicated Patient 10 met the criteria for NYHA Class IV CHF. During a review of Patient 10’s Physician’s CTI form, dated 3/1/2025, the medical director determined Patient 10 was “exhibiting imminent signs of death within six months and thus appropriate for hospice care services.” During a review of Patient 10’s LCD Hospice Eligibility Determination, dated 3/1/2025, the LCD indicated Patient 10 met the criteria for NYHA functional classification.   During an interview and a concurrent review of Patient 10’s medical records on 8/26/2025 at 1:04 p.m. with the DPCSD, Patient 10’s nursing assessments, LCD Hospice Eligibility, and primary care physician (PCP) notes were reviewed. The DPCSD stated she conducted and documented Patient 10’s initial comprehensive nursing assessment, dated 3/1/2025, and nursing recertification assessment, dated 5/29/2025. However, the DPCSD was unable to define NYHA Class IV CHF. The DPCSD stated Patient 10 had moderate SOB with activity during nursing assessments. The DPCSD stated there was no documented evidence that any clinical records were reviewed to support Patient 10’s LCD Hospice Eligibility Determination and justify Patient 10’s eligibility for hospice.  During an observation on 8/27/2025 at 11:31 a.m., Patient 10 was observed ambulatory (able to walk), independent with ADLs, and alert and oriented (no impairment in mental processes).   During an interview on 8/27/2025 at 12:02 p.m., Patient 10 stated her caregiver wanted “extra money” and referred her to the HA. Patient 10 stated she was invited to meet with “them (unable to specify name or title)” in a fast-food restaurant to talk about hospice care. Patient 10 stated, “I don’t need hospice care. All I need is someone to make sure I take my seizure medications. I am not dying, but I need the nurse to come and check my blood pressure (force exerted by the blood against the walls of the arteries) and blood sugar. I have been with them for 2 years come October.”  D. During a review of Patient 15’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of hypertensive heart disease with heart failure (condition wherein prolonged high blood pressure damages the heart muscle, leading to impaired pumping function and heart failure).  During a review of Patient 15’s Comprehensive Nursing Assessment, dated 3/1/2025, the Comprehensive Nursing Assessment indicated Patient 15 had a terminal diagnosis of heart disease and was dependent on assistance for two or more ADLs. The Comprehensive Nursing Assessment indicated Patient 15 met the criteria for NYHA Class IV CHF.  During a review of Patient 15’s Physician’s CTI form, dated 3/1/2025, the medical director determined Patient 15 “exhibits imminent signs suggestive of imminent death within the next six months, thus qualifying her for hospice care services.” During a review of Patient 15’s LCD Hospice Eligibility Determination, dated 3/1/2025, the LCD indicated Patient 15 met the criteria for NYHA functional classification.   During an interview on 8/29/2025 at 9:13 a.m., Patient 15 stated she did not have a terminal diagnosis of six (6) months or less to live. Patient 15 stated the HA nurses did not explain the hospice care and services and eligibility qualifications to receive hospice care and services. Patient 15’s caregiver stated Patient 15 was alert and oriented, ambulatory, able to feed, groom, and bathe herself.   During an interview and a concurrent review of Patient 15’s medical records on 8/29/2025 at 9:28 a.m. with the DPCSD, the DPCSD stated Patient 15 was alert and oriented, able to ambulate with a cane with mild SOB, and able to feed, groom, and bathe self. However, the DPCSD stated Patient 15’s initial comprehensive nursing assessment, dated 3/1/2025, and nursing recertification assessment, dated 5/29/2025, indicated Patient 15 met the criteria for NYHA Class IV CHF, but there was no documented evidence to support Patient 15’s terminal diagnosis. The DPCSD stated there was no documented evidence that any clinical records were reviewed to support Patient 15’s LCD Hospice Eligibility Determination and justify Patient 15’s eligibility for hospice. The DPCSD stated inaccurate patient assessments would not be valid in determining if a patient (in general) was eligible to receive hospice care and services. During a review of HA’s agency policies and procedures (P&P), titled “Admission Criteria and Process,” dated 11/2024, the P&P indicated the HA would admit any patient with a life-limiting illness that meets the admission criteria. The P&P indicated the patient’s life-limiting illness with a life expectancy of six months or less must be determined by utilizing a standard clinical prognosis criteria developed by the fiscal intermediary’s Local Coverage Determinations (LCDs) by the attending physician and hospice medical director. The P&P indicated the patient must desire hospice services and be aware of the diagnosis and prognosis. The P&P indicated the hospice registered nurse must contact the physician for clinical information in writing to certify patient for hospice care.    During a review of the agency’s policy and procedure titled "Admission Criteria and Process", revised November 2022, indicated the agency will admit any patient with a life-limiting illness that meets the admission criteria. The patient’s life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary’s Local Coverage Determination (LCDs). Constant Hospice Care, Inc will admit a patient only on recommendation of the medical director in consultation with, or input from, the patient’s attending physician. During a review of the agency’s policy and procedure titled “Certification of Terminal Illness”, revised November 2022, indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, physician member of the interdisciplinary team and/or the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification.  During a review of the agency’s policy and procedure titled, “Physician Services-Medical Director”, revised November 2022, indicated the hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patient’s medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care, including written certification of terminal illness.    Findings: a. During a review of Patient 1’s admission record, the record indicated the start of care (SOC) date of 4/1/2025 with a primary diagnosis of atherosclerosis heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls). A review of Patient 1's Physician’s Certification for Hospice Benefit, dated  4/1/2025, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During a review of Patient 1’s Comprehensive Nursing Assessment, dated 4/1/2025, the Comprehensive Nursing Assessment indicated Patient 1 had a terminal diagnosis of heart disease and was dependent on assistance for two or more activities of daily living (ADLs, including ambulation, continence, transfer, dressing, feeding). The Comprehensive Nursing Assessment indicated Patient 1 met the criteria for New York Heart Association (NYHA) functional classification (medical standard for categorizing the severity of heart failure) for Class IV congestive heart failure (Class IV CHF, severely advanced stage when a patient experiences symptoms of breathlessness, fatigue, and heart failure indicators even when at rest, and experiences severe discomfort with any level of physical activity).  During a review of Patient 1’s LCD Hospice Eligibility Determination, dated 4/1/2025, the LCD indicated Patient 1 met the criteria for NYHA functional classification.   During an interview on 8/22/2025 at 10:15 AM, the HA Medical Director (MD) stated he had no hospice experience prior to being hired by HA in 11/2022. The HA MD stated he would sign the patients’ Certification of Terminal Illness (CTI) based on the patients’ nursing assessment by the Registered Nurse (RN). The HA MD stated he did not communicate with the patients’ PCP or attending physician to discuss the patients’ terminal condition. The HA MD stated he did not request from the PCP or attending physician or review any clinical records of patients, if missing from the HA health records.  During an interview and a concurrent review of Patient 1’s medical records on 8/22/2025 at 1:25 p.m. with the DPCSD stated there was no documented evidence that any clinical records were reviewed to support Patient 1’s LCD Hospice Eligibility Determination and justify Patient 1’s eligibility for hospice.  During a joint home visit on 8/28/2025, at 1:45 p.m., with the Director of Patient Care Services Designee (DPCSD), Patient 1 was observed sitting on a couch with both legs were swollen.  During an interview on 8/28/2025 at 1:43 p.m. Patient 1 stated a social worker from medical office recommended hospice to her, but she was not informed that hospice was for patients who have six (6) months or less to live. Patient 1 stated she was “always sick” but not dying within six months.   b. During a review of Patient 6’s admission record, the record indicated Patient 6’s start of care (SOC) date was on 4/25/202 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without unspecified angina pectoris (a buildup of fats, cholesterol, and other substances in the arteries of the heart without causing chest pain).During a review of Patient 6’s Comprehensive Nursing Assessment, dated 4/25/2025, the nursing assessment indicated that Patient 6 did not need assistance when performing activities of daily living including ambulation, toileting, dressing, bathing, feeding, and transferring.  The Comprehensive Nursing Assessment indicated Patient 6 met the criteria for New York Heart Association (NYHA) class level 4 (severely advanced stage when a patient experiences symptoms of breathlessness, fatigue, and heart failure indicators even when at rest, and experiences severe discomfort with any level of physical activity). During a review of Patient 6’s Physician’s Certification for Hospice Benefit (CTI) form, dated 4/25/2025 and 7/24/2025, the medical director indicated that Patient 6 was appropriate for hospice/palliative care and met the criteria for Local Coverage Determination (LCD) eligibility (criteria a patient must meet to be deemed eligible for hospice care).  During a review of Patient 6’s LCD Hospice Eligibility Determination, dated 4/25/2025 and 7/22/2025, the LCD indicated that Patient 6 met the criteria for NYHA functional classification. During a review of Patient 6’s medical records, there were no clinical records to justify the patient's eligibility for hospice.During an observation on 8/28/2025 at 12:35 p.m., Patient 6 was observed dressed, alert, well-groomed, and ambulating independently in the kitchen/dining room area of his residence.During a concurrent interview with Patient 6, Patient 6 stated someone recommended hospice to him but was ot informed that hospice os for those who have six (6) months or less to live. During a telephone interview and a concurrent record review on 8/29/2025, at 9:30 a.m., the DPCSD stated that the hospice agency admitted the patient on 4/25/2025 with a terminal diagnosis of atherosclerotic heart disease and a functional capacity of NYHA Class 4.  The DPCSD stated that she does not explain to the patient that being in hospice means that the patient has a terminal diagnosis with a life expectancy of six (6) months or less.  The DPCSD stated that she observed Patient 6 ambulating in the dining area of his residence without shortness of breath during an observation 8/28/2025 at 12:35 p.m. C. During a review of Patient 10’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (artery that supplies blood to the heart muscle) with angina pectoris (chest pain). Patient 10’s admission record indicated Patient 10’s secondary diagnoses included orthopnea (shortness of breath when lying flat), diabetes (chronic disease characterized by high blood sugar levels), seizures, and anxiety disorder (mental disorder characterized by persistent, excessive worry that interferes with daily life).  During a review of Patient 10’s Comprehensive Nursing Assessment, dated 3/1/2025, the Comprehensive Nursing Assessment indicated Patient 10 had a terminal diagnosis of heart disease and was dependent on assistance for two or more ADLs. The Comprehensive Nursing Assessment indicated Patient 10 met the criteria for NYHA Class IV CHF. During a review of Patient 10’s Physician’s CTI form, dated 3/1/2025, the medical director determined Patient 10 was “exhibiting imminent signs of death within six months and thus appropriate for hospice care services.” During a review of Patient 10’s LCD Hospice Eligibility Determination, dated 3/1/2025, the LCD indicated Patient 10 met the criteria for NYHA functional classification.   During an interview and a concurrent review of Patient 10’s medical records on 8/26/2025 at 1:04 p.m. with the DPCSD, Patient 10’s nursing assessments, LCD Hospice Eligibility, and primary care physician (PCP) notes were reviewed. The DPCSD stated she conducted and documented Patient 10’s initial comprehensive nursing assessment, dated 3/1/2025, and nursing recertification assessment, dated 5/29/2025. However, the DPCSD was unable to define NYHA Class IV CHF. The DPCSD stated Patient 10 had moderate SOB with activity during nursing assessments. The DPCSD stated there was no documented evidence that any clinical records were reviewed to support Patient 10’s LCD Hospice Eligibility Determination and justify Patient 10’s eligibility for hospice.  During an observation on 8/27/2025 at 11:31 a.m., Patient 10 was observed ambulatory (able to walk), independent with ADLs, and alert and oriented (no impairment in mental processes).   During an interview on 8/27/2025 at 12:02 p.m., Patient 10 stated her caregiver wanted “extra money” and referred her to the HA. Patient 10 stated she was invited to meet with “them (unable to specify name or title)” in a fast-food restaurant to talk about hospice care. Patient 10 stated, “I don’t need hospice care. All I need is someone to make sure I take my seizure medications. I am not dying, but I need the nurse to come and check my blood pressure (force exerted by the blood against the walls of the arteries) and blood sugar. I have been with them for 2 years come October.”  D. During a review of Patient 15’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of hypertensive heart disease with heart failure (condition wherein prolonged high blood pressure damages the heart muscle, leading to impaired pumping function and heart failure).  During a review of Patient 15’s Comprehensive Nursing Assessment, dated 3/1/2025, the Comprehensive Nursing Assessment indicated Patient 15 had a terminal diagnosis of heart disease and was dependent on assistance for two or more ADLs. The Comprehensive Nursing Assessment indicated Patient 15 met the criteria for NYHA Class IV CHF.  During a review of Patient 15’s Physician’s CTI form, dated 3/1/2025, the medical director determined Patient 15 “exhibits imminent signs suggestive of imminent death within the next six months, thus qualifying her for hospice care services.” During a review of Patient 15’s LCD Hospice Eligibility Determination, dated 3/1/2025, the LCD indicated Patient 15 met the criteria for NYHA functional classification.   During an interview on 8/29/2025 at 9:13 a.m., Patient 15 stated she did not have a terminal diagnosis of six (6) months or less to live. Patient 15 stated the HA nurses did not explain the hospice care and services and eligibility qualifications to receive hospice care and services. Patient 15’s caregiver stated Patient 15 was alert and oriented, ambulatory, able to feed, groom, and bathe herself.   During an interview and a concurrent review of Patient 15’s medical records on 8/29/2025 at 9:28 a.m. with the DPCSD, the DPCSD stated Patient 15 was alert and oriented, able to ambulate with a cane with mild SOB, and able to feed, groom, and bathe self. However, the DPCSD stated Patient 15’s initial comprehensive nursing assessment, dated 3/1/2025, and nursing recertification assessment, dated 5/29/2025, indicated Patient 15 met the criteria for NYHA Class IV CHF, but there was no documented evidence to support Patient 15’s terminal diagnosis. The DPCSD stated there was no documented evidence that any clinical records were reviewed to support Patient 15’s LCD Hospice Eligibility Determination and justify Patient 15’s eligibility for hospice. The DPCSD stated inaccurate patient assessments would not be valid in determining if a patient (in general) was eligible to receive hospice care and services. During a review of HA’s agency policies and procedures (P&P), titled “Admission Criteria and Process,” dated 11/2024, the P&P indicated the HA would admit any patient with a life-limiting illness that meets the admission criteria. The P&P indicated the patient’s life-limiting illness with a life expectancy of six months or less must be determined by utilizing a standard clinical prognosis criteria developed by the fiscal intermediary’s Local Coverage Determinations (LCDs) by the attending physician and hospice medical director. The P&P indicated the patient must desire hospice services and be aware of the diagnosis and prognosis. The P&P indicated the hospice registered nurse must contact the physician for clinical information in writing to certify patient for hospice care. During a review of the agency’s policy and procedure titled “Certification of Terminal Illness”, revised November 2022, indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, physician member of the interdisciplinary team and/or the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. During a review of the agency’s policy and procedure titled, “Physician Services-Medical Director”, revised November 2022, indicated the hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patient’s medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care, including written certification of terminal illness.

Based on interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have 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: --- 1.The HA failed to ensure complete and accurate clinical records were documented by failing to: a. Ensure the HA included the bereavement plan of care (CP) for three of 15 sampled patients (Patient 12, Patient 13, & Patient 14).  b. Ensure an individualized CP was developed and documented to address the bleeding risks, and seizure diagnosis for five of 15 sampled patients (Patient 10, Patient 11, Patient 12, Patient 13, & Patient 14).c. Ensure the accurate documentation of the Discharge Summary for one of 15 sampled patients (Patient 13). These failures had the potential to cause a decline in the patients’ health due to the possible inconsistent care provided and lack of continuity of care due to incomplete and/or inaccurate clinical information (Refer to L672).  2. The HA failed to ensure the Certificate of Illness (CTI) form was correctly signed and contained accurate clinical information reflecting the current health condition of four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15). This failure had the potential to cause a decline in the patients’ health condition due to not having proper medical oversight and access to needed specialists, medications, and treatments. (Refer to L676)   The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the federal regulations for Clinical Records to ensure accurate and complete documentation of all the hospice care and services provided to the patients.

Based on interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live), failed to ensure complete and accurate clinical records were documented by failing to: 1.Ensure the HA included the bereavement plan of care (CP) for three of 15 sampled patients (Patient 12, Patient 13, & Patient 14).   2. Ensure HA included an individualized CP to address bleeding risks related to the use of aspirin (medication to prevent blood clots) and seizure diagnosis for five of 15 sampled patients (Patient 10, Patient 11, Patient 12, Patient 13, & Patient14). 3. The HA failed to ensure the accurate documentation of the Discharge Summary for one of 15 sampled patients (Patient 13).  These failures had the potential to cause a decline in the patients’ health due to the possible inconsistent care provided and lack of continuity of care due to incomplete and/or inaccurate clinical information. --- Findings: 1. During a review of Patient 12’s admission record, the record indicated Patient 12’s start of care (SOC) date of 3/1/2025 and end of care (EOC) date of 4/19/2025. The record indicated Patient 12’s primary diagnosis of hypertensive heart disease (HHD, heart problem due to the constant high force against the artery walls, making the heart work harder and affecting its ability to pump blood effectively) with heart failure (HF). During a review of Patient 13’s admission record, the record indicated Patient 13’s SOC date of 3/1/2025 and EOC date of 4/22/2025. The record indicated Patient 13’s primary diagnosis of HHD with HF. During a review of Patient 14’s admission record, the record indicated Patient 14’s SOC date of 4/15/2025 and EOC date of 6/16/2025. The record indicated Patient 14’s primary diagnosis of HHD with HF. During an interview and a concurrent review of the medical records on 8/26/2025 at 11:55 a.m. with Chaplain 1, the CPs of Patient 12, Patient 13, & Patient 14 were reviewed. Chaplain 1 stated there was no documented evidence that an initial bereavement assessment was conducted and bereavement plan of care developed for Patient 12, Patient 13, and Patient 14.  During a review of the HA’s P&P, titled “Contents of Clinical Record,” dated 4/2020, P&P indicated the documentation of the bereavement plan of care, including services being provided, must be maintained in the clinical records of each patient receiving hospice care and services.  2. A. During a review of Patient 11’s admission record, the record indicated Patient 11’s SOC date of 1/22/2025 and EOC date of 2/27/2025. The record indicated Patient 11’s primary diagnosis was HHD with HF.During a review of Patient 11’s medical form, titled “Current Treatment/Medication/DME List,” the medical form indicated a physician’s order with order date 2/26/2025 for Aspirin 81 milligrams  (mg, unit of measurement)1 tab once a day. During a review of Patient 12’s admission record, the record indicated Patient 12’s SOC date of 3/1/2025 and EOC date of 4/19/2025. The record indicated Patient 12’s primary diagnosis of HHD with HF. During a review of Patient 12’s medical form, titled “Current Treatment/Medication/DME List,” the medical form indicated a physician’s order with order date 3/1/2025 for Aspirin 81 mg 1 tab once a day. During a review of Patient 14’s admission record, the record indicated Patient 14’s SOC date of 4/15/2025 and EOC date of 6/16/2025. The record indicated Patient 14’s primary diagnosis of HHD with HF. During a review of Patient 14’s medical form, titled “Current Treatment/Medication/DME List,” the medical form indicated a physician’s order with order date 4/15/2025 for Aspirin 81 mg enteric-coated tablet 1 tab once a day.  B. During a review of Patient 10’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (artery that supplies blood to the heart muscle) with angina pectoris (chest pain). Patient 10’s admission record indicated Patient 10’s secondary diagnoses included seizures and anxiety disorder (mental disorder characterized by persistent, excessive worry that interferes with daily life).   During a review of Patient 10’s medical form, titled “Current Treatment/Medication/DME List,” the medical form indicated a physician’s order with order date 7/16/2025 for Levetiracetam (medication to treat seizures) 750 mg 1 tablet orally twice a day for seizures. During an interview and a concurrent review of the patients’ medical records on 8/26/2025 at 1:04 p.m. with the Director of Patient Care Services Designee (DPCSD), the CPs for Patient 11, 12, 14, & 10 were reviewed. The DPCSD stated there was no documented evidence that an individualized CP was developed and implemented to address the bleeding risks of Patient 11, Patient 12, and Patient 14 related to the use of aspirin or other anticoagulants (medications that stop the blood from clotting too easily) because they are at a higher risk for bleeding. The DPCSD stated there was no documented evidence that an individualized CP was developed and implemented to address Patient 10’s seizure diagnosis to ensure safety and proper management of the condition. During a review of the HA’s P&P, titled “Contents of Clinical Record,” dated 4/2020, P&P indicated the documentation of the plan of care developed/revised by the interdisciplinary group based on comprehensive assessments and desired outcomes with time frames, attitudes and response of the patient and family/caregiver to the plan of care and services provided, progress towards goals/outcomes of care, and outcome measure data elements, must be maintained in the clinical records of each patient receiving hospice care and services.  3.  During a review of Patient 13’s admission record, the record indicated Patient 13’s SOC date of 3/1/2025 and EOC date of 4/22/2025. The record indicated Patient 13’s primary diagnosis of HHD with HF. During an interview and a concurrent review of Patient 13’s Discharge Summary, dated 4/22/2025, on 8/26/2025 at 1:04 p.m. with the DPCSD, the DPCSD stated the RN erroneously documented that Patient 13 was discharged from a different hospice agency. The DPCSD stated it was important to ensure correct documentation, including discharge information to ensure proper transition process for the discharged patient. During a review of the HA’s P&P, titled “Contents of Clinical Record,” dated 4/2020, the P&P indicated the documentation of the discharge summary must be maintained in the clinical records of each patient receiving hospice care and services. The P&P indicated the clinical record must facilitate continuity of care among hospice interdisciplinary group members and contract personnel. The P&P indicated each entry must be dated and signed, including title and credentials, by the person providing care/service.

Based on observation, interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the Certificate of Illness (CTI) form was correctly signed and contained accurate clinical information reflecting the current health condition of four of 15 sampled patients (Patient 1, Patient 6, Patient 10, & Patient 15).This failure had the potential to cause a decline in the patients’ health condition due to not having proper medical oversight and access to needed specialists, medications, and treatments. --- Findings: A. During a review of Patient 1’s admission record, the record indicated the start of care (SOC) date of 4/1/2025 with a primary diagnosis of atherosclerosis heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls).   During a review of Patient 1’s Physician’s Certification for Terminal Illness (CTI) form, dated 4/1/2025, the medical director indicated that Patient 1 was appropriate for hospice/palliative care and met the criteria for Local Coverage Determination (LCD) eligibility (criteria a patient must meet to be deemed eligible for hospice care).    During an interview and a concurrent review of Patient 1’s medical records on 8/22/2025 at 1:25 p.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated there was no documented evidence of any clinical records to support Patient 1’s LCD Hospice Eligibility Determination and justify Patient 1’s eligibility for hospice.    During a concurrent interview of Patient 1 on 8/28/2025 at 1:43 p.m. while on a joint home visit with DPCSD, Patient 1 stated a social worker from medical office recommended hospice to her but was she was not informed that hospice was for patients who have six (6) months or less to live. Patient 1 also stated she was “always sick” but not dying within six months.     B.  During a review of Patient 6’s admission record, the record indicated the SOC date of 4/25/2025 with a primary diagnosis of atherosclerosis heart disease.  During a review of Patient 6’s Physician’s CTI form, dated 4/25/2025, the medical director indicated that Patient 6 was appropriate for hospice/palliative care and met the criteria for LCD eligibility.  During an interview and a concurrent review of Patient 6’s medical records on 8/22/2025 at 1:25 p.m. with the DPCS, the DPCSD stated there was no documented evidence of any clinical records to support Patient 6’s LCD Hospice Eligibility Determination and justify Patient 6’s eligibility for hospice.    During an observation and a concurrent interview on 8/28/2025 at 12:35 p.m. while on a joint home visit with DPCSD, Patient 6 was observed dressed, alert, well-groomed and ambulated independently in the kitchen/dining area of his residence.  Patient 6 stated someone recommended hospice to him but did not inform him that hospice was for those who have six (6) months or less to live.    During a telephone interview and a concurrent record review on 8/29/2025, at 9:30 a.m., the DPCSD stated that the hospice agency admitted the Patient 6 on 4/25/2025 with a terminal diagnosis of atherosclerotic heart disease and a functional capacity of NYHA Class IV.  The DPCSD stated that she observed Patient 6 ambulating in his residence without any shortness of breath (SOB).   C.  During a review of Patient 10’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (artery that supplies blood to the heart muscle) with angina pectoris (chest pain). Patient 10’s admission record indicated Patient 10’s secondary diagnoses included orthopnea (shortness of breath when lying flat), diabetes (chronic disease characterized by high blood sugar levels), seizures, and anxiety disorder (mental disorder characterized by persistent, excessive worry that interferes with daily life).   During a review of Patient 10’s Physician’s CTI form, dated 3/1/2025, the medical director determined Patient 10 was “exhibiting imminent signs of death within six months and thus appropriate for hospice care services.”   During an interview and a concurrent review of Patient 10’s medical records on 8/26/2025 at 1:04 p.m. with the DPCSD, the DPCSD stated there was no documented evidence of any clinical records to support Patient 10’s LCD Hospice Eligibility Determination and justify Patient 10’s eligibility for hospice.    During an observation on 8/27/2025 at 11:31 a.m. while on a joint home visit with DPCSD, Patient 10 was observed ambulatory (able to walk), independent with ADLs, and alert and oriented (no impairment in mental processes).     During an interview on 8/27/2025 at 12:02 p.m., Patient 10 stated her caregiver wanted “extra money” and referred her to the HA. Patient 10 stated she was invited to meet with “them (unable to specify name or title)” in a fast-food restaurant to talk about hospice care. Patient 10 stated, “I don’t need hospice care. All I need is someone to make sure I take my seizure medications. I am not dying, but I need the nurse to come and check my blood pressure (force exerted by the blood against the walls of the arteries) and blood sugar. I have been with them for two years come October.”    D. During a review of Patient 15’s admission record, the record indicated the SOC date of 3/1/2025 with a primary diagnosis of hypertensive heart disease with heart failure (condition wherein prolonged high blood pressure damages the heart muscle, leading to impaired pumping function and heart failure).     During a review of Patient 15’s Physician’s CTI form, dated 3/1/2025, the medical director determined Patient 15 “exhibits imminent signs suggestive of imminent death within the next six months, thus qualifying her for hospice care services.”    During an interview on 8/22/2025 at 10:15 AM, the HA MD stated he was not the primary care provider (PCP) or attending physician of Patient 1, Patient 6, Patient 10, and Patient 15. The HA MD stated he would sign the patients’ Certification of Terminal Illness (CTI) based on the patients’ nursing assessment by the Registered Nurse (RN). The HA MD stated he did not communicate with the patients’ PCP or attending physician to discuss the patients’ terminal condition or to have the PCP sign as the referring physician. The HA MD stated he did not request from the PCP or attending physician or review any clinical records of patients, if missing from the HA health records.   During an interview on 8/29/2025 at 9:13 a.m., Patient 15 stated she did not have a terminal diagnosis of six (6) months or less to live. Patient 15 stated the HA nurses did not explain the hospice care and services and eligibility qualifications to receive hospice care and services. Patient 15’s caregiver stated Patient 15 was alert and oriented, ambulatory, able to feed, groom, and bathe herself.     During an interview and a concurrent review of Patient 15’s medical records on 8/29/2025 at 9:28 a.m. with the DPCSD, the DPCSD stated there was no documented evidence to support Patient 15’s terminal diagnosis. The DPCSD stated there was no documented evidence of any clinical records to support Patient 15’s LCD Hospice Eligibility Determination and justify Patient 15’s eligibility for hospice.  The DPCSD stated that she did not explain to the patients (in general) that being in hospice means that the patient has a terminal diagnosis with a life expectancy of six (6) months or less.  The DPCSD stated inaccurate patient assessments would not be valid in determining if a patient (in general) was eligible to receive hospice care and services.  During a review of HA’s agency policy and procedures (P&P 1), titled “Contents of Clinical Record,” dated 4/2020, P&P 1 indicated the following:1. The clinical record must contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, and facilitate continuity of care.2. The following information must be available in the clinical record as applicable to care and services provided: a) source of referral, b) substantiation of the terminal diagnosis and criteria for admission, c) certification and recertification of terminal illness including physician narrative and face-to-face encounters as needed, and d) physician review of medications and plan of care oversight including justification for recertification, summary of care and coordination of care provided in other settings, when indicated.During a review of HA’s agency policy and procedures (P&P 2), titled “Certification of Terminal Illness (CTI),” dated 4/2020, P&P 2 indicated the following:1. At the time a patient and family/caregiver chooses hospice care, the HA MD and the patient’s attending physician, if any, must certify the patient’s terminal illness.2. Both the patient’s PCP or attending physician and the HA MD must sign and date the CTI and authorization for hospice services forms. The CTI form must be completed no more than 15 calendar days prior to the effective date of the hospice election.3. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification.

Based on interviews and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for FEDERAL, STATE, LOCAL LAWS & REGULATIONS was met as follows. --- The Hospice Agency (HA) failed to ensure that the agency's State license were valid and not expired to continue to furnish care and services to their patients. The HA's  active patients were 4. This deficient practice had the potential for the HA's patients not to received care and services and applicable with licensing requirements. (Refer to L799). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulations for Federal, State, Local Laws and Regulations , to ensure provision of quality care and services to patients.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the agency's State license were valid and not expired to continue to furnish care and services to their patients. The HHA active patients were 4.  This deficient practice had the potential for the HA's patients not to received care and services and applicable with licensing requirements. --- Findings:On On 8/20/25, at 11 a.m., a re-certification survey (a regulatory inspection of a healthcare facility to ensure it maintains compliance with federal and state standards for providing quality and safe patient care), was conducted at this agency.  During a review of the HHA's Active Patient Roster dated 8/21/2025, indicated there were 4 active patients under the agency's patient care services.  During a review of the HHA's State license indicated their license expired on 7/12/2025.  During a review of the HA's licensing documents indicated the HHA 's State license had expired, and the agency have not submitted a renewal application to CAB (Centralized Applications Branch, is primarily responsible for processing licensing and certification applications for health care facilities and providers).  During an interview on 5/22/2024 at 2:15 p.m., with the agency’s Human Resources Manager (RSM), RSM stated she was going to check with the Administrator (ADM) regarding the status of the agency’s State License renewal. The RSM showed a copy of check sent to CDPH for renewal and the renewal receipt was dated 8/19/2025 During a virtual video conference interview with the ADM on 8/27/2025 at 11 a.m., the ADM stated that she failed to renew the license of the hospice agency because she left the country. During a review of the guidance from the California Hospice & Palliative Care Association titled “Standards of Quality of Hospice Care,” dated 2005, the guidance indicated that the license must be issued by the Department permitting the operation of a hospice program as it constitutes the authority to accept patients and to perform the services included within the scope of these regulations and as specified on the license..

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon observation, there was no evidence the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. Patients 1-5: Upon review of IDG documentation for dates 4/16/25, 4/30/25 and 5/14/25: All 5 patient records contained the EXACT nursing contribution for all IDG dates (this was a visit narrative and even included documentation of a "blood sugar of 225"). The 5/14/25 IDG was signed only by the RN and no other discipline contributions documented.

Upon patient record review, 5 of 5 (Patient #1-5) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patients 1-5: Upon review of IDG documentation for dates 4/16/25, 4/30/25 and 5/14/25: All 5 patient records contained the EXACT nursing contribution for all IDG dates (this was a visit narrative and even included documentation of a "blood sugar of 225").

Upon client record review, 5 of 5 (Patient #1-5) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patients 1-5: Upon review of IDG documentation for dates 4/16/25, 4/30/25 and 5/14/25: All 5 patient records contained the EXACT nursing contribution for all IDG dates (this was a visit narrative and even included documentation of a "blood sugar of 225"). The 5/14/25 IDG was signed only by the RN and no other discipline contributions documented.

Upon client record review, 5 of 5 (Patient #1-5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Orders state RN weekly, SW and SC 1 per month. Plan of Care visit frequencies as follows: RN 2 every 2weeks, LVN 2 every week, CHHA 1per week, SC 2 per month, SW 2 per month. Actual visit frequencies documented as follows: RN 1 per week, LVN no visit documented, SW 1 per month, SC 2 per month. Patient 2: Orders state RN weekly, SW Declined. Plan of Care visit frequencies as follows: RN 2 every week, SW 2 per month. Actual visit frequencies documented as follows: ,RN 1 weekly, SW no visit. Patient 3: Orders state RN weekly, SW and SC 1 per month. Plan of Care visit frequencies as follows: RN 1 per month, CHHA 1per week, SC 1 per month, SW 1 per month. Actual visit frequencies documented as follows: RN 1 per week, , SW initial comprehensive visit 3/5/25 with narrative stating "will assess next recertification period" with no further visits. Patient 4: Orders state RN weekly,SW and SC 1 per month and 2 PRN. Plan of Care visit frequencies as follows: RN 2 per week, SC 2 per month and 2 PRN, SW 2 per month. Actual visit frequencies documented as follows: RN 1 per week, SW initial visit 3/4/25 with narrative stating, SW will do visits as needed", SC initial 3/4/25, PRN visit 3/11/25, scheduled visits 4/4/25 and 4/18/25 no evidence of any further visits. Patient 5: Orders and Plan of Care state MSW 1 per month. Actual visits documented shows a Recert Assessment by MSW on 2/2/0/25 with a narrative stating, "will see next recert.". (Recert period #3 began 5/23/25)

Upon patient record review 1 of 5 (Patient #4) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #4: During Home Visit, patient and nurse were discussing financial and medical insurance concerns. The RN was nodding head and this seemed to be a familiar discussion, as the nurse initiated this discussion by asking patient about the progress of her upcoming knee surgery. Patient stating that she was unable to pay rent and had to borrow money from her "caregiver". Stated she didn't understand her medical coverages and was not sure if she has "Medicare or Medi-Cal...or both" and that her plan for knee surgery has been changed due to her current insurance. The Plan of Care orders are for a Social Work visit "2 per month and 2 PRN". The medical record showed evidence of an Initial MSW visit on 3/4/25 with a narrative note stating, "SW will do visits as needed." There was no update in the plan of care with order frequency changed. No documentation of any further MSW contact or visits.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Home visit observation revealed appropriate "Bag Technique" by RN during her assessment. However; upon preparing to exit visit, the patient asked nurse to get her some water and the nurse sat her bag on a side table in living room with no barrier. (Education provided to RN whom verbalized complete understanding) During assessment/visit, the nurse washed hands, used hand sanitizer and gloves appropriately and did perform a Glucose finger stick with the patients own Glucometer and Lancet device provided in the patient's own case for the device.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 3 of 8 (Personnel #4,7,8 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(B) Sponge bath ·(C) Shampoo, sink, tub, and bed The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #4,7,8 competency did not include "Sponge Bath" and "Shampoo Sink, shampoo Bed, Shampoo tub" only "Shampoo". The agency had recently performed competency on 4,7,8 per last survey recommendation and Plan of Correction, however they did not add the required additional items.

Upon patient record review 3 of 5 (Patient #1,3,4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patients 1,3,4 have evidence of aide plan of care/ assignments that all show a visit frequency of 1 per week. The aide is visiting 2 times per week per the actual physician order.

Upon patient record review 4 of 5 (Patient #1,2,3,4) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patients 1,3,4 have evidence of aide plan of care/ assignments that all show a visit frequency of 1 per week. The aide is visiting 2 times per week per the actual physician order. There is evidence of Supervisory visits by the RN timely, however; the supervisory note documents the aide visit frequency is 1 time per week. The actual frequency is 2 per week. Patient 2 declined aide visits, however; the RN is performing Supervisory visits every visit complete with the full name of a aide and all areas assessed, however the frequency area states "Declined".

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There is a lack of evidence of oversight by Administrator and/or governing body of ensuring Administrator designee has appropriate HR documentation and patient care being provided meets patient needs. Personnel #2 had a signed job description for "Administrator". Education provided to HR Director whom is working on making changes for adding "Designee" and will have the Designee one signed. Orientation to role 03/03/25 and competencies dated 3/3/25 and again 4/28/25.

Condition of Participation: Patient’s Rights. L500

Upon observation, there was no evidence that the patient has the right: • To exercise his or her rights as a patient of the hospice • Have one's property and person treated with respect • To not be subjected to discrimination or reprisal for exercising his or her rights Unable to abate without patient visit.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon observation, there was no evidence the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. Patient #1: 3/27/25 IDG has RN note and sign only. No MSW, not actively participating in care. Patient #2: 3/27/25 IDG has RN note and sign only. No MSW, not actively participating in care.. Patient #5: IDG meeting notes 3/1, 3/15, 3/25/25 have RN signature only. No MSW, not actively participating in care. 4/10/25 IDG meeting notes have a notation for spiritual, but no signature of any disciplines MSW, not actively participating in care.

Upon client record review, 5 of 5 (Patient #1, 2, 3, 4, 5) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days Patient #1: SOC 3/27/25. 3/27/25 IDG has RN note and signature only. No SC, No MD, who are actively participating in care. Patient #2: SOC 3/27/25/27/25 IDG has RN note and signature only. No SC, No MD, who are actively participating in care. Patient #3: SOC 3/01/25 3/26/25 IDG note set up, but is totally blank with no notes or signatures to validate review/participation of RN, MSW, SC, MD, who are actively participating in care. Patient #4: SOC 3/01/25 IDG meeting notes 3/1, 3/15, 3/25 have RN signature only. No MSW, SC, MD, who are actively participating in care. 4/10/25 IDG meeting notes have a notation for spiritual, but no signature of any disciplines RN, MSW, SC, MD, who are actively participating in care.. Patient #5: SOC 3/01/25 IDG meeting notes 3/1, 3/15, 3/25 have RN signature only. No SC, MD. 4/10/25 IDG meeting notes have a notation for spiritual, but no signature of any disciplines RN, SC, MD,who are actively participating in care.

Upon client record review, 2 of 5 (Patient #1,2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: SOC 3/27/25. Only SN visit documented since 3/27/25 assessment is 4/4/25 however, the note is incomplete without narrative or signature. Orders were for SN 2/wk. Patient #2: SOC 3/27/25. Only SN visit documented since 3/27/25 assessment is 4/4/25 however, the note is incomplete without narrative or signature. Orders were for SN 2/wk.

Upon patient record review 2 of 5 (Patient #2,#5) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #2: RN comprehensive assessment notes that MSW visit is needed. There was no MSW visit made/documented and no documentation of contact or that patient declined. Patient #5: 3/6/25 communication note visiting staff called to request a walker. There was no documented evidence that the walker was obtained/provided.

Upon observation, there was no evidence the hospice maintains and documents an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases. Surveyor is unable to abate without patient visit for direct observation, that was time prohibitive related to distance and reportedly no other patients accepting of visit. The agency did present repeated competency demonstration for applicable personnel, in regards to fingersticks/glucometer related procedures and universal precautions. There was no evidence of updates to policies and procedures or performance improvement upon requests.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Surveyor is unable to abate without patient visit for direct observation, that was time prohibitive related to distance and reportedly no other patients accepting of visit. The agency did present repeated competency demonstration for applicable personnel, in regards to fingersticks/glucometer related procedures and universal precautions. There was no evidence of updates to policies and procedures or performance improvement upon requests.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 2 of 5 (Personnel #2,3 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #2,3: Competency form utilized by agency does not specify all types of shampoo, but generalizes shampoo.

Upon patient record review, 2 of 5 (Patient #1,4) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: Hospice Aide assignment sheet has frequency 1/week and physician order/plan of care has hospice aide 2/wk. Provided 2/wk. Patient #4: Hospice Aide assignment sheet has frequency of 1/wk. Physician order 2/wk and provided 2/wk. Hospice Aide assignment sheet is not authenticated with signature/credentials.

Upon patient record review 3 of 5 (Patient #3,4,5) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patients #3,5: There are no documented supervisory notes. Patient #4: There is no supervisory note documented since 3/15/25.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. Upon observation, there is confusion regarding leadership roles/titles amidst changes in the roles. No job descriptions for Alternate Admin, RN, or volunteer along with records being kept in neighboring office that does not contain hospice license but rather another agency on the wall therefore no human resource management. There continues to be evidence of ongoing deficient practices in the medical records.

Upon personnel record review, 2 of 6 (Personnel #4, 5, 6 ) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #4, 5, 6: There is no signed/dated job descriptions.

Upon personnel record review, 3 of 6 (Personnel #4, 5, 6 ) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #4, 5, 6: There is no competency for the Alt Administrator, Volunteer, DPCS.

Upon patient client record review, 4 of 5 (Patient #1, 3, 4, 5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: SOC 3/27/25. RN referenced patient on Glipizide in comprehensive narrative, but patient is on Metformin and Jardiance. Patient #3: SOC 3/1/25. Nurses notes March 7, 14, 21, 28 and April 4, 2025 are incomplete and are not authenticated with signatures. Patient #4: SOC 3/1/25. SN notes are incomplete and no narrative or signature: 3/22, 3/28, 4/4/25. 4/6/25 hospice aide note is blank except for time. Patient #5: SOC 3/1/25. SN notes are incomplete with no narrative or signature: 3/7, 3/15, 3/22, 3/28/25.

Upon observation, there was no evidence the organizational chart matches the hospice's information submitted to CMS and/or State licensing agencies for ownership and management personnel. Agency reports change in leadership staff including Administrator and Alt Administrator effective March 1, 2025. There is no evidence that the agency has reported to CDPH or CMS at the time of survey

Condition of Participation: Patient’s Rights. L500

Upon home visit review, there was no evidence that the patient has the right: • To exercise his or her rights as a patient of the hospice • Have one's property and person treated with respect • To not be subjected to discrimination or reprisal for exercising his or her rights Patients #1 and 2 stated they were not aware of their right to choose their physician.

Upon patient record review, 6 of 14 (Patients #1, 2, 3, 4, 6, 7) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #1: Upon admission, the RN noted that the patients self identified pain threshold was a 2. The patient rated the pain at level 7. The nurse documented, "not observed to be in discomfort" No call to physician. No changes in medications. At all subsequent RN visits patient rated his pain between a level 4 and level 7 with a self identified pain threshold of 2. In all RN visits it is documented, "not observed to be in discomfort". There was no communication to physician, no change in orders, and no change in plan of care. IDG's state "pain is currently managed by prescribed pain medications." Patient #2: Upon admission, the RN noted that the patient's self identified pain threshold was a 2. The patient rated her pain as a level 7 out of 10. The nurse documented, "not observed to be in discomfort" No call to physician. No changes in medications. During RN visits on 10/24/24, 10/31/24, 11/28/24, 12/2/24, 12/12/24, 12/17/24, 12/26/24, the patient rated pain at level 5 or above. The nurse documented, "not observed to be in discomfort" No call to physician. No changes in medications. No changes to POC. On 1/13/25, the nurse documents that the patient rated pain at level 5 and showed facial grimacing and guarding, though the nurse also documented, "not observed to be in discomfort". No call to physician. No changes in medications. This continued on RN visits on 01/20/25, 01/30/25, 02/05/25, 02/15/25, 02/25/25. Patient #3: Patient admitted 10/16/24. The patient stated pain was 6 and self identified threshold was 2. It was documented that the patient was also having increased BP of 169/116. There was no call to MD and nurse documented "patient not observed to be in pain.", no follow up phone call or visit for 7 days. At subsequent visits on 10/23/24, 11/06/24, 11/14/24, and 01/31/25, patient complained of pain above self identified threshold. The nurse documented during these visits that patient showed guarding and facial grimacing, as well as "patient not observed to be in pain.". No increase in frequency or change to POC occurred at any visit. Patient #4: Patient admitted with heart failure on 11/24/24. On 12/08/24, during nurse visit patient complained of level 7 that got to level 10 radiating down left arm. No call to physician no follow up visit or phone call for 8 days. Patient #6: Pt admitted on 11/04/24 with a level 7 pain and self identified threshold of 2. Pain in back, shoulders, bilateral legs and nurse documented patient had guarding. Nurse documented "patient not observed to be in pain.", no follow up visit or phone call until 11/14/24. During this visit pain level was 8 out of 10. No interventions, no call to physician, nurse documented "patient not observed to be in pain." 11/20/24 patient seen complained of level 7 pain. nurse documented "patient not observed to be in pain." Patient revoked hospice services that same day. Patient #7: Pt. admitted on 04/19/24 with level 10 of 10 pain, no interventions or call to physician, and no follow up for 7 days. Visits on 05/10/24, 05/17/24, 05/24/24, 06/14/24, patient assessed at level 6 and 7 pain with no change in frequency no follow up until next scheduled visit and no call to physician. Nurse continued to document "patient not observed to be in pain."

Upon patient record review, 2 of 14 (Patient #1, 2) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients #1 and 2 stated they were not aware of their right to choose their physician.

Upon patient record review 2 of 14 (Patient #4, 5) did not have evidence in the patient record that the comprehensive assessment identifies 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. Patient #4: There is a spiritual care initial assessment as a part of the comprehensive POC, however, the assessment was blank and the narrative of that visit stated it was not completed due to no one answering the door. Patient #5: The initial spiritual care visit on 10/04/24 is entered, however, there is no content in the visit.

Upon patient record review, 5 of 14 (Patients #3, 7, 8, 9, 10) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #3: Initial bereavement assessment was completed on 10/23/24, 7 days after admission. Patients 7, 8, 9, 10: there was no initial bereavement assessment completed.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 6 of 14 (Patients #1, 2, 3, 4, 6, 7) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #1: The patient was admitted with a level 7 pain on 01/22/25. His self identified threshold was documented as 2. It was documented that "patient not observed to be in pain." No follow up visit or phone call until 1 week later. On 01/29/25, nurse documents "patient complains of sharp bilateral leg pain" His level is documented as 5. Nurse documented "patient not observed to be in pain." No follow up phone call or visit for 1 week. At every subsequent nursing visit, patient complained of pain higher than his self identified threshold, the nurse documented "patient not observed to be in pain." without increasing frequency or changing orders. The POC states "assess any alterations in skin every visit including check size, integrity, location, type/stage, signs and symptoms of infection and any drainage." There was no further assessment of wound after first discovery. The nursing assessments state wound healing. Patient #2: Patient admitted 10/17/24 and was assessed with a level 7 pain. Her self identified threshold was 2. Nurse documented "patient not observed to be in pain." There was no call or visit for 8 days. Subsequently, at visits on 10/24/24, 10/31/24, 11/28/24, 12/2/24, 12/12/24, 12/17/24, 12/26/24, 01/13/25, 01/20/25, 01/30/25, 02/05/25 patient reported pain above self identified threshold. At most visits nurse document facial grimacing and guarding, though nurse documented "patient not observed to be in pain." During home visit on 02/25/25, the patient complained of level "6-7" pain, however told the RN that she had been having level 10 of 10 pain at night that was keeping her up in her shoulders. RN asked if she was doing exercises as that would help. There was no intervention provided, no call to physician, and no orders for change in frequency. Patient #3: Patient admitted 10/16/24. The patient stated pain was 6 and self identified threshold was 2. It was documented that the patient was also having increased BP of 169/116. There was no call to MD and nurse documented "patient not observed to be in pain.", no follow up phone call or visit for 7 days. At subsequent visits on 10/23/24, 11/06/24, 11/14/24, and 01/31/25, patient complained of pain above self identified threshold. The nurse documented during these visits that patient showed guarding and facial grimacing, as well as "patient not observed to be in pain.". No increase in frequency or change to POC occurred at any visit. Patient #4: Patient admitted with heart failure on 11/24/24. On 12/08/24, during nurse visit patient complained of level 7 that got to level 10 radiating down left arm. No call to physician no follow up visit or phone call for 8 days. Patient #6: Pt admitted on 11/04/24 with a level 7 pain and self identified threshold of 2. Pain in back, shoulders, bilateral legs and nurse documented patient had guarding. Nurse documented "patient not observed to be in pain.", no follow up visit or phone call until 11/14/24. During this visit pain level was 8 out of 10. No interventions, no call to physician, nurse documented "patient not observed to be in pain." 11/20/24 patient seen complained of level 7 pain. nurse documented "patient not observed to be in pain." Patient revoked hospice services that same day. Patient #7: Pt. admitted on 04/19/24 with level 10 of 10 pain, no interventions or call to physician, and no follow up for 7 days. Visits on 05/10/24, 05/17/24, 05/24/24, 06/14/24, patient assessed at level 6 and 7 pain with no change in frequency no follow up until next scheduled visit and no call to physician. Nurse continued to document "patient not observed to be in pain."

Upon patient record review, 6 of 14 (Patients #1, 2, 3, 4, 5, 8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: The POC did not include the integumentary system for the wound. The POC did not include interventions and goals for psychosocial for estrangement of patient from daughter or community resources through his Vietnam veteran status. The respiratory POC did not include the smoking status of patient, although it was mentioned in the psychosocial POC. Patient #2: The Respiratory did not include interventions or goals for use of nebulizer. Patient #3: The POC does not include interventions and goals for insomnia and use of melatonin. Patient #5: The POC does not include interventions and goals for GI and use of Senna for constipation. Patient #8: The POC does not include interventions and goals for GI and use of Senna for constipation or use of Pepcid for GERD.

Upon patient record review, 6 of 14 (Patients #1, 2, 3, 4, 6, 7) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient #1: The patient was admitted with a level 7 pain on 01/22/25. His self identified threshold was documented as 2. It was documented that "patient not observed to be in pain." No follow up visit or phone call until 1 week later. On 01/29/25, nurse documents "patient complains of sharp bilateral leg pain" His level is documented as 5. Nurse documented "patient not observed to be in pain." No follow up phone call or visit for 1 week. At every subsequent nursing visit, patient complained of pain higher than his self identified threshold, the nurse documented "patient not observed to be in pain." without increasing frequency or changing orders. Patient #2: Patient admitted 10/17/24 and was assessed with a level 7 pain. Her self identified threshold was 2. Nurse documented "patient not observed to be in pain." There was no call or visit for 8 days. Subsequently, at visits on 10/24/24, 10/31/24, 11/28/24, 12/2/24, 12/12/24, 12/17/24, 12/26/24, 01/13/25, 01/20/25, 01/30/25, 02/05/25 patient reported pain above self identified threshold. At most visits nurse document facial grimacing and guarding, though nurse documented "patient not observed to be in pain." During home visit on 02/25/25, the patient complained of level "6-7" pain, however told the RN that she had been having level 10 of 10 pain at night that was keeping her up in her shoulders. Rn asked if she was doing exercises as that would help that. There was no intervention provided, no call to physician, and no orders for change in frequency. Patient #3: Patient admitted 10/16/24. The patient stated pain was 6 and self identified threshold was 2. It was documented that the pt was also having increased BP of 169/116. There was no call to MD and nurse documented "patient not observed to be in pain." no follow up phone call or visit for 7 days. At subsequent visits on 10/23/24, 11/06/24, 11/14/24, and 01/31/25, patient complained of pain above self identified threshold. The nurse documented during these visits that patient showed guarding and facial grimacing, as well as "patient not observed to be in pain.". No increase in frequency or change to POC occurred at any visit. Patient #4: Patient admitted with heart failure on 11/24/24. On 12/08/24, during nurse visit patient complained of level 7 that got to level 10 radiating down his Left arm. No call to physician no follow up visit or phone call for 8 days. Patient #6: Pt admitted on 11/04/24 with a level 7 pain and self identified threshold of 2. Pain in back, shoulders, bilateral legs and nurse documented pt. had guarding. Nurse documented "patient not observed to be in pain." no follow up visit or phone call until 11/14/24. During this visit pain level was 8 out of 10. No interventions, no call to physician, nurse documented "patient not observed to be in pain." 11/20/24 patient seen complained of level 7 pain. nurse documented "patient not observed to be in pain." Patient revoked hospice services that same day. Patient #7: Pt. admitted on 04/19/24 with level 10 of 10 pain. no interventions or call to physician. no follow up for 7 days. Visits on 05/10/24, 05/17/24, 05/24/24, 06/14/24, patient assessed at level 6 and 7 pain with no change in frequency no follow up until next scheduled visit and no call to physician. Nurse continued to document "patient not observed to be in pain."

Upon patient record review, 1 of 14 (Patient #1) 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: Patient was assessed with a "stage 2 to foot measuring 2x2x2. Clean with normal saline and apply triple antibiotic cream twice daily." The order does not specify which foot the wound is on.

Upon patient record review, 5 of 14 (Patients #1, 2, 4, 5, 9) 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 #1: The patient needs assessment of DME included the needs for oxygen, a cane, and a walker. Upon home visit of patient, they also had a trapeze and egg crate mattress in the home. None of these items were included in the plan of care. Patient #2: The patient needs assessment of DME included the need for a nebulizer and O2. These DME items were not included in the POC. Patient #4: The patient needs assessment of DME included O2 and cane, neither of which were on the POC. Patient #5: The patient needs assessment of DME included O2 which was not on the POC. Patient #9: The patient needs assessment of DME included "O2 inhalation" however, Oxygen and nebulizer were not on the POC. The assessment also included the need for hospital bed, OBT, and walker. These items were not included in the POC.

Upon patient record review, 6 of 14 (Patient #1, 2, 3, 4, 6, 7) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1: This patient is a Vietnam veteran with agent orange. The patient's sister is wondering if the patient has any service connectedness. The patient lives alone and is having problems performing daily tasks. There is no evidence of problems/goals/interventions to address patient identified needs. Patient #2: Patient was admitted 10/17/24. Upon SCC initial assessment it was noted that "there is familial distress including her daughter currently acting as a single parent. Her daughter is caring for an autistic son as well as a 4 year old. Her husband had back slid into drug use and is now residing in a men's home. Her grandson is trying to apply to be compensated as the IHHS caregiver. The patient lost her spouse in 2015 and just recently lost a grand daughter to fentanyl overdose. These items are not discussed in the initial MSW assessment. The SC initial discussed psychosocial issues with the patient including loss of her spouse in 2015 and loss of a grand daughter for a Fentanyl overdose. Her daughter's husband has backslid into drug abuse and is living in a men's home and the grandson is trying to go through the process of being approved as the IHHS caregiver for the patient. There is no mention of this in the MSW POC and there are no changes or updates to the interventions or goals to the POC for either problem. There is no evidence of problems/goals/interventions to address patient identified needs. Patient #3: Patient admitted 10/16/24. The patient stated pain was 6 and self identified threshold was 2. It was documented that the patient was also having increased BP of 169/116. There was no call to MD and nurse documented "patient not observed to be in pain.", no follow up phone call or visit for 7 days. At subsequent visits on 10/23/24, 11/06/24, 11/14/24, and 01/31/25, patient complained of pain above self identified threshold. The nurse documented during these visits that patient showed guarding and facial grimacing, as well as "patient not observed to be in pain." There is no evidence of problems/goals/interventions to address patient identified needs. Patient #4: Patient admitted with heart failure on 11/24/24. On 12/08/24, during nurse visit patient complained of level 7 that got to level 10 radiating down left arm. No call to physician no follow up visit or phone call for 8 days. Patient #6: Pt admitted on 11/04/24 with a level 7 pain and self identified threshold of 2. Pain in back, shoulders, bilateral legs and nurse documented patient had guarding. Nurse documented "patient not observed to be in pain.", no follow up visit or phone call until 11/14/24. During this visit pain level was 8 out of 10. No interventions, no call to physician, nurse documented "patient not observed to be in pain." 11/20/24 patient seen complained of level 7 pain. nurse documented "patient not observed to be in pain." Patient revoked hospice services that same day. There is no evidence of problems/goals/interventions to address patient identified needs. Patient #7: Pt. admitted on 04/19/24 with level 10 of 10 pain, no interventions or call to physician, and no follow up for 7 days. Visits on 05/10/24, 05/17/24, 05/24/24, 06/14/24, patient assessed at level 6 and 7 pain with no change in frequency no follow up until next scheduled visit and no call to physician. Nurse continued to document "patient not observed to be in pain." There is no evidence of problems/goals/interventions to address patient identified needs.

Upon client record review, 2 of 14 (Patient #1, 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: At admission LVN visits were ordered for 2 visits per week and 2 prn. There has not been any LVN visits to patient. The SC is ordered for 2 visits each month, however, SC documented "will see patient once monthly and prn." and only monthly visits were performed. Patient #5: The MSW is ordered for once monthly and prn. There was no MSW visit in January.

Upon patient record review 3 of 14 (Patients 1, 2, 3) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patients #1-3: The volunteer POC states monthly visits for companionship, transportation, and meal delivery. During the home visit, the patients stated that they never had a visit from a volunteer. Patient #2: During the Spiritual care initial assessment, the patients caregiver was concerned with the patient having difficulty breathing but stated the RN said they were not qualified for oxygen because is oxygen saturation was normal. There is no documentation of this being reported to the RN and no further discussion about oxygen or dyspnea.

Condition of Participation: Infection Control.

Upon observation, there was no evidence the hospice maintains and documents an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases. The Nurse used the same fingerstick device on 2 of 3 home visits

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. The Nurse used the same fingerstick device on 2 of 3 home visits

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 17 (Personnel #10 ) did not have evidence that Hospice Aide Services are provided by a qualified individual in accordance with the appropriate state's regulations, the hospice's policies and procedures and/or job descriptions and the ACHC Glossary of Personnel Qualifications as defined by the Medicare Conditions of Participation. Personnel #10: The Hospice Aide did not have qualifications in accordance with state regulations as her Home Health Aide certification had expired in April of 2024

Upon personnel record review, 1 of 17 (Personnel #10) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #10: There is no evidence in the personnel file that the aide completed competency assessments on a patient or pseudo-patient.

Upon patient record review, 7 of 14 (Patients #1, 2, 3, 4, 5, 7, 9) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: The aide plan of care states ambulate with walker, wheelchair, and cane. This needs to be more specific. The POC states for Aide to brush teeth, however, the patient has upper and lower dentures. The POC states to apply lotion but does not specify where. Patient #2: The aide POC states ambulate with walker, wheelchair, and cane. This needs to be more specific. The POC states for Aide to brush teeth, however, the patient has upper and lower dentures. The POC states to apply lotion but does not specify where. The diet on the aide POC lists the diet as tolerated. The diet on the Comprehensive POC states mechanical soft. Bleeding precautions, fall risk, and oxygen precautions are missing from the aide POC. Patient #3: The aide POC states ambulate with walker, and cane. This needs to be more specific. The POC states for Aide to brush teeth, however, the patient has upper dentures so it should be specified if they are only brushing lower teeth. The POC states to apply lotion but does not specify where. Patient #4: The aide POC states ambulate with walker, wheelchair, and cane. This needs to be more specific. The POC states for Aide to brush teeth, however, the patient has upper and lower dentures. The POC states to apply lotion but does not specify where. The POC states pt. is continent of stool according to the RN assessment, however, the aide POC states incontinent. The diet on the POC states as tolerated, however, the Comprehensive assessment states mechanical soft. Patient #5: The aide POC states ambulation restricted, however doesn't state how. The POC states to apply lotion but does not specify where. Patient #7: The POC states to apply lotion but does not specify where. The aide POC states ambulate with walker, wheelchair, and cane. Patient #9: The POC states to apply lotion but does not specify where. The aide POC states patient is to receive incontinent care for bowel and bladder although the Comprehensive assessment states patient is continent of bowel and bladder. Aide POC states for aide to do meal prep for breakfast, lunch, dinner, and snack with no further information and aide will not be there for all four.

Upon patient record review 3 of 14(Patients #1, 2, 3) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1: The aide POC states patient is to have shower/bath weekly. During the home visit, the patient stated that the aide has never assisted in shower/bath although aide documented this was completed. During the home visit, the patient flow sheet that is signed by each staff contained entries from the Hospice aide on 01/31/25 that she did wound care. Wound care is outside the scope of a Hospice aide and it was not included on the POC. On 02/13/25, Hospice aide signed the patient flow sheet and documented "triple antibiotic cream". It is not clear what this entry meant, however, there are no entries regarding triple antibiotic cream on the Aide POC. Patient #2: The aide POC states patient is to have shower/bath weekly. During the home visit, the patient stated that the aide has never assisted in shower/bath although aide documented this was completed. Patient #3: The aide POC states patient is to have shower/bath weekly. During the home visit, the patient stated that the aide has never assisted in shower/bath although aide documented this was completed.

Upon patient record review 1 of 14 (Patients #2) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient #2: During Home visit 02/25/25, the patient flow sheet in the home was signed by aide on 12/27/24 with the notes "knee brace" there is no documentation of what this was for or that it was communicated to the RN. The aide signed the flow sheet in the home on 02/06/25 with the notes, "pain medication Norco out". There is no documentation in the record that this was called to RN or office. The next entry was 4 days later by RN. On 02/20/25, the hospice aide wrote on the flow sheet, "pain 10/10 pain on right shoulder keep her awake at night". There is no documentation of this being reported to the RN and there is no further documentation until the home visit on 02/25/25.

Upon patient record review 1 of 14 (Patient #2) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #2: The RN did a supervisory visit on 11/28/24, however did not do another one until 12/31/24 which was 33 days.

Upon personnel record review, 1 of 17 (Personnel #10 ) did not have evidence in the hospice aide personnel file that a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There is no evidence the governing body/administrator oversee the hospice operations as evidenced by the lack of nurses providing symptom management such as pain or psychosocial for patient identified needs as well as infection control practices. In addition, there is no evidence of oversight for human resource management as identified by the multiple personnel deficiencies.

Upon personnel record review, 3 of 17 (Personnel #1, 5, 10) did not have evidence that the hospice employees have received orientation on their specific job requirements.

Upon personnel record review, 1 of 17 (Personnel #5) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #5: The skills competency was incomplete.

Upon patient client record review, 10 of 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) did not have evidence that each patient record contains:(this references that the documentation is part of the patient record. Citing the inaccuracy of a component of the record is cited under other standards) • Initial plan of care • Updated plan of care • Initial assessments • Comprehensive assessments • Updated comprehensive assessments • Signed and dated clinical and progress notes Patients #1-10: All patient records had numerous visits spanning all disciplines that contained unsigned clinical and progress notes.

Upon patient client record review, 2 of 14 (Patients #1, 2) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: During home visit on 02/25/25, the patient complained of level 6 pain. The documentation from the visit states the patient did not complain of any pain. Patient #2: During home visit on 02/25/25, the patient complained of level 6 to 7 pain and was having level 10/10 pain that she described would keep her from sleeping. The documentation from the visit states the patient did not complain of any pain.

Upon client record review, 2 of 14 (Patients #6, 10) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient 6 and 10: There is no evidence that the discharge summary or the patient record, if requested was forwarded to the patient's physician.

Upon client record review, 2 of 14 (Patients #6, 10) did not have evidence that the discharge summary includes all required information. Patient 6 and 10: The discharge summary did not include POC.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care. Patient #9: The RN assessed on the initial assessment that neither the patient nor the patient caregiver could safely administer medications. There is no evidence in the record of agency performing assessment as to who is able to safely self-administer drugs and biologicals.

Upon personnel record review, 1 of 17 (Personnel #8) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #8: There was no evidence of the current license for the contract ST.

Upon personnel record review, 1 of 17 (Personnel # 7) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #7: There was no evidence of the current license for the contract OT.

Upon personnel record review, 1 of 17 (Personnel #6 ) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #6: There was no evidence of the current license for the contract PT.

Upon personnel record review, 3 of 17 (Personnel # 6, 7, 8) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records.

Upon patient record review, 3 of 3 applicable (Patient #1, 2, 5) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1 The 9/16/21 aide care plan had a frequency of per patient request for hair care. Patient #2 The 9/15/21 aide care plan had a frequency of per patient request for bathroom and hair care. Patient #5 The 7/28/21 aide care plan did not have a frequency for the following tasks: bath, hair care, mouth care, housekeeping

Upon patient record review, 2 of 5 (Patient #4, 5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #4 There was no signature, credentials, date or timestamp for the 7/28/21 chaplain visit. Patient #5 There was no signature, credentials, date or time stamp for the 7/30/21 chaplain visit.