Every finding on record at Life Hospice, Inc.

Based on interview and record review, the hospice failed to protect and promote the patient’s right for one of three sampled patients (Patient 3) who lacked decision‑making capacity and had no available family or designated agent.  This failure had the potential for the patient’s right not to be informed, not to exercise rights through a lawful representative, not to be fully protected, and expose the patient to receiving services without valid consent/election, affecting the decision‑making integrity and the patient’s overall care. Findings: --- Review of the hospice’s P&P titled Intake Process revised 2/6/26, showed the patients who do not have family and/or guardianship cannot be accepted without two Medical Director signatures. The Hospice Social Worker will be available to assist with initiating a guardianship process for those patients. Once a guardian is appointed, hospice eligibility will be reassessed, and the election of benefits will be explained to the elected guardian. Review of Patient 3’s clinical record was initiated on 3/17/26.  The clinical record showed the SOC was 10/10/25.  The patient was certified for hospice services during the certification periods from 10/10/25 to 01/07/26, and 1/8/26 to 4/7/26.  Review of the Informed Consent and Treatment Authorization dated 10/10/25, showed Patient 3 was unable to sign with the reason documented as dementia.  The informed consent was signed by two physicians and RN 1.Review of the Ethics Committee Meeting dated 2/6/26, showed the patient was evaluated and found to lack medical decision-making capacity.  The patient was unable to understand the nature of their illness, prognosis, or treatment options and is unable to communicate an informed or consistent healthcare decision.  The Ethics Committee reviewed this case due to the patient’s lack of decision-making capacity and absence of a legally appointed surrogate. The committee determined that the patient required a legal guardian to be assigned to continue remaining in hospice care. On 3/19/26 at 1315 hours, an interview and concurrent clinical record review were conducted with the DPCS.  The DPCS stated the Ethics Committee had decided to pursue legal guardianship in February 2026, and they followed up again in March 2026.  However, the legal guardianship was still pending.  The DPCS further stated obtaining signatures from two physicians for informed consent for a patient lacking capacity and without family members was not acceptable.  The hospice was aware of this requirement as they had a third‑party accreditation survey in January 2026.  The DPCS verified and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments included changes that had occurred since the initial assessment and information on the patient’s progress for one of three sampled patients (Patient 3).  This failure had the potential of not addressing the care needs for this patient. Findings: --- Review of the hospice's P&P titled Interdisciplinary Group Plan of Care revised 4/2020 showed the interdisciplinary group (in collaboration with the attending physician, if any) will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of every 15 calendar days.Review of Patient 3’s clinical record was initiated on 3/17/26.  The clinical record showed the SOC was 10/10/25.  The patient was certified for hospice services during the certification periods from 10/10/25 to 01/07/26, and 1/8/26 to 4/7/26. Review of the Informed Consent and Treatment Authorization dated 10/10/25, showed the patient was unable to sign with the reason documented as dementia. The informed consent was signed by two physicians and RN 1.Review of the Ethics Committee Meeting dated 2/6/26, showed the patient was evaluated and found to lack medical decision-making capacity.  The patient was unable to understand the nature of their illness, prognosis, or treatment options and was unable to communicate an informed or consistent healthcare decision.  The Ethics Committee reviewed this case due to the patient’s lack of decision-making capacity and absence of a legally appointed surrogate. The committee determined the patient required a legal guardian to be assigned to continue remaining in hospice care.However, the Hospice POC/IDG Reviews dated 2/19 and 3/5/26, showed no documented evidence the IDG had discussed the updated status of the guardianship for Patient 3 or the patient’s informed consent.On 3/19/26 at 1315 hours, an interview and a concurrent clinical record review were conducted with the DPCS.  The DPCS stated the Ethics Committee had decided to apply for a legal guardian and that they followed up in March 2026, but the legal guardianship was still pending.  The DPCS verified and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for two of three sampled patients (Patients 1 and 3).  This failure had the potential for not providing appropriate, consistent, and quality care to the patients. Findings: --- Review of the hospice's P&P titled Wound Assessment and Documentation undated, showed under section Procedure, Inspect and evaluate the condition of the wound in the following manner: Assess the wound location and its size; measure the length, width, and depth (use a sterile, cotton-tip applicator to measure the depth of the wound by inserting the applicator in the wound bed.  Documentation Guidelines: Document the following on the visit report: Wound measurements every two weeks, including the length, depth, and width of the wound in centimeters.1.Review of Patient 1’s clinical record was initiated on 3/17/26.  The clinical record showed the SOC was 10/10/25.  The patient was certified for hospice services during the certification period from 10/10/2025 to 01/07/2026 and 1/8/2026 to 4/7/2026.The POC/IDG Review dated 11/13/25 showed a care plan addressing a left buttock Stage 2 pressure wound. The documentation indicated the intervention included assessing changes in wound status—checking size, integrity, location, type/stage, signs and symptoms of infection, drainage, and the effectiveness of current treatment.Review of the Skin Assessment dated 11/21/25, 12/9/25, and 1/2/26 showed the RN performed a skin assessment; however, the RN failed to measure the size (length × width × depth) of the patient's left buttock Stage 2 pressure ulcer. On 3/19/26 at 1315 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS stated that wound measurements should have been completed every two weeks. The SN should have measured the wound and documented any changes in wound size. The left buttock Stage 2 pressure ulcer developed on 11/3/25. The DPCS verified and acknowledged the findings. 2. Review of Patient 3’s clinical record was initiated on 3/17/26. The clinical record showed the SOC was 10/10/25.  The patient was certified for hospice services during the certification periods from 10/10/2025 to 01/07/2026, and 1/8/2026 to 4/7/2026. Review of Patient 3's Physician's orders dated 10/10/25 showed an order for gastrostomy site care.  Documentation showed the following: cleanse with normal saline, pat dry, cover with T-drain dressing daily and as needed if soiled or dislodged. In addition, another physician's treatment order dated 10/10/25 showed an order for colostomy site care.  Documentation showed the following: cleanse with warm water, pat dry, apply the adhesive paste at the sites of the attachment and apply the colostomy pouch with valve every 5 days or as needed if soiled or dislodged and empty the bag once daily or as needed.Review of Patient 3's POC/IDG Review on Integumentary/Skin Plan of Care dated 10/10/25 showed gastrostomy site interventions included to assess gastrostomy site for signs and symptoms of infection/inflammation and colostomy site care interventions included to assess colostomy site for signs and symptoms of infection/ inflammation. Review of  Patient 3's Comprehensive Nursing Assessment Skin Assessment Narrative dated 10/10/25, 10/20/25, 11/7/25, and 1/2/26 showed RN 1 conducted colostomy site care and gastrostomy site care. However, there were no documentation on specific details of skin assessment for Patient 3's gastrostomy site and colostomy site on the mentioned dates.On 3/23/26 at 1015 hours, an interview and concurrent clinical review was conducted with RN1.  RN 1 was informed and asked if there were other documentation he could show specific details on Patient 3 gastrostomy site and colostomy site assessment as to location, description, and color.  RN 1 acknowledged there was no other documentation other than his completed narrative documentation. On 3/23/26 at 1045 hours, a phone interview was conducted with the Administrator, DPCS and in-person interview with the Office Manager.  All were informed and acknowledged the above findings.  Review of the hospice's P&P titled Wound Assessment and Documentation undated showed to inspect and evaluate the condition of the wound in the following manner: assess the wound location and its size; measure the length, width, and depth (use a sterile, cotton-tip applicator to measure the depth of the wound by inserting the applicator in the wound bed).  Under Documentation Guidelines, document the following on the visit report: Wound measurements every two weeks, including the length, depth, and width of the wound in centimeters.1.Review of Patient 1’s clinical record was initiated on 3/17/26.  The clinical record showed the SOC was 10/10/25.  The patient was certified for hospice services during the certification period from 10/10/2025 to 01/07/2026 and 1/8/2026 to 4/7/2026.The POC/IDG Review dated 11/13/25 showed a care plan addressing a left buttock Stage 2 pressure wound. The documentation indicated the intervention included assessing changes in wound status—checking size, integrity, location, type/stage, signs and symptoms of infection, drainage, and the effectiveness of current treatment.Review of the Skin Assessment dated 11/21/25, 12/9/25, and 1/2/26 showed the RN performed a skin assessment; however, the RN failed to measure the size (length × width × depth) of the patient's left buttock Stage 2 pressure ulcer. On 3/19/26 at 1315 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS stated that wound measurements should have been completed every two weeks. The SN should have measured the wound and documented any changes in wound size. The left buttock Stage 2 pressure ulcer developed on 11/3/25. The DPCS verified and acknowledged the findings.2. Review of Patient 3’s clinical record was initiated on 3/17/26. The clinical record showed the SOC was 10/10/25.  The patient was certified for hospice services during the certification periods from 10/10/2025 to 01/07/2026, and 1/8/2026 to 4/7/2026. Review of Patient 3's Physician's orders dated 10/10/25 showed an order for gastrostomy site care.  Documentation showed the following: cleanse with normal saline, pat dry, cover with T-drain dressing daily and as needed if soiled or dislodged. In addition, another physician's treatment order dated 10/10/25 showed an order for colostomy site care.  Documentation showed the following: cleanse with warm water, pat dry, apply the adhesive paste at the sites of the attachment and apply the colostomy pouch with valve every 5 days or as needed if soiled or dislodged and empty the bag once daily or as needed.Review of Patient 3's POC/IDG Review on Integumentary/Skin Plan of Care dated 10/10/25 showed gastrostomy site interventions included to assess gastrostomy site for signs and symptoms of infection/inflammation and colostomy site care interventions included to assess colostomy site for signs and symptoms of infection/ inflammation. Review of  Patient 3's Comprehensive Nursing Assessment Skin Assessment Narrative dated 10/10/25, 10/20/25, 11/7/25, and 1/2/26 showed RN 1 conducted colostomy site care and gastrostomy site care. However, there were no documentation on specific details of skin assessment for Patient 3's gastrostomy site and colostomy site on the mentioned dates.On 3/23/26 at 1015 hours, an interview and concurrent clinical review was conducted with RN1.  RN 1 was informed and asked if there were other documentation he could show specific details on Patient 3 gastrostomy site and colostomy site assessment as to location, description, and color.  RN 1 acknowledged there was no other documentation other than his completed narrative documentation. On 3/23/26 at 1045 hours, a phone interview was conducted with the Administrator, DPCS and in-person interview with the Office Manager.  All were informed and acknowledged the above findings.

Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for coordinating the care and services related to the patient/family education on the risks of refusing the medications to be checked during home visits for one of three sampled patients (Patient 2).  This failure had the potential for not providing consistent and quality care to the patient.Findings: --- The hospice’s P&P titled Interdisciplinary Group Plan of Care revised April 2020 showed the purpose was to ensure the coordination of services for each patient.  The hospice interdisciplinary group will retain professional management responsibilities for the provision of services, including inpatient care, and will insure that services are furnished in a safe and effective manner.  The interdisciplinary group will provide ongoing support for the patient and family/caregivers.Review of Patient 2's clinical record was initiated on 3/17/26.  The clinical record showed the SOC was 2/10/26. The patient was certified for hospice services during the certification period from 2/10/26 to 5/10/26. Review of Patient 2's Current Treatment/Medication List Profile included a physician's order dated 2/10/26, for insulin lispro KwikPen (antidiabetic) 100 units prefilled pen solution for injection three times daily before meals. On 3/18/26 at 0900 hours, a home visit was conducted with LVN 1 to Patient 2's residence.  A concurrent medication profile review and interview was conducted with LVN 1 and Patient 2's caregiver.  An injectable prefilled solution medication, insulin lispro KwikPen had an expiration date of 1/6/26.  LVN 1 was asked if it should have been properly disposed.  LVN 1 acknowledged it should have been properly disposed.  LVN 1 was asked about the process for checking the prescribed medications during home visits.  LVN 1 stated the medications should be checked every home visit. On 3/23/26 at 0959 hours, an interview and a concurrent clinical review was conducted with the Office Manager.  The Office Manager stated Patient 2's family and caregiver did not allow the licensed nurses to check on medications stored in the refrigerator.  The Office Manager was asked to provide any specific documentation that Patient 2's family and caregiver were provided education on the risks of refusing for the medications stored in the refrigerator to be checked during home visits.  The Office Manager acknowledged all were verbal reminders.  The Office Manager called LVN 2.  LVN 2 verified there was no documentation and  LVN 2 provided only verbal reminders. On 3/23/26 at 1100 hours, a telephone conference was conducted with the Administrator and DPCS with the Office Manager present.  They were informed of the findings.The IDG failed to maintain responsibility for coordinating with the patient/family regarding the risks of refusing to check medication stored in the refrigerator during home visits.

Condition of Participation: Patient’s Rights. L500

Upon observation, 2 of 14 (Patient #8 and 10) there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient 8: There is evidence in the patient record that the admission documents/consents/EOB/and reception of patient rights are signed by two physicians with no documented evidence of legal authority. Patient has a diagnosis of dementia and is documented with cognitive FAST score 7C. Patient 10:There is evidence in the patient record that the admission documents/consents/EOB/and reception of patient rights are signed by two physicians with no documented evidence of legal authority. Patient has a diagnosis of dementia and is documented with cognitive FAST score 7C.

Upon patient record review, 2 of 14 (Patient #8 and 10) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient 8: There is no evidence that the patient or representative was provided verbal and written information regarding the notice of policies on advance directives, the patient's rights and responsibilities. The record indicates All admission paperwork was signed by two physicians. Education was provided to ALF caregiver. Patient has diagnosis of dementia with FAST score 7C. Patient 10: There is no evidence that the patient or representative was provided verbal and written information regarding the notice of policies on advance directives, the patient's rights and responsibilities. The record indicates All admission paperwork was signed by two physicians. Education was provided to ALF caregiver. Patient has diagnosis of dementia with FAST score 7C.

Upon patient record review, 2 of 14 (Patient # 8 and 10) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient 8: There is no evidence that the patient or representative acknowledged the receipt of patient rights and responsibilities statement upon admission. The statement was signed by two physicians with no documented evidence of legal authority. Patient has a diagnosis of dementia with documented cognitive FAST score 7C. Patient 10: There is no evidence that the patient or representative acknowledged the receipt of patient rights and responsibilities statement upon admission. All admission paperwork was signed by two physicians with no documented evidence of legal authority. Patient has a diagnosis of dementia with documented cognitive FAST score 7C.

Upon observation and patient record review, 2 of 14 (Patient #8 and 10) there was no evidence the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice. Patient 8 and 10: There is no evidence that the rights of patient/representative were respected. All admission paperwork was signed by two physicians. Patients have dementia and no legal appointment representative to authorize.

Upon patient record review, 2 of 14 (Patient # 8 and 10) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient 8: There is no evidence of the rights of patient are exercised by having a person appointed to act on patient's behalf as a legal representative. Patient has a diagnosis of dementia and is cognitively impaired with FAST score of 7C and did not have an assigned representative at the time of admission. All admission paperwork was signed by 2 physicians. Patient 10: There is no evidence of the rights of patient are exercised by having a person appointed to act on patient's behalf as a legal representative. Patient has a diagnosis of dementia and is cognitively impaired with FAST score of 7C and did not have an assigned representative at the time of admission. All admission paperwork was signed by 2 physicians.

Upon client record review, 2 of 14 (Patient # 8 and 10) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient 8: There is no evidence that the patient or representative was involved in the development of the plan of care. The admission paperwork was signed by two physicians that visited patient at ALF. Patient has a diagnosis of dementia with FAST score 7C and does not have family or POA. Patient 10:There is no evidence that the patient or representative was involved in the development of the plan of care. The admission paperwork was signed by two physicians that visited patient at ALF. Patient has a diagnosis of dementia with FAST score 7C and does not have family or POA.

Upon patient record review, 2 of 14 (Patient # 8 and 10) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 8: There is no evidence that the patient/representative right to choose their attending physician was honored. All admission paperwork was signed by two physicians with no documented evidence of legal authority. Patient has a diagnosis of dementia and is documented with cognitive FAST score 7C. Patient has no family or legal representative. Patient 10: There is no evidence that the patient/representative right to choose their attending physician was honored. All admission paperwork was signed by two physicians with no documented evidence of legal authority. Patient has a diagnosis of dementia and is documented with cognitive FAST score 7C. Patient has no family or legal representative.

Upon patient record review, 2 of 14 (Patient #8 and 10) did not have evidence of the appropriate documentation for release of confidential information. Patient 8: There is evidence in the patient record that the admission documents/consents/EOB/and reception of patient rights are signed by two physicians with no documented evidence of legal authority. Patient has a diagnosis of dementia and is documented with cognitive FAST score 7C. Patient 10:There is evidence in the patient record that the admission documents/consents/EOB/and reception of patient rights are signed by two physicians with no documented evidence of legal authority. Patient has a diagnosis of dementia and is documented with cognitive FAST score 7C.

Upon patient record review, 2 of 14 (Patient #8 and 10) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient 8: There is no evidence that the patient or representative received information about the scope of services covered under the hospice benefit, including the limitations of those services. All admission paperwork was signed by two physicians with no documented evidence of legal authority. Patient has a diagnosis of dementia with documented cognitive FAST score 7C. Patient 10: There is no evidence that the patient or representative received information about the scope of services covered under the hospice benefit, including the limitations of those services. All admission paperwork was signed by two physicians with no documented evidence of legal authority. Patient has a diagnosis of dementia with documented cognitive FAST score 7C.

Upon patient record review, 2 of 14 (Patient #8 and 10) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient 8: There is no evidence that the patient or representative received information about the scope of services covered under the hospice benefit. All admission paperwork was signed by two physicians with no documented evidence of legal authority. Patient has a diagnosis of dementia with documented cognitive FAST score 7C. Patient 10: There is no evidence that the patient or representative received information about the scope of services covered under the hospice benefit. All admission paperwork was signed by two physicians with no documented evidence of legal authority. Patient has a diagnosis of dementia with documented cognitive FAST score 7C.

Upon patient record review, 3 of 14 (Patient # 1, 2, and 3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 1: The medication profile on 1/8/26 contains an order for Lorazepam 2mg/ml oral concentration. Upon home visit, family reports “We only have Lorazepam tablets.” There is no evidence of lorazepam oral concentration present in home. COS with updated order and deliver of medication. Patient 2: The medication profile on 01/08/26 does not show evidence of the following supplements including Vitamin D3 and Vitamin B1 and partner reported patient is taking both supplements at home visit medication reconciliation. COS with medication reconciliation. Patient 3: The medication profile on 1/8/26 contains orders for Lasix and potassium once daily and family reports “she is not taking Lasix or Potassium anymore.” Daughter does verbalize concerns about patient's swelling in lower extremities. COS with patient/family education.

Upon patient record review, 3 of 14 (Patient # 1, 2, and 3) 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: The updated POC on 1/8/26 contains an order for Lorazepam 2mg/ml oral concentration. Upon home visit, family reports “We only have Lorazepam tablets.” There is no evidence of lorazepam oral concentration present in home. COS with updated orders on POC. Patient 2: The updated POC on 01/08/26 does not show evidence of the following supplements including Vitamin D3 and Vitamin B1 and partner reported patient is taking both supplements at home visit medication reconciliation. COS with updated orders to include vitamins. Patient 3: The updated POC on 1/8/26 contains orders for Lasix and potassium once daily and family reports “she is not taking Lasix or Potassium anymore.” Daughter does verbalize concerns about patient's swelling in lower extremities. COS with nurse visit and education of proper use of medication.

Upon client record review, 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The visit frequency for RN is indicated one every two weeks. There is no evidence of an RN visit the week of 12/14 between visits completed on 12/2 and 12/29/25.

Upon patient client record review, 2 of 14 (Patient # 8 and 10) did not have evidence that each patient record contains: Patient 8: There is no evidence that the patient or representative right to receive notification of Non-covered items or election statement was honored. All admission paperwork was signed by two physicians. Education was provided to ALF caregiver. Patient has diagnosis of dementia with FAST score 7C. Patient 10: There is no evidence that the patient or representative right to receive notification of Non-covered items or election statement was honored. All admission paperwork was signed by two physicians. Education was provided to ALF caregiver. Patient has diagnosis of dementia with FAST score 7C.

Upon patient client record review, 2 of 14 (Patient # 6 and 8) 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 6: The POC on 12/14/25 contains an order for POLST: DNR/Full Code. POLST on file does indicate DNR not a Full Code. COS with medical record update. Patient 8: The MSW documents "Maricella as primary caregiver at B&C and Stacy, the facility administrator" provided patient information for comprehensive psychosocial assessment at SOC on 11/02/25. Patient is in ALF not B&C. Place of service is documented as Ulta Garden B&C instead of the correct place of service, Alta Gardens ALF. COS with medical record update.

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 did not have evidence that CMS and/or State licensing agencies and ACHC were notified of the change in location from Suite#100P to Suite#100M.

Upon patient record review, 1 of 11 (Patient #3) 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 #3 This patient had a bedside table. This was not included on the Plan of Care.

Upon personnel record review, 1 of 1 applicable (Personnel #9) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient or pseudo patient. The following competencies were "verbal" assessments not "observed" assessments as required: ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Toileting and elimination (Urinal)

Upon client record review, 1 of 1 applicable (Patient #9) did not have evidence that the hospice forwarded a transfer summary to include all the required content as follows: • Copy of signed consents for care • Copy of the certification of terminal illness