Every finding on record at Regency Hospice Care, Inc

Based on observation, interview, clinical review and hospice P&P review, the hospice failed to ensure Patient 3's medication profile was updated and the expired medications were properly disposed. These failures posed a risk to not meet the current patient’s needs and had potential for the use of the expired medications that could potentially affect the patient’s well-being. --- Findings: Review of the hospice's P&P titled  Medication Profile revised 11/2023 showed patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.  Using the medication profile to evaluate the use of the drugs in the home setting. The medication profile includes, but is not limited to all current medications, date prescribed, name of medication, dose, frequency, drug classification, and date discontinued. Review of the hospice's P&P titled Safe/Effective Use of Medications revised 11/2023 showed the components of the medication assessment used to determine patient and family/caregiver knowledge and skill related to medication administration will include, but not be limited to:A. Name, dosage, route, duration, time, and usage of medication, intended use as well as expected actions of drug therapyB. Preparation, self-administration, and use of medication, including over-the-counter productsC. Safeguards against contaminationD. Compounding and administration techniques (if applicable)E. Significant side effects, adverse reactions/interactions (including drug-to-drug and drug–food interactions) as well as contraindications and how to avoid and respond to such factors.F. Self-monitoring of drug therapyG. Proper storage and expiration dating of medicationsH. Refill informationI. Actions to take in the event of a missed doseJ. Proper disposal of unused or expired medications, especially controlled substances/Schedule II drugsK. Other information, as applicable.  Instructing the patient and family/caregiver regarding safe storage of medications include: The nurse will plan with the patient and family/caregiver for the safe, therapeutic storage of drugs during the assessment process. Review of Patient 3’s clinical record was initiated on 2/17/26. The clinical record showed the SOC was 2/5/24.  The patient was certified for hospice services during the certification periods from 2/5/24 to 5/4/24, 5/5/24 to 8/2/24, 8/3/24 to 10/1/24, 10/2/24 to 11/30/24, 12/01/24 to 1/29/25, 1/30/25 to 3/30/25, 3/31/25 to 5/29/25, 5/30/25 to 7/28/25, 7/29/25 to 9/26/25, 9/27/25 to 11/25/25, 11/26/25 to 1/24/26 and 1/25/26 to 3/25/26. On 2/18/26 at 1320 hours, a home visit was conducted with LVN 2 at Patient 3's residence.  A medication profile review, medication reconciliation and concurrent interview was conducted with LVN 2 and Patient 3's caregiver.  Review of Patient 3’s Current Treatment/Medication List showed Patient 3 had a physician’s order for bisacodyl rectal suppository (used for constipation) 10 mg one rectal suppository daily as needed.  However, there were 10 bisacodyl rectal suppository medications observed stored in Patient 3's medication box with an expiration date of 11/2025.  In addition, a clobetasol propionate cream (topical cream used to reduce inflammation, itching or redness) was observed in Patient 3’s medication box.  However,  the the clobetasol propionate cream was not included in Patient 3's current medication list.  Patient 3's caregiver was asked about the clobetasol propionate cream,  Patient 3’s caregiver stated the clobetasol propionate was still being used by Patient 3.  LVN 2 was made aware about the medication cream and the expired rectal suppositories.  LVN 2 verified the medication profile should have been updated for the use of clobetasol propionate cream and the expired rectal suppositories should have been properly disposed. On 2/18/26 at 1432 hours,  an interview was conducted with the DPCS.  The DPCS was informed and acknowledged the above findings.

Based on interview and record review, the hospice failed to ensure the hospice interdisciplinary group update the comprehensive assessment for three of three sampled Patients (Patients 1, 2, and 3).  This failure posed a risk for not addressing the care needs for these patients. --- Review of the hospice's P&P titled Interdisciplinary Group Meeting revised 11/2023 showed the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires.  The patient’s plan of care will be updated no less frequently than every 15 days or more frequently if the patient’s condition requires; social, cultural, and physical environments presenting obstacles to effective intervention; integration of alternative therapies into medical regime to assist in effectiveness; and any special needs of the patient.  A plan of care update will be completed for each patient and family/caregiver no lessfrequently than every 15 days utilizing the ongoing comprehensive assessment.Review of the hospice's P&P titled Interdisciplinary Group Plan of Care revised 11/2023 showed the interdisciplinary group (in collaboration with the attending physician, if any) will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of every 15 calendar days. The attending physician will receive a copy of the care plan updates.  1.Review of Patient 1’s clinical record was initiated on 2/17/26. The clinical record showed the SOC was 5/25/24.  The patient was certified for hospice services during the certification periods from 5/25/24 to 8/22/24, 8/23/24 to11/20/24, 11/21/24 to 1/19/25, 1/20/25 to 3/20/25, 3/21/25 to 5/19/25, 5/20/25 to 7/18/25, 7/19/25 to 9/16/25, 9/17/25 to 11/15/25, and 11/16/25 to 1/14/26.Review of Patient 1's History of POC/IDG showed the recent POC/IDG review was dated 4/24/25.  However, there was no evidence of documentation of POC/IDG reviews after the dated 4/24/25. Review of Patient 1's Communication Log dated 12/25/25 at 0603 hours showed, received a call from patient caregiver that patient was on the ground at 0430 hours, had pain on right thigh but managed by pain medication and would inform MD. However, there was no evidence of documentation regarding the incident of Patient 1 was found on the ground with pain on the right thigh. On 2/17/26 at 1350 hours, an interview and concurrent clinical record review were conducted with the DPCS. DPCS was informed, acknowledged there was no documentation of POC/IDG reviews after 4/24/25 and verified there was no POC/IDG review regarding incident of Patient 1 found on the ground with right thigh pain. 2. Review of Patient 3’s clinical record was initiated on 2/17/26. The clinical record showed the SOC was 2/5/24.  The patient was certified for hospice services during the certification periods from 2/5/24 to 5/4/24, 5/5/24 to 8/2/24, 8/3/24 to 10/1/24, 10/2/24 to 11/30/24, 12/01/24 to 1/29/25, 1/30/25 to 3/30/25, 3/31/25 to 5/29/25, 5/30/25 to 7/28/25, 7/29/25 to 9/26/25, 9/27/25 to 11/25/25, 11/26/25 to 1/24/26 and 1/25/26 to 3/25/26.Review of Patient 3's Communication Log at 0930 hours dated 4/25/25 showed received phone call from caregiver reported patient with chief complaint of pain and burning sensation in private area.  Caregiver applied A & D ointment with little relief, CEO made aware.Review of Patient 3's POC/IDG Review Notes dated 5/8/25 showed there was genitourinary and integumentary assessments, goals and interventions, however there was no specific POC/IDG review regarding Patient 3's chief complaint of pain and burning sensation in her private area. On 2/18/26 at 1044 hours, an interview and concurrent clinical record review were conducted with the CEO. The CEO was informed and verified there was no documentation to show Patient 3's incident of pain and burning sensation in her private are was reviewed  or discussed in their IDG meeting.   3. Review of Patient 2’s clinical record was initiated on 2/17/26. The clinical record showed the SOC was 11/24/25.  The patient was certified for hospice services during the certification periods from 11/24/2025 To 2/21/2026.a. Review of the comprehensive assessment dated 11/24/25 showed the skin impairment assessment listed a pressure ulcer on the left heel. However, there was no documentation of the stage or size (length, width, and depth). In addition, the right buttock had a stage 2 pressure ulcer, but there was no documentation of its size (length, width, and depth).b. Review of the visit note dated 12/8/25 showed the caregiver reported the patient got up with a walker and assistance but partially fell and hit her head. A small area of redness and bleeding was noted, with a scab present. Pressure was applied, and the area was covered with Band-Aids. The patient has an unsteady gait and poor balance and is unable to stand without assistance. However, there was no documentation of a neurological assessment or the location of the injury.Review of the Incident/Occurrence Report dated 12/8/25 showed Patient 2 caregiver reported the patient got up with a walker and assistance but partially fell, hitting her head. A small area of redness and bleeding was noted, with a scab present. Pressure was applied, and the area was covered with Band-Aids. The patient has an unsteady gait and poor balance and is unable to stand without assistance.On 2/18/26 at 0900 hours, an interview and concurrent document review were conducted with the DPCS. The DPCS was asked regarding neurological/mental status and the injury’s location. The DPCS stated that the location of the skin impairment should have been documented, along with the size of the redness. The DPCS further stated that the skin assessment should have been completed, including the stage and size of the pressure ulcer upon admission. The wound doctor will follow up approximately one week later. The DPCS was informed of the above findings and verified them.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for one of three sampled patients (Patient 2).  This failure had the potential for not providing appropriate, consistent, and quality care to the patients. --- 3. Review of Patient 2’s clinical record was initiated on 2/17/26. The clinical record showed the SOC was 11/24/25.  The patient was certified for hospice services during the certification periods from 11/24/2025 To 2/21/2026.Review of the Current Treatment/Medication/DME list showed a physician order dated 11/24/25 to provide spiritual counseling per initial evaluation for spiritual needs/concerns and PRN (as needed) visits upon request.Review of the Comprehensive Nursing Assessment dated 11/24/25 showed that the patient/family appeared to indicate fear, hopelessness, and were struggling with the meaning of illness. A spiritual chaplain visit was noted as needed.On 2/18/26 at 1020 hours, an interview and concurrent document review were conducted with the CEO. The CEO was asked if spiritual counseling was offered to Patient 2. The CEO stated that Patient 2 had refused the services. The CEO was then asked if there was any documentation or plan of care reflecting the patient’s refusal of spiritual counseling. The CEO stated he was unable to provide such documentation. When asked why the comprehensive nursing assessment dated 11/24/25 showed a spiritual chaplain was needed, the CEO stated the service should have been documented as either offered or refused. The CEO verified these findings. Review of hospice's P&P titled, The Plan of Care revised 11/2023, showed a written individualized patient/family plan of care will be established and maintained for each individual admitted to the hospice program.  The care provided to the patient must be in accordance with the plan of care.  The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process.  The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will bereviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs, goals and outcome achievement. Review of hospice's  P&P titled Comprehensive Assessment revised 11/2023 showed the following:The comprehensive assessment is updated by the interdisciplinary group as frequently asthe patient’s condition requires but at a minimum every 15 days.A. The interdisciplinary group is required to only update those sections that requireupdatingB. If no changes are needed, then that must be documentedC. If there has been a change in the patient’s condition/status, then the comprehensiveassessment must be updated. Review of hospice's P&P titled Ongoing Assessments revised 11/2023 showed the following:Ongoing comprehensive assessments should focus on:A. Patient's response to careB. Changes in patient condition, level of deteriorationC. Changes in patient diagnoses/prognosisD. Changes in the patient's care environment or support systems4. Based on the assessments, the plan of care—including problems, needs, goals, andoutcomes—will be reviewed and updated by the interdisciplinary group membersresponsible for the case.5. Based upon the findings of the assessment, change/verbal orders will be generated andforwarded to the physician (or other authorized independent practitioner) as needed.6. The physician will be notified to verify any changes in medications, including over-thecountermedications, and treatment/interventions that require physician approval. Review of hospice's P&P titled Prioritizing Patient Problems/Needs revised 11/2023, showed the plan of care will be updated by the interdisciplinary group as often as the condition of the patient indicates or no less than every 15 days.  As goals are achieved, additional interventions may be added to the plan of care to direct patient care. Review of hospice's P&P titled, Monitoring Patient's Response/Reporting to Physician revised date 11/2023 showed the patient's physician and/or the hospice Medical Director will be contacted on the same day when any of the following occur: A. Changes in the patient's condition B. Changes in the patient's psychosocial status C. Changes in family/caregiver support or home environment D. Inability to achieve goals within the specified time frame E. Changes in the patient’s expected response to hospice care or medications F. Changes occur regarding diagnosis, prognosis, or treatment (including procedures, medications, precautions, and limitations) G. Results are received for relevant laboratory tests ordered H. There is any problem implementing the plan of care I. With interdisciplinary group recommendations for changes in the plan of care and care plan updates J. Patient is to be discharged from hospice or a specific service is to be discontinued K. Death occurs. Review of hospice's P&P titled Patient Notification of Changes in Care revised 11/2023 showed the following: Plan of Care1. Whenever the plan of care is changed including services, frequencies, treatments, etc., the patient will be notified at the time of the visit.2. Documentation of the notification will include:A. Date/time of notificationB. Specific changes in the plan of careC. Patient response and/or acceptance 1.Review of Patient 1’s clinical record was initiated on 2/17/26. The clinical record showed the SOC was 5/25/24.  The patient was certified for hospice services during the certification periods from 5/25/24 to 8/22/24, 8/23/24 to11/20/24, 11/21/24 to 1/19/25, 1/20/25 to 3/20/25, 3/21/25 to 5/19/25, 5/20/25 to 7/18/25, 7/19/25 to 9/16/25, 9/17/25 to 11/15/25, and 11/16/25 to 1/14/26. Review of Patient 1's History of POC/IDG review showed recent updated POC/IDG review was 4/24/25.  However, there was no further evidence of documentation that POC/IDG was updated since 4/24/25.  Additionally, there was no Nursing IDG Discussion/Update Comprehensive Assessment Review or blank documentation from 1/30/25 to 4/24/25. Review of Patient 1's RN Recertification Assessment dated 11/15/25 showed the following RN 1's narrative: -The patient continues to exhibit symptoms consistent with cerebrovascular disease, including confusion, memory deficits, mild expressive language impairment, mobility limitations, lower extremity edema, and generalized weakness.-These symptoms significantly impact her functional status and support the need for continued hospice care.-Patient needs were met during this visit, and staff and caregiver were instructed to contact Hospice promptly with any concerns or changes in condition.-Plan: Continue ongoing hospice care, monitor for changes in cognition, mobility, and edema, and provide support for comfort, safety, and quality of life.However, there was no evidence of documentation to show that RN 1 recertification assessment was included in Patient 1's POC since the last updated POC/IDG was dated 4/24/25. Review of Patient 1's Communication Log dated 12/25/25 at 0603 hours showed, received a call from patient caregiver that patient was on the ground at 0430 hours, had pain on right thigh but managed by pain medication and would inform MD. However, when the phone call was received, there was no documented evidence the caregiver was further asked for more details as: what position Patient 1 was found on the ground, if there was a skin breakdown or swelling or skin discoloration, how the level of pain was assessed, what was the level of pain and  what was the pain medication taken by Patient 1 after the incident occurred.  There was also no evidence of documentation on hospice's conducted coordinated  SN visit dated 12/25/25 to assess Patient 1's change of condition who was found on the ground with pain on the right thigh.  Additionally, there was no documentation the physician was informed on the date incident occurred 12/25/25, no documentation of SN fall assessment and no SN visit documentation regarding Patient 1's incident, found on the ground with right thigh pain. On 2/17/26 at 1350 hours, an interview and concurrent clinical record review were conducted with the DPCS. DPCS was informed and verified above findings. On 2/17/26 at 1420 hours,  an interview and concurrent clinical record review were conducted with the CEO.  The CEO was asked if he was the one who received the phone call dated 12/25/25 at 0603 hours. The CEO stated he was the one who received the call.   The CEO was informed and verified above findings.  He verified he could not provide any documentation that Patient 1's caregiver was given follow up call to ask details as: what was Patient 1's position when she was found on the ground, if there was a skin breakdown or skin discoloration or swelling,  how the level of pain was assessed, what was the level of pain, what was the pain medication taken by Patient 1.  CEO further verified, there was also no documentation to show the physician was informed dated 12/25/25 when the incident occurred.  2. Review of Patient 3’s clinical record was initiated on 2/17/26. The clinical record showed the SOC was 2/5/24.  The patient was certified for hospice services during the certification periods from 2/5/24 to 5/4/24, 5/5/24 to 8/2/24, 8/3/24 to 10/1/24, 10/2/24 to 11/30/24, 12/01/24 to 1/29/25, 1/30/25 to 3/30/25, 3/31/25 to 5/29/25, 5/30/25 to 7/28/25, 7/29/25 to 9/26/25, 9/27/25 to 11/25/25, 11/26/25 to 1/24/26 and 1/25/26 to 3/25/26. Review of Patient 3's Communication Log at 0930 hours dated 4/25/25 showed received phone call from caregiver reported patient with chief complaint of pain and burning sensation in private area.  Caregiver applied A & D ointment with little relief, CEO made aware.  However, there was no evidence of  documentation that SN visit was coordinated to follow up and assess specifically on Patient 3's slight relief from interventions provided on her private area and no documentation that IDG discussed on Patient 3's chief complain of pain and burning on her private area. On 2/18/26 at 1044 hours, an interview and concurrent clinical record review were conducted with the CEO. The CEO was informed and verified the above findings.

Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for three of three sampled patients (Patients 1, 2, and 3).  This failure had the potential to cause inconsistent delivery of care which could result in the decline or lack of improvement of the patients’ health conditions. --- 3. Review of Patient 2’s clinical record was initiated on 2/17/26. The clinical record showed the SOC was 11/24/25.  The patient was certified for hospice services during the certification periods from 11/24/2025 To 2/21/2026.a. Review of the Comprehensive skin  assessment dated 11/24/25 showed that the skin impairment assessment listed a pressure ulcer on the left heel. However, there was no documentation of the stage or size (length, width, and depth). In addition, the right buttock had a stage 2 pressure ulcer, but there was no documentation of its size (length, width, and depth).Review of the Comprehensive skin assessment dated 12/5/25 showed that the left heel had a stage 4 pressure ulcer with measurements of 1.7 cm (length), 2.7 cm (width), and 0.2 cm (depth). In addition, the right buttock had a stage 3 pressure ulcer with measurements of 0.9 cm (length), 0.9 cm (width), and 0.8 cm (depth).Review of physician progress notes dated 12/04/25 showed recommendations for aggressive offloading, including the use of a low air loss mattress, heel protectors, and offloading heels on pillows; dietary recommendations for wound healing per the Hospice Plan of Care; and additional recommendations to turn and reposition the patient per facility or agency protocol, keep the skin clean and dry, avoid massaging bony prominences, provide adequate intake of protein and calories, maintain the current level of activity, mobility, and range of motion, use positioning devices to prevent prolonged pressure on bony prominences, keep the head of the bed as low as possible to reduce the risk of shearing, keep sheets dry and wrinkle-free, remove all products with fragrance including body washes and lotions, and use chemical-free, fragrance-free disposable washcloths.b. Review of the Incident/Occurrence Report dated 12/8/25 showed that Patient 2’s caregiver reported the patient got up with a walker and assistance but partially fell, hitting her head. A small area of redness and bleeding was noted, with a scab present. Pressure was applied, and the area was covered with Band-Aids. The patient had an unsteady gait and poor balance and was unable to stand without assistance from 11/24/25 to 2/21/26.However, Patient 2’s POC/IDG Review Notes dated 11/24/25 failed to show documentation of a plan of care addressing spiritual counseling, psychosocial issues, nursing services, wound assessment, nutrition, pain and environment/safety.Review of Patient 2' POC/IDG Review Notes dated 11/27/25, 12/23/25, and 1/8/26 failed to show documentation of a plan of care addressing nursing services, wound assessment, pain, nutritional and environment/safety, including the fall that occurred on 12/8/25.On 2/18/26 at 0900 hours, an interview and concurrent document review were conducted with the DPCS. The DPCS stated that the POC/IDG should develop a plan of care upon admission, 14 days after admission, and as needed for any change of condition. The POC/IDG should be updated within 24 to 48 hours after an incident or change of condition. It should have been discussed among the IDG members and documented in the POC/IDG review.  The DPCS stated that the nurse had visited patient on 12/8/25 and informed the IDG (Interdisciplinary Group), but the DPCS was unable to provide documentation. The DPCS verified the findings.  Review of hospice's P&P titled The Plan of Care revised 11/2023 showed to ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. A written individualized patient and family/caregiver plan of care will be established andmaintained for each individual admitted to the hospice program. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care.  Any change in the patient’s condition must result in a change in the plan of care, prior to implementation of the new service. Review of hospice's P&P titled Prioritizing Patient Problems/Needs revised 11/2023 showed, a written, individualized plan of care will be established within 48 hours of hospice benefit election to assist with identification and prioritization of patient immediate problems/needs. Review of hospice's P&P titled Interdisciplinary Group Plan of Care revised 11/2023 showed the interdisciplinary group (in collaboration with the attending physician, if any) will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of every 15 calendar days. The attending physician will receive a copy of the care plan updates. Review of hospice's P&P Interdisciplinary Group Meeting revised 11/2023 showed The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires. Review of hospice's P&P titled Monitoring Patient's Response/Reporting To Physician revised 11/2023 showed the patient's physician and/or the hospice Medical Director will be contacted on the same day when any of the following occur: Changes in the patient's condition. The plan of care will be updated according to hospice policies and procedures. 1.Review of Patient 1’s clinical record was initiated on 2/17/26. The clinical record showed the SOC was 5/25/24.  The patient was certified for hospice services during the certification periods from 5/25/24 to 8/22/24, 8/23/24 to11/20/24, 11/21/24 to 1/19/25, 1/20/25 to 3/20/25, 3/21/25 to 5/19/25, 5/20/25 to 7/18/25, 7/19/25 to 9/16/25, 9/17/25 to 11/15/25, and 11/16/25 to 1/14/26. Review of Patient 1's History of POC/IDG review showed recent updated POC/IDG review was 4/24/25.  However, there was no further evidence of documentation that POC/IDG was updated since 4/24/25.  Additionally, there was no Nursing IDG Discussion/Update Comprehensive Assessment Review or blank documentation from 1/30/25 to 4/24/25. Review of Patient 1's RN Recertification Assessment dated 11/15/25 showed the following RN 1's narrative: -The patient continues to exhibit symptoms consistent with cerebrovascular disease, including confusion, memory deficits, mild expressive language impairment, mobility limitations, lower extremity edema, and generalized weakness.-These symptoms significantly impact her functional status and support the need for continued hospice care.-Patient needs were met during this visit, and staff and caregiver were instructed to contact Hospice promptly with any concerns or changes in condition.- Plan: Continue ongoing hospice care, monitor for changes in cognition, mobility, and edema, and provide support for comfort, safety, and quality of life.However, there was no evidence of documentation to show individualized plan of care regarding RN 1's recertification assessment was included in Patient 1's POC since the last updated POC/IDG was dated 4/24/25. Review of Patient 1's Communication Log dated 12/25/25 at 0603 hours showed, received a call from patient caregiver that patient was on the ground at 0430 hours, had pain on right thigh but managed by pain medication and would inform MD. However, there was no evidence of individualized plan of care documentation  regarding the incident of Patient 1 was found on the ground with pain on the right thigh.  On 2/17/26 at 1350 hours, an interview and concurrent clinical record review were conducted with the DPCS. DPCS was informed and verified the above findings. 2. Review of Patient 3’s clinical record was initiated on 2/17/26. The clinical record showed the SOC was 2/5/24.  The patient was certified for hospice services during the certification periods from 2/5/24 to 5/4/24, 5/5/24 to 8/2/24, 8/3/24 to 10/1/24, 10/2/24 to 11/30/24, 12/01/24 to 1/29/25, 1/30/25 to 3/30/25, 3/31/25 to 5/29/25, 5/30/25 to 7/28/25, 7/29/25 to 9/26/25, 9/27/25 to 11/25/25, 11/26/25 to 1/24/26 and 1/25/26 to 3/25/26. Review of Patient 3's Communication Log at 0930 hours dated 4/25/25 showed received phone call from caregiver reported patient with chief complaint of pain and burning sensation in private area.  Caregiver applied A & D ointment with little relief, CEO made aware. Review of Patient 3's POC/IDG Review Notes dated 5/8/25 showed there was genitourinary and integumentary assessments, goals and interventions, however there was no specific individualized plan of care in POC/IDG review regarding Patient 3's chief complaint of pain and burning sensation in her private area.  On 2/18/26 at 1044 hours, an interview and concurrent clinical record review were conducted with the CEO. The CEO was informed and verified there was no documentation to show individualized plan of care regarding Patient 3's incident of pain and burning sensation in her private area.

Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patient’s POCs no less frequently than every 15 calendar days for two of three sampled patients (Patients 1 and 3). This failure had the potential for not providing the appropriate, consistent, and quality care to the patient. --- Findings: Review of the hospice's P&P titled  Interdisciplinary Group Meeting revised 11/2023 showed the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program.  Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires.  The patient’s plan of care will be updated no less frequently than every 15 days or more frequently if the patient’s condition requires; social, cultural, and physical environments presenting obstacles to effective intervention; integration of alternative therapies into medical regime to assist in effectiveness; and any special needs of the patient.  A plan of care update will be completed for each patient and family/caregiver no less frequently than every 15 days utilizing the ongoing comprehensive assessment. Review of the hospice's P&P titled Ongoing Assessments revised dated 11/2023 showed based on the assessments, the plan of care—including problems, needs, goals, and outcomes—will be reviewed and updated by the interdisciplinary group members responsible for the case. 1.  Review of Patient 1’s clinical record was initiated on 2/17/26. The clinical record showed the SOC was 5/25/24.  The patient was certified for hospice services during the certification periods from 5/25/24 to 8/22/24, 8/23/24 to11/20/24, 11/21/24 to 1/19/25, 1/20/25 to 3/20/25, 3/21/25 to 5/19/25, 5/20/25 to 7/18/25, 7/19/25 to 9/16/25, 9/17/25 to 11/15/25, and 11/16/25 to 1/14/26. Review of Patient 1's POC/IDG notes showed the recent POC/IDG review was dated 4/24/25.  Further review of Patient 1’s POC/IDG showed no documented evidence if Patient 1's POC/IDG was updated after 4/24/25.  In addition,  there was no  documentation on Nursing IDG Discussion/Updated Comprehensive Assessment Review from 1/2/25 to 4/24/25.  Review of Patient 1's Communication Log dated 12/25/25 at 0603 hours, showed the agency received a call from the patient caregiver the patient was found on the ground at 0430 hours, had pain on the right thigh but managed by the pain medication and would inform the MD.  However, there was no documented evidence the POC/IDG was updated regarding the incident when Patient 1 was found on the ground and had pain on the right thigh. On 2/17/26 at 1350 hours, an interview and concurrent clinical record review were conducted with the DPCS.  DPCS was informed and verified the above findings. 2.  Review of Patient 3’s clinical record was initiated on 2/17/26. The clinical record showed the SOC was 2/5/24.  The patient was certified for hospice services during the certification periods from 2/5/24 to 5/4/24, 5/5/24 to 8/2/24, 8/3/24 to 10/1/24, 10/2/24 to 11/30/24, 12/01/24 to 1/29/25, 1/30/25 to 3/30/25, 3/31/25 to 5/29/25, 5/30/25 to 7/28/25, 7/29/25 to 9/26/25, 9/27/25 to 11/25/25, 11/26/25 to 1/24/26 and 1/25/26 to 3/25/26. Review of Patient 3's Communication Log for 4/25/25 at 0930 hours, showed the agency received a telephone call from the caregiver who reported patient had a chief complaint of pain and burning sensation in the private area, caregiver applied A&D ointment  (vitamin A and D) with little relief, and the CEO was made aware. Review of Patient 3's POC/IDG Review Notes dated 5/8/25 showed there was genitourinary and integumentary assessments, goals and interventions.  However, there was no specific POC/IDG review regarding Patient 3's incident of chief complaint on pain and burning sensation in her private area.  On 2/18/26 at 1044 hours, an interview and concurrent clinical record review were conducted with the CEO. The CEO was informed and verified there was no documentation to show the IDG discussed or reviewed  Patient 3's incident of pain and burning sensation in her private area.

Based on interview and record review, the hospice failed to ensure the visit for a change of condition was coordinated and documented for two of three sampled patients (Patients 1and 3).  This failure had the potential for the patient not to receive the necessary care and interventions related to their change in condition. --- Findings: Review of the hospice P&P titled Interdisciplinary Group Plan of Care revised 11/2023 showed written evidence of care coordination will be found in the plan of care and/or interdisciplinary team meeting forms in the patient's clinical record and will involve the hospice patient’s attending physician.  Review of hospice's P&P titled Monitoring Patient's Response/Reporting to Physician revised 11/2023 showed the patient's physician and/or the hospice Medical Director will be contacted on the same day when any of the following occur: A. Changes in the patient's conditionB. Changes in the patient's psychosocial statusC. Changes in family/caregiver support or home environmentD. Inability to achieve goals within the specified time frameE. Changes in the patient’s expected response to hospice care or medicationsF. Changes occur regarding diagnosis, prognosis, or treatment (including procedures,medications, precautions, and limitations) 1.  Review of Patient 1’s clinical record was initiated on 2/17/26. The clinical record showed the SOC was 5/25/24.  The patient was certified for hospice services during the certification periods from 5/25/24 to 8/22/24, 8/23/24 to11/20/24, 11/21/24 to 1/19/25, 1/20/25 to 3/20/25, 3/21/25 to 5/19/25, 5/20/25 to 7/18/25, 7/19/25 to 9/16/25, 9/17/25 to 11/15/25, and 11/16/25 to 1/14/26. Review of Patient 1's Communication Log dated 12/25/25 at 0603 hours, showed the agency received a call from the patient caregiver the patient was found on the ground at 0430 hours, had pain on the right thigh but managed by the pain medication and would inform the MD.   However, there we no documentation of the specific details as to what Patient 1’s position when found on the ground, if Patient 1 had skin breakdown, swelling, bleeding or skin discoloration, if Patient 1 had pain, Patient 1’s pain level and  what pain medication was taken.  There was also no documented evidence on hospice's coordinated  SN visit dated 12/25/25, to assess Patient 1's change of condition when found on the ground with pain on the right thigh.  Additionally, there was no documentation if the physician was informed regarding the incident; and no SN visit note and SN fall assessment documentation when Patient 1 found on the ground with right thigh pain. On 2/17/26 at 1350 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS was informed and verified there was no documentation to show the hospice's visit coordination on 12/25/25 for the incident of fall and there was no SN visit note and SN fall assessment when Patient 1 found on the ground with right thigh pain.  The DPCS acknowledged if there was no documentation, it did not happen. On 2/17/26 at 1420 hours,  an interview and concurrent clinical record review were conducted with the CEO.  The CEO was asked if he was the one who received the phone call on 12/25/25 at 0603 hours.  The CEO stated he was the one who received the call.   The CEO was informed and acknowledged the above findings.  2.  Review of Patient 3’s clinical record was initiated on 2/17/26. The clinical record showed the SOC was 2/5/24.  The patient was certified for hospice services during the certification periods from 2/5/24 to 5/4/24, 5/5/24 to 8/2/24, 8/3/24 to 10/1/24, 10/2/24 to 11/30/24, 12/01/24 to 1/29/25, 1/30/25 to 3/30/25, 3/31/25 to 5/29/25, 5/30/25 to 7/28/25, 7/29/25 to 9/26/25, 9/27/25 to 11/25/25, 11/26/25 to 1/24/26 and 1/25/26 to 3/25/26. Review of Patient 3's Communication Log for 4/25/25 at 0930 hours, showed the agency received a telephone call from the caregiver who reported patient had a chief complaint of pain and burning sensation in the private area, caregiver applied A&D ointment (vitamin A and D) with little relief, and the CEO was made aware.  However, there was no documented evidence the SN visit was coordinated to follow up and assess Patient 3 when Patient 3 had pain and burning sensation in the private area with slight relief from the interventions provided. In addition, there was no documentation the IDG discussed Patient 3's complaint of pain and burning on her private area. On 2/18/26 at 1044 hours, an interview and concurrent clinical record review was conducted with the CEO. The CEO was informed and verified the above findings.

Upon patient record review 2 of 14(Patient #1,4) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #1: Election of Benefit (EOB) form had an effective date of 9/2/23 The comprehensive for start of Care (SOC) in patient record was 9/7/23. Patient #4: The (EOB) form had an effective date of 2/2/24 The comprehensive (SOC) in patient record was 2/5/24.

Upon patient record review, 2 of 14 (Patients #3, #5) 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 #3: Patient had an order for Nystatin Powder, Zyrtec 10mg and Loperamide 2mg. These medications were not included on medication profile. Corrected on Site (COS). Patient #5: Patient had Zithromax 250 mg x 5 days (10/26/23) on current medication profile. There was no stop date indicated. COS

Upon patient record review, 1 of 14 (Patient #2) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #2: Bereavement Risk Assessment was not completed. Patient has a son who is active in care.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #6: Patient had Zithromax 250 mg x 5 days (10/26/23) on current Plan of Care. There was not stop date indicated. COS

Upon patient record review, 2 of 14 (Patient #3,6) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #3: This patient had a walker. This item was not included on the Plan of Care. Patient #6: Record reflected patient was on Duo-Neb solution. There was no Nebulizer machine included on POC.

Upon patient record review 5 of 14 (Patients #1, #2, #3, #5, #14) 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 Patient #1:The POC listed Aide visit frequency of, 3 X's per week (9/7/23). There was only one visit first benefit week on 9/9/23. Agency obtained order clarification during this survey-Corrected on site (COS). Patient #2:The POC listed Aide visit frequency of, 3 X's per week (8/24/23). There was only one visit first benefit week on 8/26/23. Agency obtained order clarification during this survey-COS. Patient #3: The POC listed Aide visit frequency of, 3 X's per week (7/8/23). There were no visits made first benefit week. Agency obtained order clarification during this survey-COS. Patient #5: The POC listed Aide visit frequency of, 3 X's per week (10/26/23). There was only one visit first benefit week on 10/27/23. Agency obtained order clarification during this survey. Patient #14: The POC listed Aide visit frequency of, 3 X's per week (6/7/24). There were no visits made first benefit week. Agency obtained order clarification during this survey-COS

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78

Upon patient record review, 1 of 14 (Patient #4) 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. Patient #4: There was no physician narrative in space provided on CTI Recertification form. The document read "TMP" in space provided on form.

Upon patient client record review, 12 of 14 (Patients #1,2,3,4,5,6,9,10,11,12,13,14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients # 3, #12, #14: There was no evidence that "Notice of Non-Covered Items" or BFCC-QIO (Livanta) information provided. Patient #1: Election of Benefit (EOB) form had an effective date of 9/2/23 The start of Care (SOC) in patient record was 9/7/23. Additionally, There was no evidence that "Notice of Non-Covered Items" or BFCC-QIO (Livanta) information provided. Patient #2: The (EOB) form had an effective date of 8/21/23 The (SOC) in patient record was 8/24/23. Additionally, There was no evidence that "Notice of Non-Covered Items" or BFCC-QIO (Livanta) information provided. Patient #4: The (EOB) form had an effective date of 2/2/24 The (SOC) in patient record was 2/5/24. Additionally, There was no evidence that "Notice of Non-Covered Items" or BFCC-QIO (Livanta) information provided. Patient #5: The (EOB) form had an effective date of 10/25/23 The (SOC) in patient record was 10/26/23. Additionally, There was no evidence that "Notice of Non-Covered Items" or BFCC-QIO (Livanta) information provided. Patient #6, #10, #11: The EOB no effective date. Additionally, There was no evidence that "Notice of Non-Covered Items" or BFCC-QIO (Livanta) information provided. Patient #9: The (EOB) form had an effective date of 11/2/23 The (SOC) in patient record was 11/3/23. Additionally, There was no evidence that "Notice of Non-Covered Items" or BFCC-QIO (Livanta) information provided. Patient #13: The (EOB) form had an effective date of 2/26/24 The (SOC) in patient record was 2/27/24. Additionally, There was no evidence that "Notice of Non-Covered Items" or BFCC-QIO (Livanta) information provided.

Upon client record review, 2 of 14 (Patients #7, #8) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #7: There was no evidence of discharge summary sent to attending. Patient #8: There was no evidence of discharge summary sent to attending.

Upon client record review, 1 of 14 (Patient #7) did not have evidence that the discharge summary includes all required information. Patient #7: The DC Summary was blank and did not include the following : • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care • The patient's latest physician orders