Every finding on record at Monroe Hospice Care, Inc

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 - conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people 65 years of age or more and for certain younger people with disabilities]) regarding Patient Rights was met as followed: --- 1. The HA failed to ensure three of fourteen sample patients (Patient 2, Patient 8, and Patient 9) were provided notice of patients' rights in a language that was understood. This failure resulted in violation of patient rights and patients not knowing their rights and responsibilities as patients. (Refer to L502).2. The HA failed to ensure four of fourteen sampled patients (Patient 1, Patient 2, Patient 8, and Patient 9) were informed of the right to choose an attending physician. This failure resulted in violation of patient rights. (Refer to L515).3. The HA failed to inform four of fourteen sampled patients (Patient 1, Patient 2, Patient 8, and Patient 9) about the services they provide and the limitations on those services. This failure resulted in the patient not being aware about what hospice care is about and what services are covered while being in hospice (Refer to L519).The cumulative effect of these systemic practices resulted in patients not knowing their hospice services with their limitations and their rights as hospice patients.

Based on observation, interview, and record review the Hospice Agency (HA) failed to ensure three of fourteen sample patients (Patient 2, Patient 8, and Patient 9) were provided notice of patients' rights in a language that was understood.  This failure resulted in the violation of patient rights and patients not knowing their rights and responsibilities as patients. --- 1.During a record review of Patient 2’s medical record form titled “Patient Face Sheet”, the Facesheet indicated, a start of care date of 8/20/2025 with a diagnosis of atherosclerotic heart disease (heart problems cause by long term high blood pressure) of native coronary artery with angina pectoris with documented spasm.During an interview on 12/12/2025 at 9:23 a.m. with Patient 2, Patient 2 stated she (Patient 2) did not understand the admitting visiting nurse because she (visiting nurse) did not speak Spanish. Patient 2 stated that the visiting nurse called a female that spoke Spanish for translation. Patient 2 stated that the female who provided the translating services informed her (Patient 2) that the hospice program was a Medicate program that assisted people with supplies and informed her (Patient 2) that in order to receive these services, she (Patient 2) needed to sign up for the program. Patient 2 stated that she (Patient 2) signed the documents provided by the HA admitting visiting nurse and the forms were in the English language. Patient 2 stated that the admitting visiting nurse did not leave any documents or copies of the signed documents with her (Patient 2). During a concurrent observation and interview during the home visit on 12/12/2025 at 7:48 p.m., there was no agency folder or documents in Patient 2’s home. Patient 2 stated she (Patient 2) was not provided with copies of any of the documents she (Patient 2) had signed. Patient 2 stated she (Patient 2) was not provided with any documentation from the agency, including agency information. 2.During a record review of Patient 8’s Patient Face Sheet, the Facesheet indicated a start of care of 7/24/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (heart unable to pump blood effectively to the body).During an interview with Patient 8 on 12/11/2025, at 5:30 p.m., Patient 8 stated the agency had not provided any documents to her. Patient 8 stated she and her husband had signed documents but did not remember if the documents were in her preferred language, Spanish. A record review of Patient 8’s consents, dated 7/24/2025, indicated all consents were in English language.3.During a record review of Patient 9’s Patient Face Sheet, the Facesheet indicated a start of care of 7/8/2025, with a terminal diagnosis of generalized atherosclerosis (a buildup of fats and other substances in the arteries).During an interview with Patient 9, on 12/11/2025, at 10:09 a.m., Patient 9 stated her preferred language was Spanish. A record review of Patient 9’s consents dated 7/8/2025, indicated all consents were in English language.During a record review of the undated HAs form titled “Patient Bill of rights/Responsibilities”,  indicated “Upon admission, the admitting clinician will provide each patient or his/her representative with a written copy of the Patient Bill of rights/Responsibilities in advance of furnishing care. The Patient Bill of Rights/Responsibilities will be explained (verbally/orally) and distributed to the patient prior to the initiation for organization services. This explanation will be in a language and manner he/she can reasonably be expected to understand.”

Based on interview and record review, the Hospice Agency (HA) failed to ensure four of fourteen sampled patients (Patient 1, Patient 2, Patient 8, and Patient 9) were informed of the right to choose an attending physician. This failure resulted in a violation of patient rights. --- 1.During a record review of Patient 1’s medical record form titled “Patient Face Sheet”, the Facesheet indicated, a start of care date of 7/23/2025 with a diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer). The form also indicated MD1 was Patient 1’s hospice physician. During an interview on 12/12/2025 at 3:50 p.m. with Patient 1, Patient 1 stated that she (Patient 1) is under her (Patient 1) primary physician (MD4) and her (Patient 1) oncologist (MD5). Patient 1 stated she (Patient 1) last saw MD5 in November 2025 and has an upcoming appointment on 2/4/2026.  Patient 1 stated she (Patient 1) has never heard of the HAs Medical Director (MD1) or spoken to him (MD1).2.During a record review of Patient 2’s medical record form titled “Patient Face Sheet” the Facesheet indicated, a start of care date of 8/20/2025 with a diagnosis of atherosclerotic heart disease (heart problems cause by long term high blood pressure) of native coronary artery with angina pectoris with documented spasm. The form also indicated MD1 was Patient 2’s hospice physician.During an interview on 12/12/2025 at 9:23 a.m. with Patient 2, Patient 2 stated she (Patient 2) has been with her (Patient 2) primary physician (MD3) for the past 2 years. Patient 2 stated she last saw MD3 three days ago. Patient 2 stated MD3 did not refer or inform her (Patient 2) about hospice services. Patient 2 stated she (Patient 2) also sees her (Patient 2) cardiologist every 6 months. Patient 2 stated she (Patient 2) has never heard of the HAs Medical Director (MD1) or spoken to him (MD1). 3.During a record review of Patient 8’s Patient Face Sheet, indicated a start of care of 7/24/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (heart unable to pump blood effectively to the body).During an interview with Patient 8, on 12/11/2025, at 5:30 p.m., Patient 8 stated she was receiving medical care from a local clinic. Patient 8 stated she signed documents when her care started, but the agency did not provide any copies of the documents she signed. Patient 8 stated the HA did not explain anything regarding the hospice program. Patient 8 stated she was not asked if she had a primary care doctor.A record review of Patient 8’s consents, specifically the one titled, “Designation of Attending Physician”, dated 7/24/2025, indicated a signature, but no information of the designated attending physician found on the document.4.During a record review of Patient 9’s Patient Face Sheet, the Facesheet indicated a start of care date of 7/8/2025, with a terminal diagnosis of generalized atherosclerosis (a buildup of fats and other substances in the arteries).During an interview with Patient 9 on 12/11/2025, at 10:09 a.m., Patient 9 stated she had a primary care doctor she was actively seeing (Medical Doctor 2-MD 2).During an interview on 12/11/2025, at 5 p.m., with MD 2, MD 2 stated the last time MD 2 saw Patient 9 was on 10/14/2025.A record review of Patient 9’s consents, specifically the one titled, “Designation of Attending Physician”, dated 7/8/2025, indicated a signature, but no information of the designated attending physician was on the document.During a record review of the  undated HAs form titled “Patient Bill of rights/Responsibilities”,  the form indicated, “The Patient Bill of Rights/Responsibilities statement defines the right of the patient to...chose a health care provider (including an attending physician).”

Based on observation, interview and record review the Hospice Agency failed to inform four of fourteen sampled patients (Patient 1, Patient 2, Patient 8, and Patient 9) about the services they provide and the limitations on those services.  This failure resulted in the patient not being aware about what hospice care is about and what services are covered while being in hospice. --- 1).  During a record review of Patient 1’s medical record form titled “Patient Face Sheet” the Facesheet indicated a start of care date of 7/23/2025 with a diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer).During an interview on 12/12/2025 at 3:50 p.m. with Patient 1, Patient 1 stated that she (Patient 1) is under her (Patient 1) primary physician (MD4) and her (Patient 1) oncologist (MD5). Patient 1 stated she (Patient 1) last saw MD5 in November 2005 and has an upcoming appointment on 2/4/2026.  Patient 1 stated she (Patient 1) has never heard of the HAs Medical Director (MD1) or spoken to him (MD1).During an interview on 12/12/2025 at 4:45 p.m. with Patient 1’s daughter/caregiver (CG1), CG1 requested the HA’s phone number, and any resources her (Patient 1) mother can benefit from. CG1 stated she (CG1) was unaware that there was a social worker available to provide resources. During an interview on 12/12/2025 at 10:59 a.m. with the MSW, the MSW stated that she (MSW) currently did not have any patients assigned to her. The MSW stated she was not a full-time employee at the HA, she held a per diem (on demand employment paid a daily rate) status. The MSW stated that the last patient (Patient 7) she (MSW) had was back in November. MSW was asked to log into the HAs electronic medical record (EMR) system but was unable to. The MSW stated she (MSW) did not know why she was unable to log into the EMR and that she would call the ADM and return my call.  2).  During a record review of Patient 2’s medical record form titled “Patient Face Sheet”, the Facesheet indicated, a start of care date of 8/20/2025 with a diagnosis of atherosclerotic heart disease (heart problems cause by long term high blood pressure) of native coronary artery with angina pectoris with documented spasm.During an interview on 12/12/2025 at 9:23 a.m. with Patient 2, Patient 2 stated she (Patient 2) has been with her (Patient 2) primary physician (MD3) for the past 2 years. Patient 2 stated she last saw MD3 three days ago. Patient 2 stated she (Patient 2) had an inguinal hernia that required surgery but that her (Patient 2) insurance was not able to cover the procedure. During a concurrent observation and interview during the home visit on 12/12/2025 at 7:48 p.m., there was no agency folder or documents in Patient 2’s home. Patient 2 stated she was not provided with copies of any of the documents she had signed. Patient 2 stated she was not provided with any documentation from the agency, including agency information.  3).  During a record review of Patient 8’s Patient Face Sheet, indicated a start of care date of 7/24/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (heart unable to pump blood effectively to the body).During an interview with Patient 8, on 12/11/2025, at 5:30 p.m., Patient 8 stated she was receiving medical care from a local clinic. Patient 8 stated she signed documents when her care started, but the agency did not provide any copies of the documents she signed. Patient 8 stated the HA did not explain anything regarding the hospice program. Patient 8 stated she thought the “program” had ended because she had not received any visits from the HA for more than one month. Patient 8 stated she was not terminal, and no doctor had told her she was expected to die within six months. Patient 8 stated her heart was not failing, did not use oxygen, and walked using a walker due to back problems. Patient 8 stated was not aware there is limitation in health care coverage while in hospice care.4).  During a record review of Patient 9’s Patient Face Sheet, indicated a start of care of 7/8/2025, with a terminal diagnosis of generalized atherosclerosis (a buildup of fats and other substances in the arteries).During an interview with Patient 9 on 12/11/2025, at 10:09 a.m., Patient 9 stated she was not terminal, and no doctor had told her she was dying. Patient 9 stated she had a primary care doctor she was actively seeing (Medical Doctor 2-MD 2). Patient 9 stated no one explained to her that while being on hospice, she may not qualify for other medical services.During an interview on 12/11/2025, at 5 p.m., with MD 2, MD 2 stated Patient 9 did not have a terminal illness, does not have a terminal diagnosis, and MD 2 did not refer Patient 9 to hospice care. MD 2 stated the last time MD 2 saw Patient 9 was on 10/14/2025. During a record review of the undated HAs form titled “Patient Bill of rights/Responsibilities” the form indicated “Be informed in advance of services about the care to be furnished, the organization's scope of services and services under the Medicare Hospice Benefit and any limitations on these 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 the Conditions of Participations (COP - conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people 65 years of age or more and for certain younger people with disabilities]) regarding initial and Comprehensive Assessments of Patients was met as followed: --- 1.      The HA staff failed to conduct and document comprehensive assessments identifying the need for hospice care and services for five of fourteen sampled patients (Patient 1, Patient 3, Patient 8, Patient 9, and Patient 10). These patients did not have a life expectancy of six months or less. (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 (SC), and Physicians come together to discuss patients plan of care in order to be able to provide the best individualized care and support to patients and families) completed the comprehensive assessment no later than five (5) calendar days after hospice election for seven of fourteen sample selected patients (Patient 3, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, and Patient 14 ). (Refer to L 523). 3.      The HA failed to review all medications the patients were taking and update their medication profiles with the currently used medications for two of fourteen sample selected patients (Patient 1 and Patient 2). The patients were at risk for medication errors and adverse drug reactions. (Refer to L 530). 4.      The HA failed to conduct or attempt to conduct a bereavement assessment to provide bereavement counseling in accordance with the patient/family's needs for  three of fourteen sample selected patients (Patient 1, Patient 2, and Patient 3), which focused on the social, spiritual, and cultural factors that may affect the ability of the family and other individuals involved in the care, to cope with the patients’ death. (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 eight of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, Patient 10, Patient 12, and Patient 13). (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 observation, interview and record review, the Hospice Agency (HA) staff failed to conduct and document a comprehensive assessment identifying the need for hospice care and services for five of fourteen sample selected patients (Patient 1, Patient 3, Patient 8, Patient 9, and Patient 10). These patients did not have life expectancy of six months or less.   This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential to result in the patients not receiving appropriate healthcare services that could affect their quality of life. --- During an interview on 12/10/2025 at 12:40 p.m., and 12/11/2025 at 9:05 a.m., with the Administrator (ADM), the ADM stated there was no knowledgeable staff to assist with the survey.   During an interview on 12/12/2025 at 10:50 a.m. with Registered Nurse 2 (RN 2), RN 2 stated she (RN2) was not comfortable speaking on behalf of the agency regarding clinical operations of the hospice agency. During an interview on 12/12/2025 at 12:05 p.m. with the Medical Director (MD1), the MD1 stated he (MD1) was the Medical Director for the HA for the past 3 years. MD1 stated that his (MD1) responsibilities included the general oversight of nursing, employee services, and patient admissions, discharges, policies and procedures. MD1 stated that he was the “captain of the ship of patient care”.  MD1 stated admitting criteria included reviewing patients’ history and physical (H&P), medication list, nurses’ assessments, and IDG review with the expectation that the patient will be terminal with a diagnosis within 6 months. MD1 stated once a nurse assesses the patient, the nurse calls him (MD1) over the phone or video to go over the assessment. If there is sufficient information, MD1 stated, he (MD1) then tells the nurse to discuss it at the IDG meeting to ensure the patient is appropriate for hospice admission.  On 12/12/2025, at 12:45 p.m., a request was made to RN 2 to provide H&Ps for Patient 1, Patient 3, Patient 8, Patient 9, and Patient 10.1).  During a record review of Patient 1’s medical record form titled “Patient Face Sheet” the Facesheet indicated a start of care date of 7/23/2025 with a diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer).  During a record review of Patient 1’s medical record form titled “Health Services Los Angeles County” with an admission date of 7/19/2025 and discharge date of 7/22/2025, was provided by Registered Nurse 2 (RN2) and stated by RN2 to be Patient 1's history and physical that was used to determine hospice eligibility.  The form indicated Patient 1 was medically stable for home discharge with an order to receive physical and occupational therapy through a home health agency.  Lastly, the form indicated both of her (Patient 1) lungs sounded clear with auscultation (sounds heard via a stethoscope) and Patient 1 was not using accessory muscles when breathing.  During a record review on 12/10/2025 at 2:14 p.m. of Patient 1’s medical record, the record indicated nursing clinical note, visit type “RN-Eval” dated 7/23/2025 was “not started”.  During a concurrent observation and interview on 12/12/2025 at 4 p.m. with Patient 1 while at her residence, Patient 1 was awake, alert, and ambulatory with no shortness of breath noted. Patient 1 stated she (Patient 1) saw her oncologist (cancer treating doctor) in November 2025 and has another appointment in January 2026. Patient 1 stated she (Patient 1) had lung issues and was told she (Patient 1) had 3-5 years of life left. Patient 1 stated that there has not been a physician that has told her (Patient 1) that she (Patient 1) had 6 months or less to live.  Patient 1 stated she (Patient 1) never heard of the HA’s Medical Directors 1 (MD1), the Medical Social Worker (MSW), or the Spiritual Counselor (SC)’s name or spoken to any of them.During a concurrent interview and record review on 12/15/2025 at 10:07 a.m. with the Medical Director 1 (MD1) of Patient 1’s medical record, MD1 stated that there were no notes or documents in Patient 1’s medical record that would indicate why she (Patient 1) was receiving hospice services. MD1 stated that he (MD1) attempted to contact the DPCS, but that the DPCS did not answer his (MD1) calls or text.2.During a record review of Patient 3’s medical record form titled “Patient Face Sheet” the Facesheet indicated a start of care date of 7/8/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) with heart failure (heart is unable to adequately pump blood). During a record review on 12/10/2025 at 2:16 p.m. of Patient 3’s medical record, the record indicated Patient 3’s scheduled visit note dated 7/8/2025 with visit type “RN-EVAL” was “not started”. During an interview on 12/12/2025 at 10:10 a.m. with Patient 3, Patient 3 stated she (Patient 3) was not dying and therefore not a hospice patient. Patient 3 stated “Someone” brought a nurse to her (Patient 3) home that signed her (Patient 3) up for hospice services. Patient 3 stated that she (Patient 3) does not have any heart issues, and she (Patient 3) only takes vitamins. Patient 3 stated that she walks three laps around her building every other day. Patient 3 stated she (Patient 3) was not sick and wanted to cancel hospice services because she (Patient 3) did not want any trouble. Patient 3 stated she never heard or spoke with MD1. Patient 3 stated she (Patient 3) saw her (Patient 3)  primary physician last week and has been with him (primary physician) for the past 2 ½ years.3.During a record review of Patient 8’s Patient Face Sheet, the Facesheet indicated a start of care of 7/24/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (heart unable to pump blood effectively to the body).During an observation on 12/11/2025, at 2 p.m., with RN 2, Patient 8’s home was observed as a single-family home, with a black locked gate. The home visit was scheduled at 2 p.m., but Patient 8 was not home.During an interview on 12/11/2025, at 2:02 p.m., Patient 8 stated she was not home, was currently riding the bus, running errands, and did not know what time she would be home.During an interview on 12/11/2025, at 5:30 p.m., Patient 8 stated she thought the “program” had ended because she had not received any visits from the HA for more than 1 month. Patient 8 stated she was not terminal and no doctor had told her she was expected to die within 6 months. Patient 8 stated her heart was not failing, did not use oxygen, and walked using a walker due to back problems. Patient 8 stated she was able to go to church, go to stores, and ride on the bus.During an interview with the office manager (OM 2), on 12/15/20225, at 10 a.m., OM 2 stated there was no H&P for Patient 8.During an interview with MD 1, on 12/15/2025, at 10:45 a.m., MD 1 stated he had obtained Patient 8’s diagnosis from the H&P.  If there was no H&P from the nursing assessment, then he used the medication list and the Patient 8’s interview.A record review of Patient 8’s record titled, Initial Nursing Assessment, dated 7/24/2025, indicated, “She remains in declining state, with a KPS of 60 (Karnofsky Performance Status-used for hospice eligibility. A score of 60 means the patient can care for themselves but requires help with certain tasks), PPS of 60 (Palliative Performance Scale, a patient has reduced mobility, needs occasional help with self-care) and NYHA Class IV (New York Heart Association classification of heart failure IV=4, the most severe form of heart failure. Patients experience symptoms such as fatigue, shortness of breath, even at rest and cannot perform any physical activity without discomfort) heart failure, signifying marked limitations and symptoms at rest. She is ambulatory with an assistive device and requires assistance for most activities of daily living.”4).  During a record review of Patient 9’s Patient Face Sheet, the Facesheet indicated a start of care date of 7/8/2025, with a terminal diagnosis of generalized atherosclerosis (a buildup of fats and other substances in the arteries).During an interview with Patient 9 on 12/11/2025, at 10:09 a.m., Patient 9 stated she was not terminal and no doctor had told her she was dying. Patient 9 stated she had a primary care doctor whom she was actively seeing (Medical Doctor 2-MD 2). Patient 9 stated she could walk with the use of a cane but could not stand for a long period of time due to back pain. Patient 9 stated she did housekeeping, passed the vacuum, washed dishes, cleaned the restroom. Patient 9 stated she attends church and goes to the stores. Patient 9 stated she also drops off her grand daughter to school, and goes out and about.During an interview on 12/11/2025, at 5 p.m., with MD 2, MD 2 stated Patient 9 did not have a terminal illness, does not have a terminal diagnosis, and MD 2 did not refer Patient 9 to hospice care. MD 2 stated the last time MD 2 saw Patient 9 was on 10/14/2025.During an interview with OM 2, on 12/15/20225, at 10 a.m., OM 2 stated there was no H&P for Patient 9.During an interview with MD 1 on 12/15/2025, at 10:51 a.m., MD 1 stated he did not recall if he had spoken to Patient 9 or had reviewed any H&P.  MD 1 stated he certified Patient 9 for hospice care based on the nursing assessment.A record review of Patient 9’s document titled, Initial Nursing Assessment, dated 7/8/2025,  indicated “Due to the patient’s poor prognosis, progressive decline in cardiac and pulmonary function, increasing body weakness, and growing need for assistance with daily activities, the patient has opted for hospice care to focus on symptoms management and comfort.” The record also indicated a KPS score of 60 and a PPS of 60.5).  During a record review of Patient 10’s Face Sheet, the Facesheet indicated a start of care date of 1/10/2025, with a terminal diagnosis of heart failure (heart unable to pump blood effectively to the body).On 12/11/2025 at 3:03 p.m., two phone call attempts were made to interview Patient 10. The phone number was obtained from Patient 10’ Face Sheet. No other numbers were listed. Both phone call attempts indicated an automated message stating the number was not valid: “number cannot be completed as dialed.”During an interview with OM 2, on 12/15/20225, at 10 a.m., OM 2 stated there was no H&P for Patient 9.A record review of Patient 10’s document titled, Initial Nursing Assessment, dated 1/10/2025, indicated, “Patient has progressive decline in medical condition, increasing weakness and easily fatigued. Due to progressive decline in medical condition, responsible party opted to seek Hospice Care.”A record review of the HA’s undated document titled, Comprehensive Assessment, indicated, “During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient’s clinical record, including at least the following information, as relevant...Patient’s past and present medical and psychosocial history including diagnosis and any co-morbid conditions...Name and address of the patient’s attending physician...laboratory results...medical...history...Past medical and surgical care, including dates of onset/exacerbation.”

Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain (SC), and Physicians come together to discuss each patients plan of care in order to be able to provide the best individualized care and support to patients and families) completed each  comprehensive assessment no later than five (5) calendar days after hospice election for seven of fourteen sample selected patients (Patient 3, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, and Patient 14 ).  This deficient practice had the potential to result in patient’s needs not being identified. --- During an interview on 12/10/2025 at 12:40 p.m., and 12/11/2025 at 9:05 a.m., with the Administrator (ADM), the ADM stated there was no knowledgeable staff to assist with the survey.   During an interview on 12/12/2025 at 10:50 a.m. with Registered Nurse 2 (RN 2), RN 2 stated she (RN2) was not comfortable speaking on behalf of the agency regarding clinical operations of the hospice agency. During an interview on 12/12/2025 at 10:59 a.m. with the MSW, the MSW stated that she (MSW) currently did not have any patients assigned to her. The MSW stated she was not a full-time employee at the HA, she held a per diem (as needed) status. The MSW stated that the last patient (Patient 7) she (MSW) had was back in November 2025. The MSW was asked to log into the HAs electronic medical record (EMR) system but was unable to. The MSW stated she (MSW) did not know why she (MSW) was unable to log into the EMR and that she (MSW) would call the ADM and return my call.During an interview on 12/12/2025 at 12:05 p.m. with the Medical Director (MD1), the MD1 stated that he (MD1), the director of nurses, clergy, social worker, and the DPCS were the members of the IDG team and held meetings every two weeks. MD1 stated that the last hospice IDG meeting was held at the end of November.  MD1 stated admitting criteria included IDG review with the expectation that the patient will be terminal with a diagnosis within 6 months.  MD1 stated once a nurse assesses the patient, the nurse calls him (MD1) over the phone or video to go over the assessment. If there is sufficient information, MD1 stated, he (MD1) then tells the nurse to discuss it at the IDG meeting to ensure the patient is appropriate for hospice admission. MD1 stated that “Sometimes” patients do not have primary physicians, therefore they “must” conduct IDG meetings to review their case.  During an interview on 12/15/2025 at 10:07 a.m. with Medical Director 1 (MD1), MD1 stated the DPCS had him (MD1) “Doing something weird”.  MD1 stated, “I am on the mercy of (DPCS)… I rely on (DPCS) to inform me when I (MD1) need to sign documents. MD1 stated that the DPCS informed him (MD1) mid-November that she (DPCS) had resigned from the HA. MD1 stated that he (MD1) was unable to contact the DPCS, since then. 1).  During a record review of Patient 3’s medical record form titled “Patient Face Sheet” the Facesheet indicated a start of care date of 7/8/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) with heart failure (heart is unable to adequately pump blood). During a record review on 12/10/2025 at 1:41 p.m. of Patient 3’s medical record, the record indicated Patient 3’s IDTs dated 7/9/2025, 7/23/2025, 8/6/2025, 8/20/2025, and 9/3/2025 were “unsigned”.  2).  During a record review of Patient 6’s medical record form titled “Patient Face Sheet” the Facesheet indicated, a start of care date of 3/11/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) without heart failure.During a record review on 12/10/2025 at 1:40 p.m. of Patient 6’s medical record, the record indicated Patient 6’s IDT meetings dated 3/12/2025 and 3/26/2025 were “not started” and “unsigned”.During a record review of Patient 6’s medical record form titled “Initial Orders and Plan of Care” dated 3/11/2025, the form indicated it was left blank. The form also indicated there were no care problems identified. Lastly, the form indicated the names of three registered nurses and the Medical Director (MD1) were documented, but the form did not contain any of their signatures.3).  During a record review of Patient 7’s medical record form titled “Patient Face Sheet’ indicated a start of care date of 11/3/2025 with a primary diagnosis of cerebral infarction (stroke) unspecified. During a record review on 12/12/2025 at 11:11 a.m. of Patient 7’s medical record, the record indicated there were no IDT meetings documented during her (Patient 7) 1st 90 days certification period of 11/3/2025 to 1/31/2026.During a record review of Patient 7’s medical record form titled “Initial Orders and Plan of Care” dated 11/3/2025, the form indicated it was left blank. The form also indicated there were no care problems identified. Lastly, the form indicated the names of two licensed vocational nurses, one registered nurse, the Medical Director (MD1) and a social worker were documented, but the form did not contain any of their signatures.4).  During a record review of Patient 8’s Patient Face Sheet, indicated a start of care date of 7/24/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (heart unable to pump blood effectively to the body).During an interview with Patient 8, on 12/11/2025, at 5:30 p.m., Patient 8 stated she was not offered MSW and SC services. Patient 8 stated she did not decline MSW and SC services.A record review of Patient 8’s record titled, Initial Orders and Plan of Care, for certification period 7/24/2025 to 10/21/2025, indicated Patient 8 had declined MSW and SC services. Further review of the record indicated, “These initial orders and Plan of Care were developed through the communication and input from the following team members”; the record was signed by nursing and MD 1 only. A record review of Patient 8’s records did not indicate the MSW and SC had contributed to completion of the comprehensive assessment and plan of care for the initial certification period of 7/24/2025 to 10/21/2025. There was no MSW and no SC assessment.5.  During a record review of Patient 9’s Patient Face Sheet, the Facesheet indicated a start of care date of 7/8/2025, with a terminal diagnosis of generalized atherosclerosis (a buildup of fats and other substances in the arteries).During an interview with Patient 9 on 12/11/2025, at 10:09 a.m., Patient 9 stated a social worker came to her house one time and never returned. Patient 9 stated she did not remember the HA offering MSW services. Patient 9 stated the HA did not offer SC services.A record review of Patient 9’s record titled, Initial Orders and Plan of Care, for certification period 7/8/2025 to 10/5/2025, indicated Patient 9 had declined MSW and SC services. Further review of the record indicated, “These initial orders and Plan of Care were developed through the communication and input from the following team members”; the record was signed by nursing and MD 1 only. A record review of Patient 9’s records did not indicate the MSW and SC had contributed to completion of the comprehensive assessment and plan of care for the initial certification period of 7/8/2025 to 10/5/2025. There was no MSW and no SC assessment.6).  During a record review of Patient 10’s Face Sheet, the Facesheet indicated a start of care date of 1/10/2025, with a terminal diagnosis of heart failure (heart unable to pump blood effectively to the body).A record review of Patient 10’s record titled, Initial Orders and Plan of Care, for certification period 10/24/2023 to 1/21/2024, indicated Patient 10 had declined MSW and SC services.  Further review of the record indicated, “These initial orders and Plan of Care were developed through the communication and input from the following team members”; the record was not signed by anyone. A record review of Patient 10’s records did not indicate the MSW and SC had contributed to completion of the comprehensive assessment and plan of care for the initial certification period of 10/24/2023 to 1/21/2024. There was no MSW and no SC assessment.7).  During a record review of Patient 14’s Face Sheet, the Facesheet indicted a start of care date of 4/23/2025, with a terminal diagnosis of heart disease.During a record review of Patient 14’s doctor orders, dated 10/15/2025, the doctor's orders indicated Patient 14 was discharged from the HA on 10/15/2025, due to the patient desiring curative treatment.A record review of Patient 14’s record titled, Initial Orders and Plan of Care, for certification period 4/23/2025 to 7/21/2025, indicated Patient 14 had declined MSW and SC services. Further review of the record indicated, “These initial orders and Plan of Care were developed through the communication and input from the following team members”; the record was not signed by nursing and MD 1. A record review of Patient 14’s records did not indicate the MSW and SC had contributed to completion of the comprehensive assessment and plan of care for the initial certification period of 4/23/2025 to 7/21/2025. There was no MSW and no SC assessment. A record review of the HA’s undated document titled, Comprehensive Assessment, indicated, “A comprehensive patient assessment will be performed by the interdisciplinary group no later than five (5) calendar days after hospice care in consultation with attending physician.

Based on observation, interview and record review, the Hospice Agency (HA) staff failed to review all medications the patients were taking and update their medication profiles with the currently used medications for two of fourteen sample selected patients (Patient 1 and Patient 2). The patients were at risk for medication errors and adverse drug reactions. This deficient practice had the potential to place the patient at risk for medication errors and adverse drug reactions. --- 1).  During a record review on 12/10/2025 at 1:52 p.m. of Patient 1’s medical record, the record indicated Patient 1 was currently taking Tramadol (pain medication) daily. The record also indicated Patient 1’s Atorvastatin (medication to treat high cholesterol) was not listed on her medication profile. During a joint home visit on 12/12/2025 at 4 p.m. with Registered Nurse 1 (RN1) while at Patient 1’s residence, RN1 stated that the only medication Patient 1 was currently taking was Atorvastatin.  RN1 also stated Patient 1 had comfort kit medications at her home.  RN1 did not complete a medication reconciliation during the home visit.  RN1 stated that since Patient 1 was his only patient with the HA, he (RN1) knew her medications.During an interview on 12/12/2025 at 4 p.m. with Patient 1, Patient 1 stated she is currently only taking Atorvastatin.  Patient 1 requested RN1 to provide more of the medication because she (Patient 1) was running low on the medication.2).  During a record review of Patient 2’s medical record form titled “Patient Face Sheet” the Facesheet indicated, a start of care date of 8/20/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) without heart failure.During a concurrent observation, interview and record review with Registered Nurse 2 (RN 2) while at the home visit on 12/12/2025, at 7:33 p.m., RN 2 reviewed the medications Patient 2 was taking using Patient 2’s Medication Profile.  Patient 2 stated she was taking Farxiga (diabetic medication) 10 mg (mg-milligram, unit of measurement) one (1) tablet daily.  This medication was not listed.  Continued review of Patient 2’s medications, indicated the following medication was listed on the Medication Profile, but Patient 2 stated she was no longer taking: Rosuvastatin (for high cholesterol). Patient 2 stated she last took the medication a month ago. A record review of the HA’s undated document titled Medication Profile, indicated, “The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.

Based on interview and record review the Hospice Agency (HA) failed to conduct or attempt to conduct a bereavement assessment to provide bereavement counseling in accordance with the patient/family's needs for three of fourteen sample selected patients (Patient 1, Patient 2, and Patient 3,), which focused on the social, spiritual, and cultural factors that may affect the ability of the family and other individuals involved in the care, to cope with the patients’ death.  This failure had the potential to result in patient’s family and/or caregivers to not be assessed for factors that may place them at risk for a significantly negative bereavement experience. --- During an interview on 12/10/2025 at 11 a.m. with the Administrator (ADM), the ADM indicated the HA’s had a Spiritual Counselor (SC) during the entrance conference. The SC was also assigned the role of the Volunteer Coordinator and the Bereavement Director.During an interview on 12/10/2025 at 12:40 p.m., and 12/11/2025 at 9:05 a.m., with the Administrator (ADM), the ADM stated there was no knowledgeable staff to assist with the survey.  On 12/11/2025 at 4:56 p.m. the HA’s Medical Social Worker (MSW) was called at the number provided by the ADM with no answer. Message with call back number left.On 12/11/2025 at 4:58 p.m. the HA’s Spiritual Counselor was called at the number provided by the ADM with no answer. Message with call back number left. During an interview on 12/12/2025 at 10:50 a.m. with Registered Nurse 2 (RN 2), RN 2 stated she (RN2) was not comfortable speaking on behalf of the agency regarding clinical operations of the hospice agency.During an interview on 12/12/2025 at 10:59 a.m. with the MSW, the MSW stated that she (MSW) currently did not have any patients assigned to her. The MSW stated she was not a full-time employee at the HA, she held a per diem status. The MSW stated that the last patient (Patient 7) she (MSW) had was back in November. MSW was asked to log into the HAs electronic medical record (EMR) system but was unable to. The MSW stated she (MSW) did not know why she was unable to log into the EMR and that she would call the ADM and return my call.  MSW did not return a call as stated.On 12/12/2025 at 11:15 a.m. the HA’s Spiritual Counselor was called at the number provided by the ADM with no answer. Message with call back number left. 1).  During a record review of Patient 1’s medical record form titled “Patient Face Sheet” the Facesheet indicated, a start of care date of 7/23/2025 with a diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer).During a record review on 12/10/2025 at 2:14 p.m. of Patient 1’s medical record, the record did not indicate there was a note from the SC under the section “Visit Notes”.During a concurrent observation and interview on 12/12/2025 at 4 p.m. with Patient 1 at her residence, Patient 1 greeted Registered Nurse 1 (RN1) and the surveyor at door. Patient 1 was awake, alert, and ambulatory with no shortness of breath noted. Patient 1 stated she (Patient 1) saw her oncologist (cancer treating doctor) in November 2025 and has another appointment in January 2026. Patient 1 stated she (Patient 1) had lung issues and was told she (Patient 1) had 3-5 years of life left. Patient 1 stated that there has not been a physician that has told her that she had six (6) months or less to live. Patient 1 stated she  never heard of the HA’s Medical Directors (MD1), the Medical Social Worker (MSW), or the Spiritual Counselor (SC)’s name or spoken to any of them.2).  During a record review of Patient 2’s medical record form titled “Patient Face Sheet” the Facesheet indicated, a start of care date of 8/20/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) without heart failure.During a record review on 12/10/2025 at 2:15 p.m. of Patient 2’s medical record, the record did not indicate there was a note from the SC under the section “Visit Notes”.3).  During a record review of Patient 3’s medical record form titled “Patient Face Sheet” the Facesheet indicated a start of care date of 7/8/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) with heart failure (heart is unable to adequately pump blood).During a record review on 12/10/2025 at 2:16 p.m. of Patient 3’s medical record, the record did not indicate there was a note from the SC under the section “Visit Notes”.During a record review on 12/10/2025 at 1:41 p.m. of Patient 3’s medical record, the record indicated Patient 3’s Interdisciplinary group (IDT - meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain (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) dated 7/9/2025, 7/23/2025, 8/6/2025, 8/20/2025, and 9/3/2025 were “unsigned”. A record review of the HA’s undated document titled, Comprehensive Assessment, indicated, “During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient’s clinical record, including at least the following information, as relevant...A bereavement assessment of the needs of the patient’s family and other individuals...”

Based on observation, interview and record review, the Hospice Agency (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 eight of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, Patient 10, Patient 12, and Patient 13).  This deficient practice had the potential to result in harm harm if patients are prevented from reaching their goals, due to IDG not addressing changes in the patient's condition. --- During an interview on 12/10/2025 at 12:40 p.m., and 12/11/2025 at 9:05 a.m., with the Administrator (ADM), the ADM stated there was no knowledgeable staff to assist with the survey.   During an interview on 12/12/2025 at 10:50 a.m. with Registered Nurse 2 (RN 2), RN 2 stated she (RN2) was not comfortable speaking on behalf of the agency regarding clinical operations of the hospice agency. During an interview on 12/12/2025 at 10:59 a.m. with the MSW, the MSW stated that she (MSW) currently did not have any patients assigned to her. The MSW stated she was not a full-time employee at the HA, she held a per diem status. The MSW stated that the last patient (Patient 7) she (MSW) had was back in November 2025. The MSW was asked to log into the HAs electronic medical record (EMR) system but was unable to. The MSW stated she (MSW) did not know why she was unable to log into the EMR and that she would call the ADM and return my call.During an interview on 12/12/2025 at 12:05 p.m. with the Medical Director (MD1), the MD1 stated that he (MD1), the director of nurses, clergy, social worker, and the DPCS were the members of the IDG team and held meetings every two weeks. MD1 stated that the last hospice IDG meeting was held at the end of November. MD1 stated admitting criteria included IDG review with the expectation that the patient will be terminal with a diagnosis within 6 months. MD1 stated once a nurse assesses the patient, the nurse calls him (MD1) over the phone or video to go over the assessment. If there is sufficient information, MD1 stated, he (MD1) then tells the nurse to discuss it at the IDG meeting to ensure the patient is appropriate for hospice admission. MD1 stated that “sometimes” patients do not have primary physicians, therefore they “must” conduct IDG meetings to review their case.  During an interview on 12/15/2025 at 10:07 a.m. with the Medical Director 1 (MD1), the MD1 stated, “I am on the mercy of (DPCS)… I rely on (DPCS) to inform me when I (MD1) need to sign documents. MD1 stated that the DPCS informed him (MD1) mid-November that she (DPCS) had resigned from the HA. MD1 stated that he (MD1) was unable to contact the DPCS, since then.On 12/11/2025 at 4:58 p.m. the HA’s Spiritual Counselor was called at the number provided by the ADM with no answer. Message with call back number left. On 12/12/2025 at 11:15 a.m. the HA’s Spiritual Counselor was called at the number provided by the ADM with no answer. Message with call back number left.1).  During a record review of Patient 1’s medical record form titled “Patient Face Sheet” the Facesheet indicated a start of care date of 7/23/2025 with a diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer).During a record review of Patient 1’s medical record form titled “IDT Plan of Care & Review of Comprehensive Assessment” dated 10/30/2025, indicated “no care problems identified”. The form did not indicate it was signed by any of the HA’s core members, registered nurse (RN), medical director (MD), medical social worker (MSW), or spiritual counselor (SC).During a concurrent interview and record review on 12/10/2025 at 11:56 a.m. with the Licensed Vocational Nurse/Case Manager/Office Manager (OM1) of Patient 1’s medical record form titled “Certification of Plan of Care” dated 10/21/2025 to 1/18/2026, the form indicated it was left blank. OM1 indicated the form was not complete. OM1 stated the form did not indicate Patient 1’s frequency of visits, nursing interventions, and no Certification of Terminal Illness (CTI - a doctor's official statement that a patient has an incurable condition, expected to cause death within 6 months). Lastly, the form indicted “no care problems identified”.During a concurrent interview and record review on 12/10/2025 at 1:18 p.m. with the OM1 of Patient 1’s medical record form titled “Nursing Recertification Assessment” dated 10/20/2025, the form indicated it was left blank and “in progress”. The OM1 stated Patient 1’s nursing recertification assessment was plotted in her  calendar for the visit on 10/20/2025, but the visit was not done. The OM1 stated Patient 1’s nursing recertification assessment was to be completed to be able to update Patient 1’s individualized plan of care and to determine if Patient 1’s continues to require hospice services.During a concurrent observation and interview on 12/12/2025 at 4 p.m. with Patient 1 while at her residence, Patient 1 was awake, alert, and ambulatory with no shortness of breath noted. Patient 1 stated she (Patient 1) saw her oncologist (cancer treating doctor) in November 2025 and has another appointment in January 2026. Patient 1 stated she (Patient 1) had lung issues and was told she (Patient 1) had 3-5 years of life left. Patient 1 stated that there has not been a physician that has told her (Patient 1) that she (Patient 1) had six (6) months or less to live. Patient 1 stated she (Patient 1) never heard of the HA’s Medical Directors 1 (MD1), the Medical Social Worker (MSW), or the Spiritual Counselor (SC)’s name or spoken to any of them.During a concurrent interview and record review on 12/15/2025 at 10:07 a.m. with the Medical Director 1 (MD1) of Patient 1’s medical record, MD1 stated that there were no notes or documents in Patient 1’s medical record that would indicate why she (Patient 1) was receiving hospice services. MD1 stated that he (MD1) attempted to contact the DPCS, but that the DPCS did not answer his (MD1) calls or text. During a record review of Patient 1’s undated medical record form titled “Interdisciplinary Team (IDT)” , the Form indicated the IDTs dated 10/30/2025, 11/13/2025, and 11/27/2025 were “not started” and “unsigned”. 2).  During a record review of Patient 2’s medical record form titled “Patient Face Sheet” the Facesheet indicated, a start of care date of 8/20/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) without heart failure.During a record review on 12/10/2025 at 2:16 p.m. of Patient 2’s medical record, the record indicated Patient 2’s scheduled visit notes dated 11/18/2025 and 12/2/2025 were “not started”.During a record review of Patient 2’s medical record form titled “IDT Plan of Care & Review of Comprehensive Assessment” dated 11/19/2025,  the assessment indicated “no care problems identified”.  The form did not indicate it was signed by any of the HA’s core members, registered nurse (RN), medical director (MD), medical social worker (MSW), or spiritual counselor (SC).During a record review of Patient 2’s undated medical record form titled “Interdisciplinary Team (IDT)”  the IDT form indicated IDTs dated 11/19/2025 and 12/3/2025 were “not started” and “unsigned”.During a concurrent interview and record review on 12/10/2025 at 12 p.m. with the OM1 of Patient 2’s medical record form “Certification of Plan of Care” dated 11/18/2025 to 1/16/2026, OM1 indicated the form was not complete. OM1 stated the form did not indicate Patient 2’s frequency of visits, nursing interventions, and no CTI. The form also indicated it was left blank.During a concurrent interview and record review on 12/10/2025 at 1:20 p.m. with the OM1 of Patient 2’s undated medical record form titled “Nursing Clinical Note”  the OM1 stated that the nursing clinical note was initially plotted in Patient 2’s calendar for visit as visit type “RN – Recert /on-site” on 11/5/2025 . The OM1 stated Patient 2’s nursing rectification assessment was plotted/scheduled for 11/5/2025, but it was not completed. The OM1 stated that there was a “Clinical Nursing Note” but the nurse has the option to change it to a recertification note when she or he documents it. Lastly, the Nursing Clinical Note was left blank.During an interview on 12/12/2025 at 9:23 a.m. with Patient 2, Patient 2 stated that she (Patient 2) had monthly hospice nurse visits, that last about 8-10 minutes. Patient 2 stated that she has been with her primary physician (MD3) for the past two years and saw him (MD3) last three days ago.  Patient 2 stated that MD3 did not refer her to hospice services. Patient 2 stated that she (Patient 2) was not dying and had not been told by a doctor that she was going to die in six (6) months or less.  Patient 2 stated that she (Patient 2) does not know why the HA was writing and stating that she (Patient 2) had a certain time to live, and that it was a lie. Patient 2 stated that she (Patient 2) has not heard of or from MD1. During an observation of the home visit on 12/12/2025, at 7 p.m., with RN 2, while at Patient 2’s residence, Patient 2 greeted the survey team in the lobby of a locked multi-floor, multi-unit apartment complex. Patient 2 was walking without the use of an assistive device, breathing was unlabored, and Patient 2 was not in distress while walking.During a concurrent interview and record review on 12/15/2025 at 10:24 a.m. with MD1 of Patient 2’s medical record, MD1 stated Patient 2 was on her 3rd recertification period.  MD1 stated that based on Patient 2’s medical record the HA was treating her without his (MD1) authorization. 3).  During a record review of Patient 3’s medical record form titled “Patient Face Sheet” the Facesheet indicated, a start of care date of 7/8/2025 with a diagnosis of hypertensive heart disease (heart problems caused by long term high blood pressure) with heart failure (heart is unable to adequately pump blood). During a record review of Patient 3’s undated medical record form titled “Interdisciplinary Team (IDT)”, the IDT form  indicated IDTs dated 10/15/2025, 10/29/2025, 11/12/2025, 11/26/2025, and 12/10/2025 were “not started” and “unsigned”.During a record review of Patient 3’s medical record form titled “IDT Plan of Care & Review of Comprehensive Assessment” dated 10/15/2025,the assessment indicated “no care problems identified."  The form did not indicate it was signed by any of the HA’s core members, registered nurse (RN), medical director (MD), medical social worker (MSW), or spiritual counselor (SC).During a concurrent interview and record review on 12/10/2025 at 12:05 p.m. with the OM1 of Patient 3’s medical record form “Certification of Plan of Care” dated 10/6/2025 to 1/3/2026, OM1, the form was partially complete.  OM1 stated the form did not indicate Patient 3’s nursing interventions. Lastly, the Certification of Plan of Care form was left blank. During a concurrent interview and record review on 12/10/2025 at 1:25 p.m. with the OM1 of Patient 3’s undated medical record form titled “Nursing Clinical Note” the OM1 stated that the nursing clinical note was initially plotted in Patient 3’s calendar for visit as visit type “RN – Recert/on-site” on 9/30/2025.  The OM1 stated Patient 3’s nursing rectification assessment was plotted/scheduled for 9/30/2025, but it was not completed. The OM1 stated that there was a “Clinical Nursing Note” but the nurse had the option to change it to a recertification note when she or he documents it. Lastly, the Nursing Clinical Note was left blank.During an interview on 12/12/2025 at 10:10 a.m. with Patient 3, Patient 3 stated she (Patient 3) was not dying and therefore not a hospice patient. Patient 3 stated that she  does not have any heart issues, and only takes vitamins.  Patient 3 stated that she walks three laps around her building every other day. Patient 3 stated she was not sick and wanted to cancel hospice services because she did not want any trouble. Patient 3 stated she never heard or spoke with MD1. Patient 3 stated she saw her primary physician last week and has been with him (primary physician) for the past 2 ½ years. During a concurrent interview and record review on 12/15/2025 at 10:42 a.m. with MD1 of Patient 3’s medical record, MD1 stated he (MD1) does not recall Patient 3 being discussed at the IDG meetings. Then MD1 stated he (MD1) did recall Patient 3. MD1 stated he determined Patient 3 was a hospice candidate based on her diagnosis, comorbidities, and the nursing assessment. 4).  During a record review of Patient 8’s Patient Face Sheet, the Facesheet indicated a start of care date of 7/24/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (heart unable to pump blood effectively to the body).During a concurrent interview and record review of Patient 8’s medical records on 12/10/2025, at 11:56 p.m., with the Case Manager/Office Manager (OM 1), OM 1 reviewed Patient 8’s Certification of Plan of Care, dated 10/22/2025 to 1/19/2026. OM 1 stated the Plan of Care (POC) was not completed because services and frequency of services were missing. The OM 1 stated the records “Certification of Plan of Care” was the plan of care the nurses needed to provide care to the patients.During a concurrent interview and record review of Patient 8’s medical records on 12/10/2025, at 1:32 p.m., with the OM1, the OM 1 stated there was no recertification assessment in Patient 8’s records for the certification period 10/22/2025 to 1/19/2026. The OM 1 stated the recertification assessment was to see if patient needed the services being provided, to see if patient still required hospice, to see if there were any changes, to correct the action and to do the plan of care.  OM 1 stated the plan of care could not be updated if there was no recertification assessment. The risk of not doing a recertification assessment was the quality of care was going to be affected. OM 1 stated, “It will not be good, if we cannot provide the care the patient needs.”During a record review on 12/10/2025 of Patient 8’s medical records, no IDG notes were documented for the current certification period 10/22/2025 to 1/19/2025 to validate the IDG group met and updated the comprehensive assessment and plan of care. During an interview with Patient 8, on 12/11/2025, at 5:30 p.m., Patient 8 stated she was not offered MSW and SC services. Patient 8 stated she did not decline MSW and SC services. 5). During a record review of Patient 9’s Patient Face Sheet, the Facesheet indicated a start of care date of 7/8/2025, with a terminal diagnosis of generalized atherosclerosis (a buildup of fats and other substances in the arteries).During an interview with Patient 9 on 12/11/2025, at 10:09 a.m., Patient 9 stated she had an ulcer (a chronic inflammation of the bowel that causes pain and other symptoms) that was a big problem to her health. Patient 9 stated the ulcer gave her a lot of pain. Patient 9 stated taking ibuprofen (for pain, not recommended for patients with ulcers) along with a protein drink, both provided by the HA, helped. During a record review on 12/10/2025, of Patient 9’s medical records, the review indicated there was no IDG notes documented for the recertification period 10/06/2025 to 01/03/2026 to validate the IDG group met and updated the comprehensive assessment and plan of care.6).  During a record review of Patient 10’s Face Sheet, the Facesheet indicated a start of care date of 1/10/2025, with a terminal diagnosis of heart failure (heart unable to pump blood effectively to the body).During a concurrent interview and record review of Patient 10’s medical records on 12/10/2025, at 1:17 p.m., with the OM1,  OM 1 stated there was no recertification assessment in Patient 10’s records for the certification period 11/06/2025 to 1/4/2026. OM 1 stated the recertification assessment needed to be done within five (5) days of when the recertification for hospice services was due.During a record review on 12/10/2025, of Patient 10’s medical records, the review indicated there was no IDG notes documented for the recertification period 11/6/2025 to 1/4/2026 to validate the IDG group met and updated the comprehensive assessment and plan of care.7).  During a record review of Patient 12’s Face Sheet, the Facesheet indicated a start of care date of 12/3/2024, with a terminal diagnosis of malignant neoplasm of the nipple and areola (breast cancer).During a record review of Patient 12’s Physician’s Orders, dated 10/12/2025, the orders indicated Patient 12 was discharged on 10/12/2025 from the HA due to declining further services.During a record review on 12/15/2025, of Patient 12’s medical records, the review indicated there was no IDG notes documented for the recertification period 9/29/2025 to 11/27/2025 to validate the IDG group met and updated the comprehensive assessment and plan of care.8).  During a record review of Patient 13’s Face Sheet, the Facesheet indicated a start of care date of 3/10/2025, with a terminal diagnosis of hypertensive heart disease (high blood pressure) without heart failure.During a record review of Patient 13’s Physician’s Orders, dated 10/1/2025, the orders indicated Patient 12 was discharged on 10/1/2025, due to Patient 12 desiring curative treatment.During a record review on 12/10/2025, of Patient 13’s medical records, the review indicated there was no IDG notes documented for the recertification period 9/6/2025 to 11/4/2025 to validate the IDG group met and updated the comprehensive assessment and plan of care.A record review of the HA’s undated document titled, Comprehensive Assessment, indicated, “The comprehensive assessment is updated by the interdisciplinary group as frequently as the patient’s condition requires but at a minimum every 15 days.”A record review of HA’s undated form titled “Interdisciplinary Group Membership and Responsibilities” the form indicated “The hospice interdisciplinary group members include at a minimum: the physician, registered nurse, social worker, pastoral or other counselor."   The form also indicated “The interdisciplinary group responsibilities include... Participation in the periodic review and updating of the plan of care for each patient receiving 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 meet the Condition of Participation (COP - conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people 65 years of age or more and for certain younger people with disabilities]) for compliance with Interdisciplinary Group (IDG - a team composed of professionals from different discipline who work together collaboratively to provide comprehensive care for patients), Care Planning, and Coordination of Services for Patients as follows: --- 1.      1. The HA failed to ensure six of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, and Patient 10) had an individualized plan of care developed. This failure resulted in patients, caregivers, and nurses to not be aware of the individualized hospice care, the patients required and needed, placing the patients at risk of not passing with dignity. (Refer to L545). 2.      2. The HA failed to ensure two of fourteen sample selected patients (Patient 1 and Patient 2) hospice plan of care was provided to other healthcare providers providing services. (Refer to L557). The cumulative effect of these systemic practices resulted in the failure of the Hospice Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Interdisciplinary Group, Care Planning, and Coordination of Services to ensure the quality of care is provided to patients certified to receive hospice benefits.

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 six of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, and Patient 10) had individualized plan of care developed. This failure resulted in patients, caregivers, and nurses to not be aware of the individualized hospice care the patients required and needed, placing the patients at risk of not passing with dignity. --- During an interview on 12/10/2025 at 12:40 p.m., and 12/11/2025 at 9:05 a.m., with the Administrator (ADM), the ADM stated there was no knowledgeable staff to assist with the survey.   During an interview on 12/12/2025 at 10:50 a.m. with Registered Nurse 2 (RN 2), RN 2 stated she (RN2) was not comfortable speaking on behalf of the agency regarding clinical operations of the hospice agency. 1).  During a record review of Patient 1’s medical record form titled “Patient Face Sheet” the Facesheet indicated, a start of care date of 7/23/2025 with a diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer).During a record review of Patient 1’s medical record form titled “IDT Plan of Care & Review of Comprehensive Assessment” dated 10/30/2025, indicated “no care problems identified”. The form did not indicate it was signed by any of the HA’s core members, registered nurse (RN), medical director (MD), medical social worker (MSW), or spiritual counselor (SC).During a record review of Patient 1’s undated medical record form titled “Interdisciplinary Team (IDT)” the IDT form indicated the IDTs dated 10/30/2025, 11/13/2025, and 11/27/2025 were “not started” and “unsigned”.During a concurrent interview and record review on 12/10/2025 at 11:56 a.m. with the Licensed Vocational Nurse/Case Manager/Office Manager (OM1) of Patient 1’s medical record form titled “Certification of Plan of Care” dated 10/21/2025 to 1/18/2026, the form indicated it was left blank.  OM1 indicated the form was not complete.  OM1 stated the form did not indicate Patient 1’s frequency of visits, nursing interventions, and no Certification of Terminal Illness (CTI - a doctor's official statement that a patient has an incurable condition, expected to cause death within 6 months). Lastly, the form indicted “no care problems identified”. 2).  During a record review of Patient 2’s medical record form titled “Patient Face Sheet” the Facesheet indicated, a start of care date of 8/20/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) without heart failure.During a record review of Patient 2’s medical record form titled “IDT Plan of Care & Review of Comprehensive Assessment” dated 11/19/2025, the IDT assessment form indicated “No care problems identified."  The form did not indicate it was signed by any of the HA’s core members, registered nurse (RN), medical director (MD), medical social worker (MSW), or spiritual counselor (SC).During a record review of Patient 2’s undated medical record form titled “Interdisciplinary Team (IDT)” the IDT form indicated IDTs dated 11/19/2025 and 12/3/2025 were “not started” and “unsigned”.During a concurrent interview and record review on 12/10/2025 at 12 p.m. with OM1 of Patient 2’s medical record form “Certification of Plan of Care” dated 11/18/2025 to 1/16/2026, OM1 indicated the form was not complete. OM1 stated the form did not indicate Patient 2’s frequency of visits, nursing interventions, and no CTI. The form also indicated it was left blank.3).  During a record review of Patient 3’s medical record form titled “Patient Face Sheet” the Facesheet indicated, a start of care date of 7/8/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) with heart failure (heart is unable to adequately pump blood). During a record review of Patient 3’s medical record form titled “IDT Plan of Care & Review of Comprehensive Assessment” dated 10/15/2025, the IDT Assessment form indicated “No care problems identified"  The form did not indicate it was signed by any of the HA’s core members, registered nurse (RN), medical director (MD), medical social worker (MSW), or spiritual counselor (SC).During a record review of Patient 3’s undated medical record form titled “Interdisciplinary Team (IDT)” \, the IDT form indicated IDTs dated 10/15/2025, 10/29/2025, 11/12/2025, 11/26/2025, and 12/10/2025 were “not started” and “unsigned”.During a concurrent interview and record review on 12/10/2025 at 12:05 p.m. with the OM1 of Patient 3’s medical record form “Certification of Plan of Care” dated 10/6/2025 to 1/3/2026, OM1 indicated the form was partially complete. OM1 stated the form did not indicate Patient 3’s nursing interventions. Lastly, the Certification of Plan of Care form was left blank. 4).  During a record review of Patient 8’s Patient Face Sheet, the Facesheet indicated a start of care of 7/24/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (heart unable to pump blood effectively to the body).During an interview on 12/11/2025, at 5:30 p.m., Patient 8 stated she thought the “program” had ended because she had not received any visits from the HA for more than one month.  During a concurrent interview and record review of Patient 8’s medical records on 12/10/2025, at 11:56 p.m., with the Case Manager/Office Manager (OM 1), OM 1 reviewed Patient 8’s Certification of Plan of Care, dated 10/22/2025 to 1/19/2026. OM 1 stated the POC was not completed because services and frequency of services were missing. The OM 1 stated the records “Certification of Plan of Care” was the plan of care the nurses needed to provide care to the patients.5).  During a record review of Patient 9’s Patient Face Sheet, the Facesheet indicated a start of care of 7/8/2025, with a terminal diagnosis of generalized atherosclerosis (a buildup of fats and other substances in the arteries).During an interview with Patient 9 on 12/11/2025, at 10:09 a.m., Patient 9 stated she had an ulcer (a chronic inflammation of the bowel that causes pain and other symptoms) that was a big problem to her health. Patient 9 stated the ulcer gave her a lot of pain. Patient 9 stated taking ibuprofen (for pain, not recommended for patients with ulcers) along with a protein drink, both provided by the HA, helped.During a concurrent interview and record review of Patient 9’s medical records on 12/10/2025, at 11:56 p.m., with OM1, OM 1 reviewed Patient 9’s Certification of Plan of Care, dated 10/06/2025 to 1/3/2026. OM 1 stated the POC was not completed because nursing interventions were missing.6).  During a record review of Patient 10’s Face Sheet, indicated a start of care date of 1/10/2025, with a terminal diagnosis of heart failure (heart unable to pump blood effectively to the body).During a concurrent interview and record review of Patient 10’s medical records on 12/10/2025, at 11:56 p.m., with OM1, OM 1 reviewed Patient 10’s Certification of Plan of Care, dated 11/06/2025 to 1/4/2026. OM 1 stated the POC was not completed because nursing interventions were missing. During a record review of HA’s form titled “The Plan of Care” undated, indicated “A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program.”

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 two of fourteen sample selected patients (Patient 1 and Patient 2) hospice plans of care were provided to patients and patients family/caregiver. This failure had the potential to result in missed care, duplicity of care, and/or miscommunications amongst patient providers. --- 1).  During a record review of Patient 1’s medical record form titled “Patient Face Sheet” the Facesheet indicated, a start of care date of 7/23/2025 with a diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer).During an interview on 12/12/2025 at 4:45 p.m. with Patient 1’s daughter/caregiver (CG1), CG1 requested the HA’s phone number, and any resources her (Patient 1) mother can benefit from. CG1 stated she (CG1) was unaware that there was a social worker available to provide resources. The CG1 stated that the initial nurse that had her mother (Patient 1) sign documents did not leave anything at their residence. The CG1 stated that she (CG1) wanted to call the HA several times but keeps forgetting to request the number from Registered Nurse 1 (RN1) after his (RN1) home visits. 2).  During a record review of Patient 2’s medical record form titled “Patient Face Sheet” the Facesheet indicated a start of care date of 8/20/2025 with a diagnosis of atherosclerotic heart disease (heart problems cause by long term high blood pressure) of native coronary artery with angina pectoris with documented spasm.During a concurrent observation and interview during a home visit of Patient 2's home on 12/12/2025 at 7:48 p.m., there was no agency folder or documents in Patient 2’s home. Patient 2 stated she was not provided with copies of any of the documents she had signed. Patient 2 stated she was not provided with any documentation from the agency, including agency information.During a record review of the HA’s undated form titled “Patient Bill of Rights/Responsibilities”   the form indicated “Each patient will be an active, informed participant in his/her plan of care."  The form also indicated “Upon admission, the admitting clinician will provide each patient or his/her representative with a written copy of the Patient Bill of Rights/Responsibilities in advance of furnishing care.  A copy will be maintained by the patient.”

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 Director of Patient Care Services (DPCS) and Administrator (ADM) provided patient care oversight and failed to ensure the Conditions of Participations (COP, conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) regarding Organization and administration of services was met as follows:1. Failing to ensure there was a Registered Nurse responsible clinical oversight of nursing services.2. Failing to ensure all patients were assessed and a plan of care was developed based on the needs of the patients.3. Failing to ensure there was a Medical Director responsible for the overall medical management of patients.4. Failing to ensure the DPCS and Medical Director were responsible for the Interdisciplinary Group. --- As a result of the non-compliance, Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, and Patient 10 remained hospice patients without an assessment that identified the patients’ needs, were left without a plan of care that was based on the patient’s health care needs, and were not monitored of their care to ensure patients remained free of potential harm that could lead to hospitalization and death.   The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulation for Organization and administration of services to ensure it provided the necessary care and services to the patients.

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 governing body and administrator assume full responsibility for the day-to-day operation of the hospice and provision of care for six of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, and Patient 10).As a result of the non-compliance, Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, and Patient 10 remained hospice patients without an assessment that identified the patients’ needs, were left without a plan of care that was based on the patient’s health care needs, and were not monitored of their care to ensure patients remained free of potential harm that could lead to hospitalization and death. On 12/12/2025 at 1:20 p.m., an Immediate Jeopardy (IJ, 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 patient) was identified in the presence of the agency’s Administrator (ADM) and Registered Nurse 2 (RN2), related to the hospice agency failing to ensure the governing body and administrator assume full responsibility for the day-to-day operation of the hospice and provision of care for six of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, and Patient 10).  The survey Team requested an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 12/22/2025, at 1:30 p.m., the survey team completed the survey task and conducted an exit conference in the presence of the ADM, Registered Nurse 3 (RN 3) and the Office Manager (OM 2), with the IJ situation not removed. --- Findings: During an interview on 12/10/2025, at 11:56 a.m., with the Licensed Vocational Nurse / Case Manager / Office Manager (OM1), the OM1 stated patient’s (in general) record titled “Certification of Plan of Care” were the plans of care the nurses used to provide patient care.  During an interview on 12/10/2025, at 12:40 p.m., with the Administrator (ADM), the ADM stated that the Director of Patient Care Services (DPCS) and the Director of Patient Care Services Designee (DD) were unable to assist with the survey on 12/10/2025. The ADM stated that he (ADM) was trying to convince the DPCS to be at the HA on 12/11/2025 for assistance with the survey process.  During an interview on 12/10/2025, at 12:43 p.m., with the ADM, the ADM stated that there was no Registered Nurse (RN) available for sample patient record review or interview on 12/10/2025.  During an interview on 12/10/2025, at 1:16 p.m., with OM1, the OM1 stated patients nursing recertification assessments were to determine if a patient continues to require hospice services and/or to identify if there had been any changes in the patient’s condition. The OM1 stated the individualized patient plan of care was based on the information gathered by the nursing recertification assessment. The OM1 stated that patients individualized plans of care cannot be updated when the nursing recertification assessment was not completed. The OM1 stated patients (in general) were at risk of receiving poor quality care without an accurate and complete nursing recertification assessment. During an interview on 12/10/2025, at 1:17 p.m., with OM1, the OM1 stated that a patients hospice service was unable to move forward without an updated plan of care. OM1 stated patients’ (in general) care plans were required to be able to provide the service and needs of the patients (in general) because the care plans were used by the clinicians to provide individualized patient care.  During an interview on 12/10/2025, at 1:28 p.m., with OM1, the OM1 stated that nurses (in general), medical social workers, and spiritual counselors, must document their home visits the same day after their visit. OM1 stated that when a member of staff does not document their home visit notes after one week of their visit the Office Manager (OM2) contacts them to remind them to document and complete their visit notes. The OM1 stated it was important to document home visit notes “because we need to know if the patient has been seen and taken care of and if they are following their plan of care.” During an interview on 12/11/2025, at 9:05 a.m., with the ADM, the ADM stated there was no RN available for sample patient record review or interview on 12/11/2025. The ADM stated that the DD had not been at HA since March of 2025. The ADM stated that the DPCS would not be at the HA on 12/11/2025 due to “not being profitable” and the DPCS opting to look for other employment.  During an interview on 12/11/2025, at 9:45 a.m., with the ADM, the ADM stated that the DD had not been at HA since March of 2025. The ADM stated that the DD was not employed at the HA.  During an interview on 12/12/2025, at 9:15 a.m., the ADM stated the members of the governing body were the ADM and the DPCS. The ADM stated he had no idea of the clinical operations of the agency, which is why the ADM made sure the DPCS was overseeing the clinical operations. During an interview on 12/12/2025, at 9:18 a.m., the ADM stated the Medical Director (MD1) and DPCS were responsible for the IDG meetings. The ADM stated the expectation for the DPCS, was to ensure every document such as Certification for Terminal Illness (CTI, a doctor's official statement that a patient has an incurable condition, expected to cause death within 6 months), visit notes, were completed for each patient. The ADM stated completion of CTI documents was important to make sure everything was compliant and to make sure the HA serviced patients appropriately.   During an interview on 12/12/2025, at 9:23 a.m., the ADM stated he (ADM) expected the Medical Director (MD1) to oversee the hospice eligibility of every patient. The ADM stated he did not know what the Medical Director’s (MD1) role was regarding the CTIs. During an interview on 12/12/2025, at 9:26 a.m., the ADM stated the expectation for the IDG (IDG, a core team of nurses, social workers, doctors, chaplains who work in partnership to create a holistic plan for terminally ill patients) meeting notes, clinical notes, and plan of care (POC,  individualized patient plans for care) team was to discuss each patient for the certification period, to see if patients needed to change the plan of care such as increasing medication. The ADM stated the medical director, DPCS, social worker, and spiritual counselor were expected to attend the IDG meetings. During an interview on 12/12/2025, at 9:28 a.m., the ADM stated the DD was supposed to cover the DPCS. The ADM stated the DD needed to have knowledge of the situation of the agency. The ADM stated the DPCS, and the DD were not reliable. The ADM stated he (ADM) was not aware the patients (in general) were missing assessments, CTI’s, Interdisciplinary Group meetings. The ADM stated he (ADM) trusted the DPCS had ensured all these were completed and there was nursing oversight. The ADM stated he (ADM) learned through the survey process that these things were not done. During an interview on 12/12/2025, at 9:36 a.m., the ADM stated he was not aware of what was happening in the HA because he (ADM) put his trust in the DPCS. The ADM stated he did not know how the doctor’s orders were processed. The ADM stated Registered Nurse 3 (RN 3) was a nurse whom he paid to do quality assurance tasks. The ADM stated RN 3 was not listed in the employee list. During an interview on 12/12/2025, at 10:50 a.m., with the Registered Nurse 2 (RN 2), RN2 stated Registered Nurse 4 (RN 4) was the DPCS. RN 2 stated she was not comfortable speaking on behalf of the agency regarding clinical operations of the hospice agency. On 12/12/2025 at 11:26 a.m. a call was made to the DPCS with the number provided by the ADM, with no answer. Message with call back number left.  During an interview on 12/12/2025, at 12:05 p.m., with the Medical Director (MD1), the MD1 stated he (MD1) was the Medical Director for the HA for the past 3 years. MD1 stated that his (MD1) responsibilities included the general oversight of nursing, employee services, and patient admissions, discharges, policies and procedures. MD1 stated that he was the “captain of the ship of patient care”. MD1 stated he (MD1), the director of nurses, clergy, social worker, and the DPCS were the members of the IDG team and held meetings every two weeks. MD1 stated that the last hospice IDG meeting was held at the end of November. MD1 stated the HA adhered to the CMS guidelines. MD1 stated admitting criteria included reviewing patients’ history and physical (H&P), medication list, nurses’ assessments, and IDG review with the expectation that the patient will be terminal with a diagnosis within 6 months. MD1 stated once a nurse assesses the patient, the nurse calls him (MD1) over the phone or video to go over the assessment. If there is sufficient information, MD1 stated, he (MD1) then tells the nurse to discuss it at the IDG meeting to ensure the patient is appropriate for hospice admission. MD1 stated a CTI is then generated within 72 hours of admission. MD1 stated that the HA nursing staff writes the CTI draft, because “they are pretty good.” MD1 stated that he (MD1) does more of a home health agency writing, and that is why he (MD1) leaves the hospice CTI writing to the hospice nurses. MD1 stated he (MD1) reviews and revises with minor adjustments if necessary. MD1 stated recertifications are written within 72 hours after discussing patients in the IDG meetings.  During an interview on 12/15/2025 at 10:07 a.m. with the Medical Director 1 (MD1), the MD1 stated that the DPCS had him (MD1) “doing something weird”. MD1 stated that the DPCS would write patients’ findings on paper and would have him (MD1) read and sign off on them. The MD1 stated the DPCS would write on the patients’ CTIs physician narrative, and he (MD1) would make edits if necessary and sign it. The MD1 stated, “I am on the mercy of (DPCS)… I rely on (DPCS) to inform me when I (MD1) need to sign documents. MD1 stated the DPCS was also a Nurse Practitioner, and she (DPCS) would do the patients visits. MD1 stated during the IDG meetings, if the HA staff informed him (MD1) that the patient was declining, that would trigger the DPCS to write a CTI narrative. The MD1 stated he (MD1) noticed that the HA nurses were not turning in their nursing assessments during the last 2-3 IDG meetings. MD1 stated that the narrative documented on the certification of terminal illness and patient associated factors support patients’ diagnosis for hospice admission. MD1 stated that the DPCS informed him (MD1) mid-November that she (DPCS) had resigned from the HA. MD1 stated that he (MD1) was unable to contact the DPCS, since then.  During an interview on 12/15/2025, at 11:11 a.m., the ADM stated RN 4 was a newly hired case manager on 12/14/2025. The ADM stated RN 4 was not DPCS. On 12/15/2025, at 12:40 p.m., a call was made to the DPCS with the number provided by the ADM, with no answer. Message with call back number left.  During a record review of the HA’s employee list, RN 4 was not listed as the agency’s employee. A. During a record review of Patient 1’s medical record form titled “Patient Face Sheet” indicated, a start of care (SOC) date of 7/23/2025 with a diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer).During a concurrent observation and interview on 12/12/2025, at 4 p.m., with Patient 1 at her (Patient 1) residence, Patient 1 greeted Registered Nurse 1 (RN1) and surveyor at door. Patient 1 was awake, alert, and ambulatory with no shortness of breath noted. Patient 1 stated she (Patient 1) saw her oncologist (cancer treating doctor) in November 2025 and has another appointment in January 2026. Patient 1 stated she (Patient 1) had lung issues and was told she (Patient 1) had 3-5 years of life left. Patient 1 stated that there has not been a physician that has told her (Patient 1) that she (Patient 1) had 6 months or less to live. Patient 1 stated she (Patient 1) never heard of the HA’s Medical Directors 1 (MD1), the Medical Social Worker (MSW), or the Spiritual Counselor (SC)’s name or spoken to any of them.During a concurrent interview and record review on 12/15/2025, at 10:07 a.m., with the Medical Director 1 (MD1) of Patient 1’s medical record, MD1 stated Patient 1 was being treated without a CTI. The MD1 stated that there were no notes or documents in Patient 1’s medical record that would indicate why she (Patient 1) was receiving hospice services. MD1 stated that he (MD1) attempted to contact the DPCS, but that the DPCS did not answer his (MD1) calls or text.  A1.  During a concurrent interview and record review on 12/10/2025, at 11:56 a.m., with the OM1 of Patient 1’s medical record form “Certification of Plan of Care” dated 10/21/2025 to 1/18/2026, the form indicated it was left blank. OM1 indicated the form was not complete. OM1 stated the form did not indicate Patient 1’s frequency of visits, nursing interventions, and no CTI. The form indicted “no care problems identified”.   A2.  During a concurrent interview and record review on 12/10/2025 at 1:18 p.m. with the OM1 of Patient 1’s medical record form titled “Nursing Recertification Assessment” dated 10/20/2025, the form indicated it was left blank and “in progress”. The OM1 stated Patient 1’s nursing recertification assessment was plotted in her (Patient 1) calendar for visit on 10/20/2025, but the visit was not done. The OM1 stated Patient’s 1 nursing recertification assessment documentation, if done, was to be completed within 5 days of visit. The OM1 stated Patient 1’s nursing recertification assessment was to be completed to be able to update Patient 1’s individualized plan of care and to determine if Patient 1’s continues to require hospice services.  A3.During a record review of Patient 1’s medical record form titled “Interdisciplinary Team (IDT)” undated, indicated IDTs dated 10/30/2025, 11/13/2025, and 11/27/2025 were “not started” and “unsigned”.During a record review of Patient 1’s medical record form titled “IDT Plan of Care & Review of Comprehensive Assessment” dated 10/30/2025, indicated “no care problems identified”. The form did not indicate it was signed by any of the HA’s core members, registered nurse (RN), medical director (MD), medical social worker (MSW), or spiritual counselor (SC).  A4.  During a record review of Patient 1’s medical record form titled “Certification of terminal Illness (CTI)” dated 10/20/2025, indicated the Medical Director (MD1)’s name was listed as the hospice physician, but it did not contain his (MD1’s) signature. The CTI form was left blank.  A5.  During a record review on 12/10/2025 at 2:13 p.m. of Patient 1’s medical record, the record indicated Patient 1’s scheduled visit notes dated November 7, 14, 21, 28, and December 5 were “not started”.  B.  During a record review of Patient 2’s medical record form titled “Patient Face Sheet” indicated, a start of care date of 3/11/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) without heart failure.During an interview on 12/12/2025, at 9:23 a.m., with Patient 2, Patient 2 stated she (Patient 2) had monthly hospice nurse visits, that last about 8-10 minutes. Patient 2 stated she (Patient 2) did not understand the hospice nurse that visits her (Patient 2) and that she (visiting nurse) calls a lady that speaks Spanish to translate. Patient 2 stated that she (Patient 2) has been with her (Patient 2) primary physician (MD3) for the past 2 years and saw him (MD3) last three days ago. Patient 2 stated that MD2 did not refer her to hospice services. Patient 2 stated that she (Patient 2) was not dying and had not been told by a doctor that she (Patient 2) was going to die in 6 months or less. Patient 2 stated that she (Patient 2) does not know why the HA was writing and stating that she (Patient 2) had a certain time to live, and that it was a lie. Patient 2 stated that she (Patient 2) has not heard of or from MD1.  During an observation of the home visit on 12/12/2025, at 7:00 p.m., with RN 2, Patient 2 greeted the survey team in the lobby of a locked multi-floor, multi-unit apartment complex. Patient 2 was walking without the use of an assistive device, breathing was unlabored, and Patient 2 was not in distress while walking.During a concurrent interview and record review on 12/15/2025, at 10:24 a.m., with the MD1 of Patient 2’s medical record, MD1 stated Patient 2 was on her (Patient 2) 3rd recertification period. MD1 stated that based on Patient 2’s medical record the HA was treating her (Patient 2) without his (MD1) authorization. MD1 stated that Patient 2’s CTI was not signed by him (MD1). MD1 stated that his (MD1) signature indicated she (Patient 2) was authorized for a new hospice recertification. MD1 stated that Patient 2’s medical record did not contain a face-to-face medical evaluation/assessment. B1.  During a concurrent interview and record review on 12/10/2025, at 12 p.m., with the OM1 of Patient 2’s medical record form “Certification of Plan of Care” dated 11/18/2025 to 1/16/2026, OM1 indicated the form was not complete. OM1 stated the form did not indicate Patient 2’s frequency of visits, nursing interventions, and no CTI. The form also indicated it was left blank.  B2.  During a concurrent interview and record review on 12/10/2025, at 1:20 p.m., with the OM1 of Patient 2’s medical record form titled “Nursing Clinical Note” undated, the OM1 stated that the nursing clinical note was initially plotted in Patient 2’s calendar for visit as visit type “RN – Recert / on-site” on 11/5/2025. The OM1 stated Patient 2’s nursing rectification assessment was plotted/scheduled for 11/5/2025, but it was not completed. The OM1 stated that there was a “Clinical Nursing Note” but the nurse has the option to change it to a recertification note when she or he documents it. Lastly, the Nursing Clinical Note was left blank.  B3.  During a record review of Patient 2’s medical record form titled “Interdisciplinary Team (IDT)” undated, indicated IDTs dated 11/19/2025 and 12/3/2025 were “not started” and “unsigned”.During a record review of Patient 2’s medical record form titled “IDT Plan of Care & Review of Comprehensive Assessment” dated 11/19/2025, indicated “no care problems identified”. The form did not indicate it was signed by any of the HA’s core members, registered nurse (RN), medical director (MD), medical social worker (MSW), or spiritual counselor (SC).  B4.  During a record review of Patient 2’s medical record form titled “Certification of terminal Illness (CTI)” dated 11/17/2025, indicated the Medical Director (MD1)’s name was listed as the hospice physician, but it did not contain his (MD1’s) signature. The CTI form was left blank.  B5.  During a record review on 12/10/2025 at 2:16 p.m. of Patient 2’s medical record, the record indicated Patient 2’s scheduled visit notes dated 11/18/2025 and 12/2/2025 were “not started”.  C. During a record review of Patient 3’s medical record form titled “Patient Face Sheet” indicated, a start of care date of 7/8/2025, with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) with heart failure (heart is unable to adequately pump blood). During an interview on 12/12/2025, at 10:10 a.m., with Patient 3, Patient 3 stated she (Patient 3) was not dying and therefore not a hospice patient. Patient 3 stated “someone” brought a nurse to her (Patient 3) home that signed her (Patient 3) up for hospice services. Patient 3 stated that she (Patient 3) did not have any heart issues, and she (Patient 3) only takes vitamins. Patient 3 stated she walks three laps around her building every other day. Patient 3 stated she (Patient 3) was not sick and wanted to cancel hospice services because she (Patient 3) did not want any trouble. Patient 3 stated she never heard or spoke with MD1. Patient 3 stated she (Patient 3) saw her primary physician last week and has been with him (primary physician) for the past 2 ½ years. During a concurrent interview and record review on 12/15/2025 at 10:42 a.m. with MD1 of Patient 3’s medical record, MD1 stated he (MD1) could not recall Patient 3 being discussed at the IDG meetings. MD1 stated he (MD1) did recall Patient 3. MD1 stated he (MD1) determined Patient 3 was a hospice candidate based on her (Patient 3) diagnosis, comorbidities, and the nursing assessment. MD1 stated he (MD1) informs HA staff to request patients H&P and information from their primary physician. MD1 stated that the “usual response” from the DPCS was “yeah doctor, we are working on them”. C1.  During a concurrent interview and record review on 12/10/2025 at 12:05 p.m. with the OM1 of Patient 3’s medical record form “Certification of Plan of Care” dated 10/6/2025 to 1/3/2026, OM1 indicated the form was partially complete. OM1 stated the form did not indicate Patient 3’s nursing interventions. Lastly, the Certification of Plan of Care form was left blank.   C2.  During a concurrent interview and record review on 12/10/2025, at 1:25 p.m., with the OM1 of Patient 3’s medical record form titled “Nursing Clinical Note” undated, the OM1 stated that the nursing clinical note was initially plotted in Patient 3’s calendar for visit as visit type “RN – Recert / on-site” on 9/30/2025. The OM1 stated Patient 3’s nursing rectification assessment was plotted/scheduled for 9/30/2025, but it was not completed. The OM1 stated that there was a “Clinical Nursing Note” but the nurse had the option to change it to a recertification note when she or he documents it. Lastly, the Nursing Clinical Note was left blank.   C3.  During a record review of Patient 3’s medical record form titled “Interdisciplinary Team (IDT)” undated, indicated IDTs dated 10/15/2025, 10/29/2025, 11/12/2025, 11/26/2025, and 12/10/2025 were “not started” and “unsigned”.During a record review of Patient 3’s medical record form titled “IDT Plan of Care & Review of Comprehensive Assessment” dated 10/15/2025, indicated “no care problems identified”. The form did not indicate it was signed by any of the HA’s core members, registered nurse (RN), medical director (MD), medical social worker (MSW), or spiritual counselor (SC).   C4.During a record review of Patient 3’s medical record form titled “Certification of terminal Illness (CTI)” dated 10/5/2025, indicated “Based on current clinical evaluation, disease trajectory, and overall decline, the patient meets the criteria for certification of terminal illness with a life expectancy of six months or less if the illness follows its expected course.” The form also indicates Patient 3 exhibited progressive cardiac and pulmonary decline, fatigue, mild cognitive impairment, decrease functional status, increasing need for assistance with activities of daily living. MD1’s electronic signature was on form and dated 10/8/2025. C5.  During a record review on 12/10/2025 at 2:16 p.m. of Patient 3’s medical record, the record indicated Patient 3’s scheduled visit notes dated 10/15/2025, 10/29/2025, 11/12/2025, 11/26/2025, and 12/10/2025 were “not started”.   D. During a record review of Patient 8’s Patient Face Sheet, indicated a start of care of 7/24/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (heart unable to pump blood effectively to the body).During an observation on 12/11/2025, at 2:00 p.m., with RN 2, Patient 8’s home was observed as a single-family home, with a black locked gate. Patient 8’s home visit was scheduled at 2:00 p.m., but Patient 8 was not home.During an interview on 12/11/2025, at 2:02 p.m., with Patient 8, Patient 8 stated she was not home and was currently riding the bus, running errands. Patient 8 stated she did not know what time she would be home.During an interview on 12/11/2025, at 5:30 p.m., Patient 8 stated she thought the “program” had ended because she had not received any visits from the HA for more than 1 month. Patient 8 stated she was not terminal, and no doctor had told her she was expected to die within 6 months. Patient 8 stated her heart was not failing, did not use oxygen, and walked using a walker due to back problems. Patient 8 stated she was able to go to church, go to stores, and ride on the bus. D1.  During a concurrent interview and record review of Patient 8’s medical records on 12/10/2025, at 11:56 p.m., with the Case Manager/Office Manager (OM 1), OM 1 reviewed Patient 8’s Certification of Plan of Care, dated 10/22/2025 to 1/19/2026. OM 1 stated the POC was not completed because services and frequency of services were missing. The OM 1 stated the records “Certification of Plan of Care” was the plan of care the nurses needed to provide care to the patients. D2.  During a concurrent interview and record review of Patient 8’s medical records on 12/10/2025, at 11:56 p.m., with the OM 1, OM 1 reviewed Patient 8’s medical records.  OM 1 stated there was no CTI for the current recertification period 10/22/2025 to 1/19/2026. During a concurrent interview and record review on 12/15/2025, at 10:45 a.m., with MD 1, MD 1 reviewed Patient 8’s medical records. MD 1 stated the CTI was blank. MD 1 stated the DPCS had MD 1 sign the CTI on a paper document.During an interview on 12/15/2025 at 11:45 a.m., with the ADM, the ADM stated there was no paper CTI documents in the HA. The ADM stated the CTI documents were an agreement between MD 1 and the DPCS. D3.  During a concurrent interview and record review of Patient 8’s medical records on 12/10/2025, at 1:32 p.m., with the OM1,  the OM 1 stated there was no recertification assessment in Patient 8’s records for the certification period 10/22/2025 to 1/19/2026. The OM 1 stated the recertification assessment was to see if Patient 8 needed the services being provided,  if patient still required hospice,  if there were any changes, to correct the action and to do the plan of care. The OM 1 stated the plan of care could not be updated if there was no recertification assessment. The risk of not doing a recertification assessment was that the quality of care was going to be affected. The OM 1 stated, “It will not be good, if we cannot provide the care the patient needs.” D4.  During a record review on 12/10/2025, of Patient 8’s medical records, the review indicated there were no IDG notes documented for the recertification period 10/22/2025 to1/19/2026. D5.  During a record review on 12/10/2025, of Patient 8’s medical records, the review indicated there was no visit notes documented for the recertification period 10/22/2025 to1/19/2026. E. During a record review of Patient 9’s Patient Face Sheet, indicated a start of care of 7/8/2025, with a terminal diagnosis of generalized atherosclerosis (a buildup of fats and other substances in the arteries).During an interview with Patient 9 on 12/11/2025, at 10:09 a.m., Patient 9 stated she was not terminal, and no doctor had told her she was dying. Patient 9 stated she had a primary care doctor she was actively seeing (Medical Doctor 2-MD 2).During an interview on 12/11/2025, at 5:00 p.m., with MD 2, MD 2 stated Patient 9 did not have a terminal illness, does not have a terminal diagnosis, and MD 2 did not refer Patient 9 to hospice care. MD 2 started the last time MD 2 saw Patient 9 was on 10/14/2025. E1.During a concurrent interview and record review of Patient 9’s medical records on 12/10/2025, at 11:56 p.m., with OM1, OM 1 reviewed Patient 9’s Certification of Plan of Care, dated 10/06/2025 to 1/3/2026. OM 1 stated the POC was not completed because nursing interventions were missing. E2.  During a record review of Patient 9’s medical records, the review indicated there was no IDG notes documented for the recertification period 10/06/2025 to 01/03/2026. E3.  During a record review of Patient 9’s medical records, the review indicated there was no visit notes documented for the recertification period 10/06/2025 to 01/03/2026. F.  During a record review of Patient 10’s Face Sheet, indicated as start of care of 1/10/2025, with a terminal diagnosis of heart failure (heart unable to pump blood effectively to the body). F1.During a concurrent interview and record review of Patient 10’s medical records on 12/10/2025, at 11:56 p.m., with OM1, OM 1 reviewed Patient 10’s Certification of Plan of Care, dated 11/06/2025 to 1/4/2026. OM 1 stated the POC was not completed because nursing interventions were missing. F2:  During a concurrent interview and record review of Patient 10’s medical records on 12/10/2025, at 1:17 p.m., with the OM1, the OM 1 stated there was no recertification assessment in Patient 10’s records for the certification period 11/06/2025 to 1/4/2026. The OM 1 stated the recertification assessment needed to be done within 5 days of when the recertification for hospice services was due. F3.During a concurrent interview and record review of Patient 10’s medical records on 12/10/2025, at 11:56 p.m., with the OM 1, OM 1 reviewed Patient 10’s medical records.  OM 1 stated the CTI for the current recertification period 11/06/2025 to 1/04/2026, was not signed. During a concurrent interview and record review on 12/15/2025 at 10:58 a.m., with MD 1, MD 1 reviewed Patient 10’s CTI for certification period 11/6/2025 to 1/4/2026. MD 1 stated the CTI was not signed and the DPCS had written the narrative.   F4.  During a record review on 12/10/2025, of Patient 10’s medical records, the review indicated there was no IDG notes documented for the recertification period 11/6/2025 to 1/4/2026. F5.  During a record review on 12/10/2025, of Patient 10’s medical records, the review indicated there were no visit notes documented for the recertification period 11/6/2025 to 1/4/2026.  During a review of the HA’s undated document titled, Executive Director/Administrator, indicated, “The Executive Director/Administrator is responsible for the overall direction of the hospice services...is responsible for the provision of hospice services, directly...is responsible for establishing standards of care to comply with federal and state regulations and guidelines...The administrator has overall responsibility for day-to-day operations, complying with applicable rules and regulations, and reporting to the governing body.”

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 (COP - conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people 65 years of age or more and for certain younger people with disabilities]) for Medical Director was met as evidenced by: --- 1.      The HA failed to ensure the medical director and/or physician designee (who is a hospice employee or under  contract with the hospice) reviewed patients clinical information to determine hospice (health care that focuses on the palliation of a terminally ill patient’s pain and symptoms and attending to their emotional and spiritual needs at the end of life) care criteria is met and/or provide an initial written certification that the patient had six months or less to live if the illness runs its normal course for eight of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10). (Refer to L 667).  2.      The HA failed to ensure the medical director and/or physician designee conducted a review and verified the patient’s clinical information to determine the patient's need of recertification of terminal illness for continued hospice care and services for six of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, and Patient 10). (Refer to L 668). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulations for Medical Director services to ensure the highest quality of patient care is provided to the patients certified to receive hospice services.

Based on observation, interview and record review, the hospice agency failed to ensure the medical director and/or physician designee (who is a hospice employee or under the contract with the hospice) reviewed patients clinical information to determine hospice (health care that focuses on the palliation of a terminally ill patient’s pain and symptoms and attending to their emotional and spiritual needs at the end of life) care criteria is met and/or provide an initial written certification that the patient had six months or less to live, if the illness runs its normal course, for eight of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10).  These deficient practices resulted in the hospice medical director and/or the designee to certify patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses. It also resulted in patients not being certified by a medical doctor for hospice care, which can result in lack of and inappropriate care being provided to the patients. --- During an interview on 12/10/2025 at 12:40 p.m., and 12/11/2025 at 9:05 a.m., with the Administrator (ADM), the ADM stated there was no knowledgeable staff to assist with the survey.   During an interview on 12/12/2025 at 10:50 a.m. with Registered Nurse 2 (RN 2), RN 2 stated she (RN2) was not comfortable speaking on behalf of the agency regarding clinical operations of the hospice agency. On 12/12/2025 at 11:26 a.m. a call was made to the Director of Patient Care Services (DPCS) with the number provided by the ADM, with no answer. Message with call back number left. On 12/15/2025 at 12:40 p.m. a call was made to the DPCS with the number provided by the ADM, with no answer. Message with call back number left. During an interview on 12/12/2025, at 9:18 a.m., the  ADM stated the expectation of the DPCS was to ensure every document such as Certification for Terminal Illness (CTI - a doctor's official statement that a patient has an incurable condition, expected to cause death within 6 months), visit notes, were completed for each patient. The ADM stated completion of documents was important to make sure everything was compliant. To make sure the HA serviced patients appropriately.   During an interview on 12/12/2025, at 9:28 a.m., the ADM stated the Director of Patient Care Services Designee (DD) was supposed to cover the DPCS. The DD needed to have knowledge of the situation. The ADM stated the DPCS, and the DD were not reliable. The ADM stated he was not aware the patients were missing assessments, CTI’s, and Interdisciplinary Group meetings. The ADM stated he trusted the DPCS had ensured all these were completed and there was nursing oversight. The ADM stated he learned through the survey process that these things were not done. During an interview on 12/12/2025 at 12:05 p.m. with the Medical Director (MD1), MD1 stated he (MD1) was the Medical Director for the HA for the past three (3) years.  MD1 stated that his (MD1) responsibilities included the general oversight of nursing, employee services, and patient admissions, discharges, policies and procedures.  MD1 stated that he was the “Captain of the ship of patient care."   MD1 stated admitting criteria included reviewing each patients’ history and physical (H&P), medication list, nurses’ assessments, and IDG review with the expectation that the patient will be terminal with a diagnosis within six (6) months.  MD1 stated once a nurse assesses the patient, the nurse calls him (MD1) over the phone or video to go over the assessment. If there is sufficient information, MD1 stated, he (MD1) then tells the nurse to discuss it at the IDG meeting to ensure the patient is appropriate for hospice admission. MD1 stated a CTI is then generated within 72 hours of admission. MD1 stated that the HA nursing staff writes the CTI draft, because “They are pretty good.”  MD1 stated that he (MD1) does more of a home health agency writing, and that is why he (MD1) leaves the hospice CTI writing to the hospice nurses. MD1 stated he (MD1) reviews and revises with minor adjustments if necessary.  During an interview on 12/15/2025 at 10:07 a.m. with the Medical Director 1 (MD1), the MD1 stated that the DPCS would write patients’ findings on paper and would have him (MD1) read and sign off on them. The MD1 stated the DPCS would write on the patients’ CTIs physician narrative, and he (MD1) would make edits if necessary and sign it. The MD1 stated, “I am on the mercy of (DPCS)… I rely on (DPCS) to inform me when I (MD1) need to sign documents. MD1 stated that the narrative documented on the certification of terminal illness and patient associated factors support patients’ diagnosis for hospice admission. MD1 stated that the DPCS informed him (MD1) mid-November that she (DPCS) had resigned from the HA. MD1 stated that he (MD1) was unable to contact the DPCS, since then.  1).  During a record review of Patient 1’s medical record form titled “Patient Face Sheet” the Facesheet indicated, a start of care date of 7/23/2025 with a diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer).During a record review of Patient 1’s medical record form titled “Certification of Terminal Illness” dated 7/23/2025, with a certification period of 7/23/2025 to 10/20/2025,  the CTI form indicated MD1 signed the form on 7/25/2025. The form also indicated MD1 noted “I have reviewed and agreed with the Plan of Care that includes initial orders and plan of care, medication profile and plan of care problems (identified in assessments) and admission to hospice.” Lastly, the form indicated MD1 attest that he (MD1) composed the narrative and reviewed Patient 1’s medical record and examined her (Patient 1). During a record review of Patient 1’s medical record form titled “Health Services Los Angeles County” with an admission date of 7/19/2025 and discharge date of 7/22/2025, provided by Registered Nurse 2 (RN2) and stated by RN2 to be her (Patient 1) history and physical used to determine hospice eligibility. The form indicated Patient 1 was medically stable for home discharge with ordered to receive physical and occupational therapy through a home health agency. Lastly, the form indicated both of her (Patient 1) lungs sounded clear with auscultation (sounds heard via a stethoscope) and was not using accessory muscles when breathing.  During a record review on 12/10/2025 at 2:14 p.m. of Patient 1’s medical record, the record indicated nursing clinical note, visit type “RN-Eval” dated 7/23/2025 was “not started”.During a concurrent observation and interview on 12/12/2025 at 4 p.m. with Patient 1 while at her residence, Patient 1 was awake, alert, and ambulatory with no shortness of breath noted. Patient 1 stated she (Patient 1) saw her oncologist (cancer treating doctor) in November 2025 and has another appointment in January 2026. Patient 1 stated she (Patient 1) had lung issues and was told she (Patient 1) had 3-5 years of life left. Patient 1 stated that there has not been a physician that has told her (Patient 1) that she (Patient 1) had 6 months or less to live. Patient 1 stated she (Patient 1) never heard of the HA’s Medical Directors 1 (MD1), the Medical Social Worker (MSW), or the Spiritual Counselor (SC)’s name or spoken to any of them.During a concurrent interview and record review on 12/15/2025 at 10:07 a.m. with the Medical Director 1 (MD1) of Patient 1’s medical record, MD1 stated that there were no notes or documents in Patient 1’s medical record that would indicate why she (Patient 1) was receiving hospice services. MD1 stated that he (MD1) attempted to contact the DPCS, but that the DPCS did not answer his (MD1) calls or text. 2).  During a record review of Patient 2’s medical record form titled “Patient Face Sheet” the Facesheet indicated a start of care date of 8/20/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) without heart failure.During an interview on 12/12/2025 at 9:23 a.m. with Patient 2, Patient 2 stated that she (Patient 2) had monthly hospice nurse visits, that last about 8-10 minutes. Patient 2 stated that she (Patient 2) has been with her (Patient 2) primary physician (MD3) for the past 2 years and saw him (MD3) last three days ago. Patient 2 stated that MD3 did not refer her to hospice services. Patient 2 stated that she (Patient 2) was not dying and had not been told by a doctor that she (Patient 2) was going to die in 6 months or less. Patient 2 stated that she (Patient 2) does not know why the HA was writing and stating that she (Patient 2) had a certain time to live, and that it was a lie. Patient 2 stated that she (Patient 2) has not heard of or from MD1. During an observation of the home visit on 12/12/2025, at 7 p.m., with RN 2, while at Patient 2’s residence, Patient 2 greeted the survey team in the lobby of a locked multi-floor, multi-unit apartment complex. Patient 2 was walking without the use of an assistive device, breathing was unlabored, and Patient 2 was not in distress while walking.During a concurrent interview and record review on 12/15/2025 at 10:24 a.m. with MD1 of Patient 2’s medical record, MD1 stated Patient 2 was on her 3rd recertification period.  MD1 stated that based on Patient 2’s medical record the HA was treating her (Patient 2) without his (MD1) authorization. 3).  During a record review of Patient 3’s medical record form titled “Patient Face Sheet” the Facesheet indicated, a start of care date of 7/8/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) with heart failure (heart is unable to adequately pump blood). During a record review of Patient 3’s medical record form titled “Certification of Terminal Illness” dated 7/8/2025, with a certification period of 7/8/2025 to 10/5/2025, the CTI indicated the MD1 signed the form on 7/11/2025.  The form also indicated MD1 noted “I have reviewed and agreed with the Plan of Care that includes initial orders and plan of care, medication profile and plan of care problems (identified in assessments) and admission to hospice.” Lastly, the form indicated MD1 attest that he (MD1) composed the narrative and reviewed Patient 3’s medical record and examined her (Patient 3).During an interview on 12/12/2025 at 10:10 a.m. with Patient 3, Patient 3 stated she (Patient 3) was not dying and therefore not a hospice patient. Patient 3 stated that she (Patient 3) does not have any heart issues, and she only takes vitamins. Patient 3 stated that she walks three laps around her building every other day. Patient 3 stated she was not sick and wanted to cancel hospice services because she did not want any trouble. Patient 3 stated she never heard or spoke with MD1. Patient 3 stated she (Patient 3) saw her primary physician last week and has been with him (primary physician) for the past 2 ½ years. During a concurrent interview and record review on 12/15/2025 at 10:42 a.m. with MD1 of Patient 3’s medical record, MD1 stated he (MD1) does not recall Patient 3 being discussed at the IDG meetings. Then MD1 stated he (MD1) did recall Patient 3. MD1 stated he (MD1) determined Patient 3 was a hospice candidate based on her (Patient 3) diagnosis, comorbidities, and the nursing assessment.4).  During a record review of Patient 6’s medical record form titled “Patient Face Sheet” indicated, a start of care date of 3/11/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) without heart failure.During a record review of Patient 6’s medical record form titled “Certification of Terminal Illness” dated 3/11/2025, with a certification period of 3/11/2025 to 6/8/2025, the CTI indicated MD1's name was on the form but it did not have his  signature. Lastly, the form did not indicate it had a physician narrative documented. During a record review on 12/10/2025 at 1:40 p.m. of Patient 6’s medical record, the record indicated Patient 6’s IDT meetings dated 3/12/2025 and 3/26/2025 were “not started” and “unsigned”.During a record review of Patient 6’s medical record form titled “Initial Orders and Plan of Care” dated 3/11/2025, the form indicated it was left blank. The form also indicated there were no care problems identified. Lastly, the form indicated the names of three registered nurses and the Medical Director (MD1) were documented, but the form did not contain any of their signatures.During a concurrent interview and record review on 12/15/2025 at 10:35 a.m. with MD1 of Patient 6’s medical record, MD1 stated Patient 6 was admitted on 3/11/2025, but was discharged already. MD1 stated that he (MD1) asked the Administrator (ADM) where Patient 6’s documents were and he (ADM) was unable to tell him (MD1). MD1 stated that “they - the people in the office” created Patient 6’s CTI dated 3/11/2025 on 12/10/2025.  MD1 stated “It’s somebody's attempt to produce electronic evidence.” Lastly, MD1 stated Patient 6’s medical records were physical papers at that time, but the ADM was unable to produce the physical documents. MD1 stated that the HA does not have anything that he (MD1) signed for Patient 6. 5. During a record review of Patient 7’s medical record form titled “Patient Face Sheet’ the Facesheet indicated a start of care date of 11/3/2025 with a primary diagnosis of cerebral infarction (stroke) unspecified. During a record review of Patient 7’s medical record form titled “Initial Orders and Plan of Care” dated 11/3/2025, the form indicated it was left blank. The form also indicated there were no care problems identified. Lastly, the form indicated the names of two licensed vocational nurses, one registered nurse, the Medical Director (MD1) and a social worker were documented, but the form did not contain any of their signatures.During a record review of Patient 7’s medical record form titled “Certification of Terminal Illness” with certification period from 11/3/2025 to 1/31/2026, did not indicate there was a physician written certification. The form had the names of the Medical Director 1 (MD1) and Registered Nurse 1’s (RN1), but the form did not contain either one’s signatures. During a record review of Patient 7’s medical record form titled “Hospice Death Event Form” dated 11/21/2025,  the form indicated the form was left blank except for the “date of death – 11/21/2025” and “time of death – 11:50:00”. During a record review of Patient 7’s medical record form titled “Physician Order Detail” dated 11/21/2025, the form indicated it was an “order type – death" and “order read back and verified with physician” was checked off.  The form had MD1's name under “physician”, but the form did not have MD1's signature. Lastly, the form did not indicate the HA staffs name that wrote the order. During a record review of the HAs form titled “Patient Discharge Report” dated from 6/1/2025 to 11/30/2025, the report indicated Patient 7’s discharge reason was due to “Death”. 6). During a record review of Patient 8’s Patient Face Sheet, the Facesheet indicated a start of care of 7/24/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (heart unable to pump blood effectively to the body).During an observation on 12/11/2025, at 2 p.m., with RN 2, Patient 8’s home was observed as a single-family home, with a black locked gate. The home visit was scheduled at 2 p.m., but Patient 8 was not home.During an interview on 12/11/2025, at 2:02 p.m., Patient 8 stated she was not home, was currently riding the bus, running errands, and did not know what time she would be home.During an interview on 12/11/2025, at 5:30 p.m., Patient 8 stated she thought the “program” had ended because she had not received any visits from the HA for more than 1 month. Patient 8 stated she was not terminal and no doctor had told her she was expected to die within 6 months. Patient 8 stated her heart was not failing, did not use oxygen, and walked using a walker due to back problems. Patient 8 stated she was able to go to church, go to stores, and ride on the bus.During an interview with the office manager (OM 2), on 12/15/20225, at 10 a.m., OM 2 stated there was no H&P for Patient 8.During an interview with MD 1, on 12/15/2025, at 10:45 a.m., MD 1 stated he had obtained Patient 8’s diagnosis from the H&P.  If there was no H&P from the nursing assessment, then he used the medication list and the Patient 8’s interview.A record review of Patient 8’s record titled, Initial Nursing Assessment, dated 7/24/2025, indicated, “She remains in declining state, with a KPS of 60 (Karnofsky Performance Status-used for hospice eligibility. A score of 60 means the patient can care for themselves but requires help with certain tasks), PPS of 60 (Palliative Performance Scale, a patient has reduced mobility, needs occasional help with self-care) and NYHA Class IV (New York Heart Association classification of heart failure IV=4, the most severe form of heart failure. Patients experience symptoms such as fatigue, shortness of breath, even at rest and cannot perform any physical activity without discomfort) heart failure, signifying marked limitations and symptoms at rest. She is ambulatory with an assistive device and requires assistance for most activities of daily living.”A record review of Patient 8’s, CTI, for the initial certification period of 7/24/2025 to 10/21/2025, indicated, “She also experiences mild episodes of chest pressuring during ADL’s and increased shortness of breath episodes with exertion, both of which are relieved by rest”. Further review of the record indicated MD 1 had signed the document.7).  During a record review of Patient 9’s Patient Face Sheet, indicated a start of care of 7/8/2025, with a terminal diagnosis of generalized atherosclerosis (a buildup of fats and other substances in the arteries).During an interview with Patient 9 on 12/11/2025, at 10:09 a.m., Patient 9 stated she was not terminal and no doctor had told her she was dying. Patient 9 stated she had a primary care doctor she was actively seeing (Medical Doctor 2-MD 2). Patient 9 stated she could walk with the use of a cane but could not stand for a long period of time due to back pain. Patient 9 stated she did housekeeping, passed the vacuum, washed dishes and cleaned the restroom. Patient 9 stated she attends church, goes to the stores. Patient 9 stated she also drops off her grand daughter to school, and goes out and about.During an interview on 12/11/2025, at 5 p.m., with MD 2, MD 2 stated Patient 9 did not have a terminal illness, does not have a terminal diagnosis, and MD 2 did not refer Patient 9 to hospice care. MD 2 stated the last time MD 2 saw Patient 9 was on 10/14/2025.During an interview with OM 2, on 12/15/20225, at 10 a.m., OM 2 stated there was no H&P for Patient 9.During an interview with MD 1 on 12/15/2025, at 10:51 a.m., MD 1 stated he did not recall if he had spoken to Patient 9 or had reviewed any H&P.  MD 1 stated he certified Patient 9 for hospice care based on the nursing assessment.A record review of Patient 9’s document titled, Initial Nursing Assessment, dated 7/8/2025,  indicated “Due to the patient’s poor prognosis, progressive decline in cardiac and pulmonary function, increasing body weakness, and growing need for assistance with daily activities, the patient has opted for hospice care to focus on symptoms management and comfort.” The record also indicated KPS of 60 ad PPS of 60.A record review of Patient 9’s CTI, for the initial certification period of 7/8/2025 to 10/5/2025, indicated, “Based on current clinical evaluation, disease trajectory, and overall decline, the patient meets the criteria for certification of terminal illness with a  life expectancy of six months or less if the illness follows its expected course”. Further review of the record indicated MD 1 had signed the document.8).  During a record review of Patient 10’s Face Sheet, the Facesheet indicated a start of care date of 1/10/2025, with a terminal diagnosis of heart failure (heart unable to pump blood effectively to the body).On 12/11/2025 at 3:03 p.m., two phone call attempts were made to interview Patient 10. The phone number was obtained from Patient 10’ Face Sheet. No other numbers were listed. Both phone call attempts indicated an automated message stating the number was not valid: “number cannot be completed as dialed.”During an interview with OM 2, on 12/15/2025, at 10 a.m., OM 2 stated there was no H&P for Patient 9.A record review of Patient 10’s document titled, Initial Nursing Assessment, dated 1/10/2025, indicated, “Patient has progressive decline in medical condition, increasing weakness and easily fatigued. Due to progressive decline in medical condition, responsible party opted to seek Hospice Care.”During a concurrent interview and record review with MD 1, on 12/15/2025, at 10:58 a.m., MD 1 reviewed Patient 10’s CTI for the initial certification period 10/24/2023 to 1/21/2024. MD 1 stated there was no CTI documented for the first certification period.  A record review of the HA’s undated document titled, Certification of Terminal Illness, indicated, “At the time of admission to hospice, the hospice Medical Director or the patient’s attending physician will complete a certification narrative that reflect the patient’s individual circumstances based on: his/her review of the patient’s medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patient’s attending physician will sign the certification of terminal illness an authorization for hospice services forms) ...Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification.”

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the medical director and/or physician designee conducted a review and verified the patient’s clinical information to determine the patients need for recertification of terminal illness for continued hospice care and services for six of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, and Patient 10).  This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential to result in the patients not receiving appropriate healthcare services that could affect their quality of life. --- During an interview on 12/10/2025 at 12:40 p.m., and 12/11/2025 at 9:05 a.m., with the Administrator (ADM), the ADM stated there was no knowledgeable staff to assist with the survey.   During an interview on 12/12/2025 at 10:50 a.m. with Registered Nurse 2 (RN 2), RN 2 stated she (RN2) was not comfortable speaking on behalf of the agency regarding clinical operations of the hospice agency. On 12/12/2025 at 11:26 a.m. a call was made to the Director of Patient Care Services (DPCS) with the number provided by the ADM, with no answer. Message with call back number left. On 12/15/2025 at 12:40 p.m. a call was made to the DPCS with the number provided by the ADM, with no answer. Message with call back number left. During an interview on 12/12/2025, at 9:18 a.m., the  ADM stated the expectation of the DPCS was to ensure every document such as Certification for Terminal Illness (CTI - a doctor's official statement that a patient has an incurable condition, expected to cause death within 6 months), and visit notes, were completed for each patient. The ADM stated completion of  documents are important to make sure everything was compliant and to make sure the HA serviced patients appropriately.   During an interview on 12/12/2025, at 9:28 a.m., the ADM stated the Director of Patient Care Services Designee (DD) was required to cover the DPCS. The DD needed to have knowledge of the situation. The ADM stated the DPCS, and the DD were not reliable. The ADM stated he was not aware the patients were missing assessments, CTI’s and  Interdisciplinary Group meetings. The ADM stated he trusted the DPCS had ensured all these were completed and there was nursing oversight. The ADM stated he learned through the survey process that these things were not done.During an interview on 12/12/2025 at 12:05 p.m. with the Medical Director (MD1), the MD1 stated he (MD1) was the Medical Director for the HA for the past 3 years. MD1 stated that his (MD1) responsibilities included the general oversight of nursing, employee services, and patient admissions, discharges, policies and procedures. MD1 stated that he was the “captain of the ship of patient care”. MD1 stated admitting criteria included reviewing patients’ history and physical (H&P), medication list, nurses’ assessments, and IDG review with the expectation that the patient will be terminal with a diagnosis within 6 months. MD1 stated once a nurse assesses the patient, the nurse calls him (MD1) over the phone or video to go over the assessment. If there is sufficient information, MD1 stated, he (MD1) then tells the nurse to discuss it at the IDG meeting to ensure the patient is appropriate for hospice admission. MD1 stated that the HA nursing staff writes the CTI draft, because “they are pretty good.” MD1 stated that he (MD1) does more of a home health agency writing, and that is why he (MD1) leaves the hospice CTI writing to the hospice nurses. MD1 stated he (MD1) reviews and revises with minor adjustments if necessary. MD1 stated recertifications are written within 72 hours after discussing patients in the IDG meetings.  During an interview on 12/15/2025 at 10:07 a.m. with the Medical Director 1 (MD1), the MD1 stated that the DPCS would write patients’ findings on paper and would have him (MD1) read and sign off on them. The MD1 stated the DPCS would write on the patients’ CTIs physician narrative, and he (MD1) would make edits if necessary and sign it. The MD1 stated, “I am on the mercy of (DPCS)… I rely on (DPCS) to inform me when I (MD1) need to sign documents. MD1 stated that the DPCS was also a Nurse Practitioner, and she (DPCS) would do the patients visits. MD1 stated that during the IDG meetings, if the HA staff informed him (MD1) that the patient was declining, that would trigger the DPCS to write a CTI narrative. The MD1 stated he (MD1) noticed that the HA nurses were not turning in their nursing assessments during the last 2-3 IDG meetings. MD1 stated that the narrative documented on the certification of terminal illness and patient associated factors support patients’ diagnosis for hospice admission. MD1 stated that the DPCS informed him (MD1) mid-November that she (DPCS) had resigned from the HA. MD1 stated that he (MD1) was unable to contact the DPCS, since then.  1).  During a record review of Patient 1’s medical record form titled “Patient Face Sheet” indicated, a start of care date of 7/23/2025 with a diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer).During a concurrent interview and record review on 12/10/2025 at 11:56 a.m. with the Licensed Vocational Nurse / Case Manager / Office Manager (OM1) of Patient 1’s medical record form titled “Certification of Plan of Care” dated 10/21/2025 to 1/18/2026, the form indicated it was left blank. OM1 indicated the form was not complete. OM1 stated the form did not indicate Patient 1 had a documented Certification of Terminal Illness (CTI - a doctor's official statement that a patient has an incurable condition, expected to cause death within 6 months). Lastly, the form indicted “no care problems identified”.During a concurrent interview and record review on 12/10/2025 at 1:18 p.m. with the OM1 of Patient 1’s medical record form titled “Nursing Recertification Assessment” dated 10/20/2025, the form indicated it was left blank and “in progress”. The OM1 stated Patient 1’s nursing recertification assessment was plotted in her (Patient 1) calendar for visit on 10/20/2025, but the visit was not done. The OM1 stated Patient 1’s nursing recertification assessment was to be completed to be able to determine if Patient 1’s continues to require hospice services.During a concurrent observation and interview on 12/12/2025 at 4 p.m. with Patient 1 while at her residence, Patient 1 was awake, alert, and ambulatory with no shortness of breath noted. Patient 1 stated she (Patient 1) saw her oncologist (cancer treating doctor) in November 2025 and has another appointment in January 2026. Patient 1 stated she (Patient 1) had lung issues and was told she (Patient 1) had 3-5 years of life left. Patient 1 stated that there has not been a physician that has told her (Patient 1) that she (Patient 1) had 6 months or less to live. Patient 1 stated she (Patient 1) never heard of the HA’s Medical Directors 1 (MD1), the Medical Social Worker (MSW), or the Spiritual Counselor (SC)’s name or spoken to any of them.During a concurrent interview and record review on 12/15/2025 at 10:07 a.m. with the Medical Director 1 (MD1) of Patient 1’s medical record, MD1 stated that there were no notes or documents in Patient 1’s medical record that would indicate why she (Patient 1) was receiving hospice services. MD1 stated that he (MD1) attempted to contact the DPCS, but that the DPCS did not answer his (MD1) calls or text. 2).  During a record review of Patient 2’s medical record form titled “Patient Face Sheet” the Facesheet indicated, a start of care date of 8/20/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) without heart failure.During a record review on 12/10/2025 at 2:16 p.m. of Patient 2’s medical record, the record indicated Patient 2’s scheduled visit notes dated 11/18/2025 and 12/2/2025 were “not started”.During a concurrent interview and record review on 12/10/2025 at 12 p.m. with the OM1 of Patient 2’s medical record form “Certification of Plan of Care” dated 11/18/2025 to 1/16/2026, OM1 indicated the form was not complete. OM1 stated the form did not indicate Patient 2 had a documented CTI. The form also indicated it was left blank.During a concurrent interview and record review on 12/10/2025 at 1:20 p.m. with the OM1 of Patient 2’s undated medical record form titled “Nursing Clinical Note” the OM1 indicated that the nursing clinical note was initially plotted in Patient 2’s calendar for visit as visit type “RN – Recert on-site” on 11/5/2025. The OM1 stated Patient 2’s nursing rectification assessment was plotted/scheduled for 11/5/2025, but it was not completed. The OM1 stated that there was a “Clinical Nursing Note” but the nurse has the option to change it to a recertification note when she or he documents it. Lastly, the Nursing Clinical Note was left blank.During an interview on 12/12/2025 at 9:23 a.m. with Patient 2, Patient 2 stated that she had monthly hospice nurse visits, that last about 8-10 minutes.  Patient 2 stated that she has been with her primary physician (MD3) for the past 2 years and saw him (MD3) last three days ago. Patient 2 stated that MD3 did not refer her to hospice services. Patient 2 stated that she was not dying and had not been told by a doctor that she was going to die in six months or less. Patient 2 stated that she does not know why the HA was writing and stating that she had a certain time to live, and that it was a lie. Patient 2 stated that she has not heard of or from MD1. During an observation of the home visit on 12/12/2025, at 7:00 p.m., with RN 2, at Patient 2’s residence, Patient 2 greeted the survey team in the lobby of a locked multi-floor, multi-unit apartment complex. Patient 2 was walking without the use of an assistive device, breathing was unlabored, and Patient 2 was not in distress while walking.During a concurrent interview and record review on 12/15/2025 at 10:24 a.m. with the MD1 of Patient 2’s medical record, MD1 stated Patient 2 was on her 3rd recertification period. MD1 stated that based on Patient 2’s medical record the HA was treating her without his (MD1) authorization. 3).  During a record review of Patient 3’s medical record form titled “Patient Face Sheet”, the Facesheet indicated, a start of care date of 7/8/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) with heart failure (heart is unable to adequately pump blood). During a concurrent interview and record review on 12/10/2025 at 1:25 p.m. with the OM1 of Patient 3’s medical record form titled “Nursing Clinical Note” undated, the OM1 stated that the nursing clinical note was initially plotted in Patient 3’s calendar for visit as visit type “RN – Recert on-site” on 9/30/2025.  The OM1 stated Patient 3’s nursing rectification assessment was plotted/scheduled for 9/30/2025, but it was not completed. The OM1 stated that there was a “Clinical Nursing Note” but the nurse had the option to change it to a recertification note when she or he documents it. Lastly, the Nursing Clinical Note was left blank.During an interview on 12/12/2025 at 10:10 a.m. with Patient 3, Patient 3 stated she was not dying and therefore not a hospice patient. Patient 3 stated that she does not have any heart issues, and she only takes vitamins. Patient 3 stated that she walks three laps around her building every other day. Patient 3 stated she was not sick and wanted to cancel hospice services because she did not want any trouble. Patient 3 stated she never heard or spoke with MD1. Patient 3 stated she saw her primary physician last week and has been with him (primary physician) for the past 2 ½ years. During a concurrent interview and record review on 12/15/2025 at 10:42 a.m. with MD1 of Patient 3’s medical record, MD1 stated he (MD1) does not recall Patient 3 being discussed at the IDG meetings. Then MD1 stated he did recall Patient 3.  MD1 stated he (MD1) determined Patient 3 was a hospice candidate based on her diagnosis, comorbidities, and the nursing assessment. 4).  During a record review of Patient 8’s Patient Face Sheet, the Facesheet indicated a start of care of 7/24/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (heart unable to pump blood effectively to the body).During an observation on 12/11/2025, at 2 p.m., with RN 2, Patient 8’s home was observed as a single-family home, with a black locked gate. The home visit was scheduled at 2 p.m., but Patient 8 was not home.During an interview on 12/11/2025, at 2:02 p.m., Patient 8 stated she was not home, was currently riding the bus, running errands, and did not know what time she would be home.During an interview on 12/11/2025, at 5:30 p.m., Patient 8 stated she thought the “program” had ended because she had not received any visits from the HA for more than 1 month. Patient 8 stated she was not terminal and no doctor had told her she was expected to die within 6 months. Patient 8 stated her heart was not failing, did not use oxygen, and walked using a walker due to back problems. Patient 8 stated she was able to go to church, go to stores, and ride on the bus.During a concurrent interview and record review of Patient 8’s medical records on 12/10/2025, at 1:32 p.m., with the OM1, the OM 1 stated there was no recertification assessment in Patient 8’s records for the certification period 10/22/2025 to 1/19/2026. The OM 1 stated the recertification assessment was to see if patient needed the services being provided, to see if patient still required hospice, to see if there were any changes, to correct the action and to do the plan of care. During a concurrent interview and record review of Patient 8’s medical records on 12/10/2025, at 11:56 p.m., with the OM 1, OM 1 reviewed Patient 8’s medical records.  OM 1 stated there was no CTI for the current recertification period 10/22/2025 to 1/19/2026.During a concurrent interview and record review on 12/15/2025, at 10:45 a.m., with MD 1, MD 1 reviewed Patient 8’s medical records. MD 1 stated the CTI for the recertification period 10/22/2025 to 1/19/2025 was blank. MD 1 stated the DPCS had MD 1 sign the CTI on a paper document.During an interview on 12/15/2025 at 11:45 a.m., with the ADM, the ADM stated there was no paper CTI documents in the HA. The ADM stated the CTI documents were an agreement between MD 1 and the DPCS.5).  During a record review of Patient 9’s Patient Face Sheet, indicated a start of care of 7/8/2025, with a terminal diagnosis of generalized atherosclerosis (a buildup of fats and other substances in the arteries).During an interview with Patient 9 on 12/11/2025, at 10:09 a.m., Patient 9 stated she was not terminal and no doctor had told her she was dying. Patient 9 stated she had a primary care doctor she was actively seeing (Medical Doctor 2-MD 2). Patient 9 stated she could walk with the use of a cane but could not stand for a long period of time due to back pain. Patient 9 stated she did housekeeping, passed the vacuum, washed dishes, cleaned the restroom. Patient 9 stated she attends church and goes to the stores. Patient 9 stated she also drops off her grand-daughter to school, and goes out and about.During an interview on 12/11/2025, at 5:00 p.m., with MD 2, MD 2 stated Patient 9 did not have a terminal illness, does not have a terminal diagnosis, and MD 2 did not refer Patient 9 to hospice care. MD 2 stated the last time MD 2 saw Patient 9 was on 10/14/2025.During a concurrent interview and record review with MD 1 on 12/15/2025, at 10:51 a.m., MD 1 reviewed Patient 9’s CTI, for the recertification period 10/6/2025 to 1/3/2025. The record indicated, “She demonstrates progressive cardiac and pulmonary decline, fatigue, weakness…and increasing need for assistance with ADL’s. Due to her poor prognosis and functional decline, she has elected hospice care for comfort and symptom management…I confirm that this narrative was composed by me and is based on my review of the patient’s medical record and/or examination of the patient.” MD 1 stated the DPCS had written the narrative, trusted the writing of the CTI, and MD 1 reviewed and signed the CT6).  During a record review of Patient 10’s Face Sheet, indicated as start of care of 1/10/2025, with a terminal diagnosis of heart failure (heart unable to pump blood effectively to the body).On 12/11/2025 at 3:03 p.m., two phone call attempts were made to interview Patient 10. The phone number was obtained from Patient 10’ Face Sheet. No other numbers were listed. Both phone call attempts indicated an automated message stating the number was not valid: “number cannot be completed as dialed.”During a concurrent interview and record review with MD 1, on 12/15/2025, at 10:58 a.m., MD 1 reviewed Patient 10’s CTI for the recertification period 11/6/2025 to 1/4/2026. The record indicated a narrative was written but the record was not signed by MD 1. MD 1 stated the DPCS had written the narrative.During a record review of Patient 10’s CTI, the following recertification periods did not have a CTI:2nd: 1/22/2024 to 4/20/2024.3rd: 4/21/2024 to 6/19/2024. 4th: 6/20/24 to 8/18/2024. 5th: 8/19/24 to 10/17/2024. 6th: 9/18/24 to 11/16/2024.  A record review of the HA’s undated document titled, Certification of Terminal Illness, indicated, “A subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director.  At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patient’s medical record, or if applicable, examination of the patient.”

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 (COP - conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people 65 years of age or more and for certain younger people with disabilities]) on Clinical Records was met as follows: --- 1.      The HA failed to ensure six of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, and Patient 10) medical records included visit notes, plan of care, and assessments. (Refer to L672). 2.      The HA failed to ensure four of fourteen sample selected patient's (Patient 1, Patient 2, Patient 6, and Patient 7) medical record included physician orders. (Refer to L678). 3.      The HA failed to ensure clinical records were appropriately authenticated for seven of fourteen sample selected patients (Patient 1, Patient 2, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10).  (Refer to L679). 4.      The HA failed to ensure contents and information in the patients’ medical records were safeguarded from unauthorized access by HA staff and/or contracted staff to make any alterations or modifications for one of fourteen sample selected patient (Patient 8) (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 interview and record review, the HA failed to ensure six of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, and Patient 10) medical records included visit notes, plan of care, and assessments. This failure resulted in an incomplete medical record and had the potential to result in harm to the patient by not having medical records documented to monitor their plan of care and response to treatment, to determine if a change of care was needed. --- During an interview on 12/10/2025 at 11:56 a.m. with the Licensed Vocational Nurse/Case Manager / Office Manager (OM1), OM1 stated patient record titled “Certification of Plan of Care” were the plans of care the nurses used to provide patient care. During an interview on 12/10/2025 at 1:16 p.m. with OM1, OM1 stated patients nursing recertification assessments were to determine if a patient continues to require hospice services and/or to identify if there had been any changes in the patient’s condition. The OM1 stated the individualized patient plan of care was based on the information gathered by the nursing recertification assessment. The OM1 stated that patients individualized plans of care cannot be updated when the nursing recertification assessment was not completed. The OM1 stated that patients were at risk of receiving poor quality care without an accurate and complete nursing recertification assessment. During an interview on 12/10/2025 at 1:17 p.m. with OM1, the OM1 stated that a patients hospice service was unable to move forward without an updated plan of care. OM1 stated that patients’ care plans were required to be able to provide the service and needs of the patients because the care plans were used by the clinicians to provide individualized patient care.  During an interview on 12/10/2025 at 1:28 p.m. with OM1, the OM1 stated that nurses, medical social workers, and spiritual counselors, must document their home visits the same day after their visit. OM1 stated that when a member of staff does not document their home visit notes after one week of their visit the Office Manager (OM2) contacts them to remind them to document and complete their visit notes. The OM1 stated it was important to document home visit notes “because we need to know if the patient has been seen and taken care of and if they are following their plan of care.” 1).  During a record review of Patient 1’s medical record form titled “Patient Face Sheet” indicated, a start of care date of 7/23/2025 with a diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer).During a concurrent interview and record review on 12/10/2025 at 1:18 p.m. with the OM1 of Patient 1’s medical record form titled “Nursing Recertification Assessment” dated 10/20/2025, the form indicated it was left blank and “in progress”. The OM1 stated Patient 1’s nursing recertification assessment was plotted in her (Patient 1) calendar for visit on 10/20/2025, but the visit was not done. The OM1 stated Patient’s 1 nursing recertification assessment documentation, if done, was to be completed within 5 days of visit. The OM1 stated Patient 1’s nursing recertification assessment was to be completed to be able to update Patient 1’s individualized plan of care and to determine if Patient 1’s continues to require hospice services. During a record review of Patient 1’s medical record form titled “IDT Plan of Care & Review of Comprehensive Assessment” dated 10/30/2025, indicated “no care problems identified”. The form did not indicate it was signed by any of the HA’s core members, registered nurse (RN), medical director (MD), medical social worker (MSW), or spiritual counselor (SC).During a record review on 12/10/2025 at 2:13 p.m. of Patient 1’s medical record, the record indicated Patient 1’s scheduled visit notes dated November 7, 14, 21, 28, and December 5 were “not started”. 2).  During a record review of Patient 2’s medical record form titled “Patient Face Sheet” indicated, a start of care date of 3/11/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) without heart failure.During a concurrent interview and record review on 12/10/2025 at 12 p.m. with the OM1 of Patient 2’s medical record form “Certification of Plan of Care” dated 11/18/2025 to 1/16/2026, OM1 indicated the form was not complete. OM1 stated the form did not indicate Patient 2’s frequency of visits, nursing interventions, and no CTI. The form also indicated it was left blank. During a concurrent interview and record review on 12/10/2025 at 1:20 p.m. with the OM1 of Patient 2’s medical record form titled “Nursing Clinical Note” undated, the OM1 stated that the nursing clinical note was initially plotted in Patient 2’s calendar for visit as visit type “RN – Recert / on-site” on 11/5/2025. The OM1 stated Patient 2’s nursing rectification assessment was plotted/scheduled for 11/5/2025, but it was not completed. The OM1 stated that there was a “Clinical Nursing Note” but the nurse has the option to change it to a recertification note when she or he documents it. Lastly, the Nursing Clinical Note was left blank. During a record review on 12/10/2025 at 2:16 p.m. of Patient 2’s medical record, the record indicated Patient 2’s scheduled visit notes dated 11/18/2025 and 12/2/2025 were “not started”. 3.During a record review of Patient 3’s medical record form titled “Patient Face Sheet” indicated, a start of care date of 7/8/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) with heart failure (heart is unable to adequately pump blood). During a concurrent interview and record review on 12/10/2025 at 12:05 p.m. with the OM1 of Patient 3’s medical record form “Certification of Plan of Care” dated 10/6/2025 to 1/3/2026, OM1 indicated the form was partially complete. OM1 stated the form did not indicate Patient 3’s nursing interventions. Lastly, the Certification of Plan of Care form was left blank.  During a concurrent interview and record review on 12/10/2025 at 1:25 p.m. with the OM1 of Patient 3’s medical record form titled “Nursing Clinical Note” undated, the OM1 stated that the nursing clinical note was initially plotted in Patient 3’s calendar for visit as visit type “RN – Recert / on-site” on 9/30/2025. The OM1 stated Patient 3’s nursing rectification assessment was plotted/scheduled for 9/30/2025, but it was not completed. The OM1 stated that there was a “Clinical Nursing Note” but the nurse had the option to change it to a recertification note when she or he documents it. Lastly, the Nursing Clinical Note was left blank. During a record review on 12/10/2025 at 2:16 p.m. of Patient 3’s medical record, the record indicated Patient 3’s scheduled visit notes dated 10/15/2025, 10/29/2025, 11/12/2025, 11/26/2025, and 12/10/2025 were “not started”. 4.During a record review of Patient 8’s Patient Face Sheet, indicated a start of care of 7/24/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (heart unable to pump blood effectively to the body).During a concurrent interview and record review of Patient 8’s medical records on 12/10/2025, at 11:56 p.m., with the OM 1, OM 1 reviewed Patient 8’s Certification of Plan of Care, dated 10/22/2025 to 1/19/2026. OM 1 stated the POC was not completed because services and frequency of services were missing. The OM 1 stated the records “Certification of Plan of Care” was the plan of care the nurses needed to provide care to the patients.During a concurrent interview and record review of Patient 8’s medical records on 12/10/2025, at 1:32 p.m., with the OM1, the OM 1 stated there was no recertification assessment in Patient 8’s records for the certification period 10/22/2025 to 1/19/2026. The OM 1 stated the recertification assessment was to see if patient needed the services being provided, to see if patient still required hospice, to see if there were any changes, to correct the action and to do the plan of care. The OM 1 stated the plan of care could not be updated if there was no recertification assessment. The risk of not doing a recertification assessment was the quality of care was going to be affected. The OM 1 stated, “It will not be good, if we cannot provide the care the patient needs.”During a record review on 12/10/2025, of Patient 8’s medical records, the review indicated there was no visit notes documented for the recertification period 10/22/2025 to 1/19/2026.5.During a record review of Patient 9’s Patient Face Sheet, indicated a start of care of 7/8/2025, with a terminal diagnosis of generalized atherosclerosis (a buildup of fats and other substances in the arteries).During a concurrent interview and record review of Patient 9’s medical records on 12/10/2025, at 11:56 p.m., with OM1, OM 1 reviewed Patient 9’s Certification of Plan of Care, dated 10/06/2025 to 1/3/2026. OM 1 stated the POC was not completed because nursing interventions were missing.During a record review of Patient 9’s medical records, the review indicated there was no visit notes documented for the recertification period 10/06/2025 to 01/03/2026.6.During a record review of Patient 10’s Face Sheet, indicated as start of care of 1/10/2025, with a terminal diagnosis of heart failure (heart unable to pump blood effectively to the body).During a concurrent interview and record review of Patient 10’s medical records on 12/10/2025, at 11:56 p.m., with OM1, OM 1 reviewed Patient 10’s Certification of Plan of Care, dated 11/06/2025 to 1/4/2026. OM 1 stated the POC was not completed because nursing interventions were missing.During a concurrent interview and record review of Patient 10’s medical records on 12/10/2025, at 1:17 p.m., with the OM1, the OM 1 stated there was no recertification assessment in Patient 10’s records for the certification period 11/06/2025 to 1/4/2026. The OM 1 stated the recertification assessment needed to be done within 5 days of when the recertification for hospice services was due. During a record review on 12/10/2025, of Patient 10’s medical records, the review indicated there was no visit notes documented for the recertification period 11/6/2025 to 1/4/2026. A record review of the HA’s undated document titled, Clinical/Service Data Collection, indicated, “Policy...Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided.”

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 selected patients (Patient 1, Patient 2, Patient 6, and Patient 7) medical record included physician orders.   This failure resulted in the HA staff not knowing what services were ordered for the patients. --- During an interview on 12/11/2025 at 5 p.m. with Registered Nurse 1 (RN1), RN1 stated that he (RN1) was a visiting nurse and was responsible for the assessment of the patient, review of the medications, consents, and equipment/supplies request . RN1 stated that he (RN1) did not contact the Medical Director (MD1) for patient orders and that the Office Manager (OM2) was responsible for contacting MD1. During an interview on 12/15/2025 at 10:07 a.m. with the Medical Director 1 (MD1), the MD1 stated, “I am on the mercy of (DPCS)… I rely on (DPCS) to inform me when I (MD1) need to sign documents.  MD1 stated that the DPCS informed him (MD1) mid-November that she (DPCS) had resigned from the HA. MD1 stated that he (MD1) was unable to contact the DPCS, since then.During an interview on 12/15/2025 at 10:24 a.m. with the MD1, the MD1 stated that he (MD1) dictated patients orders to the DPCS. 1).  During a record review of Patient 1’s medical record form titled “Patient Face Sheet”, the Facesheet indicated a start of care date of 7/23/2025 with a diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer).During a record review of Patient 1’s medical record form titled “Physician Order Details” dated 10/20/2025, the physician order indicated the order type was “recertification” and included Patient 1’s level of care, terminal diagnosis, and medications orders. The form did not have the authors name or MD1’s signature. During a concurrent interview and record review on 12/10/2025 at 11:56 a.m. with the Licensed Vocational Nurse/Case Manager/Office Manager (OM1) of Patient 1’s medical record form titled “Certification of Plan of Care” dated 10/21/2025 to 1/18/2026, the form indicated it was left blank, including section “Orders for Discipline and treatments”.  OM1 indicated the form was not complete.  OM1 stated the form did not indicate Patient 1’s frequency of visits, nursing interventions, and no Certification of Terminal Illness (CTI - a doctor's official statement that a patient has an incurable condition, expected to cause death within six months). During a concurrent observation and interview on 12/12/2025 at 4 p.m. with Patient 1 while at her residence, Patient 1 stated she (Patient 1) never heard of the HA’s Medical Directors 1 (MD1), the Medical Social Worker (MSW), or the Spiritual Counselor (SC)’s name or spoken to any of them.During a concurrent interview and record review on 12/15/2025 at 10:07 a.m. with the Medical Director 1 (MD1) of Patient 1’s medical record, MD1 stated that there were no notes or documents in Patient 1’s medical record that would indicate why she (Patient 1) was receiving hospice services.  MD1 stated that he (MD1) attempted to contact the DPCS, but that the DPCS did not answer his (MD1) calls or text. 2).  During a record review of Patient 2’s medical record form titled “Patient Face Sheet” the Facesheet indicated, a start of care date of 8/20/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) without heart failure.During a record review of Patient 2’s medical record form titled “Physician Order Details” dated 11/17/2025,  the physician orders indicated the order type was “recertification” and included Patient 2’s level of care, terminal diagnosis, co-morbidity diagnosis, and medications orders. The form did not have the authors name or MD1’s signature.During a concurrent interview and record review on 12/10/2025 at 12 p.m. with the OM1 of Patient 2’s medical record form “Certification of Plan of Care” dated 11/18/2025 to 1/16/2026,  OM1 indicated the form was not complete, including the section “Orders for Discipline and treatments”. OM1 stated the form did not indicate Patient 2’s frequency of visits, nursing interventions, and no CTI. The form also indicated it was left blank.During an interview on 12/12/2025 at 9:23 a.m. with Patient 2, Patient 2 stated that she had monthly hospice nurse visits, that last about 8-10 minutes. Patient 2 stated that she has not heard of or from MD1. During a concurrent interview and record review on 12/15/2025 at 10:24 a.m. with MD1 of Patient 2’s medical record, MD1 stated Patient 2 was on her 3rd recertification period. MD1 stated that based on Patient 2’s medical record the HA was treating her (Patient 2) without his (MD1) authorization. 3.  During a record review of Patient 6’s medical record form titled “Patient Face Sheet”, the Facesheet indicated, a start of care date of 3/11/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) without heart failure.During a record review of Patient 6’s medical record form titled “Initial Orders and Plan of Care” dated 3/11/2025, the form indicated it was left blank. The form also indicated the names of three registered nurses and the Medical Director (MD1) were documented, but the form did not contain any of their signatures.During a record review of Patient 6’s medical record form titled “Physician Order Details” dated 3/11/2025 at 12 a.m., the physician orders indicated the order type was “referred for evaluation”.  The form indicated Patient 6’s level of care and terminal diagnosis. The form did not indicate the author's name. Lastly, the form did not have a physician's name or signature. During a record review of Patient 6’s medical record form titled “Physician Order Details” dated 3/11/2025 at 2:32 p.m., the physician order indicated the order type was “Admission Order”.  The form indicated Patient 6’s level of care and terminal diagnosis. The form did not indicate the author's name. Lastly, the form had MD1’s name listed as the ordering physician, but it did not have his (MD1) signature. During a record review of Patient 6’s medical record form titled “Physician Order Details” dated 4/30/2025, the physician's order indicated the order type was “Update Medication”. The form did not indicate the author's name. Lastly, the form had MD1’s name listed as the ordering physician, but it did not have his (MD1) signature.During a record review of Patient 6’s medical record form titled “Physician Order Details” dated 5/23/2025, the physician order details indicated the order type was “Update Medication”. The form did not indicate the author's name. Lastly, the form had MD1’s name listed as the ordering physician, but it did not have his (MD1) signature.During a record review of Patient 6’s medical record form titled “Physician Order Details” dated 6/3/2025, the physician order detail indicated the order type was “Discharge from Hospice”. The form indicated Patient 6’s reason for discharge was “Patient moves out of service area” and summary “declined further services”.  The form did not indicate the author's name.  Lastly, the form had MD1’s name listed as the ordering physician, but it did not have his (MD1) signature.During a record review of Patient 6’s medical record form titled, “Certification of Terminal Illness” dated 3/11/2025, with a certification period of 3/11/2025 to 6/8/2025, the CTI indicated MD1s name was on the form but it did not have his (MD1) signature. During a concurrent interview and record review, on 12/15/2025 at 10:35 a.m. with MD1 of Patient 6’s medical record, MD1 stated Patient 6 was admitted on 3/11/2025, but was discharged already.  MD1 stated that Patient 6’s medical record did not contain a discharge order. MD1 stated Patient 6’s medical records were physical papers at that time, but the ADM was unable to produce the physical documents. MD1 stated that the HA does not have anything that he (MD1) signed for Patient 6.4).  During a record review of Patient 7’s medical record form titled “Patient Face Sheet’, the Facesheet indicated a start of care date of 11/3/2025 with a primary diagnosis of cerebral infarction (stroke) unspecified. During a record review of Patient 7’s medical record form titled “Initial Orders and Plan of Care” dated 11/3/2025,  the form indicated the names of two licensed vocational nurses, one registered nurse, the Medical Director (MD1) and a social worker were documented, but the form did not contain any of their signatures.During a record review of Patient 7’s medical record form titled “Physician Order Detail” dated 11/21/2025, the physician order detail indicated it was an “order type – death" and “order read back and verified with physician” was checked off.  The form had MD1s name under “physician”, but the form did not have MD1s signature. Lastly, the form did not indicate author's name. During a record review of the undated HAs form titled “Verification of Physician Orders”  indicated “Orders will be obtained from a licensed physician for care and services to be provided to hospice patients. Verbal orders will be taken and documented only by professional, licensed hospice personnel. The verbal order will be documented by the staff receiving the order, indicated by staff signature and credentials, and cosigned by the physician per policy and /or state licensure requirements.”

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 clinical records were appropriately authenticated for seven of fourteen sample selected patients (Patient 1, Patient 2, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10).  This failure had the potential to result in unauthorized and inaccurate patient information or an inaccurate assessment to be entered in the patients’ clinical record that could affect the patient’s quality of care and well-being. --- During an interview on 12/10/2025 at 12:40 p.m., and 12/11/2025 at 9:05 a.m., with the Administrator (ADM), the ADM stated there was no knowledgeable staff to assist with the survey.   During an interview on 12/12/2025 at 10:50 a.m. with Registered Nurse 2 (RN 2), RN 2 stated she (RN2) was not comfortable speaking on behalf of the agency regarding clinical operations of the hospice agency. 1).  During a record review of Patient 1’s medical record form titled “Patient Face Sheet” the Facesheet indicated a start of care date of 7/23/2025, with a diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer).During a record review of Patient 1’s medical record form titled “Physician Order Details” dated 10/20/2025, the Facesheet indicated the order type was “recertification."  The form did not have the authors name or the Medical Director’s (MD1) signature. 2).  During a record review of Patient 2’s medical record form titled “Patient Face Sheet”, the Facesheet indicated a start of care date of 8/20/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) without heart failure.During a record review of Patient 2’s medical record form titled “Physician Order Details” dated 11/17/2025, the Facesheet indicated the order type was “recertification."   The form did not have the authors name or MD1’s signature.3).  During a record review of Patient 6’s medical record form titled “Patient Face Sheet” the Facesheet indicated, a start of care date of 3/11/2025 with a diagnosis of hypertensive heart disease (heart problems cause by long term high blood pressure) without heart failure.During a record review of Patient 6’s medical record form titled “Initial Orders and Plan of Care” dated 3/11/2025, the form indicated it was left blank. The form also indicated the names of three registered nurses and the Medical Director (MD1) were documented but the form did not contain any of their signatures.During a record review of Patient 6’s medical record form titled “Physician Order Details” dated 3/11/2025 at 12 a.m., the physician order detail indicated the order type was “referred for evaluation."  The form did not indicate the author or physician’s name or signature. During a record review of Patient 6’s medical record form titled “Physician Order Details” dated 3/11/2025 at 2:32 p.m., the physician's order detail indicated the order type was “Admission Order."  The form did not indicate the author's name. Lastly, the form had MD1’s name listed as the ordering physician, but it did not have his (MD1) signature. During a record review of Patient 6’s medical record form titled “Physician Order Details” dated 4/30/2025, the physician's order detail indicated the order type was “Update Medication."  The form did not indicate the author's name. Lastly, the form had MD1’s name listed as the ordering physician, but it did not have his (MD1) signature.During a record review of Patient 6’s medical record form titled “Physician Order Details” dated 5/23/2025, indicated the order type was “Update Medication”. The form did not indicate the author's name. Lastly, the form had MD1’s name listed as the ordering physician, but it did not have his (MD1) signature.During a record review of Patient 6’s medical record form titled “Physician Order Details” dated 6/3/2025, indicated the order type was “Discharge from Hospice”. The form did not indicate the author's name. Lastly, the form had MD1’s name listed as the ordering physician, but it did not have his (MD1) signature.During a record review of Patient 6’s medical record form titled “Certification of Terminal Illness” dated 3/11/2025, with a certification period of 3/11/2025 to 6/8/2025, indicated MD1s name was on the form but it did not have his (MD1) signature. 4).  During a record review of Patient 7’s medical record form titled “Patient Face Sheet’ the Facesheet indicated a start of care date of 11/3/2025 with a primary diagnosis of cerebral infarction (stroke) unspecified. During a record review of Patient 7’s medical record form titled “Initial Orders and Plan of Care” dated 11/3/2025,  the form indicated the names of two licensed vocational nurses, one registered nurse, the Medical Director (MD1) and a social worker were documented, but the form did not contain any of their signatures.During a record review of Patient 7’s medical record form titled “Certification of Terminal Illness” with certification period from 11/3/2025 to 1/31/2026, did not indicate there was a physician written certification. The form had the names of the Medical Director 1 (MD1) and Registered Nurse 1’s (RN1), but the form did not contain either one’s signatures. During a record review of Patient 7’s medical record form titled “Hospice Death Event Form” dated 11/21/2025, the form indicated “date of death – 11/21/2025” and “time of death – 11:50:00”.  The form did not contain the author's signature. During a record review of Patient 7’s medical record form titled “Physician Order Detail” dated 11/21/2025, the form indicated it was an “order type – death" and “order read back and verified with physician” was checked off.  The form had MD1's name under “physician”, but the form did not have MD1s signature.  Lastly, the form did not indicate author's name. 5).  During a record review of Patient 8’s Patient Face Sheet, the Facesheet indicated a start of care date of 7/24/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (heart unable to pump blood effectively to the body).During a record review of Patient 8’s document titled, Initial Nursing Assessment, dated 7/24/2025, the assessment indicated the name of Registered Nurse 6 as the nurse performing the assessment. However, the record did not indicate it was signed/authenticated.6).  During a record review of Patient 9’s Patient Face Sheet, the Facesheet indicated a start of care date of 7/8/2025, with a terminal diagnosis of generalized atherosclerosis (a buildup of fats and other substances in the arteries).During a record review of Patient 9’s document titled, Initial Nursing Assessment, dated 7/18/2025, the assessment did not indicate it was signed/authenticated.7).  During a record review of Patient 10’s Face Sheet, the Facesheet indicated a start of care date of 1/10/2025, with a terminal diagnosis of heart failure (heart unable to pump blood effectively to the body).During a record review of Patient 10’s document titled Initial Orders and Plan of Care, indicated the following certification periods were not signed/authenticated:1st 10/24/2023 to 1/21/2024.2nd: 1/22/2024 to 4/20/2024.3rd: 4/21/2024 to 6/19/2024. 4th: 6/20/24 to 8/18/2024. 5th: 8/19/24 to 10/17/2024. 6th: 9/18/24 to 11/16/2024. A record review of the HA’s undated document titled, Clinical/Service Data Collection, indicated, “The clinical/service note will include...signature of clinician/technician and his/her credentials.”

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 contents and information in the patients’ medical records were safeguarded from unauthorized access by the HA staff to make any alterations or modifications for two of fourteen sample selected patients (Patient 8 and Patient 10).  This failure has the potential to result in unauthorized and inaccurate patient information or inaccurate assessment to be entered in the patients’ clinical record that could affect the patient’s quality of care and well-being. --- During an interview on 12/10/2025 at 12:40 p.m., and 12/11/2025 at 9:05 a.m., with the Administrator (ADM), the ADM stated there was no knowledgeable staff to assist with the survey.   During an interview on 12/12/2025 at 10:50 a.m. with Registered Nurse 2 (RN 2), RN 2 stated she (RN2) was not comfortable speaking on behalf of the agency regarding clinical operations of the hospice agency.During an interview with the ADM on 12/15/2025, at 10:00 a.m., the ADM stated he had hired a Director of Patient Care Services Designee (Registered Nurse 6-RN 6) on 12/14/2025.1).  During a record review of Patient 8’s Patient Face Sheet, the Facesheet indicated a start of care date of 7/24/2025, with a terminal diagnosis of hypertensive heart disease with heart failure (heart unable to pump blood effectively to the body).During a record review of Patient 8’s document titled, IDT, dated 10/22/2025, the IDT indicated the note was created on 12/10/2025.  Further review of the record indicated RN 6 had begun the IDT for Patient 8 on 7/24/2025.During an interview with the ADM on 12/15/2025, at 11:42 a.m., the ADM was asked why RN 6 was on Patient 8’s IDT record for 7/24/2025, if RN 6 was just hired on 12/14/2025? The ADM stated RN 6 used to work at the HA in July 2025 but did not have any employee file or other records to validate her employment at the agency in July 2025.A continued review of Patient 8’s records titled, Initial Comprehensive Assessment, dated 7/24/2025 and Consents dated 7/24/2025, indicated RN 6 name was on the records.2. During a record review of Patient 10’s Face Sheet, the Facesheet indicated a start of care  date of 1/10/2025, with a terminal diagnosis of heart failure (heart unable to pump blood effectively to the body).During a record review on 12/10/2025 of Patient 10’s medical records, the review indicated there was no IDG notes documented for the recertification period for 11/6/2025 to 1/4/2026 to validate the IDG group met and updated the comprehensive assessment and plan of care.During a record review of Patient 10’s IDG/IDT notes on 12/15/2025,  the IDG group notes were present and indicated user “ha.one” had created the note for IDG meeting dated 11/19/2025 on 12/10/2025.  During an interview with the ADM on 12/15/2025, at 11:11 a.m., the ADM stated that Registered Nurse 3 (RN 3) was hired on 12/14/2025 as a case manager.  During an interview with the ADM on 12/15/2025, at 12:02 p.m., the ADM stated he did not know who the user name “ha.one” belonged to. During an interview with the ADM on 12/15/2025, at 12:12 p.m., the ADM stated the username “ha.one”, belonged to RN 3.  The ADM stated RN 3 had previously worked at the HA as quality assurance.  The ADM stated he did not have an employee file for RN 3. During a record review of the HA’s medical record user list, indicated username “ha.one”, was linked to a name titled, “One, Hazel,” office staff, with administrative access.  A continued review of the record indicated users name included their full legal name, with credentials, and labeled field staff.  A record review of the HA’s undated document titled, Access to Information,” indicated,  “Policy Only authorized personnel will have access to the clinical/service...records...Personnel will only have access to information on those patients to which they are actively providing care and service, such as shift nurses...Office personnel will only have access to information on those patients to which they are actively providing service, such as working on bills, following up on complaints, etc.”A record review of the HA’s undated document titled, Clinical/Service Data Collection, indicated, “Entries to the clinical/service record will be made only by organization personnel and/or by contract personnel who have a written agreement with the organization.”

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 all employees with direct contact with patients had a criminal background check. This failure had the potential to result in placing the patients at risk for being taken care of by a potentially dangerous person that may cause harm and serious injury. --- During an interview on 12/10/2025 at 12:40 p.m., and 12/11/2025 at 9:05 a.m., with the Administrator (ADM), the ADM stated there was no knowledgeable staff to assist with the survey.   During an interview on 12/12/2025 at 10:50 a.m. with Registered Nurse 2 (RN 2), RN 2 stated she was not comfortable speaking on behalf of the agency regarding clinical operations of the hospice agency. During a concurrent interview and record review on 12/11/2025 at 11:51 a.m. with the ADM, of the Medical Social Worker’s (MSW) personnel record, the ADM stated that he (ADM) ran a criminal background check on the MSW in 2024, to comply with the Federal regulations after another survey.  During a concurrent interview and record review on 12/11/2025 at 11:58 a.m. with the ADM, the ADM stated that a background check was important to ensure employees do not have any case or legal issues that might affect the integrity of the company. The ADM stated that patients can also be affected by not knowing the status of an employee's criminal background. The ADM stated that depending on the employee's infraction, the employee can cause the same harm to the patients which can cause harm.  During a concurrent interview and record review on 12/11/2025 at 12:01 p.m. with the ADM, of the Volunteer’s (VOL1) personnel record, the ADM stated that VOL1’s personnel record was incomplete.  The ADM stated that the VOL1’s personnel record should be complete to ensure she (VOL1) had all her (VOL1) required licenses, certificates, and competencies UpToDate, to ensure patient safety. During a concurrent interview and record review on 12/11/2025 at 12:10 p.m. with the ADM of the Certified Home Health Aide (CHHA1) personnel record, the ADM stated that CHHA1 did not have a criminal background check in her personnel record.  The ADM stated that a background check was important for patient safety.

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 (COP - conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people 65 years of age or more and for certain younger people with disabilities]) on Compliance with Federal, State and Local laws and regulations related to the health and Safety of Patients was met as follows: --- 1.      The HA failed to ensure a qualified administrator was responsible for the day-to-day operations of the agency for six of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, and Patient 10). (Refer to State Article 5.1 and SOM Appendix M L 651).The cumulative effect of these systemic practices resulted in the failure of the Hospice Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Federal, State and Local laws and regulations related to the health and Safety of Patient to ensure the quality of care are provided to patients certified to receive hospice benefits.

Upon patient record review, 7 of 14 (Patients #1, #2, #3, #5, #6, #8, #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 Patient #1: Namenda 5mg and Oxygen missing on Medication profile. Patient #2: Fexofenadine 180 mg, Omeprazole 20mg, Vitamin C, Amlodipine 5mg and Zithromax 250mg missing on Medication profile. Patient #3: Oxygen missing on Medication profile. Patients #5, #6, #8, #10: Had no medications listed on Medication Profile.

Upon patient record review, 3 of 14 (Patients #9, #13, #14) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patients #9, #13, #14: Did not have Initial Bereavement Risk Assessment completed to date.

Upon patient record review, 7 of 14 (Patients #1, #2, #3 #5, #6, #8, #10) did not have evidence the plan of care (POC) must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: Namenda 5mg and Oxygen missing on POC. Patient #2: Fexofenadine 180 mg, Omeprazole 20mg, Vitamin C, Amlodipine 5mg and Zithromax 250mg missing on POC. Patient #3: Oxygen missing on POC. Patients #5, #6, #8, #10: Had no medications listed on POC.

Upon patient record review, 3 of 14 (Patients #1, #2, #3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: This patient had an Oxygen Concentrator and E-Tank. These were not included on the Plan of Care. Patient #2 and #3: This patient had a Nebulizer Machine. These were not included on the Plan of Care.

Upon client record review, 3 of 14 (Patient #6,#7,#9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patients #6, #7, #9: No SN visits indicated on POC. SN visiting 1x per week per calendar.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence the hospice offers bereavement counseling that includes: • Development of a bereavement plan of care (POC) that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #3: The medical record had no evidence of a bereavement POC. The Bereavement Coordinator has been sending card and letters per Policies and Procedures and provided a collaboration note in patients chart only.

Upon patient record review 1 of 14 (Patient #3) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #3: The POC listed Aide visit frequency of, 1x per week. There are no visits performed by hospice aide from SOC to current date. Per agency they have a private aide (non-hospice) that visits.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel.

Upon patient record review, 12 of 14 (Patients #1, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14) did not have evidence that the medical director or physician designee provides written certification of terminal illness (CTI) that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patients #1, #5, #8: The CTI did not include any primary terminal conditions or related diagnoses. Also, the Medical Director did not sign/date the CTI. Patient #4: The CTI did not include any related diagnoses. Patients #6, #7, #9, #10, #11, #12, #13, #14: The CTI did not have physician narrative, signature or date on the form.

Upon patient record review, 10 of 14 (Patients #1, #5, #7#, #8, #9, #10, #11, #12, #13, #14) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patients #1, #5, #8: The Recertification CTI did not include any primary terminal conditions or related diagnoses. Also, the Medical Director did not sign/date the CTI. Patients #7, #9, #10, #11, #12, #13, #14: The Recertification CTI did not have physician narrative, signature or date on the form.

Upon patient client record review, 14 of 14 (Patients #1 through #14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #1, #2, : The Hospice Medicare Election statement does not provide BFCC-QIO contact information. Also,the patient name missing on form. Patients #3, #4, #5, #6, #7, #8, #9, #10, #13: The Hospice Medicare Election statement does not provide BFCC-QIO contact information. Patients #11: The Hospice Medicare Election statement does not provide BFCC-QIO contact information. Also, no effective date noted in space provided on the form. Patient #12:The Hospice Medicare Election statement does not provide BFCC-QIO contact information or Notice of Non Coved Items addendum information. Also, no effective date noted in space provided on the form. Patient #14: The Hospice Medicare Election statement does not provide BFCC-QIO contact information. Also, effective date written on form was 8/30/23 and the EMR SOC is 8/31/23.

Upon client record review, 4 of 14 (Patients #11, #12, #13, #14) did not have evidence that the discharge summary includes all required information. Patients #11, #12, #13 #14: Did not have information populated on end of care summary for the following: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care

Upon observation, there was no evidence the hospice has the appropriate licenses/permits required by state or local rules and regulations. Upon observation, the hospice license expired 12/16/23. Agency did provide copy of check stub dated 12/6/23 and invoice from California Department of Health with due date of 12/16/23. License has not been received by agency to date.