Every finding on record at Mado Hospice Inc

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient #3: Patient admitted to hospice with Alzheimer's Disease. In the nursing comprehensive assessment as well as during home visit, patient found to be non verbal and unable to communicate needs. The owner of the board and care home signed consents. When asked during interview at surveyor home visit, the board and care owner stated she did not have a power of attorney or guardianship, but that the patient had no family. There is no documentation of a legal decision maker for this patient.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #3: Patient admitted to hospice with Alzheimer's Disease. In the nursing comprehensive assessment as well as during home visit, patient found to be non verbal and unable to communicate needs. The owner of the board and care home signed consents. When asked during interview at home visit, the board and care owner stated she did not have a power of attorney or guardianship, but that the patient had no family. There is no documentation of a legal decision maker for this patient.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #3: Patient admitted to hospice with Alzheimer's Disease. In the nursing comprehensive assessment as well as during home visit, patient found to be non verbal and unable to communicate needs. The owner of the board and care home signed consents. When asked during interview at home visit, the board and care owner stated she did not have a power of attorney or guardianship, but that the patient had no family. There is no documentation of a legal decision maker for this patient.

Upon observation, there was no evidence the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice. Patient #3: Patient admitted to hospice with Alzheimer's Disease. In the nursing comprehensive assessment as well as during home visit, patient found to be non verbal and unable to communicate needs. The owner of the board and care home signed consents. When asked during interview at surveyor home visit, the board and care owner stated she did not have a power of attorney or guardianship, but that the patient had no family. There is no documentation of a legal decision maker for this patient.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #3: Patient admitted to hospice with Alzheimer's Disease. In the nursing comprehensive assessment as well as during home visit, patient found to be non verbal and unable to communicate needs. The owner of the board and care home signed consents. When asked during interview at home visit, the board and care owner stated she did not have a power of attorney or guardianship, but that the patient had no family. There is no documentation of a legal decision maker for this patient.

Upon client record review, 1 of 14 (Patient #3) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient #3: Patient admitted to hospice with Alzheimer's Disease. In the nursing comprehensive assessment as well as during home visit, patient found to be non verbal and unable to communicate needs. The owner of the board and care home signed consents. When asked during interview at surveyor home visit, the board and care owner stated she did not have a power of attorney or guardianship, but that the patient had no family. There is no documentation of a legal decision maker for this patient.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #3: Patient admitted to hospice with Alzheimer's Disease. In the nursing comprehensive assessment as well as during home visit, patient found to be non verbal and unable to communicate needs. The owner of the board and care home signed consents. When asked during interview at home visit, the board and care owner stated she did not have a power of attorney or guardianship, but that the patient had no family. There is no documentation of a legal decision maker for this patient.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence of the appropriate documentation for release of confidential information. Patient #3: Patient admitted to hospice with Alzheimer's Disease. In the nursing comprehensive assessment as well as during home visit, patient found to be non verbal and unable to communicate needs. The owner of the board and care home signed consents. When asked during interview at home visit, the board and care owner stated she did not have a power of attorney or guardianship, but that the patient had no family. There is no documentation of a legal decision maker for this patient.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #3: Patient admitted to hospice with Alzheimer's Disease. In the nursing comprehensive assessment as well as during home visit, patient found to be non verbal and unable to communicate needs. The owner of the board and care home signed consents. When asked during interview at surveyor home visit, the board and care owner stated she did not have a power of attorney or guardianship, but that the patient had no family. There is no documentation of a legal decision maker for this patient.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient admitted to hospice with Alzheimer's Disease. In the nursing comprehensive assessment as well as during home visit, patient found to be non verbal and unable to communicate needs. The owner of the board and care home signed consents. When asked during interview at home visit, the board and care owner stated she did not have a power of attorney or guardianship, but that the patient had no family. There is no documentation of a legal decision maker for this patient.

Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patients #1-10: There was no evidence in the record of an ongoing process to monitor effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate therapy and or drug therapy currently associated with laboratory monitoring when there are medication changes. The place for documentation of this in the EMR was in the IDG meetings and was left blank on every IDG meeting.

Upon patient record review, 2 of 14 (Patient #1, 2) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #1: Patient admitted 08/26/25 with a documented 5 wounds. The wounds were measured and fully assessed. There are no further measurements in the chart despite Agency wound care policy which is to measure a minimum of every two weeks. On 9/08/2025 wounds on R and L lower legs are documented as "resolved". The wound on R buttock was documented "resolved" on 09/22/25, and the Wound on L buttock "resolved" 09/29/25. Since 09/29/25, there has been documentation of wound dressing being changed, but no complete wound assessment or measurements have been updated. Upon surveyor home visit, patient noted to have 3 open wounds including the lower right leg and R hip in addition to the lower back/sacral wound. Patient seen on 10/30/25, caregiver complained of patient experiencing severe pain. LVN documented that MD called. On 10/31/25, order written for Norco 10/325 PRN however, no follow up call or visit to patient until 11/4/25 (4 days).During surveyor visit with LVN on 12/02/25, Patient had a pulse of 40 and pulse ox of 82%. There was no call to doctor and no interventions provided to patient for either of these abnormal results. Patient #2: On 08/21/25, Dr. ordered hydrocodone/acetaminophen 10/325mg PRN for pain. The Norco 5/325mg remained on the med list. On 08/28/25, patient complained of pain level of 6, no follow up call or visit for 7 days.

Upon patient record review, 5 of 14 (Patients #1, 2, 4, 6, 9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: The patient is taking Eliquis. There are no interventions or goals on the plan of care for use of anticoagulants or bleeding precautions. The patient was admitted with 5 wounds. There are no interventions or goals for wound care or maintenance. The patient was admitted with an indwelling foley catheter. There are no interventions or goals for indwelling foley catheter on the plan of care. The patient has a nebulizer. There are no interventions or goals for use of a nebulizer on the plan of care. Patient #2: The patient has a nebulizer. There are no interventions or goals for use of a nebulizer on the plan of care. Patient #4: The patient is taking Eliquis. There are no interventions or goals on the plan of care for use of anticoagulants or bleeding precautions. Patient #6: The patient has a nebulizer. There are no interventions or goals for use of a nebulizer on the plan of care. Patient #9: The patient has a nebulizer. There are no interventions or goals for use of a nebulizer on the plan of care.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: The POC states that the patient has a nebulizer. Upon surveyor home visit with nurse, patient also has Full electric hospital bed, full side rails x 2, Low air loss mattress, and an over bed table not on the plan of care.

Upon patient record review, 2 of 14 (Patients #1, 2) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1: The patient reportedly had wounds that resolved on 09/08/25, 09/22/25, and 09/29/25. The plan of care did not include wounds and was not updated as wounds were "resolved". The patient had a foley when admitted, it was removed on 09/07/25. This was not updated or reflected in the initial or updated plan of care. Patient #2: The patient was started on Ambien on 09/04/25 due to continued difficulties sleeping. There was no update to the plan of care.

Upon client record review, 1 of 14 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Patient was admitted with 5 wounds. Per RN documentation wounds were measured and "All wounds cleansed with normal saline and treated with Santyl to areas of slough, covered with non-adherent pads and Mepilex border foam." There were no wound orders entered. Documentation does not show that a frequency of dressing change was determined. At visit on 09/15/25, nurse documents wound care done. Medi honey to clean wound bed and Santyl to areas of slough then covered with non-adherent pads and Mepilex border foam. There were no physician orders entered for change in wound care order, or wound care order at all. The patient had a foley catheter, 16 French 10 cc balloon. There is no order for a foley catheter. On 09/07/25, catheter was removed and not reinserted, no orders for foley removal.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: The aide assignment orders include providing foley care and change condom catheter every visit. The patient does not have a condom catheter and has not had a foley in place since 09/07/25. The assignment states assist with feeding. It does have aspiration precautions, but lists the diet as "other" and patient is on a pureed diet.

Upon patient record review 2 of 14 (Patient #1, 4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1: The aide documents performing foley care and condom catheter care every visit. Patient has not had a foley since 09/07/25 and has never had a condom catheter. The aide assignment orders vital signs every visit, there are no documented vital signs in Aide documentation. Patient #4: Patient was discharged from hospice on 10/07/25. There are aide visits documented on 10/10/25 and 10/13/25 after patient was no longer on hospice services.

Upon personnel record review, 8 of 11 (Personnel # 1, 2, 3, 4, 8, 9, 10, 11) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #1, 2, 3, 4, 8, 9, 10, 11: There is no evidence in the personnel records that W2 personnel or contracted staff had training on hospice philosophy.

Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes: • The Medical Director must be a doctor of medicine or osteopathy who is an employee or is under contract. • When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director. The agency stated that they have been working to replace their medical Director. They began with talking to another Medical Director in June and sent a contract, which appears to have been signed, however, the physician subsequently rescinded the offer. The separated with the current Medical Director 11/24/25. At this time they reached back out to the Medical Director candidate and a contract was drawn up for 11/25/25, however, during my interview with this physician, he stated he did not have a contract, had not been oriented and had no idea the name of the medical director designee. They state that they have the new contract, it just has not been sent or signed yet by the new physician. The agency presented the unsigned contract to me during survey. The agency also revealed that there had been no change form submitted to CMS for a change in medical director which is required as the Medical Director is considered a "managing" employee along with the administrator.

Upon patient client record review, 1 of 14 (Patient #3) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #3: Patient admitted to hospice with Alzheimer's Disease. In the nursing comprehensive assessment as well as during home visit, patient found to be non verbal and unable to communicate needs. Election of Benefit form(s) signed by board and care representative. There is no documentation of a legal decision maker for this patient or these forms signed by legal decision maker.

Upon patient client record review, 2 of 14 (Patient #1, 2) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient #1: On 10/31/25, order written for Norco 10/325 PRN however, during visit on 11/04/25, no mention of starting narcotic or documentation of if effective. Patient #2: Patient admitted 08/09/25 with documented pain level of 7. Dr. ordered Norco 5/325 PRN. During the next visit on 08/14/25, The nurse documented that the patient had no pain, however, no mention of Norco started last visit and how often it had been being used with what efficacy.

Upon patient client record review, 1 of 14 (Patient #3) did not have evidence that each patient record contains Advance Directives. Patient #3: POLST was signed by board and care representative and there was no evidence of signature by patient or a legally recognized decisionmaker.

Upon personnel record review, 6 of 11 (Personnel #1, 2, 3, 8, 9, 10 ) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #1, 2, 3, 8, 9, 10: Although the agency obtained national background checks, as well as OIG and National Sex Offenders reports, there is no evidence that a state background check was run.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. T Patient 2: The medication list indicates carbidopa 25mg/100mg 1 tablet po 4 x daily. Confirmed via the MD order and during the onsite visit that the patient is taking Sinemet for Parkinson's, which is combined carbidopa and levodopa. (corrected onsite)

Upon patient record review, 1 of 5 (Patient #5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 5: The medication list indicates the patient is utilizing albuterol/ipratropium 3mg/0.5mg per 3mL inhale 1 vial via nebulizer 3 x daily; however, the plan of care does not indicate the patient has a nebulizer.