Every finding on record at Luar Hospice Care Inc

Based on observation, interview and record review, the Hospice (a specialized form of medical care for people who are nearing the end of life) Agency (HA-an organization that provides care and support to terminally ill patients [patients with six months of less left to live] and their families, focusing on comfort and quality of life rather than curative treatments) failed to ensure the Conditions of Participation (CoP-a set of minimum professional standards all hospice agencies must meet to participate in Medicare [a federal health insurance program that helps people pay for healthcare] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) regarding Patient Rights was met as follows: --- 1.The HA failed to ensure the Durable Power of Attorney (DPOA- a legal document that lets a patient name someone else to make decisions about the patient's health care in case the patient is not able to) for one (1) of 14 sampled patients (Patient 1) agreed to hospice services and was provided with information about the rights and responsibilities of hospice care. (Refer to L504). 2.The HA failed to ensure one (1) of 14 sampled patients (Patient 1) DPOA (Patient 1's DPOA) was informed and consented to the administration of psychotropic medications (medications that affect brain function) (Refer to L507). The cumulative effect of these systemic practices resulted in Patient 1 and Patient 1's DPOA not knowing Patient 1s hospice services and Patient 1s rights as a hospice patient.

Based on observation, interview, and record review, the Hospice (a program that provides care and support for patients who are terminally ill [have six months ofless to live] and have stopped treatment to cure their disease) Agency (HA-an organization that provides specialized care focused on comfort and quality of life for terminally ill patients who are no longer seeking curative treatment ) failed to ensure the Durable Power of Attorney (DPOA -a legal document that gives a person the authority to make medical decisions for another person) for one of 14 sampled patients (Patient 1) agreed to hospice services and was provided with information about the rights and responsibilities of hospice care. This deficient practice resulted in Patient 1 and Patient 1's DPOA not knowing their hospice services with their limitations and the rights of hospice patients. The State Survey Agency (the Department) attempted to contact the Owner/Administrator (ADM) starting on 3/19/25 to 3/21/25 in order to call an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for the agency's failure of ensuring Patient 1's DPOA agreed to hospices services and was provided information about the rights and responsibilities of hospice care, but have been unable to get in contact with the ADM. The Department was unable to conduct an exit conference with the ADM due to the ADM not responding to attempted phone calls from 3/19/25 to 3/21/25. --- During a review of Patient 1s Personal Information sheet, the Personal Information sheet indicated a start of care (SOC-the day the patient officially begins receiving hospice services) date on 11/15/2024, with a diagnosis of Alzheimers disease (a brain disorder that gradually destroys memory and thinking skills). During a record review of the HAs patient consent forms (a legal document that outlines a patient's agreement to receive hospice care), Patient 1s consent to hospice care was not found. During a record review of Patient 1s electronic medical record (EMR), there were no documents uploaded into the medical record. There were no consent forms for Patient 1 noted in Patient 1's EMR. During an interview on 3/11/2025, at 2:08 p.m., Registered Nurse 1 (RN 1) stated that Patient 1s consents to hospice care was not in the office and that RN 1 was not aware of the location of Patient 1s consent to hospice care. During an interview on 3/12/2025, at 9:34 a.m., Patient 1s DPOA stated that Patient 1 was not terminally ill. Patient 1s DPOA stated that he (Patient 1s DPOA) was not aware that Patient 1 was in hospice care, nor how long Patient 1 had been in hospice care. Patient 1s DPOA stated no one had spoken to him (Patient 1s DPOA) to determine if he (Patient 1s DPOA) was agreeable to put Patient 1 in hospice care. Patient 1s DPOA stated he (Patient 1s DPOA) never signed any hospice care related documents. Patient 1s DPOA stated the hospice agency did not ask him (Patient 1s DPOA) for a copy of Patient 1s DPOA document. During a concurrent observation, interview and record review on 3/12/2025 at 10:44 a.m., at the home visit of Patient 1 with RN 1, observed the HAs folder on Patient 1s nightstand. Inside the folder, observed Patient 1s Hospice Agency Agreement form dated 11/15/2024. A review of the Hospice Agency Agreement form indicated that the patient or responsible party signature meant an agreement with the HA about election of Medicare hospice benefit, release of information and consent for treatment, consent and election of hospice physician, decline of specific services, patient acknowledgement in receipt of information, and competency checklist of medications for patient at home. Further review of the record indicated the initials ";M.J.". RN 1 stated Patient 1s DPOA signed the Hospice Agreement form because Patient 1 was unable to sign due to memory loss. RN 1 then reviewed the record and stated the name of the DPOA was not written on the record. During a record review of Patient 1s Durable Power of Attorney indicated Patient 1 had signed the DPOA document on 4/6/2024. Further review of the record indicated the initials of Patient 1 written on the DPOA document did not match with the initials written on Patient 1s Hospice Agency Agreement dated 11/15/2024. During an interview on 3/12/2025 at 1:43 p.m., the ADM stated that if patients had a DPOA, the HA needs to verify the information and get a copy of the DPOA document because the DPOA is the one who makes healthcare decisions for the patient. The ADM stated the agency did not have any patients who had a DPOA.

Based on observation, interview, and record review, the Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA-an organization that provides specialized care focused on comfort and quality of life for terminally ill patients who are no longer seeking curative treatment ) failed to ensure one of 14 sampled patient's (Patient 1) Durable Power of Attorney (DPOA -a legal document that gives a person the authority to make medical decisions for another person) was informed and consented to the administration of psychotropic medications (medications that affect brain function). This deficient practice resulted in Patient 1 and Patient 1's DPOA not being made aware of the risk, benefits, and alternatives to psychotropic medications and increased the risk for unnecessary medications. The State Survey Agency (the Department) attempted to contact the Owner/Administrator (ADM) starting on 3/19/25 to 3/21/25 in order to call an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for failing to ensure Patient 1's DPOA was informed and consented to the administration of psychotropic medications for Patient 1, but have been unable to get in contact with the ADM. The Department was unable to conduct an exit conference with the ADM due to the ADM not responding to attempted phone calls from 3/19/25 to 3/21/25. --- During a review of Patient 1s Personal Information sheet, the Personal Information sheet indicated a start of care (SOC-the day the patient officially begins receiving hospice services) date on 11/15/2024, with a diagnosis of Alzheimers disease (a brain disorder that gradually destroys memory and thinking skills). During a record review on 3/11/2025, at 1:50 p.m. of the HAs patient consent forms (a legal document that outlines a patient's agreement to receive hospice care), Patient 1s consent for psychotropic medications were not found. During a record review of Patient 1s Physician Orders dated 11/15/24, the following orders were noted: 1. Ambien (medication used to help a patient sleep) five milligrams (mg-unit of measure) one tablet to be taken orally at bedtime 2. Lorazepam (medication used to treat anxiety) 0.5 mg, one table every four to six hours as needed for anxiety 3. Lexapro (medication used to treat depression) 10 mg, one table daily 4. Risperidone (medication used to treat schizophrenia [a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others) one mg, one tablet twice a day. During an interview on 3/12/2025, at 9:34 a.m., Patient 1s DPOA stated no one from the HA informed him (Patient 1s DPOA) that Patient 1 needed psychotropic medications. Patient 1s DPOA stated he (Patient 1s DPOA) spoke to Registered Nurse 1 (RN 1) about three weeks ago to inquire who had prescribed medications for Patient 1. Patient 1s DPOA stated that he (Patient 1s DPOA) requested a return call from Patient 1s HA Physician. Patient 1s DPOA stated he (Patient 1s DPOA) never got a call from Patient 1s HA Physician. During an interview on 3/12/2025, at 11:21 a.m., Registered Nurse 1 (RN 1) stated he (RN 1) had done the start of care visit for Patient 1 on 11/15/24. RN 1 stated Medical Director 1 (MD 1) was the medical director for the HA. RN 1 stated that MD 1 ordered all the medication for Patient 1 upon admission on 11/15/2024. RN 1 stated that he (RN 1) was the one who received the orders for Patient 1 from MD 1. RN 1 stated that Patient 1 was prescribed the following psychotropic medications: 1. Ambien 2. Lorazepam 3. Lexapro 4. Risperidone

Based on observation, interview and record review, the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Conditions of Participations regarding initial and Comprehensive Assessments of Patients was met as followed: --- 1.      The HA failed to conduct and document an accurate initial assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for three of fourteen sampled patients (Patient 1, Patient 3, and Patient 5). (Refer to L 522). 2.      The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after election of hospice care for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 12, and Patient 14).  (Refer to L 523). 3.      The HA failed to review all medications four of fourteen sampled patients (Patient 1, Patient 4, Patient 5, and Patient 12) were taking and update their medication profiles with the currently used medications. (Refer to L 530).4.      The HA failed to ensure ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 12, Patient 13, and Patient 14) receive an initial bereavement assessment. (Refer to L 531).  5.      The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for seven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). (Refer to L 533). The cumulative effect of these systemic practices resulted in the hospice agency admitting patients who did not meet admission criteria and did not qualify for the Medicare hospice benefit.

Based on record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) staff failed to conduct and document an accurate initial assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for three of fourteen sampled patients (Patient 1, Patient 3, and Patient 5). This failure resulted in patients being admitted without addressing all their immediate needs which is necessary to gather the essential information necessary to begin the plan of care and provide the immediate necessary care and services. --- The HA did not provide the survey team with knowledgeable staff from 3/10/2025 to 3/23/2025 to review the documents as written below.  1. A review of Patient 1’s Personal Information sheet indicated a start of care date on 11/15/2024, with a diagnosis of Alzheimer’s disease (a brain disease that destroys memory and thinking skills).   During an interview on 3/12/2025, at 9:34 a.m., Patient 1’s DPOA (Durable Power of Attorney) stated that Patient 1 was not terminally ill. The DPOA stated that the DPOA was not aware Patient 1 was in hospice care, nor how long Patient 1 had been in hospice care. The DPOA stated no one had spoken to him (DPOA) to determine if he (DPOA) was agreeable to put Patient 1 in hospice care. The DPOA stated he (DPOA) never signed any hospice care related documents.     During an observation of the home visit on 3/12/2025 at 10:40 a.m., with Registered Nurse (RN 1), Patient 1 was awake and alert. Patient 1 was lying in bed, with both side rails up. Patient 1 was non-interview able. During a record review of Patient 1’s record titled, “Comprehensive Nursing Assessment”, dated 11/15/2024, indicated Patient 1 qualified for hospice care due to “the following conditions exist as evidenced in or reported by medical history, patient, pcg (primary care giver)/family”...“According to the patient’s family, the patient’s condition has progressively deteriorated in the past few months. Due to the patient’s poor prognosis, worsening comorbidities and declining family wishes for no further aggressive treatment and has not opted for hospice care for palliative measures, symptom management, and comfort care only.” Further review of the record did not indicate a Registered Nurse had done the assessment.A record review of Patient 1’s medical record did not indicate any documented evidence to support the medical conditions documented. 2. During a record review of Patient 3’s medical record form titled “Personal Information”, indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain).  A record review of Patient 3’s document titled, “Comprehensive Nursing Assessment”, dated 11/20/2024, indicated Patient 3 was admitted to hospice care due to heart disease and heart failure level 4 (New York Hear Association IV-NYHA 4, the most severe case of heart failure). The record further indicated “The following conditions exist as evidenced in or reported by medical history, patient, pcg/family.” Further review of the record did not indicate a Registered Nurse had done the assessment.A record review of Patient 3’s medical record did not indicate any documented evidence to support the medical conditions documented. 3.During a record review of Patient ‘5s medical record form titled “Personal Information”, indicated a Start of Care (SOC) date of 11/8/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). The form indicated MD2 was listed as Patient 5’s MD.  During a record review of Patient 5’s medical record form titled “Comprehensive Nursing Assessment” dated 11/8/2024, indicated the form was blank and it did not have an HA’s staffs name assigned to the form.  During a record review of the HA’s form untitled, dated 3/13/2025, indicated Patient 5 had a SOC date of 11/8/2025 and an End of Care (EOC) date of 3/7/2025. During a record review of the HA’s form untitled, dated 3/18/2025, indicated Patient 5 had a SOC date of 11/8/2025 and an End of Care (EOC) date of 3/5/2025.

Based on interview and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain  (Spiritual Counselor-SC), and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after election of hospice care for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 12, and Patient 14).  This failure resulted in patients not being properly evaluated which resulted in not being provided the individualized focused care. --- During an interview on 3/11/2025, at 1:18 p.m., with Registered Nurse 1 (RN 1), RN1 stated “not sure”, when asked who the bereavement coordinator, and chaplain were. During an interview on 3/12/2025 at 1:20 p.m., with the Administrator (ADM), the ADM stated the HA did not have a SC or Bereavement Coordinator since December 2023 because he (ADM) did not know it was a requirement to have one. The HA did not provide the survey team with knowledgeable staff from 3/10/2025 to 3/23/2025 to review the documents as written below. 1. A review of Patient 1’s Personal Information sheet indicated a start of care date on 11/15/2024, with a diagnosis of Alzheimer’s disease (a brain disease that destroys memory and thinking skills). A record review of Patient 1’s medical record did not indicate a spiritual assessment was done. A record review of Patient 1’s document titled, “Psychosocial Assessment”, dated 1/17/2025, indicated the assessment was done by the MSW. Patient 1’s SOC was 11/15/2024. 2. During a record review of Patient 2’s medical record form titled “Personal Information”, indicated an SOC of 12/12/2024, with a terminal diagnosis of heart disease (a range of conditions that affect the heart which includes blood vessel disease, irregular heartbeats, or congenital heart defects).    A record review of Patient 2’s document titled, “Psychosocial Assessment”, dated 1/23/2025, indicated the assessment was done by the MSW. Patient 2’s SOC was 12/12/2024. 3. During a record review of Patient 3’s medical record form titled “Personal Information”, indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). A record review of Patient 3’s medical records did not indicate a Spiritual Assessment and a psychosocial assessment. 4.During a record review of Patient 4‘s medical record form titled “Personal Information”, indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood). The form indicated Medical Director 2 (MD2) was listed as Patient 4’s Medical Director (MD). During a record review of Patient 4’s medical record form titled “History of POC (plan of care – individualized care plan)/IDG” undated, indicated there were two entries made on 2/3/2025 and 2/17/2025. During a record review of Patient 4’s electronic medical records (EMR) did not indicate any documented evidence Patient 4 had a comprehensive assessment completed by the IDG within five days of admission.  5.During a record review of Patient ‘5s medical record form titled “Personal Information”, indicated a Start of Care (SOC) date of 11/8/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). The form indicated MD2 was listed as Patient 5’s MD.  During a record review of Patient 5’s medical record form titled “History of POC/IDG” undated, indicated there were no entries made.  During a record review of Patient 5’s EMR did not indicate any documented evidence Patient 5 had a comprehensive assessment completed by the IDG within five days of admission.   6.During a record review of Patient 6‘s medical record form titled “Personal Information”, indicated a SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). The form indicated MD2 was listed as Patient 6’s MD. During an interview on 3/14/2025 at 2:53 p.m. with Patient 6, Patient 6 stated he (Patient 6) has not seen a doctor for the past 2 years.  During a record review of Patient 6’s EMR form titled “History of POC/IDG” undated, indicated the first entry was documented on 11/25/2024 and last entry was documented on 2/3/2025. During a record review of Patient 6‘s medical record form titled “POC/IDG Review” dated 11/25/2024, indicated the form was not signed by any of the IDG members.  During a record review of Patient 6’s EMR did not indicate any documented evidence Patient 6 had a comprehensive assessment completed by the IDG within five days of admission.  7.During a record review of Patient 7‘s medical record form titled “Personal Information”, indicated a SOC date of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (progressive lung disease causing airflow obstruction with difficulty breathing). The form indicated MD2 was listed as Patient 7’s MD. During an interview on 3/14/2025 at 3:34 p.m. with Patient 7’s family member (FM1), FM1 stated Patient 7 has not seen a medical doctor for the past 6-7 months. During a record review of Patient 7’s medical record form titled “History of POC/IDG” undated, indicated the first entry was documented on 11/13/2024 and the last entry was documented on 2/3/2025. During a record review of Patient 7‘s medical record form titled “POC/IDG Review” dated 11/13/2024, indicated the form was not signed by any of the IDG members.  During a record review of Patient 7’s EMR did not indicate any documented evidence Patient 7 had a comprehensive assessment completed by the IDG within five days of admission.  8. During a record review of Patient 12‘s medical record form titled “Personal Information”, indicated an SOC of 11/3/2024, with a terminal diagnosis of chronic diastolic heart failure.  During a review of Patient 12’s “POC/IDG Review” with the following dates:  11/4/2024 and 2/3/2024, the IDG did not indicate a registered nurse, medical director, chaplain or social worker completed the comprehensive assessment. During a review of Patient 12’s History of Psychosocial Assessment, there were no notes written by a social worker.    During a review of Patient 12’s History of Spiritual Assessment, there were no notes written by a spiritual counselor.  9.During a record review of Patient 14‘s “medical record form titled Personal Information”, indicated an SOC of 11/12/2024, with a terminal diagnosis of chronic diastolic heart failure.   During a review of Patient 14’s “POC/IDG Review” with the following dates:  11/13/2024 and 1/20/2025, the IDG did not indicate a registered nurse, medical director, chaplain or social worker, completed the comprehensive assessment. During a review of Patient 14’s History of Psychosocial Assessment, there were no notes written by a social worker.

Based on observation, interview, and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) staff failed to review all medications four of fourteen sampled patients (Patient 1, Patient 4, Patient 5, and Patient 12) were taking and update their medication profiles with the currently used medications. This failure had the potential to place patients were at risk for medication errors and adverse drug reactions. --- The HA did not provide the survey team with knowledgeable staff from 3/10/2025 to 3/23/2025 to review the documents as written below. 1. A review of Patient 1’s Personal Information sheet indicated a start of care date on 11/15/2024, with a diagnosis of Alzheimer’s disease (a brain disease that destroys memory and thinking skills). During a concurrent observation at the home visit on 3/12/2025, at 11:11 a.m., with Registered Nurse 1 (RN 1), RN1 reviewed the medications Patient 1 was taking. An observation of RN 1 indicated RN 1 was using the medication list from the Board and Care facility to review the medications. During a concurrent observation, interview, and record review at the home visit on 3/12/2025, at 11:14 a. m., RN 1 brought undated record titled, “Current Treatment/Medication. DME list” from Patient 1’s folder located at her bedside. RN 1 stated the only medication Patient 1 was on was Amlodipine (medication to treat high blood pressure) 5 mg (mg-milligram unit of measurement). The following medications were listed on the record and not at the home visit: Nystatin (anti-fungal medication) and Bacitracin (antibiotic medication). 2.During a record review of Patient 4‘s medical record form titled “Personal Information”, indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood).  During a record review of Patient 4’s medical record form titled “Current Treatment / Medication / DME List” undated, indicated Patient 4 was currently prescribed/taking the following: 1. Lispro (medication to treat diabetes – high blood sugar) unknown dosage, route intracavernous (a medical procedure that involves injecting a medication directly into the penis to induce an erection); 2. Lantus (medication to treat diabetes) unknown dosage once a day; 3. Metformin (medication to treat diabetes) one tablet twice a day; and 3. Pantoprazole (medication to treat stomach acid) unknown dosage. During a record review of Patient 4’s medical record form titled “Physician Orders” dated 2/21/2025, indicated the Owner/Administrator (ADM) took and read back the orders on 2/21/2025. The form also indicated the Medical Doctor 2 (MD2)’s name was listed. The form did not indicate the form was signed by MD2. Patient 4 was prescribed the following medications:-Lispro 100unit/ml (milliliters) dose not written and route “intracavernous”-Lantus 100units/ml dose not written and frequency once a day-Metformin 500mg (milligrams) 1 tab twice a day-Pantoprazole 40mg dose not written During a joint home visit on 3/12/2025 at 9 a.m. with RN1 at Patient 4’s home, Patient 4’s medications were reconciled RN1. RN1 asked Patient 4 for his medications. Patient 4 provided RN1 with a black bag with several medication bottles. RN1 took out some of the medication bottles from Patient 4’s black bag, looked at them then returned them to the bag.  During a concurrent observation and record review on 3/12/2025 at 9 a.m. of Patient 4’s medication bottle labels comparing them with Patient 4’s HA’s medical record form titled “Current Treatment / Medication / DME List” the following differences were noted:Medication list: -Lispro 100unit/ml (milliliters) dose not written and route “intracavernous”-Lantus 100units/ml dose not written and frequency once a day-Metformin 500mg (milligrams) 1 tab twice a day-Pantoprazole 40mg dose not writtenLabel: -Lispro 160-220 4 units, 221-280 6 units, “subcutaneously (under the skin)”-Lantus 18 units every night at bedtime-Metformin 500mg 2 tabs twice a day-Pantoprazole 40mg 1 tab once a day Patient 4’s black bag also contained the following medications that were not listed on Patient 4’s HA’s medical record form titled “Current Treatment / Medication / DME List”:-Potassium Chloride (supplement) 20 mEq (milliequivalent – unit of measure) one tab three times per day, filled on 11/12/2024-Fluticasone (medication to treat respiratory issues) 110 mcg (micrograms – unit of measure) 1 puff every day filled 5/4/2024-Refresh tears – no label-acetaminophen (pain medication) 500 mg tab once a day as needed filled 11/12/2024-metoclopramide (nausea medication) 5mg 1 tab three times per day, filled 10/11/2024-demeclocycline (antibiotic medication) 150 mg 2 tabs twice a day, filled 3/5/2025 During a concurrent observation, interview and record review on 3/12/2025 at 9 a.m. with Patient 4, Patient 4’s medication bottles were reviewed. Patient 4 stated that aside from the medication inside his black bag, he (Patient 4) also takes vitamins that were in his drawer. The following medications were inside Patient 4’s dresser drawer: 1. B12 (supplement) and 2. Potassium gummies 500 mg.3.During a record review of Patient ‘5s medical record form titled “Personal Information”, indicated a Start of Care (SOC) date of 11/8/2024 and an End of Care (EOC) of 3/7/2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain).  During a record review of Patient 5’s medical record form titled ““Current Treatment / Medication / DME List” undated, indicated the form was left blank.  4. During a record review of Patient 12‘s medical record form titled “Personal Information”, indicated an SOC of 11/3/2024, with a terminal diagnosis of chronic diastolic heart failure.   During a joint home visit on 10/3/2023 at 10:30 a.m., with Licensed Vocational Nurse 1 (LVN 1) at Patient 12’s home residence, Patient 12 was observed. Patient 12 was alert and oriented, on oxygen at 2 liters per min (L/min) via nasal canula and lying in bed.   A review of Patient 12’s Medication Profile indicated for the following:-Lidocaine (a medication used on different parts of the body to cause numbness or loss of feeling) Pain Relief 4%, one patch, transdermal (absorbed through the skin), daily for pain-Metformin Hydrochloride (medication used to treat high blood sugar levels), 500 mg, one tablet, oral, daily for Diabetes Mellitus-Oxybutynin Chloride (medication used to treat symptoms of an overactive bladder), 5 mg, one tablet, oral, daily for BPH (benign prostatic hyperplasia, a noncancerous enlargement of the prostate gland)-Ventolin (an inhaled medication used to treat or prevent bronchospasm), 100 mcg, one puff, respiratory (inhalation), daily for shortness of breath (SOB)-Alprazolam (a medication, sold under the brand name Xanax, used to relieve symptoms of anxiety, including anxiety caused by depression), 0.25 mg, one tablet, oral, as needed by mouth-Xanax (a medication used to treat anxiety disorders and anxiety caused by depression), 0.5 mg, one tablet, oral, once a day at bedtime, for anxiety, insomnia During an interview and record review on 3/12/2025 at 11:15 a.m., with LVN1 Patient 12’s Medication Profile and medications were reviewed. The following medications were on-hand:-Lidocaine Pain Relief 5%, one patch, transdermal, daily for pain-Oxybutynin Chloride, 5 mg, one tablet, oral, at night for BPH-Ventolin 100 mcg, two puffs in the morning and two puffs at night, respiratory (inhalation), daily for shortness of breath (SOB)-Gentamycin (medication used to treat serious bacterial infection) 0.3 % eye drops, Instill one drop into both eyes twice a day for 7 days-Naproxen (a nonsteroidal anti-inflammatory drug [NSAID] used to relieve symptoms of arthritis (eg, osteoarthritis, rheumatoid arthritis), 500 mg tablet, take one tablet by mouth two times a day for pain.Ipratropium (a bronchodilator medication that dilates the airways of the lungs)-Diclofenac gel (a medication used to relieve pain from arthritis in certain joints such as those of the knees, ankles, feet, elbows, wrists, and hands)LVN1 stated that the lidocaine pain relief patch on hand was 5% did not match the strength prescribed in the Patient 12’s medication profile which was 4%. LVN1 stated that the Ventolin order on the medication list did not match the prescription label of the mediation on hand.  LVN1 stated that Patient 12’s medication on hand, gentamycin, naproxen and ipratropium were not listed on Patient 12’s Medication Profile.During an interview on 3/12/2025 at 11:23 a.m. with Caregiver 1 (CGR1), CGR1 stated that the indication for Patient 12’s oxybutynin was for bladder incontinence, not for BPH.   During an observation and interview on 3/12/2025 at 11:24 a.m. with CGR1, several small, pink pills split in half in a mediation bottle with the name “alprazolam” written in black marker was observed.  CGR1 stated that he could not find the medication bottle for Xanax, 0.5 mg or alprazolam, 0.25 mg, and only had this “alprazolam” bottle.  CGR1 stated he knew what the pills were because he cut the pills in half himself.  CGR1 stated they were the 0.5 mg pill of alprazolam, and he cut them in half to 0.25 mg.  CGR1 stated he gave one half cut pill to Patient 12 every night.

Based on interview and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 12, Patient 13, and Patient 14 ) receive an initial bereavement assessment. This failure had the potential to result in placing the patients and their family/caregiver at risk of spiritual and emotional distress. --- During an interview on 3/11/2025, at 1:18 p.m., with Registered Nurse 1 (RN 1), RN 1 stated “not sure”, when asked who the bereavement coordinator was. During an interview on 3/12/2025 at 1:20 p.m., with the Administrator (ADM), the ADM stated the HA did not have a SC or Bereavement Coordinator since December 2023 because he (ADM) did not know it was a requirement to have one. The HA did not provide the survey team with knowledgeable staff from 3/10/2025 to 3/23/2025 to review the documents as written below. 1. A review of Patient 1’s Personal Information sheet indicated a start of care date on 11/15/2024, with a diagnosis of Alzheimer’s disease (a brain disease that destroys memory and thinking skills). A record review of Patient 1’s medical record did not indicate an initial bereavement assessment was done. 2. During a record review of Patient 2’s medical record form titled “Personal Information”, indicated an SOC of 12/12/2024, with a terminal diagnosis of heart disease (a range of conditions that affect the heart which includes blood vessel disease, irregular heartbeats, or congenital heart defects).    A record review of Patient 2’s medical records did not indicate an initial bereavement assessment was done. 3. During a record review of Patient 3’s medical record form titled “Personal Information”, indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). A record review of Patient 3’s medical records did not indicate initial bereavement assessment was done. 4.During a record review of Patient 4‘s medical record form titled “Personal Information”, document indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood).  During an interview on 3/12/2025 at 9 a.m. with Patient 4, Patient 4 stated he (Patient 4) was not offered spiritual counselor services by the HA. During a record review of Patient 4’s medical record form titled “History of Bereavement Assessment” undated, indicated there were no entries made.  During a record review of Patient 4’s medical record form titled “History of Visit Notes” undated, did not indicate a medical doctor, a registered nurse, or a spiritual counselor made an entry.  During a record review of Patient 4’s electronic medical records (EMR) did not indicate a Spiritual Assessment, or an Initial Bereavement Assessment was completed.  5.During a record review of Patient ‘5s medical record form titled “Personal Information”, indicated a Start of Care (SOC) date of 11/8/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain).  During a record review of Patient 5’s medical record form titled “History of Bereavement Assessment” undated, indicated there were no entries made.  During a record review of Patient 5’s medical record form titled “History of Visit Notes” undated, did not indicate a registered nurse, or a spiritual counselor made an entry.  During a record review of Patient 5’s EMR did not indicate a Spiritual Assessment, or an Initial Bereavement Assessment was completed. 6.During a record review of Patient 6‘s medical record form titled “Personal Information”, document indicated an SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). During an interview on 3/14/2025 at 2:53 p.m. with Patient 6, Patient 6 stated he (Patient 6) has not seen a doctor for the past 2 years.  During a record review of Patient 6’s medical record form titled “History of Bereavement Assessment” undated, indicated there were no entries made.  During a record review of Patient 6’s medical record form titled “History of Visit Notes” undated, did not indicate the medical doctor, a registered nurse, or a spiritual counselor made an entry.  During a record review of Patient 6’s EMR did not indicate a Spiritual Assessment, or an Initial Bereavement Assessment was completed.  7.During a record review of Patient 7‘s medical record form titled “Personal Information”, document indicated an SOC of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (progressive lung disease causing airflow obstruction with difficulty breathing).  During an interview on 3/14/2025 at 3:34 p.m. with Patient 7’s family member (FM1), FM1 stated Patient 7 has not seen a medical doctor for the past 6-7 months.  During a record review of Patient 7’s medical record form titled “History of Bereavement Assessment” undated, indicated there were no entries made.  During a record review of Patient 7’s medical record form titled “History of Visit Notes” undated, did not indicate the medical doctor, a registered nurse, or a spiritual counselor made an entry.  During a record review of Patient 7’s EMR did not indicate a Spiritual Assessment, or an Initial Bereavement Assessment was completed. 8.During a record review of Patient 12‘s medical record form titled “Personal Information”, indicated an SOC of 11/3/2024, with a terminal diagnosis of chronic diastolic heart failure. Patient 12 medical record form did not indicate an authorized representative or an emergency contact.During a review of Patient 12’s History of Spiritual Assessment, the History of Spiritual Assessment indicated that no spiritual assessment was completed for Patient 12, who was on hospice services for four months. During a review of Patient 12’s History of Bereavement Assessment, the History of Bereavement Assessment indicated that no initial bereavement assessment was completed for Patient 12.  9.During a record review of Patient 13‘s medical record form titled “Personal Information”, indicated an SOC of 11/18/2024, with a terminal diagnosis of Alzheimer’s Disease.During a review of Patient 13’s History of Spiritual Assessment, the History of Spiritual Assessment indicated that no spiritual assessment was completed for Patient 13.During a review of Patient 13’s History of Bereavement Assessment, the History of Bereavement Assessment indicated that no initial bereavement assessment was completed for Patient 13.    10.During a record review of Patient 14‘s “medical record form titled Personal Information”, indicated an SOC of 11/12/2024, with a terminal diagnosis of chronic diastolic heart failure.  During a review of Patient 14’s History of Bereavement Assessment, the History of Bereavement Assessment indicated that no initial bereavement assessment was completed for Patient 14.During a review of Patient 14’s History of Spiritual Assessment, the History of Spiritual Assessment indicated that no spiritual assessment was completed for Patient 14, who was on hospice services for four months.

Based on observation, interview and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for seven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7).  This failure resulted in patients not being properly evaluated which resulted in not being provided individualized focused care. --- During an interview on 3/12/2025 at 1:20 p.m., with the Administrator (ADM), the ADM stated the HA did not have a SC or Bereavement Coordinator since December 2023 because he (ADM) did not know it was a requirement to have one. During an interview on 3/12/2025 at 1:22p.m., with the ADM, the ADM stated the HA did not have a Director of Nurses (DON) since December 2023. The ADM stated he (ADM) was the one overseeing the licensed nurses. During an interview on 3/12/2025 at 1:35 p.m., with the ADM, the ADM stated he (ADM) was not sure what the IDG was.  During an interview on 3/13/2025, at 11:50 a.m., the ADM stated there was no Medical Director from December 2023 until January 2025, when the new Medical Director was hired. The HA did not provide the survey team with knowledgeable staff from 3/10/2025 to 3/23/2025 to review the documents as written below. Findings: 1. A review of Patient 1’s Personal Information sheet indicated a start of care date on 11/15/2024, with a diagnosis of Alzheimer’s disease (a brain disease that destroys memory and thinking skills). During an observation of the home visit on 3/12/2025 at 10:40 a.m., with RN 1, Patient 1 was awake and alert. Patient 1 was lying in bed, with both side rails up. Patient 1 was non-interview able.  During an interview at the home visit on 3/12/2025, at 11:21 a.m., RN 1 stated he had done the start of care visit. RN 1 stated the medications ordered on admission included psychotropic medications (those that affect brain function) Ambien (to help sleep), Lorazepam (treats anxiety), Lexapro (treats depression), and Risperidone (treats symptoms of schizophrenia).      A record review of Patient 1’s medical records did not indicate any evidence of a medical evaluation and medical documents to support Patient 1’s medical diagnoses and need for psychotropic medications.  During a concurrent interview and record review on 3/13/2025, at 11:01 a.m., with the HA’s contracted pharmacist (PHARM 1), Patient 1’s record titled, “Physician’s Order”, dated 11/15/2024 was reviewed. PHARM 1 stated the ADM placed the orders for Ambien 5 (mg-milligrams, unit of measurement) 1 tablet oral at bedtime, Lorazepam 0.5 mg 1 tablet every 4 to 6 hours as needed for anxiety, Lexapro 10 mg 1 tablet once a day, and Risperidone 1 mg 1 tablet twice a day. During a concurrent interview and record review on 3/13/2025, at 11:01 a.m., with PHARM 1, Patient 1’s record titled, “Physician’s Order”, dated 12/27/2024 was reviewed. PHARM 1 stated the ADM placed the orders for increase of medication doses: Ambien 10 1 tablet oral at bedtime, Lorazepam 2 mg 1 tablet oral, every 4 to 6 hours as needed for anxiety, and Risperidone 2 mg 1 tablet oral, twice a day. A record review of Patient 1’s document titled, “POC/IDG Review”, dated 1/6/2025, did not indicate about the patient behaviors and need to change the medication dosages. The record indicated “Currently taking Risperidone 1 mg BID for schizophrenia…On Ambien 5 mg tablet for insomnia management.” Further review of the record did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to update the comprehensive assessment. A record review of Patient 1’s document titled, “POC/IDG Review”, dated 1/20/2025, did not indicate monitoring regarding patient behavior while on psychotropic medications. The record indicated “Currently taking Risperidone 1 mg BID for schizophrenia. Further review of the record did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to update the comprehensive assessment. A record review of Patient 1’s document titled, “POC/IDG Review”, dated 2/3/2025, did not indicate monitoring regarding patient behavior while on psychotropic medications. The record indicated “Currently taking Risperidone 1 mg BID for schizophrenia…On Ambien 5 mg tablet for insomnia management.” Further review of the record did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to update the comprehensive assessment. During an interview on 3/14/2025, at 11:48 a.m., the Pharmacist (PHARM 2), stated Risperidone for patients who have dementia, puts them at risk of early death and stroke. The medication has a black box warning (the drug has a serious risk of side effects that may impact life). When this medication is increased, there are significant risks and side effects such as movement disorder, dry mouth, dizziness, drowsiness, which puts the patient at risk of falling. Increasing the dose, increases the risk.  During an interview on 3/14/2025, at 11:48 a.m., the PHARM 2 stated Lorazepam required well documented evidence of behavior to justify the need for the medication. The risks of this medication were drowsiness, dizziness, risk of fall with injury, especially in the elderly. If the medication was increased to 2mg, it would require a medical evaluation. Especially psychiatry, especially if the indication was schizophrenia.  The PHARM 2 stated it was problematic to increase Lorazepam and Risperidone at the same time, as clinical rationale was needed. Normally, one medication would be increased at a time, to try to see if it is effective in controlling the issues. If you increase medications at the same time, you don’t know which medication is effective, and you are increasing the risk of injury. The PHARM 2 stated medications Risperidone and Lorazepam, together were a form of chemical restraint. Having Ambien, in addition, really ensured Patient 1 was asleep.  A record review of Patient 1’s document titled, “POC/IDG Review”, dated 11/16/2024, 11/25/2024, and 12/9/2024 did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to update the comprehensive assessment.  A record review of Patient 1’s document titled, “POC/IDG Review”, dated 12/23/2024, indicated “occasionally exhibits s/s (signs and symptoms) of anxiety relieved with current medications”. Further review of the record did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to update the comprehensive assessment.  A record review of Patient’s 1 medical record indicated the last document “POC/IDG” was dated 2/3/2025. No other IDG’s were documented. 2. During a record review of Patient 2’s medical record form titled “Personal Information”, indicated an SOC of 12/12/2024, with a terminal diagnosis of heart disease (a range of conditions that affect the heart which includes blood vessel disease, irregular heartbeats, or congenital heart defects).    A record review of Patient 2’s document titled, “POC/IDG Review”, dated 12/13/2024, 1/20/2025, and 2/3/2025 did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to update the comprehensive assessment. 3. During a record review of Patient 3’s medical record form titled “Personal Information”, indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). A record review of Patient 3’s document titled, “POC/IDG Review”, dated 11/25/2024, 2/3/2025, and 2/17/2025 did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to update the comprehensive assessment.  A record review of Patient 3’s medical record indicated the last document “POC/IDG” was dated 2/17/2025. No other IDG’s were documented.  4.During a record review of Patient 4‘s medical record form titled “Personal Information”, document indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood). During a record review of Patient 4’s medical record form titled “History of POC/IDG” undated, indicated there were two entries made on 2/3/2025 and 2/17/2025. During a record review of Patient 4‘s medical record form titled “POC/IDG Review” dated 2/3/2025, an17 2/3/2025, indicated the forms were not signed by any of the IDG members.  During a record review of Patient 4’s EMR did not indicate any documented evidence Patient 4 had any comprehensive assessments completed by the IDG.  5.During a record review of Patient ‘5s medical record form titled “Personal Information”, indicated a Start of Care (SOC) date of 11/8/2024 and an End of Care (EOC) of 3/7/2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain).  During a record review of the HA’s form untitled, dated 3/13/2025, indicated Patient 5 had a SOC date of 11/8/2025 and an EOC date of 3/7/2025. During a record review of the HA’s form untitled, dated 3/18/2025, indicated Patient 5 had a SOC date of 11/8/2025 and an EOC date of 3/5/2025. During a record review of Patient 5’s medical record form titled “History of POC/IDG” undated, indicated there were no entries made.  During a record review of Patient 5’s electronic medical record (EMR) did not indicate any documented evidence Patient 5 had any comprehensive assessments completed by the IDG.   6.During a record review of Patient 6‘s medical record form titled “Personal Information”, indicated a SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain).  During an interview on 3/14/2025 at 2:53 p.m. with Patient 6, Patient 6 stated he (Patient 6) has not seen a doctor for the past 2 years.  During a record review of Patient 6’s EMR form titled “History of POC/IDG” undated, indicated the first entry was documented on 11/25/2024 and last entry was documented on 2/3/2025. During a record review of Patient 6‘s medical record form titled “POC/IDG Review” dated 11/25/2024, 1/6/2025, 1/20/2025, and 2/3/2025, indicated the forms were not signed by any of the IDG members.  During a record review of Patient 6’s EMR did not indicate any documented evidence Patient 6 had any comprehensive assessments completed by the IDG. 7.During a record review of Patient 7‘s medical record form titled “Personal Information”, indicated a SOC date of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (progressive lung disease causing airflow obstruction with difficulty breathing). During an interview on 3/14/2025 at 3:34 p.m. with Patient 7’s family member (FM1), FM1 stated Patient 7 has not seen a medical doctor for the past 6-7 months. During a record review of Patient 7’s medical record form titled “History of POC/IDG” undated, indicated the first entry was documented on 11/13/2024 and the last entry was documented on 2/3/2025. During a record review of Patient 7‘s medical record form titled “POC/IDG Review” dated 11/13/2024, 1/6/2025, 1/20/2025, and 2/3/2025, indicated the forms were not signed by any of the IDG members.  During a record review of Patient 7’s EMR did not indicate any documented evidence Patient 7 had any comprehensive assessment completed by the IDG.

Based on observation, interview, and record review, the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation regarding care planning and coordination of services for patients was met as follows: --- 1. The HA failed to ensure it had an interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain (SC), and Physicians (MD) come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and their families) to provide care and oversight to seven of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). (Refer to L539).2. The HA failed to ensure their interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain (SC), and Physicians (MD) come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and their families) included an MD, or an SC to holistically plan the care for seven of fourteen sample patients (Patient 4, Patient 5, Patient 6, Patient 7, Patient 12, Patient 13, and Patient 14). (Refer to L541). 3. The HA failed to ensure one of fourteen sample patients (Patient 5) had an individualized Plan of Care (POC) established to reflect Patient 5’s problems, interventions, goals, and services necessary to provide essential care. (Refer to L545).  4. The HA failed to ensure the services and frequencies of those services were outlined for six of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, and Patient 7). (Refer to L547).  5. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) reviewed and revised seven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7) plan of care (POC- an individualized care planned) at least every 15 days as required.. (Refer to L552).  The cumulative effect of these systemic practices resulted in the HA not providing the services/care as ordered and had the potential for the patients not receiving appropriate healthcare services that could affect their quality of life.

Based on observation, interview, and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure it had an interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain (SC), and Physicians (MD) come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and their families) to provide care and oversight to seven of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7)This failure resulted in patients not being properly evaluated which resulted in not being provided individualized focused care. --- During an interview on 3/11/2025, at 1:18 p.m., with Registered Nurse 1 (RN1), RN1 stated “not sure”, when asked who the bereavement coordinator was. During an interview on 3/12/2025 at 1:20 p.m., with the Administrator (ADM), the ADM stated the HA did not have a SC or Bereavement Coordinator since December 2023 because he (ADM) did not know it was a requirement to have one. During an interview on 3/12/2025 at 1:35 p.m., with the ADM, the ADM stated he (ADM) was not sure what the IDG was. During an interview on 3/12/2025 at 2:18 p.m. with the Medical Director 2 (MD2), the MD2 stated she (MD2) has been the HA’s Medical Director since February 2025. The MD2 stated she (MD2) did not know who the Medical Director was prior to her (MD2). The MD2 stated she (MD2) took over the HA’s patients care.  During an interview on 3/13/2025, at 11:50 a.m., with the ADM, the ADM stated he became the owner of the HA in December of 2023. The ADM stated there was no assigned Medical Director for the HA from December 2023 until January 2025. The ADM stated the first and only HA Medical Director, was MD2. The ADM stated MD2 was hired in January 2025.  During a record review of document provided by MD2, untitled, dated “as of January 31,2025” indicated MD2 signed a contract with the HA on 1/31/2025. The document was signed by the ADM on 2/3/2025 and MD2 on 1/31/2025. The HA did not provide the survey team with knowledgeable staff from 3/10/2025 to 3/23/2025 to review the documents as written below.  1. A review of Patient 1’s Personal Information sheet indicated a start of care date on 11/15/2024, with a diagnosis of Alzheimer’s disease (a brain disease that destroys memory and thinking skills). During an observation of the home visit on 3/12/2025 at 10:40 a.m., with RN 1, Patient 1 was awake and alert. Patient 1 was lying in bed, with both side rails up. Patient 1 was non-interview able.  During an interview at the home visit on 3/12/2025, at 11:21 a.m., RN 1 stated he had done the start of care visit. RN 1 stated the medications ordered on admission included psychotropic medications (those that affect brain function) Ambien (to help sleep), Lorazepam (treats anxiety), Lexapro (treats depression), and Risperidone (treats symptoms of schizophrenia).      A record review of Patient 1’s medical records did not indicate any evidence of a medical evaluation and medical documents to support Patient 1’s medical diagnoses and need for psychotropic medications.  During a concurrent interview and record review on 3/13/2025, at 11:01 a.m., with the HA’s contracted pharmacist (PHARM 1), Patient 1’s record titled, “Physician’s Order”, dated 11/15/2024 was reviewed. PHARM 1 stated the ADM placed the orders for Ambien 5 (mg-milligrams, unit of measurement) 1 tablet oral at bedtime, Lorazepam 0.5 mg 1 tablet every 4 to 6 hours as needed for anxiety, Lexapro 10 mg 1 tablet once a day, and Risperidone 1 mg 1 tablet twice a day. During a concurrent interview and record review on 3/13/2025, at 11:01 a.m., with PHARM 1, Patient 1’s record titled, “Physician’s Order”, dated 12/27/2024 was reviewed. PHARM 1 stated the ADM placed the orders for increase of medication doses: Ambien 10 1 tablet oral at bedtime, Lorazepam 2 mg 1 tablet oral, every 4 to 6 hours as needed for anxiety, and Risperidone 2 mg 1 tablet oral, twice a day. A record review of Patient 1’s document titled, “POC/IDG Review”, dated 1/6/2025, did not indicate about the patient behaviors and need to change the medication dosages. The record indicated “Currently taking Risperidone 1 mg BID for schizophrenia…On Ambien 5 mg tablet for insomnia management.” Further review of the record did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to provide an individualized plan of care. A record review of Patient 1’s document titled, “POC/IDG Review”, dated 1/20/2025, did not indicate monitoring regarding patient behavior while on psychotropic medications. The record indicated “Currently taking Risperidone 1 mg BID for schizophrenia. Further review of the record did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to provide an individualized plan of care.  A record review of Patient 1’s document titled, “POC/IDG Review”, dated 2/3/2025, did not indicate monitoring regarding patient behavior while on psychotropic medications. The record indicated “Currently taking Risperidone 1 mg BID for schizophrenia…On Ambien 5 mg tablet for insomnia management.” Further review of the record did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to provide an individualized plan of care. During an interview on 3/14/2025, at 11:48 a.m., the Pharmacist (PHARM 2), stated Risperidone for patients who have dementia, puts them at risk of early death and stroke. The medication has a black box warning (the drug has a serious risk of side effects that may impact life). When this medication is increased, there are significant risks and side effects such as movement disorder, dry mouth, dizziness, drowsiness, which puts the patient at risk of falling. Increasing the dose, increases the risk.  During an interview on 3/14/2025, at 11:48 a.m., the PHARM 2 stated Lorazepam required well documented evidence of behavior to justify the need for the medication. The risks of this medication were drowsiness, dizziness, risk of fall with injury, especially in the elderly. If the medication was increased to 2mg, it would require a medical evaluation. Especially psychiatry, especially if the indication was schizophrenia.  The PHARM 2 stated it was problematic to increase Lorazepam and Risperidone at the same time, as clinical rationale was needed. Normally, one medication would be increased at a time, to try to see if it is effective in controlling the issues. If you increase medications at the same time, you don’t know which medication is effective, and you are increasing the risk of injury. The PHARM 2 stated medications Risperidone and Lorazepam, together were a form of chemical restraint. Having Ambien, in addition, really ensured Patient 1 was asleep.  A record review of Patient 1’s document titled, “POC/IDG Review”, dated 11/16/2024, 11/25/2024, and 12/9/2024 did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to provide an individualized plan of care. A record review of Patient 1’s document titled, “POC/IDG Review”, dated 12/23/2024, indicated “occasionally exhibits s/s (signs and symptoms) of anxiety relieved with current medications”. Further review of the record did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to provide an individualized plan of care.  2. During a record review of Patient 2’s medical record form titled “Personal Information”, indicated an SOC of 12/12/2024, with a terminal diagnosis of heart disease (a range of conditions that affect the heart which includes blood vessel disease, irregular heartbeats, or congenital heart defects).    A record review of Patient 2’s document titled, “POC/IDG Review”, dated 12/13/2024, 1/20/2025, and 2/3/2025 did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to provide an individualized plan of care.  3. During a record review of Patient 3’s medical record form titled “Personal Information”, indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). A record review of Patient 3’s document titled, “POC/IDG Review”, dated 11/25/2024, 2/3/2025, and 2/17/2025 did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to provide an individualized plan of care. 4.During a record review of Patient 4‘s medical record form titled “Personal Information”, document indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood). 5.During a record review of Patient ‘5s medical record form titled “Personal Information”, indicated a Start of Care (SOC) date of 11/8/2024 and an End of Care (EOC) of 3/7/2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain).  6.During a record review of Patient 6‘s medical record form titled “Personal Information”, indicated a SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain).  7.During a record review of Patient 7‘s medical record form titled “Personal Information”, indicated a SOC date of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (progressive lung disease causing airflow obstruction with difficulty breathing).

Based on interview and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure their interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain (SC), and Physicians (MD) come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and their families) included an MD, and an SC to holistically plan the care for seven of fourteen sample patients (Patient 4, Patient 5, Patient 6, Patient 7, Patient 12, patient 13, and Patient 14).  This failure had the potential to result in patients not being provided the individualized end of life care needed, which could lead to frustration, pain and suffering. --- During an interview on 3/11/2025, at 1:18 p.m., with Registered Nurse 1 (RN1), RN1 stated “not sure”, when asked who the bereavement coordinator was. During an interview on 3/12/2025 at 1:20 p.m., with the Administrator (ADM), the ADM stated the HA did not have a SC or Bereavement Coordinator since December 2023 because he (ADM) did not know it was a requirement to have one. During an interview on 3/12/2024, at 1:15 p.m., the ADM stated he did not have contact information for Medical Director 1 (MD 1). A request was made for the employee file for MD 1. The ADM stated he would email the file. The file was not sent to the survey team as of 3/24/2025. During an interview on 3/12/2025 at 2:18 p.m. with the Medical Director 2 (MD2), the MD2 stated she (MD2) has been the HA’s Medical Director since February 2025. The MD2 stated she (MD2) did not know who the Medical Director was prior to her (MD2). The MD2 stated she (MD2) took over the HA’s patients care.  During an interview on 3/13/2025 at 11:50 a.m., with the ADM, the ADM stated he became the owner of the HA in December of 2023. The ADM stated there was no assigned Medical Director for the HA from December 2023 until January 2025. The ADM stated the first and only HA Medical Director, was MD2. The ADM stated MD2 was hired in January 2025.  During a record review of document provided by MD2, untitled, dated “as of January 31,2025” indicated MD2 signed a contract with the HA on 1/31/2025. The document was signed by the ADM on 2/3/2025 and MD2 on 1/31/2025. The HA did not provide the survey team with knowledgeable staff from 3/10/2025 to 3/23/2025 to review the documents as written below.  1.During a record review of Patient 4‘s medical record form titled “Personal Information”, document indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood). During a record review of Patient 4’s medical record form titled “History of POC/IDG” undated, indicated there were two entries made on 2/3/2025 and 2/17/2025. During a record review of Patient 4‘s medical record form titled “POC/IDG Review” dated 2/3/2025, and 2/3/2025, indicated the forms were not signed by any of the IDG members.  During a record review of Patient 4’s EMR did not indicate any documented evidence Patient 4 had any comprehensive assessments completed by an IDG.  2.During a record review of Patient ‘5s medical record form titled “Personal Information”, indicated a Start of Care (SOC) date of 11/8/2024 and an End of Care (EOC) of 3/7/2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain).  During a record review of Patient 5’s medical record form titled “History of POC/IDG” undated, indicated there were no entries made.  During a record review of Patient 5’s electronic medical record (EMR) did not indicate any documented evidence Patient 5 had any comprehensive assessments completed by an IDG.  3.During a record review of Patient 6‘s medical record form titled “Personal Information”, indicated a SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain).  During an interview on 3/14/2025 at 2:53 p.m. with Patient 6, Patient 6 stated he (Patient 6) has not seen a doctor for the past 2 years.  During a record review of Patient 6’s EMR form titled “History of POC/IDG” undated, indicated the first entry was documented on 11/25/2024 and last entry was documented on 2/3/2025. During a record review of Patient 6‘s medical record form titled “POC/IDG Review” dated 11/25/2024, 1/6/2025, 1/20/2025, and 2/3/2025, indicated the forms were not signed by any of the IDG members.  During a record review of Patient 6’s EMR did not indicate any documented evidence Patient 6 had any comprehensive assessments completed by an IDG. 4.During a record review of Patient 7‘s medical record form titled “Personal Information”, indicated a SOC date of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (progressive lung disease causing airflow obstruction with difficulty breathing). During an interview on 3/14/2025 at 3:34 p.m. with Patient 7’s family member (FM1), FM1 stated Patient 7 has not seen a medical doctor for the past 6-7 months. During a record review of Patient 7’s medical record form titled “History of POC/IDG” undated, indicated the first entry was documented on 11/13/2024 and the last entry was documented on 2/3/2025. During a record review of Patient 7‘s medical record form titled “POC/IDG Review” dated 11/13/2024, 1/6/2025, 1/20/2025, and 2/3/2025, indicated the forms were not signed by any of the IDG members.  During a record review of Patient 7’s EMR did not indicate any documented evidence Patient 7 had any comprehensive assessment completed by an IDG. 5.During a record review of Patient 12‘s medical record form titled “Personal Information”, indicated an SOC of 11/3/2024, with a terminal diagnosis of chronic diastolic heart failure. During a review of Patient 12’s “POC/IDG Review” with the following dates:  11/4/2024, 2/3/2025, and 2/17/2025, the IDG did not indicate a registered nurse, medical director, chaplain or social worker updated the comprehensive assessment. 6.During a record review of Patient 13‘s medical record form titled “Personal Information”, indicated an SOC of 11/18/2024, with a terminal diagnosis of Alzheimer’s Disease.  During a review of Patient 13’s “POC/IDG Review” with the following dates:  1/6/2025 and 1/20/2025, the IDG did not indicate a registered nurse updated the comprehensive assessment. 7.During a record review of Patient 14‘s “medical record form titled Personal Information”, indicated an SOC of 11/12/2024, with a terminal diagnosis of chronic diastolic heart failure.   During a review of Patient 14’s “POC/IDG Review” with the following dates:  11/13/2024, 1/20/2025, and 2/3/2025, the IDG did not indicate a registered nurse, medical director, chaplain or social worker, updated the comprehensive assessment.

Based on record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure one of fourteen sample patients (Patient 5) had an individualized Plan of Care (POC) established to reflect Patient 5’s problems, interventions, goals, and services necessary to provide essential care.  This failure had the potential to result in missed care and visits which may lead to worsening of condition causing hospitalization and/or death. --- The HA did not provide the survey team with knowledgeable staff from 3/10/2025 to 3/23/2025 to review the documents as written below. During a record review of Patient ‘5s medical record form titled “Personal Information”, indicated a Start of Care (SOC) date of 11/8/2024 and an End of Care (EOC) of 3/7/2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain).  During a record review of Patient 5’s medical record form titled “History of POC/IDG” undated, indicated there were no entries made.  During a record review of Patient 5’s medical record form titled “POC Summary” dated as of 3/11/2025, indicated all sections from 1-14 were left blank.  During a record review of Patient 5’s electronic medical record (EMR) did not indicate any documented evidence Patient 5 had any comprehensive assessments completed by an IDG.

Based on 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 services and frequencies of those services were planned and scheduled for six of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, and Patient 7) This failure had the potential to cause confusion among patients and their caregivers/family. It also could have potentially cause missed visits due to not know when HA staff was to visit. --- 1. A review of Patient 1’s Personal Information sheet indicated a start of care date on 11/15/2024, with a diagnosis of Alzheimer’s disease (a brain disease that destroys memory and thinking skills). A record review of Patient 1’s document titled, “POC/IDG Review”, dated 11/16/2024, 11/25/2024, and 12/9/2024, 12/23/2024, 1/6/2025, 1/20/2025, and 2/3/2025, did not indicate a frequency of visits. A record review of Patient 1’s document titled, “POC Summary as of 3/11/2025", did not indicate the frequency of visits. 2.During a record review of Patient 2’s medical record form titled “Personal Information”, indicated an SOC of 12/12/2024, with a terminal diagnosis of heart disease (a range of conditions that affect the heart which includes blood vessel disease, irregular heartbeats, or congenital heart defects).    A record review of Patient 2’s document titled, “POC/IDG Review”, dated 12/13/2024, 1/20/2025, and 2/3/2025 did not indicate a frequency of visits. 3. During a record review of Patient 3’s medical record form titled “Personal Information”, indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). A record review of Patient 3’s document titled, “POC/IDG Review”, dated 11/25/2024, 2/3/2025, and 2/17/2025 did not indicate a frequency of visits. A record review of Patient 3’s document titled, “POC Summary as of 3/12/2025", did not indicate the frequency of visits. 4.During a record review of Patient 4‘s medical record form titled “Personal Information”, document indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood). During a record review of Patient 4’s medical record form titled “POC (individualized plan of care) Summary” dated as of 3/11/2025, indicated section frequency of visits was left blank.  During a record review of Patient 4’s EMR, Patient 4’s EMR did not indicate any documented evidence Patient 4 had a comprehensive assessment completed by the HA’s interdisciplinary group (IDG - meeting where the Registered Nurse, Medical Social Worker, Chaplain, and Physician come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and their families), including Patient 4’s services and their frequency.  5.During a record review of Patient 6‘s medical record form titled “Personal Information”, indicated a SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain).  During a record review of Patient 6’s medical record form titled “POC (individualized plan of care) Summary” dated as of 3/11/2025, indicated section frequency of visits was left blank.  During a record review of Patient 6’s EMR, Patient 6’s EMR did not indicate any documented evidence Patient 6 had a comprehensive assessment completed by the HA’s IDG, including Patient 6’s services and their frequency.  6.During a record review of Patient 7‘s medical record form titled “Personal Information”, indicated a SOC date of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (progressive lung disease causing airflow obstruction with difficulty breathing). During a record review of Patient 7’s medical record form titled “POC (individualized plan of care) Summary” dated as of 3/11/2025, indicated section frequency of visits was left blank.  During a record review of Patient 7’s EMR, Patient 7’s EMR did not indicate any documented evidence Patient 7 had a comprehensive assessment completed by the HA’s IDG, including Patient 7’s services and their frequency.

Based on interview and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) reviewed and revised seven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7) plan of care (POC- an individualized care planned) at least every 15 days as required.   This failure resulted in patients not being properly evaluated which resulted in not being provided individualized focused care. --- During an interview on 3/12/2025 at 1:20 p.m., with the Administrator (ADM), the ADM stated the HA did not have a SC or Bereavement Coordinator since December 2023 because he (ADM) did not know it was a requirement to have one. During an interview on 3/12/2025 at 1:22p.m., with the ADM, the ADM stated the HA did not have a Director of Nurses (DON) since December 2023. The ADM stated he (ADM) was the one overseeing the licensed nurses. During an interview on 3/12/2025 at 1:35 p.m., with the ADM, the ADM stated he (ADM) was not sure what the IDG was.  During an interview on 3/13/2025, at 11:50 a.m., the ADM stated there was no Medical Director from December 2023 until January 2025, when the new Medical Director was hired. The HA did not provide the survey team with knowledgeable staff from 3/10/2025 to 3/23/2025 to review the documents as written below.   1. A review of Patient 1’s Personal Information sheet indicated a start of care date on 11/15/2024, with a diagnosis of Alzheimer’s disease (a brain disease that destroys memory and thinking skills). During an observation of the home visit on 3/12/2025 at 10:40 a.m., with RN 1, Patient 1 was awake and alert. Patient 1 was lying in bed, with both side rails up. Patient 1 was non-interview able.  During an interview at the home visit on 3/12/2025, at 11:21 a.m., RN 1 stated he had done the start of care visit. RN 1 stated the medications ordered on admission included psychotropic medications (those that affect brain function) Ambien (to help sleep), Lorazepam (treats anxiety), Lexapro (treats depression), and Risperidone (treats symptoms of schizophrenia).      A record review of Patient 1’s medical records did not indicate any evidence of a medical evaluation and medical documents to support Patient 1’s medical diagnoses and need for psychotropic medications.  During a concurrent interview and record review on 3/13/2025, at 11:01 a.m., with the HA’s contracted pharmacist (PHARM 1), Patient 1’s record titled, “Physician’s Order”, dated 11/15/2024 was reviewed. PHARM 1 stated the ADM placed the orders for Ambien 5 (mg-milligrams, unit of measurement) 1 tablet oral at bedtime, Lorazepam 0.5 mg 1 tablet every 4 to 6 hours as needed for anxiety, Lexapro 10 mg 1 tablet once a day, and Risperidone 1 mg 1 tablet twice a day. During a concurrent interview and record review on 3/13/2025, at 11:01 a.m., with PHARM 1, Patient 1’s record titled, “Physician’s Order”, dated 12/27/2024 was reviewed. PHARM 1 stated the ADM placed the orders for increase of medication doses: Ambien 10 1 tablet oral at bedtime, Lorazepam 2 mg 1 tablet oral, every 4 to 6 hours as needed for anxiety, and Risperidone 2 mg 1 tablet oral, twice a day. A record review of Patient 1’s document titled, “POC/IDG Review”, dated 1/6/2025, did not indicate about the patient behaviors and need to change the medication dosages. The record indicated “Currently taking Risperidone 1 mg BID for schizophrenia…On Ambien 5 mg tablet for insomnia management.” Further review of the record did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to update the plan of care. A record review of Patient 1’s document titled, “POC/IDG Review”, dated 1/20/2025, did not indicate monitoring regarding patient behavior while on psychotropic medications. The record indicated “Currently taking Risperidone 1 mg BID for schizophrenia. Further review of the record did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to update the plan of care. A record review of Patient 1’s document titled, “POC/IDG Review”, dated 2/3/2025, did not indicate monitoring regarding patient behavior while on psychotropic medications. The record indicated “Currently taking Risperidone 1 mg BID for schizophrenia…On Ambien 5 mg tablet for insomnia management.” Further review of the record did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to update the plan of care. During an interview on 3/14/2025, at 11:48 a.m., the Pharmacist (PHARM 2), stated Risperidone for patients who have dementia, puts them at risk of early death and stroke. The medication has a black box warning (the drug has a serious risk of side effects that may impact life). When this medication is increased, there are significant risks and side effects such as movement disorder, dry mouth, dizziness, drowsiness, which puts the patient at risk of falling. Increasing the dose, increases the risk.  During an interview on 3/14/2025, at 11:48 a.m., the PHARM 2 stated Lorazepam required well documented evidence of behavior to justify the need for the medication. The risks of this medication were drowsiness, dizziness, risk of fall with injury, especially in the elderly. If the medication was increased to 2mg, it would require a medical evaluation. Especially psychiatry, especially if the indication was schizophrenia.  The PHARM 2 stated it was problematic to increase Lorazepam and Risperidone at the same time, as clinical rationale was needed. Normally, one medication would be increased at a time, to try to see if it is effective in controlling the issues. If you increase medications at the same time, you don’t know which medication is effective, and you are increasing the risk of injury. The PHARM 2 stated medications Risperidone and Lorazepam, together were a form of chemical restraint. Having Ambien, in addition, really ensured Patient 1 was asleep.  A record review of Patient 1’s document titled, “POC/IDG Review”, dated 11/16/2024, 11/25/2024, and 12/9/2024 did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to update the plan of care.  A record review of Patient 1’s document titled, “POC/IDG Review”, dated 12/23/2024, indicated “occasionally exhibits s/s (signs and symptoms) of anxiety relieved with current medications”. Further review of the record did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to update the plan of care.  A record review of Patient’s 1 medical record indicated the last document “POC/IDG” was dated 2/3/2025. No other IDG’s were documented. 2. During a record review of Patient 2’s medical record form titled “Personal Information”, indicated an SOC of 12/12/2024, with a terminal diagnosis of heart disease (a range of conditions that affect the heart which includes blood vessel disease, irregular heartbeats, or congenital heart defects).    A record review of Patient 2’s document titled, “POC/IDG Review”, dated 12/13/2024, 1/20/2025, and 2/3/2025 did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to update the plan of care. 3. During a record review of Patient 3’s medical record form titled “Personal Information”, indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). A record review of Patient 3’s document titled, “POC/IDG Review”, dated 11/25/2024, 2/3/2025, and 2/17/2025 did not indicate a signature for the MD, SC, MSW, and RN to validate the group met to update the plan of care.  A record review of Patient 3’s medical record indicated the last document “POC/IDG” was dated 2/17/2025. No other IDG’s were documented. 4.During a record review of Patient 4‘s medical record form titled “Personal Information”, document indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood). During a record review of Patient 4’s medical record form titled “History of POC/IDG” undated, indicated there were two entries made on 2/3/2025 and 2/17/2025. During a record review of Patient 4‘s medical record form titled “POC/IDG Review” dated 2/3/2025, an17 2/3/2025, indicated the forms were not signed by any of the IDG members.  During a record review of Patient 4’s EMR did not indicate any documented evidence Patient 4 had any comprehensive assessments completed by the IDG.  5.During a record review of Patient ‘5s medical record form titled “Personal Information”, indicated a Start of Care (SOC) date of 11/8/2024 and an End of Care (EOC) of 3/7/2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain).  During a record review of the HA’s form untitled, dated 3/13/2025, indicated Patient 5 had a SOC date of 11/8/2025 and an EOC date of 3/7/2025. During a record review of the HA’s form untitled, dated 3/18/2025, indicated Patient 5 had a SOC date of 11/8/2025 and an EOC date of 3/5/2025. During a record review of Patient 5’s medical record form titled “History of POC/IDG” undated, indicated there were no entries made.  During a record review of Patient 5’s electronic medical record (EMR) did not indicate any documented evidence Patient 5 had any comprehensive assessments completed by the IDG.   6.During a record review of Patient 6‘s medical record form titled “Personal Information”, indicated a SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain).  During an interview on 3/14/2025 at 2:53 p.m. with Patient 6, Patient 6 stated he (Patient 6) has not seen a doctor for the past 2 years.  During a record review of Patient 6’s EMR form titled “History of POC/IDG” undated, indicated the first entry was documented on 11/25/2024 and last entry was documented on 2/3/2025. During a record review of Patient 6‘s medical record form titled “POC/IDG Review” dated 11/25/2024, 1/6/2025, 1/20/2025, and 2/3/2025, indicated the forms were not signed by any of the IDG members.  During a record review of Patient 6’s EMR did not indicate any documented evidence Patient 6 had any comprehensive assessments completed by the IDG. 7.During a record review of Patient 7‘s medical record form titled “Personal Information”, indicated a SOC date of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (progressive lung disease causing airflow obstruction with difficulty breathing). During an interview on 3/14/2025 at 3:34 p.m. with Patient 7’s family member (FM1), FM1 stated Patient 7 has not seen a medical doctor for the past 6-7 months. During a record review of Patient 7’s medical record form titled “History of POC/IDG” undated, indicated the first entry was documented on 11/13/2024 and the last entry was documented on 2/3/2025. During a record review of Patient 7‘s medical record form titled “POC/IDG Review” dated 11/13/2024, 1/6/2025, 1/20/2025, and 2/3/2025, indicated the forms were not signed by any of the IDG members.  During a record review of Patient 7’s EMR did not indicate any documented evidence Patient 7 had any comprehensive assessment completed by the IDG.

Based on interview and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation for License Professional Services was met as evidence by: --- 1. The HA failed to provide evidence their licensed providers were authorized and qualified to provide hospice services to fourteen of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L584).The cumulative effect of these systemic practices resulted in the HA not ensuring their license personnel were providing services/care as required and had the potential for the patients not receiving appropriate healthcare services that could affect their quality of life.

Based on interview and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to provide evidence their licensed providers were authorized and qualified to provide hospice services to fourteen of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14 ). This failure had the potential to result in patient being taken care of unqualified and unauthorized staff. --- During an interview on 3/11/2025 at 12:54 p.m., with Registered Nurse 1 (RN 1), the RN1 stated he (RN1) did not know where the employee files were. RN 1 stated he (RN1) did not know where the human resource files were for the employees.During an interview on 3/11/2025 at 1:00 p.m., RN 1 stated employee files were important to have because the surveyors were requesting them. The employee files were to make sure everyone is compliant with their cardiopulmonary resuscitation certificate (CPR), license, competency and evaluations.During an observation on 3/11/2025 at 1:46 p.m., of the HA, 4 rooms were observed. The cabinets, file cabinets, and drawers were empty.During an interview on 3/13/2025 at 11:50 a.m., with the Administrator (ADM), the ADM stated he (ADM) was not a licensed nurse or a licensed medical doctor. 1. A review of Patient 1’s Personal Information sheet indicated a start of care date on 11/15/2024, with a diagnosis of Alzheimer’s disease (a brain disease that destroys memory and thinking skills). A record review of Patient 1’s documented “Physician Order”, dated 11/15/2024, indicated the ADM “Phone Order/Read Back Order”, with MD 1. A record review of Patient 1’s documented “Physician Order”, dated 2/11/2025, indicated Registered Nurse 2 (RN 2) “Phone Order/Read Back Order”, with MD 1, to discontinue medications Ambien (to help sleep), Risperidone (controls symptoms of schizophrenia), and Lorazepam (to help with anxiety). A record review on 3/13/2025, at 10:55 a.m., of the HA’s employee list did not indicate RN 2 was employed at the HA. A record review on 3/13/2025, at 2:10 p.m., an electronic license verification was done at the California Board of Registered Nursing and the California Board of Licensed Vocational Nursing website. RN 2’s name as listed in Patient 1’s medical records titled, “Physician’s Certification for Hospice Benefit”, dated 11/15/2024 to 1/13/2025. There was no indication RN 2 was licensed as a Registered Nurse and/or Licensed Vocational Nurse. 2. During a record review of Patient 2’s medical record form titled “Personal Information”, indicated an SOC of 12/12/2024, with a terminal diagnosis of heart disease (a range of conditions that affect the heart which includes blood vessel disease, irregular heartbeats, or congenital heart defects).    3. During a record review of Patient 3’s medical record form titled “Personal Information”, indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). 4.During a record review of Patient 4‘s medical record form titled “Personal Information”, document indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood). 5.During a record review of Patient ‘5s medical record form titled “Personal Information”, indicated a Start of Care (SOC) date of 11/8/2024 and an End of Care (EOC) of 3/7/2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain).  6.During a record review of Patient 6‘s medical record form titled “Personal Information”, indicated a SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain).  7.During a record review of Patient 7‘s medical record form titled “Personal Information”, indicated a SOC date of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (progressive lung disease causing airflow obstruction with difficulty breathing). 8.During a record review of Patient 8‘s medical record form titled “Personal Information”, indicated an SOC of 12/10/2024, with a terminal diagnosis of heart disease. 9.During a record review of Patient 9‘s medical record form titled “Personal Information”, indicated an SOC of 11/14/2024, with a terminal diagnosis of heart disease. 10.During a record review of Patient 10‘s medical record form titled “Personal Information”, indicated an SOC of 11/21/2024, with a terminal diagnosis of cerebral stroke syndrome.  11.During a record review of Patient 11‘s medical record form titled “Personal Information”, indicated an SOC of 12/14/2024, with a terminal diagnosis of Alzheimer’s Disease. 12.During a record review of Patient 12‘s medical record form titled “Personal Information”, indicated an SOC of 11/3/2024, with a terminal diagnosis of chronic diastolic heart failure. 13.During a record review of Patient 13‘s medical record form titled “Personal Information”, indicated an SOC of 11/18/2024, with a terminal diagnosis of Alzheimer’s Disease. 14.During a record review of Patient 14‘s “medical record form titled Personal Information”, indicated an SOC of 11/12/2024, with a terminal diagnosis of chronic diastolic heart failure.

Based on interview and record review, the Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA-an organization that provides specialized care focused on comfort and quality of life for terminally ill patients who are no longer seeking curative treatment ) failed to ensure the Conditions of Participation (CoP-a set of minimum professional standards all hospice agencies must meet to participate in Medicare [a federal health insurance program that helps people pay for healthcare] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) regarding Core Services was met as followed: --- 1. The Hospice Agency failed to ensure a Director of Nurses (DON) directed and supervised the nursing care for ten of fourteen sample patients (Patient 1, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 14). The cumulative effect of this systemic practice resulted in the HA not providing the nursing services/care as required and had the potential for the patients not to receive healthcare services that could affect their well-being and quality of life. The HA failed to ensure four of fourteen sample patients (Patient 4, Patient 5, Patient 6, and Patient 7) terminal illness were being managed by a Medical Director (MD). (Refer to L590).The HA failed to ensure ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 12, Patient 13, and Patient 14) receive bereavement services. (Refer to 596). The HA failed to ensure seven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7) and their family/caregivers receive spiritual counseling. (Refer to L598). The cumulative effect of these systemic practices resulted in the HA not providing the services/care as ordered and had the potential for the patients not receiving appropriate healthcare services that could affect their quality of life.

Based on interview and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure four of fourteen sample patients (Patient 4, Patient 5, Patient 6, Patient 7, and Patient 13) terminal illness were being managed by a Medical Director (MD). This failure resulted in patients not having the supervised medical care required which could then result to hospitalization and or death. --- During an interview on 3/12/2025 at 1:12 p.m. with the Owner/Administrator (ADM), the ADM stated he (ADM) took ownership of the HA in December 2023. ADM stated there were no patients when he (ADM) took ownership of the HA.  During an interview on 3/12/2024, at 1:15 p.m., the ADM stated he did not have contact information for Medical Director 1 (MD 1). A request was made for the employee file for MD 1. The ADM stated he would email the file. The file was not sent to the survey team. During an interview on 3/12/2025 at 2:18 p.m. with the Medical Director 2 (MD2), the MD2 stated she (MD2) has been the HA’s Medical Director since February 2025. The MD2 stated she (MD2) did not know who the Medical Director was prior to her (MD2). The MD2 stated she (MD2) took over the HA’s patients care.  During an interview on 3/13/2025 at 11:50 a.m., with the ADM, the ADM stated he became the owner of the HA in December of 2023. The ADM stated there was no assigned Medical Director for the HA from December 2023 until January 2025. The ADM stated the first and only HA Medical Director, was MD2. The ADM stated MD2 was hired in January 2025.  During a record review of document provided by MD2, untitled, dated “as of January 31,2025” indicated MD2 signed a contract with the HA on 1/31/2025. The document was signed by the ADM on 2/3/2025 and MD2 on 1/31/2025. The HA did not provide the survey team with knowledgeable staff on 3/10/2025 to 3/24/2025 to review the documents as written below. 1.During a record review of Patient 4‘s medical record form titled “Personal Information”, indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood).  During an interview on 3/12/2025 at 9 a.m. with Patient 4, Patient 4 stated he (Patient 4) has never been told he had 6 months or less to live. Patient 4 stated he (Patient 4) has not spoken to a doctor from the HA.  During a record review of Patient 4’s medical record form titled “Physician’s Certification for Hospice Benefit (CTI – document used to declare a patient’s life expectancy of six months or less if their illness runs its normal course)” dated 1/27/2025 to 3/27/2025, did not indicate it was completed or certified by a Medical Director (MD). 2.During a record review of Patient ‘5s medical record form titled “Personal Information”, indicated a SOC date of 11/8/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). The form did not have Patient 5’s contact phone number listed.  During a record review of Patient 5’s medical record form titled “Physician’s Certification for Hospice Benefit” dated 11/8/2024 to 2/5/2025, did not indicate it was completed or certified by an MD.  3.During a record review of Patient 6‘s medical record form titled “Personal Information”, indicated a SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). During an interview on 3/14/2025 at 2:53 p.m. with Patient 6, Patient 6 stated he (Patient 6) has not seen a doctor for the past 2 years. Patient 6 stated he (Patient 6) has not been told by anyone that he (Patient 6) had 6 months or less to live.  During a record review of Patient 6’s medical record form titled “Physician’s Certification for Hospice Benefit” dated 11/23/2024 to 1/21/2025, did not indicate it was completed or certified by an MD. During a record review of Patient 6’s medical record form titled “Physician’s Certification for Hospice Benefit” dated 1/22/2025 to 3/22/2025, did not indicate it was completed or certified by an MD.  4.During a record review of Patient 7‘s medical record form titled “Personal Information”, indicated a SOC date of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (progressive lung disease causing airflow obstruction with difficulty breathing).  During an interview on 3/14/2025 at 3:34 p.m. with Patient 7’s family member (FM1), FM1 stated Patient 7 has not seen a medical doctor for the past 6-7 months. During a record review of Patient 7’s medical record form titled “Physician’s Certification for Hospice Benefit” dated 11/12/2024 to 2/9/2025, did not indicate it was completed or certified by an MD. During a record review of Patient 7’s medical record form titled “Physician’s Certification for Hospice Benefit” dated 2/10/2025 to 5/10/2025, did not indicate it was completed or certified by an MD. 5.During a record review of Patient 13‘s medical record form titled “Personal Information”, indicated an SOC of 11/18/2024, with a terminal diagnosis of Alzheimer’s Disease.   During a record review of Patient 14’s “CTI”, for certification period #9 from 1/11/2025 to 3/11/2025, did not indicate the patient was certified by an MD for hospice care.  During a record review of the Patient 13’s Medication Profile, the Medication Profile did not indicate an order for lorazepam or morphine sulfate.  During a record review of Patient 13’s Visit Note CC (Continuous care), dated 1/30/2025 and timed 12 p.m. to 12 p.m., the visit note indicated that at 2 a.m. and 11 a.m., lorazepam was given as ordered by MD for manifested signs of anxiety and restlessness.  The visit note indicated at 6 a.m. morphine sulfate (an opioid pain-relieving medication used to treat moderate to severe pain), 100mg/5mL solution was administered as prescribed and ordered by the MD for pain manifested by facial grimacing and moaning. During a record review of Patient 13’s Visit Note CC, dated 1/31/2025 and timed 12 a.m. to 9 a.m., the visit note indicated that at 4 a.m., morphine sulfate, 100mg/5 mL was administered as prescribed and ordered by the MD. During a record review of Patient 13’s Visit Note CC, dated 1/31/2025 and timed 12 a.m. to 9 a.m., the visit note indicated that at 6 a.m., the MD pronounced the time of death at 6:31 a.m.

Based on observation, interview, and record review, the Hospice (a specialized form of medical care for people who are nearing the end of life) Agency (HA-an organization that provides care and support to terminally ill patients [patients with six months of less left to live] and their families, focusing on comfort and quality of life rather than curative treatments) failed to ensure a Director of Nurses (DON) directed and supervised the nursing care for ten of fourteen sample patients (Patient 1, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 14). This failure had the potential for Patient 1, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 14 to experience harm. The State Survey Agency (the Department) attempted to contact the Owner/Administrator (ADM) starting on 3/19/25 to 3/21/25 in order to call an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for failing to ensure a DON directed and supervised the nursing care; but have been unable to get in contact with the ADM. The Department was unable to conduct an exit conference with the ADM due to the ADM not responding to attempted phone calls from 3/19/25 to 3/21/25. --- 1. During a record review of Patient 1s medical record form titled ";Personal Information", the Personal Information form indicated a start of care (SOC-the day the patient officially begins receiving hospice services) of 11/15/2024, with a terminal diagnosis of Alzheimers Disease (a brain disorder that gradually destroys memory and thinking skills). During a record review of Patient 1s records titled, ";Plan of Care/ Interdisciplinary Group (POC/IDG- a Medical Doctor, Registered Nurse, Medical Social Worker, and Spiritual Counselor meet to discuss the patients status and plan for care) Review", dated 11/16/2024, 11/25/2024, 12/9/2024, 12/23/2024, 1/6/2025, 1/20/2025, and 2/3/2025, The POC/IDG review did not indicate a Registered Nurses signature to validate the update of the comprehensive assessment and plan of care. 2. During a record review of Patient 3s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries [A blood vessel that carries blood from the heart to tissues and organs in the body]) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). During a record review of Patient 3s records titled, ";POC/IDG Review", dated 11/25/2024, 1/3/2025, and 1/17/2025, the POC/IDG Review did not indicate a registered nurses signature to validate the update of the comprehensive assessment and plan of care. 3. During a record review of Patient 4s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood). During a record review of Patient 4s medical record form titled, ";Comprehensive Nursing Assessment" dated 1/27/2025, the Comprehensive Nursing Assessment did not indicate a registered nurse competed Patient 4s comprehensive nursing assessment. During a record review of Patient 4s medical record form titled, ";POC (Plan of Care – a written document that outlines a patients needs, goals and the specific interventions nurses will implement to address those needs and achieve those goals.) Summary" dated as of 3/11/2025, the POC indicated the form was incomplete. The POC form did not indicate that a registered nurse reviewed Patient 4s POC Summary. During a record review of Patient 4s medical record form titled, ";POC/IDG Review" dated 2/3/2025 and 2/17/2025, the POC/IDG review did not indicate a registered nurse updated Patient 4s comprehensive assessments. During a record review of Patient 4s medical record form titled, ";Physicians Orders" dated 2/21/2025, the physician orders did not indicate a registered or license vocational nurse received the physician orders. The physician orders indicated that the physicians orders were taken and recorded by the Administrator (ADM). 4. During a record review of Patient 6s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). During a record review of Patient 6s medical record form titled, ";POC Summary" dated 3/11/2025, the POC indicated the form was incomplete. The POC form also did not indicate that a registered nurse reviewed Patient 6s POC Summary. During a record review of Patient 6s medical record form titled, ";POC/IDG Review" dated 11/25/2024, 1/6/2025, 1/20/2025, and 2/3/2025, the POC/IDG Review did not indicate a registered nurse updated Patient 6s comprehensive assessments. During a record review of Patient 6s medical record form titled, ";Physicians Orders" dated 2/18/2025, the physician orders did not indicate a registered or license vocational nurse received the physician orders. The form indicated physicians orders were taken and recorded by the ADM. 5. During a record review of Patient 7s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-progressive lung disease causing airflow obstruction with difficulty breathing). During a record review of Patient 7s medical record form titled, ";Updated Assessment" dated 1/21/2025, the Updated Assessment did not indicate a registered nurse completed Patient 7s updated assessment. During a record review of Patient 7s medical record form titled, ";POC Summary" dated 3/11/2025, the POC Summary indicated the form was incomplete. The form also did not indicate a registered nurse reviewed Patient 7s POC Summary. During a record review of Patient 7s medical record form titled, ";POC/IDG Review" dated 11/13/2024, 1/6/2025, 1/20/2025, and 2/3/2025, the POC/IDG Review did not indicate a registered nurse updated Patient 7s comprehensive assessments. During a record review of Patient 7s medical record form titled, ";Physicians Orders" dated 11/12/2024, the physician orders did not indicate a registered or license vocational nurse received the physician orders. The form indicated physicians orders were taken and recorded by the ADM. 6. During a record review of Patient 8s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 12/10/2024, with a terminal diagnosis of heart disease. During a review of Patient 8s ";IDG" with the following dates: 12/10/24, 1/6/25, 1/20/25, 2/3/25, 2/17. 25, and 2/17/25, the IDG did not indicate a registered nurse updated the comprehensive assessment. 7. During a record review of Patient 10s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 11/21/2024, with a terminal diagnosis of cerebral stroke syndrome (a medical emergency that occurs when blood flow to part of the brain is suddenly interrupted or reduced, leading to brain damage). During a review of Patient 10s ";POC/IDG Review" with the following dates: 11/25/24, 12/9/24, 12/23/24, 1/6/25, 1/20/25, and 2/3/25; the POC/IDG review did not indicate a registered nurse updated the comprehensive assessment. 8. During a record review of Patient 11s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 12/14/2024, with a terminal diagnosis of Alzheimers Disease. During a review of Patient 11s ";POC/IDG Review" with the following dates: 12/23/24, 1/6/25, 1/20/25, and 2/3/25; the POC/IDG Review did not indicate a registered nurse updated the comprehensive assessment. 9. During a record review of Patient 12s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 11/3/2024, with a terminal diagnosis of chronic diastolic heart failure (a condition in which your heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly). During a review of Patient 12s ";POC/IDG Review" with the following dates 11/4/2024, 2/3/2025, and 2/17/2025, the POC/IDG Review did not indicate a registered nurse updated the comprehensive assessment and plan of care. During a record review of Patient 12s ";Comprehensive Nursing Assessment" dated 11/03/2024, the assessment did not indicate a registered nurse completed Patient 12s comprehensive nursing assessment. 10. During a record review of Patient 14s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 11/12/2024, with a terminal diagnosis of chronic diastolic heart failure. During a review of Patient 14s ";POC/IDG Review" with the following dates: 11/13/2024, 1/20/2025, and 2/3/2025, the POC/IDG Review did not indicate a registered nurse updated the comprehensive assessment and plan of care. During a record review of Patient 14s ";Comprehensive Nursing Assessment" dated 11/12/2024, the assessment did not indicate a registered nurse completed Patient 14s comprehensive nursing assessment. During an interview on 3/10/2025 at 2:38 p.m. with Registered Nurse 1 (RN1), RN1 stated he (RN 1) was hired by the HA as a visiting nurse. RN1 stated he (RN 1) did not have the Director of Nurses 1 (DON1)s phone number. RN 1 stated that he (RN 1) is able to provide DON 1s electronic mail (e-mail) address. During an interview on 3/10/2025 at 2:47 p.m. with the ADM, the ADM stated he (ADM) unable to get in contact with DON 1. The ADM was requested and able to provide the Director of Nurses Designees (DD1) phone number. During an interview on 3/10/2025 at 3 p.m. with the DD1, DD1 stated she (DD 1) was not able to assist with the survey process because she (DD 1) was only hired ";a week ago" and does not have access to the HAs patients medical records. DD1 stated she (DD1) was unable to get a hold of the DON1. On 3/11/2025 at 10 a.m. the HA door was locked with no answer. On 3/11/2025 at 10:42 a.m. the DON1 and the DD1 were called, with no response. During an interview on 3/11/2025 at 12:51 p.m. with the RN1, RN1 stated he (RN1) was hired as the Director of Nurses Designee on 3/10/2025. During an interview on 3/11/2025 at 1:10 p.m. with the RN1, RN1 stated the DON1 was the acting DON. During an interview on 3/11/2025 at 3:17 p.m. with the Intake Coordinator (IC), the IC stated DON1 was no longer the acting DON. IC stated that Director of Nurses 2 (DON2) was the new acting DON who started working for the HA ";a week ago". During an interview on 3/12/2025 at 1:12 p.m. with the ADM, the ADM stated since the HAs change of ownership on December 2023, the HA has not had a DON. The ADM stated DON2 was hired ";last week". During an interview on 3/12/2025, at 1:15 p.m., with the ADM, the ADM stated he (ADM) was not a licensed nurse. During an interview on 3/12/2025, at 1:22 p.m., with the ADM, the ADM stated he (ADM) was the one overseeing the HAs licensed nurses (Registered Nurses and Licensed Vocational Nurses). The ADM stated he (ADM) knew the nurses were providing the ";right care" as long as they (referring to the licensed nurses) are doing their (referring to the licensed nurses) visits. The ADM just had to make sure the nurses were doing their visits. During an interview on 3/12/2025 at 1:49 p.m. with the DON2, DON2 stated she (DON2) was hired on 3/11/2025. DON2 stated she (DON2) was not told what she (DON2) was ";walking into" (to become involved in) and left the HA. During a record review on 3/12/2025 at 7:42 p.m. of an email sent by DON1, DON1 stated she (DON1) was not associated with the HA. During an interview on 3/13/2025 at 3:15 p.m. with the ADM, the ADM stated he (ADM) was responsible for everything that goes on with the HA. No Registered Nurse or Director of Nurses were provided to assist with the survey process on 3/10/2025, 3/13/2025, and 3/14/2025

Based on interview and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 12, Patient 13, and Patient 14) receive bereavement services.  This failure had the potential to result in placing the patients and their family/caregiver at risk of spiritual and emotional distress. --- During an interview on 3/11/2025, at 1:18 p.m., with Registered Nurse 1 (RN1), RN1 stated “not sure”, when asked who the bereavement coordinator was. During an interview on 3/12/2025 at 1:20 p.m., with the Owner/Administrator (ADM), the ADM stated the HA did not have a Spiritual Counselor (SC) or Bereavement Coordinator since December 2023 because he (ADM) did not know it was a requirement to have one. The HA did not provide the survey team with knowledgeable staff from 3/10/2025 to 3/24/2025 to review the documents as written below. 1. A review of Patient 1’s Personal Information sheet indicated a start of care date on 11/15/2024, with a diagnosis of Alzheimer’s disease (a brain disease that destroys memory and thinking skills).  A record review of Patient 1’s medical record did not indicate bereavement services were rendered. 2. During a record review of Patient 2’s medical record form titled “Personal Information”, indicated an SOC of 12/12/2024, with a terminal diagnosis of heart disease (a range of conditions that affect the heart which includes blood vessel disease, irregular heartbeats, or congenital heart defects).    A record review of Patient 2’s medical record did not indicate bereavement services were rendered. 3. During a record review of Patient 3’s medical record form titled “Personal Information”, indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). The record also indicated patient died on 2/10/2025. A record review of Patient 3’s medical record did not indicate bereavement services were rendered. There was no initial bereavement assessment, post death assessment, and post death plan of care.  A record review of Patient 3’s record titled, “Discharge Summary”, dated 2/10/2025, indicted “...Patient discharged from (another HA)”.  4.During a record review of Patient 4‘s medical record form titled “Personal Information”, document indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood).  During an interview on 3/12/2025 at 9 a.m. with Patient 4, Patient 4 stated he (Patient 4) was not offered spiritual counselor services by the HA. During a record review of Patient 4’s medical record form titled “History of Bereavement Assessment” undated, indicated there were no entries made.  During a record review of Patient 4’s medical record form titled “History of Visit Notes” undated, did not indicate a medical doctor, a registered nurse, a medical social worker, or a spiritual counselor made an entry.  During a record review of Patient 4’s electronic medical records (EMR) did not indicate a Spiritual Assessment, or bereavement services were rendered.   5.During a record review of Patient ‘5s medical record form titled “Personal Information”, indicated a Start of Care (SOC) date of 11/8/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain).  During a record review of Patient 5’s medical record form titled “History of Bereavement Assessment” undated, indicated there were no entries made.  During a record review of Patient 5’s medical record form titled “History of Visit Notes” undated, did not indicate a registered nurse, a medical social worker, or a spiritual counselor made an entry.  During a record review of Patient 5’s EMR did not indicate a Spiritual Assessment, or bereavement services were rendered.  6.During a record review of Patient 6‘s medical record form titled “Personal Information”, document indicated an SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). During a record review of Patient 6’s medical record form titled “History of Bereavement Assessment” undated, indicated there were no entries made.  During a record review of Patient 6’s medical record form titled “History of Visit Notes” undated, did not indicate the medical doctor, a registered nurse, a medical social worker, or a spiritual counselor made an entry.  During a record review of Patient 6’s EMR did not indicate a Spiritual Assessment, or bereavement services were rendered.  7.During a record review of Patient 7‘s medical record form titled “Personal Information”, document indicated an SOC of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (progressive lung disease causing airflow obstruction with difficulty breathing).  During a record review of Patient 7’s medical record form titled “History of Bereavement Assessment” undated, indicated there were no entries made.  During a record review of Patient 7’s medical record form titled “History of Visit Notes” undated, did not indicate the medical doctor, a registered nurse, a medical social worker, or a spiritual counselor made an entry.  During a record review of Patient 7’s EMR did not indicate a Spiritual Assessment, or bereavement services were rendered.  8.During a record review of Patient 12‘s medical record form titled “Personal Information”, indicated an SOC of 11/3/2024, with a terminal diagnosis of chronic diastolic heart failure.  During a review of Patient 12’s History of Bereavement Plan of Care, the History of Bereavement Plan of Care indicated that no bereavement plan of care was completed for Patient 12.  During a review of Patient 12’s History of Spiritual Assessment, there were no notes written by a spiritual counselor.During a review of Patient 12’s History of Bereavement Assessment, the History of Bereavement Assessment indicated that no bereavement assessment was completed for Patient 12.  During a review of Patient 12’s History of Spiritual Assessment, the History of Spiritual Assessment indicated that no spiritual assessment was completed for Patient 12, who was on hospice services for four months.9.During a record review of Patient 13‘s medical record form titled “Personal Information”, indicated an SOC of 11/18/2024, with a terminal diagnosis of Alzheimer’s Disease.During a review of Patient 13’s History of Bereavement Assessment, the History of Bereavement Assessment indicated that no bereavement assessment was completed for Patient 13. During a review of Patient 13’s History of Bereavement Plan of Care, the History of Bereavement Plan of Care indicated that no bereavement plan of care was completed for Patient 13.   During a review of Patient 13’s History of Spiritual Assessment, the History of Spiritual Assessment indicated that no spiritual assessment was completed for Patient 13.During an interview on 3/21/2025 at 2:17 p.m. with Family Member 2 (FM2), FM2 stated that it was difficult to get a hold of the HA staff taking care of Patient 13.  FM2 stated she called several times and finally spoke to someone who was not a nurse and who told her that Patient 13 was fine.  FM2 stated that Patient 13 died on 1/31/2025 and that the nurse called her to let them know Patient 13 died.  When FM2 was asked if she received a card or phone call after 1/31/2025, FM2 stated she had not heard from the HA since then and had not received a condolence card. 10.During a record review of Patient 14‘s “medical record form titled Personal Information”, indicated an SOC of 11/12/2024, with a terminal diagnosis of chronic diastolic heart failure.   During a review of Patient 14’s History of Bereavement Assessment, the History of Bereavement Assessment indicated that no bereavement assessment was completed for Patient 14.  During a review of Patient 14’s History of Bereavement Plan of Care, the History of Bereavement Plan of Care indicated that no bereavement plan of care was completed for Patient 14.   During a review of Patient 14’s History of Spiritual Assessment, the History of Spiritual Assessment indicated that no spiritual assessment was completed for Patient 14, who was on hospice services for four months.

Based on interview and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure seven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7) and their family/caregivers receive spiritual counseling. This failure had the potential to result in placing patients and their family/caregiver under distress by not providing a way to express their grieving process. --- During an interview on 3/11/2025, at 1:18 p.m., with Registered Nurse 1 (RN1), RN1 stated “not sure”, when asked who the bereavement coordinator was. During an interview on 3/12/2025 at 1:20 p.m., with the Owner/Administrator (ADM), the ADM stated the HA did not have a Spiritual Counselor (SC) or Bereavement Coordinator since December 2023 because he (ADM) did not know it was a requirement to have one. The HA did not provide the survey team with knowledgeable staff from 3/10/2025 to 3/24/2025 to review the documents as written below. 1. A review of Patient 1’s Personal Information sheet indicated a start of care date on 11/15/2024, with a diagnosis of Alzheimer’s disease (a brain disease that destroys memory and thinking skills). A record review of Patient 1’s medical record did not indicate spiritual services were rendered. 2. During a record review of Patient 2’s medical record form titled “Personal Information”, indicated an SOC of 12/12/2024, with a terminal diagnosis of heart disease (a range of conditions that affect the heart which includes blood vessel disease, irregular heartbeats, or congenital heart defects).    A record review of Patient 2’s medical record did not indicate spiritual services were rendered. 3. During a record review of Patient 3’s medical record form titled “Personal Information”, indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). A record review of Patient 3’s medical record did not indicate spiritual services were rendered. 4.During a record review of Patient 4‘s medical record form titled “Personal Information”, document indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood).  During an interview on 3/12/2025 at 9 a.m. with Patient 4, Patient 4 stated he (Patient 4) was not offered spiritual counselor services by the HA. During a record review of Patient 4’s medical record form titled “History of Spiritual Assessment” undated, indicated there were no entries made.  During a record review of Patient 4’s medical record form titled “History of Visit Notes” undated, did not indicate a medical doctor, a registered nurse, a medical social worker, or a spiritual counselor made an entry.  During a record review of Patient 4’s electronic medical records (EMR) did not indicate a spiritual assessment or services were rendered.   5.During a record review of Patient ‘5s medical record form titled “Personal Information”, indicated a Start of Care (SOC) date of 11/8/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain).  During a record review of Patient 5’s medical record form titled “History of Spiritual Assessment” undated, indicated there were no entries made.  During a record review of Patient 5’s medical record form titled “History of Visit Notes” undated, did not indicate a registered nurse, a medical social worker, or a spiritual counselor made an entry.  During a record review of Patient 5’s EMR did not indicate a spiritual assessment or services were rendered.  6.During a record review of Patient 6‘s medical record form titled “Personal Information”, document indicated an SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). During a record review of Patient 6’s medical record form titled “History of Spiritual Assessment” undated, indicated there were no entries made.  During a record review of Patient 6’s medical record form titled “History of Visit Notes” undated, did not indicate the medical doctor, a registered nurse, a medical social worker, or a spiritual counselor made an entry.  During a record review of Patient 6’s EMR did not indicate a spiritual assessment or services were rendered.  7.During a record review of Patient 7‘s medical record form titled “Personal Information”, document indicated an SOC of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (progressive lung disease causing airflow obstruction with difficulty breathing).  During a record review of Patient 7’s medical record form titled “History of Spiritual Assessment” undated, indicated there were no entries made.  During a record review of Patient 7’s medical record form titled “History of Visit Notes” undated, did not indicate the medical doctor, a registered nurse, a medical social worker, or a spiritual counselor made an entry.  During a record review of Patient 7’s EMR did not indicate a spiritual assessment or services were rendered.

Based on interview and record review, the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to meet the Condition of Participation for hospice aide and homemaker services as follows: --- 1.The HA failed to ensure their Certified Home Health Aides (CHHA) were certified and qualified to take care of three of fourteen sample patient (Patient 3, Patient 4 and Patient 6). (Refer to L609).2.The HA failed to ensure to provide the assigned Certified Home Health Aide (CHHA) written patient care instructions for three of fourteen sample patients (Patient 3, Patient 4 and Patient 6). (Refer to L625). The cumulative effect of these systemic practices resulted in the HA not providing the services/care as ordered and had the potential for the patients not receiving appropriate healthcare services that could affect their quality of life.

Based on record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure their Certified Home Health Aides (CHHA) were certified and qualified to take care of three of fourteen sample patient (Patient 3, Patient 4 and Patient 6).This failure had the potential to result in patients being taken care of unqualified individuals who might cause injury and harm placing the patients at risk for hospitalization. --- During an interview on 3/11/2025 at 12:54 p.m., with Registered Nurse 1 (RN 1), the RN1 stated he (RN1) did not know where the employee files were. RN 1 stated he (RN1) did not know where the human resource files were for the employees.During an interview on 3/11/2025 at 1:00 p.m., with RN 1, RN1 stated employee files were important to have because the surveyors were requesting them. The employee files were to make sure everyone is compliant with their cardiopulmonary resuscitation certificate (CPR), license, competency and evaluations.During an observation on 3/11/2025 at 1:46 p.m., of the HA, 4 rooms were observed. The cabinets, file cabinets, and drawers were empty.During an interview on 3/13/2025 at 11:50 a.m., with the Owner/Administrator (ADM), the ADM stated he (ADM) was not a licensed nurse or a licensed medical doctor. 1.During a record review of Patient 3’s medical record form titled “Personal Information”, indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). A record review of Patient 3’s medical records indicated CHHA visits.  A record review of Patient 3’s record titled, “HA Assignment”, dated 11/20/2024 indicated the ADM had signed the document. However, the document was not filled out.  2.During a record review of Patient 4‘s medical record form titled “Personal Information”, document indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood).  During a record review of Patient 4’s medical record form titled “History of HA (home aide) Visits” undated, indicated there were four entries made on 2/3/2025, 2/10/2025, 2/17/2025, and 2/24/2025.  3.During a record review of Patient 6‘s medical record form titled “Personal Information”, document indicated an SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). During a record review of Patient 6’s medical record form titled “History of HA (home aide) Visits” undated, indicate there were 29 entries made.

Based on record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure to provide the assigned Certified Home Health Aide (CHHA) written patient care instructions for three of fourteen sample patients (Patient 3, Patient 4 and Patient 6). This failure had the potential to result in missed or inappropriate care and treatment provided by the CHHA that might cause injury and harm placing the patients at risk for hospitalization. --- 1.During a record review of Patient 3’s medical record form titled “Personal Information”, indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). A record review of Patient 3’s medical records indicated CHHA visits.  A record review of Patient 3’s record titled, “HA Assignment”, dated 11/20/2024 indicated the ADM had signed the document. However, the document was not filled out. 2.During a record review of Patient 4‘s medical record form titled “Personal Information”, document indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood).  During a record review of Patient 4’s medical record form titled “History of HA (home aide) Assignment” undated, indicated there was one entry made on 1/27/2025. During a record review of Patient 4’s medical record form titled “HA (home aide) Assignment” dated 1/27/2025, indicated the form was left blank.                                              During a record review of Patient 4’s medical record form titled “History of HA (home aide) Visits” undated, indicated there were four entries made on 2/3/2025, 2/10/2025, 2/17/2025, and 2/24/2025. During a record review of Patient 4’s medical record form titled “HA (home aide) Visit Note” dated 2/3/2025, indicate the form was left blank. The form also indicated it was signed by the Owner/Administrator (ADM).  During a record review of Patient 4’s medical record form titled “HA (home aide) Visit Note” dated 2/10/2025, indicate the form was left blank. The form also indicated it was signed by the Home Aide 1 (HA1). During a record review of Patient 4’s medical record form titled “HA (home aide) Visit Note” dated 2/17/2025, indicate the form was left blank. The form also indicated it was signed by the Home Aide 1 (HA1). During a record review of Patient 4’s medical record form titled “HA (home aide) Visit Note” dated 2/24/2025, indicate the form was left blank. The form also indicated it was signed by the Home Aide 1 (HA1).  3.During a record review of Patient 6‘s medical record form titled “Personal Information”, document indicated an SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). During a record review of Patient 6’s medical record form titled “History of HA (home aide) Assignment” undated, indicated there was one entry made on 11/23/2024. During a record review of Patient 6s medical record form titled “HA (home aide) Assignment” dated 11/23/2024, indicated the form was left blank. The form also indicated it was signed by registered Nurse 3 (RN3).  During a record review of Patient 6’s medical record form titled “History of HA (home aide) Visits” undated, indicate there were 29 entries made.  During a record review of Patient 6’s medical record form titled “HA (home aide) Visit Note” dated 11/29/2024, indicate the form was left blank. The form also indicated it was signed by the Home Aide 2 (HA2). During a record review of Patient 6’s medical record form titled “HA (home aide) Visit Note” dated 2/28/2025, indicate the form was left blank. The form also indicated it was signed by the Home Aide 2 (HA2). During a record review of Patient 6’s medical record form titled “HA (home aide) Visit Note” dated 3/3/2025, indicate the form was left blank. The form also indicated it was signed by the Home Aide 2 (HA2). During a record review of Patient 6’s medical record form titled “HA (home aide) Visit Note” dated 3/7/2025, indicate the form was left blank. The form also indicated it was signed by the Home Aide 2 (HA2).

Based on observation, interview and record review, the Hospice (a specialized form of medical care for people who are nearing the end of life) Agency (HA-an organization that provides care and support to terminally ill patients [patients with six months of less left to live] and their families, focusing on comfort and quality of life rather than curative treatments) failed to ensure the Conditions of Participation (CoP-a set of minimum professional standards all hospice agencies must meet to participate in Medicare [a federal health insurance program that helps people pay for healthcare] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) regarding Organizational Environment was met as followed: --- 3. The HA failed to ensure nursing and physician services were available 24 hours a day, seven days a week for fourteen or fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L653). The cumulative effect of these systemic practices resulted in the HA not providing the services/care as ordered and had the potential for the patients not receiving appropriate healthcare services that could affect their quality of life. 1. The HA failed to ensure the governing body and administrator, assumed full responsibility for the day-to-day operation of the hospice and provision of care for 10 of 14 sampled patients (Patient 1, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 14). (Refer to L651). 2. The HA failed to provide medical, nursing, volunteer and spiritual counseling services for 10 of 14 sampled patients (Patient 1, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 14). (Refer to L652). The cumulative effect of this systemic practice resulted in the HA not providing the nursing and medical services/care as required and had the potential for the patients not to receive healthcare services that could affect patients well-being and quality of life; and potentially be hospitalized with the risk of death.

Based on observation, interview, and record review, the Hospice (a specialized form of medical care for people who are nearing the end of life) Agency (HA-an organization that provides care and support to terminally ill patients [patients with six months of less left to live] and their families, focusing on comfort and quality of life rather than curative treatments) failed to ensure a governing body and administrator, assumed full responsibility for the day-to-day operation of the hospice and provision of care for ten of fourteen sampled patients (Patient 1, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 14). As a result, Patient 1, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 14 where provided hospice services without medical and nursing supervision, which had the potential to affect the patients care and services that could lead to hospitalization and death. The State Survey Agency (the Department) attempted to contact the Owner/Administrator (ADM) starting on 3/19/25 to 3/21/25 in order to call an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for failing to ensure a governing body and administrator, assumed full responsibility for the day-to-day operation of the hospice and provision of care of patients, but have been unable to get in contact with the ADM. The Department was unable to conduct an exit conference with the ADM due to the ADM not responding to attempted phone calls from 3/19/25 to 3/21/25. --- During a record review of Patient 1s medical record form titled ";Personal Information", the Personal Information form indicated a start of care (SOC-the day the patient officially begins receiving hospice services) of 11/15/2024, with a terminal diagnosis of Alzheimers Disease (a brain disorder that gradually destroys memory and thinking skills). During an interview on 3/12/2025, at 11:21 a.m. with Registered Nurse 1 (RN 1), RN 1 stated that the HAs Medical Director is Medical Director 1 (MD 1). During a record review of Patient 1s Physician Orders dated 11/15/24, the following orders were noted: 1. Ambien (medication used to help a patient sleep) five milligrams (mg-unit of measure) one tablet to be taken orally at bedtime 2. Lorazepam (medication used to treat anxiety) 0.5 mg, one table every four to six hours as needed for anxiety 3. Lexapro (medication used to treat depression) 10 mg, one table daily 4. Risperidone (medication used to treat schizophrenia [a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others) one mg, one tablet twice a day. During a record review of Patient 1s medical records, there was no evidence of a medical evaluation and medical documents to support Patient 1s medical diagnoses and need for psychotropic medications for certification periods 11/15/2024 to 1/13/2025 and 1/14/2025 to 3/14/2025. During an interview on 3/13/2025, at 4:01 p.m., Medical Director 2 (MD 2) stated she (MD 2) did not see Patient 1 in person. MD 2 stated she was not 100% sure she had reviewed any medical information or was given any additional information about Patient 1. 2. During a record review of Patient 3s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries [A blood vessel that carries blood from the heart to tissues and organs in the body]) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). During a record review of Patient 3s HAs medical records, Patient 3s medical records did not indicate any evidence of a medical evaluation and supervision. 3. During a record review of Patient 4s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood). During a record review of Patient 4s HAs medical records, the medical records did not indicate any evidence of a medical evaluation and supervision. 4. During a record review of Patient 6s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). A record review of Patient 6s HAs medical records, the medical records did not indicate any evidence of a medical evaluation and supervision. 5. During a record review of Patient 7s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-progressive lung disease causing airflow obstruction with difficulty breathing). A record review of Patient 7s HAs medical records, the medical records did not indicate any evidence of a medical evaluation and supervision. 6. During a record review of Patient 8s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 12/10/2024, with a terminal diagnosis of heart disease. A record review of Patient 8s HAs medical records, the medical records did not indicate any evidence of a medical evaluation and supervision. 7. During a record review of Patient 10s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 11/21/2024, with a terminal diagnosis of cerebral stroke syndrome (a medical emergency that occurs when blood flow to part of the brain is suddenly interrupted or reduced, leading to brain damage). A record review of Patient 10s HAs medical records, the medical records did not indicate any evidence of a medical evaluation and supervision. 8. During a record review of Patient 11s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 12/14/2024, with a terminal diagnosis of Alzheimers Disease. A record review of Patient 11s HAs medical records, the medical records did not indicate any evidence of a medical evaluation and supervision. 9. During a record review of Patient 12s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 11/3/2024, with a terminal diagnosis of chronic diastolic heart failure (a condition in which your heart's main pumping chamber [left ventricle] becomes stiff and unable to fill properly). A record review of Patient 12s HAs medical records, the medical records did not indicate any evidence of a medical evaluation and supervision. 10.During a record review of Patient 14s medical record form titled ";Personal Information", indicated an SOC of 11/12/2024, with a terminal diagnosis of chronic diastolic heart failure. A record review of Patient 14s HAs medical records, the medical records did not indicate any evidence of a medical evaluation and supervision. During an interview on 3/12/2025 at 1:15 p.m., with the Administrator (ADM), the ADM stated he (ADM) did not know who the HAs governing body was and did not know the terminology. The ADM stated he (ADM) was the one responsible for the day-to-day operation of the HA. During an interview on 3/12/2025 at 1:20 p.m., with the ADM, the ADM stated the (ADM) HA did not have a Spiritual Counselor/Chaplain (SC) or Bereavement Coordinator since December 2023 because he (ADM) did not know it was a requirement for HAs to have one. During an interview on 3/12/2025 at 1:20 p.m., with the ADM, the ADM stated he (ADM) had an associates degree in Sociology, and this was his (ADM) first time working in a HA setting. The ADM stated he (ADM) did not have any certificates to show class completions for hospice care related courses. The ADM stated he (ADM) learned about general information regarding hospice care through online videos. During an interview on 3/12/2025 at 1:22p.m., with the ADM, the ADM stated the HA did not have a Director of Nurses (DON) since December 2023. The ADM stated he (ADM) was the one overseeing the licensed nurses. During an interview on 3/12/2025 at 1:35 p.m., with the ADM, the ADM stated he (ADM) was not sure what IDG (interdisciplinary group - a Medical Doctor, Registered Nurse, Medical Social Worker, and Spiritual Counselor meet to discuss the patients status and plan for care) was. The ADM stated he (ADM) did not deal with patient care. The ADM stated he (ADM) made sure patient visits were made and made sure patients had a direct phone number of the nurses, so they can get a hold of the nurse. During an interview on 3/12/2025 at 1:40 p.m., with the ADM, the ADM was asked if the HA had a quality assurance and performance improvement program (QAPI – a data driven approach to improving the quality of care and services). The ADM asked what a QAPI was. The ADM initially stated that the HA did not have a QAPI. The ADM then stated the HA should have a QAPI program. During an interview on 3/13/2025 at 11:50 a.m., with the ADM, the ADM stated there was no Medical Director (MD) from December 2023 until January 2025.

Based on observation, interview, and record review, the Hospice (a specialized form of medical care for people who are nearing the end of life) Agency (HA-an organization that provides care and support to terminally ill patients [patients with six months of less left to live] and their families, focusing on comfort and quality of life rather than curative treatments) failed to ensure it provided medical, nursing, volunteer and spiritual counseling services to 10 of 14 sampled patients (Patient 1, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 14). As a result, Patient 1, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 14 where provided hospice services without the supervision and care of an Medical Director (MD), Director of Nurses (DON), or a Spiritual Counselor/Chaplain (SC), which had the potential to affect the patients as well as the family/caregivers care and services, which could lead to stress, hospitalization and death. The State Survey Agency (the Department) attempted to contact the Owner/Administrator (ADM) starting on 3/19/25 to 3/21/25 in order to call an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident)for failing to ensure the HA provided medical, nursing, volunteer and spiritual counseling services; but have been unable to get in contact with the ADM. The Department was unable to conduct an exit conference with the ADM due to the ADM not responding to attempted phone calls from 3/19/25 to 3/21/25. --- 1. During a record review of Patient 1s medical record form titled ";Personal Information", the Personal Information form indicated a start of care (SOC-the day the patient officially begins receiving hospice services) of 11/15/2024, with a terminal diagnosis of Alzheimers Disease (a brain disorder that gradually destroys memory and thinking skills). During a record review of Patient 1s Durable Power of Attorney indicated Patient 1 had signed the DPOA document on 4/6/2024. During a record review of Patient 1s Physician Orders dated 11/15/24, the following orders were noted: · Ambien (medication used to help a patient sleep) five milligrams (mg-unit of measure) one tablet to be taken orally at bedtime · Lorazepam (medication used to treat anxiety) 0.5 mg, one table every four to six hours as needed for anxiety · Lexapro (medication used to treat depression) 10 mg, one table daily · Risperidone (medication used to treat schizophrenia [a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others) one mg, one tablet twice a day. During a record review of Patient 1s medical records, there was no evidence of a medical evaluation and medical documents to support Patient 1s medical diagnoses and need for psychotropic medications for certification periods 11/15/2024 to 1/13/2025 and 1/14/2025 to 3/14/2025. During an interview on 3/12/2025, at 11:21 a.m. with Registered Nurse 1 (RN 1), RN 1 stated that the HAs Medical Director is Medical Director 1 (MD 1). During an interview on 3/13/2025, at 4:01 p.m., Medical Director 2 (MD 2) stated she (MD 2) did not see Patient 1 in person. MD 2 stated she was not 100% sure she had reviewed any medical information or was given any additional information about Patient 1. During an interview on 3/12/2025, at 9:34 a.m., Patient 1s DPOA stated that he (Patient 1s DPOA) was not aware that Patient 1 was in hospice care, nor how long Patient 1 had been in hospice care. Patient 1s DPOA stated no one had spoken to him (Patient 1s DPOA) to determine if he (Patient 1s DPOA) was agreeable to put Patient 1 in hospice care. Patient 1s DPOA stated he (Patient 1s DPOA) never signed any hospice care related documents. Patient 1s DPOA stated the hospice agency did not ask him (Patient 1s DPOA) for a copy of Patient 1s DPOA document. During an interview on 3/12/2025 at 1:43 p.m., the ADM stated that if patients had a DPOA, the HA needs to verify the information and get a copy of the DPOA document because the DPOA is the one who makes healthcare decisions for the patient. The ADM stated the agency did not have any patients who had a DPOA. During a record review of Patient 1s undated document titled, ";Decline of Specific Services" indicated that Patient 1 declined the following services: · ";Volunteer Services · Social Workers · Spiritual Counselors". During a record review of Patient 1s HAs medical records, there was no Spiritual Assessment and Initial Bereavement Assessment noted. 2. During a record review of Patient 3s medical record form titled ";Personal Information", indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). A record review of Patient 3s medical records did not indicate a Spiritual Assessment or an Initial Bereavement Assessment. 3. During a record review of Patient 4s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood). During a record review of Patient 4s medical record form titled, ";Comprehensive Nursing Assessment" dated 1/27/2025, the Comprehensive Nursing Assessment did not indicate a registered nurse competed Patient 4s comprehensive nursing assessment. During a record review of Patient 4s medical record form titled, ";POC (Plan of Care – a written document that outlines a patients needs, goals and the specific interventions nurses will implement to address those needs and achieve those goals.) Summary" dated as of 3/11/2025, the POC indicated the form was incomplete. The POC form did not indicate that a registered nurse reviewed Patient 4s POC Summary. During a record review of Patient 4s medical record form titled ";Physicians Certification for Hospice Benefit" dated 1/27/2025 to 3/27/2025, did not indicate it was completed and certified by a Medical Director (MD). During a record review of Patient 4s medical record form titled ";History of Spiritual Assessment" undated, indicated there were no entries made. During a record review of Patient 4s medical record form titled ";History of Psychosocial Assessment" undated, indicated there were no entries made. During a record review of Patient 4s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. During a record review of Patient 4s medical record form titled ";History of Visit Notes" undated, did not indicate the medical doctor, a registered nurse, or a spiritual counselor made an entry. During a record review of Patient 4s medical records, the medical records did not indicate a Spiritual Assessment, or an Initial Bereavement Assessment was completed. During an interview on 3/12/2025 at 9 a.m. with Patient 4, Patient 4 stated he (Patient 4) has not spoken to a physician from the HA. Patient 4 stated he (Patient 4) was not offered spiritual counselor services by the HA. 4. During a record review of Patient 6s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). During a record review of Patient 6s medical record form titled, ";POC Summary" dated 3/11/2025, the POC indicated the form was incomplete. The POC form also did not indicate that a registered nurse reviewed Patient 6s POC Summary. During a record review of Patient 6s medical record form titled ";Physicians Certification for Hospice Benefit" dated 11/23/2024 to 1/21/2025, did not indicate it was completed and certified by an MD. During a record review of Patient 6s medical record form titled ";Physicians Certification for Hospice Benefit" dated 1/22/2025 to 3/22/2025, did not indicate it was completed and certified by an MD. During a record review of Patient 6s medical record form titled ";History of Spiritual Assessment" undated, indicated there were no entries made. During a record review of Patient 6s medical record form titled ";History of Psychosocial Assessment" undated, indicated there were no entries made. During a record review of Patient 6s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. During a record review of Patient 6s medical record form titled ";History of Visit Notes" undated, did not indicate the medical doctor, a registered nurse, or a spiritual counselor made an entry. During a record review of Patient 6s medical records, the medical records did not indicate a Spiritual Assessment, or an Initial Bereavement Assessment was completed. During an interview on 3/14/2025 at 2:53 p.m. with Patient 6, Patient 6 stated he (Patient 6) has not seen a physician for the past 2 years. 5. During a record review of Patient 7s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-progressive lung disease causing airflow obstruction with difficulty breathing). During a record review of Patient 7s medical record form titled, ";Updated Assessment" dated 1/21/2025, the assessment did not indicate a registered nurse competed Patient 7s updated assessment. During a record review of Patient 7s medical record form titled, ";POC Summary" dated 3/11/2025, the POC Summary indicated the form was incomplete. The form also did not indicate a registered nurse reviewed Patient 7s POC Summary. During a record review of Patient 7s medical record form titled ";Physicians Certification for Hospice Benefit" dated 11/12/2024 to 2/9/2025, the form did not indicate it was completed and certified by an MD. During a record review of Patient 7s medical record form titled ";Physicians Certification for Hospice Benefit" dated 2/10/2025 to 5/10/2025, the form did not indicate it was completed and certified by an MD. During a record review of Patient 7s medical record form titled ";History of Spiritual Assessment" undated, indicated there were no entries made. During a record review of Patient 7s medical record form titled ";History of Psychosocial Assessment" undated, indicated there were no entries made. During a record review of Patient 7s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. During a record review of Patient 7s medical record form titled ";History of Visit Notes" undated, did not indicate the medical doctor, a registered nurse, or a spiritual counselor made an entry. During a record review of Patient 7s medical records, the medical records did not indicate a Spiritual Assessment, or an Initial Bereavement Assessment was completed. During an interview on 3/14/2025 at 3:34 p.m. with Patient 7s family member (FM1), FM1 stated Patient 7 has not seen a physician for the past "; six to seven months". 6. During a record review of Patient 8s medical record form titled ";Personal Information", indicated an SOC of 12/10/2024, with a terminal diagnosis of heart disease (a range of conditions that affect the heart which includes blood vessel disease, irregular heartbeats, or congenital heart defects) During a review of Patient 8s ";Comprehensive Nursing Assessment" dated 12/10/24 it indicated that a psychosocial and spiritual assessment was needed for Patient 8 and that Patient 8 would be referred to the appropriate disciplines. During a review of Patient 8s ";History of Spiritual Assessment" indicated no spiritual assessment was completed for Patient 8. During a record review of Patient 8s medical records did not indicate that a Spiritual Assessment or an Initial Bereavement Assessment was completed. No Spiritual Counselor on staff to interview. 7. During a record review of Patient 10s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 11/21/2024, with a terminal diagnosis of cerebral stroke syndrome (a medical emergency that occurs when blood flow to part of the brain is suddenly interrupted or reduced, leading to brain damage). During a review of patient 10s visit notes it indicated SN visits of 1/week and CHHA 2/week. No MSW, or chaplain visits indicated for PT10. During a review of Patient 10s ";Comprehensive Nursing Assessment" dated 11/21/24, the assessment indicated that a psychosocial and spiritual assessment was needed for Patient 10 and that Patient 10 would be referred to the appropriate disciplines. During a review of Patient 10s ";History of Spiritual Assessment , noted was that no spiritual assessment was completed for Patient 10. A record review of Patient 10s medical records did not indicate a Spiritual Assessment, or an Initial Bereavement Assessment was completed. No Spiritual Counselor on staff to interview. 8. During a record review of Patient 11s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 12/14/2024, with a terminal diagnosis of Alzheimers Disease. During a review of Patient 11s ";Comprehensive Nursing Assessment" dated 12/14/24, the assessment indicated that a psychosocial and spiritual assessment was needed for Patient 11 and that Patient 11 would be referred to the appropriate disciplines. During a review of Patient 11s ";History of Spiritual Assessment , noted was that no spiritual assessment was completed for Patient 11. During a record review of Patient 11s medical records, noted was that no Spiritual Assessment, or an Initial Bereavement Assessment was completed. No Spiritual Counselor on staff to interview. 9. During a record review of Patient 12s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 11/3/2024, with a terminal diagnosis of chronic diastolic heart failure (a condition in which your heart's main pumping chamber [left ventricle] becomes stiff and unable to fill properly). During a review of Patient 12s Comprehensive Nursing Assessment, dated 11/3/2024, the Comprehensive Nursing Assessment indicated that a Spiritual Counselor visit was needed for Patient 12. The Comprehensive Nursing Assessment indicated that skilled nursing visit weekly and as needed and certified home health aide visits two times weekly. During a review of Patient 12s History of Bereavement Plan of Care, noted was that no bereavement plan of care was completed for Patient 12. During a review of Patient 12s History of Bereavement Assessment, noted was that no bereavement assessment was completed for Patient 12. During a review of Patient 12s History of Spiritual Assessment, noted was that no spiritual assessment was completed for Patient 12. During a record review of Patient 12s medical records, noted was that no Spiritual Assessment or an Initial Bereavement Assessment was completed for Patient 12. There was no Spiritual Counselor on staff to interview. 10. During a record review of Patient 14s medical record form titled ";Personal Information", the Personal Information form indicated a SOC of 11/12/2024, with a terminal diagnosis of chronic diastolic heart failure. During a review of Patient 14s Comprehensive Nursing Assessment, dated 11/13/2024, that the SN visit weekly and as needed and CHHA visit two times weekly. The Comprehensive Nursing Assessment indicated that a spiritual assessment was needed for Patient 14. During a review of Patient 14s History of Bereavement Plan of Care, noted was that no bereavement plan of care was completed for Patient 14. During a review of Patient 14s History of Bereavement Assessment, noted was that no bereavement assessment was completed for Patient 14. During a review of Patient 14s History of Spiritual Assessment, noted was that no spiritual assessment was completed for Patient 14. During a record review of Patient 14s medical records, noted was that no Spiritual Assessment or an Initial Bereavement Assessment was completed for Patient 14. There was no Spiritual Counselor on staff to interview. During an interview on 3/11/2025, at 1:18 p.m., with Registered Nurse 1 (RN 1), RN1 stated ";not sure", when asked who the bereavement coordinator, chaplain, and volunteer coordinator was. During an interview on 3/12/2025 at 1:15 p.m., with the Owner/Administrator (ADM), the ADM stated he (ADM) was the one responsible for the day-to-day operation of the agency. During an interview on 3/12/2025 at 1:20 p.m., with the ADM, the ADM stated the HA did not have a Spiritual Chaplain or Bereavement Coordinator since December 2023. During an interview on 3/12/2025 at 1:22p.m., with the ADM, the ADM stated the HA did not have a DON since December 2023. The ADM stated he (ADM) was the one overseeing the licensed nurses. During an interview on 3/12/2025 at 1:49 p.m. with Director of Nursing 2 (DON2), DON2 stated she (DON2) was hired on 3/11/2025 by the HA. The DON2 stated she (DON2) was not told what she (DON2) was walking into (becoming involved in) and left the HA. During an interview on 3/12/2025 at 2:18 p.m. with Medical Director 2 (MD2), MD2 stated she (MD2) has been the HAs Medical Director since February 2025. MD2 stated she (MD2) did not know who the Medical Director was prior to her (MD2). The MD2 stated she (MD2) took over the HAs patients care. During an interview on 3/13/2025, at 11:50 a.m., with the ADM, the ADM stated that the HA did not have an MD from December 2023 until January 2025, when the new MD was hired. During a record review of document provided by MD2, untitled, dated ";as of January 31, 2025" indicated MD2 signed a contract with the HA on 1/31/2025. The document was signed by the ADM on 2/3/2025 and MD2 on 1/31/2025.

Based on observation, interview, and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure nursing and physician services were available 24 hours a day, seven days a week for fourteen or fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure had the potential to result in missed or inappropriate care provided to patients that might cause injury, hospitalization and/or death. --- During an interview on 3/10/2025 at 12:30 p.m. with the Owner/Administrator Friend (FR), the FR stated he spoke limited English and was requested to contact owner or administrator for survey assistance. During an interview on 3/10/2025 at 2:38 p.m. with Registered Nurse 1 (RN1), RN1 stated he was hired at the HA as a visiting nurse. RN1 stated he did not have the Director of Nurses 1 (DON1)’s phone number but was able to provide her email. During an interview on 3/10/2025 at 2:47 p.m. with the Owner/Administrator (ADM), the ADM stated he was out of town and has been unable to get a hold of the Director of Nurses 1 (DON1). The ADM was requested and able to provide the Director of Nurses Designees (DD1) phone number. The ADM requested to reschedule the survey. The ADM was made aware that the survey process needs to continue at this time.  During an interview on 3/10/2025 at 3 p.m. with the DD1, DD1 stated she was not able to assist with the survey process because she was hired a week ago and does not have patients medical record access. The DD1 stated she was unable to get a hold of the DON1. The DD1 requested to reschedule survey for tomorrow. During an interview on 3/10/2025 at 3:25 p.m. with the ADM, the ADM stated he (ADM) was still unable to get in contact with DON1 for survey assistance. On 3/11/2025 at 10 a.m. the HA door was locked with no answer.  On 3/11/2025 at 10:42 a.m. the DON1 and the DD1 were called, with no answer. Unable to leave a voicemail to the DON1 due to “voicemail not set up yet”. Message with call back number left on the DD1’s voice mail. During an interview on 3/11/2025 at 12:51 p.m. with the RN1, the RN1 stated he (RN1) was hired as the Director of Nurses Designee on 3/10/2025. During an interview on 3/11/2025 at 1:10 p.m. with the RN1, the RN1 stated the DON1 was the acting DON.  During an interview on 3/11/2025 at 3:17 p.m. with the Intake Coordinator (IC), the IC stated the DON1 was no longer the acting DON. IC stated that the Director of Nurses 2 (DON2) was the new acting DON who started working for the HA a week ago.  An email was sent on 3/12/2025 at 12:09 p.m. to DON1’s email provided by RN1, requesting a call back.  During an interview on 3/12/2025 at 1:12 p.m. with the ADM, the ADM stated since the change of ownership on December 2023, the HA has not had a DON. The ADM stated DON2 was hired last week. During an interview on 3/12/2025, at 1:15 p.m., with the ADM, the ADM stated he (ADM) was not a licensed nurse. The ADM stated he (ADM) did not have contact information for Medical Director 1 (MD 1). A request was made for the employee file for MD 1. The ADM stated he (ADM) would email the file. The file was not sent to the survey team as of 3/24/2025. During an interview on 3/12/2025, at 1:22 p.m., with the ADM, the ADM stated he (ADM) was the one overseeing the licensed nurses. The ADM stated he (ADM) knew the nurses were providing the right care as long as they are doing their visits. The ADM stated the nurses had a license and experience. The ADM just had to make sure the nurses were doing their visits. During an interview on 3/12/2025 at 1:49 p.m. with the DON2, the DON2 stated she (DON2) was interviewed last week for the DON position and was hired on 3/11/2025. The DON2 stated she (DON2) was not told what she (DON2) was walking into and left the HA.  During an interview on 3/12/2025 at 2:18 p.m. with the Medical Director 2 (MD2), the MD2 stated she (MD2) has been the HA’s Medical Director since February 2025. The MD2 stated she (MD2) did not know who the Medical Director was prior to her (MD2). The MD2 stated she (MD2) took over the HA’s patients care.  During a record review on 3/12/2025 at 7:42 p.m. of email sent by DON1, the DON1 stated she (DON1) was not associated with the HA. During an interview on 3/13/2025 at 10:20 a.m. with the ADM, the ADM stated RN1 had an emergency and will not be able to assist with the survey today. The ADM stated that he (ADM) would look for another nurse for assistance.  During an interview on 3/13/2025 at 11:50 a.m., with the ADM, the ADM stated he became the owner of the HA in December of 2023. The ADM stated there was no assigned Medical Director for the HA from December 2023 until January 2025. The ADM stated the first and only HA Medical Director, was MD2. The ADM stated MD2 was hired in January 2025.  During a concurrent observation and interview on 3/13/2025 at 3:15 p.m. with the ADM the ADM requested to reschedule the survey until he is in town and that he was going to call Centers for Medical and Medicare (CMS) to reschedule. The ADM stated he (ADM) was responsible for everything that goes on with the HA. HA door was knocked several times with no answer.  During a record review on 3/14/2025 at 11:01 a.m. of a text message received from the ADM, the ADM stated, “I told you to reschedule yesterday. So please do so when I am present. Thanks again.” No Registered Nurse or Director of Nurses were provided to assist with the survey process on 3/10/2025, 3/13/2025, and 3/14/2025 to 3/24/2025.  1.During a record review of Patient 1’s medical record form titled “Personal Information”, indicated an SOC of 11/15/2024, with a terminal diagnosis of Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities). 2.During a record review of Patient 2’s medical record form titled “Personal Information”, indicated an SOC of 12/12/2024, with a terminal diagnosis of heart disease (a range of conditions that affect the heart).   3.During a record review of Patient 3’s medical record form titled “Personal Information”, indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain).  4.During a record review of Patient 4‘s medical record form titled “Personal Information”, indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood). The form indicated Medical Director 2 (MD2) was listed as Patient 4’s Medical Director (MD). 5.During a record review of Patient ‘5s medical record form titled “Personal Information”, indicated a SOC date of 11/8/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). The form did not have Patient 5’s contact phone number listed. The form indicated MD2 was listed as Patient 5’s MD. 6.During a record review of Patient 6‘s medical record form titled “Personal Information”, indicated a SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). The form indicated MD2 was listed as Patient 6’s MD. 7.During a record review of Patient 7‘s medical record form titled “Personal Information”, indicated a SOC date of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (progressive lung disease causing airflow obstruction with difficulty breathing). The form indicated MD2 was listed as Patient 7’s MD. 8.During a record review of Patient 8‘s medical record form titled “Personal Information”, indicated an SOC of 12/10/2024, with a terminal diagnosis of heart disease. 9.During a record review of Patient 9‘s medical record form titled “Personal Information”, indicated an SOC of 11/14/2024, with a terminal diagnosis of heart disease. 10.During a record review of Patient 10‘s medical record form titled “Personal Information”, indicated an SOC of 11/21/2024, with a terminal diagnosis of cerebral stroke syndrome. 11.During a record review of Patient 11‘s medical record form titled “Personal Information”, indicated an SOC of 12/14/2024, with a terminal diagnosis of Alzheimer’s Disease. 12.During a record review of Patient 12‘s medical record form titled “Personal Information”, indicated an SOC of 11/3/2024, with a terminal diagnosis of chronic diastolic heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). 13.During a record review of Patient 13‘s medical record form titled “Personal Information”, indicated an SOC of 11/18/2024, with a terminal diagnosis of Alzheimer’s Disease. 14.During a record review of Patient 14‘s medical record form titled “Personal Information”, indicated an SOC of 11/12/2024, with a terminal diagnosis of chronic diastolic heart failure.

Based on observation, interview and record review, the Hospice (a specialized form of medical care for people who are nearing the end of life) Agency (HA-an organization that provides care and support to terminally ill patients [patients with six months of less left to live] and their families, focusing on comfort and quality of life rather than curative treatments) failed to ensure the Conditions of Participation (CoP-a set of minimum professional standards all hospice agencies must meet to participate in Medicare [a federal health insurance program that helps people pay for healthcare] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) regarding Medical Director was met as follows: --- 1.The HA failed to ensure that there was a contract with an appointed MD for 14 of 14 sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) from December 2023 to February 2025 to ensure that the medical care and services, and continuous assessment of patient health status were provided to Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14; who were assessed to received hospice care. (Refer to L666).2. The HA failed to ensure the HA's  MD completed and provided an initial Certification of Terminal Illness (CTI – document used to declare a patient’s life expectancy of six months or less if their illness runs its normal course) that reflected the patient's current health status and identifies patients' need for hospice care and services related to hospice eligibility and management of terminal illness for 14 of 14 sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L667).3. The HA failed to ensure the HA's  MD failed to recertify, fill out, and sign the Certification of Terminal Illness (CTI – a document stating a patient’s life expectancy is six months or less if their illness runs its normal course, and it must be completed by a medical doctor)  that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for 13 of 14 sample patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L668).The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated (established by law) compliance with Federal regulation for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services.

Based on observation, interview, and record review, the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to: 1.Ensure there was a contract with an appointed Medical Director (MD) for 14 of 14sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) from December 2023 to February 2025. 2.Ensure that the medical care and services, and continuous assessment of patient health status were provided to fourteen of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) assessed to received hospice care. As a result, Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14 did not have a continued medical assessment of the care being provided that can potentially affect the patients care and services that could lead to hospitalization and death. The State Survey Agency (the Department) attempted to contact the Owner/Administrator (ADM) starting on 3/19/25 to 3/21/25 in order to call an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for failing to ensure there was a contract with an appointed MD and failing to ensure that the medical care and services, and continuous assessment of patients health status were provided. The Department has been unable to get in contact with the ADM. The Department was unable to conduct an exit conference with the ADM due to the ADM not responding to attempted phone calls from 3/19/25 to 3/21/25. --- 1. During a record review of Patient 1s medical record form titled ";Personal Information", the Personal Information form indicated a start of care (SOC-the day the patient officially begins receiving hospice services) of 11/15/2024, with a terminal diagnosis of Alzheimers Disease (a disease characterized by a progressive decline in mental abilities). During an interview on 3/12/2025, at 11:21 a.m., RN 1 stated he (RN 1) conducted the start of care visit for Patient 1 on 11/15/24. RN 1 stated Medical Director 1 (MD 1) was the medical director at the time of Patient 1s SOC. RN 1 stated MD 1 ordered all the medications on admission for Patient 1. RN 1 stated that he (RN 1) was the nurse who received the orders from MD 1. During a record review of Patient 1s Certification of Terminal Illness (CTI- a document to confirm a patient's prognosis [prediction] of having six months or less to live due to their illness for certification period #12 from 11/15/2024 to 1/13/2025, the CTI indicated MD 1 as the certifying medical director. The document was not signed by a physician. During a record review of Patient 1s Physician Orders dated 11/15/24, the following orders were noted: 1. Ambien (medication used to help a patient sleep) five milligrams (mg-unit of measure) one tablet to be taken orally at bedtime 2. Lorazepam (medication used to treat anxiety) 0.5 mg, one table every four to six hours as needed for anxiety 3. Lexapro (medication used to treat depression) 10 mg, one table daily 4. Risperidone (medication used to treat schizophrenia [a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others) one mg, one tablet twice a day. During a concurrent interview and record review on 3/14/2025, at 3:38 p.m., Patient 1s record titled, ";Physicians Order", dated 11/15/2024, was reviewed with the EMR representative (REP 3). The record indicated the ADM had entered the medication orders for Ambien, Lorazepam, Lexapro, and Risperidone. The record indicated MD 1 as the ordering physician. During a record review of Patient 1s HAs medical records, there were no medical evaluations and medical documents to support Patient 1s medical diagnoses and need for psychotropic medications. 2. During a record review of Patient 2s medical record form titled ";Personal Information", the personal information form indicated a SOC of 12/12/2024, with a terminal diagnosis of heart disease (a group of conditions that affect the heart and its blood vessels). During a record review of Patient 2s ";CTI", for certification period #3 from 12/12/2024 to 2/9/2025, the CTI indicated MD 1s name as the certifying medical director. The document did not indicate a narrative was entered on the physicians portion of the form to support a hospice care admission. 3. During a record review of Patient 3s medical record form titled ";Personal Information", the personal information form indicated a SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries [a blood vessel that carries blood away from the heart to the body's tissues and organs, typically carrying oxygenated blood]) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). During a record review of Patient 3s ";CTI", for certification period #13 from 11/20/2025 to 1/18/2025 the CTI indicated MD 1s name as the certifying medical director. The document did not indicate a narrative was entered on the physicians portion of the form to support a hospice care admission. 4. During a record review of Patient 4s medical record form titled ";Personal Information", the personal information form indicated a SOC date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood). During an interview on 3/12/2025 at 9 a.m. with Patient 4, Patient 4 stated he (Patient 4) has never been told he had six months or less to live. Patient 4 stated he (Patient 4) has not spoken to a doctor from the HA. During a record review of Patient 4s medical record form titled ";Physicians Certification for Hospice Benefit (CTI – document used to declare a patients life expectancy of six months or less if their illness runs its normal course)" dated 1/27/2025 to 3/27/2025, the CTI did not indicate it was completed or certified by a Medical Director (MD). 5. During a record review of Patient 5s medical record form titled ";Personal Information", the personal information form indicated a SOC date of 11/8/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). During a record review of Patient 5s medical record form titled ";Physicians Certification for Hospice Benefit" dated 11/8/2024 to 2/5/2025, the CTI did not indicate it was completed or certified by a MD. 6. During a record review of Patient 6s medical record form titled ";Personal Information", the personal information form indicated a SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). During an interview on 3/14/2025 at 2:53 p.m. with Patient 6, Patient 6 stated he (Patient 6) has not seen a doctor for the past two years. Patient 6 stated he (Patient 6) has not been told by anyone that he (Patient 6) had six months or less to live. During a record review of Patient 6s medical record form titled ";Physicians Certification for Hospice Benefit" dated 11/23/2024 to 1/21/2025, the CTI did not indicate it was completed or certified by an MD. During a record review of Patient 6s medical record form titled ";Physicians Certification for Hospice Benefit" dated 1/22/2025 to 3/22/2025, the CTI did not indicate it was completed or certified by an MD. 7. During a record review of Patient 7s medical record form titled ";Personal Information", the form indicated a SOC date of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-progressive lung disease causing airflow obstruction with difficulty breathing). During an interview on 3/14/2025 at 3:34 p.m. with Patient 7s family member (FM1), FM1 stated Patient 7 has not seen a medical doctor for the past six to seven months. During a record review of Patient 7s medical record form titled ";Physicians Certification for Hospice Benefit" dated 11/12/2024 to 2/9/2025, the CTI did not indicate it was completed or certified by an MD. During a record review of Patient 7s medical record form titled ";Physicians Certification for Hospice Benefit" dated 2/10/2025 to 5/10/2025, the CTI did not indicate it was completed or certified by an MD. 8. During a record review of Patient 8s medical record form titled ";Personal Information", the form indicated an SOC of 12/10/2024, with a terminal diagnosis of heart disease. During a record review of Patient 8s ";CTI", for certification period # 17 from 12/10/24 to 2/7/25, the CTI did not indicate the patient was certified for hospice care. 9. During a record review of Patient 9s medical record form titled ";Personal Information", the form indicated a SOC of 11/14/2024, with a terminal diagnosis of heart disease. During a record review of Patient 9s ";CTI", for certification period # 6 from 11/14/24 to1/12/25, the CTI did not indicate the patient was certified for hospice care. 10. During a record review of Patient 10s medical record form titled ";Personal Information", the form indicated a SOC of 11/21/2024, with a terminal diagnosis of cerebral stroke syndrome (occurs when blood flow to part of the brain is disrupted, causing brain damage or death). During a record review of Patient 10s ";CTI", for certification period # 10 from 11/21/24 to 1/19/25, the CTI did not indicate the patient was certified for hospice care. 11. During a record review of Patient 11s medical record form titled ";Personal Information", indicated an SOC of 12/14/2024, with a terminal diagnosis of Alzheimers Disease. During a record review of Patient 11s ";CTI", for certification period #1 from 12/14/24 to 3/13/25, the CTI did not indicate the patient was certified for hospice care. 12. During a record review of Patient 12s medical record form titled ";Personal Information", the form indicated a SOC of 11/3/2024, with a terminal diagnosis of chronic diastolic heart failure (a condition in which your heart's main pumping chamber [left ventricle] becomes stiff and unable to fill properly). During a record review of Patient 12s ";CTI", for certification period #4 from 11/4/2024 to 1/2/2025, the CTI did not indicate it was completed and certified an MD. During an interview on 3/12/2025 at 10:36 a.m. with Caregiver 1 (CGR1), CGR1 stated he (CGR1) and Patient 12 had not met or talked with MD1. CGR1 stated that Patient 12s physician is not a physician associated with the HA. 13. During a record review of Patient 13s medical record form titled ";Personal Information", the form indicated a SOC of 11/18/2024, with a terminal diagnosis of Alzheimers Disease. During a record review of Patient 13s ";CTI", for certification period #14 from 11/18/2024 to 1/17/2025, did not indicate it was completed and certified an MD. 14. During a record review of Patient 14s ";medical record form titled Personal Information", the form indicated a SOC of 11/12/2024, with a terminal diagnosis of chronic diastolic heart failure. During a record review of Patient 14s ";CTI", for certification period #8 from 11/12/2024 to 1/10/2025, the CTI did not indicate that it was completed and certified by an MD. During a record review of Patient 14s ";CTI", for certification period #10 from 3/12/2025 to 5/10/2025, the CTI did not indicate the patient was certified for hospice care. The CTI indicated that the certification was based on a Face-to-Face Encounter (in person meeting). The CTI Face to Face Narrative and Certifying Physician Narrative did not indicate it was completed and certified by an MD. During an interview on 3/13/2025 at 10:20 a.m. with Patient 14, Patient 14 stated that she (Patient 1) did not know who MD1 was, and did not recall talking to a physician from the HA. During an interview on 3/12/2025 at 1:12 p.m. with the Administrator (ADM), the ADM stated he (ADM) took ownership of the HA in December 2023. ADM stated there were no patients when he (ADM) took ownership of the HA. During an interview on 3/12/2025 at 2:18 p.m. with the Medical Director 2 (MD2), MD2 stated she (MD2) has been the HAs Medical Director since February 2025. The MD2 stated she (MD2) did not know who the Medical Director was prior to her (MD2). The MD2 stated she (MD2) took over the HAs patients care. During an interview on 3/13/2025 at 11:50 a.m., with the ADM, the ADM stated that there was no assigned Medical Director (MD) for the HA from December 2023 until January 2025. The ADM stated the first and only HA Medical Director, was MD2. The ADM stated MD2 was hired in January 2025. During a record review of document provided by MD2, untitled, dated ";as of January 31,2025" indicated MD2 signed a contract with the HA on 1/31/2025. The document was signed by the ADM on 2/3/2025.

Based on observation, interview, and record review, a Hospice Agencys (HA - agency providing care to terminally ill patients who have six months or less to live) Medical Director (MD) failed to fill out and provide an initial Certification of Terminal Illness (CTI, document used to declare a patients life expectancy of six months or less if their illness runs its normal course) that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for fourteen of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). As a result, Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14 were placed at increased risk for losing their hospice eligibility/hospice benefits, not receive hospice care when needed in the future, and had the potential to not receive the necessary care and services that could lead to potential hospitalization and death. The State Survey Agency (the Department) attempted to contact the Owner/Administrator (ADM) starting on 3/19/25 to 3/21/25 in order to call an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for failing to complete and provide an initial CTI that reflected the patients current health status and identified the patients' need for hospice care and services related to hospice eligibility and management of terminal illness; but have been unable to get in contact with the ADM. The Department was unable to conduct an exit conference with the ADM due to the ADM not responding to attempted phone calls from 3/19/25 to 3/21/25. --- Findings: During an interview on 3/12/2025 at 1:12 p.m. with the Owner/Administrator (ADM), the ADM stated he (ADM) took ownership of the HA in December 2023. ADM stated there were no patients when he (ADM) took ownership of the HA. During an interview on 3/12/2024, at 1:15 p.m., the ADM stated he did not have contact information for Medical Director 1 (MD 1). A request was made for the employee file for MD 1. The ADM stated he would email the file. The file was not sent to the survey team. During an interview on 3/12/2025 at 2:18 p.m. with the Medical Director 2 (MD2), the MD2 stated she (MD2) has been the HAs Medical Director since February 2025. The MD2 stated she (MD2) did not know who the Medical Director was prior to her (MD2). The MD2 stated she (MD2) took over the HAs patients care. During an interview on 3/13/2025 at 11:50 a.m., with the ADM, the ADM stated he (ADM) became the owner of the HA in December of 2023. The ADM stated there was no assigned Medical Director for the HA from December 2023 until January 2025. The ADM stated the first and only HA Medical Director, was MD2. The ADM stated MD2 was hired in January 2025. During a record review of document provided by MD2, untitled, dated ";as of January 31,2025" indicated MD2 signed a contract with the HA on 1/31/2025. The document was signed by the ADM on 2/3/2025 and MD2 on 1/31/2025. During an interview on 3/13/2025, at 3:49 p.m., with MD2, MD 2 stated she (MD2) began taking care of patients at the HA in February 2025. MD 2 stated her (MD2) role as medical director was to oversee the care of patients for the hospice, communicate regarding symptom management, complete certificates, and give orders for medications. MD 2 stated she (MD2) has not been able to get into the Electronic Medical Record (EMR), has not been able to log in since February 2025. MD 2 stated Hospice Staff (HS) 1 was helping her (MD2) with access to the EMR. MD 2 stated she (MD2) texted the order to HS 1, and HS 1 transcribed the order. MD 2 stated she (MD2) did not know what HS 1 did with the orders. MD 2 stated she (MD2) did not know if HS 1 was a nurse. MD 2 stated she (MD2) had not signed any of the orders because she (MD2) did not have access to the EMR. MD 2 stated she (MD2) had not completed any of the CTIs because she (MD2) was unable to log into the EMR. MD 2 stated she (MD2) worked remotely and relied on the nursing assessment to manage the care of the patients. During an interview on 3/13/2025, at 4:01 p.m., with MD2, MD 2 stated she (MD2) did not see patients directly in person. MD 2 stated she (MD2) worked with the staff on the ground- staff saw patients and information was reported to MD 2. 1. During a review of Patient 1s ";Personal Information", indicated an SOC of 11/15/2024, with a terminal diagnosis of Alzheimers Disease (a disease characterized by a progressive decline in mental abilities). During a review of Patient 1s ";CTI", for certification period #12 from 11/15/2024 to 1/13/2025, Patient 1's CTI indicated MD 1 was the medical director. The document indicated a narrative was written but there was no signature from the doctor. During an interview on 3/12/2025, at 9:34 a.m., Patient 1s DPOA (Durable Power of Attorney) stated that Patient 1 was not terminally ill. The DPOA stated that the DPOA was not aware Patient 1 was in hospice care, nor how long Patient 1 had been in hospice care. During an observation of the home visit on 3/12/2025 at 10:40 a.m., with RN 1, Patient 1 was awake and alert. Patient 1 was lying in bed, with both side rails up. Patient 1 was non-interview able. During an interview at the home visit on 3/12/225, at 10:42 a.m., the Board and Care Staff (BCS 1) stated Patient 1 had not been on sedatives (medications that make you sleep) for 1 week because the HA said she didnt need them. During an interview at the home visit on 3/12/2025, at 11:21 a.m., RN 1 stated he had done the start of care visit. RN 1 stated MD 1 was the medical director. RN 1 stated MD 1 ordered all the medications on admission, and RN 1 was the one who took the orders. The medications ordered on admission included psychotropic medications (those that affect brain function) Ambien (to help sleep), Lorazepam (treats anxiety), Lexapro (treats depression), and Risperidone (treats symptoms of schizophrenia). During a concurrent interview and record review on 3/13/2025, at 11:01 a.m., with the HAs contracted pharmacist (PHARM 1), Patient 1s record titled, ";Physicians Order", dated 11/15/2024 was reviewed. PHARM 1 stated the ADM placed the orders for Ambien 5 (mg-milligrams, unit of measurement) 1 tablet oral at bedtime, Lorazepam 0.5 mg 1 tablet every 4 to 6 hours as needed for anxiety, Lexapro 10 mg 1 tablet once a day, and Risperidone 1 mg 1 tablet twice a day. During a concurrent interview and record review on 3/13/2025, at 11:01 a.m., with PHARM 1, Patient 1s record titled, ";Physicians Order", dated 12/27/2024 was reviewed. PHARM 1 stated the ADM placed the orders for increase of medication doses: Ambien 10 1 tablet oral at bedtime, Lorazepam 2 mg 1 tablet oral, every 4 to 6 hours as needed for anxiety, and Risperidone 2 mg 1 tablet oral, twice a day. During an interview on 3/13/2025, at 11:19 a.m., PHARM 1 stated if Patient 1 was not a hospice patient, the amount of medications needed were based on the psychiatric status, the need of the patient, and medical condition. It is the doctors decision on what medication and dose the patient needs. Under hospice care, the patient needed to be under the care of a medical director, and under hospice policy and procedure. During a review of Patient 1s medical records did not indicate any evidence of a medical evaluation and medical documents to support Patient 1s medical diagnoses and need for psychotropic medications for initial certification period 11/15/2024 to 1/13/2025. During an interview on 3/14/2025, at 11:48 a.m., the Pharmacist (PHARM 2), stated Risperidone for patients who have dementia, puts them at risk of early death and stroke. The medication has a black box warning (the drug has a serious risk of side effects that may impact life). When this medication is increased, there are significant risks and side effects such as movement disorder, dry mouth, dizziness, drowsiness, which puts the patient at risk of falling. Increasing the dose, increases the risk. During an interview on 3/13/2025, at 4:01 p.m., MD 2 stated she received a text message from RN 1 on 2/3/2025 saying Patient 1s son (DPOA-Durable power of attorney) was complaining about his mom being drowsy.MD 2 stated she did not see Patient 1 directly in person, or physically. MD 2 stated she was not 100% sure she had reviewed any medical information or was given any additional information about Patient 1. During an interview on 3/14/2025, at 11:48 a.m., the PHARM 2 stated Lorazepam required well documented evidence of behavior to justify the need for the medication. The risks of this medication were drowsiness, dizziness, risk of fall with injury, especially in the elderly. If the medication was increased to 2 mg, it would require a medical evaluation. Especially psychiatry, especially if the indication was schizophrenia. The PHARM 2 stated it was problematic to increase Lorazepam and Risperidone at the same time, as clinical rationale was needed. Normally, one medication would be increased at a time, to try to see if it is effective in controlling the issues. If you increase medications at the same time, you dont know which medication is effective, and you are increasing the risk of injury. The PHARM 2 stated medications Risperidone and Lorazepam, together were a form of chemical restraint. Having Ambien, in addition, really ensured Patient 1 was asleep. 2. During a review of Patient 2s ";Personal Information", indicated an SOC of 12/12/2024, with a terminal diagnosis of heart disease (a range of conditions that affect the heart). During a review of Patient 2s ";CTI", for certification period #3 from 12/12/2024 to 2/9/2025, the document indicated MD 1s name as the certifying medical director. The document did not indicate a narrative was entered on the doctors portion of the form to support a hospice care admission. During a review of Patient 2s medical records did not indicate any evidence of a medical evaluation and medical documents to support Patient 2s medical diagnoses and need for hospice care. 3. During a review of Patient 3s medical record form titled ";Personal Information", indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). During a review of Patient 3s ";CTI", for certification period #13 from 11/20/2025 to 1/18/2025 the document indicated MD 1s name as the certifying medical director. The document did not indicate a narrative was entered on the doctors portion of the form to support a hospice care admission. During a review of Patient 3s medical records did not indicate any evidence of a medical evaluation and medical documents to support Patient 3s medical diagnoses and need for hospice care. 4. During a review of Patient 4s medical record form titled ";Personal Information", indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood). The form indicated Medical Director 2 (MD2) was listed as Patient 4s Medical Director (MD). During an interview on 3/12/2025 at 9 a.m. with Patient 4, Patient 4 stated he (Patient 4) has never been told he had 6 months or less to live. Patient 4 stated he (Patient 4) has not spoken to a doctor from the HA. During a review of Patient 4s medical record form titled ";Physicians Certification for Hospice Benefit (CTI)" dated 1/27/2025 to 3/27/2025, indicated Medical Director 1 (MD1) was listed as Patient 4s MD. The form did not indicate it was completed or certified by an MD. 5. During a review of Patient 5s medical record form titled ";Personal Information", indicated a SOC date of 11/8/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). The form did not have Patient 5s contact phone number listed. The form indicated MD2 was listed as Patient 5s MD. During a review of Patient 5s medical record form titled ";Physicians Certification for Hospice Benefit" dated 11/8/2024 to 2/5/2025, indicated MD1 was listed as Patient 5s MD. The form did not indicate it was completed or certified by an MD. 6. During a review of Patient 6s medical record form titled ";Personal Information", indicated a SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). The form indicated MD2 was listed as Patient 6s MD. During an interview on 3/14/2025 at 2:53 p.m. with Patient 6, Patient 6 stated he (Patient 6) has not seen a doctor for the past 2 years. Patient 6 stated he (Patient 6) has not been told by anyone that he (Patient 6) had 6 months or less to live. During a review of Patient 6s medical record form titled ";Physicians Certification for Hospice Benefit" dated 11/23/2024 to 1/21/2025, indicated MD1 was listed as Patient 6s MD. The form did not indicate it was completed or certified by an MD. 7. During a review of Patient 7s medical record form titled ";Personal Information", indicated a SOC date of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (progressive lung disease causing airflow obstruction with difficulty breathing). The form indicated MD2 was listed as Patient 7s MD. During an interview on 3/14/2025 at 3:34 p.m. with Patient 7s family member (FM1), FM1 stated Patient 7 has not seen a medical doctor for the past 6-7 months. During a review of Patient 7s medical record form titled ";Physicians Certification for Hospice Benefit" dated 11/12/2024 to 2/9/2025, indicated MD1 was listed as Patient 7s MD. The form did not indicate it was completed or certified by an MD. 8. During a review of Patient 8s medical record form titled ";Personal Information", indicated an SOC of 12/10/2024, with a terminal diagnosis of heart disease. During a review of Patient 8s ";CTI", for certification period # 17 from 12/10/24 to 2/7/25, did not indicate the patient was certified for hospice care. 9. During a review of Patient 9s medical record form titled ";Personal Information", indicated an SOC of 11/14/2024, with a terminal diagnosis of heart disease. During a review of Patient 9s ";CTI", for certification period # 6 from 11/14/24 to1/12/25, did not indicate the patient was certified for hospice care. 10. During a review of Patient 10s medical record form titled ";Personal Information", indicated an SOC of 11/21/2024, with a terminal diagnosis of cerebral stroke syndrome. During a review of Patient 10s ";CTI", for certification period # 10 from 11/21/24 to 1/19/25, did not indicate the patient was certified for hospice care. 11. During a review of Patient 11s medical record form titled ";Personal Information", indicated an SOC of 12/14/2024, with a terminal diagnosis of Alzheimers Disease. During a review of Patient 11s ";CTI", for certification period #1 from 12/14/24 to 3/13/25, did not indicate the patient was certified for hospice care. The section for certifying physician narrative was left completely blank. During an interview with caretaker for (PT11) on 3-12-25 at 12:05pm, she stated that she was there on his first visit with agency staff and does not recall them going over his status o f 6 months or less to live, she stated she would have definitely remembered that. 12. During a review of Patient 12s medical record form titled ";Personal Information", indicated an SOC of 11/3/2024, with a terminal diagnosis of chronic diastolic heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Patient 12s ";CTI", for certification period #4 from 11/4/2024 to 1/2/2025, did not indicate the patient was certified for hospice care. The CTI indicated that the certification was based on a medical history, record and patient status and team assessment. The CTI was not signed/dated by a Medical Director. During an interview on 3/12/2025 at 10:36 a.m. with Caregiver 1 (CGR1), CGR1 stated he (CGR1) and Patient 12 had not met or talked with MD1. CGR1 stated that Patient 12s physician was MD3, who was not a physician of the hospice agency. 13. During a review of Patient 13s medical record form titled ";Personal Information", indicated an SOC of 11/18/2024, with a terminal diagnosis of Alzheimers Disease. During a review of Patient 13s ";CTI", for certification period #14 from 11/18/2024 to 1/17/2025, did not indicate the patient was certified for hospice care. The CTI indicated that the certification was based on a Face to Face Encounter. The CTI Face to Face Narrative and Certifying Physician Narrative were blank and the CTI was not signed/dated by a Medical Director. 14. During a review of Patient 14s medical record form titled ";Personal Information", indicated an SOC of 11/12/2024, with a terminal diagnosis of chronic diastolic heart failure. During a review of Patient 14s ";CTI", for certification period #8 from 11/12/2024 to 1/10/2025, did not indicate the patient was certified for hospice care. The CTI indicated that the certification was based on a Face to Face Encounter. The CTI indicated that Patient 14 was a maximum assist (patient requires significant help from a caregiver or device to perform the task, with the caregiver performing 75-99% of the work while the individual contributes 25% or less) for ambulation, toileting and feeding. The CTI Face to Face Narrative and Certifying Physician Narrative did not indicate it was completed and certified by a MD. During an interview on 3/13/2025 at 10:20 a.m. with Patient 14, Patient 14 stated that her primary doctor was not MD1, that she did not know who MD1 was, and did not recall talking to a doctor from the hospice agency. Patient 14 stated she had yearly check ups with her primary physician and that she was probably not a terminally ill patient. Patient 14 stated she was able to walk one block independently, was able to go to the bathroom independently, and was able to feed herself.

Based on observation, interview, and record review, a Hospice Agencys (HA - agency providing care to terminally ill patients who have six months or less to live) Medical Director (MD) failed to recertify, fill out, and sign the Certification of Terminal Illness (CTI – a document stating a patients life expectancy is six months or less if their illness runs its normal course, and it must be completed by a medical doctor) that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for thirteen of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). As a result, Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14 were placed at increased risk for losing their hospice eligibility/hospice benefits, not receive hospice care when needed in the future, and had the potential to not receive the necessary care and services that could lead to potential hospitalization and death. The State Survey Agency (the Department) attempted to contact the Owner/Administrator (ADM) starting on 3/19/25 to 3/21/25 in order to call an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for the MD failing to recertify, fill out, and sign the CTI that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness; but have been unable to get in contact with the ADM. The Department was unable to conduct an exit conference with the ADM due to the ADM not responding to attempted phone calls from 3/19/25 to 3/21/25. --- During an interview on 3/12/2025, at 1:12 p.m. with the ADM, the ADM stated he (ADM) took ownership of the HA in December 2023. The ADM stated there were no patients when he (ADM) took ownership of the HA. During an interview on 3/12/2024, at 1:15 p.m., with the ADM, the ADM stated he (ADM) did not have contact information for Medical Director 1 (MD 1). A request was made for the employee file for MD 1. The ADM stated he would email the file. The file was not sent to the survey team. During an interview on 3/12/2025, at 2:18 p.m., with Medical Director 2 (MD2), MD2 stated she (MD2) had been the HAs Medical Director since February 2025. MD2 stated she (MD2) did not know who the Medical Director was prior to her (MD2). The MD2 stated she (MD2) took over the HAs patients care. During an interview on 3/13/2025, at 11:50 a.m., with the ADM, the ADM stated he (ADM) became the owner of the HA in December of 2023. The ADM stated there was no assigned Medical Director for the HA from December 2023 until January 2025. The ADM stated the first and only HA Medical Director, was MD2. The ADM stated MD2 was hired in January 2025. During a review of a document provided by MD2, untitled, dated ";as of January 31, 2025" indicated MD2 signed a contract with the HA on 1/31/2025. The document was signed by the ADM on 2/3/2025 and MD2 on 1/31/2025. During an interview on 3/13/2025, at 3:49 p.m., with MD2, MD 2 stated she (MD2) began taking care of patients at the HA in February 2025. MD 2 stated her (MD2) role as medical director was to oversee the care of patients for the hospice, communicate regarding symptom management, complete certificates, and give orders for medications. MD 2 stated she (MD2) had not been able to get into the Electronic Medical Record (EMR), had not been able to log in since February 2025. MD 2 stated Hospice Staff (HS) 1 was helping her (MD2) with access to the EMR. MD 2 stated she (MD2) texted the order to HS 1, and HS 1 transcribed the order. MD 2 stated she (MD2) did not know what HS 1 did with the orders. MD 2 stated she (MD2) did not know if HS 1 was a nurse. MD 2 stated she (MD2) had not signed any of the orders because she (MD2) did not have access to the EMR. MD 2 stated she (MD2) had not completed any of the CTIs because she (MD2) was unable to log into the EMR. MD 2 stated she (MD2) worked remotely and relied on the nursing assessment to manage the care of the patients. During an interview on 3/13/2025, at 4:01 p.m., with MD2, MD 2 stated she (MD2) did not see patients directly in person. MD 2 stated she (MD2) worked with the staff on the ground- staff saw patients and information was reported to MD 2. 1.During a review of Patient's Personal Information, the Personal Information indicated an SOC of 11/15/2024, with a terminal diagnosis of Alzheimers Disease (a disease characterized by a progressive decline in mental abilities). During an interview on 3/12/2025, at 9:34 a.m., Patient 1s DPOA (Durable Power of Attorney) stated that Patient 1 was not terminally ill. The DPOA stated that the DPOA was not aware Patient 1 was in hospice care, nor how long Patient 1 had been in hospice care. During an observation of the home visit on 3/12/2025 at 10:40 a.m., with RN 1, Patient 1 was awake and alert. Patient 1 was lying in bed, with both side rails up. Patient 1 was non-interview able. During a review of Patient 1s recertification ";CTI", for certification period #13 from 1/14/2025 to 3/14/2025, indicated MD 1s name as the certifying medical director. The CTI did not indicate a doctors narrative or signature. During an interview at the home visit on 3/12/2025, at 11:21 a.m., RN 1 stated MD 1 was the medical director for the start of care. RN 1 stated MD 1 ordered all the medications on admission, and RN 1 was the one who took the orders. The medications ordered on admission included psychotropic medications (those that affect brain function) Ambien (to help sleep), Lorazepam (treats anxiety), Lexapro (treats depression), and Risperidone (treats symptoms of schizophrenia). During a concurrent interview and record review on 3/13/2025, at 11:01 a.m., with PHARM 1, Patient 1s record titled, ";Physicians Order", dated 12/27/2024 was reviewed. PHARM 1 stated the ADM placed the orders for increase of medication doses: Ambien 10 mg 1 tablet oral at bedtime, Lorazepam 2 mg 1 tablet oral, every 4 to 6 hours as needed for anxiety, and Risperidone 2 mg 1 tablet oral, twice a day. During an interview on 3/13/2025, at 11:19 a.m., PHARM 1 stated if Patient 1 was not a hospice patient, the amount of medications needed were based on the psychiatric status, the need of the patient, and medical condition. It is the doctors decision on what medication and dose the patient needs. Under hospice care, the patient needed to be under the care of a medical director, and under hospice policy and procedure. During a review of Patient 1s clinical records indicated there was no medical evaluation and medical documents to support Patient 1s medical diagnoses and need for psychotropic medications during the recertification period 1/14/2025 to 3/14/2025. During an interview on 3/14/2025, at 11:48 a.m., Pharmacist 2 (PHARM 2), stated Risperidone (antipsychotic medication used to improve mood, thoughts, and behaviors) for patients who have dementia (memory loss and mental changes), puts them at risk of early death and stroke. The medication has a black box warning (the drug has a serious risk of side effects that may impact life). When this medication is increased, there are significant risks and side effects such as movement disorder, dry mouth, dizziness, drowsiness, which puts the patient at risk of falling. Increasing the dose, increases the risk. During an interview on 3/13/2025, at 4:01 p.m., MD 2 stated she received a text message from RN 1 on 2/3/2025 saying Patient 1s son (DPOA-Durable power of attorney) was complaining about his mom being drowsy.MD 2 stated she did not see Patient 1 directly in person, or physically. MD 2 stated she was not 100% sure she had reviewed any medical information or was given any additional information about Patient 1. During an interview on 3/14/2025, at 11:48 a.m., the PHARM 2 stated Lorazepam required well documented evidence of behavior to justify the need for the medication. The risks of this medication were drowsiness, dizziness, risk of fall with injury, especially in the elderly. If the medication was increased to 2 mg, it would require a medical evaluation. Especially psychiatry, especially if the indication was schizophrenia. The PHARM 2 stated it was problematic to increase Lorazepam and Risperidone at the same time, as clinical rationale was needed. Normally, one medication would be increased at a time, to try to see if it is effective in controlling the issues. If you increase medications at the same time, you dont know which medication is effective, and you are increasing the risk of injury. The PHARM 2 stated medications Risperidone and Lorazepam, together were a form of chemical restraint. Having Ambien, in addition, really ensured Patient 1 was asleep. During a record review of Patient 1s ";CTI", for recertification period #14 from 3/15/2025 to 5/13/2025, indicated MD 1s name as the certifying medical director. The did not indicate a doctors narrative or signature. During a review of Patient 1s medical records on 3/18/2025, indicated Patient 1 was discharged from the agency on 3/5/2025, with discharge reason ";Administrative Discharge". 2.During a review of Patient 2s Personal Information, the Personal Information indicated an SOC of 12/12/2024, with a terminal diagnosis of heart disease (a range of conditions that affect the heart which includes blood vessel disease, irregular heartbeats, or congenital heart defects). During a review of Patient 2s ";CTI", for recertification period #3 from 2/10/2024 to 4/10/2025, indicated the Registered Nurse (RN) had done a recertification visit under the section titled, ";RN Prognosis Summary". Further review of the document did not indicate a doctors narrative or signature. During a review of Patient 2s Discharge Summary, dated 2/10/2025, the Discharge Summary indicated Patient 2 died. The Discharge Summary indicated the patient was discharged from a different hospice agency, not Luar Hospice. 3.During a review of Patient 3s Personal Information, indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). During a review of Patient 3s ";CTI", for recertification period #14 from 1/19/2025 to 3/19/2025, indicated MD 1s name as the medical director. The CTI did not include a doctors narrative or signature. Further review of the record indicated a recertification visit was done, under section ";RN Prognosis Summary". 4.During a review of Patient 5's Personal Information, the Personal Information indicated a Start of Care (SOC) date of 11/8/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). The Personal Information did not have Patient 5s contact phone number listed. Lastly, the form indicated MD2 was listed as Patient 5s MD. During a review of Patient 5s Physicians Certification for Hospice Benefit, dated 2/6/2025 to 4/6/2025, the Physicians Certification for Hospice Benefit indicated MD1 was listed as Patient 5s MD. The Physicians Certification for Hospice Benefit indicated it was not completed or certified by an MD. 5. During a review of Patient 6s Personal Information, the Personal Information indicated a SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). The form indicated MD2 was listed as Patient 6s MD. During an interview on 3/14/2025, at 2:53 p.m., with Patient 6, Patient 6 stated he (Patient 6) had not seen a doctor for the past 2 years. Patient 6 stated he (Patient 6) had not been told by anyone that he (Patient 6) had six months or less to live. During a review of Patient 6s Physicians Certification for Hospice Benefit, dated 1/22/2025 to 3/22/2025, did not indicate it was completed or certified by an MD. indicated MD1 was listed as Patient 6s MD. The form did not indicate it was completed or certified by an MD. 6.During a record review of Patient 7s medical record form titled ";Personal Information", indicated a SOC date of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (progressive lung disease causing airflow obstruction with difficulty breathing). The form indicated MD2 was listed as Patient 7s MD. During an interview on 3/14/2025 at 3:34 p.m. with Patient 7s family member (FM1), FM1 stated Patient 7 has not seen a medical doctor for the past 6-7 months. During a record review of Patient 7s medical record form titled ";Physicians Certification for Hospice Benefit" dated 2/10/2025 to 5/10/2025, indicated MD1 was listed as Patient 7s MD. The form did not indicate it was completed or certified by an MD. 7.During a record review of Patient 8s medical record form titled ";Personal Information", indicated an SOC of 12/10/2024, with a terminal diagnosis of heart disease. During a record review of Patient 8s ";CTI", for recertification period # 17 from 12/10/24 to 2/7/25, did not indicate the patient was certified for hospice care. During an interview on 3-12-25 at 12:30pm PT 8 was asked if anyone from the agency ever explained to him that in his present condition, he had 6 months or less to live, he stated no this is the first time Im hearing that. 8.During a record review of Patient 9s medical record form titled ";Personal Information", indicated an SOC of 11/14/2024, with a terminal diagnosis of heart disease. During a record review of Patient 9s ";CTI", for recertification period # 6 from 11/14/24 to1/12/25, did not indicate the patient was certified for hospice care. 9.During a record review of Patient 10s medical record form titled ";Personal Information", indicated an SOC of 11/21/2024, with a terminal diagnosis of cerebral stroke syndrome. During a record review of Patient 10s ";CTI", for recertification period # 10 from 11/21/24 to 1/19/25, did not indicate the patient was certified for hospice care. During an interview on 3-12-25 at 12:20pm PT10 stated no one from the agency explained to him that he had only 6 months or less to live. 10.During a record review of Patient 11s medical record form titled ";Personal Information", indicated an SOC of 12/14/2024, with a terminal diagnosis of Alzheimers Disease. During a record review of Patient 11s ";CTI", for recertification period #1 from 12/14/24 to 3/13/25, did not indicate the patient was certified for hospice care. 11.During a record review of Patient 12s medical record form titled ";Personal Information", indicated an SOC of 11/3/2024, with a terminal diagnosis of chronic diastolic heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a record review of Patient 12s ";CTI", for recertification period #5 from 1/3/2025 to 3/3/2025, did not indicate the patient was certified for hospice care. The CTI indicated that the certification was based on a Face to Face Encounter. The CTI Face to Face Narrative and Certification narrative did not indicate it was completed and certified by the MD. During a record review of Patient 12s ";CTI", for recertification period #6 from 3/4/2025 to 5/2/2025, did not indicate the patient was certified for hospice care. The CTI indicated that the certification was based on a Face to Face Encounter. The CTI Face to Face Narrative and Certification narrative did not indicate it was completed and certified by the MD. During an interview on 3/12/2025 at 10:36 a.m. with Caregiver 1 (CGR1), CGR1 stated he (CGR1) and Patient 12 had not met or talked with MD1. CGR1 stated that Patient 12s physician was MD3, who was not a physician of the hospice agency. 12.During a review of Patient 13s medical record form titled ";Personal Information", the indicated an SOC of 11/18/2024, with a terminal diagnosis of Alzheimers Disease. During a record review of Patient 13s ";CTI", for certification period #15 from 1/18/2025 to 3/18/2025, did not indicate the patient was certified for hospice care. The CTI indicated that the certification was based on a Face to Face Encounter. The CTI Face to Face Narrative and Certifying Physician Narrative did not indicate it was completed and certified by the MD. 13.During a record review of Patient 14s medical record form titled ";Personal Information", indicated an SOC of 11/12/2024, with a terminal diagnosis of chronic diastolic heart failure. During a record review of Patient 14s ";CTI", for certification period #9 from 1/11/2025 to 3/11/2025, did not indicate the patient was certified for hospice care. The CTI indicated that the certification was based on a Face to Face Encounter. The CTI Face to Face Narrative and Certifying Physician Narrative did not indicate it was completed and certified by the MD. During a record review of Patient 14s ";CTI", for certification period #10 from 3/12/2025 to 5/10/2025, did not indicate the patient was certified for hospice care. The CTI indicated that the certification was based on a Face to Face Encounter. The CTI Face to Face Narrative and Certifying Physician Narrative did not indicate it was completed and certified by the MD. During an interview on 3/13/2025, at 10:20 a.m., with Patient 14, Patient 14 stated that her primary doctor was not MD1, that she did not know who MD1 was, and did not recall talking to a doctor from the hospice agency. Patient 14 stated she had yearly check ups with her primary physician and that she was probably not a terminally ill patient. Patient 14 stated she was able to walk one block independently, was able to go to the bathroom independently, and was able to feed herself.

Based on observation, interview and record review, the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation on Clinical Records was met as follows: --- 1. The HA failed to ensure one of fourteen sample patients (Patient 5)’s medical record included the initial nursing assessment, comprehensive assessment, updated comprehensive assessments, initial plan of care, updated plan of care, and the clinical notes. (Refer to L672). 2.The HA failed to ensure one of fourteen sample patients (Patient 1) had signed copies of their patient rights notice in their medical record. (Refer to L673). 3. The HA failed to ensure fourteen of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) medical records were authenticated. (Refer to L679). 4. The HA failed to ensure ten of fourteen sample patients (Patient 1, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 14) medical records were safeguarded. (Refer to L680).  The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients’ medical records are safeguarded from unauthorized access by any individuals or hospice staff.

Based on record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure one of fourteen sample patients (Patient 5)’s medical record included the initial nursing assessment, comprehensive assessment, updated comprehensive assessments, initial plan of care, updated plan of care, and the clinical notes. This failure had the potential to result in placing the patient at risk for missed and inappropriate care and services which could lead to missed care, injury, hospitalization, and/or death. --- The HA did not provide the survey team with knowledgeable staff from 3/10/2025 to 3/24/2025 to review the documents as written below. During a record review of Patient ‘5s medical record form titled “Personal Information”, indicated a Start of Care (SOC) date of 11/8/2024 and an End of Care (EOC) of 3/7/2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain).  During a record review of Patient 5’s medical record form titled “Comprehensive Nursing Assessment” dated 11/8/2024, indicated the form was left blank.  During a record review of Patient 5’s medical record form titled “Updated Assessment” dated 2/13/2025, indicated the form was left blank. The form also indicated it was signed by Registered Nurse 4 (RN4).  During a record review of Patient 5’s medical record form titled “Updated Assessment” dated 2/27/2025, indicated the form was left blank. The form also indicated it was signed by Registered Nurse 4 (RN4).  During a record review of Patient 5’s medical record form titled “History of POC/IDG” undated, indicated there were no entries made.  During a record review of Patient 5’s medical record form titled “POC Summary” dated as of 3/11/2025, indicated all sections from 1-14 were left blank.  During a record review of Patient 5’s medical record form titled “History of Spiritual Assessment” undated, indicated there were no entries made.  During a record review of Patient 5’s medical record form titled “History of Psychosocial Assessment” undated, indicated there were no entries made.  During a record review of Patient 5’s medical record form titled “History of Bereavement Assessment” undated, indicated there were no entries made.  During a record review of Patient 5’s medical record form titled “Current Treatment/Medication/DME List” undated, indicated there were no entries made.  During a record review of Patient 5’s medical record form titled “Visit Notes MD (Medical Director)” dated 2/10/2025, indicated the form was left blank. The form also indicated it was signed by the Medical Director 1 (MD1). During a record review of Patient 5’s medical record form titled “Visit Notes LVN (License Vocational Nurse)” dated 11/12/2024, indicated the form was left blank. The form also indicated it was signed by LVN2.  During a record review of Patient 5’s medical record form titled “Visit Notes LVN” dated 2/17/2025, indicated the form was left blank. The form also indicated it was signed by LVN2.  During a record review of Patient 5’s medical record form titled “Visit Notes LVN” dated 2/24/2025, indicated the form was left blank. The form also indicated it was signed by LVN2.  During a record review of Patient 5’s medical record form titled “Physician’s Certification for Hospice Benefit” dated from 11/8/2024 to 2/5/2025, indicated it was left blank. During a record review of Patient 5’s medical record form titled “Physician’s Certification for Hospice Benefit” dated from 2/6/2025 to 4/6/2025, indicated it was left blank.During a record review of Patient 5’s medical record form titled “Physicians Orders” undated, indicated there were no entries made.  During a record review of Patient 5’s medical record form titled “Discharge Summary” dated 3/7/2025, indicated the form was left blank. During a record review of Patient 5’s electronic medical record (EMR) did not indicate any documented evidence Patient 5 had an initial nursing assessment, comprehensive assessment, updated comprehensive assessments, initial plan of care, updated plan of care, and the clinical notes.

Based on observation, interview, and record review the Hospice Agency (HA) failed to ensure one of fourteen sample patients (Patient 1) had signed copies of their patient rights notice in their medical record. This failure resulted in an incomplete medical record. --- A review of Patient 1’s Personal Information sheet indicated a start of care date on 11/15/2024, with a diagnosis of Alzheimer’s disease (a brain disease that destroys memory and thinking skills). During an observation of the HA’s office on 3/11/2025, at 1:46 p.m., with Registered Nurse 1 (RN 1), four (4) rooms were observed. A corner shelf in one of the rooms indicated documents in file folders. RN 1 stated these were the patient consent forms. RN 1 stated 17 files where counted. RN 1 stated he did not know where the other files were.  During a record review on 3/11/2025, at 1:50 p.m., Patient 1’s file was not found within the 17 files counted. During an interview on 3/11/2025, at 2:08 p.m., RN 1 stated Patient 1’s consents to hospice care where not in the office and was not aware of the location of Patient 1’s consent. During an interview on 3/11/2025 at 2:58 p.m., the intake coordinator (IC) stated the patients’ records should be in the office. When asked if she knew where Patient 1’s file was, the IC stated she would look for them as perhaps, the records were with the nurse. The IC later stated the missing consents were in the computer folder and she need to scan them and upload them into the EMR. The IC stated once the document was scanned into the EMR, she had to print them and put them into a file. Within a week, she had to print everything out and create a physical chart (file). The IC stated the original signed documents were given to the Administrator (ADM), who brought the documents to the office.  During a record review on 3/11/2025, from 4:02 p.m. to 4:09 p.m., of Patient 1’s electronic medical record (EMR), there was no documents uploaded into the medical record. The EMR did not indicate the presence of consents.

Based on interview and record review, the Hospice Agency (HA) failed to ensure fourteen of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) medical records were authenticated This failure resulted in incomplete medical records. --- During an interview on 3/12/2024, at 1:15 p.m., the Administrator (ADM) stated he did not have contact information for Medical Director 1 (MD 1).  During an interview on 3/12/2025 at 2:18 p.m. with the Medical Director 2 (MD2), the MD2 stated she (MD2) has been the HA’s Medical Director since February 2025. The MD2 stated she (MD2) did not know who the Medical Director was prior to her (MD2).  During an interview on 3/13/2025 at 11:50 a.m., with the ADM, the ADM stated there was no assigned Medical Director for the HA from December 2023 until January 2025. The ADM stated the first and only HA Medical Director, was MD2. The ADM stated MD2 was hired in January 2025.  During a record review of document provided by MD2, untitled, dated “as of January 31,2025” indicated MD2 signed a contract with the HA on 1/31/2025. The document was signed by the ADM on 2/3/2025 and MD2 on 1/31/2025. The HA did not provide the survey team with knowledgeable staff on 3/10/2025, 3/13/2025, and 3/14/2025 to review the documents as written below. 1.During a record review of Patient 1’s medical record form titled “Personal Information”, indicated an SOC of 11/15/2024, with a terminal diagnosis of Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities). During a record review of Patient 1’s “CTI”, for certification period #12 from 11/15/2024 to 1/13/2025, indicated MD 1’s name as the certifying medical director. The document indicated a narrative was entered on the doctor’s portion of the form. However, the document was not signed by a doctor.  During a concurrent interview and record review on 3/14/2025, at 3:38 p.m., Patient 1’s record titled, “Physicians Order”, dated 11/15/2024, was reviewed with the EMR representative (REP 3). The record indicated the ADM had entered medication orders which included Lorazepam (to treat anxiety), Ambien (to help sleep), Lexapro (treats depression), and Risperidone (to treat symptoms of schizophrenia-a brain illness), all which were psychotropic medications (medications that affect brain function). The record indicated MD 1’s name as the ordering doctor. The orders were not signed.  2.During a record review of Patient 2’s medical record form titled “Personal Information”, indicated an SOC of 12/12/2024, with a terminal diagnosis of heart disease (a range of conditions that affect the heart which includes blood vessel disease, irregular heartbeats, or congenital heart defects).    During a record review of Patient 2’s “CTI”, for certification period #3 from 12/12/2024 to 2/9/2025, the document indicated MD 1’s name as the certifying medical director. The document did not indicate a doctor’s signature.  3.During a record review of Patient 3’s medical record form titled “Personal Information”, indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). During a record review of Patient 3s “CTI”, for certification period #13 from 11/20/2025 to 1/18/2025 the document indicated MD 1’s name as the certifying medical director. The document did not indicate a doctor’s signature. 4.During a record review of Patient 4‘s medical record form titled “Personal Information”, indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood).   During a record review of Patient 4’s medical record form titled “Physician’s Certification for Hospice Benefit (CTI – document used to declare a patient’s life expectancy of six months or less if their illness runs its normal course)” dated 1/27/2025 to 3/27/2025, did not indicate a doctor’s signature. 5.During a record review of Patient ‘5s medical record form titled “Personal Information”, indicated a SOC date of 11/8/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). The form did not have Patient 5’s contact phone number listed.  During a record review of Patient 5’s medical record form titled “Physician’s Certification for Hospice Benefit” dated 11/8/2024 to 2/5/2025, did not indicate a doctor’s signature. 6.During a record review of Patient 6‘s medical record form titled “Personal Information”, indicated a SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain).  During a record review of Patient 6’s medical record form titled “Physician’s Certification for Hospice Benefit” dated 11/23/2024 to 1/21/2025, did not indicate a doctor’s signature. During a record review of Patient 6’s medical record form titled “Physician’s Certification for Hospice Benefit” dated 1/22/2025 to 3/22/2025, did not indicate a doctor’s signature.  7.During a record review of Patient 7‘s medical record form titled “Personal Information”, indicated a SOC date of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (progressive lung disease causing airflow obstruction with difficulty breathing).   During a record review of Patient 7’s medical record form titled “Physician’s Certification for Hospice Benefit” dated 11/12/2024 to 2/9/2025, did not indicate a doctor’s signature. During a record review of Patient 7’s medical record form titled “Physician’s Certification for Hospice Benefit” dated 2/10/2025 to 5/10/2025, did not indicate a doctor’s signature.  8.During a record review of Patient 8‘s medical record form titled “Personal Information”, indicated an SOC of 12/10/2024, with a terminal diagnosis of heart disease. During a record review of Patient 8’s “CTI”, for certification period # 17 from 12/10/24 to 2/7/25, did not indicate a doctor’s signature. 9.During a record review of Patient 9‘s medical record form titled “Personal Information”, indicated an SOC of 11/14/2024, with a terminal diagnosis of heart disease. During a record review of Patient 9’s “CTI”, for certification period # 6 from 11/14/24 to1/12/25, did not indicate a doctor’s signature. 10.During a record review of Patient 10‘s medical record form titled “Personal Information”, indicated an SOC of 11/21/2024, with a terminal diagnosis of cerebral stroke syndrome.  During a record review of Patient 10’s “CTI”, for certification period # 10 from 11/21/24 to 1/19/25, did not indicate a doctor’s signature. 11.During a record review of Patient 11‘s medical record form titled “Personal Information”, indicated an SOC of 12/14/2024, with a terminal diagnosis of Alzheimer’s Disease. During a record review of Patient 11’s “CTI”, for certification period #1 from 12/14/24 to 3/13/25, did not a indicate a doctor’s signature. 12.During a record review of Patient 12‘s medical record form titled “Personal Information”, indicated an SOC of 11/3/2024, with a terminal diagnosis of chronic diastolic heart failure. During a record review of Patient 12’s “CTI”, for certification period #4 from 11/4/2024 to 1/2/2025, did not indicate a doctor’s signature.  13.During a record review of Patient 13‘s medical record form titled “Personal Information”, indicated an SOC of 11/18/2024, with a terminal diagnosis of Alzheimer’s Disease. During a record review of Patient 13’s “CTI”, for certification period #14 from 11/18/2024 to 1/17/2025, did not indicate a doctor’s signature. 14.During a record review of Patient 14‘s “medical record form titled Personal Information”, indicated an SOC of 11/12/2024, with a terminal diagnosis of chronic diastolic heart failure.   During a record review of Patient 14’s “CTI”, for certification period #8 from 11/12/2024 to 1/10/2025, did not a indicate a doctor’s signature.

Based on observation, interview, and record review, the Hosice Agency (HA) failed to ensure ten of fourteen sample patients (Patient 1, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 14) medical records were safeguarded. This failure resulted in patient record privacy violation. --- During an interview on 3/11/2025 at 2:43 p.m., a census report was requested to Registered Nurse 1 (RN 1). RN 1 stated the office printer was not working but the printer upstairs worked. RN 1 stated the upstairs was a community designated area where everyone can use to print things. RN 1 stated the administrator’s fried (FR) was the agency clerk and he was in charge of making sure the phone calls were transferred to the right people. During a concurrent observation and interview on 3/11/2025, at 12:48 p.m., RN 1 and FR took the surveyor to where the printed census was. An observation of the upstairs area indicated an office space with a door labeled suite 201. The Office Employee (OE) stated suite 201 was the property management office. The OE stated RN 1 sent her an email to print out. The OE provided a copy of what was printed. The document indicated the HA’s active patient list.  A record review of the documented given by the OE on 3/11/2025, indicated the active patient list was sent from Luar Hospice to the property management email.  The following 10 patients were listed in the active patient list: 1.During a record review of Patient 1’s medical record form titled “Personal Information”, indicated an SOC of 11/15/2024, with a terminal diagnosis of Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities). 2.During a record review of Patient 3’s medical record form titled “Personal Information”, indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain).   3.During a record review of Patient 4‘s medical record form titled “Personal Information”, indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood).   4.During a record review of Patient 6‘s medical record form titled “Personal Information”, indicated an SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). 5.During a record review of Patient 7‘s medical record form titled “Personal Information”, indicated an SOC of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (progressive lung disease causing airflow obstruction with difficulty breathing).  6.During a record review of Patient 8‘s medical record form titled “Personal Information”, indicated an SOC of 12/10/2024, with a terminal diagnosis of heart disease.  7.During a record review of Patient 10‘s medical record form titled “Personal Information”, indicated an SOC of 11/21/2024, with a terminal diagnosis of cerebral stroke syndrome.  8.During a record review of Patient 11‘s medical record form titled “Personal Information”, indicated an SOC of 12/14/2024, with a terminal diagnosis of Alzheimer’s Disease. 9.During a record review of Patient 12‘s medical record form titled “Personal Information”, indicated an SOC of 11/3/2024, with a terminal diagnosis of chronic diastolic heart failure.  10.During a record review of Patient 14‘s medical record form titled “Personal Information”, indicated an SOC of 11/12/2024, with a terminal diagnosis of chronic diastolic heart failure.

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Conditions of Participations (conditions that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) regarding Drugs, biologicals, medical supplies, and DME was met as followed: --- The HA failed to ensure one of fourteen sampled patients (Patient 1) psychotropic medications (medications that affect brain function) were ordered by a licensed medical provider. Patient 1 did not have a medical evaluation to determine if the medications were needed and were not ordered by a licensed health practitioner. (Refer to L690). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory (written law) mandated compliance with Federal regulation for drug, biological, medical supplies, and DME services to ensure the highest quality of patient care are provided to the patients certified to receive hospice services.

Based on observation, interview, and record review, the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure one of fourteen sampled patients (Patient 1) psychotropic medications (medications that affect brain function) were ordered by a licensed medical provider. Patient 1 did not have a medical evaluation to determine if the psychotropic medications medications were needed and were not ordered by a licensed health practitioner. As a result, Patient 1s was given medications without a licensed medical provider order. Patient 1 was admitted into hospice care without a medical evaluation and was given psychotropic medications without the consent of the Durable Power of Attorney (DPOA, an agent to act on behalf of another in making financial, legal, or medical decisions) and without a doctors order. This placed Patient 1 at risk of hospitalization and death due to the side effects of the psychotropic medications. The State Survey Agency (the Department) attempted to contact the Owner/Administrator (ADM) starting on 3/19/25 to 3/21/25 in order to call an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for failing to ensure psychotropic medications were ordered by a licensed medical provider; but have been unable to get in contact with the ADM. The Department was unable to conduct an exit conference with the ADM due to the ADM not responding to attempted phone calls from 3/19/25 to 3/21/25. --- Findings: During an interview on 3/11/2025 at 12:54 p.m., with Registered Nurse 1 (RN 1), RN1 stated he (RN1) did not know where the employee files were. RN 1 stated he (RN1) did not know where the human resource files were for the employees. During an observation on 3/11/2025 at 1:46 p.m., of the HA, 4 rooms were observed. The cabinets, file cabinets, and drawers were empty. During an interview on 3/13/2025 at 11:50 a.m., with the Owner/Administrator (ADM) the ADM stated he (ADM) was not a licensed nurse or a licensed medical doctor. During a review of Patient 1s medical record form titled ";Personal Information" undated, indicated Patient 1's start of care date was 11/15/2024, with a primary diagnosis of Alzheimers disease (gradual memory loss). During an interview on 3/12/2025, at 9:34 a.m., with Patient 1s DPOA, DPOA stated he (DPOA) was not aware Patient 1 was in hospice care. The DPOA stated no one from the HA informed him (DPOA) that Patient 1 needed medications. The DPOA stated Patient 1 was fine and was walking around when she (Patient 1) first entered the Board and Care facility in October 2024. The DPOA stated Patient 1 became drowsy, sleepy, and unable to walk around when the agency placed Patient 1 on psychotropic medications by the HA. The DPOA stated he (DPOA) learned about the psychotropic medications in January 2025, when he (DPOA) visited Patient 1 and noticed she (Patient 1) was very drowsy, almost comatose, could not wake her (Patient 1) up and was just sleeping. The DPOA stated he (DPOA) spoke to RN 1 about three weeks ago to inquire who had prescribed medications for Patient 1 and a request was placed to speak to the doctor. The DPOA stated RN 1 told him (DPOA) the doctor was very busy and would call him (DPOA) back. The DPOA stated he (DPOA) never got a call from a doctor. During an observation of the home visit on 3/12/2025 at 10:40 a.m., with RN 1, Patient 1 was awake and alert. Patient 1 was lying in bed, with both side rails up. Patient 1 was non-interview able. During an interview at the home visit on 3/12/2025, at 11:21 a.m., with RN1, the RN 1 stated he (RN1) had done the start of care visit. RN 1 stated the Medical Director 1 (MD 1) was the medical director. RN 1 stated MD 1 ordered all the medications on admission, and RN 1 was the one who took the orders. The medications ordered on admission included psychotropic medications (those that affect brain function) Ambien (to help sleep), Lorazepam (treats anxiety), Lexapro (treats depression, [persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities]), and Risperidone (treats symptoms of schizophrenia [mental illness that affects a person's thoughts, perceptions, emotions, and behavior]). During a review of Patient 1s ";Physician Order", dated 11/15/2024, indicated the ADM ";Phone Order/Read Back Order", with MD 1. During a concurrent interview and record review on 3/13/2025, at 11:01 a.m., with the HAs contracted pharmacist (PHARM 1) of Patient 1s record titled, ";Physicians Order", dated 11/15/2024 was reviewed. PHARM 1 stated the ADM placed the orders for Ambien 5 (mg-milligrams, unit of measurement) 1 tablet oral at bedtime, Lorazepam 0.5 mg 1 tablet every 4 to 6 hours as needed for anxiety, Lexapro 10 mg 1 tablet once a day, and Risperidone 1 mg 1 tablet twice a day. PHARM 1 stated the orders were confirmed with the ADM. PHARM 1 stated she (PHARM 1) did not know if the ADM was a nurse. During a review of Patient 1s ";Physician Order", dated 12/19/2024, indicated the ADM ";Phone Order/Read Back Order", with MD 1, for a refill order for the following medications: Ambien (sedative and is used for the short-term treatment by helping you fall asleep)10 mg Amlodipine Besylate (lowers blood pressure) 5 mg Escitalopram (is used to treat depression and generalized anxiety disorder [feelings of worry, unease, or apprehension]) 10 mg Lexapro (is used to treat depression and generalized anxiety disorder [feelings of worry, unease, or apprehension]) 10 mg Lorazepam (produces a calming effect on the brain and nerves, which helps to reduce anxiety symptoms) 0.5 mg Risperidone (antipsychotic medication that treats mental health conditions schizophrenia)1 mg. Rivastigmine Tartrate (used to treat dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities) 1.5 mg. During a review of Patient 1s documented ";Physician Order", dated 12/27/2024, indicated the ADM ";Phone Order/Read Back Order", with MD 1. During a concurrent interview and record review on 3/13/2025, at 11:01 a.m., with PHARM 1, Patient 1s ";Physicians Order", dated 12/27/2024 was reviewed. PHARM 1 stated the ADM placed the orders for increase of medication doses: Ambien 10 1 tablet oral at bedtime, Lorazepam 2 mg 1 tablet oral, every 4 to 6 hours as needed for anxiety, and Risperidone 2 mg 1 tablet oral, twice a day. During an interview on 3/13/2025, at 11:50 a.m., with the ADM, the ADM stated there was no Medical Director from December 2023 until January 2025, when the new Medical Director was hired. During a review of Patient 1s medical records did not indicate any evidence of a medical evaluation and medical documents to support Patient 1s medical diagnoses and need for psychotropic medications. During a review of Patient 1s ";Physician Order", dated 2/4/2025, indicated Registered Nurse 1 (RN 2) ";Phone Order/Read Back Order", with MD 1 to discontinue medications Escitalopram, Lexapro, Ambien, Rivastigmine Tartrate, Ambien, and Lorazepam. During a review of Patient 1s ";Physician Order", dated 2/11/2025, indicated RN 2 ";Phone Order/Read Back Order", with MD 1, to discontinue medications Ambien, Risperidone, and Lorazepam. During a review on 3/13/2025, at 10:55 a.m., of the HAs employee list did not indicate RN 2 was employed at the HA. During a review on 3/13/2025, at 2:10 p.m., of an electronic license verification at the California Board of Registered Nursing and the California Board of Licensed Vocational Nursing website. RN 2s name as listed in Patient 1s medical records titled, ";Physicians Certification for Hospice Benefit", dated 11/15/2024 to 1/13/2025. There was no indication RN 2 was licensed as a Registered Nurse and/or Licensed Vocational Nurse. During an interview on 3/13/2025, at 4:01 p.m., with Medical Director 2 (MD 2), MD 2 stated she (MD2) did not see Patient 1 directly in person, or face to face encounter with Patient 1. MD 2 stated she (MD2) was not 100% sure she (MD2) had reviewed any medical information or was given any additional information about Patient 1. During an interview on 3/14/2025, at 11:48 a.m., with the Pharmacist (PHARM 2), PHARM 2 stated the Risperidone medication was prescribed for patients who have dementia, and puts them at risk of early death and stroke. PHARM 2 stated Risperidone medication has a black box warning (the drug has a serious risk of side effects that may impact life), and when Risperidone medication is increased, there are significant risks and side effects such as movement disorder, dry mouth, dizziness, drowsiness, which puts the patient at risk of falling. Increasing the dose, increases the risk. During an interview on 3/14/2025, at 11:48 a.m., with the PHARM 2, PHARM 2 stated Lorazepam required well documented evidence of behavior to justify the need for the medication. PHARM 2 stated the risks of Lorazepam medication were drowsiness, dizziness, risk of fall with injury, especially in the elderly. PHARM2 stated when the medication increased to 2 mg, it would require a medical evaluation especially psychiatry, especially if the indication was schizophrenia. The PHARM 2 stated it would be problematic to increase Lorazepam and Risperidone at the same time, as clinical rationale was needed. PHARM2 stated normally, one medication would be increased at a time, to try to see if effective in controlling the issues and if increase both medications at the same time, it would not know which medication was effective, and would increase the risk of injury. The PHARM 2 stated medications Risperidone and Lorazepam, together were a form of chemical restraint. Having Ambien, in addition, ensured Patient 1 was asleep.

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Conditions of Participations(CoP-a set of minimum professional standards all hospice agencies must meet to participate in Medicare [a federal health insurance program that helps people pay for healthcare] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) regarding Personnel Qualifications was met as followed: --- The Hospice Agency failed to ensure that the Owner/Administrator (ADM) who is not a healthcare practitioner, did not enter physician orders for medication into patients medical records for ten of fourteen sampled patients (Patient 1, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 14). (Refer to L784). As a result, Patient 1, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 14s had medication and treatment orders that were written by an unlicensed and unqualified personnel (ADM) that could lead to hospitalization and death. The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated (State laws) compliance with Federal regulation for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services. The HA failed to provide evidence criminal background checks were done for their staff before providing care and services for fourteen of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L795).

Based on interview, and record review, the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to ensure that the Owner/Administrator (ADM) who is not a healthcare practitioner, did not enter physician orders for medication into patients medical records for ten of fourteen sampled patients (Patient 1, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 14). As a result, Patient 1, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 14s had medication and treatment orders that were written by an unlicensed and unqualified personnel (ADM) that could lead to hospitalization and death. The State Survey Agency (the Department) attempted to contact the Owner/Administrator (ADM) starting on 3/19/25 to 3/21/25 in order to call an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for failing to ensure that a non-healthcare practitioner did not enter physicians orders for medication into patient medical records, but have been unable to get in contact with the ADM. The Department was unable to conduct an exit conference with the ADM due to the ADM not responding to attempted phone calls from 3/19/25 to 3/21/25. --- Findings: During an interview on 3/11/2025, at 12:54 p.m., with Registered Nurse 1 (RN 1), RN1 stated he (RN1) did not know where the employee files were. RN 1 stated he (RN1) did not know where the human resource files were for the employees. During an observation on 3/11/2025, at 1:46 p.m., of the HA, four rooms were observed. The cabinets, file cabinets, and drawers were empty. During an interview on 3/13/2025, at 11:50 a.m., with the ADM, the ADM stated he (ADM) was not a licensed nurse or a licensed medical doctor. 1.During a review of Patient 1s undated Patient Information, the Patient Information indicated a start of care date of 11/15/2024. During a review of Patient 1s Physician Order, dated 11/15/2024, the Physician Order indicated the ADM ";Phone Order/Read Back Order," with Medical Director 1 (MD 1). During a review of Patient 1s Physician Order, dated 12/19/2024, indicated the ADM ";Phone Order/Read Back Order," with MD 1, for a refill order for the following medications: Ambien(medication to help sleep), 10 milligrams (mg, a unit of measurement), Amlodipine Besylate (medication to help lower blood pressure) 5 mg, Escitalopram (Lexapro, antidepressant [anti-sadness] medication) 10 mg, Lorazepam (treats anxiety-nervousness), 0.5 mg, Risperidone (antipsychotic medication used to improve mood, thoughts, and behaviors) 1 mg, and Rivastigmine Tartrate (used to treat mild to moderate dementia [memory loss and mental changes]) 1.5 mg. During a review of Patient 1s documented ";Physician Order", dated 12/27/2024, indicated the ADM ";Phone Order/Read Back Order", with MD 1. During an interview on 3/12/2025, at 9:34 a.m., Patient 1s DPOA (Durable Power of Attorney) stated Patient 1 was fine and was walking around when she (Patient1) first entered the Board and Care facility in October 2024. The DPOA stated Patient 1 became drowsy, sleepy, and unable to walk around since being put on medications by the hospice agency around January 2025. The DPOA stated he (DPOA) learned about the medications in January 2025, when he visited Patient 1 and noticed Patient 1 was very drowsy, almost comatose, could not wake her up and was just sleeping. The DPOA stated he spoke to RN 1 about three weeks ago to inquire who had prescribed medications for Patient 1 and a request was placed to speak to the doctor. The DPOA stated RN 1 told him the doctor was very busy and would call him back. The DPOA stated he never got a call from a doctor. During an observation of the home visit on 3/12/2025, at 10:40 a.m., with RN 1, Patient 1 was awake and alert. Patient 1 was lying in bed, with both side rails up. Patient 1 was non-interview able. During an interview at the home visit on 3/12/2025, at 11:21 a.m., with RN 1, RN1 stated he (RN1) had done the start of care visit. RN 1 stated MD 1 was the Medical Director. RN 1 stated MD 1 ordered all the medications on admission, and RN 1 was the one who took the orders. RN1 stated the medications ordered on admission included psychotropic medications (those that affect brain function) Ambien, Lorazepam, Lexapro, and Risperidone. During a concurrent interview and record review on 3/13/2025, at 11:01 a.m., with the HAs contracted pharmacist (PHARM 1), Patient 1s record titled, ";Physicians Order," dated 11/15/2024 was reviewed. PHARM 1 stated the ADM placed the orders for Ambien 5 mg one tablet oral at bedtime, Lorazepam 0.5 mg one tablet every 4 to 6 hours as needed for anxiety, Lexapro 10 mg 1 tablet once a day, and Risperidone 1 mg 1 tablet twice a day. PHARM 1 stated the orders were confirmed with the ADM. PHARM 1 stated she did not know if the ADM was a nurse. During a concurrent interview and record review on 3/13/2025, at 11:01 a.m., with PHARM 1, Patient 1s record titled, ";Physicians Order," dated 12/27/2024 was reviewed. PHARM 1 stated the ADM placed the orders for increase of medication doses: Ambien 10 1 tablet oral at bedtime, Lorazepam 2 mg 1 tablet oral, every 4 to 6 hours as needed for anxiety, and Risperidone 2 mg 1 tablet oral, twice a day. During an interview on 3/13/2025, at 11:50 a.m., the ADM stated there was no Medical Director from December 2023 until January 2025, when the new Medical Director was hired. During an interview on 3/14/2025, at 11:48 a.m., with PHARM 2, PHARM 2 stated Risperidone for patients (in general) who have dementia would put the patients at risk of early death and stroke (occurs when the supply of blood to the brain is reduced or blocked completely, which prevents brain tissue from getting oxygen and nutrients). PHARM 2 stated the medication has a black box warning (the drug has a serious risk of side effects that may impact life). PHARM2 stated when Risperidone is increased, there are significant risks and side effects such as movement disorder, dry mouth, dizziness, drowsiness, which puts the patient at risk of falling. Increasing the dose, increases the risk. During an interview on 3/14/2025, at 11:48 a.m., PHARM 2 stated Lorazepam required well documented evidence of behavior to justify the need for the medication. PHARM2 stated the risks of Lorazepam were drowsiness, dizziness, risk of fall with injury, especially in the elderly. PHARM 2 stated if the medication was increased to 2mg, it would require a medical evaluation. PHARM 2 stated it was problematic to increase Lorazepam and Risperidone at the same time, as clinical rationale was needed and stated that normally, one medication would be increased at a time, to try to see if it is effective in controlling the issues. PHARM2 stated that in general, an increase of medications (in general) at the same time, "you do not know which medication is effective, and you are increasing the risk of injury." PHARM 2 stated medications Risperidone and Lorazepam, together were a form of chemical restraint (restrict a person's freedom of movement or to control behavior), and having Ambien, in addition, really ensured Patient 1 was asleep. 2. During a review of Patient 3s Personal Information, the Personal Information indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain). During a review of Patient 3s Physicians Orders, dated 11/20/2024, the Physician Orders indicated the ADM who is a non-licensed individual, entered the medication orders in Patient 3s clinical record. 3. During a review of Patient 4s Personal Information, the Personal Information indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood). During a review of Patient 4s Physicians Orders, dated 2/21/2025, the Physician Orders indicated the ADM who is a non-licensed individual entered the medication orders into Patient 4s electronic clinical record (EMR), The Physician Orders did not indicate if Patient 4 had allergies. The Physician orders indicated MD2s name was typed under MD Signature, and it was not signed. 4. During a review of Patient 6s Personal Information, the Personal Information indicated a SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). During a review of Patient 6s Physicians Orders, dated 2/18/2025, the Physician Orders indicated the ADM who is a non-licensed individual entered the medication orders into Patient 6s EMR. The Physician Orders did not indicate if Patient 6 had allergies. The Physician Orders indicated Medical Doctor 1 (MD1)s name was typed under MD Signature, and it was not signed. 5. During a review of Patient 7s Personal Information, the Personal Information indicated a SOC date of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (progressive lung disease causing airflow obstruction with difficulty breathing). During a review of Patient 7s Physicians Orders dated 11/12/2024, the Physicians Orders indicated the ADM who is a non-licensed individual entered the medication orders in Patient 7s medical record. The Physicians Orders did not indicate if Patient 7 had allergies. The Physicians Orders indicated MD1s name was typed under MD Signature, and it was not signed. 6. During a review of Patient 8s Patient Information, undated, the Patient Information indicated a start of care date of 12/10/2024. During a record review of Patient 8s Physicians Orders, dated 2/14/2025, the Physicians Orders indicated medication orders were entered into the medical record and sent to the pharmacy for dispensing, by the ADM who is a non-licensed individual. 7. During a review of Patient 10s undated Patient Information, the Personal Information indicated a start of care date of 11/21/2024. During a review of Patient 10s Physician Orders, dated 2/17/2025, the Physician Orders indicated the ADM who is a non-licensed individual entered the medication orders into Patient 10s clinical record and sent to the pharmacy for dispensing. 8.During a review of Patient 11s undated Patient Information, the Personal Information indicated a start of care date of 12/14/2024. During a review of Patient 11s Physician Orders, dated 3/11/2025, the Physician Orders indicated the ADM who is a non-licensed individual entered the mediation orders into Patient 11s clinical record and sent to the pharmacy for dispensing. 9.During a review of Patient 12s undated Patient Information, the Patient Information indicated a start of care date of 11/3/2024. During a review of Patient 12s Physicians Orders, dated 2/24/2024, the Physician Orders indicated the ADM, who is a non-licensed individual entered the medication orders into Patient 12s clinical record. 10.During a review of Patient 14s undated Patient Information, the Patient Information indicated a start of care date of 11/12/2024. During a review of Patient 14s Physicians Orders, dated 3/4/2025, the Physicians Orders indicated the ADM who is a non-licensed individual entered the medication orders were entered into Patient 14s clinical record. The Department was not able to obtain any policies and procedures.

Based on interview and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) failed to provide evidence criminal background checks were done for their staff before providing care and services for fourteen of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14).  This failure had the potential to result in patients being taken care of by potentially dangerous individuals. --- During an interview on 3/11/2025 at 12:54 p.m., with Registered Nurse 1 (RN 1), the RN1 stated he (RN1) did not know where the employee files were. RN 1 stated he (RN1) did not know where the human resource files were for the employees.During an observation on 3/11/2025 at 1:46 p.m., of the HA, 4 rooms were observed. The cabinets, file cabinets, and drawers were empty.During an interview on 3/13/2025 at 11:50 a.m., with the Owner/Administrator (ADM), the ADM stated he (ADM) was not a licensed nurse or a licensed medical doctor. 1.During a record review of Patient 1’s medical record form titled “Personal Information”, indicated an SOC of 11/15/2024, with a terminal diagnosis of Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities). 2.During a record review of Patient 2’s medical record form titled “Personal Information”, indicated an SOC of 12/12/2024, with a terminal diagnosis of heart disease (a range of conditions that affect the heart).   3.During a record review of Patient 3’s medical record form titled “Personal Information”, indicated an SOC of 11/20/2024, with a terminal diagnosis of atherosclerotic (the buildup of plaque [fatty deposits] inside the arteries, causing them to narrow and harden) heart disease of native coronary (heart) artery with refracting angina pectoris (chest pain).  4.During a record review of Patient 4‘s medical record form titled “Personal Information”, indicated a start of care (SOC) date of 1/27/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood). The form indicated Medical Director 2 (MD2) was listed as Patient 4’s Medical Director (MD). 5.During a record review of Patient ‘5s medical record form titled “Personal Information”, indicated a SOC date of 11/8/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). The form did not have Patient 5’s contact phone number listed. The form indicated MD2 was listed as Patient 5’s MD. 6.During a record review of Patient 6‘s medical record form titled “Personal Information”, indicated a SOC date of 11/23/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries causing chest pain). The form indicated MD2 was listed as Patient 6’s MD. 7.During a record review of Patient 7‘s medical record form titled “Personal Information”, indicated a SOC date of 11/12/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (progressive lung disease causing airflow obstruction with difficulty breathing). The form indicated MD2 was listed as Patient 7’s MD. 8.During a record review of Patient 8‘s medical record form titled “Personal Information”, indicated an SOC of 12/10/2024, with a terminal diagnosis of heart disease. 9.During a record review of Patient 9‘s medical record form titled “Personal Information”, indicated an SOC of 11/14/2024, with a terminal diagnosis of heart disease. 10.During a record review of Patient 10‘s medical record form titled “Personal Information”, indicated an SOC of 11/21/2024, with a terminal diagnosis of cerebral stroke syndrome. 11.During a record review of Patient 11‘s medical record form titled “Personal Information”, indicated an SOC of 12/14/2024, with a terminal diagnosis of Alzheimer’s Disease. 12.During a record review of Patient 12‘s medical record form titled “Personal Information”, indicated an SOC of 11/3/2024, with a terminal diagnosis of chronic diastolic heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). 13.During a record review of Patient 13‘s medical record form titled “Personal Information”, indicated an SOC of 11/18/2024, with a terminal diagnosis of Alzheimer’s Disease. 14.During a record review of Patient 14‘s medical record form titled “Personal Information”, indicated an SOC of 11/12/2024, with a terminal diagnosis of chronic diastolic heart failure.